2.11 Self-harm and suicidal behaviour
In the UK suicide is the leading cause of death in young people accounting for 14% of deaths in 10-19 year olds. Self-harm is a common precursor to suicide, and children and young people who deliberately harm themselves may unintentionally kill themselves by accident, but not all young people who exhibit self-harming behaviours are at high risk of suicide. Recent studies have indicated that just over half (52%) of under 20 year olds had a known history of self harm prior to death by suicide. Levels of self harm have risen significantly in the last 15 years with one recent study suggesting that as many as 1 in 5 (20%) young women report having self-harmed, twice the rate in young men and three times more than 15 years ago. (Suicide by Children and Young People: University of Manchester, 2017)
This guidance is intended to support practitioners to identify and support children and young people who are harming themselves or displaying suicidal behaviour. Any agency/practitioner who is made aware of a child or young person self-harming or contemplating suicide must take this seriously and offer appropriate help and intervention as the earliest possible opportunity.
- Risks and indicators
- Warning signs
- Protection and action to be taken
- Establishing the appropriate level of intervention
- Young person presenting at hospital
- Consent and confidentiality
- Further information
Self-harm is any behaviour where the intent is to deliberately cause self-harm. This could include:
- swallowing hazardous material or substances
- over/under-using medication, e.g. insulin
- hitting/punching/head banging
- skin picking/scratching/hair pulling
- taking an overdose of tablets
- alcohol/drug misuse
- self-strangulation / attempted hanging
Some people who self-harm may have a strong desire to kill themselves. However, there are other factors motivating self-harm, including a desire to escape an unbearable situation or emotional pain; to reduce tension and stress; to express hostility; to take control; or to punish self or others.
Self-harm has tended to be a secretive behaviour that can go on for a long time before being uncovered, although the increased incidence of self harm, especially in young women, has removed some of the taboo and it is now more likely to be talked about than it ever was previously. Children and young people may struggle to express their feelings in other ways and use the act of self harm to release their emotions.
The most common forms of self-harm are cutting and overdosing, with high rates of alcohol and drug use.
Attempted suicide is self-harm with the intent to take life, resulting in non-fatal injury. Suicide is self-harm that results in death.
Approximately three quarters of young people who die as a result of suicide are male and the most common methods of suicide are asphyxiation, for example by hanging, followed by overdosing. There has been a recent increase in deaths by suicide in young people, reversing a decline over the previous ten years.
Risks and indicators
There are a number of risk factors that can lead to a child or young person being vulnerable to self-harm or suicidal behaviour, many of which are common to lots of young people but most of whom will come through them over time. However a number of risk factors may combine leading to increased risk and, for some young people, attempted suicide or actual death by suicide may occur as a result of a crisis triggered by a 'final straw' stress such as a relationship breakdown, a family incident or exam pressures.
Risk factors include:
- depression or anxiety
- low self-esteem
- abuse or neglect
- unresolved issues regarding sexual orientation
- bereavement and experience of suicide by significant others
- poor parental relationships or parental separation
- domestic abuse
- social isolation and loneliness
- bullying, including cyber-bullying
- academic pressure (especially related to exams in April and May)
- suicide or self-harm related internet use
- physical health conditions that may have a social impact
- trouble at school or with the police
- alcohol or drug misuse
- family factors (mental ill health, physical illness or substance misuse)
Children or young people who are self-harming or who are contemplating suicide may display changes in behaviour, for example:
- suicide-related internet use (searching for information about suicide or posting messages with suicidal content)
- physical marks or scarring on the body
- expressions of suicidal ideation (especially to peers)
- reluctance to undress or expose specific parts of the body where injuries may be located
- changes in mood
- lowering of school grades
- becoming withdrawn
- changes in eating or sleeping habits
- expressing feelings of hopelessness or failure
- abuse of drugs or alcohol
- isolation from friends and family
Studies have also shown, however, that a proportion of young people have died as a result of suicide where this has appeared to have been 'out of the blue' with no known previous expression of suicidal intention, no reports of previous self-harm and where risk factors were not obviously present. This indicates that it is not always possible to identify young people at high risk of suicide.
Protection and action to be taken
When an incident of self-harm/suicidal behaviour is identified, the practitioner should talk to the child or young person in a respectful, calm and non-judgemental way to establish as far as possible whether they have taken any substances or injured themselves in order to establish as a priority whether the young person requires urgent medical attention. If urgent medical attention is required then this should be arranged without delay.
If medical attention is not required then it would be appropriate to explore with the child or young person the nature of their self-harming behaviour or suicidal ideation. This is not a formal mental health risk assessment at this stage as most practitioners will not be sufficiently qualified or experienced to undertake one, but a conversation with the young person will hopefully provide useful information which will inform a formal risk assessment by a suitably qualified practitioner (for example a GP, mental health or CAMHS practitioner) if a referral is made to a specialist service.
Questions which could be asked at this stage include:
- How long have they felt like this?
- Are they at risk of harm from others?
- Are they worried about something?
- Do they have any health and any other problems such as relationship difficulties, abuse or 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 could 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?
- Have they thought about ending their life? If yes, have they thought about how they would do this? How often do they think about doing this? Do they have a plan now?
- Do they know anyone else who has died as a result of suicide?
- Have they told anyone else about how they are feeling and, if so, who and have they arranged support?
- Can they identify an adult they can trust to talk to should they feel the need to self-harm?
Establishing the appropriate level of intervention
The responses provided by the young person will inform the decision about whether the child or young person is in need of additional support as part of the local early help offer, or whether an assessment by a specialist service such as CAMHS or a social work assessment is required. Practitioners should consult their local Thresholds guidance to establish what level of intervention is required and seek advice from their designated Safeguarding Lead. If there is still uncertainty, practitioners should contact specialist services for further advice as to the appropriate intervention.
Where the risk of suicide or serious self-harm is low the child or young person may require additional support which can be provided through the school or college or by an early help service commissioned to address lower level mental health issues. Where the risks are thought to be higher it may be necessary to make a referral to CAMHS for a mental health risk assessment or, if the child is at risk of suffering significant harm, a referral to children's social care may be necessary.
An assessment should consider whether:
- the parents/carers are providing adequate quality of care
- the child is exhibiting behaviour beyond the control of their parent/carer and their self-harming behaviour is beyond parental control
- the child is too young or has learning difficulties and is unable or does not give an explanation that is consistent with self-harming
- the child is being harmed or suspected of being harmed by another adult or child – this may include injury from a sibling or bullying by other children, for example.
Each early help, social care, CAMHS or multi-disciplinary assessment must produce a plan which addresses the child’s needs, seeks to alleviate the child’s distress, and, where appropriate, seeks to support the parents/carers in their parenting of the child.
If early help services have not achieved change and/or the child is unlikely to reach or maintain a satisfactory level of health or development, or their health or development is likely to be significantly impaired, a referral to children's social care should be considered.
The referral should include information about the child/young person’s background, history and family circumstances, the community context, and the specific concerns about the current circumstances.
Young person presenting at hospital
Where a child or young person presents at hospital, the healthcare professionals should undertake an assessment and can seek further advice from CAMHS emergency services.
Guidance from the National Institute of Health and Care Excellence (NICE) should be followed (see NICE website). For example, triage, assessment and treatment should be undertaken by paediatric nurses and doctors trained to work with children and young people who self-harm, ideally in a separate area of the emergency department for children and young people.
If hospital admission is appropriate all young people under 16 years should be admitted onto a paediatric ward under the overall care of a paediatrician and assessed as soon as is practicable. Alternative placements may be needed in some situations, depending on the child’s age, circumstances and physical/mental health.
A mental health professional should undertake a preliminary examination and decide what further assessment is required.
In cases of attempted suicide a hospital admission will usually be arranged to enable a psycho-social assessment, which should consider whether or not the child is at risk of significant harm and the need to refer to CAMHS and/or children's social care for assessment. CAMHS should provide a prompt assessment once a referral has been made by a hospital on young person who has been admitted following a suicide attempt or serious incident of self-harm.
Consent and confidentiality
Children and young people need to be made aware that it may not be possible for their support workers to offer complete confidentiality. If a child or young person is at serious risk of harming themselves or others, it would not be appropriate to maintain complete confidentiality. This should be explained at the beginning of any conversation with a young person.
Information will need to be gathered from the young person about the nature and extent of their self-harming behaviour or about the nature of their suicidal thoughts of behaviours. This will inform an assessment of their needs and a plan for the provision of support or specialist 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 is competent to consent or to refuse consent to sharing information. Consideration should include the child’s age, mental and emotional maturity, intelligence, vulnerability and comprehension. A child at serious risk of self-harm may lack emotional understanding and comprehension and a judgement will be required as to whether they are Gillick competent.
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; or if 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 cannot/should not be sought, information should still be shared if 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; or the risk is sufficiently great to outweigh the harm or the prejudice to anyone which may be caused by the sharing.
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 person with parental responsibility should give consent unless the circumstances for sharing without consent apply.
Further clarification is available in the Government's 'Information Sharing and Suicide prevention Consensus Statement' (2014).
- Managing self-harm in young people. Royal College of Psychiatrists. 2014.
- Self-harm Quality Standard. National Institute for Health and Care Excellence. 2013.
- Dealing with Self Harm. Services for Children and Young People. NSPCC. 2008
- Truth Hurts: Report of the National Inquiry into Self-harm among Young People. Mental Health Foundation. 2006
- The Truth About Self-Harm. Mental Health Foundation.
- Hawton, K, Rodham, K and Evans, E (2006), By Their Own Hand: Deliberate Self-harm and Suicidal Ideas in Adolescents. London: Jessica Kingsley
- Gillick Competency
- Information Sharing and Suicide Prevention: Consensus Statement (2014)
- Suicide by Children and Young People: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (University of Manchester, 2017)
Reviewed September 2017