What risks need to be considered?
Risks to a young person’s safety should be considered broadly to include risks related to vulnerability to harm from others (e.g. exploitation, domestic violence, intimate partner violence, neglect), risk of overdose if using substances or taking prescribed medications, risk of infection if injecting drugs, sexual health risks and risk of unplanned pregnancy, suicidality and risks associated with self-harming behaviour. Risk to others includes risk of violence (including domestic violence, intimate partner violence), risks of neglect, abuse or other harm to children and risks associated with risk taking behaviour (e.g. driving while intoxicated). This resource covers:
- Assessing and responding to risk of self-harm and suicidality;
- Assessing and responding to risk of harm from others;
- Assessing and responding to risk of harm to others;
- Considering sexual health risks
- Considering risk related to alcohol and other drugs (AOD)
Other important risks to a young person’s mental health and wellbeing, such as risk of experiencing homelessness, social isolation, school refusal and deterioration of their mental and/or physical health, are important to consider in general assessment, treatment-planning and interventions. However, as the focus of this resource is on managing safety concerns, they are not included here.
Some key principles in risk assessment
While considering risks across a number of areas, it is important to acknowledge that regardless of the domain of concern (e.g. self-harm, sexual health, risk of harm to others), risk is dynamic and needs to be assessed and monitored throughout a young person’s care. Similarly, when safety plans are developed, they need to be regularly revisited and reviewed. It is also crucial to note that a risk assessment is never complete until it has been appropriately documented and shared with all parties who need to be involved to keep everyone safe.
Safety assessment should always be accompanied by a safety response, or risk intervention. In order to do this effectively, when assessing risk, clinicians need to work from a formulation-based approach to support a young person to identify: factors that increase their risk, their strengths, their key supports, other protective factors that reduce their risk, and ways to increase their internal and external coping responses. In any risk intervention it is of value to work toward increasing a young person’s sense of optimism, hope, connectedness and self-efficacy.
The young person’s permission should be sought to involve their family and or other key support people in safety assessment and response. If they are unsure about this, then it is important to explore their concerns, clarify why it is important to include them and address concerns they may have about doing so. It is important to discuss the benefits of the young person’s family and friends being aware of what to do if the young person is feeling unsafe. There may be some instances in which involving families is not deemed to be appropriate (e.g. domestic violence concerns). Prior to commencing any kind of assessment with young people and family and friends, it is important to be transparent about confidentiality and its limits. In any risk assessment, it is important to consider whether confidentiality needs to be breached to fulfil duty of care responsibilities. Mandatory reporting requirements also need to be considered.
Who needs to assess what when it comes to safety concerns?
All clinicians working with young people have an important role to play in assessing and responding to safety concerns across a number of domains. The level of assessment and intervention provided will vary by individual clinician and will depend on what is in the scope of their role (e.g. as a GP, or AHP) and expertise in relation to the type of risk identified (e.g. sexual health, domestic violence), and who else is involved in the young person’s care (within headspace and externally) and available to support the young person. Involving other providers within headspace in managing safety concerns, and referring to/working with external services (e.g. tertiary mental health, forensic services, child welfare) should be prioritised to ensure a holistic and comprehensive response to risk management and intervention.
1. Assessing and responding to risk of self-harm and suicidality
In considering a young person’s risk of self-harm and/or suicidality, it is important to consider:
- general risk factors (e.g. level of distress, risk-taking behaviour, limited social supports, AOD use),
- their history of self-harm and suicidal behaviour (e.g. previous suicide attempts),
- other vulnerabilities (e.g. exposure to abuse or neglect), and
- whether the young person is included in groups of young people that are at higher risk of suicidality and/or self-harm.
Young people experiencing mental ill-health (including substance use problems) are over-represented in both self-harm and suicide statistics. In addition, young people may be at elevated risk of self-harm and/or suicidality if they are included in the following groups:
- Aboriginal and Torres Strait Islander young people;
- young people in immigration detention;
- young people in/in recent contact with juvenile justice facilities;
- young people in contact with, or who have recently left statutory care;
- young people in rural or remote communities;
- sexuality and gender diverse young people;
- young people with dual diagnosis (AOD and mental ill-health);
- young women are at higher risk of self-harm, while young men are at higher risk of suicide;
- young people who have been exposed to suicide or suicide-related behaviour are also at higher risk of suicidal behaviour.
When working with any young person, it is important to assess risk sensitively and let the young person know that you assess risk with all young people you see. Helpful questions to consider in conducting an assessment for risk of suicidality and self-harm, and some more resources that may be helpful can be found here.
2. Vulnerability to harm from others
In addition to considering risk of harm to the self, it is important to consider whether a young person is vulnerable to experiencing harm from others. A young person’s vulnerability may be increased by factors such as AOD use, mental health symptoms (e.g. risk-taking behaviour, disinhibition) and if they are experiencing homelessness. A young person may also be at risk of harm from others, including domestic violence, intimate partner violence, child abuse and/or neglect.
Clinicians need to be aware of mandatory reporting requirements and their duty of care to a young person. A notification to child welfare, the police and/or referral to family support services may be indicated. Child welfare services operate differently in different states and mandatory reporting requirements vary by jurisdiction. The list of professions required to make mandatory reports also varies by jurisdiction. It is important to be aware of the reporting requirements for your jurisdiction and profession in addition to being familiar with local child welfare service processes and your service’s policies.
Clinicians are encouraged to seek supervision and secondary consultation with senior clinicians and/or specialist services (e.g. youth law or child support services) for guidance in managing concerns regarding a young person’s vulnerability to harm. It is important to be transparent with young people and family and friends about the limits of confidentiality from the outset, revisit these conversations as needed and support young people, family and friends in the process as much as possible if their confidentiality has to be breached.
Helpful resources and guidance for assessing and supporting young people at risk of domestic violence is available through www.woah.org.au – What’s OK at Home (developed by the Domestic Violence Resource Centre). Online tools to support young people to develop a safety plan are included. There is also a section of the website for ‘adult allies’. Assessing and managing domestic violence risk can be complex. Where there are concerns regarding domestic violence, in addition to considering mandatory reporting requirements, family violence services should be involved for specialist consultation and consideration of whether a referral is indicated. The police may also need to be involved if there are acute concerns regarding the safety of a young person or someone in their home.
Intimate partner violence (IPV) is prevalent among young people. AHPs and GPs are ideally placed to screen for IPV and provide early intervention. It is important to assess whether a young person is at risk of, or currently experiencing, intimate partner violence. More guidance on assessing risk of intimate partner violence is available here
Consider directing young people to bodytalk.org.au to find out more about respectful relationships and warning signs for unhealthy relationships. As above, if a young person is assessed to be at risk of IPV, it is important to consider whether mandatory reporting is required, and what other services may need to be involved to keep the young person safe.
3. Assessing and responding to risk of causing harm to others
In addition to considering the risk of harm to a young person, it is also important to assess a young person’s risk of causing harm to others. This is particularly important to consider for young people with mental health and/or substance use concerns as both AOD use and mental health difficulties may be associated with factors that increase risk of harm to others. For example an increase in aggression, confusion, disorientation, and vulnerability to experiencing psychotic symptoms may all increase a young person’s risk of violence (see the Orygen clinical practice point: Assessing and managing the risk of violence in early psychosis). For more guidance on assessing and managing risk of violence in young people, health professionals are encouraged to read the Orygen Clinical Practice in Youth Mental Health: Assessing and managing the risk of violence in early psychosis. While the background content and research is specific to psychosis, the broad clinical tips on assessing and managing risk of violence and recommended screening tools are more generally applicable to young people experiencing other mental health and substance use difficulties.
When working with young parents, it is important to consider whether there is a risk of harm or neglect to children. In relation to AOD use, risk of harm to others also includes considering the risks to a foetus for women who are pregnant, in addition to considering the broader child safety risks for young parents using substances.
Regarding child safety concerns, a notification to child welfare and/or referral to family support services may be indicated for children and an unborn child/children. As noted in section 2, it is important to be aware of the reporting requirements for your jurisdiction and profession in addition to being familiar with local child welfare service processes and your service’s policies.
4. Assessing and responding to sexual health risks
Clinicians working in primary care are ideally placed to have conversations with a young person about their sexual health and to provide risk assessment and early intervention. Clinicians should consider:
- Is the young person sexually active? Note that sexual activity in a young person aged 14 or younger should be a ‘red flag’ for further and broader risk assessment and requires careful documentation and consideration if mandatory reporting is required
- For AHPs it might be appropriate for the clinician to ask more general questions such as;
- Are you using any form of contraception to avoid pregnancy and/or STIs?
- If not, brief exploration of the risks of pregnancy is indicated.
- Current use and knowledge of contraceptives?
- Risks of STIs
- Risk of unplanned pregnancy
- Was a GP consulted, and how was this contraceptive chosen?
- Is the contraceptive suitable and effective as used by the young person?
- Has sex has ever been forced upon them or have they ever felt coerced into having sex? It is important to assess for trauma in a trauma-informed way
- Is there a history of coercion to have unprotected sex in a context of consent to sexual activity?
- Does the young person have sex under the influence of AOD and does this increase their sexual health risks? Coercion to use AOD and/or coercion to have unprotected sex may be more likely in this context.
- There may be a risk of acquiring HIV and other blood borne viruses through injection and sexual risk behaviours of the young person’s partner(s).
- Does the person have a mental health problem that may reduce their ability to negotiate boundaries?
- Checking vaccination status is important for key vaccine preventable STIs including Hepatitis A and B and HPV (genital warts and cervical cancer).
In considering the above risks, clinicians need to consider:
- The young person’s age, and capacity to consent to treatment - whether mandatory reporting is required
- If AOD increases risk, what harm reduction strategies can be used?
- Offering access to online psychoeducation – encourage the young person to visit www.bodytalk.org.au to find out more about sexual health and sex education
- Would the young person benefit from motivational interviewing around contraception?
- Is the young person aware that concerns about sexual behaviour and sexual health are common among young people and that they can access sexual health services confidentially at headspace?
- Does the young person need advice on what to do when an STI test comes back positive?
5. Assessing and responding to risks of harm related to alcohol and other drug use
Young people who are using AOD may be at an increased risk of harm to themselves, and from others. It is important to consider:
- Is the young person experiencing direct harm from use? This may include financial risks, work or social problems, trouble concentrating, depression, extreme weight loss due to reduced appetite, disturbed sleep, and/or skin sores.
- Are they at risk of indirect harm from use? This may include increased risk of violence, injury, STIs, unplanned pregnancy, trauma, legal involvement, and/or increased risk of depression or psychosis
- What is the relationship between the young person’s AOD use, self-harm, suicidal thoughts and other vulnerability to harm? For example, do suicidal thoughts occur during substance use or during periods of withdrawal or both? Have these thoughts ever been acted on?
- Does the young person’s AOD use increase their risk of harm others?
- For pregnant young women - Is there a risk of foetal alcohol syndrome or other substance-related harm to an unborn child?
- For young parents – Is there a risk of harm and/or neglect to children?
- Does AOD use make the young person more vulnerable to impulsive suicidality or to aggression?
- If injecting, it is important to gauge the level of risk for transmission of blood born viruses such as HIV and Hepatitis C. If indicated, support the young person to access needle and syringe programs.
- Is the young person at risk of intentional or unintentional overdose using alcohol and other drugs and/or prescribed/acquired medications?
- Does the young person’s pattern of use indicate dependency? Consider the young person’s:
- Risk of alcohol withdrawal.
- Risk of cannabis withdrawal.
In considering the above risks, clinicians need to consider:
- Have I balanced the need to maintain a non-judgemental stance in working with substance use with consideration of safety concerns and my clinical responsibility to the young person?
- What harm reduction approaches have already been implemented and what additional measures may be indicated?
- Has the young person been provided with psychoeducation about the risk of AOD use exacerbating existing mental health difficulties or triggering new ones (e.g. psychotic symptoms)? This is particularly important to consider in young people experiencing manic and psychotic symptoms, and those with a family history of mania or psychosis in first-degree relatives
- Is anyone else at risk in relation to the young person’s substance use? Note to consider risk of neglect or harm to any children/dependents, unborn children if pregnant, family members/carers and partners.
- Have I considered risks associated with prescribed medications?
- What do I need to document in relation to the young person’s risks?
- Who else needs to be involved to manage safety concerns?
- What would a safety plan need to include to minimise risks and build on a young person’s strengths and supports?
- If AOD use contributes to risk of harm to the self or others, have we (the clinician and young person) incorporated agreed harm reduction strategies into the safety plan? For example, if increased AOD use is a warning sign that a young person is self-harming, experiencing suicidal ideation, or vulnerable to harm from others, then the AOD use can act as a trigger for safety actions. Examples of safety actions could be not using alone and engaging supports.
- How can I work with the young person and their family and friends, to reduce their risk?