Three structured interviews providing a checklist of key questions to be asked by health professionals assessing suicide risk of children and adolescents in crisis situations. The questions allow for a quick and comprehensive assessment, reminding clinicians of the factors they should consider when deciding if a risk is significant or not, and ensuring that factors are not neglected or overlooked.
Aims and objectives
The NICE Quality Standard on depression in children and young people (QS48) includes two statements which require a thorough and timely assessment of suicide risk in order to be achieved. Quality Statement Three states that children and young people with suspected severe depression and at high risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health Services) professionals within a maximum of 24 hours of referral. Quality Statement Four states that children and young people with suspected severe depression but not at high risk of suicide are assessed by CAMHS (Child and Adolescent Mental Health Services) professionals within a maximum of 2 weeks of referral. Our aim was to produce a checklist of key questions that could be used by health professionals to assess suicide (and other) risks in children and adolescents, both quickly and comprehensively, in crisis situations.
Reasons for implementing your project
Suicides in children are very rare, and predicting them is difficult. The NICE Quality Standard on depression in children and young people states that children and young people with suspected severe depression should be are seen by a child and adolescent mental health service (CAMHS) professional within 2 weeks of referral, or within a maximum of 24 hours if at a high risk of suicide. Prompt access to services is essential if children and young people are to receive the right treatment at the right time. Arrangements should be in place so that children and young people referred to CAMHS with suspected severe depression and a high risk of suicide are kept in a safe place and seen as an emergency, within a maximum of 24 hours, to help prevent injury or worsening of symptoms.
A mental health professional called to assess a child or adolescent during a crisis situation, either in Accident and Emergency or at young person's home, will need to assess his or her suicide risk quickly. This assessment is usually done via an interview. Although a professional?s interviewing skills are often well developed we felt that having a checklist of questions to ask would provide a fail-safe structure for obtaining the necessary information on which to base a comprehensive assessment.
The use of surgical checklists has been proven to improve patient safety in the operating theatre. The idea of a checklist in this situation is to remind clinicians of the factors they should be considering when deciding if a risk is significant or not, and to ensure that factors are not neglected or overlooked. Fluid factors, such as hopelessness and what the patient says are important to consider when assessing suicide risk, but are often overlooked in statistical models because they are not easily weighted.
How did you implement the project
The team at APT produced the DICES System for Risk Assessment in Mental Health and Risk Management in Mental Health, so we were aware of the areas of concern that needed to be covered. The work for children was therefore a step on from this, making sure that questions were phrased in the most appropriate way.
We devised a structured interview/checklist assessment in 3 parts:
- Part 1 is questions to ask the parenter(s). ('parenter' is the term we use for the person(s) doing the parenting)
- Part 2 is questions to ask the young person
- Part 3 is questions for the clinician to as him or herself
The questions address both fixed factors such as age, gender etc and fluid factors such as level of hopelessness that a person might be experiencing at any one time. We included a questionnaire for the parent or carer, to guard against any omissions, deliberate or otherwise, from the young person. The questions for the clinician are there to help analyse the information obtained during the other structured interviews and face-to-face contact. These questions include assessing fluid factors such as hopelessness which is established as a correlate of suicide risk. This information can then be shared with colleagues, and an informed clinical judgement can be made on the risk. Clinical judgment is important because sometimes a person ticks few boxes according to statistical weightings, yet that person is at significant risk of harming themselves. If any significant risks are identified then a risk management plan should be put into place, for suicide or other problems which may become apparent during the interview process.
We have written to the service manager who sponsored the course for which these structured interviews were designed, to ask the people who received this structured interview how they are getting on with it. The nature of a 'checklist' is that it is difficult to tell whether it works in the sense of having 'results'. In terms of measurement, one piece of hard data that should become available would be a measure of what percentage of people who were given the structured interview have put it to use in practice (Only about 30 people have received this structured interview so far). The checklist is based on the DICES Series of checklists, which more than 6000 people have subscribed to use. It could be argued that this large number is indicative of their usefulness, or about the weight that a sponsoring organisation attaches to them. That said, this is not, the checklist we are discussing in this example.
Key learning points
1) Although most professionals welcomed a tool that would ensure they 'covered all the bases', a minority thought that 'having a form to fill in' hampered the development of rapport and relationship between client and professional. This was overcome to a degree by inviting professionals to take the role of specific clients while other professionals administered the structured interview to them. The rationale behind this was to enable the "client-professionals" to feel what it felt like to be on the receiving end of the structured interview. Many (though not all) agreed that "it was good that the professional had some framework and structure to operate within", and that "nothing would be missed".
2) Some professionals felt there might be a problem with the (optional) "logging-on" questions. For example, some felt that a question such as "How can I help?" may lead to a very long interaction which may ultimately result in disappointment. This was overcome mainly through discussion and re-writing instructions under the "logging-on" section to clarify that these questions are optional and that their function is that of courtesy. So, if the courtesy can be achieved another way, then their purpose is gained.
-Clinical judgement is vital when assessing suicide risk. -Fluid factors, such as hopelessness, are important to consider when assessing suicide risk but are often overlooked in statistical models because they are not easily weighted. -When making an assessment it is not the average level of a person's mood that is important, but the troughs they go into. You can only get this type of information by talking to the person and their 'significant others' (usually parents) and taking into account fluid factors such as hopelessness and simply how they say they feel. -A structured interview or checklist of questions can act as a fail-safe for clinicians to make sure that all important factors have been considered when making an assessment.