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

Risk Management and Mental Health Crisis

Who is this document for?

This document is for practitioners involved in providing crisis support to children and young people, from initial compassionate responses through to specialist services

What will this document support you to do?

This document will provide an overview of what things should be considered in relation to risk management when supporting someone experiencing a mental health crisis.

When might this document be most helpful?

This document will be most helpful to practitioners and service leads when developing and delivering services that interact with children and young people.

Risk Management and Mental Health Crisis Presentations

Risk in relation to managing crisis presentations can feel like a difficult and complex area. Within this document, we have reiterated the risk section from the Children and Young People’s Community Mental Health and Wellbeing Supports and Services Framework. This is repeated here for two reasons:

• Firstly, it is acknowledged that some of the community supports and services will at various points support children and young people at, or near, crisis point. It is also important to recognise that not all of these services will have a primary role in supporting a child or young person during a crisis. Escalation may therefore be needed where a more specialist response is required.
• Secondly, the principles outlined in that framework form the initial basis of risk assessment and management in crisis settings.

The rest of this section looks at what is needed to fully support crisis presentations, including recognising how this may differ between specialist and universal settings.

Risk (as outlined in the Children and Young People’s Community Mental Health and Wellbeing Supports and Services Framework)

There is degree of risk involved in the provision of community-based mental health support, including for example:

• Managing crisis or suicidal ideation. While community-based supports and services are aimed at promoting positive mental health and wellbeing and supporting those in emotional distress, children, young people and their families will sometimes present at these services in need of urgent care, or their needs may change over the course of accessing support.
• Managing adult or child protection concerns.
• Ensuring supports and services, including digital resources, are of sufficient quality to meet needs and have effective escalation routes.

The management of risk should be considered in relation to both face-to-face and digital services, and should include each local partnership collaborating on how risk will be managed and monitored across the range of local supports and services.

Important risk mitigations include:

• Ensuring clear, agreed escalation routes to CAMHS and adult mental health services. Usually, this will be how to seek advice from a clinician where a child or young person is not getting better or is raising concern. It should also include how to support children, young people and their families to access urgent assessment both in-hours and out-of-hours from other professionals including GPs, mental health specialists, nurses and social work if required.
• Clear escalation routes to adult and child protection processes.
• Appropriate professional oversight and necessary safeguards, which includes all staff being aware of the need to assess risk and of their own capacity to do so at a local level.
• Appropriate staff training and support.
• In relation to digital services, an up-to-date knowledge of the latest online threats and harmful trends, and an understanding of the impact technology can have on children and young people’s health and relationships.

In addition, the following factors are important to consider:

• Multiagency responses which are proportionate, person-centred, trauma-informed, and needs-led.
• All escalation routes are clear and agreed – this should include agreed understanding of crisis response procedures in a local area, and an understanding of urgent^[26] vs. emergency presentations (requires immediate response) and how to respond to them.
• Appraisal of immediate need should take place. The nearest Accident and Emergency Department is available to deal with life threatening emergencies (such as severe bleeding, breathing difficulties, or other serious injury).
• NHS24 is available for urgent - but not life threatening - injuries and severe mental distress. Other means of removing a child from a seriously stressful situation or providing intensive support for serious distress, including access to emergency accommodation, should be considered.
• Routes to intervention should include the most suitable NHS service where appropriate in instances where there is physical injury, overdose, non-suicidal self-injury, intoxication or assault.
• Services should be clear on how to raise a Notification of Concern (NoC) and have consistent processes in place for all staff.
• How a child or young person is practically supported to the service they need. This could include availability of a suitable vehicle, as well as an appropriate adult to accompany them to and from the assessment/intervention site, and support them throughout.
• If a child or young person refuses to go to, or stay at, the support service, this could be due to various factors such as anxiety. If required, an assessment should be made of their capacity to make decisions about their health and welfare, and consideration given to appropriate use of mental health legislation with parental/carer engagement as appropriate.
• How crisis responses are impact assessed with respect to equalities and children’s rights.

In particular, crisis services, including CAMHS and specialist third sector providers, should:

• Support wider agencies in managing and holding risk around crisis which does not require escalation;
• Work with local partners to develop crisis response procedures;
• Take into account a child/young person's developmental stage and any relevant life transitions when considering, reviewing and adapting risk management approaches.
• Be mindful of the experiences of children who have already encountered adverse experiences, including of particular agencies or interventions.
• Directly involve the child, family, carers, and members of the child’s care/support network in planning, prioritisation, decision-making, and review of support provision.
• Determine support which provides maximum benefit whilst being minimally restrictive and best secures the welfare of the child or young person.

Services supporting children and young people may already be aware of the National Risk Framework to Support the Assessment of Children and Young People^[27] which aims to support practitioners at all levels, in any agency, to be able to approach risk identification, assessment, analysis and management with more confidence and competence.

This National Risk Framework has GIRFEC as its heart and uses the National Practice Model^[28] and 5 GIRFEC questions to support decision making, all of which also apply to the Framework for Supporting Children and Young People Experiencing a Mental Health Crisis.

Within the National Practice Model there is an emphasis on professional judgement and curiosity. Crisis presentations can, at times, feel pressed and urgent. Taking the space and time to explore curiosity around the child/young person’s experience and situation, coupled with attuned professional judgement, helps to provide a measured, holistic response to the crisis situation.

GIRFEC in Practice

There are five key GIRFEC questions that practitioners should ask themselves when considering a child or young person’s wellbeing needs, whilst maintaining a focus on the rights of the child. The child or young person should fully participate in discussions when considering these questions:

1. What is getting in the way of this child or young person’s wellbeing?

2. Do I have all the information I need to help this child or young person?

3. What can I do now that is needed and appropriate to help this child or young person?

4. What can my agency or organisation do now to help this child or young person?

5. What additional help, if any, may be needed from others?

There are four tools within the National Practice Model which allow practitioners to map out what a child or young person needs:

• ‘The eight wellbeing indicators: Using the wellbeing indicators (SHANARRI) in the ‘Wellbeing Wheel’ to observe, discuss and record information which may indicate the scaffolding of support needed for a child or young person.
• The ‘My World’ Triangle: Helps to understand a child or young person’s whole world. It can be used to explore their experience at every stage, recognising there are connections between the different parts of their world. In the assessment process, it can be used to explore strengths, needs and risks.
• The Resilience Matrix: Used in more complex situations, the Resilience Matrix helps organise and analyse information when there is a perceived risk to a child or young person.
• Planning, action and review using the ‘Wellbeing Wheel’: When the child or young person’s needs are clear, they can be summarised using the Wellbeing Wheel to develop an individual plan to provide support.’

The Resilience Matrix^[29] supports in the appraisal of complex situations, helping practitioners to consider and manage the crisis presentation. The focus on highlighting the resilient factors of a child/young person, their family and the services they are engaging with helps foster a strengths-based approach. Additionally, the focus of the tool on changing environmental hazards/stressors helps provide a practical perspective on diverting the child/young person away from crisis.

Transition Points

We know that many risk factors present earlier than always accounted for. So it is important to ensure that we do not make assumptions such as “too young” or “too early”. It is also important to consider both sides of transitions. Whilst there will be a psychological impact after an event, there can also be heightened anxiety or distress in the lead up to an event or change. Providing support to help the child or young person feel in control ahead of transition points has the potential to reduce the feelings of helplessness which can accompany crisis.

Putting in place specific support, such as Transition Care Plans in the case of moving between CAMHS and adult mental health services, can help improve understanding and increase feelings of control around transition points and handovers.

Using the GIRFEC approach, practitioners and lead professionals, who are supporting a child, young person, or their family through any type of transition, should support a child or young person's wellbeing through transitions by working alongside them, and other practitioners involved in transition planning. This could be a transition from CAMHS to adult mental health services, or from primary school to secondary school. They should ensure the views and rights of the young person and family are considered in decisions throughout a transition. Effective transfer of information between services during transitions, in line with information sharing guidance, is also essential to achieving successful outcomes for the child or young person and their family.

Finally, we know that protected characteristics and different demographics (including care experience or being on the edges of care) can significantly impact how critical points and transitions are experienced. The principle of Place, focused on a collaborative, community based response, plays a key role in providing consistency and stability across a child or young person’s journey.