Supporting children and young people experiencing a mental health crisis: framework

Overview of the Framework

Who is this document for?

This document is for anyone who may encounter a child or young person experiencing a mental health crisis.

What will this document support you to do?

This document will introduce the basic components of the Framework and provide an overview of the core principles of good crisis support.

When might this document be most helpful?

This document will be most helpful for when initially looking to learn more about the Framework.

Vision

Our vision is that every child and young person in Scotland, and their family members and carers, will be able to access effective and appropriate support when they are experiencing a mental health crisis. This vision sits within Getting It Right For Every Child (GIRFEC), which is the Scottish Government’s long standing, national commitment to provide all children, young people and their families with the right support at the right time.

What Do We Mean By Mental Health Crisis

To support service development when talking about crisis presentations, we have used the definition of crisis agreed in The Multi-Agency Partnership Approach to Distress Framework for Collaboration^[2]:

Crisis is a state where a person is unable to cope and they may be a risk to themselves or others. They are likely to require urgent help from others to manage their mental health risks.

We have chosen to use this definition so that we are using the term “crisis” consistently across children’s and adult services.

We intend for there to be some flexibility in how we apply this definition in relation to accessing support and services. We do not want this definition to become prescriptive, and we want to avoid creating another barrier to children and young people accessing the right help and support.

For the purposes of this Framework, our application of the definition of “crisis” is mainly focused on mental health crisis. This includes, but is not limited to, suicidal crisis.

A mental health crisis can occur for a variety of reasons in a child or young person’s life. These can include social, economic, health, and other factors.

It is important that defining a mental health crisis should not be based on clinical diagnostic criteria, or an expectation that a mental health crisis will lead to a mental health diagnosis. Crisis may not necessarily be related to a mental health condition (e.g. a crisis could arise as a result of a difficult social situation), and the main aim should always be to provide the appropriate support.

We know that:

• Young people in crisis can, and will, ask for help in a wide variety of settings. This could include universal services such as education, and specialist services such as Child and Adolescent Mental Health Services (CAMHS).
• Not every child or young person in crisis will require escalation or onwards referral to specialist help – although some will.
• Given that each set of circumstances is unique, the pathway for every crisis presentation will look different in each case.
• So too will the help provided by each setting. This will look different depending on where the presentation occurs.

About the Framework

Given the above, this Framework aims to set out our expectations of what good practice looks like for anyone who has a role in supporting children and young people aged between 12 and 18 years old (26 for care experienced young people in line with legalisation) experiencing a mental health crisis^[3].

We acknowledge that there are currently gaps in provision of crisis support, as well as a lack of clarity around escalation. This document aims to set out what good looks like for any child or young person who presents in a crisis. Addressing the gaps that we know exist will be a crucial part of implementing this Framework in practice. Developing a detailed implementation plan, in close collaboration with partners and stakeholders, will therefore be key to success. The forthcoming implementation plan will be accompanied by an escalation pathway to guide practitioners to the most suitable form of support when a child or young person is experiencing a mental health crisis.

This Framework does not introduce additional responsibilities for services. Instead, it clarifies how existing processes including GIRFEC processes should be applied when children and young people experience a mental health crisis.

Aims

This Framework provides the principles of what cohesive and effective support for children and young people experiencing a mental health crisis should look like across Scotland.

The Framework seeks to:

• Outline how GIRFEC and mental health supports come together across specialist and community services to respond to a mental health crisis;
• Support joint working across different services and structures to support improvements, and;
• Improve awareness and understanding of how we support Scotland's children and young people while they are experiencing a mental health crisis.

The expectations set out in this Framework reflect existing good practice and established responsibilities across services. For many practitioners, this will describe what they already do through safeguarding, child protection, GIRFEC assessment and planning, and local escalation arrangements.

At a local level, the Framework is a tool for partners, service managers, commissioners, planners, and practitioners to reflect on their current practice. The principles of good crisis support should inform an integrated, consistent approach to the provision of crisis support for children and young people. This should always have GIRFEC at its core.

The Framework also highlights the contribution and role which a range of services can play when supporting children and young people experiencing a mental health crisis. This includes specialist crisis services, health services, social work, and other statutory services. It is important to note that this will include services which are not typically designed to deliver crisis support, but which may be the first port of call for a child or young person when they ask for help. This may include third sector services, schools, youth groups and other settings.

At a national level, the Framework is a tool to inform future policy development and guidance, supporting greater consistency in expectations around crisis support for children, young people and the adults that support them.

The Framework should be read alongside current safeguarding, child protection^[4] and GIRFEC guidance^[5], and should be applied through established local procedures and professional roles.

Core Principles

This Framework aims to promote a ‘no wrong door’ whole system approach to improving and responding to mental health crisis. This means that any service which may encounter a child or young person experiencing a mental health crisis should be:

• Available in a way which meets the child or young person’s needs wherever they require help;
• Centred in equity, equality and rights;
• Trauma informed, and;
• Attuned and responsive to what children and young people really need (during and after a crisis, including a focus on recovery).

A ‘no wrong door’ approach does not mean that all services are expected to manage crisis alone. Instead, it means that wherever a child or young person first presents in crisis, they are met with a compassionate response, and are supported to access the most appropriate help.

The following principles provide more detail on what we know works in relation to delivering a person-centred approach. These principles can apply to all services, from initial presentation to more specialist support. A mental health crisis may not be a single event, so services also need to continually consider - and be responsive to - changing needs and risks.

Right Support, Right Time, Right Place

• Choice of support which is trauma informed and set in a comfortable environment
• Ensuring all services are skilled in the first steps of crisis response
• Reach in support
• Support and signposting for parents/carers
• Alignment of services

Centring Equity, Equality and Rights

• Age appropriate (evolving capacity) and proportionate responses
• Listening and responding to the experiences of children, young people and families
• Free from stigma and discrimination
• Continuously improving
• Telling your story only once

Responsive Services

• Creating a safe space for the child or young person and supported handover
• Connected support – collaboration and working together
• Governance: data sharing and risk management
• Importance of using local data to understand local populations
• Connections between services and support in accessing further services/ resources

These principles could be delivered through a variety of different types of supports and services to suit local population need and requirements. Local areas, through collaborative planning, should determine what type of support their population requires. This could include supports such as:

• Safe spaces
• Peer support groups
• Family support hubs
• Additional training for non-specialist workforce
• Targeted interventions for high-risk groups
• Enhanced youth work
• Development of local crisis protocols
• Out of hours support and advice for practitioners
• Face to face provision supported by digital services such as online support platforms and text-based services.

Who the Framework is relevant to

This Framework is relevant to all services and supports that assist children and young people who are experiencing a mental health crisis. This includes crises that involve suicidality and self-harming behaviours, however, not all presentations will include these.

This Framework acknowledges the fundamental role that mental health services - both inpatient and community - play in providing support and treatment to children and young people experiencing a mental health crisis. However, it also outlines the wider system that plays an important part in their care. This can be through education, social work, third sector, emergency services such as the police, and youth work. These agencies can all play a key role in children and young people’s lives.

Each presentation involving mental health crisis is unique, and will be shaped by the individual circumstances and experiences of the child or young person.

The way a child or young person communicates distress, or presents when in crisis, depends on many factors. These can include their age, personal triggers, their support system, and their overall health. It is crucial that any response is person-centred, trauma-informed, compassionate and based on the specific needs of the child or young person.

It is vital that defining a mental health crisis should not be based on clinical diagnostic criteria or an expectation that a mental health crisis will lead to a mental health diagnosis. This should be based on individual need and circumstances.

Age Range

The Framework is intended for children and young people who are between the ages of 12 to 18 years old inclusive (26 for care experienced young people in line with legislation). It also has relevance to parents, carers and wider families/supports.

Within the age range of the Framework, there are a number of key milestones. These include the point at 12 years when a child may be able consent to medical treatment. At 16 years, a young person has legal capacity before being classed as an adult by many services and institutions at 18 years.

We know that those aged below 12 years old can also experience a mental health crisis. However, we also acknowledge that those between 8 to 12 years old are in a different developmental stage. Not all interventions and ways of working would be appropriate for this age group.

Notwithstanding this, age should not be a barrier to accessing support when a child or young person is in crisis. The support that is offered should always be based on the developmental needs of the individual. The right help and support should still be available for any child or young person who requires it, in line with GIRFEC, and as outlined by Article 24 in the UNCRC^[6]:

‘Every child has the right to the best possible health and to healthcare services that will help them attain this, including mental health’.

Additionally, from 16 years, older teenagers may start to interact with supports and services for adults. There is no universal transition point for children and young people’s services. Some cease at 16 years, and others continue to age 18. This is particularly important in relation to crisis or unscheduled care. If there is an urgent mental health issue, a 16-18 year old could, in very rare circumstances for example, be admitted to an adult mental health ward if no beds are available in an adolescent unit. The ‘Admission to adult mental health wards for under 18's Best Practice Guidance’ (2020) is clear young people should be admitted to a specialist CAMHS ward but provides guidance on how best to manage admissions when this is not possible.

We know that crisis presentations can vary in how they appear across age ranges, and for different children and young people. They may present as being worried, sad, upset, angry, aggressive, not eating or drinking, running away, putting themselves in dangerous situations, exhibiting risk-taking behaviour, and engaging in self-harming behaviours. This list is not exhaustive - crisis can present in many different ways.

Higher Risk Groups

There are a number of groups of children and young people who are at a higher risk of either experiencing crisis or presenting with more complex needs, shaped by life experiences^[7], such as those who have one or multiple adverse childhood experiences. This can be compounded by stigma, discrimination, and systemic inequalities when trying to access support.

Children and young people may belong to multiple high-risk groups, and these should not be viewed in isolation. A person-centred approach, in line with GIRFEC, is essential to understanding and responding to each individual’s needs.

It will be important for crisis supports and services to ensure that there is both equality^[8] of access but also equity^[9] of access, care and outcomes. Some of these groups may require specific interventions should crisis occur, while others may just need the service to be mindful of their needs.

We know that stigma and discrimination can also be a barrier to accessing support from services. All services should seek to be fully accessible, culturally understanding, and responsive in a sensitive way to diverse needs.

A key consideration of this work is that children and young people in crisis are likely to seek help where they are most comfortable. This may be to those for whom working with crisis is not their primary role. Wherever they present in crisis, services and professionals should be compassionate and able to support individuals into services that meet their needs and circumstances. This means ensuring that services are not only accessible for children and young people but also that they are available in a variety of ways to reduce barriers around access, such as in a variety of languages.

We also know that crisis presentations among neurodivergent children and young people and disabled children and young people may differ from their peers^[10]. Examples include: sensory overload, communication breakdown, physical health deterioration, internalised distress and difficulty with transitions.

Neurodivergent children and young people, or children and young people with learning needs, may face additional challenges in accessing crisis support. Services must proactively consider physical, sensory, cognitive, and communication needs to ensure inclusive and responsive care.

Background: Why the Framework is Needed

Young people have told us that there is currently a gap in support relating to crisis support. They have expressed concern around how services have responded to them when they sought support while experiencing a mental health crisis^[11].

Our recent engagement with young people from the Young Islanders Network found that children and young people would value improved visibility of services, increased training for adults in their lives such as in school and in youth work, and ensuring any improvements to crisis services take into consideration the diversity of Scotland’s islands.

Furthermore, feedback shared with us by young people from the Suicide Prevention Youth Advisory Group shows that “even when in crisis, they do not always want answers, they sometimes just want people to listen to them”. They would prefer to access support in non-clinical settings with people that they have a trusted relationship with.

In June 2023, the Mental Health and Wellbeing Strategy^[12] was published which recognises the need to expand and improve the support available to people in mental health crisis and those who care for them. This builds on the previous work of the Children and Young People’s Mental Health and Wellbeing Joint Delivery Board^[13], which was tasked with ensuring that crisis support is available 24/7 to children and young people.

Through this work, three key issues in relation to crisis support in Scotland were identified:

1. High demand for services and variability in access;
2. Balance of digital and in-person supports, and;
3. Need for a whole system approach.

The Child and Family Mental Health Joint Strategic Board^[14], was established in 2024. The Barriers and Access to Supports and Services Implementation Group, a sub-group of the Board, has supported the development of this Framework to drive forward improvements, and ultimately deliver improved crisis support, for children, young people and the adults that support them.

Currently, we have limited data on the numbers of children and young people who present to services experiencing a mental health crisis in Scotland. This is predominantly due to crisis presentations being recorded in different ways, data not always being linked across different organisations, or on some occasions, no data being collected at all. However, we do know that within Scotland there is high demand for access to mental health services for children and young people. A recent systematic review^[15] has shown that numbers of children and young people presenting in crisis in other parts of the United Kingdom are increasing. According to this review, the key areas of focus are:

• Awareness of existing provision;
• Supportive responses embedded within emergency departments if the crisis involves a life threatening emergency;
• Considering the evidence base and availability of different types of support such as online or by telephone, and;
• Increasing access to community support with clear escalation to specialist social support and/or clinical services if necessary.

Evidence has shown that the aim of “good crisis support” should:

• Stabilise and manage the present crisis initially;
• Assess needs of child or young person and develop support plan with them;
• Support child or young person’s engagement with community support and/or treatment;
• Keep children and young people in their home environment, where appropriate, as an alternative to inpatient admission;
• Escalate and provide a handover for children and young people to additional mental health services where necessary;
• Offer peer support, and;
• Have an appropriately trained and supervised workforce

Definitions

The following definitions are included to provide a common understanding and consistency that can be shared across agencies and services. These definitions have been taken from a range of sources including the Mental Health and Wellbeing

Strategy (2023) and the Multi-Agency Partnership Approach to Distress: Framework for Collaboration, and will hopefully ensure that with common understanding, services are best able to meet a child or young person’s mental health and wellbeing needs.

• Mental wellbeing is a person’s internal positive view that they are coping well psychologically with the everyday stresses of life and can work productively and fruitfully. Good mental wellbeing means a person will feel content and live their life the way they choose.
• Distress can be described as a sudden change in wellbeing from regular behaviour patterns with expressions of intense emotions (e.g. anxiety, hopelessness, loneliness). It is an emotional pain which may have led the person to seek help, and which does not require further emergency service involvement.
• Mental illness is a health condition that affects emotions, thinking and behaviour, which substantially interferes with or limits our life. If left untreated, mental illnesses can significantly impact daily living, including our ability to work, care for family, and relate and interact with others. Mental illness is a term used to cover several conditions (e.g. depression, post-traumatic stress disorder, schizophrenia) with different symptoms and impacts for varying lengths of time for each person. Mental illnesses can range from mild through to severe illnesses that can be lifelong.
• Crisis is a state where a person is unable to cope and they may be a risk to themselves or others. They are likely to require urgent help from others to manage their mental health risks.
• Mental wellbeing, mental health and mental illness are linked to a combination of factors covering biology (e.g. genetics, health and neurodiversity), psychology (e.g. thoughts, emotions and beliefs) and social factors (e.g. culture, poverty and discrimination). These three areas combine with a person’s life experiences to impact the state of mind. This impact varies over time, does not progress in a straight line and is specific to an individual.
• Unscheduled Care is unanticipated, so presentations are unplanned to the services (i.e. where a person did not arrange an appointment). Unscheduled care incidents cannot reasonably be foreseen or planned in advance of contact with relevant services.
• Urgent Care is an illness, distress or injury that requires urgent attention but is not necessarily life or limb-threatening. There is an expectation that urgent care is time sensitive to mitigate risk or to prevent the situation from escalating (e.g. a person displaying signs of impaired decision making).