Self Harm and Suicidal Behaviour

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Self Harm and Suicidal Behaviour

SCOPE OF THIS CHAPTER

Any child or young person, who self-harms or expresses thoughts about this or about suicide, must be taken seriously and 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 and follow Durham's Self-Harm Guidance for Professionals working with children and young people (see Local Documents).

AMENDMENT

This chapter was updated in May 2023 to include information from Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance.

Definition
Indicators
Risks
Protective and Supportive Action
Issues – Information Sharing and Consent
Further Information
Local Documents

1. Definition

Definitions from Mental Health First Aid 2016) are:

Self-harm is a behaviour and not an illness;
People self-harm to cope with emotional distress or to communicate that they are distressed;
Self-harm can be seen as a common crisis associated with other mental health issues, such as depression, anxiety or psychotic illnesses;
Acts of self-harm occur seemly out of the person’s control or even awareness, during ‘trance like’ or dissociative states, therefore the term ‘self-harm’ is used rather than ‘deliberate’ self-harm.

People may self-harm to:

Cope with, or validate the emotional pain of psychological trauma, such as abuse. (Hurting themselves becomes an external reflection of the way they feel inside);
Survive overwhelming emotions and control feelings of helplessness and powerlessness. Intense feelings can be numbed or released by acts of self-harm and may give the person a sense of regaining control and make them ‘feel better’;
Fulfil a (perceived) need to punish themselves for actual or perceived transgressions;
Attempt to feel something when they feel disconnected from their emotions and themselves;
Communicate feelings of distress and despair where the person may lack the ability to do so in another way;
Inflicting pain can lead to the release of endorphins giving a temporary lift to mood.

It is important to note that:

Self-harm is NOT the same thing as attempted suicide. In fact, it can be a means of staying alive;
There is a risk that the person may seriously harm themselves by accident, which may result in death;
Those that self-harm themselves are at increased risk of suicide due but the only way to know for sure whether a person is experiencing suicidal thoughts is to ask them directly.

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, homophobic bullying, mental health problems including eating disorders, family problems such as domestic 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, placing ligatures around neck;
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.

(Mental Health Foundation (2022))

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:

Clarify if self-harm is used as a coping mechanism or whether there is suicidal intent;
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;
If method of self-harm has changed to more high risk behaviours, for example where previous cutting has now changed to ligature use;
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. Where the method of self-harm has changed to include more high risk behaviours, parents should be advised to be more vigilant of items in the home that could be used to ligature and professional advice should be sought at this stage if not done so already. Where there has been an escalation in self-harm, advice should be sought from CAMHS services (CAMHS Crisis Team is available 24/7).

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

In Durham, there is a self-harm and suicide pathway and guidance for practitioners. There is additional guidance for schools (see Local Documents).

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/Fraser guidelines should be used. Advice should be sought from a CAMHS Crisis Team 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.