Self Harm and Suicidal Behaviour

1. Definition

Definitions from the Mental Health Foundation (2003) are:

• Deliberate self-harm is self-harm without suicidal intent, resulting in non-fatal injury. Self-harm is defined as intentional self-poisoning or self-injury, irrespective of motive (NICE, 2011);
• Attempted suicide is self-harm with intent to take life, resulting in non-fatal injury;
• Suicidal intent is indicated by evidence of premeditation (such as saving up tablets), taking care to avoid discovery, failing to alert potential helpers, carrying out final acts (such as writing a will) and choosing a violent or aggressive means of deliberate self-harm allowing little chance of survival;
• Suicide is an intentional, self-inflicted, life-threatening act resulting in death from a number of means.

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.

Self-harm is a broad term that can be used to describe the various things that young people do to hurt themselves. It includes cutting or scratching the skin, burning/branding with cigarettes/lighters, scalding, overdose of tablets or other toxins, tying ligatures around the neck, banging limbs/head and hair pulling (Mental Health Foundation, 2006).

The relationship between self-harm and suicidal behaviour is a complicated one. Suicidal behaviour refers to thoughts and behaviours related to suicide and self-harm that don't have a fatal outcome. These thoughts include the more specific outcomes of suicidal ideation (an individual having thoughts about intentionally taking their own life); suicide plan (the formulation of a specific action by a person to end their own life) and suicide attempt (engagement in a potentially self-injurious behaviour in which there is at least some intention of dying as a result of the behaviour).

For the vast majority of young people self-harm is a maladaptive coping strategy intended to help them continue with life not end it. Most self -harm in adolescents inflicts little actual harm, does not come to the attention of medical services and appears to serve an emotional regulation function to manage emotional distress. Self-harm will inevitably reflect an attempt to manage a high level of psychological distress and is usually precipitated by an interpersonal crises and reactive to systemic factors; e.g. being bullied, difficulties at school or work, interpersonal difficulties or relationship breakups, physical or sexual abuse, domestic violence, death of a family member or friend etc. Self-harming behaviour is therefore best understood as a meaning based threat response representing an attempt to cope with the stressors within the individual's life.

Self-harm in primary school aged children is uncommon, with prevalence rates of approx. 0.8%. It is therefore important that particular consideration is given to the possibility of current safeguarding concerns in children of this age group.

2. Indicators

The indicators that a child or young person may be at risk of taking actions to harm themselves or attempt suicide can cover a wide range of life events such as bereavement, bullying at school or a variety of forms of cyber bullying, often via mobile phones, mental health problems including eating disorders, family problems such as domestic violence and abuse or any form of child abuse as well as conflict between the child and parents/carers.

The signs of the distress the child may be under can take many forms and can include:

• Cutting behaviours;
• Other forms of self-harm, such as burning, scalding, banging, hair pulling;
• Self-poisoning;
• Not looking after their needs properly emotionally or physically;
• Direct injury such as scratching, cutting, burning, hitting yourself, swallowing or putting things inside;
• Staying in an abusive relationship;
• Taking risks too easily;
• Eating distress (anorexia and bulimia);
• Addiction for example, to alcohol or drugs;
• Low self-esteem and expressions of hopelessness.

3. 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 focus of the assessment should be on the child or young person's needs, and how to support their immediate and long term psychological and physical safety.

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.

4. Protective and Supportive Action

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 may find it more difficult to express their thoughts.

Practitioners should talk to the child or young person and establish:

• If they have taken any substances or injured themselves, if so, the severity of this and whether medical treatment is needed;
• Find out if there is an immediate concern for the child or young person's safety;
• The location of the child or young person;
• Find out who they are with – if anyone;
• Find out 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;
• Find out what they would like to happen - their hopes and expectations.

And explore the following in a private environment, not in the presence of other pupils or patients depending on the setting:

• 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?

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;
• Feel that you need to manage this alone, seek support, advice and guidance as required. (if you need to gain further information or support, advise the young person of the timeframe for when you will be in touch again and agree the preferred contact details).

Referral to Children's Social Care:

The child or young person may be likely to suffer significant harm, which requires child protection services under s47 of the Children Act 1989, may be a Child in Need of services (s17 of the Children Act 1989), or may require an early help assessment (see Thresholds for Access to Services for Children and Families in Leicester, Leicestershire and Rutland Children's Social Care).

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

Where hospital care is needed:

Where a child or young person requires hospital treatment in relation to physical self-harm, practice should be in line with the National Institute of Health and Clinical Excellence (NICE) June 2013 (see NICE website): Those children who attend University Hospitals of Leicester NHS Trust ("UHL") will be assessed for their clinical need and managed within the hospital accordingly. All children who attend UHL will have a mental health assessment prior to their discharge. A plan for any mental health follow up will be put in place by the assessing mental health team prior to the child leaving hospital.

5. 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 Gillick Competence 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.

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/carers 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/carer with parental responsibility should give consent unless the circumstances for sharing without consent apply.

Further Information

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

Self-harm in Young People: Information for Parents, Carers and Anyone Who Works with Young People, Royal College of Psychiatrists

The Truth About Self-harm, The Mental Health Foundation

Suicide Prevention: Resources and Guidance, GOV.UK

Suicide by Children and Young People 2017, (HQIP)

Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance

Help Lines and Websites, including Local Resources: