Self Harm and Suicidal Behaviour

Definition

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.

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, 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.

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.

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;
• 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.

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.

Referral to Children’s Social Care:

The child or young person may be likely to suffer significant harm, which requires child protection services under Article 42 of the Children (Jersey) Law 2002. In this case a MASH enquiry with appropriate consent (see Children and Young Person Safeguarding Referrals Procedure).

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): Information on the updated Self Harm Care Pathway will be made available through the Safeguarding website when ready.

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:

• Suicide prevention: resources and guidance (GOV.UK, 2017);
• 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).

Medical Practitioners

• National Institute for Health and Care Excellence;
• Royal College of Psychiatrists Managing Self-harm in Young People (2014).

Managing the media

• Media Guidelines for Reporting Suicide.

Websites:

• Self Harm;
• National Self Harm Network;
• Papyrus;
• Get Connected.

Amendments to this Chapter

This chapter was added in June 2015.