SCOPE OF THIS CHAPTER
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.
This chapter was added to the manual in November 2019 and in December 2019 the Pan Bedfordshire guidance - ‘What to do if you believe a child or young person might be at risk of suicide was added.
Definitions from the Mental Health Foundation (2003) are:
The term self-harm rather than deliberate self-harm is the preferred term as it 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 and young people who deliberately self-harm may kill themselves by accident.
Self-harm can be described as 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 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 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 violence and 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:
An assessment of risk should be undertaken at the earliest stage and should enquire about and consider the child or young person's:
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 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. 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. GP's should be aware of risk of self-harm when prescribing medication for the young people who self-harm and their family. Whilst no medication is safe taken in this context, certain medication may pose a much greater risk of harm, or death, and this should be considered when prescribing to at risk young people and others in the household.
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 may find it more difficult to express their thoughts.
Practitioners should talk to the child or young person and establish:
And explore the following in a private environment, not in the presence of other pupils or patients depending on the setting:
Referral to Children's Social Care:
The child or young person may be a Child in Need of services (s17 of the Children Act 1989), which could take the form of an early help assessment or a Common Assessment Framework (CAF) support service or they may be likely to suffer significant harm, which requires child protection services under s47 of the Children Act 1989.
The referral should include information about the back ground history and family circumstances, the community context and the specific concerns about the current circumstances, if available.
Where 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 and young people who self-harm in a separate area of the emergency department for children and young people.
Special attention should be given to:
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:
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:
For all children and young people, 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.
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:
If consent to information sharing is refused, or can/should not be sought, information should still be shared in the following circumstances:
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:
Only valid for 48hrs