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2.27 Safeguarding Children and Young People who Self-Harm

RELEVANT GUIDANCE

Safeguarding Children and Young People with Suicidal Behaviour

Flowchart for Action for Safeguarding Children and Young People who Self-Harm

Child and Adolescent Mental Health Service (CAMHS)

Young Minds: Provides information and advice on child mental health issues

Childline: Provides a free and confidential telephone service for children. Helpline: 0800 1111. Supporting Children at Risk of Suicide.

Samaritans: Telephone support for adults and under 18's who are experiencing difficult feelings. They provide a 24-hour service offering confidential emotional support to anyone in crisis. Helpline 08457 909090 (UK)

Papyrus - website and organisation which supports the prevention of young suicide

This chapter was added to the manual in September 2014.


Contents

  1. Introduction
  2. What is Self-Harm?
  3. Why do Children and Young People Self-Harm?
  4. Indicators that a Child or Young Person may be Self-Harming
  5. Responding to Children and Young People who Self-Harm
  6. Alternatives to Self-Harm
  7. Children and Young People from Black and Minority Ethnic Groups
  8. Transition between Services
  9. Additional Resources


1. Introduction

Self-harm is not usually triggered by one isolated event but rather a set of circumstances that leave young people overwhelmed and unable to manage their feelings: it is not the core problem but a sign and symptom of underlying emotional difficulties, used as a way of coping. Self-harm can be quite different from a suicide attempt since self-harm may be the means by which a child or young person tries to survive emotional pain, rather than being inspired by a desire to end life. However, in some cases, it can be part of the same continuum, since they are both symptoms of acute distress, and there is evidence that people who self-harm are at an increased risk of suicide.


2. What is Self-Harm?

Deliberate self-harm includes any intentional act of self-injury or self-poisoning, irrespective of the apparent motivation or intention. Self-harm is not usually about trying to get other people's attention. It often comes from feeling numb or empty, or wanting some relief. It might be linked to feeling depressed or anxious, low self-esteem, drug and alcohol abuse, relationship problem, bullying or worries about sexuality.

The most common activities are cutting and overdosing although there are many other forms such as hitting, burning, pulling hair, picking or scratching skin, swallowing things that are not edible, inserting objects into the body, and banging head and other body parts against walls. There are other activities such as eating disorders, drug and alcohol misuse and risk taking behaviours.


3. Why do Children and Young People Self-Harm?

There are many stress factors that may trigger self-harming. The NSPCC (2009) lists a number that children and young people identified:

  • Being bullied at school and online;
  • Not getting on with parents;
  • Stress and worry about academic performance and not getting on with examinations;
  • Parental divorce;
  • Bereavement;
  • Unwanted pregnancy;
  • Experience of abuse in earlier childhood (whether sexual, physical, neglect and/or emotional) - severe and prolonged sexual abuse is known to lead to a higher incidence of self-harm;
  • Difficulties associated with sexuality - lesbian, gay, bisexual and transgender young people are estimated to be two or three times more likely to self-harm than heterosexual young people, and homophobic bullying at school is implicated in higher rates of self-harm;
  • Problems to do with race, culture or religion;
  • Child Sexual Exploitation;
  • Low self-esteem;
  • Feeling rejected.

Although there are no typical groups of people who self-harm, about four times as many girls as boys do it. The groups of children and young people who may be more vulnerable to self-harm can include:

  • Young people in residential settings, such as the armed services, prison, sheltered housing, hostels and boarding schools;
  • Lesbian, gay, bisexual and transgender young people;
  • Young Asian women;
  • Young people with learning disabilities;
  • Young people with existing mental health problems;
  • Young people with substance misuse problems;
  • Vulnerable young people who miss appointments and go off the radar.


4. Indicators that a Child or Young Person may be Self-Harming

Self-harm is frequently misunderstood and stigmatised, and consequently remains hidden. Young people often feel guilty and ashamed and these feelings may be compounded by the reaction they receive when disclosing. This is a critical determinant of whether they choose to access services.

Although many young people might try to hide their self-harming behaviour, there are some obvious and less obvious signs that someone might be self-harming which include:

  • Psychological signs:
    • Obvious changes in mood;
    • Changes in sleeping and eating patterns;
    • Losing interest and pleasure in activities that were once enjoyed;
    • Decreased participation and poor communication with friends and family;
    • Hiding or washing their own clothes and avoiding situations where exposure of arm and legs is required (e.g. swimming);
    • Problems in social or intimate relationships;
    • Strange excuses provided for injuries;
    • Problems with work, school, social or family life.
  • Physical signs:
    • Unexplained injuries, such as scratches, cuts or burn marks;
    • Unexplained physical complaints such as headaches or stomach pains;
    • Wearing clothes that cover up arms and legs, even in hot weather.


5. Responding to Children and Young People who Self-Harm

Most of this section is taken from NICE guidelines.

See Flowchart for Action for Safeguarding Children and Young People who Self-Harm

A “harm minimisation” approach, which prioritises “least harm” rather than focusing on stopping it altogether, may be appropriate when it is likely that immediate referral or information sharing will compound difficulties and not be in the best interests of the child or young person.

If the young person has harmed themselves and they are in immediate danger, call the emergency services and follow the Safeguarding Children and Young People with Suicidal Behaviour Procedure, Children and Young People whose Lives are in Immediate Danger.

When working with people who self-harm, consider the risk of domestic or other violence or exploitation. A referral to Early Help Assessment or the use of a Early Help Assessment may be appropriate with their consent. A child protection referral should be made if the child or young person discloses abuse or neglect - see Referrals to Children’s Social Care.

Children and young people may be reluctant to disclose their self-harming because they are fearful that their disclosure will not be treated confidentially and that their parents and their GP or school will be informed. The worker should ask the child or young person whether they would like their family, carers or significant others to be involved in their care. Subject to the person's consent and right to confidentiality, encourage the family, carers or significant others to be involved where appropriate.

Workers who work with children or young people who self-harm should:

  • Always treat people with same care, respect and privacy as any child or young person;
  • Aim to develop a trusting, supportive and engaging relationship with them;
  • Take full account of the likely distress associated with self-harm;
  • Offer the choice of male or female staff for assessment and treatment. If it is not possible to give people a choice, explain why and record it in case notes;
  • Always ask the child or young person to explain in their own words why they have self-harmed. When people self-harm often, the reason for each act may be different on each occasion; don't assume it is done for the same reasons;
  • Involve the child or young person in decision-making and provide information about treatment or referral options;
  • Be aware of the stigma and discrimination sometimes associated with self-harm, both in the wider society and the health and other services, and adopt a non-judgemental approach;
  • Aim to foster the child or young person’s autonomy and independence wherever possible. This needs to be balanced with the capacity of the young person with perceived risks and the responsibilities and the views of parents or carers;
  • Maintain continuity of therapeutic relationships wherever possible;
  • Ensure that information about episodes of self-harm is communicated sensitively to other team members and services;
  • Be familiar with local and national resources, as well as organisations and websites that offer information and/or support for people who self-harm. There is a list of available resources at the end of this procedure - see Section 9, Additional Resources;
  • Be able to discuss and provide advice about access to these resources.


6. Alternatives to Self-Harm

The Camelot Foundation collated a list of substitutes for self-harm that young people have found to be successful:

  • Using a red felt tip pen to mark where you might usually cut;
  • Hitting a punch bag to vent anger and frustration;
  • Hitting pillows or cushions or having a good scream into a pillow or cushion;
  • Rubbing ice across your skin where you might usually cut or holding an ice cube in the crook of your arm or leg;
  • Getting outdoors and having a fast walk;
  • All other forms of exercise - really good for changing your mood and releasing adrenaline;
  • Making lots of noise either with a musical instrument or just banging on pots and pans;
  • Writing negative feelings on a piece of paper then ripping it up;
  • Keeping a diary;
  • Scribbling on a large piece of paper with a red crayon or pen;
  • Putting elastic bands on wrists, arms or legs and flicking them instead of cutting or hitting;
  • Calling and talking to a friend (not necessarily about self-harm);
  • Collage or art work - doing something creative.


7. Children and Young People from Black and Minority Ethnic Groups

Ensure that children and young people from black and minority ethnic groups who self-harm have the same access to services as other people who self-harm based on clinical need and that services are culturally appropriate. When language is a barrier to accessing or engaging with services for people who self-harm, provide them with:

  • Information in their preferred language and in an accessible format;
  • Psychological or other interventions, where needed, in their preferred language;
  • Independent interpreters.


8. Transition between Services

Workers should anticipate that the ending of treatment, services or relationships, as well as transitions from one service to another, can provoke strong feelings and increase the risk of self-harm, and:

  • Plan in advance these changes with the person who self-harms and provide additional support, if needed, with clear contingency plans should crises occur;
  • Record plans for transition to another service and share them with other health and social care professionals involved;
  • Give copies to the service user and their family, carers or significant others if this is agreed with the child or young person;
  • CAMHS and adult health and social care professionals should work collaboratively to minimise any potential negative effect of transferring young people from CAMHS to adult services;
  • Time the transfer to suit the young person, even if it takes place after they reach the age of 18 years.


9. Additional Resources

Child and Adolescent Mental Health Service (CAMHS)

Young Minds: Provides information and advice on child mental health issues

Childline: Provides a free and confidential telephone service for children. Helpline: 0800 1111. Supporting Children at Risk of Suicide.

Samaritans: Telephone support for adults and under 18's who are experiencing difficult feelings. They provide a 24-hour service offering confidential emotional support to anyone in crisis. Helpline 08457 909090 (UK)

Papyrus - website and organisation which supports the prevention of young suicide

End