This page provides key information to explain what mental health, stress and adverse childhood events are and will help build your understanding of its complexity as a risk factor to suicide for children and young people.
- What are the risk factors for suicide for children and young people?
- Why are they important to consider in suicide prevalence?
- How prevalent are they?
- ZSA Suicide Prevention Resource Map – key takeaways
- How do they occur?
- What are the consequences?
- Impact of COVID-19
- National guidelines for practice
- Key approaches
- Case studies
- ZSA Suicide Prevention Resource Map - related indicators
Risk factors for suicide in children and young people are broad and far reaching. Suicide is often driven by experiencing distressing events, which influences how a person thinks and feels about themselves and the world around them. Reaching this point of crisis can be the result of a sudden decline in psychological well-being, with this being more likely in those living with a mental health disorder.
Mental health disorders are characterised as significantly impacting a person’s functioning in their daily lives (ICD-11), this can include ‘common mental health disorders’ such as depression and anxiety (NICE, 2011), as well as a range of other disorders such as schizophrenia, psychosis, bipolar and eating disorders.
Childhood and adolescent represents a “period of physical, emotion, social and psychological development” (CQC, 2017). Therefore children and young people who do experience mental health difficulties can also experience considerable challenges with their social and emotional functioning and behaviour.
For example, a young person suffering with depression may become socially isolated or become aggressive to others. These associated problems are otherwise known in educational settings as ‘Social, Emotion and Mental Health’ (SEMH) needs (Department for Education & Department for Health, 2015).
The development of 'mental disorders' in childhood and early adulthood (ICD-10 diagnosic classification) is also a potential risk factor for suicide. Even though they are distinct (include emotional, behavioural, hyperactivity and other types of mental disorders), characteristics of these and the combination of biological, behavioural, psychosocial and cultural factors sitting behind these disorders often overlap with each other, usually resulting in mental health issues (Clark et al., 2017).[5}
Paying close attention to the psychological wellbeing and mental health of children and young people is vital as experiencing a mental health crisis in response to distressing events (or worsening of mental health disorder symptoms) significantly increases risk of suicide; this being one of the three leading causes of death among young people (WHO, 2020).
Data published in 2022 showed that there were 2,041 suicides and probable suicides by people aged 10-19 in England and Wales from 2010 to 2022 (Office for National Statistics, 2022). Poor mental health is additionally associated with a range of other harmful behaviours which can have severe implications, these being self-harm, substance use, risky sexual behaviours and exposure to abuse and violence.
10 to 20% of children and young people worldwide experience mental health conditions, with half of these developing before the age of 14 and one in five young persons experiencing a mental health condition each year (WHO, 2020).
The likelihood of children (both boys and girls) aged 5 to 16 years old developing a mental disorder has increased since 2017, with 11% children in 2017 to 16% in 2020. As children get older the likelihood of developing a mental disorder has found to be higher, with 27% of young women being likely to develop one compared to 13% of young men (NHS Digital, 2020).
The Suicide Prevention Resource Map includes a series of indicators that are of interest in exploring risk factors of suicide for children and young people. Examples of these include:
- Percentage of school pupils with social, emotional and mental health needs varies between 1.5% in Hillingdon and 4.4% in Wirral, with a median average of 2.7% in 2020.
- Income Deprivation Affecting Children Index (IDACI) for ages 0 to 15 varies between 6% in NHS Horsham and Mid Sussex CCG and 31% in NHS Blackpool CCG, with a median average of 16% in 2019.
- Rate of homeless households with children or pregnant women per 1,000 households varies between 1 in Camden to 8 in Newham, with a median average of 1 in 2017/18.
- Referrals to children's social services per 10,000 population varies between 176 in North Somerset to 1,337 in Middlesbrough, with a median average of 490 in 2020/21.
- Children in need due to abuse or neglect per 10,000 population (aged under 18) varies between 60 in Hertfordshire and 481 in Rotherham, with a median average of 187 in 2018.
- Number of looked after children per 10,000 population (aged under 18) varies between 0 in Isles of Scilly and 210 in blackpool, with a median average of 67 in 2020/21.
- Percentage of looked after children whose emotional wellbeing is a cause for concern (aged 5-16) varies between 18% in Westminster and 60% in Dorset, with a median average of 38% in 2019/20.
For more suggested data indictors to explore in the map, please refer to the list provided at the bottom of this page.
Childhood and adolescence can be challenging. These crucial formative years are when children and young people gain vital knowledge and social-emotional skills that will shape their future wellbeing and mental health as adults. It is not only important to teach young people how to cope with life’s stresses, but also to protect them from traumatic events which may have significant effects for those who are already vulnerable.
These traumatic events early in life are otherwise known as Adverse Childhood Experiences (ACEs). These have been found to significantly increase a child’s risk of developing a range of mental and physical health conditions in later life (Annual Report of the Director of Public Health, 2018).
ACEs includes any detrimental experiences which could impact a child or young person and have implications on their wellbeing as they grow into adulthood (Public Health England, 2018). These range from direct forms of harm (such as emotional, physical and sexual abuse, or neglect) to indirect forms influenced by the environment a child grows up in (including domestic violence in the home, parental separation, mental illness, substance misuse and a family member in prison). Income deprivation is also important to consider here as is an indicator of poverty and socioeconomic position. Research has linked the two with a lower socioeconomic position found to be associated with a greater risk of ACEs (Walsh et al., 2019; Lewer et al., 2020).
ACEs are thought to be a prominent factor of influence for health and wellbeing throughout the lifespan. ACEs have also been found to hinder childhood development, including the development of coping mechanisms which are relied upon to manage distressing emotions in later life. Not having a range of cognitive and behavioural skills to hand leaves a person less able to manage their emotions, and therefore, more likely to experience crisis in the face of challenging situations.
Additionally, exposure to ACEs increases the likelihood of adopting health risk behaviours leading to psychological and physical health consequences, including likelihood of developing mental illness (Education Policy Institute, 2019). ACEs have also been found to play a pivotal role in the development of serious mental illnesses (SMIs) in early adulthood, including psychosis, schizophrenia and bipolar disorder (Garno et al., 2005; Varese et al., 2012).
ACEs are unlikely to be limited to one type, but instead co-occur alongside others (Felitti et al., 1998). This has significant consequences with research finding that more ACEs a child experiences, the higher their risk of reaching crisis and attempting suicide in their lifetime (Choi et al., 2017).
Young people also experience other sources of stress, these of which may vary in comparison to other age groups (such as adults and older adults). Some examples of stressors young people may face could include:
- Living circumstances – living in an area of high socio-economic deprivation has been found to have a detrimental effect on young people’s mental health and wellbeing, likely to be linked with heightened social stress (Visser et al., 2021). Strained family relationships, involvement of social services, living in care and homelessness are all additional factors that increase stress, and as a consequence increase risk for developing a mental heath problem (Narendorf, 2017)
- Periods of transition – these represent a significant time of change to independent living, involving forming new habits, meeting new people and learning to manage competing demands (Mind, 2019). Examples include leaving school and going to university or for those receiving mental health support, transitioning from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) at the age of 18. Many of these transitions occur between the ages of 16 and 18 which coincide with a key development stage. This adds further complexity to the challenges likely to be experienced during that time (Singh, 2009)
- Social media – research has found that high levels of social media usage amongst young people is a likely source of stress within this population group (Meier et al., 2016)
- Bullying - this has been linked to poorer wellbeing and higher risk of self harm and suicidal behaviours (John et al., 2018). Some demographic groups have found to be particularly impacted by bullying, including young people that identify as part of the LGBT+ community (Kelleher, 2009)
- School exclusion – being excluded from school has been found to not only be associated with psychological distress and poor mental health as a result, but can also contribute to reasons behind the exclusion (Ford et al., 2017). Other factors that were associated with exclusion include poor general health, learning disabilities and poor parental mental health. This was also found to be more common amongst boys, secondary school students and those living in deprivation.
This is not to say that all children and young people who experience stress at a young age, including ACEs, will go on to develop mental health problems, but instead this heightens their risk. This vulnerability is thought to be likely contributed to by a combination of social and biological factors, with research finding a 30 to 40% likelihood due to genetic predisposition, and 60 to 70% due to environmental factors (BPS, 2018).
Below is a brief summary of the range of contributing factors to the development of poor psychological wellbeing and mental health:
- The persons internal state and aptitude – the resilience and capacity a person has to handle the challenges, and handle the emotional difficulties they face (Schultze-Lutter, Schimmelmann and Schmidt, 2016)
- The societal and demographic factors they are subject to – pre-disposing factors such as poverty or social isolation (Mental Health Foundation, 2016) as well as factors related to their genetics, race and culture (Mental Health Foundation, 2019).
- Situational factors – the likelihood and severity of the inciting incidents, presence of protective factors and access to support (Schneiderman, Irsonson and Siegel, 2005).
The consequences of not addressing the risk factors of poor psychological well-being and mental health in childhood, is that they leave children and young adults more at risk of not only a mental health crisis (which earlier was established as a risk factor for suicide), but makes it much more likely to lead to poorer health outcomes in adulthood (Otto et al., 2020).
Young people can also turn to substance misuse, such as excessive drinking and taking drugs. Substance misuse is often relied upon as a coping mechanism to manage social stress and distressing thoughts and feelings experienced as a result. Using substances can perpetuate the cycle of precipitating and being a consequence of poor mental health. Substance misuse can also worsen mental health and act to reinforce negative thoughts and feelings. Young people who use substances are also more at risk of becoming homeless (Mallett, Rosenthal & Keys, 2005), with this previously being identified as being linked to poorer mental health (Narendorf, 2017).
Poor mental health, specifically depression, is estimated to be the second greatest contributor to disability-adjusted life years (DALYs), a measure of the overall burden of disease (NICE, 2011). Major stressful experiences early in life or ACEs are not only likely to contribute to a young person’s wellbeing, but also is a key risk factor in the development of serious mental illness (SMIs) such as schizophrenia, psychoses or bipolar disorder in adulthood. Living with an SMI has significant and enduring consequences in quality of life and early mortality, including a heightened risk of suicide, due to the stark health and social inequalities these individuals face.
To find out more about SMI in adulthood, see our ZSA Facts for Action for Serious Mental Illness.
Research found that over the COVID-19 lockdown there was an increase in poorer mental health across the general population (Understanding Society, 2020). Young people have experienced numerous disruptions in their education (e.g. home schooling, online learning, exam cancellation), limited contact with friends and support networks, limited opportunities to enjoy every day activities, loss of part time jobs and difficulty entering the job market after leaving school (Lee, 2020; Children’s Commissioner, 2021; Das et al., 2020). Children from poorer backgrounds have been particularly impacted by school disruptions, with limited access to digital based learning resources.
The consequences of the pandemic have severely impacted the well-being of young people, putting them at higher risk of developing other mental health problems, substance misuse and dying by suicide (WHO, 2020).
54 to 59% of children and young people aged 11 to 22 years old who were likely to be experiencing mental health problems before the start of the pandemic reported that lockdown had made their life worse, compared to 37 to 39% of their counterparts that were unlikely to be experiencing mental health problems prior to lockdown (NHS Digital, 2020). It has been forecasted that 1.5 million children and young people will need new or additional support for their mental health needs as a result of the COVID-19 pandemic (Centre of Mental Health, 2020).
Children and young people are also spending more time at home which has found to worsen relationships within families and leave young people exposed to incidences of domestic violence (Centre for Mental Health, 2020). In addition to major disruption to routine and social isolation, these relationship strains and exposure to ACEs (i.e. domestic violence, abuse) contribute to explaining why children have experienced an increase in suicidal thoughts and incidences of self-harm during the pandemic (XenZone, 2020).
Research by NHS England and NHS Improvement estimate that despite the increase in demand for children and young people’s services during lockdown, referrals have dropped by 30 to 40% (Health and Social Care Committee, 2020). The reported increase in distressing experiences as a result of the COVID-19 lockdowns and the lack accessible support during this time, leaves children at a higher risk of developing significant and long lasting mental health issues. This includes increasing the risk of developing an SMI in adulthood, especially within families already struggling with other social stressors (Varese et al., 2012; Garno et al., 2005).
For more information about the impact of COVID-19, see Facts for Action for Children and Young People’s Services.
The Five Year Forward View for Mental Health published by the NHS in 2016 outlined a long-term transformation of mental health services (NHS, 2016). The plan detailed a new commitment to funding to expand Children and Adolescent Mental Health Services (CAMHS) to improve the mental health outcomes for young people.
For more information on these changes, see Facts for Action for Children and Young People Services.
NICE have produced a series of guidelines, public health guidelines, quality standards and clinical standards are relevant to the prevention recognition and evidence-based management of a range of children and young people’s mental health and emotional wellbeing needs. The easiest way to find this guidance is to use NICE pathways.
- Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care (NICE Guideline NG26).
- Looked-after children and young people (Public Heath Guideline PH28)
- Children’s attachment (Quality Standard QS133)
- Early years: promoting health and wellbeing in under 5s (Quality Standard QS128)
- Social and emotional wellbeing in primary education (Public Health Guideline PH12)
- Transition from children’s to adults’ services for young people using health or social care services (NICE Guideline NG43)
- Drug misuse prevention (Quality Standard QS165)
- Alcohol: preventing harmful use in the community (Quality Standard QS83)
Treatment for mental health illnesses are primarily delivered by primary care services such as IAPT or secondary care services including Children and Young People Mental Health Services (CAMHS) which provide inpatient and community based interventions.
The British Psychological Society (BPS) provide a series of guidelines to help clinicians work in a psychologically informed way. As part of this, the BPS work alongside NICE in developing guidelines for the treatment of mental health disorders in children and young people.
The BPS have a range of resources and publications in relation to working with children, young people and their families (CYPF), for more information please visit the BPS’ CYPF faculty website.
The BPS advocates for an evidence-based preventative approach which puts emphasis on introducing effective interventions early on and incorporating them through children’s lives, with a broader focus on wider issues around children’s development and psychological wellbeing (BPS, 2021). By putting preventative measures in place, this will in turn reduce the demand on primary and secondary mental health services for children and young people, as well as adults.
This systemic population based approach presents countless opportunities to support children and their families, creating integrated formal and more cultural based care systems within the community. Schools present one of these key opportunities whereby school staff and parents can be supported to understand challenges to mental health and wellbeing, and learn what they can do to help. The introduction of NHS-led Mental Health Support Teams in schools whereby children and young people are offered counselling services will also contribute to this movement. As described in the NHS’ Long Term Plan for Mental Health, the aim is to achieve 20 to 25% national coverage by 2023, with 100% coverage by 2027 (NHS, 2016). However, this may not capture the needs of every young person, including those who have been excluded from school, or those who themselves or their family have a poor relationship with their educators and so lack the opportunity and the support to be included.
Another development called for by the BPS is the formation of community peer support structures which focus upon building community resilience, benefiting children and young people and their families (BPS, 2021.
The BPS also call for trained assessors to be able to identify and understand early social and emotional needs of individual young people prior to implementing interventions. Additionally, the inclusion of applied psychologists such as Clinical and Educational Psychologists would be the most appropriate trained professionals to undertake leadership of preventative and reactive measures.
Lastly, a family-focused community-based approach is also needed in order to address increasing levels of family conflict and relationship breakdown. A cross-departmental strategy would be required to lead effective change in these areas, bringing together the Department for Health and Social Care (and the Department for Education), Department for Work and Pensions and Ministry of Housing, Communities and Local Government (BPS, 2021).
This particular approach would also go far in helping to address Adverse Childhood Experiences (ACEs), with helping support families that are in distress and specific identifying risk factors for trauma (e.g. bereavement, relationship breakdown, abuse). It would also go towards addressing the concern of missing children and young people that have been excluded from school or caught in-between a breakdown of the partnership between families and schools.
Case studies listed below are good examples whereby a population approach to reducing the prevalence and the impact of poor mental health for children and young people. Some of these case studies form part of our original Facts for Action work which provide additional contextual information within these themes. For more information about each of them, please follow the individual links.
- Mental Health Support Teams (South London and Maudsley NHS Foundation, SlaM) – low intensity school intervention to help young people to improve their mental health and wellbeing, improve their access to mental health support and related services and provide training to schools and parents.
- Preventing and tackling bullying in Warden Park Primary Academy (Sussex) – following a review of behaviour and anti-bullying practices, the school changed a series of working practices to reduce incidents.
- Child Friendly Leeds – runs a variety of initiatives to help organisations improve outcomes for children in the city of Leeds, increasing the number of children in education, employment and training, and reducing school absences.
- Contextual Safeguarding in Hackney – a project that aims to protect children and young people from the risks associated with their social environment.
- Percentage of school pupils with social, emotional and mental health needs
- Income Deprivation Affecting Children Index (IDACI) (Aged 0-15)
- Rate of homeless households with children or pregnant women per 1,000 households
- Number of school fixed term exclusions as a percentage of the school population
- Percentage of 15 year olds who were bullied in the past couple of months
Child abuse and neglect/safeguarding
- Referrals to children's social services per 10,000 population
- Children in need due to abuse or neglect per 10,000 population (aged under 18)
- Number of child protection plans starting during the year per 10,000 population
- Children subject to a child protection plan with initial category of abuse per 10,000 population (aged under 18)
- Children who started to be looked after due to abuse or neglect per 10,000 population (aged under 18)
Looked after children
- Number of looked after children per 10,000 population (aged under 18)
- Children who started to be looked after due to abuse or neglect per 10,000 population (aged under 18)
- Percentage of looked after children whose emotional wellbeing is a cause for concern (aged 5-16)
- Percentage of looked after children who have been identified as having a substance misuse problem during the year
- Referrals into CAMHS per 100,000 registered population (0-18)
- Referrals accepted into CAMHS per 100,000 registered population (0-18)
- CAMHS referral acceptance rate
- Mean waiting time from referral to 1st routine CAMHS appointment
- Mean waiting time from referral to 2nd routine CAMHS appointment
- Total CAMHS contacts per 100,000 registered population (0-18)
- Conversion rate - percentage of people who had a first CAMHS appointment who had a second appointment
- Average annual number of contacts per person on the caseload of CAMHS
- Hospital admissions for mental health conditions for children and young people (aged 0 to 17) per 100,000 population
- Hospital admissions as a result of self-harm per 100,000 population (aged 10-24)
- Admissions due to alcohol for under 18 year olds per 100,000 population
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 NICE (2011). Common mental health problems: identification and pathways to care, clinical guideline [CG123]. Available at: https://www.nice.org.uk/guidance/cg123/chapter/Introduction
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 Ford, T., Parker, C., Salim, J., Goodman, R., Logan, S. & Henley, W. (2017). The relationship between exclusion from school and mental health: a secondary analysis of the British Child and Adolescent Mental Health Surveys 2004 and 2007. Psychological Medicine, 48(4), 629-641. Available at: https://doi.org/10.1017/S003329171700215X
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 Mental Health Foundation (2019). Black, Asian and Minority Ethnic (BAME) communities. Available at: https://www.mentalhealth.org.uk/a-to-z/b/black-asian-and-minority-ethnic-bame-communities
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 Understanding Society (2020). Understanding Society Working paper Series. Available at: https://www.understandingsociety.ac.uk/research/working-papers
 Lee, C., Cadigan, J. & Rhew, I. (2020). Increases in loneliness amongst young adults during the Covid-19 pandemic and association with the increase in mental health problems. Journal of Adolescent Health, 67(5), 714-717. Available at: https://www.sciencedirect.com/science/article/abs/pii/S1054139X20304924
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 Das, S. Kim, A. & Karmakar, S. (2020). Change-Point Analysis of Cyberbullying-Related Twitter Discussions During COVID-19. 16th Annual Social Informatics Research Symposium (ASIS&T). Available at: https://arxiv.org/abs/2008.13613
 Centre for Mental Health (2020). Covid-19 and the nation’s mental health: October 2020. Available at: https://www.centreformentalhealth.org.uk/publications/covid-19-and-nations-mental-health-october-2020
 XenZone (2020). How Covid-19 is Affecting the Mental Health of Young People in the BAME Community. Available at: https://xenzone.com/wp-content/uploads/2020/07/Week16ADULTv2.pdf
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 NHS (2016). The Five Year Forward View for Mental Health: A report from the independent Mental Health Taskforce to the NHS in England. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf
 NICE (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, NICE guideline [NH26]. Available at: https://www.nice.org.uk/guidance/ng26
 BPS (2021). British Psychological Society briefing: Children and Young People’s Mental Health and Psychological Wellbeing. Available at: https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/BPS%20Briefing%20-%20Children%20and%20Young%20Peoples%20Mental%20Health%20and%20Wellbeing.pdf
Content reviewed and updated 13/09/22
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