Self Harm and Suicidal Behaviour

Definitions from the Mental Health Foundation (2003) are:

• Deliberate self-harm is self-harm without suicidal intent, resulting in non-fatal injury;
• Attempted suicide is self-harm with intent to take life, resulting in non-fatal injury;
• Suicide is self-harm, resulting in death.

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 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.

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, homophobic bullying, 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.

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;
• Always keeping themselves fully covered, regardless of temperature (when there are not cultural considerations).

It is important that practitioners remain professionally curious and vigilant for any indication both in behaviour and language and have consideration into the impact of the child’s history.

For children or young people with a learning disability neurodivergence and / or a sensory disability.

Self-injury and repetitive harming behaviour could be a form of communication about both their immediate and wider environment. Practitioners should take a specialist approach on what the child is saying and what physical, environmental or emotional changes have occurred, the physical soothing the behaviour could bring and if an immediate solution could be implemented.

There is evidence to conclude that many individuals who act on self-harm or suicidal impulses can have no plans or intentions to do so, even minutes before hand. Both the NICE guidance for Self-harm: assessment, management and preventing recurrence and the NHS England Staying safe from suicide guidance emphasise that the use of suicide prediction tools, scales and stratification are flawed and should not be used and that a psychosocial approach should be taken.

The 10 key principles, within the NHS Guidelines, staying safe from suicide gives guidance on the overarching principles that should be used a framework when working with children and young people and that attention to safety should be part of a wider, holistic approach to mental health care.

Adopting a warm and empathic approach, active listening and open communication supports the building of a creating a safe space for the child and nurtures a collaborative relationship.  

If a child has a sensory or learning disability how they communicate must be learnt to ensure they have been understood.  If they communicate without language, any Positive Behaviour Support (PBS) plans should be studied, and observations should be undertaken at different times of the day to support understanding of what their reaction is to their environmental stimuli to inform their likes and dislikes and what makes them happy and sad. Those that know them best should be involved with helping with understanding their means of communication throughout the planning process.

Practitioners should talk to the child or young person in a private space and explore topics that are relevant to their age which could include :

• 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;
• If they are experiencing any delusional thoughts or behaviours;
• Find out what is troubling them and if they feel they are overwhelmed or have control over their current situation;
• 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;
• If they have peers or are experiencing social isolation;
• Find out what changes the child or young person has gone through;
• If they are experiencing physical issues such as prolonged pain or infection that could impact wellbeing and behaviour such as UTI;
• If there is any history or family history regarding self-harm or suicide ideation;
• If there any signs or symptoms of a mental illness such as depression or anxiety;
• Do they have an AI companion? These companions differ from more generalised task-orientated AI chat bots such as Chat GTP and Alexa. They are programmed to emulate emotional intelligence, emotional support and companionship. It is important to remain professionally curious and try to understand what topics they discuss with these companions. These topics may direct the AI to algorithms which could lead to risks of being exposed to harmful AI behaviour which in turn could compound their issues;
• If they use social media, forums, chat rooms etc and how these make them feel. Consider if the Online Safety Act 2023 has impacted their internet use and if this has had any negative or positive impact;
• They should explore;
• 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?

Summarise with the child to clarify your understanding of what they have shared.

Consider:

• Self-harming can be secretive and often associated with guilt and embarrassment. This can present challenges when trying to approach the subject of self-harm with a young person.
• It is important that the adult checks their own feeling and thoughts before asking any questions. If the feelings and thoughts are negative in anyway, they will be communicated to the young person non-verbally and this may hinder the helping process.
• It is important to young people to have someone to talk to who listens properly and does not judge.
• Take a non-judgemental attitude towards the young person. Try to reassure them that you understand that the self-harm is helping them to cope at the moment and you want to 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.

This information should form the basis of a safety plan. As a minimum the three ‘Ps should be included the presenting problem and the precipitating and protective factors.  

The NHS Guidelines, Staying Safe from Suicide Guidance breaks down the activity and framework for the Safety assessment and formulation of the safety management planning into;

1. Assessment – practitioners should listen, engage and validate the child or young person with acceptance. They should gather risk information from the past, present and assess for the future and support them with realistic hope. Information should be evidence based;
2. Safety formulation - A shared understanding of current problems and what makes situations better or worse; and
3. Safety management and planning - What immediate actions are needed? The plan should be finalised collaboratively to manage future changes and to be reviewed dynamically as and when needed.

The focus of the plan should be on the child or young person’s needs, and how to support their immediate and long term psychological and physical safety. Practitioners should be assured that any access to items that they can self-harm are acknowledged and addressed. For example, access to medication within the home and making stakeholders aware, such as the prescribing GP.

The plan should be clear, state who to contact and at what point, depending on the presenting risk level. It should be reviewed as and when needed and clearly outline the next steps to be taken and by whom. The process of the safety planning should be talked through with the child or young person in an accessible way and that the child, as far as practicable, understands what the plan means for them. Their challenges and feelings should be acknowledged and positive steps should be explored with them to develop realistic hope. If the young person is caring for a child or is pregnant, the welfare of the child or unborn baby should also be considered within the planning.

Referral to Children's Social Care:

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 or a support service or they may be likely to suffer significant harm, which requires child protection services under s47 of the Children Act 1989.

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. If appropriate discuss the referral with the child and give information of what supportive actions could happen.

If any concerning information arises regarding the child’s home environment, then, depending on risk either a police call should be made if in immediate danger (or any other children or vulnerable adults are in danger in property) or  a safeguarding alert should be made to the children’s safeguarding team.

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 Care Excellence (NICE) (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); With a clear outline of how the clinician has balanced this with any presenting risk consideration;
• 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 and assessed fully the following day.

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 CYPMHS 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 Child and Adolescent Psychiatrist.

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. Any available history regarding previous ability to consent should be sought. 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.

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 links relate to publications about self-harm and suicide with sections about children and young people:

NICE guidance for Self-harm: assessment, management and preventing recurrence

NHS England  Staying safe from suicide guidance

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

Suicide Prevention: Resources and Guidance, GOV.UK

Suicide by Children and Young People 2017, (HQIP)

Websites

Mind

The Mix - Essential Support for Under 25s

National Self Harm Network

Papyrus

Young Minds

Feeling Suicidal? Find Hope and Support

Understanding Child Self-Harm & Keep Them Safe | NSPCC

Self-Injurious Behaviour — CAMHS

Get help - free, 24/7, confidential mental health text support service | Shout 85258

Self Injury Support

Resource Hub - Harmless