3.9.4 Self-Harm and Suicidal Behaviour

1. Definitions of Deliberate Self-harm and Suicide

Any child or young person who self-harms or expresses thoughts about this or about suicide has to be taken seriously and appropriate help and intervention offered at that point.

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 difference between suicide and deliberate self-harm is not always so clear. For example, deliberate self-harm is a common precursor to suicide, also children and young people who deliberately self-harm may kill themselves by accident.

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:

• Cutting behaviours;
• Other forms of self-harm, such as burning, scalding, banging, hair pulling;
• Self-poisoning.

Self-harm as a broad term for many acts that cause personal harm, ranging from someone:

• 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).

The different meanings affect research results, as studies use different parameters. They also have implications in terms of the breadth of services set up locally for children and young people, in relation to self-harm.

2. Assessment of Risk

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 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.

3. Information Sharing and Consent

See Underlying Principles and Values Procedure, Information Sharing and Confidentiality.

Informed consent to share information should be sought if the child or young person is competent unless:

• The situation is urgent and there is not time to seek consent;
• 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.

Parents should be kept informed and involved in decisions about sharing information even if the child is competent or over 16. However if the competent young person wishes to limit the information given to his parents or does not want them to know it at 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. For any age 16 to 18 presenting to and assessed in Sheffield by the mental health liaison team at the Northern General Hospital there is a requirement to contact the care provider. The care provider whether formal or informal should be made aware of the discharge plan and given an opportunity to share their concerns.

4. Responding to the Child or Young Person

In every case, the practitioner who is made aware that a child or young person has self-harmed, or is contemplating this or suicide, should talk with them without delay and:

• Ascertain if they have taken any substances, including tablets, or injured themselves (if so, the child or young person should receive urgent medical attention, even if they appear well, as harmful effects can sometimes be delayed);
• Find out if there is an immediate concern for the child or young person’s safety;
• Try to find out what may be troubling them;
• Explore to what extent self-harm is likely or imminent or planned;
• Ascertain what help or support the child or young person would wish.

A supportive attitude, 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 will find it more difficult to express their thoughts.

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

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) Self-harm in over 8s: long-term management Clinical guideline [CG133]Published: 23 November 2011 (see NICE website): 

• Triage, assessment and treatment for under 16's should take place in a separate area of the Emergency Department; (Over 16's will be seen at Sheffield Teaching Hospitals, Emergency Department and the Operational and Escalation pathway for the Assessment of 16/17 year old young people who present in crisis will be followed);
• Where a child or young person attends the hospital following self-harm and/or suicidal ideation between the hours of 09.00 – 19.00 a detailed assessment can be completed the same day and the young person discharged home with a collaboratively made safety plan. Outside of these hours young people may be required to be admitted to the hospital overnight and a detailed assessment completed the following day;
• Assessment should be undertaken by healthcare practitioners 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 child protection issues;
• Initial management should include advising carers of the need to remove all medications or other means of self-harm available to the child or young person who has self-harmed;
• All care planning should be collaborative and communicated with relevant others e.g. carers;
• Referral for additional support e.g. Early Help should be undertaken in conjunction with the young person and their carers with consent.

Any child or young person who refuses admission should be reviewed by a senior Paediatrician in Accident and Emergency and, if necessary, their management discussed with the on-call Child and Adolescent Psychiatrist.

6. Making a Referral to Children's Social Care

Where a young person is displaying Self-Harms and / or Suicidal Behaviour assessment should include consideration of the Multi Agency Threshold Guidance. Assessments indicating level 5 need referral for specialist assessment made via the Sheffield Safeguarding Hub. The same process applies  where a young person who is a carer for a child or is pregnant, self-harms, or threatens this. Referrals must also be made in respect of the child/unborn baby to Children's Social Care: see Referrals Procedure.

7. Further Information

Self-harm in young people: information for parents, carers and anyone who works with young people (Royal College of Psychiatrists)

Self Harm and Longer Term Management. National Clinical Guideline Number 133 The British Psychological Society & The Royal College of Psychiatrists, 2012

The truth about self-harm – The Mental Health Foundation

Suicide prevention: resources and guidance (GOV.UK)

Suicide by Children and Young People 2017 (HQIP)

Suicide amongst children and young people (Mental Health Foundation, 2003)

Truth Hurts: Report of the National Inquiry into Self-harm among Young People (Mental Health Foundation, 2006)

Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance

Websites:

Mind

The Mix – essential support for under 25s

Young Minds

National Self Harm Network

Papyrus