Authors' objectives: Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway. To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK. Risk assessment occupies a central place in the management of children and adolescents who present to acute paediatric care settings at risk for self-harm and suicide. A risk assessment should be included within a detailed clinical assessment that includes evaluation of biological, social and psychological factors that are relevant to the child/adolescent. However, current National Institute for Health and Care Excellence (NICE) guidance cautions against using tools or checklists to predict the risk of suicide (risk screening) and against using risk-screening tools to determine subsequent clinical management. Current guidelines for self-harm (NICE. Self-harm: assessment, management and preventing recurrence NICE guideline [NG225] London: 2022) require a risk formulation as part of every psychosocial assessment, to be conducted a mental health professional who has received training in conducting psychosocial assessments and risk formulation. By gaining an accurate picture of the circumstances of a child or adolescent a mental health professional can target a future pathway to appropriate intervention and treatment. However, evidence from surveys suggests that risk assessment continues to serve its historic functions of protecting the community and avoiding claims of negligence rather than being grounded in the welfare of the child/adolescent. As a consequence risk assessment is not currently harnessing its full potential as an intervention to prevent self-harm and suicide. Numerous risk-assessment tools, including some risk-screening tools, are used across different services and information is neither gathered consistently nor completely. In some cases risk-screening tools are viewed as a tick-box exercise or even used for purposes for which the available tools or checklists are not designed. The focus of this review is on the well-being of the children or adolescents themselves and not on the actuarial function of managing risk of harm to others. Despite extensive numbers of tools and approaches, the relationship between risk assessment for self-harm and suicide and treatment intervention and outcome remains unclear. Uncertainties remain, especially around ‘what works, for whom, and why?’ To understand the underlying mechanisms for risk assessment for self-harm and suicide, why they occur and how they vary by context and then to review risk-screening tools currently in use in the UK and similar contexts and to explore how different approaches to using these tools impact upon risk assessment for self-harm and suicide within child and adolescent mental health services (CAMHS).

Authors' results and conclusions: From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan. No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement. Results from the realist synthesis Fourteen programme theories were identified and tested. These included 11 propositions relating to the conduct of risk assessment for self-harm and suicide and a further three propositions relating to what is considered unhelpful. Candidate Programme Theory Components Identified from the Literature Through this preliminary review, successful interventions are considered to require the following: IF risk-assessment approaches are simple, accessible and part of a wider assessment process THEN staff are able to generate standardised, informative and clinically useful assessments LEADING TO appropriate use of support and services. IF clinical staff focus clinical risk-assessment processes on building relationships THEN clinicians and adolescents trust each other LEADING TO frank and open communication within the clinical encounter. IF the emphasis of clinical risk-assessment processes is on gathering good-quality information on (i) the current situation, (ii) past history and (iii) social factors THEN staff use information to inform a collaborative approach to management LEADING TO coordinated and integrated care. IF staff are comfortable asking young patients about suicidal thoughts THEN young service users share relevant information concerning their circumstances LEADING TO an appropriate service response. IF risk-assessment processes are conducted consistently across mental health services THEN the quality of response to young service users does not depend upon each individual contact LEADING TO the availability of consistent information across services. IF staff are trained in how to assess, formulate and manage risk, including appropriate referral THEN staff feel equipped to manage the risks for children and adolescents who present to health services LEADING TO an emphasis on positive risk taking. IF staff are supported by on-going supervision THEN staff feel able to deliver a consistent approach to risk assessment LEADING TO a reduction in adverse events. IF families and carers are involved in the assessment process THEN families and carers are given an opportunity to express their views on potential risk LEADING TO a collaboratively developed risk-management plan. IF mental health staff communicate risk assessments with primary care THEN young people are directed to appropriate care LEADING TO successful health outcomes. IF the management of risk is personal and individualised THEN young people don’t see their care as ‘protocol driven’ and won’t feel alienated LEADING TO their engagement with care. IF organisations involved in risk assessment utilise a whole-system approach THEN this strengthens the standards of care for everyone, LEADING TO the safe management of supervision, delegation and onward referral. Three ‘counter programme theories’ relate to how risk assessment might result in unintended consequences: IF staff view risk-assessment tools as a way of predicting future suicidal behaviour THEN staff incorrectly interpret individual levels of need for care LEADING TO inappropriate use of restrictive practices, such as involuntary hospitalisation, restraint, sedation and seclusion (for the service user). IF clinicians use risk-screening tools and scales in isolation within the risk-assessment process THEN treatment decisions are determined by a score LEADING TO incorrect interpretation of individual need for care and inappropriate utilisation of CAMHS (for the service). IF staff develop tools for risk assessment locally THEN checklists and scales lack formal psychometric evaluation LEADING TO limited clinical utility of tools for risk assessment and unnecessarily restrictive treatment options. Exploring the 11 positive propositions helped in the identification of five particularly useful features include the following: (1) incorporation of tools within wider standardised and consistent assessment processes; (2) trusted relationships that encourage clear and open communication, including family involvement; (3) good-quality information within a personalised and individualised approach; (4) appropriate training and supervision; and (5) appropriate interagency communication and referral networks, within a whole-system approach. Similarly exploration of the three negative propositions helped in the identification of three negative features: (1) misuse of risk-assessment tools for prediction; (2) use of tools in isolation, typically within a ‘scoring’ approach; and (3) development of local tools with little formal validation. A total of 49 reports of tools or approaches to assessing the risk of self-harm and suicidality among children or adolescents were identified from the reviews (n = 8) or original studies (n = 41). Our analysis extended the 29 assessment tools included in a previous scoping review (Carter T, Walker GM, Aubeeluck A, Manning JC. Assessment tools of immediate risk of self-harm and suicide in children and young people: a scoping review. J Child Health Care 2019;23:178–99.); adding two recent tools (Manning JC, Walker GM, Carter T, Aubeeluck A, Witchell M, Coad J; The CYP-MH SAT study group. Children and Young People-Mental Health Safety Assessment Tool (CYP-MH SAT) study: protocol for the development and psychometric evaluation of an assessment tool to identify immediate risk of self-harm and suicide in children and young people (10-19 years) in acute paediatric hospital settings. BMJ Open 2018;8:e020964. 20180412; Vrouva I, Fonagy P, Fearon PR, Roussow T. The risk-taking and self-harm inventory for adolescents: development and psychometric evaluation. Psychol Assess 2010;22:852–65.) and expanding beyond formal tools to include overall approaches. We included tools previously included in the scoping review (Carter et al. 2019) where used in a UK context and with a primary focus on suicide. Tools varied in length, response and scoring format, age ranges and degree of psychometric testing (Carter et al. 2019). In particular, tools lacked predictive validity. Most assessments were tested across broad age ranges, and so lack sensitivity to the age groups of particular interest to this review. The relative lack of tools for children, as opposed to adolescents, is noticeable. Tools were subject to limited psychometric testing, and no single tool was valid or reliable for use with children presenting in mental health crisis to non-mental health settings (Carter et al. 2019).

Authors' recommendations: Further studies evaluating the utility of specific risk-screening tools and instruments are not warranted, although additional evaluations of risk-assessment processes would benefit from further qualitative insights. Such evaluations could provide an accurate picture of what assessment processes are being used and the clinical value ascribed to each component according to the principles of psychosocial assessment. Further research is required to evaluate the value to young persons, health professionals and health services of a complete and holistic assessment, not simply provision of an alternative tool. An evaluated approach to overall assessment could then be used to support safety management decisions across acute paediatric care settings. In particular, health systems and organisational leadership initiatives could benefit from further close examination of how theoretical tensions between risk minimisation and patient-centred care are enacted at a practical and operational level.

Authors' methods: Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites. A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines. Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment. Two complementary reviews were conducted: (1) a realist synthesis; and (2) a mapping review of risk-screening tools and risk-assessment approaches (PROSPERO database registration number: CRD42021276671). MEDLINE (including Epub Ahead of Print & In-Process), PsycINFO, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library. Importantly, the electronic search was complemented by innovative use of the scite tool as well as forward citation searching via Google Scholar and checking for additional relevant articles from reference lists. A comprehensive search of MEDLINE, PsycINFO, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library was conducted in September 2021. Targeted ‘grey’ literature searches to identify reports/case studies in websites.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR135079

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/VKTY5822

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/VKTY5822

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk