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 should talk with the child or young person as soon as possible. If the child or young person is contemplating suicide, this should be without delay.
In February 2018, this chapter was extensively updated. In particular information was added to Section 4, Protective and Supportive Action with regards to the local support available.
- Protective and Supportive Action
- Issues – Information Sharing and Consent
- Further Information
Self-harm is ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (NICE 2004).
- Self-harm is becoming increasingly common in young people;
- Self-harm is usually a sign of significant emotional distress, which may or may not be accompanied by suicidal thoughts or intent. As part of all assessments it is important to try to understand and establish the purpose of each act of self-harm. The treatment of self-harm is the most important service response in preventing suicide in young people. Previous self-harm is common in young people who die by suicide, occurring in around 52% of under 20s. (2017) Suicide by children and young people - National Confidential Inquiry Report;
- Self-harm includes a wide range of behaviours that can often be secretive and 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 to help them find appropriate help and support.
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.
We know that young people who are experiencing abuse do not always tell us directly, they indicate something is wrong through their behaviours, this is the same with self-harm. They may not tell someone directly (at first),we have to notice changes in their behaviour , enquire when they seem distressed, be interested in them and caring towards them so that they feel able to tell us what is happening.
Types of self-harm include:
- Cutting behaviours;
- Other forms of self-harm, such as burning, scalding, banging, hair pulling;
- 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.
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, anxiety;
- Social circumstances, including any safeguarding or child protection concerns ,history of abuse including domestic abuse and parental mental health problems;
- Evidence or disclosure of substance misuse;
- Previous history of self-harm or suicidal thoughts/behaviour;
- Previous history of self-harm or suicide in the wider family or peer group;
- Feeling overwhelmed, lack of sense of belonging, without any control of their situation and hopelessness.
Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged (NICE 2011).
The Columbia Suicide Severity Rating Scale (C-SSRS) supports suicide risk assessment through a series of simple, plain-language questions that anyone can ask. The answers help users identify whether someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. Free online training is available for using this scale.
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.
As levels of risk may fluctuate, a point of contact with a safety plan should be agreed to enable the child or young person to make contact if they need to.
Research indicates that many children and young people have expressed their distress / suicidal thoughts prior to taking action but the signs have not been recognised by those around them or have not been taken seriously enough.
In many cases the means to self-harm may be easily accessible medication in the immediate environment which increases the risk for impulsive actions. A plan for safe storage of medication in the household and an individualised safety plan for other potentially harmful 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 the risks 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 young people at risk and others in the household.
If the young person is caring for a child or is pregnant, the welfare of the child or unborn baby should also be considered in the assessment.
4. 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 and listen to the child or young person in a private safe environment, not in the presence of other pupils/friends/family and establish:
- If and how they have self-harmed;
- The immediate trigger and underlying stresses/concerns/issues (find out what is troubling them and how long have they felt like this)?
- Explore how imminent or likely (further) self-harm might be (their intentions/plans and risk of impulsive behaviours);
- 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.
- 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?
- Dismiss what the child or young person says;
- Disempower the child or young person;
- Ignore or dismiss their feelings or behaviour;
- See it as attention seeking or manipulative;
- Trust appearances alone, as many children and young people learn to cover up their distress.
Self-harm in primary school age children
Self-harm in children is a safeguarding concern for families and Children's Services.
Staff should always be mindful of the underlying factors which may lead a child or young person of any age to self-harm. This is particularly the case for children of primary school age as self-harm in this age group is less common. The National CAMHS Workforce Programme in their Children and Young People who Self-harm Handbook (March 2011) quote a survey of more than 10,000 children found that the prevalence of self-harm among 5-10 year-olds was 0.8% among children without any mental health issues and only slightly higher for those with any form of mental health problem.
Self-harm in primary school children is less common. Whenever information comes to the attention of staff which suggests that a primary age child may have self-harmed, staff should consider whether abuse is causing the child to self-harm or whether the carer/child could be excusing non-accidental injuries as self-inflicted. All such cases must be discussed with children's social care.
Even in those unusual cases where a primary age child is thought to have self-harmed it is important to recognise that this behaviour is an indicator of emotional distress and the child will need support to address this. Any pattern or repeated incidents of self-harm in primary age children specialist assessment and enquiries under Section 47 of the Children Act 1989.
Abuse as a cause to self-harm should also be considered in assessments of secondary age children.
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 Common Assessment Framework (CAF) 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.
In Nottingham City, there is the CAMHS SHARP (self-harm awareness and resource project). SHARP aim to raise awareness, build confidence and skills, and provide support to front-line service providers and professionals to intervene and manage young people who present with self-harm and suicidal behaviours by offering training, professional consultations and school clinics. Contact should be made through Children & Families Direct on 0115 8764800.
CAMHS Crisis Team
Where there is a mental health crisis and/or young person is expressing suicidal thoughts/plans – is at immediate risk of suicide but there is no medical need/emergency as it is prior to the young person acting on their thoughts, contact the CAMHS crisis team for advice via CAMHS SPA (Single Point of Access) teams:
City – 0115 8764000
County – 0115 8542299
CAMHS Crisis - 0115-8440560.
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 2004 (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:
- Young person's consent (including Gillick competence);
- Parental consent;
- Child protection issues;
- Use of the Mental Health Act and the Children Act;
All children and young people who have self harmed (ref NICE Guidance) 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:
- 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. If safeguarding concerns remain at the point when a child is medically fit for discharge an agreed plan to address those concerns and safeguard the child should be made between the responsible Consultant and Children’s Social Care prior to discharge (see Referrals Procedure).
During admission, the CAMHS 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 ensure all medication is securely stored, preventing easy access to 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.
Recent additional guidance, Achieving Better Access to 24/7 Urgent and Emergency Mental Health Care (2016) approves self-harm assessments to be undertaken in the ED without an overnight stay in specific circumstances.
A decision not to admit should only be made after a full biopsychosocial assessment has been completed by a practitioner who is trained, competent and experienced in working with children and young people.
For this divergence from the NICE guidance to apply, the full biopsychosocial assessment must clearly evidence that:
- The child or young person is not in need of physical treatment; and
- There are no concerns regarding immediate recurrence of self-harm if the child or young person returns home; and
- The family/carer is able to manage the child or young person’s needs; and
- The child or young person has a personalised care plan in place that covers these circumstances; and/or
- There is an alternative safe and appropriate place for the child or young person to go to; and
- There are no safeguarding concerns.
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 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 as in the latest national strategy:
Minded - MindEd is a free educational resource on children and young people's mental health for all adults.
The Columbia Lighthouse Project - the Columbia-Suicide Severity Rating Scale (C-SSRS)
Hospital Emergency Departments
QMC (Queens Medical Centre) Nottingham: 0115 9249924
Kings Mill Hospital Mansfield: 01623 622515
Bassetlaw Hospital Worksop: 01909 500990
NHS 111 service website
CAMHS SERVICES – City Targeted CAMHS (SPA – Single Point of Access)
Tel: 0115 8764000
Nottingham City - CAMHS SHARP (self-harm awareness and resource project)
Contact should be made through Children & Families Direct on 0115 8764800.
Community CAMHS, (North, South, West), (SPA – Single Point of Access)
Tel: 0115 8542299
Fax: 0115 8411238
Self Harm – The Mix a UK based charity that provides free, confidential support for young people under 25 via online, social and mobile.
Self Injury Support (support for girls and women)
National Self Harm Network – Online forum offering support to individuals who self harm to reduce emotional distress and improve their quality of life.
Samaritans or telephone: 116 123
Childline or telephone 0800 1111
Papyrus - A confidential support and advice to young people and anyone worried about a young person. We run a national helpline, HOPELineUK (Tel: 0800 068 4141), including text and email services, staffed by a team of mental health professionals who provide practical help and advice to vulnerable young people and to those concerned about any young person who may be at risk of suicide.
Harmless - A user-led organisation offering support services and information to people who self-harm, their family and friends.
LifeSIGNS - Raises awareness and provides information on self harming.
KOOTH.com - Kooth is an online counselling and emotional well-being platform for children and young people, accessible through mobile, tablet and desktop.
Calmharm App - free to download – Calm Harm provides tasks that help you resist or manage the urge to self-harm.