 Hello and welcome everyone to tonight's MHPN webinar Suicide Ideation in Primary School Age Children and welcome to the over 1600 people of you who logged in already to this webinar. My understanding is that MHPN has had an unprecedented amount of interest in this webinar so we look forward to being able to bring this to you. MHPN would also like to acknowledge that the traditional carestotians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay respects to the elders past, present and future, for the memories, the traditions, the culture and hopes of the Aboriginal and Torres Strait Islander Australians. Please also note that we acknowledge that Suicide Ideation for Aboriginal young children is an issue which is very serious and also overrepresented but we don't feel that tonight we would be able to do that specific issue justice and so it won't be covered specifically in tonight's webinar. However if you do have an interest in this area the Western Australia Coroner recently delivered a report relating to an inquest into the deaths of 13 children and young people in the Kindleey region. So that might be something that you're interested in reading. So my name is Dan Moss. I'm the workforce development manager at the Merging Minds, we're a national workforce centre for children's mental health under 12 years old. So this is something this webinar tonight, something that I'm really interested in and looking forward to hearing from each of our presenters. Before we start a self-care message the purpose of this webinar is to give health professionals the skills they need so they can help people work more effectively with children and their parents in the future. Personal stories of illness are very important and MHPN often includes consumers and carers on our panels. The chat box that will operate tonight however is not a forum for personal stories. It is designed to complement the panel discussion by allowing professionals to share resources and their experience with practice. So thank you for respecting this. But if any of tonight's content does cause the stress please seek care and if you require contact beyond blue on 1300 224636 or contact your local GP or local mental health service. Okay so now I'd like to introduce tonight's very exciting panel and firstly I'd like to welcome Dr Lino Grady who's a psychologist in Victoria and Lynn what we're about to know first of all is how you became interested in this topic. Thanks Dan and it's great to be here and hi everyone I've been thinking about when did I start thinking and working in in the space and it goes back a couple of decades actually probably 25 years ago when I started working with parents and parents of teenagers who had teenagers did a whole lot of issues and suicide was one of those and a few years ago I just just kept cropping up in lots of what I was doing whether it was in schools or supervising psychology interns that I that I do keep coming up so a few years ago I decided I should tackle it a bit more head-on so I undertook the Master of Suicidology through Griffith University and I did that that was a three-year program and and it's such an interesting challenging difficult topic that it just keeps me keeps me interested so it's been a kind of a bit of a lifelong interest really that's been there. Yeah thanks Lynn and while we have you here um we just mentioned the W.A. Caron's report um in the Kimberleys um have you got any comment or any observations you'd like to make about that? Yeah I've been reading I saw that that came out last week and I was very conscious that it was very timely in terms of tonight's webinar and um have been working my way through the report it's very long several hundred pages report and there are sections that are that are very relevant and we'll pick up on some of those tonight but I I think the main the main issue that comes through is there's um Aboriginal kids and um adults Aboriginal and Torres Strait Islanders are always overrepresented in stats and there are some specific elements in terms of the lives of kids in the Kimberley that come through and and have written about and the Coroner reported upon um but there are also some things that that are relevant across the board as well so the great challenge I guess is how do we how do we do justice for all all children and young people and adults but how do we particularly understand the complexities with that overlays in terms of Aboriginal and Torres Strait Islander needs and and that panel isn't the panel to do that it needs to be done collaboration and and co-designed and led by Aboriginal communities so yeah it's important that we acknowledge that but we also know that there are children young people who are impacted in adults as well from non-Indigenous people especially and who are impacted as well so we all need to work together yeah thank you for that and for Lynn I'm much appreciated our next panelist tonight is Dr Andrew Leitch who's going to be providing us with their DPs perspective Andrew when we're considering a co-study like that as Joshua um and we're developing a mental health plan with you what other professionals do you consider important to include thanks Dan or the obvious professional we normally include is the psychologist and that is someone who's obviously very important who we refer to quite often on a mental health care plan but we also have a lot of other important health professionals that we can include on a mental health plan and who are funded such as an occupational therapist who can also do mental health work with our patients especially our pediatric patients and who have a lot of skills to offer and also social workers who can help and support us on a mental health plan so depending on what the child and parent might be interested in in dealing with and what problems might arise we can utilize lots of different health professionals and there's so many programs out there now that we can incorporate on the mental plans that might involve group therapy for kids or different social skill programs for kids for kids with low self-esteem or trouble with schooling and so these different allied health professionals can be really helpful with those and we incorporate them on the plan and then there's also online programs as well that are often put on the plan to make sure that they're included as well they're not obviously funded in the program but they're good to utilize and remind parents about Thank you, Anne-Marie. Our next panel tonight is Dr Hugh Kim Lee who's a psychiatrist and Kim can you tell us in terms of suicide ideation is medication for children helpful or useful? Hi there Dan thanks for that as a child and adolescent psychiatrist it's really important that we do a thorough assessment and come up with a formulation that informs our management plan and as a child and adolescent psychiatrist the question of medication often comes up but it's definitely not at the forefront of my mind in terms of treatment obviously if it's a mild to moderate severity we're looking at more therapeutic solutions and managing it through non-pharmacological means but if we've come up with a diagnosis and formulation that is looking at a more of a biological cause or contribution to their suicidality in their mental state then medication would be useful in that situation. Thank you Kim. Our final presenter tonight is Ellen Sinclair Ellen is a mental health nurse Ellen in your role and do you receive many referrals for young children who are having suicidal thoughts? I think we might have just lost Ellen there so we might move on to the come back to Ellen at a later stage. So let's talk a little bit about the ground rules tonight and particularly in the webinar platform so we have about 2100 people logged in at the moment so there's going to be quite a lot of traffic in the general chat room. The chat box is the general chat amongst other health benefits professionals. So if you have a question that can't be asked through the chat box please submit a question tab. Also there will be slides and resources that are connected to the webinar in that tab. If you have any technical issues please click the technical support FAQs tab to help with your technical issues. There is a number to call if that you're still having difficulties and if every participant is having difficulties you'll be alerted by an announcement. In terms of learning outcomes so tonight through an exploration of suicide ideation in primary school aged children this webinar will provide participants with the opportunity to identify factors that are likely to increase the risk of suicidal thoughts in primary school children implement a referral pathway that allows the development of a collaborative mental health plan for primary school aged children who have suicidal ideation and describe protective factors within families schools and communities that can assist prevention of suicide ideation in primary school aged children. So now we're going to move on to Lynn's presentation and then we'll be talking about suicide ideation from the psychologist Professor Corgan Lynn. Thanks Dan. I just want to think about the first initial thoughts I guess when we think about child suicide and I guess acknowledge that thought of a child dying by suicide is there is a confronting one. It certainly challenges ideas that we might hold about how children go and develop so we still have ideas around childhoods being a time of happiness a time in life where you don't have some any worries but it can be challenging to hear that children can be so distressed all their life things so difficult that suicide enters into their mind. There's lots of debate and in the coroner's report as well the WA report that's come out there is a there's quite a bit that's talked about in terms of children's understanding of death and their capacity to have the intent to suicide and that can leave people with questions around is it actually suicide was it an accident and the coroner does look into that and is very clear and does make the determination that of the 13 deaths that 12 of them were were suicide ones that have no confinding. So she does talk about that and it really comes back to some of the research that was done back in the 90s actually in terms of children's understanding of death and there was certainly ideas then that children from about the age of eight can certainly understand the permanent success and so it's fair to then understand that that they can understand suicide so it's an area of we still need to understand further but certainly something that's useful for us to think about and and I guess not let us get in the way of minimising or not not taking it seriously I guess is an important message. There are a lot of questions in the registration about statistics and what do we know and what don't we know and I deliberately put in what don't we know yet because there's a lot we don't know in fact the stats for children between five and fourteen only started to in Australia to be counted several years ago so 2011 they started to be reported so if we look at last year's statistics from the Australian Bureau statistics 98 deaths by suicide occurred in 2017 in the age group five to 17 years and most of those were in the older age group and 2017 suicide in Australia remained the leading cause of death of children between five and 17 years of age and that was representing a 10% increase in death from the year before and there was an overall 9% in deaths so overall in that year there's lots of caution that we need to take around that because it's not it's not great news at all that the deaths are increasing but it's not that simple either there are sometimes differences across states and territories and a whole lot of factors that come into how how the suicide is determined and there are different coronial processes and different awareness that that impacts on that so we have to be careful and there's certainly recommendations these days that we look at rather than year by year we actually look at blocks of three to five years sort of patterns and that's some of the international discussions that are happening it's hopeless trying to compare internationally it's even quite hard across states and territories to compare steps because then it's just not done in the same way so we need to have a lot of caution I guess that that then brings us to what do we know about younger children and so the Australian Bureau statistics has looked at period 2010 2014 and that's where it's been able to break down that younger age group age of five to 14 I guess in that time and you can see there that they were pretty equal in terms of males and females and that's quite different to adult population you might be aware that that's typically in adult populations and even young adults that are using more males dying of suicide females attempt suicide more but males are usually dying more from suicide so it's quite different in children so I think one of the challenges is if you think about this and you'll be different me to how we might be thinking about in adults that we can't just make the same assumptions about that some of the things to flag this is probably an underestimation that there's probably more that would be death but there's some doubt about it or there are reasons why it hasn't been called a suicide for children so it's probably underestimation and that would fit with what we know in terms of suicide ideation and attempts a regional tri-state islander's more likely to die by suicide let's talk about that already and if we just look at hard cold statistics as opposed to thinking about suicide as individuals and the devastation around that statistically speaking we're talking about small numbers which also make it difficult to make any any real claims or do a whole lot of conclusions for it so it's a source of data that in many ways it doesn't give us a whole lot to work with but we certainly know that thoughts and talk about suicide is much more common here. In terms of the case study I think it's useful always to think about the Drough and Brenner social-octological model I'm a community psychologist so I always think about things in this way so children particularly developing with the context of relationships in the family being the most significant influence on children's mental health and we certainly see that in the case study with Joshua so he does seem to be very impacted significantly growing his family circumstances and reports feeling left out and unimportant leaving it no one cares about him and he's experienced a lot of change and change from family circumstances which would fit with what we might think about in terms of distant detective factors there are protective factors there but there are also some things that have happened that could be considered as factors as well. Now I squeezed a lot of information onto this slide this is some data that came out of the kids helpline that your town did some analysis of and this is this came out a couple of years or two ago now and I remember the time thinking this should be something we should be hearing more about and it wasn't heard about as much as I thought it would be and there are reports there I've put the link there for you you might like to read some more but some of the things just to look at here is that the kids helpline people were saying that they they regularly get get calls from children under 14 who are talking about suicide and and do ring in relation to concerns around suicide and that can be from quite a young age sevens and up they also talk about the asking the question around whether or not they've made a suicide plan or have had an attempt of suicide you can see there's the statistics and it's not just the oldest kids actually a number of the younger ones as well and then the biggest worry and I guess the biggest message to me tonight is did you receive help when you are thinking about suicide you can see there that 74% of the children under 14 didn't receive help so they were trying to get help or asking people to help and they weren't getting it so that says a lot I think in terms of what one thing we can do is to be ready to offer some help I think the other thing that's useful and there are various theories that that crop up but this is a couple that I I quite like that I thought were sharing and the the graph there is from Wasserman and Wasserman 2012 and I kind of think about there's opportunities going to be and you can see there that it's it shows these observed behaviours related to suicide above the line and then non-observed behaviours below the line so suicide ideation and thoughts of suicide and even the planning can be happening under the line and it's only when it picks up and comes above the line that it's told might say something or show something or say that there's these feelings suicidal or attempting suicide in some way that it becomes observable and if people don't pick up on that well then it can go down again or it can come back up again depending on what happens and then it can go down that trajectory so of course suicide might happen possibly as well but but this is sort of a pattern that I think is useful for us to be ready for so thinking about what's going on below that line I think it's a really important message and I think from the case study we can certainly see that Josh was feeling invisible and alienated and he did speak to the family doctor and I guess my view is that now it's time we know that we're above the line we can do something about that when it's below the line it's harder to deal with. Another research article that I found that I thought was also really useful came out of the United Kingdom last year and it's done clean from others that some research with young adults who were actually suicidal they were in hospital and they found that there were four groups in terms of the experiences of these patients in terms of expressing their emotional pain to somebody else including health professionals which is always confronting to here as well as a health professional and they found these four groups so there was the unspoken and unheard experience where it wasn't it was all below the line and it wasn't spoken and no one noticed and so people felt invisible and alienated wordless with the description the second group where it was spoken so it became above the line observed but it was unheard so it was spoken but didn't no one picked up on it which is a bit like what we're hearing from the kids helpline data that children trying to reach out and get some help and and not getting it so people can feel depersonalised distracted the third one is spoken and heard where people can speak it and they're heard and acknowledged and the fourth one where it's probably the best one where it's unspoken but heard so it's below the line and people are still hearing it noticing behaviours noticing subtleties noticing changes so I think we're in a good position to do that and I'll just finish off by I think the other sort of thing to think about we always have to be thinking about working with families when we're talking about children and we have to think about how that might impact on them we might be the person who is going to share with the family that this is what's happening or the family might be coming to see us in terms of realising this is quite serious and so looking at this study which looks at the experiences and you can see they're the vast experiences that parents can have when when they're told that this is teenagers but when they're told experience suicidality suicide attempts so it's important I think to think about that when we're trying to provide some support and wondering why people are not wanting to hear what we've got to say or seem like they're not really doing what we want them to do so I think that's important to hear as well and I'll stop there Dan thanks. Thanks so much Lynn that was a really comprehensive presentation thank you for that our next presenter tonight is Dr Andrew Leitch Andrew welcome and report your presentation. Thanks Dan I think with Joshua the first challenge is engaging him in a general practice setting and a healthcare setting as a whole and that is perhaps one of the biggest challenges is trying to help him to adapt to that healthcare setting and finding a way in to help him to express his emotions 11 year olds or 10 year olds or even children in general probably do have trouble voicing their emotions and so I try to work out a way to build that rapport it might be just sitting and listening starting off with mum and getting mum in to talk to her about what has been happening with Joshua and having a bit of an access that way to then be able to relate to Joshua and his world or age appropriate language with Joshua talking a bit about his world in terms of what football team he goes for what sports he enjoys what computer games he is playing just so that you can make him feel more comfortable in this setting and I think from there accessing a little bit more detail into his emotional state 11 year olds and 10 year olds think they're coming to the GP or into the healthcare setting for coughs and colds and broken bones they don't necessarily think they're coming in here to talk about depression and anxiety which are quite heavy topics with alone suicidal thoughts so that is the first thing before we start to break into more difficult discussions and that's what I want to start with it actually takes a lot of patience and a lot of time and an investment of time which will pay off later moving on to the next of deeper issues which is a big buzzword at the moment which is resilience and what has broken that resilience for Joshua it's been a bit of a disequilibrium for him more negatives than positives really a breakdown in some of his family situation the loss of his father leading on to a real loss of contact with some of his real positive influences such as his grandparents and spending more time isolated in his with his technology losing touch with some of the outside experiences such as playing basketball and sports and then some of the school I would like to know a little bit more about his school and and and what is happening at school you know we know bullying is a big impact on mental health and depression and and you know it can can lead on to suicidal thoughts so asking these questions about how is your well-going how is school and how is home and just an open-ended question can really help us to understand Joshua more and what has led to that disbalance with his resilience and his understanding of what's been happening I guess the big job for us in GP is to assess his risk and I wanted to give this some time in the slide assessing risk is difficult and we have to be very careful I guess it's how we work things with kids it's not always easy I would probably gauge with how I've been going along with the consult as to how I might do that sometimes it needs to be developmentally sensitive so I mean you know if he's a younger child we might use different words we might say you know look there's some really big difficult topics we've talked about today and you've mentioned to mum that you're feeling really depressed and and you're feeling like you want to end your life what do you mean by that so we asked him to word it in his own words if he's not opening up to me I would ask him to draw a picture and pictures can be very powerful and I've had many kids bring in pictures that show a lot of explanation so about how they're actually going so pictures or writing or discussion if it's a very serious risk situation they might be having a knife under their pillow or they might be having a rope under their pillow and we really need to act on that here and now if it's a less serious situation they might be describing that they don't want to wake up in the morning because their world is caving in so we can get a quick assessment of how he's going and what he actually means by death and dying and getting an understanding of that and I think that's the crucial thing for Josh and and he and what he means by he wanted he's wanting to kill himself so and then working collaborative inclusively on what I mean is we really try to trying to get his family on board trying to get his school on board and get that collaborative approach get the whole team on board because the more people we have together as a team the better this will be a better outcome it will be for Josh it's harder just doing this one on one and if we can get Joshua to accept that then it'll be much easier for all of us I'm always thinking about other medical causes it's great if we can just check in on his health check in on any secondary causes that might be contributing obviously looking at diet and sleep it's always important to to think about whether he's sleeping properly whether is any sleep apnea whether he's eating well looking at his meals doing some blood tests for iron and and considering imaging and then technology's obviously having a bit of an impact on him which we'll hear about a bit later and other things such as ADHD or autism and screening for those in a secondary test or as in doing some screening questionnaires and sending him off to a pediatrician or developmental pediatrician. Finally the management of Joshua now this is probably going to take follow-up and and I'm happy if it's acute enough to see him straight away the next day or to organize an urgent follow-up appointment a book block off another appointment that day if we have to because this obviously takes priority a mental health care plan is probably the next step for Joshua to get him on to seeing psychologists as I mentioned or an occupational therapist support for mum and family and getting mum back to see her separately she needs her own instead of her own help 24 seven contact numbers I've got printed here and I would hand them straight on to her which would be kids help plan I've mentioned head space here because we know that they offer services for for young people but if she they wants to she could also source them private psychologists and the child and then adolescent mental health services locally which can offer private psychiatry or other advice to GPs who might be able to help with their plan and follow-up for Joshua and I think that really important thing of safety netting and close follow-up telling mum and Joshua that we are here for him we're here to support him and and we are happy to see him as regularly as he needs to and in a really supportive non-judgmental way so that he can have that regular close contact thank you Andrew and that was a really really great presentation and great to hear GPs such as yourself engaging so well with with children and families so thank you so much for that that was excellent our next presenter is Ellen Sinclair Ellen we have some technical issues to start with I apologize about that um that is an interesting question we were just interested to know do you receive many referrals for young children who are having suicidal thoughts in your own Ellen we might just leave you there for the minute we're just having some sound difficulties sorry about that again for the technical issues we'll um see if we can resolve those and get back to you so we might now go to Dr Hugh Kim Lee who's going to give us his perspective as a as a child psychiatrist him if you'd like to start your presentation thank you thanks Dan so I'm a child and adolescent psychiatrist based here in Adelaide South Australia and as a camp psychiatrist I guess we are seeing children who are the most at risk and vulnerable and usually they've seen quite a few other clinicians beforehand so I think in terms of basic principles it's important to remember that communication between the multi disciplinary clinicians is really important and for GPs and psychologists if you are making a referral to a psychiatrist it would be helpful for you to send any reports or information that would support the assessment in terms of in a camp setting a lot of the time people get caught up in terms of risk categorization and I did my training in New South Wales that I had a lot of influence from Chris Ryan and Matthew large who did a lot of studies and looked at the evidence with regards to risk categorization I just want to say a caveat that there are some limitations to risk categorization and uh saying that someone is at high risk shouldn't replace a thorough assessment formulation and treatment plan in terms of a clinical assessment in the camp setting suicide ideation is a common presentation but completed suicide is rare as a psychiatrist I would be interested in did Joshua have any past history of suicide attempts and does he meet the clinical criteria for a mental illness for example does he have the hopelessness the worthlessness the excessive guilt of a major depressive disorder and those are the main things that I'd be assessing to look at in terms of understanding his suicide ideation and does he have any current plans and his life does he have a method does he have suicide notes are the interesting questions might be what is keeping him alive what are his protective factors does he want to die or does he want to just disappear because of the emotional difficulties that he might be having in his life in a camp setting our priority groups are children who are under the guardianship of the minister and Aboriginal and Indigenous populations because they are at most risk in terms of looking at questions around his family and the developmental history I'd be looking at is family history is there a family history of mental illness and suicide attempts his father passed away when he was quite young I'd be interested to know if his father actually committed suicide and whether he is aware of the causes of his father's death are there reports from his psychologist that he saw after six sessions and what were the reasons why he stopped the sessions and did he find these sessions useful what happened developmentally did his mother have personal depression and did that affect his early attachment was he a planned pregnancy were there any other medical complications how were his milestones and what is his relationship like with Travis it appears a distant in the story that was presented to us and have they considered medication have they talked about this with their GP already as the GP specifically asked for us to consider medication has he seen a psychologist recently and has the therapy not seen as effective in terms of a working clinical formulation from the history that was presented to me I felt that Joshua was a 10-year-old male who presented with a past issue of major depression is showing signs of a relapse of his depressive disorder with poor concentration more withdrawn and poor social connections there being a loss of his usual activities and I suspect that there is a biological predisposition to a mental illness from his family history of his mother drinking and a big question mark about his father in addition to the loss of his father there have been other multiple losses loss of his parentified role in the family loss of connection with his mother and a loss of connection with his paternal grandparents I do also wonder if he's using online games as a means to escape and seek connection and I'd like to explore this further and online gaming is a specific interest of mine and there have been federal national surveys in Australia that show the strong link between online gaming time and depression symptoms from a psychiatrist perspective discussing antidepressants would I prescribe antidepressants for Joshua well with the information presented in front of me unlikely I probably wouldn't prescribe based on this information and without a current mental state examination I think as a psychiatrist it's very key that we do document how we saw him in the clinic session and I would always prefer to have a try at a psychological therapy first and if there's no improvement then I would consider a combination with a selective serotonin reuptake inhibitor such as prooxypane which is showing the most evidence in terms of the side effect profile you'd want to start with a low dose and consider the side effects that would affect his polar ability and adherence to medications but also there is a concern that there is a black box warning that there is an increased risk of agitation and increased suicidal ideation when starting an antidepressant in a person under the age of 18 so I'm fairly conservative in my prescribing of antidepressants in primary school as children but certainly in teenagers this is something that I would consider and in our CAM setting we have actually have a policy now that we must as a prescriber if we do prescribe an antidepressant that we must see them within the two weeks of commencement to minimize any concerns with regards to suicidality and risk due to starting a medication and also I also like to refer to the Black Dog Institute of in their guide in terms of prescribing for teens which I think is quite handy and often and disinformation to the GP so thanks. Thanks for that Kim that was yeah a really great presentation and we've got many questions for you popping up on the chat box so lots of interest in some of your work there so thank you okay so we're going to go back to Ellen and check that the technical issues have been resolved Ellen are you your back I'm hoping so oh you sound beautiful that's okay much better so welcome back for the first time and let's let's move on with your presentation thanks for going with us all right no worries there's been a lot of fabulous information already given so I'll just be very specific talking about my role as I perform it in the primary care setting as I said I work very closely with the GP I would also be working very closely with Joshua and his mum so we would be talking about talking about what their needs are I would be building of course building rapport with both of them trying to get a good idea of what has happened in the past with any counselling that's been attempted I think there's two particular points I want to address it's basically safety which has been talked a little bit about but also keeping him engaged in treatment because I see that as a major part of my role in conversation with his mum I would certainly validate her very much in her the difficulties they've had since she lost her husband as a family at her at her great work at keeping the family together the role that her new husband has played so giving him lots of validation because there's no doubt she will be feeling the effects of now having a depressed and suicidal child which would really impact on her and her family so lots of validation there and talking about what I can help with in my position in conjunction with the GP so as part of the safety of course going through you can read there on the slide I was generally on the side of safety in conjunction with the GP and we would refer this refer Joshua to can for the child adolescent mental health service and certainly psychological intervention would be inspired it has been tried before and concluded after three sessions I would certainly have a conversation with him about that find out what the issues might be there could be all sorts of reasons so you know getting getting a good idea from him why that didn't continue would be a step in the right direction to try and keep him involved with her at this time so some of the things listed there will certainly go through I would I would be led by him I would be led by how much he wanted to talk and also giving him some choices some of the initial part of the conversation would certainly be with him and his mother generally moms are very very keen to allow their children to be alone because they're sort of hoping they'll come out with lots of stuff that they haven't thought they can talk to her about so but then there would always be a five minutes or so at the end of the session and asking his permission as far as what we I can share with his mum being clear about some of the stuff especially around his safety I can't think of course so that would be the the bulk of what I would talk to him about collaborative goal-setting asking him what he wants unless you ask you don't know talk to a discuss with his mum about individual versus family therapy start to sound her out around family therapy because she's there thinking you know he's got the problem he needs the help but maybe having a conversation about perhaps the family needs a bit of assistance and even if and and it depends on what services are available they differ throughout Australia so somewhere metropolitan area or regional area like here I am in Newcastle I have reasonable access to services some areas the access isn't good at all so that certainly would be part of the conversation and also ongoing monitoring so again family GP the family is very likely to be quite well connected already but having that open door and sort of saying to mum if he's not keen to keep involved if he's not keen to continue with whichever therapist or service he's with so please bring him back so we can have a bit of a conversation about that and see what if we can get to the bottom of this see if there's some new information that he might be forthcoming with because of the family dynamics he may not be receptive to opening up to mum and his stepdad at home very much at all again school involvement all of those things as Andrew mentioned before all the people in his life need to be involved and on the same page with creating a protective team around Joshua and trying to lessen that feeling of being not heard and feeling abandoned so as a mental health nurse in a primary care practice so it was my two things primarily looking at some safety and also keeping him engaged in whatever treatment we supported him into because there'd be no doubt that he would need ongoing treatment from the initial assessment that we've given us. Thank you so much Ellen. You speak quite a bit there about a collaborative goal setting with the family. Ashley in the chat room has asked the question around how do you suggest practitioners engage parents in the therapeutic process with children like Joshua where parents are resistant or not very keen to attend sessions where parents are not keen yeah yeah look that's a real challenge I think what both well in this situation is mum is there mum is a bit stuck in the middle as he's had the stepdad she's the mother of Joshua so I would be I would be taking that is a really positive thing and I think really validating the obvious care and concern and that she's already seeking treatment so yeah look you've got to look for the strength and it's stepdad isn't keen because that's the most likely scenario you can have family therapy with whatever family members are available he's been strategies to move so back to their family and try and put into place. Right thanks so much Ellen. Andrew a question for you from Cappy and there's quite a few similar questions like this in the chat room at the moment. Question around does suicide or ideation mean that a report must be made immediately for child protection or even that a child should be prevented from leaving a professional premises? Very good question I wouldn't think that's the case with ideation and I would need to assess their I think getting a really good understanding of what they again what they're understanding and what they're meaning of what they're actually trying to say to you in terms of what they mean by they want to kill themselves getting in their terms and getting in their description as I said so if they have an active plan and if they are really quite definite about it then I think we do need to get some action in place but child protection I use a state by state law and so each state probably has its own regulation around that area and you would have to look that up in each state in terms of how to approach that topic. If there was an immediate problem in terms of that Joshua saying that he was at risk and he was looking at you know having a going home and not feeling safe I would probably say that we need to send him straight to hospital for an assessment so that he could be supported and that might involve mum if mum was able to take him would utilize that if she was feeling overwhelmed by the whole situation would we involve certifying you know getting some kind of an ambulance to be involved or you know you try not to escalate these situations because that just makes the whole matter worth I think so where possible I would use de-escalation and trying to talk to Josh about whether we can do a close follow-up and really try to help him through the situation without having to go to that page now but Kim I haven't got to also help with that as well I don't know if there's any other ideas around that. Kim would you like to comment on that? Oh yeah sure I think it's a poorly word question and that it means that the person who asked the question didn't really consider that each individual case is case by case basis and that suicidal ideation although it should be taken seriously if you do have any doubts by all means call an ambulance and send them to the hospital for an expert opinion but I guess it comes down to how comfortable you are and your clinical experience and it's that balance between knowing where you are in terms of how comfortable you are sending them home and your clinical judgment and taking it case by case basis and I guess managing the risk and managing resources as well. Thank you Kim so while we have you there's been some real interest in your much of your presentation but particularly around the material you talked about on gaming and social media do you see gaming and social media as influencing of children's thoughts about suicide? Yeah definitely I think Instagram CEO recently just came out to say that they are going to start banning self-harm images on Instagram because there have been some well-publicized events where there were essentially children affected by social media and in terms of my own experience in the southern Adelaide region there was a widely publicized traumatic death in the area of a young person who had experienced cyber bullying and we definitely experienced an increase in presentations and the schools and the school well-being counselors experienced an increase in presentations and that would reflect the research on cluster suicides and what we call a contagion effect where people relate to the stories on the news if it's the same gender the same age then they might have increased suicide ideation or be triggered essentially and the research would say that when newspapers go on strike then there are decreased suicidal presentations or suicidal episodes so that's why there are very queer journalistic guidelines in terms of what's put out into the public and I guess social media does not currently have those responsibilities in place I think Australia has started to put some laws in but certainly the Instagram CEO making a stance on reducing and eliminating self-harm images is a forward in terms of gaming as a whole another kettle of fish but I don't think we have time to think about that today. Thanks Kim. Lynn a question from you from Jason. What's the difference between a safety plan for an adult and a safety plan for a child? That's a good question Jane I think we don't have a lot of information around safety plans for children so there's not a lot of research that I've seen around that but safety planning is certainly the evidence-based practice at the moment for responding to a person who presents with suicide ideation or plan and I think you would apply the same principle so the idea of a safety plan is that you're addressing a whole lot of things that are happening around the person so what are the when the suicide ideation thoughts the plan when are they likely to happen and what are the triggers for that so I think you could do that with children if there's a plan or they've got ideas around what they would actually do what their plan is well then you reduce the means so you'd want to identify that as well and have a plan around that and you'd want parents to be heavily involved in this as well you'd want to have some plans in the safety plan also about when they do feel these thoughts coming on or when they're feeling stressed and hopefully the earlier they're starting to recognise those signs the better and then you'd look at well what can you do how do you how do you manage those you talk to somebody do you ring family hopefully if you're in a school what would that look like and you'd need the plan to be tailored to the school in the home situation so I think you could use the same principle of a safety plan that you would use with adults you'd obviously tailor it as I think Andrew was talking about listening to the child's language how what words are they using what makes sense to them tailor it to fit before the child and families what makes sense to them and age appropriate so I think you'd tailor it for sure and you'd engage them in doing that and you'd be using information you're gathering through that assessment process and tailoring into the plan and then and then getting parents and teachers on board with that so I think it's a really essential tool to develop together in collaboration together and then to review and monitor and see how it's going see how it's easy to get the child to have a lot of input children having agencies is really important in this time all the time but in this time particularly thank you Lynn um we're getting some questions around um children with uh disability and uh the link between disability particularly autism and um suicidal thoughts um Kim could you maybe talk about our children with autism um uh more at more at risk um of suicide ideation um and if so how can I be supported thanks stan in terms of my experience with kids on the spectrum their presentation is usually uh about emotional dysregulation and aggression towards other people it's been pretty rare for me to come across a young person who's autistic with suicidal ideation but I did have a look at the research around suicidality and keep on the spectrum and it shows that males who have had a history of depression have increased risk of suicidality and suicide attempts and the key feature in terms of it's what autistic is that their social communication competence and their ability to make friends impacts on their suicidal ideation later in life so usually when they're a teenager they realize that their autism affects their relationships and their friendships and their ability to mainframe maintain friendships and then they might become depressed and then suicidal because of their efficiencies thank you Kim um Zoe from the chat room has asked are there any particular risk assessment safety plan tools or questionnaires that the panel can recommend um Ellen I wonder whether we might start that one with you I tend to use um interview I tend to use interview questions uh so there's no specific um so I use now okay thank you for that um what about for you Andrew are there any particular tools that have been useful for you in your work as a GP I've been using the strengths and difficulties questionnaire which um has been very useful uh there are age categories for that which can be used for both the parents the teacher and the child um and I often get them to fill that out in the waiting room and then bring that in um it can be helpful as well for the parents to fill in something like a dust 21 or a k10 if they are going to be presenting to me separately because it's helpful to screen them uh when I see them separately um but the strengths and difficulties is probably one of my favorites the spent anxiety for is helpful for children as well I know there are many different tools out there so I try not to get too overwhelmed with them but um there's a couple to start with um the k10 obviously is a good one for the older um probably the older teenager and adult um uh uh kids thank you Andrew um some questions coming in around preventative strategies in terms of what can we do as uh invite families but also in schools and communities to um uh help children um to get the children and support children before um suicidal ideations become the factor uh Lynn I'm wondering whether you might like to comment on that thank you Dan this is like my favorite favorite question and a lot of um a lot of the research is really looking at what is it that we need to do that will prevent us getting to the point of suicide people having suicidal thoughts and um action so I guess a whole whole school approach is really important so that sense of belonging connection is really important there are theories around suicide that that people who don't feel like they belong feel like they're they're isolated are at greater risk of um as a suicide so let's begin with the belonging connectedness um effective evidence-based responses to bullying in school so that you really got very effective anti-bullying strategies bullying is often seen raised as as the you know main issue I'm allowed to um to suicide but it's got to be a whole lot of different things that are coming together it's not just one thing but obviously a child who's vulnerable already is going to have a big impact on so we have to look at all those underlying risks and protective factors I think so belonging connectedness in the school good um relationship between schools and families the inability to pick up on things really early children knowing it's okay to talk about all sorts of feelings that we're not kind of focusing just on on being happy all the time which is something that the parents and schools sometimes get caught up in so if you're feeling upset you're distressed you're feeling whatever all sorts feelings who can you talk to about that what can you do about that who can support you and support each other and good social emotional curriculum in schools to really support that in an evidence-based way so explicit teaching and then practice of that and good relationships between schools and and health professionals in the community so that if there are concerns that there are really rapid pathways to get some help as early as possible so I think when we talk about suicide prevention we can talk about it in this holistic really early preventative way um and then have responses to when things go wrong but ideally we get to a point more and more where we sort of catching things much earlier and and don't kind of get to this point where where we're having to do this prevention in terms of that child being immediately at least and worrying about that and the stress that comes from that that's the short version and I'll stop there thanks Lynn Andrew I wonder whether you might like to comment from a GP perspective given the the numbers of some children in their families who who visit the GP every year yeah thanks Dan I guess the GP motto is prevention is better than cure the whole idea of GP care is to prevent illness so I think more and more now in GP land we are coming more aware of mental illness it's becoming an increasing part of our work and as part of that when we see patients for more regular health screening measures such as health checks immunization or regular routine visits we are more in tune to how their mental health might be going and particularly in the pediatric setting so that might be a really important aspect of how we could have or how we could screen for Joshua and his family and and touching base with the family as they come in especially the other siblings as well and and I guess that's where prevention comes in if we can catch these things a little bit earlier even just a few months or weeks earlier could we have stepped in and implemented some changes and and as as Lynn has said you know that that can make a huge difference moving forward and those changes can be as simple as you know we'll see you we'll see you again a little bit more regularly or involve we'll involve some allied health or we'll we'll send you to somewhere that might help get some social input so I think that you're right with with prevention I think that's really the key in that in that setting all good in hindsight but something that we can look for in future planning yeah thanks Andy you point around when do we involve allied health professionals is an interesting one Ellen I'm wondering whether you could tell me on that in terms of what what points did you in your role to Cairns or a psychiatrist or to family services for a child like Joshua with Joshua and Joshua's family I would they're on the side of caution and straight away with a child this young with suicide ideation I think just touching on what Andrew just said to about prevention if you look at him he had a build-up of risk factors from about the age of five and the family that had a build-up of risk factors considering how his mother had a substance use issue for a while there so directly involved with what is happening now I would I would do it immediately for further assessment I think just for safety reasons that as far as the prevention goes I think any child or family that comes through to do a thorough assessment which is where I spend a little bit of time talking about the family situation major events that have happened that is where your risk factors perhaps come up and when you start getting you know one or more risk factors then it just raises a bit of a red flag to think that you know the family might need a closer look or even just talking about it and raising it as an issue with mum earlier to sort of say you know this is really really stressful and could be impacting on your children and just give a few points on what will go up for thank you so much Ellen we have a question coming through from Lynn and Kim perhaps you might I'd be able to answer this can there be an issue of complex grief that has not been considered and you know in your practice how would children's grief as it is associated to suicidal thoughts be identified for me to go first or Kim yes okay yeah look I think in the case study certainly grief complex grief where there's some unresolved issues can certainly play a role in this might if you do look at the case study and look at the the death when Joshua was five the death of his dad Joshua's then put in a position of being the man about the house the man of the house so put into a different role and then assert by that role when stepfather came on the scene and some other siblings came so I guess if you think about that patrols perspective and trying to make sense of what's happened in the family and making sense of the death of his father and that that whole voice that you might have or the way that you can express that there might have been some concerns around that and he certainly we know that he did see somebody when he was younger with designs of depression and then didn't didn't end up finishing that treatment so I think it is really important and I think we have to think about suicide in this very way so what are all the what what's the meaning around it so if we think about suicidal thoughts and actions as being a way of the form of communication if you like that things that are not good so psychic is one of the language one of the years talked about so if we think about a child with psychic and this is the way of expressing it instead of coming out in this way I think grief is a really important part of that but then grief and all that goes with it so it's grief and the loss of the dad but then the change in the family circumstances the change in house the change in connections to others as well so there's multiple griefs and perhaps unresolved which has been talked about in terms of complex grief so I think it's a really important part of this this whole picture that we're talking down in the case study right thank you Lynn Angel a question for you um if uh you had a child uh whose client like Joshua who was really resistant to engaging um in care what what might you do what might be some of those kind of strategies that yours use are you referring to resistance to psychology yeah or yep um I'd be keen to find out why his resistance um what might be some of the underlying fears he's got and whether that comes from the previous um treatment he had with a psychologist um in terms of what do you know did it did it not go well did he not connect to the psychologist did he not have his goals met with the psychologist um or you know sometimes it can be as simple as he was um with a psychology he just didn't relate to and he just wanted wants to see someone who matches up to him better and we need to sort of work on that or um it could be that we need to find some some goals that you know that he wants to to go through and we often I often ask them what would you like to get out of your psychology sessions you know there's something something you feel is really important to you that you'd like to achieve out of these sessions so so it can be it could just be working around some strategies like that um if it if it's not um if it's not to do with the dynamics of the psychology sessions is it is it broader than that is it the type of um therapy he's getting and sometimes I switch from from psychology to occupational therapy there might be um we might need to change things up a little bit and and utilize some different types of treatment on the mental health care plan as I mentioned earlier um or do we need to look more towards group type therapy and we've got some social skill type treatments as I said um you know to help him with um how he's feeling with his with his um social sort of um self-esteem at school which he's struggling with to make friends and feeling with um how he adapts to school where do we need to help him with becoming more positive for the school environment so um there could be lots of different factors and I guess exploring that with with Joshua and and what what is that resistance what is that barrier to psychology because that is a really important aspect of getting him treatment that is evidence based that Kim has said it's going to help him um to be improved and to to get better um if we can break down that barrier for him it's going to be an important step to recovery great thank you Andrew um Ellen perhaps we've got time for a quick comment about that uh from you just wanted to make a real-life example just happened happened to have something happen today that illustrated why a child wants to drop out during um treatment uh because the 12-year-old you mentioned that his father hit him when he was younger uh the response from the psychologist was I may need to make a mandatory report um and the result was so in my office seeing me saying I don't want to go back um we'll not talk to this person again etc etc now there's many reasons why that sort of comment might have been made but it sounds to me like it wasn't and or particularly well now we don't know that that happened with Joshua but we do know that his mum was drinking at the time um if something had come up through he's talking to the psychologist and he felt like mum was threatened it could be an example so again just a real-life example just to be aware of when you uh talking to young children how they perceive uh those sorts of comments um and even if you're thinking it not necessarily a great idea to uh to mention it that's about all the time we had for um chat room questions so thank you so much for everyone that asked those questions we had so many great questions that we couldn't get to just uh because of the volume that we had uh in the chat room tonight the number of participants um I'm now going to invite all our presenters just to sum up uh for for a couple of minutes with with final thoughts uh so to start with Lynn I might ask for your final thoughts for tonight okay thanks Dan I think the first thing is is listen and take any talk of suicide seriously and see it as an opportunity to understand what's going on for the child and do your planning safety planning around that make sure kids know the helpline kids helpline number because they they need to have a range of options so ideally they've got people in um in their lives that they can talk to and make sure they've got that that number and that it's okay for them to call that um and just say I prompt around one of the resources that I think people find really useful is the resource that I wrote it doesn't have my name on it but I did the work for headspace last year and it's in the on the list of resources and it's um a headspace one understanding suicide suicide attempts and self-harm in primary school aged children so I think if there are some other questions hopefully that that document might answer some of them so have a look at that thanks thanks Andrew uh yeah and I think in summary of mine it's really engaging Josh early making him feel welcome in the health setting um letting him know he's in a safe space um and having that open communication uh building that rapport with him and then creating a great mental care plan that created that sets him up with um appropriate um L.O. Health professionals that secures his safety and ensuring that he is um safe and not at risk um and doing that appropriate risk assessment um and if if needing get needed getting follow up um closely so that we can um ensure that he is followed up appropriately um and offering support to the family as well thank you so much for that Andrew um Kim some some closing comments from you good assessment and formulation should inform your management plan and good communication between the different multi-disciplinary uh clinicians make sure that you have consent to send off any important letters or reports anything doubt just pick up the phone and call your local mental health worker and get some advice over them and they can direct you thank you Kim and Ellen yeah just a point I'd like to make it would be really great if good information was given by allied health to GP about their interests their strengths do they like working with so that a good referral can be made um with you know good information so that more you know appropriate people are matched with the appropriate young person so that engagement is so important and if that's not um expedited properly then it really slows down treatment thank you Ellen and I think that's a really good place to finish um I'm um sure you'll join me in thanking our um panelists tonight um what is a really kind of challenging topic but I'm sure you'll agree that um all four of our presenters managed to provide a collaborative curious and engagement practical um hints and um strategy to be able to work with uh school-age children and their parents uh in a preventative way so thank you very much to all of you okay so that uh finishes the uh formal part of tonight's um webinar thanks to the well over 2000 of you who joined us um don't forget to complete the the survey feedback um click the survey feedback uh tab at the top of your screen to open the survey and uh we'd really be appreciative of your thoughts of tonight's webinar um and don't forget also that MHPM has a great suite of webinars coming up on the 25th of February which is a Monday night um emerging minds and MHPM will be presenting on supporting children's mental health after trauma um and then they'll be collaborating to recognise and address the mental health impacts of loneliness on Wednesday the 3rd of April on March the 13th there'll be the next cva webinar on military member to civilian identity in transition and on Monday March 18th there'll be a webinar on mental illness terrorism and grievance for shield violence understanding the nexus so just like to say that MHPM supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners share tips and resources and build local referral pathways and engage in cpd activities to learn more about joining MHPM or go to the news section on the website you can also indicate your interest throughout our exit survey if you're interested in joining any networks over the holiday break go to the MH website MHPM website and before I close I'd just like to acknowledge that the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present thank you to everyone for participating in tonight's webinar cheers