Supportive practices for young people in out-of-home care who are at risk of suicidality
Sebastian Trew, Douglas Russell, Daryl Higgins
This short article discusses suicide and presents material some people may find distressing. If you or someone you know is feeling depressed or suicidal, please contact one of the following services:
- In an emergency, call 000
- Lifeline: 13 11 14
- Kids Help Line (5–25 years): 1800 55 1800
- Suicide Call Back Service: 1300 659 467
- Beyond Blue: 1800 512 348
- MensLine Australia: 1300 789 978
Suicide is the leading cause of death for young Australians aged 15–24 years and the fifth leading cause of death for children aged 1–14 (Australian Institute of Health and Welfare [AIHW], 2021). Evidence suggests children and young people in out-of-home care (OOHC) are almost five times more likely to display suicidal behaviour than peers with no OOHC involvement (Russell, Trew, & Higgins, 2021). This short article summarises the evidence for two core interventions that significantly decreased suicidality and might support practitioners when working with children and young people displaying suicidal behaviours.
Why are children and young people in OOHC more likely to be exposed to risk factors for suicidality?
Although there is no evidence to suggest that placement of children and young people in OOHC itself causes suicidal behaviour in children and young people, some authors (e.g. Evans et al., 2017) have suggested that children and young people in OOHC (foster, kinship, residential care) are more likely to be exposed to risk factors for suicidality. Children and young people in OOHC typically experience complex trauma associated with their experiences of abuse and neglect prior to entering care and may be at risk of further harm when in care (Evans et al., 2017). For this group, trauma-related outcomes can present as depression, anxiety, drug/alcohol use, comorbid psychiatric disorders and self-harming (Australian Institute of Family Studies, Chapin Hall Center for Children University of Chicago, & New South Wales Department of Family and Community Services, 2015).
Experiences of abuse or neglect in childhood predict suicidality both directly and indirectly via links between anxiety, child maltreatment and perceived lack of social support (Bahk, Jang, Choi, & Lee, 2017; Bensley, Van Eenwyk, Spieker, & Schode, 1999; Kaplan et al., 1999; Locke & Newcomb, 2005; Thompson et al., 2012; Trew, Russell, & Higgins, 2020). This is sometimes referred to as ‘cumulative harm’ (Bromfield, Gillingham, & Higgins, 2007). So, both abuse and associated trauma are direct and indirect predictors suggesting that suicidality is the result of cumulative harm arising from the interaction of factors such as abuse, neglect, anxiety, lack of social support, over time (Carballo et al., 2019).
This suggests a heightened risk for suicide-related behaviours in young people in OOHC, as most trauma-related outcomes reported in children and young people in OOHC are also key risk factors for suicidal behaviours. To effectively reduce suicidal thoughts and behaviours among children and young people in OOHC, reducing trauma and its related outcomes for this group is likely to be critical.
Gaps in our knowledge for how to support children and young people in OOHC at risk of suicidal behaviour
Given that most trauma-related outcomes reported in children and young people in the OOHC system are also key risk factors for suicidal behaviours among young people generally (Trew et al., 2020), this group is likely to benefit from trauma-informed care models (Wall, Higgins, & Hunter, 2016). It remains difficult, however, to know whether general trauma-reduction strategies might be effective. The evidence for these models is limited, as identified in a recent systematic review of organisation-wide, trauma-informed care models in OOHC (Bailey et al., 2019). In the Australian context, the absence of an overarching trauma-informed care framework for OOHC – coupled with a universally low evidence base to understand the effectiveness of such models – makes evaluation difficult (Bailey et al., 2019). There remains, therefore, limited guidance for child protection practitioners working from a trauma-informed approach with children and young people in OOHC at risk of suicidal behaviour.
Interventions for children and young people in OOHC at risk of suicidality
Practitioners working with children and young people in OOHC might provide further support to this group by incorporating into their practice elements of evidence-based interventions that are shown to be effective in reducing suicidal factors in children and young people in the general population (Trew et al., 2020). Such suicide prevention interventions include emotional regulation-based interventions (e.g. dialectical behaviour therapy). Dialectical behaviour therapy is a form of cognitive behavioural therapy that teaches individuals to manage their emotional experience and has been shown to decrease trauma-based symptoms and suicidality in adolescents (Geddes, Dziurawiec, & Lee, 2013).
Evidence-based interventions for the general population are listed in Table 1.
|Interventions with strong to moderate evidence||Interventions with promising evidence|
|Multisystemic therapy and family therapies such as Attachment-Based Family Therapy||Dialectical behaviour therapy (DBT)|
|Therapeutic assessments||Cognitive behaviour therapy (CBT)|
|Brief interventions||Interpersonal therapy|
|Suicide prevention and intervention skills||Group therapy|
|Gatekeeper Suicide Prevention|
There is limited evidence to show what works best to support children and young people in OOHC at risk of suicidal behaviour. Only two interventions have been trialled and evaluated with children and young people in OOHC settings (see Bonet, Palma, & Santos, 2020 and Kerr, DeGarmo, Leve, & Chamberlain, 2014). Both interventions are based on the theory that those who engage in suicidal behaviours have high levels of emotional dysregulation and, hence, the interventions focus on improving emotional regulation in children and young people (Eaddy et al., 2019; Trew et al., 2020; Wolff et al., 2019). These interventions have some evidence of effectiveness in reducing suicidal ideation and suicidal orientation.
The first of these (Kerr et al., 2014) is a family-based intervention, Treatment Foster Care Oregon (formerly Multidimensional Treatment Foster Care). Its aim is to reduce the challenging or maladaptive behaviours that a young person displays towards their carer by supporting the carer to reinforce the positive behaviours of the young person until these positive behaviours become preferred by the young person. This, in turn, leads to an increase in positive interactions between the young person and carer. It does not specifically target suicide risk but seeks to reduce problem behaviours and justice system involvement that can be linked to increased depression and suicidal thoughts and attempts (Kerr et al., 2014). A 12-year longitudinal study that evaluated suicidal ideation and suicide attempts in 13–17 year olds placed in foster care found that Treatment Foster Care Oregon reduced suicidal ideation and depressive symptoms.
The second (Bonet et al., 2020) is a short version of Emotional Intelligence Therapy. The purpose is to provide to people the skills to manage extreme emotions (Machera & Machera, 2017). Therapists facilitate 16 weekly 90-minute sessions to seven groups of 7–11 young people (aged 12–17) in residential care. An evaluation of the effectiveness of Emotional Intelligence Therapy measured the suicidal behaviour of participants at the beginning of treatment and 16 weeks post-treatment using the Inventory of Suicide Orientation, where participants were classified as having a low, moderate or high suicide orientation. It found that there was a significant decrease in suicidal ideation and hopelessness.
What are the evidence-based implications for practitioners working with children and young people in OOHC?
Out of the two interventions, Treatment Foster Care Oregon may align better with the current practice of child and youth protection workers in Australia, as Emotional Intelligence Therapy requires qualified and trained therapists to administer the therapy group sessions. For practitioners working in OOHC, combining elements from the Treatment Foster Care Oregon intervention with their current practice experience and established relationships appears promising. Practitioners might work with carers and young people to develop their communication skills and work with young people to develop their emotional regulation with an aim to reduce challenging or maladaptive behaviours.
Some specific activities from the intervention that could be incorporated into OOHC practice include daily telephone contact with carers, weekly supervision with the carer and young person, individual therapy for the young person, and group therapy focused on caregiver/young person management strategies (Kerr et al., 2014).
There is limited evidence on how children and young people in OOHC at risk of suicidal behaviour can be supported, with just two studies evaluating interventions with this group. Nonetheless, to reduce the risk for suicidal behaviours among children and young people in OOHC, there is some emerging evidence that interventions that improve emotional regulation are suitable and effective for this group. Practitioners can play an important role in supporting children and young people and their families by utilising elements of interventions such as Treatment Foster Care Oregon that work to reduce suicidality by addressing emotional regulation in children and young people.
How this resource was developed
This resource was developed from a rapid evidence review we published on suicide interventions in OOHC (Trew et al., 2020). The National Suicide Prevention Taskforce, through the Suicide Prevention Research Fund managed by Suicide Prevention Australia, commissioned the Institute of Child Protection Studies at Australian Catholic University to conduct a review that looked at:
a. the risk factors for suicidal behaviour in children and young people at the general population level
b. characteristics of young people who have experienced maltreatment and trauma and been placed in OOHC (Trew et al., 2020).
Further reading and related resources for practitioners and organisational leaders, service and program designers
- Effective interventions to reduce suicidal thoughts and behaviours among children in contact with child protection and out-of-home care systems – a rapid evidence review
This rapid evidence review outlines the role played by involvement in the child protection system – including placement in OOHC – as a risk factor for suicidal behaviour. The effectiveness of interventions focused on OOHC for at-risk children in reducing suicidal thoughts, suicide attempts and suicide deaths are also reviewed.
- Trauma-informed care in child/family welfare services
This AIFS policy and practice paper defines and clarifies what trauma-informed service delivery means in the context of delivering child and family welfare services in Australia. It describes how exposure to traumatic life events such as child abuse, neglect and domestic violence is a driver of service need.
- Trauma treatment – Client-level interventions (child & adolescent)
This resource summarises the types of interventions that are designed to help an individual process a trauma or multiple traumas and learn how to cope with the feelings associated with the experience (e.g. fear, post-traumatic stress, anxiety, depression).
- Vulnerable yet forgotten? A systematic review identifying the lack of evidence for effective suicide interventions for young people in contact with child protection systems
This paper summarises the types of suicide prevention interventions that have been used and evaluated with children and young people, staff and carers in out-of-home care/child protection systems.
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Bailey, C., Klas, A., Cox, R., Bergmeier, H., Avery, J., & Skouteris, H. (2019). Systematic review of organisation‐wide, trauma‐informed care models in out‐of‐home care (OoHC) settings. Health & Social Care in the Community, 27(3), e10–e22.
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1 Strong to moderate evidence refers to evidence drawn from one or more high quality studies (i.e. randomised control studies, quasi-experimental studies) that show the effectiveness of the intervention. Promising interventions are those supported by one or more correlational studies (i.e. non-experimental research that show a relationship between two or more factors) that have some evidence they can be effective, however there is not yet enough research evidence to show they can be effective with the specific issue or population in question or across a wide range of settings
Sebastian Trew is Research Officer at the Institute of Child Protection Studies.
Douglas Russell is Senior Research Officer at the Institute of Child Protection Studies.
Professor Daryl Higgins is Director at the Institute of Child Protection Studies.
Featured image: © GettyImages/Courtney Hale