Self-harm and Suicidal Behaviour

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Self-harm and Suicidal Behaviour

REGULATIONS AND STANDARDS

The Fostering Services (England) Regulations 2011
Regulation 15 - Health of child placed with foster parents

Fostering Services: National Minimum Standards:
STANDARD 4 - safeguarding children
STANDARD 6 - promoting good health and wellbeing

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.

Definition
Indicators
Risks
Protective and Supportive Action
Information Sharing and Consent
Specialist Support
Notifications
Further Information

1. 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.

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 and circumstances. These can include racial discrimination, disability, mental health problems, bullying, family dynamics, bereavement, domestic violence history and previous caring responsibilities.

It is important to consider the impact on children and young people who have experienced trauma historically and the current influence on their wellbeing.

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;
Unexplained injury if the behaviours are not witnessed such as unexplained bruises, cuts or cigarette burns;
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, lack of motivation, self-loathing and withdrawal from things that were important to them.

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.. It is important to try and understand what the child is communicating and if any physical, environmental or emotional changes have occurred, and how the behaviours are soothing them and if an immediate solution could be implemented.

3. Risks

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.

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 the Fostering Agency and the foster carers.

Good multi-disciplinary working is important and all health professionals including the GP should be aware of the child or young person's risk of self-harm to avoid prescribing medication without the foster carers knowledge or support.

All planning should be dynamically reviewed in line with the children/ young person’s needs.

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 care plan.

4. Protective and Supportive Action

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 should be learnt and observations of their responses to their environmental stimuli will assist to inform their likes and dislikes and what makes them happy and sad.

Foster carers should talk to the child or young person and establish:

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;
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 dictate 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 child/ 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 them 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 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.

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 Clinical Excellence (NICE) June 2013 (see NICE website):

The foster carer will support the child and young person at this time. If an alternative placement is needed to support the child or young person's mental health, the Agency and the foster carer will help move the child or young person and support the multi-disciplinary team in any way they can.

The multi-disciplinary team around the child or young person will make decisions around consent issues and whether the young person needs to be detained to safeguard the child or young person from harm.

5. Information Sharing and Consent

The best assessment of the child or young person's needs and the risks 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 Gilick 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 child/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.

6. Specialist Support

If necessary, specialist advice or support should be sought such as from Children and Young People's Mental Health Services (CYPMHS). The CYPMHS workers and consultant psychiatrist will help formulate a protection plan around keeping the child or young person safe and advice on safety issues, medication use and how to respond and support the child and young person. They should also help support the Agency and foster carer to support the young person.

7. Notifications

If there is any suspicion that the child may be involved in self-harming or any attempts of suicide, the foster carer must notify the Agency and the social worker must be informed as soon as practicable.

All self-harming must be recorded by the foster carer.

An Incident Report must also be completed.

If First Aid is administered, details must be recorded.

A risk assessment undertaken (if it does not already exist with a view to deciding whether a strategy should be adopted to reduce or prevent the behaviour) and that strategy should be included in the child's Placement Plan.

Consideration should be given by the Agency to whether the incident is a Notifiable incident to Ofsted. See Notifications of Significant Events Procedure.