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1.3.33 Self Harm and Suicidal Behaviour


Self-harm harm (self-poisoning or self-injury regardless of the motivation or intent associated with the act) is a common problem among young people with many presenting to clinical services via general hospitals, but many more do not come to the attention of clinical services at all. Self-harm is strongly associated with completed suicide so it is extremely important that patients are assessed and treated for this problem effectively.

Community-based studies estimate that around 10% of young people have self-harmed. Self-harm is often repeated; in young people presenting to hospital for self-harm around half will have a history of prior harm and 18% will repeat the behaviour within a year (and present to hospital) again. Self-harm is strongly linked to completed suicide with 40–60% of those who die by suicide having self-harmed in the past, making it the strongest predictor of eventual suicide. In one consecutive case series study, 80% of young people who died by suicide had self-harmed in the preceding year. Suicide risk among self-harm patients is hundreds of times higher than the general population. Suicide is now the commonest cause of death in people age 20 – 24 in the UK. It should be said however, that the majority of young people who self-harm do not go on to commit suicide.

Given these associations, it is vitally important that young people who self-harm are taken seriously and are treated compassionately by anyone who becomes aware of their self harm.

The Safeguarding Boards for Dorset and Bournemouth and Poole are working to provide clearer pathways for professionals in this area. This policy was updated in May 2016. Learning from Dorset Serious Case Reviews should be considered alongside this Policy. See Serious Case Reviews and Other LSCB Audits Procedure.


Quick Links:

Definition
Why do Young People Self-Harm?
Contributory Factors
Protective and Supportive Action in Response to Self-Harm
Risks
Issues – Information Sharing and Consent
The Role of Schools
Sources of Help
Further Information
Amendments to this chapter


Definition

Hawton, in his extensive studies of young people who self harm, defines self-harm as:

An act with a non fatal outcome in which an individual deliberately did one or more of the following:

  • Initiated behaviour (e.g. self cutting, jumping from a height) which they intended to cause self-harm;
  • Ingested a substance in excess of the prescribed or generally recommended therapeutic dose;
  • Ingested a recreational or illicit drug that was an act the person regarded as self harm;
  • Ingested a non-ingestible substance or object.
Self-cutting and overdose are the commonest methods.

The term self-harm rather than deliberate self-harm is the preferred term as it a more neutral terminology recognising that whilst the act is intentional it is often not within the young person’s ability to control it.

Self-harm is a common precursor to suicide and children and young people who deliberately self-harm may kill themselves by accident or intentionally.

Self-harm can be described as wide range of behaviours that someone does to themselves in a deliberate and usually hidden way. In the vast majority of cases self-harm remains a secretive behaviour that can go on for a long time without being discovered. Many children and young people may struggle to express their feelings in another way and will need a supportive response to assist them to explore their feelings and behaviour and the possible outcomes for them.


Why do Young People Self-Harm?

Young people self-harm for a number of reasons. When asked why they do this the main reasons given were often mixed and multiple:

Wanting to get relief from a terrible state of mind 72%
Wanting to die 53%
Wanting to punish themselves 46%
Wanting to show how desperate they were feeling 41%
Wanting to find out if someone really loved me 31%
Wanting attention 24%
Wanting to frighten someone 21%
Wanting to get their own back on someone 14%

Self-harm is seen as a coping mechanism, a way of coping with something that the person cannot deal with or communicate in any other way. It has been likened to a “Message in a Bottle” (Kingsbury).


Contributory Factors

Risk factors for self-harm include:

  • Mental health & well being:
    • Depression and anxiety – especially in girls;
    • Impulsivity – associated with poor problem solving skills - especially in girls;
    • Self esteem – low self esteem – in both boys and girls;
    • Antisocial behaviour – clearer association shown for girls than boys;
    • Drug use – one of strongest predictors for both boys and girls;
    • Alcohol use – greater rates of self harm with higher consumption;
    • Smoking – incremental increase in self-harm the more an individual smokes.
  • Personal characteristics and experiences:
    • Schoolwork – having problems keeping up with schoolwork;
    • Bullying – important cause of stress and physical and emotional problems;
    • Sexual abuse – being forced physically or verbally to engage in sexual activities against their will, or being a victim of CSE;
    • Physical abuse – associated with increased rates of repetition;
    • Sexual orientation and behaviour – homosexual or bisexual orientation or transgender issues.
  • Family characteristics:
    • Living apart from both parents;
    • Family discord, lack of support or supervision from parents, parental criticism.
  • Experience of suicidal behaviour in others:
    • Having a friend or family member who self-harms.
  • Influence of media’s portrayal of suicide and self-harm;
  • Music –  Which lyrics promote negative emotional states.

Protective and Supportive Action in Response to Self-Harm

A supportive response demonstrating respect and understanding of the child or young person, along with a non-judgmental stance, are of prime importance. Note also that a child or young person who has a learning disability, is traumatised or has been abused  may find it more difficult to express their thoughts and feelings and may need time to process before they can answer.

Practitioners should talk to the child or young person in a quiet place, respecting their privacy and try to establish:

  • If they have taken any substances or injured themselves;
  • What is troubling them;
  • Explore how imminent or likely self-harm might be;
  • Find out what help or support the child or young person would wish to have;
  • Find out who else may be aware of their feelings;
  • How long have they felt like this?
  • Are they at risk of harm from others?
  • Are they worried about something?
  • Ask about the young person's health and any other problems such as relationship difficulties, abuse and sexual orientation issues?
  • What other risk taking behaviour have they been involved in?
  • What have they been doing that helps?
  • What are they doing that stops the self-harming behaviour from getting worse?
  • What can be done in school or at home to help them with this?
  • How are they feeling generally at the moment?
  • What needs to happen for them to feel better?
  • Who can they talk to? Who can they turn to for help?

Do not:

  • Panic or try quick solutions;
  • Dismiss what the child or young person says;
  • Believe that a young person who has threatened to harm themselves in the past will not carry it out in the future;
  • Disempower the child or young person;
  • Ignore or dismiss the feelings or behaviour;
  • See it as attention seeking or manipulative;
  • Trust appearances, as many children and young people learn to cover up their distress, particularly those who are victims of CSE (they may be well presented if they have been bought presented, make up etc.).

Risks

An assessment of risk should be undertaken at the earliest stage and should enquire about and consider the child or young person’s:

  • Level of planning and intent;
  • Frequency of thoughts and actions;
  • Signs or symptoms of a mental health disorder such as depression;
  • Evidence or disclosure of substance misuse;
  • Previous history of self harm or suicide in the wider family or peer group;
  • Delusional thoughts and behaviours;
  • Feeling overwhelmed and without any control of their situation.

Any assessment of risks should be talked through with the child or young person and regularly updated as some risks may remain static whilst others may be more dynamic such as sudden changes in circumstances within the family or school setting.

The level of risk may fluctuate and a point of contact with a backup should be agreed to allow the child or young person to make contact if they need to.

The research indicates that many children and young people have expressed their thoughts prior to taking action but the signs have not been recognised by those around them or have not been taken seriously. In many cases the means to self-harm may be easily accessible such as medication or drugs in the immediate environment and this may increase the risk for impulsive actions. A plan for safe storage of medication in the household and other potential items which may be used by young people to self-harm should be made with all at risk young people and their parents/carers. GP’s should be aware of risk of self-harm when prescribing medication for the young people who self-harm and their family. Whilst no medication is safe taken in this context, certain medication may pose a much greater risk of harm, or death, and this should be considered when prescribing to at risk young people and others in the household.

If the young person is caring for a child or pregnant the welfare of the child or unborn baby should also be considered in the assessment.

Referral to Children’s Social Care

The referral should include information about the background history and family circumstances, the community context and the specific concerns about the current circumstances, if available.

The child or young person may be a Child in Need of services (s17 of the Children Act 1989), which could take the form of an early help assessment, a Common Assessment Framework (CAF) or single assessment to identify their needs or they may be likely to suffer significant harm, which requires child protection assessment under s47 of the Children Act 1989. It is unlikely that a child protection plan is going to be the appropriate approach for a child who is self-harming, but assessment may still be undertaken under s47 enquiries.

Where hospital care is needed

Where a child or young person requires hospital treatment in relation to physical self-harm, practice should be as follows, in line with the National Institute of Health and Clinical Excellence (NICE) June 2013 (see NICE website):

Triage, assessment and treatment should be undertaken by paediatric nurses and doctors trained to work with children and young people who self-harm in a separate area of the emergency department for children and young people.

Special attention should be given to:

  • Confidentiality;
  • Young person's consent (including Gillick competence);
  • Parental consent;
  • Child protection issues;
  • Use of the Mental Health Act and the Children Act;
  • Admission.

All children and young people should normally be admitted into a paediatric ward under the overall care of a paediatrician for a full psycho-social assessment.

Alternative placements may be needed, depending on:

  • Age;
  • Circumstances of the child and their family;
  • Time of presentation;
  • Child protection issues;
  • Physical and mental health of the child or young person;
  • Occasionally, an adolescent psychiatric ward may be needed.

After admission, the paediatric team should obtain consent for mental health assessment from the child or young person's parent, guardian or legally responsible adult.

During admission, the CAMHS team should:

  • Provide consultation for the young person, their family, the paediatric team, social services, and education staff;
  • Undertake assessment addressing needs and risk for the child (similar to adults, see assessment of needs and assessment of risk), the family, the social situation of the family and young person, and child protection issues.

For all children and young people, advise carers to remove all means of self-harm, including medication, before the child or young person goes home.

Any child or young person who refuses admission should be discussed with a senior Paediatrician and, if necessary, their management discussed with the on-call CAMHS crisis or out of hours worker who may then consult with the Child and Adolescent Psychiatrist.


Issues – Information Sharing and Consent

The best assessment of the child or young person’s needs and the risks, they may be exposed to, requires useful information to be gathered in order to analyse and plan the support services. In order to share and access information from the relevant professionals the child or young person’s consent will be needed.

Professional judgement must be exercised to determine whether a child or young person in a particular situation is competent to consent or to refuse consent to sharing information. Consideration should include the child's chronological age, mental and emotional maturity, intelligence, vulnerability and comprehension of the issues. A child at serious risk of self-harm may lack emotional understanding and comprehension and the Fraser guidelines should be used. Advice should be sought from a Child and Adolescent Psychiatrist if use of the Mental Health Act may be necessary to keep the young person safe (if they have a mental health problem of a nature and severity necessitating admission to hospital).

Informed consent to share information should be sought if the child or young person is competent unless:

  • The situation is urgent and delaying in order to seek consent may result in serious harm to the young person;
  • Seeking consent is likely to cause serious harm to someone or prejudice the prevention or detection of serious crime.

If consent to information sharing is refused, or can/should not be sought, information should still be shared in the following circumstances:

  • There is reason to believe that not sharing information is likely to result in serious harm to the young person or someone else or is likely to prejudice the prevention or detection of serious crime; and
  • The risk is sufficiently great to outweigh the harm or the prejudice to anyone which may be caused by the sharing; and
  • There is a pressing need to share the information.

Professionals should keep parents informed and involve them in the information sharing decision even if a child is competent or over 16. However, if a competent child wants to limit the information given to their parents or does not want them to know it at all; the child's wishes should be respected, unless the conditions for sharing without consent apply.

Where a child is not competent, a parent with parental responsibility should give consent unless the circumstances for sharing without consent apply.


The Role of Schools

Schools can play an important role in primary prevention – by raising awareness about Mental Health problems in general. Successful Mental health programmes focus on addressing and managing the difficulties faced by young people and equipping them with the skills to cope, including recognising problems in peers and the best ways to help them. Schools staff need to be included in all relevant planning meetings, to be aware of the problems and pressures young people face and of sources of help and support for them.


Sources of Help

Confidential phone lines

Internet

Young Minds – Mental Health information for parents, carers, young people, professionals
Website: www.youngminds.org.uk

Elefriends – Moderated website where young people can receive support any time of day or night
Website: www.elefriends.org.uk

MindEd – Online advice and training for families and professionals
Website: www.minded.org.uk

Papyrus – For prevention of young suicide - provides advice, support, training
Website: www.papyrus-uk.org


Further Information

The links relate to publications about self-harm and suicide with sections about children and young people as in the latest national strategy:

‘Preventing suicide in England: a cross government outcomes strategy to save lives’ September 2012.

Mental Health Foundation (2003) Suicide amongst children and young people

Truth Hurts: Report of the National Inquiry into Self-harm among Young People. Mental Health Foundation 2006

Hawton, K, Rodham, K and Evans, E (2006), By Their Own Hand: Deliberate Self-harm and Suicidal Ideas in Adolescents. London: Jessica Kingsley

Royal College of Psychiatrists Managing Self-harm in Young People (2014)

Guidance for Developing a Local Suicide Prevention Action Plan: Information for  Public Health Staff in Local Authorities (2014)

Self harm in children and young people handbook, ChiMat (2011)

Kingsbury, S.J. 1993. Parasuicide in adolescence: a message in a bottle. ACPP Review & Newsletter, 15, 253-259

Townsend E. 2014. Self-harm in young people. Evidenced Based Mental Health, 17: 97 – 99

Websites:

National Self Harm Network Forum
Website: www.nshn.co.uk

Papyrus – For prevention of young suicide - provides advice, support, training
Website: www.papyrus-uk.org

MindEd – Online advice and training for families and professionals
Website: www.minded.org.uk

Get Connected - free, confidential helpline service for young people under 25 who need help, but don't know where to turn.
Tel: 0808 8084 994
Website: www.getconnected.org.uk


Amendments to this chapter

This chapter was reviewed and updated in August 2016. It has been substantially amended throughout and should be read in its entirety.

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