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

Case Studies

Who is this document for?

This document is for anyone who may encounter a child or young person experiencing a mental health crisis and who would like to learn from fictional case studies to expand their knowledge.

What will this document support you to do?

This document will provide more information around the evidence context and national policy positions and how to apply the core principles of this Framework into practice.

When might this document be most helpful?

This document will be most helpful when looking to gain context for what the Framework looks like in practice.

The following case studies provide examples of good practice when a child or young person is experiencing a mental health crisis. They are fictional examples, based on real-life experiences of stakeholders who have experience of working with children and young people.

Some of the content in these case studies may have an emotional impact on you. Support is always available, and some of the national sources of help are listed here.

If you are ever in immediate danger or have the means to cause yourself any harm, you should dial 999 and request an ambulance

Mind to Mind

If you're feeling anxious, stressed or low, or having problems sleeping or dealing with grief, find out how you can improve your mental wellbeing by hearing what others have found helpful by visiting NHS Inform Mind to Mind

Breathing Space

Breathing Space is Scotland's free, confidential listening service for individuals over 16 experiencing symptoms of low mood, depression or anxiety. You can contact them on 0800 83 85 87 Monday to Thursday from 6:00pm to 2:00am and 24 hours a day at weekends (from 6:00pm Friday to 6:00am Monday).

Samaritans

Samaritans provide confidential, non-judgemental emotional support 24/7 for people who are experiencing feelings of distress or despair. You can contact Samaritans free by phoning 116 123 or emailing jo@samaritans.org

NHS 24 Mental Health Hub

NHS 24 mental health services are available to everyone in Scotland. The services available include listening, offering advice and guiding you to further help if required. The Mental Health Hub is open 24/7 and you can contact them on 111.

Childline

Childline is a free service for children and young people for when they need support or advice. It is open 24/7, and there are many ways to get help. You can call 0800 1111 or visit their Childline website.

NHS Education Scotland

Background

Molly was 14 when she was seen in the unscheduled care part of Child and Adolescent Mental Health Services (CAMHS). This was due to Molly attempting suicide two days previously by overdose. Molly disclosed to a guidance teacher at school that she had taken an overdose.

The guidance teacher urgently referred Molly and her parents to Accident and Emergency (A&E), immediately after speaking to Molly, and then submitted a Notification of Concern to social work. Molly was seen in A&E and was then seen by the CAMHS Unscheduled Care Team, for immediate support including safety planning, prior to discharge from A&E. Molly was then followed up by Community CAMHS within the next few days for further assessment and risk formulation. Community CAMHS also contacted the school guidance teacher.

Right Support, Right Time, Right Place

Practitioners working in A&E undertook a physical examination and tests with Molly to make sure she was physically well enough to be treated by the CAMHS Unscheduled Care Team. The approach by A&E practitioners incorporated the Time Space Compassion approach to help ensure that Molly felt supported and listened to.

At the CAMHS Unscheduled care assessment in A&E, the CAMHS Unscheduled Care Mental Health team member spent time engaging with Molly, finding out some of the ordinary aspects of Molly’s life (like who she lived with, what her hobbies and interests were) and outlining the plan for the session, with clear guidance about how long the session would likely be, and that it would involve talking through what had been happening. It was suggested to Molly that she had some time on her own with the mental health worker, if that felt comfortable for her. It was also suggested to her parents that they could also speak to the mental health worker separately. In both of these meetings the mental health worker discussed confidentiality and the need to inform social work. The aim of these meetings was to assess the lead up and intent behind the overdose, and to ascertain how Molly was feeling now about the overdose and her future. This was all conducted in a very strength-based, person-centred, trauma informed and compassionate way.

Molly explained that stress had been building for the past few months in many aspects of her life, alongside a 6-month history of low mood, relating to grief, significant events that had taken place in the family, culminating in the withdrawal of many hobbies and from forms of support. The above assessment very much considered the emotional needs of Molly and her parents at this incredibly stressful time.

Centring Equity, Equality and Rights

Molly was 14 at the time of taking an overdose, In Scotland, children over 12 can provide consent to proposed medical treatment where a doctor considers they have sufficient understanding to provide informed consent. The guidance teacher was very kind and compassionate with Molly and had explained to her that she needed to share the information about Molly taking an overdose with her colleagues in health, as she was very concerned about Molly’s health and safety. Molly was happy for the guidance teacher to let A&E know what had happened to her. Molly was worried about her parents becoming angry when they found out, so when the Guidance Teacher spoke to professionals, they reassured her that they would help her parents to understand that the most important thing they could do at that point, was to be open and supportive to her. The Guidance Teacher also explained that her parents would be mostly very worried about her, and that their response would likely be related to feeling fearful about her health.

Responsive Services

The guidance teacher followed local risk management protocols and organised for Molly to be taken immediately to A&E following disclosure of the overdose. She was able to draft a short letter outlining the information shared by Molly so that her parents could show this to A&E staff.

As previously stated, Molly was followed up by community CAMHS, and a formulation and risk management plan was collaboratively put in place and safety plan was reviewed. A written copy of the A&E and CAMHS assessments were sent to Molly’s GP. The management plan included some skills and practices for school to introduce, to support Molly. Community CAMHS worked with Molly, her parents, and the school to develop an Anticipatory Care Plan. When Molly and her family left the community CAMHS appointment, they had a clear sense of what had led to Molly feeling suicidal and had some ideas and supports to prevent Molly’s anxiety building to such extremes again. Molly and her family agreed with the safety plan and were given appropriate contact numbers should things escalate for Molly outside of CAMHS operating hours.

Closing Details

Molly was seen in CAMHS weekly for 4 weeks, and a remote school meeting was held with Molly, her parents, the CAMHS Worker, and school staff to think about her pattern of strengths and needs including communication and sensory differences. This resulted in some adjustments to her school schedule, such as a ‘soft start’ to a Monday, twice weekly check in with pastoral care to review ongoing academic challenges, being offered a lunchtime relaxation group and time in the quiet art room during some breaktimes. After the four sessions in CAMHS were complete, Molly was discharged.

Lighthouse Perth

Background

Who does the case study involve: Eve, 13-year-old, Doris, 15-year-old and the girl’s Mother.

What is their background: Both girls and Mum live in the city and both girls attend one of the local high schools. Mum works full-time and leaves the house at 8am every morning.

What is the crisis situation: Eve is struggling at school because of ongoing bullying which is having a major effect on her mental health. Eve gets a text message at 8:30am to say she will be ‘attacked’ when she goes to school that day. Eve can’t see any way out so proceeds to attempt to end her life.

Doris enters the room to get her school bag, sees what is happening, intervening before physical harm can take place. Both girls are understandably distressed. Doris rings Mum who returns home immediately. Eve refuses to go to A&E so Mum rings Lighthouse Perth for help.

Right Support, Right Time, Right Place

How is support put in place which provides:

• Choice of support which is trauma informed and set in a comfortable environment: Both girls and Mum are advised to come straight into the crisis centre where they have trained staff on site who can provide a trauma informed approach to all 3, providing as much TIME needed as it takes, a SAFE, trauma informed space to de-escalate the situation and provide a level of COMPASSION to all 3 separately to ensure Eve has a safety plan in place, Doris can talk through the trauma she has just experienced and Mum is supported so she is able to provide the relevant on-going support going forward at home.
• Ensuring all services are skilled in the first steps of crisis response: all staff at Lighthouse are trained to deal with a ‘rapid response’ situation such as this and Eve, Doris & Mum each have 1 to 1 support tailored to their needs at that time.
• Reach In Support – rather than the individual having to make connections: the Lighthouse contact Eve’s GP with Mum’s consent and arrange an emergency appointment for later that day so that Eve is referred to CAMHS to ensure any mental health needs are identified.
• Support for parents/carers: Mum is supported to deal with the trauma but also on how to support Eve and Doris when they are ready to leave Lighthouse. Mum is re-assured that the Lighthouse will then continue to see Eve as outreach in school every week ,until she is happy to stop the sessions. Shared safety plan with Mum and explained how it works. Also advised Mum that if Dad (lives separately) would like to discuss what has happened and needs support then the Lighthouse will be happy to see him too. Doris offered further support if needed due to the trauma.
• Alignment of services: contacted school to ensure they were aware of the incident and what support was now in place. Also advised school that it would be advisable for Eve to have a few days off. Shared safety plan with school with Eve’s consent and discussed bullying text that had been received for school to deal with.
• Contacted CAMHS and updated them on what the plan going forward with Eve was so there would be no duplication and they were aware a safety plan had already been completed.
• Submitted a Notification of Concern to social work due to attempt to end life and experience of severe bullying.

Centring Equity, Equality and Rights

• Age Appropriate (evolving capacity) and proportionate responses: all 3 people were supported differently even though they were part of the same critical incident and a staff member who deals specifically with family support was assigned to Mum.
• Listening to the experiences of CYP and families and seeing the whole person: Mum is from a different ethnic background (where youth mental health/suicide is seen differently) but the girls have both grown up here so this had to be respected when talking to each of them individually. The trigger for Eve was the bullying but just by listening to her, they were able to ascertain that there was more going on which was leading to her poor mental health; a complex web soon became apparent, hence the inclusion of colleagues from CAMHS in update and the recovery plan.
• Free from Stigma and Discrimination: navigating this with Mum was more of a challenge due to the cultural differences in beliefs but taken forward with TIME, SPACE & COMPASSION ensured this was achieved. Also, made it very clear to Eve that staying away from school for a few days was not in any way to hide what had happened, but rather, to give her the space to recover.
• Continuously Improving: provided a learning opportunity due to the challenges around navigating different protected characteristics, supporting both the girls and the Mum but also treating them as a family unit.
• Telling your story only once: their contact with the school, GP and CAMHS ensured that Eve would not be having to start from the beginning every time as she did find it hard and upsetting to disclose what had happened.

Responsive Services

• Supporting the child or young person and warm handover: they were able to activate their ‘rapid response’ protocol to ensure Eve, Doris and Mum were seen without delay; they were all in the crisis centre within 30 minutes of Mum making the phone call. All other agency contact was done by Lighthouse, including a notification of concern to social work due to the attempt to end her life (with the permission of the family) to ensure every handover was warm and informed. The family stayed with us until the GP appointment at 1pm.
• Connected Support – collaboration and working together: working with the school in this instance was paramount to Eve’s recovery journey and to the care put in place by school for Doris around the trauma she had witnessed.
• Governance: they took time to explain to Mum and the girls why it was important that the school, GP & CAMHS had all the relevant information to ensure the right support was in place going forward.
• Importance of using local data to understand local populations: knowing the area, family name and school attended had suggested we might have cultural differences to take into consideration and enabled us to be better prepared for the family arriving at the crisis centre.
• Connections between services and support in accessing further services/resources: we have pre-established links with our local GP’s, schools and CAMHS which was vital in this instance to ensure a smooth de-escalation and recovery plan was in place which was very beneficial to the whole family.

Closing Details

What was the resolution: Eve is now in a good place, has better coping techniques and strategies to deal with stressful situations and can now regulate her mental health better. Eve returned to school the following week and a support programme was already in place for her, avoiding any stigma around the incident.

Eve spent the next 10 weeks working with us on her recovery. She was seen by CAMHS for assessment, but no underlying mental health issue was apparent, and they were happy to discharge after 2 sessions and for us to provide the on-going support.

Mum and Dad engaged with us well and when we discharged Eve she said that her parents were really supportive which she was surprised at and would never have spoken to them previously about mental health.

Eve & her sister Doris also now have a bond that they didn’t have before and regularly check in with how each other is feeling and coping with day-to-day life. They both know they can contact us at any time via our crisis line if they are struggling.

What elements of good practice were highlighted: if our ‘rapid response’ service was not available, the journey for Eve and her family could have been very different, an immediate response was needed and being able to provide the TIME, SPACE & COMPASSION around this response gave us the platform to navigate the crisis and also supporting to bond this family together in their journey through a very upsetting time.

Without applying a ‘whole family approach’ to the situation, the recovery could have been much longer and the same results harder to achieve. We needed the whole family unit to be on-board and also supporting the work we were doing with Eve at her 1 to 1 sessions.

Agency networking was also imperative to achieving such a positive outcome for this young person and her family.