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3.14 Children who Self Harm and/or Display Suicidal Behaviour

SCOPE OF THIS CHAPTER

This chapter offers guidance for practitioners and managers on the indicators and risks associated with self-harm and suicidal behaviour. A supportive response demonstrating respect and understanding of the child or young person, along with a non-judgemental approach, are of prime importance. The flowchart indicates the process for urgent and non-urgent self-harm incidents. Please see Appendix 1: OSCB Flowchart for Procedure for supporting young people who self harm.

Any child or young person who self-harms or expresses thoughts about self-harm or suicide must be taken seriously; appropriate help and intervention should be offered at the earliest point. Any practitioner, who is made aware that a child or young person has self-harmed, or is contemplating this or suicide, should talk with the child or young person without delay. In many cases self-harm may be 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.

RELATED GUIDANCE

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

Websites

AMENDMENT

This chapter was reviewed and substantially updated in December 2015. It should be read in its entirety.


Contents

  1. Definition
  2. Self-Harm Quality Standard (NICE 2013)
  3. Prevalence
  4. Risk Factors for Self-Harm
  5. Trigger Factors for Self-Harm
  6. The Development and Continuation of Self-Harm
  7. If You Have Concerns That a Young Person May be Self-Harming
  8. Assessment and Management of Risk
  9. Urgent Management
  10. Non Urgent Management
  11. Confidentiality
  12. Further Information
  13. References

    Appendix 1: OSCB Flowchart for Procedure for supporting young people who self harm


1. Definition

Self-harm is used to refer to any act of self poisoning or self-injury that is carried out irrespective of the motivation. This commonly involves taking an overdose or self-injury by cutting but can  also include, hitting or bruising, burning, hanging, suffocation, over or under- medicating (National Institute for Health and Care Excellence, (NICE) 2013). Self-harm can be a precursor to suicide and children and young people who self-harm may kill themselves by accident.


2. Self-Harm Quality Standard (NICE 2013)

The Quality Standard covers the initial management and provision of support longer term for children, young people and adults who self-harm. These standards are that management should include;

  • Compassion, respect and dignity;
  • An initial assessment wherever presenting, of physical health, mental state, safeguarding concerns, social circumstances, risk of repetition or suicide;
  • A comprehensive psychological assessment;
  • Monitoring to reduce further risk of self-harm;
  • When in a healthcare setting it should be a safe physical environment;
  • Continued support and a collaborative management plan;
  • People receiving care have a discussion with the lead health professional about psychological interventions;
  • A development plan for movement between services.


3. Prevalence

Research studies in the UK and internationally (Madge et al 2011, Madge et al 2008, Whitlock and Rodham 2013) show that approximately 10% of adolescents report having self-harmed. Studies consistently show that self-harm is more common in female adolescents. Data collected (See, Health & Social Care Information Centre) shows that hospital admission episodes and consultant episodes are rising year on year and bear out research results that episodes are consistently higher in females.


4. Risk Factors for Self-Harm

Research indicates that the following factors increase the risk of self-harm (Madge et al 2011). The child or young persons:

  • History of self-harm and current self-harming behaviour;
  • Thoughts of suicide or self-harm;
  • Evidence of suicide planning and intent;
  • Signs or symptoms of mental health problems e.g. 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;
  • Hopelessness about their situation and the future;
  • Impulsivity;
  • Lack of problem solving skills;
  • Use of internet self-harm sites;
  • Media awareness of suicide.

Any assessment of risk factors 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 for example sudden changes in circumstances within the family or school setting. Please see, Self harm guidelines for staff within school and residential settings in Oxfordshire (Oxford Health 2012)

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.

Some children and young people may express their thoughts or change their behaviour in some way prior to self-harming but the signs are not always recognised by those around them or may not be taken seriously. Possible warning signs include a change in eating or sleeping habits, increased isolation from family or friends, expressing feelings of failure, uselessness or loss of hope, talking about self-harming or suicide, changes in activity or mood and giving away possessions. 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.


5. Trigger Factors for Self-Harm

Possible triggers 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, homophobic bullying, peer relationship problems, mental health problems including eating disorders, family problems such as domestic abuse, being taken into police custody, being detained or any form of child abuse as well as conflict between the child/young person and parents.

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

  • Self-cutting;
  • 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 themselves, swallowing or putting; things inside their body;
  • Staying in an abusive relationship;
  • Risk taking behaviours;
  • Eating difficulties including anorexia nervosa and bulimia nervosa;
  • Alcohol and/or drug use and addiction;
  • Low self-esteem and expressions of hopelessness. 


6.The Development and Continuation of Self-Harm

Self-harm can have a number of functions for the young person and can become a way of coping with a difficult situation. Examples of functions include a reduction in tension, distraction from problems, a form of escape, an outlet for anger and rage, an opportunity to feel physical pain to distract from emotional pain, a way of punishing self or others, a way of eliciting care, a means of getting identity with a peer group, a way of communicating a difficult situation, and finally it can also be a suicidal act.

Once self-harm is established the young person may be caught in a cycle of self-harm where positive effects such as a reduction in tension can lead to further self-harm, and negative effects such as shame can lead to an increase in tension and a repeat of the self-harm to manage the negative emotions.

development of self-harm behaviour in young people


7. If You Have Concerns That a Young Person May be Self-Harming

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. (See Appendix 1: OSCB Flowchart for Procedure for supporting young people who self harm.)

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

  • If they have taken any substances or injured themselves;
  • 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.

Try to explore the following in a private environment, not in the presence of other pupils or patients:

  • How long have they felt like this?
  • Who else have they told for e.g. parents?
  • 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?

Unhelpful actions:

  • Panic or trying quick solutions;
  • Dismissing what the child or young person says;
  • Not believing that a young person who has threatened to harm themselves in the past will not carry it out in the future;
  • Disempowering the child or young person;
  • Ignoring or dismissing the feelings or behaviour;
  • Seeing it as attention seeking or manipulative behaviour;
  • Trusting appearances, as many children and young people learn to cover up their distress.


8. Assessment and Management of Risk

It is important to establish whether the young person is at risk from self-harm. Any assessment of risk should be talked through with the 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. For further guidance see, for example, The Education and Residential Care Guidelines.

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

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

Some young people may be accessing websites that encourage self-harm. It is important to explore how much time young people are spending on the internet, which sites they are accessing, whether they have had any negative experiences with cyberbullying and whether they interact with people they have never met on the internet.

Management of risk will depend on the level of risk. 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 the risks when prescribing medications for 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.


9. Urgent Management

Urgent management in this context refers to urgent medical care as a result of self harming behaviour. If a child/young person is in need of urgent medical attention they should be taken to Accident and Emergency if they appear drowsy or acutely unwell an ambulance should be requested by calling 999.

Where Hospital Care is Needed

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

Detailed information regarding treatment and care once admitted to the Oxford University Hospital Trust can be found here. (See, Education and Residential Care Guidelines, Self harm referral pathway and Deliberate self-harm proforma.) 

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

Under 16

All children and young people under the age of 16 should be admitted into a paediatric ward under the overall care of a paediatrician. The day following admission a comprehensive psychosocial assessment will be performed by the mental health team. This assessment will cover risks and needs, personal background, family and social factors and any child protection issues.

Over 16

If the young person is medically unwell they will be admitted to the emergency assessment unit or medical ward and will have a comprehensive psychosocial assessment when medically fit for this. If it is not necessary for the young person to be admitted they will be seen by the self-harm service and a comprehensive psychosocial assessment carried out before discharge from the emergency department.

Following Psychosocial Assessment

The assessor will make a plan with the young person, family and professionals. The plan may include involvement of Social Services, referral to PCAMHS or CAMHS, the Early Intervention Service, School Counselling or discharge back to the GP. If there is a continuing high risk they may be transferred to a psychiatric inpatient unit for young people (Highfield Unit).

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

If a child or young person refuses admission this should be discussed with a senior Paediatrician and, if necessary, their management discussed with the on-call Child and Adolescent Psychiatrist.


10. Non Urgent Management

Where there is minor self-harm and no immediate need for urgent medical treatment for example where minor cutting has been discovered, the professional working with the young person should talk to them to ascertain how safe they are. The professional should seek permission to talk to the young person’s parents in order to maximise support available and to ensure that parents are aware of the risk so that they can safeguard their child. Where the risks are low help and support can be provided in the Early Intervention Hub or by other professionals as appropriate, such as school counsellors. If the professional is concerned about safeguarding they can contact their area social work team for a no names consultation or make a MASH referral. (Click here for information relating to reporting concerns including making a MASH referral.)

If the professional is concerned about the risk of further more serious self-harm they can contact the PCAMHS consultation line - to follow, make a referral to mental health services through the single point of access - to follow, or take the person to their GP. The GP will be able to access the CAMHS Crisis team for an urgent mental health assessment.


11. Confidentiality

Confidentiality is a key concern for young people. Professionals should respect the young person’s wishes around confidentiality as far as is possible but their health, safety and welfare are paramount. If a professional considers that a young person is at serious risk of self-harm their parents will need to be part of a plan to keep them safe. In this situation confidentiality cannot be kept, unless there are specific reasons why the family should not be involved. If this is explained at the outset of any meeting the young person can make an informed decision as to how much information they wish to divulge.

There may be some information disclosed that is safe to keep confidential. It needs to be clear to the young person exactly what information is to be disclosed and to whom. If in any doubt practitioners should consult PCAMHS or CAMHS.

Professional judgement must be exercised to determine whether a child or young person in a particular situation is competent to consent to information sharing. 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 Gillick Competency should be assessed

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

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.

Please refer to the OSCB guidance; Information Sharing Protocol.


12. Further Information

The following web links relate to publications about self-harm and suicide with sections about children and young people this is not a comprehensive list.

Department of Health

Preventing suicide in England: a cross government outcomes strategy to save lives (2012).

Mental Health Foundation 

Mental Health Foundation Website

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

NSPCC

There are a number of documents related to self-harm on the NSPCC website.

Self-Harm Specific Websites

The websites below provide valuable information for practitioners relating to self- harm. Some websites (not listed) aimed at young people who wish to find further information about self-harming behaviours are not helpful. Practitioners need to be aware of these websites and advise against their use.


13. References

Cornell Research Programme on self–injury

Duggan J.M, Whitlock J (2012) An investigation of online behaviors: self-injury in cyber space. Encyclopedia of Cyber Behaviour. IGI Global

Health and Social Care Information Centre

Kidger J, Heron J, Lewis G, Evans J, Gunnell D, (2012) Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: a self-report survey in England. BMC Psychiatry. 12 (69)1-12

Madge N, Hawton K, McMahon E,M, Corcoran P, De Leo D, de Wilde E,J, Fekete S, van Heeringen K, Ystgaard M, Arensman E, (2011) Psychological characteristics, stressful life events and deliberate self-harm: findings from the child and Adolescent Self Harm in Europe (CASE) study. European Child Adolescent Psychiatry, 20 (10), 499-508.

Madge N, Hewitt A, Hawton K, et al. (2008). Deliberate self-harm within an international community sample of young people: comparative findings from the Child and Adolescent Self-harm in Europe (CASE) Study. J Child Psychol Psychiatry, 49, 667–77.

National Institute for Health and Clinical excellence (2013) Quality Standard for self-harm.

Whitlock J, Rodham K, (2013) Understanding Non Suicidal Self-injury in Youth. School Psychology Forum: Research in Practice, 7, (4) 1-18


Appendices

Appendix 1: OSCB Flowchart for Procedure for supporting young people who self harm.

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