Media playback is unsupported on your device Media caption "Our son didn't want to die"

Issues ranging from parental separation to sexual abuse and bullying are among factors involved in child suicides in Wales, a study has found.

Research, published by Public Health Wales and Swansea University, examined the deaths of 33 young people aged 13 to 18, over a four-year period.

There was rarely a single reason why they had taken their own life.

The study said stigma related to self-harm was a "major challenge" and could be preventing families seeking help.

Lynne Neagle AM, who chairs the Welsh assembly's cross party group on suicide prevention, said she believed it was "nothing short of a public health emergency".

Reducing Adverse Childhood Experiences (ACEs) was among key ways of preventing suicide, the study said.

Others included preventing alcohol and substance misuse, and improving education and training opportunities.

The major study is a follow-up to a research project which reported in 2014.

It follows evidence from across the UK of an increase in deaths by suicide in young people since 2010. Statistically, it is not possible to detect differences in the suicide rate in Wales because of the small numbers involved.

What were background issues to the suicides?

Adverse childhood experiences Risk factors in young suicide cases Category Yes No Verbal/emotional abuse 5 24 Physical abuse 5 24 Sexual abuse 5 24 Sexual assault 3 26 Parental separation 18 11 Household domestic violence 7 22 Household mental illness 8 21 Household alcohol abuse <3 27-29 Household drug use <3 27-29 Household member in prison <3 27-29 Neglect 4 25 Bullying 10 19 Bereavement 6 24

In the study, the youngest of the 33 cases reviewed was 13 years old and 70% were male.

Seventy per cent had experienced at least one ACE. Some of the issues in the background included: substance misuse; poverty - more than half lived in an area classified as deprived; sexual abuse and assault; bereavement; shame; difficulties in education, employment or training; and lack of awareness around self-harm.

Six of the children had expressed their distress on social media beforehand; five had a family history of suicide or suicidal behaviour.

Eight had recently experienced a relationship break-up, while six had experienced issues with attendance at school and truancy.

The review notes there is rarely a single reason why a child or young person takes his or her own life. It's usually due to a variety of risk factors, circumstances and adverse experiences, which the children's commissioner - in her introduction to the report - calls "complex".

Despite this, suicide is potentially preventable.

"A number of young people had episodes of self-harm where parents were unsure of how to respond and so were not accessing services even when this was suggested by schools or healthcare services," the study said.

"Stigma related to self-harming behaviours remains a major challenge to suicide prevention efforts."

Image copyright Family photo Image caption Josh Merrells loved the guitar, piano and animals - and was creative, says his parents, and liked to stand out in how he looked

'I don't think he wanted to die - I just don't think he wanted to live like that any more'

Josh Merrells was found dead in woodland near his home in Gowerton near Swansea on 6 August. He was 15.

His mother June said Josh was "a character" and "well loved."

"He struggled in school academically because he was dyslexic - and because of that he found his creativity," she said.

He also had struggles with bullying, had lost someone close to him through suicide last year, and came out as gay.

"We knew Josh was gay before he knew - and embraced it and fully accepted it," said father Michael.

His mother said: "There were a lot of factors, not just one."

Image caption Josh's parents Michael and June, with a photo of Josh playing his guitar

He was self-harming and made attempts on his own life, which led to him being referred for help, and his parents knew he was struggling.

Michael said: "He admitted he'd tried several times to end it - various methods - and laughed it off, nonchalant. You speak to him, he's normal, happy. In fact, the last weekend, he was the most bubbly and charismatic we'd every seen him."

On the evening Josh died, he left food in the fridge to eat later and went to a friend's home.

"There was nothing out of the blue that night, nothing odd," said June.

"I don't think he wanted to die - I just don't think he wanted to live like that any more."

'Humbled'

An inquest will look at the circumstances around his death.

Michael said: "There's too much of a rush to try to label these kids, focus on the condition and not the individual. I discussed this with Josh and he felt that he would give them the answers they needed so they'd leave him alone.

"We begged on occasions - he's going to do this, he's only got to get it right once. The question was constantly raised - 'you don't feel like that now, do you?' And he'd go, 'no, no, of course I don't'. So 'Ok, there you are.' Tick, gone."

They are not sure if the outcome would have been different but his GCSE results were better than expected, he was optimistic about the school year ahead and had found a good GP.

June and Michael said they had been "humbled" by support from the community and Josh's friends.

"Someone tagged him as 'the rainbow of the village' - so everywhere we see now, is a rainbow," said Michael.

Image copyright Getty Images/PHW

What needs to happen?

Review leader Prof Ann John, national lead for suicide and self-harm prevention at Public Health Wales, said suicide was not inevitable and the review offered a framework for tackling some of the issues leading to it.

"We need to be tackling issues such as alcohol and substance misuse in young people and making sure young people who are abused, sexually assaulted or bereaved are able to access the talking therapies that we know can support them," she said.

Lynne Neagle AM, who chairs the Welsh assembly's cross party group on suicide prevention, said the review was the "closest thing we have to hearing the voices of those young people who have died by suicide".

"Nothing is more important than preventing young people dying by suicide," she said. "I believe it is nothing short of a public health emergency."

She said the clear opportunities for suicide prevention needed to be seized with "vigour, determination and urgency".

Kate Heneghan, head of the suicide prevention charity Papyrus, in Wales, said it believed "talking about suicide is the only way to challenge stigma and we know that talking openly encourages young people struggling with thoughts of suicide to seek help".

"By asking 'are you having thoughts of suicide?' you have conveyed that you are a safe person to talk to and will help them to seek help."

She added: "What really struck a chord was reading about the number of young people included in the report who had episodes of self-harm where parents were unsure how to respond.

"All too often at Papyrus we hear from bereaved parents who say they felt lost, they didn't know what to do or where to turn and wished they had known about our helpline service when they were struggling to keep their child safe."

Prof Sally Holland, Wales' children's commissioner added: "I am passionate about pushing for earlier and more joined up support for children's mental health and social care needs. This review provides stark evidence of the importance of the need for these changes in Welsh communities."

Six key suicide prevention opportunities:

Ongoing action to restrict the access of children and young people to alcohol, along with full implementation of guidance to prevent substance misuse.

Continued interventions for children who have experienced ACEs. This should also include greater engagement with safeguarding boards to raise awareness of the importance of protecting children from the effects of domestic violence and sexual abuse.

Management of self-harm.

Raising the age of participation in education, employment or training, including looking at support mechanisms for 16 to 18-year-olds.

Better information sharing, including with private schools and state services.

Better knowledge and awareness of self-harm and other risk factors for suicide.

If you or anyone you know is having suicidal thoughts, you can contact the Samaritans at 116 123 or jo@samaritans.org; or see their website. Or you can visit the BBC Action Line website.

You can also contact the Community Advice and Listening Line for Wales, which offers a free confidential support service with help to find local mental health services, on 0800 132 737 or text 'Help' to 81066.