PG41. Self Harm and Suicidal Behaviour

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, or is contemplating this or suicide, should talk with the child or young person without delay.

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 the intent to take life, resulting in non-fatal injury;
• Suicide is self-harm, resulting in death.

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.

Deliberate self-harm is a common precursor to suicide and children and young people 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 and young people may struggle to express their feelings and will need a supportive response to assist them to explore their feelings and behaviour and the possible outcomes for them.

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 abuse or any form of child abuse as well as conflict between the child and parents.

The signs of the distress the child may be under can take many forms and can include:

• Cutting behaviours;
• Other forms of self-harm, such as burning, scalding, banging, hair pulling;
• Self-poisoning;
• Not looking after their needs properly emotionally or physically;
• Direct injury such as scratching, cutting, burning, hitting yourself, swallowing or putting things inside;
• Unexplained injury if the behaviours are not witnessed, such as unexplained bruises, cuts or cigarette burns;
• Staying in an abusive relationship;
• Taking risks too easily;
• Eating distress (anorexia and bulimia or binge eating disorder);
• Addiction for example, to alcohol or drugs;
• Low self-esteem and expressions of hopelessness, lack of motivation, self-loathing and withdrawal from things that were important to them;
• Always keeping themselves fully covered, regardless of temperature (when there are no cultural considerations).

It is important that practitioners remain professionally curious and vigilant for any indication, both in behaviour and language, and consider the impact of the child’s history.

For children or young people with a learning disability, neurodivergence, and/or a sensory disability.

Self-injury and repetitive harming behaviour could be a form of communication about both their immediate and wider environment. Practitioners should take a specialist approach on what the child is saying and what physical, environmental or emotional changes have occurred, the physical soothing the behaviour could bring and if an immediate solution could be implemented.

An assessment of risk should be undertaken at the earliest stage and should consider the child or young person's:

• Level of planning and intent;
• Frequency of thoughts and actions;
• Signs of depression;
• Signs 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 over 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.

The level of risk may fluctuate and a point of contact with a backup should be agreed to allow the child or young person to make contact if they need to.

The research indicates that many children and young people have expressed their thoughts prior to taking action but the signs have not been recognised by those around them or have not been taken seriously. In many cases the means to self-harm may be easily accessible such as medication or drugs in the immediate environment and this may increase the risk for impulsive actions.

If the young person is caring for a child or pregnant the welfare of the child or unborn baby should also be considered in the assessment.

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 will find it more difficult to express their thoughts.

Practitioners should talk to the child or young person and establish:

• If they have taken any substances or injured themselves, if so, the severity of this and whether medical treatment is needed;
• Find out if there is an immediate concern for the child or young person’s safety;
• Find out what is troubling them and if they feel they are overwhelmed or have control over their current situation ;
• Explore how imminent or likely self-harm might be;
• 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.
• If they have peers or are experiencing social isolation;
• Find out what changes the child or young person has gone through;
• If they are experiencing physical issues such as prolonged pain or infection that could impact wellbeing and behaviour such as UTI;
• If there is any history or family history regarding self-harm or suicide ideation;
• If there any signs or symptoms of a mental illness such as depression or anxiety;
• Do they have an AI companion? These companions differ from more generalised task-orientated AI chat bots such as Chat GTP and Alexa. They are programmed to emulate emotional intelligence, emotional support and companionship. It is important to remain professionally curious and try to understand what topics they discuss with these companions. These topics may direct the AI to algorithms which could lead to risks of being exposed to harmful AI behaviour which in turn could compound their issues;
• If they use social media, forums, chat rooms etc and how these make them feel. Consider if the Online Safety Act 2023 has impacted their internet use and if this has had any negative or positive impact;
• They should explore:
  • How long have they felt like this?
  • 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?

Summarise with the child to clarify your understanding of what they have shared.

Consider:

• Self-harming can be secretive and often associated with guilt and embarrassment. This can present challenges when trying to approach the subject of self-harm with a young person;
• It is important that the adult checks their own feeling and thoughts before asking any questions. If the feelings and thoughts are negative in anyway, they will be communicated to the young person non-verbally and this may hinder the helping process;
• It is important to young people to have someone to talk to who listens properly and does not judge;
• Take a non-judgemental attitude towards the young person. Try to reassure them that you understand that the self-harm is helping them to cope at the moment and you want to help.

Do not:

• Panic or try quick solutions;
• Dismiss what the child or young person says;
• Believe that a young person who has threatened to harm themselves in the past will not carry it out in the future;
• Disempower the child or young person;
• Ignore or dismiss the feelings or behaviour;
• See it as attention seeking or manipulative;
• Trust appearances, as many children and young people learn to cover up their distress.

This information should form the basis of a safety plan. As a minimum the three ‘Ps should be included the presenting problem and the precipitating and protective factors.  

The NHS Guidelines, Staying Safe from Suicide Guidance breaks down the activity and framework for the Safety assessment and formulation of the safety management planning into;

1. Assessment – practitioners should listen, engage and validate the child or young person with acceptance. They should gather risk information from the past, present and assess for the future and support them with realistic hope. Information should be evidence based;
2. Safety formulation - A shared understanding of current problems and what makes situations better or worse; and
3. Safety management and planning - What immediate actions are needed? The plan should be finalised collaboratively to manage future changes and to be reviewed dynamically as and when needed.

The focus of the plan should be on the child or young person’s needs, and how to support their immediate and long term psychological and physical safety. Practitioners should be assured that any access to items that they can self-harm are acknowledged and addressed. For example, access to medication within the home and making stakeholders aware, such as the prescribing GP.

The plan should be clear, state who to contact and at what point, depending on the presenting risk level. It should be reviewed as and when needed and clearly outline the next steps to be taken and by whom. The process of the safety planning should be talked through with the child or young person in an accessible way and that the child, as far as practicable, understands what the plan means for them. Their challenges and feelings should be acknowledged and positive steps should be explored with them to develop realistic hope. If the young person is caring for a child or is pregnant, the welfare of the child or unborn baby should also be considered within the planning.

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. 

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.

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:

• 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);
• Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance.
• Websites:
  • The Mix – essential support for under 25s;
  • Mind;
  • www.firstsigns.org.uk;
  • www.nshn.co.uk;
  • www.papyrus-uk.org;
  • www.getconnected.org.uk.