Self-Harm and Suicide

SCOPE OF THIS CHAPTER

This document aims to provide practitioners with some basic guidelines in how to recognise and support children and young people who self-harm and/or express active suicidal intent.

Children and young people can often engage in dangerous or risk taking activities, however not all of these are categorised as purposeful self-harming. For example, drug and alcohol use, reckless driving and un-safe sex are risky behaviours for adolescents and can be harmful, but they are not always considered self-harm.

'In its broadest sense, self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way, which are damaging'. (Young people and Self Harm: A national Inquiry First interim Report 2004).

Although acts of self-harm and attempted suicide do not necessarily involve an intention to die, there is a strong association between self-harm, attempted suicide and subsequent death by suicide. Self-harm is always a sign of something being seriously wrong. Every child or young person who self-harms must be taken seriously and offered help.

This chapter was added to the manual in March 2019.

1. Self-Harm

'Self-harm is most often an expression of deep-rooted emotional problems that a young person has difficulty expressing in less harmful ways. It can be seen as a form of communication and has been described as an 'inner scream. Paradoxically, self-harm is often a means of coping with difficult feelings and, some argue, lessens the desire to attempt suicide. In this sense, it represents restraint, and may therefore be seen as a survival strategy' (MIND).

However, some children who self-harm will also experience suicidal feelings. According to the Samaritans, young people who self-harm are 100 times more likely than others to die from suicide.

Generally, suicide implies an action so drastic that it is obvious that the young person's life would end. With self-harm, the intention is not to die but to inflict damage on oneself. The young person may lack judgement about the level of self-harm applied and this can lead to irreversible harm or accidental death.

There are many forms of self-harm. These can include:

Cutting with sharp or blunt instruments - razor blades, broken glass, plastic utensils;
Scratching, with fingernails or other objects;
Stick things in their body;
Hair pulling;
Burning or scalding;
Banging their head, throwing themselves against something hard to break bones and bruise themselves;
Swallowing in appropriate objects such as razor blades;
Ingesting bleach or other chemicals;
Taking excessive amounts of over the counter medicines or prescribed drugs;
Inhaling substances such as paint, glue, aerosols, lighter fuel, chemical thinners or petrol;
Passivity in relation to self-caring, risk taking, use of drugs and alcohol, eating disorders;
Staying in an abusive relationship.

Someone who self-harms is usually in a state of distress and high emotion when they carry out the self-harm, even though to others it may appear that they are quite cool and deliberate in their actions. They may plan the self-harm in advance or may carry it out suddenly. It may happen once or twice but others self-injure on a regular basis.

1.1 Why do young people harm themselves?

Support line organisations such as ChildLine, have reported that many children and young people who self-harm have spoken about experiencing family problems, abuse, bullying, general unhappiness and feelings of depression.

Self-harm is a way of dealing with difficult feelings that can build up, making emotional 'numbness' feel real. It can also be a way of punishing oneself if feelings of guilt and shame become overwhelming and unbearable. Young people can self-injure to feel:

More in control;
Reduction in tension/distress;
More connected and alive.

An episode of self-harm can be triggered by a stressful event or an argument with a parent, carer or close friend. Very often the young person is trying to cope independently with their feelings of upset or a difficult problem encountered for the first time. They do not know how to solve their problems, or lack the support they need to cope with a big upset. They can feel overwhelmed and see no other way out.

1.2 Who self-harms?

Research can help us identify which children and young people are most likely to self-harm, the profile includes young people who:

Are very sensitive and very self-critical;
Have enormous low self-esteem and lack confidence;
Have great difficulty in liking or praising themselves;
Are very caring and thoughtful;
Are often highly intelligent;
Are often there for others, supporting them and hiding their own difficulties;
Have many more problems and life events that other adolescents (boyfriend/girlfriend problems, death of a close relative and physical abuse);
Experience eating disorders;
They often have friends who self-harm;
Belong to a sub culture such as Goths;
Are gay or bisexual.

2. Suicide

Girls attempt suicide more often than boys, though young men's attempts are more likely to be fatal. Suicide can be linked with depression, loss, failure and abuse.

'Suicide is the third main cause of death in young people after illness and accidents' (MIND).

'15-19-year-olds girls are more likely to attempt suicide, but boys are much more likely to die as a result of a suicide attempt' (MIND).

2.1 Influencing factors

There are many factors that can influence a child or young person to attempt or commit suicide. It is usually a combination of factors rather than one specific reason that precipitates suicide. Mental health difficulties can be a huge factor.

Research shows that risk factors for suicide include the following:

Depression and other mental health difficulties - Around one in ten children and young people will experience behavioural, emotional or mental health problems at some point in their lives, with twice as many boys, aged five to ten years, diagnosed with a mental health disorder compared to girls;
Substance abuse;
Prior suicide attempt;
Family history of mental health difficulties or substance abuse;
Family history of suicide - especially of a parent;
Family violence - physical or sexual abuse;
Firearms in the home;
Incarceration - youth offending / prison;
Exposure to suicidal behaviour of others - peers or media figures.

3. At Risk Groups

3.1 Bullying

For most young people, being bullied is a transient experience; however, severe or persistent bullying can have long-lasting and devastating effects on a young person's mental health. The emotional consequences of bullying include a sense of inferiority, helplessness and fear. Above all, bullying is an attack on a child's self-esteem. The young person may feel worthless and a failure. Sleep can be affected, often punctuated by bad dreams and nightmares. Persistent bullying can lead to self-injury and has been associated with suicidal ideation.

3.2 Black and Minority Ethnic Groups

Young people who experience racism or discrimination on account of their race, colour or religion are at increased risk of developing mental health problems. Families may experience racism or prejudice in housing, education or employment, compounding disadvantage. Stereotyping can lead to racist comments or even violence. Young people from minority ethnic groups may feel isolated without a sense of belonging. Young people of mixed parentage may experience additional identity and peer-related issues. Black and minority ethnic young people are over-represented in the mental health system, and they may experience forms of institutional prejudice that affect their future life chances. South Asian young women are more likely to attempt suicide than young men and women from other minority ethnic groups.

3.3 Emotional, Sexual or Physical Abuse and Neglect

Children who have been physically abused live in constant fear of the abuse happening again. Emotional abuse often takes the form of humiliation, belittling, rejecting, showing little interest in a child, and constant criticism. It is sometimes associated with parents who misuse alcohol, street drugs or other substances. Long-term emotional abuse can have a more debilitating effect on a young person's development. Sexual abuse is often accompanied by confusion, shame and feeling dirty. Young people who have been sexually abused sometimes self-injure and may even attempt suicide.

3.4 Gay and Lesbian Young People

Adolescence can be particularly challenging for gay, lesbian, bisexual and trans- gender young people. This is the time when young people form personal identities, and a young person's mental health may suffer if they do not get adequate support from families and friends. Problems can be exacerbated by the prejudices of others and a society that is sometimes judgemental and condemning. As well as ridicule, young men and women may face real or imagined threats of violence as a result of homophobia. The young person is sometimes told that this is a 'phase' they will grow out of, which can result in denial or the suppression of feelings. Gay and lesbian young people are over-represented in statistics on self-injury, depression and suicide.

3.5 Living in Care

By definition, Children Looked After have often already experienced traumatic events in their lives and may have previously used self-harm as a coping mechanism. Permanency is vital in helping the young person to rebuild or maintain a positive level of mental health. The Department of Health have highlighted that Children Looked After are five times more likely than their peers to experience a mental health disorder. There is a risk that the young person will continue to act upon these impulses as a response to the social care that is provided for them.

3.6 Living with a Parent with a Mental Health Problem

Some children and young people live with a parent who has a serious mental illness, such as depression, personality disorder or schizophrenia. The child may be affected by their parents often reduced capacity to cope as a parent, and also by the parent's illness directly. Both parents and children may feel isolated and unsupported, which can lead to distress. Furthermore, living with a parent with a significant mental illness increases the chances of a young person developing mental health problems themselves.

3.7 Prison

As many as 9 out of 10 young people in prison are thought to have at least one or a combination of mental health problems. These include personality disorder, psychosis, neurotic disorder or substance misuse; schizophrenia and bipolar disorder are also found. Many young people who end up in prison have already experienced multiple disadvantages and often not completed full-time education. Some young people in prison have experienced a range of traumas, including sexual abuse. A significant number have self-harmed or attempted suicide. Suicide and attempted suicide in prison by young men remains a serious concern. The experience of prison, the loss of liberty, being away from family and friends, and threats of violence will tend to exacerbate already complex problems.

Children and young people also suffer when a parent or close family member is sent to prison. When a parent is incarcerated, the effect of such parent-child separation may be similar to a sudden bereavement. As well as possible practical problems relating to care, loss of income and the loss of the adult as a role model, children may experience a wide range of feelings, which at times can become quite overwhelming. A child may believe that 'they' have been 'bad', that they are to blame for what has happened, and therefore may be traumatised by feelings of guilt. They may become embarrassed or feel the stigma associated with imprisonment and are therefore less likely to seek support. This can also be the case when embarrassment is felt by the wider family and the child is affected by a 'code of secrecy' leaving them confused and frustrated. In addition, children and young people with a parent in prison may feel anger towards the adult who has let them down or apparently 'abandoned' them.

3.8 Depression

Depression is characterised by on-going sadness, irritability and feelings of anxiety, guilt and a sense of worthlessness. It is deeper and more persistent than feeling just low in mood. If left untreated, depression can have serious implications for a young person and their family. School performance is likely to be adversely affected as the young person loses motivation and energy and has difficulty concentrating. Young people who are depressed find it hard to establish and maintain friendships and they may turn to alcohol and drugs as a means of coping. Eating habits are often affected, with the young person either over/under eating. Sleep patterns are also likely to be affected. Sometimes the child's depression manifests itself as anger, violence or rage. Depression in young people is treatable, especially where there is early diagnosis and treatment and support from family and friends.

3.9 Anorexia Nervosa

Anorexia nervosa is an eating disorder that can have serious physical and psychological consequences. It mainly affects girls, though it is increasingly being found in boys. Normally starting around the mid-teens, it can continue well into adulthood. The young person often has a distorted body image and has a morbid fear of putting on weight. A young person with anorexia is not without an appetite, but they self-inflict weight loss by cutting out calorific foods, most often fats. Anorexia has little to do with 'looking good' or simply dieting: often it is more to do with deep-rooted emotional problems and difficult feelings. Controlling their weight can feel like bringing control back into a young person's life. Anorexia is often associated with low self-esteem, depression and perfectionism.

3.10 Bulimia Nervosa

Bulimia is an eating disorder that mainly affects girls but is increasingly being found in boys. It often begins in the mid-to-late teens. It is associated with the alternation between eating foods high in calories (binge eating) and self-inflicted purging, which can take a number of forms, including self-induced vomiting and the use of laxatives and diuretics, in order to maintain a desired body weight. Bulimia is often a secret condition with actions hidden from family and friends. In common with anorexia, it is often symptomatic of underlying emotional difficulties and carries with it a sense of shame and guilt.

3.11 Binge Eating

Young people with a binge eating disorder consume extreme quantities of food, often when not hungry, causing great physical discomfort. The young person feels embarrassed and guilty about the eating and often feels that things have become out of control.

3.12 Illegal Drugs / Excessive Amounts of Alcohol

Illegal drugs / excessive amounts of alcohol can exacerbate the risk of self-harm, suicide and accidental death.

4. Additional System and Practitioner Risks

Mitchell and Stowe 2002 'Self harm and Suicidal Behaviour in Young Offenders' gave additional risks as listed below. Although their focus is on young offenders, their points can be applied to other children and young people.

Risk is increased when:

Systematic assessment of risk is not carried out;
Risk indicators are denied or minimised by responsible professionals;
Information is not passed from one professional to another;
Clinical responsibility is not clearly defined or transferred appropriately;
Inadequate support from family, friends and community based services;
Carers unaware of services available locally;
Provision of resources is inadequate;
Risk strategy that does not include policies and procedures for clinical risk assessment, risk management, induction and continuous training for new and established staff and serious incident review.

5. Assessment of Children and Young People

The mental health of children and young people is considered to be 'everybody's responsibility' - anyone who works with young people, not just those whose primary role is in mental health, has a responsibility for children's emotional health and wellbeing.

The social work practitioner has the opportunity to observe and build a positive relationship with the child or young person and establish if there is potential for the young person to self-harm and where appropriate undertake a through risk assessment with specialist agencies.

Formation of a plan requires the ability to assess suicidal intention and the continuing risk of the young person acting on suicidal or self-harming impulses. An assessment must be made of the young person's overall mental health and development, their psychosocial situation and the ability of those adults responsible for them to ensure their safety. The social work practitioner can:

Be aware of the personal circumstances and 'at risk factors' that exist for each individual child or young person;
Build a relationship and see the child by themselves;
Make observations i.e. the child or young person hiding parts of the their body under clothing i.e. long sleeves, saying they have accidentally hurt themselves;
Monitor changes in the demeanour of the young person, for example the child may show an improvement in their mood and become more alert. However, they can actually be at greater risk of self-harm and suicide as an increase in mood can increase motivation levels to inflict self-harm;
Encourage the child or young person to talk about their worries. Listen and help them to find their own solutions to problems.

6. Responding to the Child or Young Person

In every case, where the practitioner is aware that a child or young person has self-harmed, or is contemplating this or suicide, must talk to them without delay. The practitioner must:

Ascertain if the child or young person has ingested any substances or injured themselves. If so, the child or young person should receive urgent medical attention, even if they appear well. Harmful effects can sometimes be delayed, especially with medication such as paracetamol. Even in small quantities this drug can cause liver failure;
Always consider if immediate medical help is needed and act as any responsible adult in accessing this, contacting emergency services if necessary;
Explore to what extent self-harm is likely. Has the child made imminent or future plans identifying how, where and when?
Explore what help or support the child or young person would want;
Support the child or young person in identifying and accessing resources such as support groups, counselling and their GP;
Where a child or young person is also the carer for a child or is pregnant, self-harms or threatens this, a referral must be made in respect of the child/unborn child;
Wherever there is serious concern for a child or young person, consideration must be given to initiating a formal enquiry under Section 47 of the Children Act 1989. This process applies to all children including Children Looked After; those with a Child Protection Plan and in receipt of current social work intervention. A multi-agency strategy meeting must take place quickly and this would normally need to include CAMHS;
The purpose of the meeting would be to:
- Discuss concerns and agree whether the child or young person is at risk of significant harm;
- Agree plans for an interagency assessment and management of risk;
- Establish a care plan to support the child or young person in their home environment;
- Consider support services for the family. They may be feeling angry, frightened or guilty about the child or young person self-harming, especially if the child or young person has attempted suicide previously or another member of the family has self-harmed or died;
- Maintain focus on the needs of the child or young person throughout any Section 47 Enquiry, as this process may well be a stressor for the child or young person;
- Close liaison must be maintained with other agencies who have a role in providing help and support for the child or young person;
- Measures are put in place to minimise the risk of further self-harm which may arise from the distress of Section 47 Enquiries;
- It would be beneficial for the child or young person to have direct support from an identified professional, with whom they have a positive relationship.
Where the child or young person is currently the subject of Family Court Proceedings, whether public or private law, the Court must be informed of any self-harm or attempted suicide incident.

7. Child or Young Person Requiring Hospital Treatment for Physical Harm

Where a child for young person requires hospital treatment in relation to physical self-harm the following procedure should be followed in line with the NICE Guidance - When to suspect child maltreatment:

Triage, assessment and treatment for under 16's should take place in a separate area of A&E;
There should be overnight admission to a Paediatric or Adolescent ward with a detailed assessment the following day, with input from the CAMHS service;
Assessment should be undertaken by healthcare professionals experienced in this field;
Assessment should follow the same principles as for adults who self-harm but should also include a full assessment of the family, their social situation, family history and any child protection issues;
Initial management should include advising parents/carers of the need to remove medications and any other means of self-harm from the home environment.

Where a child or young person refuses admission must be reviewed by the senior Paediatrician in A&E and if necessary, their care management discussed with the on call Child and Adolescent Psychiatrist.

8. Interagency Procedures

8.1 Informed Consent to Share Information

It is good practice to establish issues of confidentiality with the child or young person at the beginning of the relationship if they are competent to do so. If the child or young person later discloses that they self-harm or have suicidal feelings, as the practitioner you can then share this information with other agencies where necessary. If consent to information sharing has been refused or cannot be sought, information should still be shared in the following circumstances:

The situation is urgent and there is not time to seek consent;
There is reason to believe that not sharing information is likely to result in serious harm to the young person or someone else;
Seeking consent is likely to cause serious harm to someone.

Parents should be kept informed and involved in decisions about sharing information even if the child is competent and over 16. However, if the competent young person wishes to limit the information given to his/her parents or does not want them to know all, the young person's wishes should be respected unless the conditions for sharing without consent apply. Where a child or young person is not deemed competent, a person with parental responsibility should give consent unless the circumstances for sharing without consent apply. Where the parent is the Local Authority consent must be given by the Deputy Director or Director of Children Services.

Children under 16 years of age can receive medical treatment, including treatment for mental disorders, when a parent gives consent. If a child is in care, the local authority takes the parent's place. A child can give consent for their own treatment if they are deemed to be 'Gillick competent'; that is, they are considered to have sufficient understanding to make such a choice. A person over 16 years of age is considered to be an adult and can therefore make their own decisions about treatment.

9. Recording

Observations and interactions with the child or young person must be recorded on Liquid Logic and must show that an assessment of risk of self-harm has been undertaken as part of the Child and Family Assessment and how any concerns about the child or young person have been managed internally or with other specialist agencies.