3.9 Self-harm and Suicidal Behaviour
Please see the self-harm pathway for further information.
- Self-harm pathway
- Action to be taken
- Issues - Information Sharing and Consent
- Further information
Download the Self-harm pathway.
NHS England defines self-harm as: 'when somebody intentionally damages or injures their body. It’s usually a way of coping with or expressing overwhelming emotional distress.'
The term self-harm rather than deliberate self-harm is the preferred term as it is 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 who deliberately self-harm may kill themselves by accident.
Self-harm can be described as a 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 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.
The NSPCC has details of the warning signs to look for. These include:
Physical signs of self-harm
These are commonly on the head, wrists, arms, thighs and chest and include:
- bald patches from pulling out hair
Young people who self-harm are also very likely to keep themselves covered up in long-sleeved clothes even when it's really hot.
Emotional signs of self-harm
The emotional signs are harder to spot and don't necessarily mean that a young person is self-harming. But if you see any of these as well as any of the physical signs then there may be cause for concern.
- depression, tearfulness and low motivation
- becoming withdrawn and isolated, for example wanting to be alone in their bedroom for long periods
- unusual eating habits; sudden weight loss or gain
- low self-esteem and self-blame
- drinking or taking drugs
Action to be taken
The NSPCC has detailed information on what action should be taken if a child is self-harming. This includes:
- Show understanding
- Talk it over
- Discover the triggers
- Build their confidence
- Choose who you tell carefully
- Help them find new ways to cope
If 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):
Triage, assessment and treatment should be undertaken by paediatric nurses and doctors trained to work with children who self-harm in a separate area of the emergency department for children.
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 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.
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, advise carers to remove all means of self-harm, including 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.
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/carers 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/carer with parental responsibility should give consent unless the circumstances for sharing without consent apply.
- Self-harm in young people: information for parents, carers and anyone who works with young people Royal College of Psychiatrists
- The truth about self-harm – The Mental Health Foundation
- Suicide prevention: resources and guidance (GOV.UK)
- Suicide by Children and Young People 2017 (HQIP)
- The Mix – essential support for under 25s
- National Self Harm Network
- Young Minds
- Charlie Waller Memorial Trust