2.11 Self-harm and suicidal behaviour
These guidelines are to help people working with children and young people to support people up to the age of 18 who are harming themselves or displaying suicidal behaviour. Any agency/practitioner who is made aware of a child or young people self-harming or contemplating suicide must take this seriously and offer appropriate help and intervention as the earliest possible opportunity.
- Warning signs
- Responding to self-harm or suicidal behaviour
- Confidentiality and consent
- 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
- skin picking/scratching/hair pulling
- taking an overdose of tablets
- alcohol/drug misuse
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 is a common precursor to suicide, and children and young people who deliberately self-harm may kill themselves by accident.
Self-harm is secretive behaviour that can go on for a long time before being uncovered. Children and young people may struggle to express their feelings in another way and will need a supportive response to help them to explore their feelings and behaviour.
It is thought that around 13% of young people may try to hurt themselves on purpose at some point between the ages of 11 and 16, but the actual figure could be much higher (selfharmUK statistics).
Attempted suicide is self-harm with the intent to take life, resulting in non-fatal injury. Suicide is self-harm that results in death.
There are a number of risk factors that make a child or young person vulnerable to self-harm or suicidal behaviour, including:
- depression or anxiety
- low self-esteem
- abuse or neglect
- poor parental relationships or parental separation
- domestic violence
- bullying, including cyber-bullying
- pressure at school
- trauma or bereavement
- trouble at school or with the police.
Children or young people who are self-harming or who are contemplating suicide may display changes in behaviour, for example:
- physical marks on the body
- 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- becoming withdrawn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.
An assessment of risk should be undertaken at the earliest possible stage and should consider the child or young person’s level of planning and intent to self-harm or suicide; and the frequency of those thoughts and actions. Evaluation of any warning signs should also be undertaken, including whether there is a history of self-harm or suicide in the wider family or peer group.
The assessment of risks should be talked through with the child or young person and regularly updated, as there may be changes in circumstances that increase the risk of self-harm or suicidal behaviour.
If the means to self-harm are easily accessible, such as medication or drugs in the immediate environment, 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. GPs should be aware of risk of self-harm when prescribing medication for the young people who self-harm and their family.
Responding to self-harm or suicidal behaviour
If there is concern that a child or young people is self-harming or is demonstrating suicidal behaviour, it is important that that is a supportive response that demonstrates respect and understanding of the child or young person, and is non-judgemental.
When an incident of self-harm/suicidal behaviour is identified, the practitioner should talk to the child or young person and establish whether they have taken any substances or injured themselves, and what has led to their behaviour. They should explore (in private):
- 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?
It is important not to panic or try and solve the issue quickly, or to dismiss what the child or young person is saying or feeling. It is also important not to trust appearances as children and young people often cover up distress they are feeling.
Referral to children’s social care
The child or young person may be in need of an early help or social work assessment and coordination of support services. If the child is likely to suffer significant harm, they may require protection under section 47 of the Children Act 1989.
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 child in need referral 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.
Child presenting at hospital
Where a child or young person presents at hospital, the healthcare professionals should undertake 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, in a separate area of the emergency department for children and young people.
All children and young people 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 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.
Confidentiality and consent
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, confidentiality cannot be kept. This must be explained at the outset of any meeting.
Information must be gathered on the child or young person’s needs 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 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 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; 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 can/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.
- Guidance for Developing a Local Suicide Prevention Action Plan: Information for Public Health Staff in Local Authorities. Public Health England. 2014.
- Managing self-harm in young people. Royal College of Psychiatrists. 2014.
- Self-harm Quality Standard. National Institute for Health and Care Excellence. 2013.
- Preventing suicide in England: a cross government outcomes strategy to save lives Department of Health. 2012
- 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