8.1 Self-harm, suicidal behaviour & suicide

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 procedure does not cover self-injurious behaviours which is sometimes present in the context of Learning Disability or Autism and this should be assessed with reference to the learning disability safeguarding procedures (Safeguarding children with disabilities).

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

Deliberate self-harm is a common precursor to suicide and children and young people who deliberately self-harm may die 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 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, bullying (including homophobic, transphobic etc), 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;
• Mismanagement of prescribed medication (e.g insulin)
• Not looking after their needs properly emotionally or physically;
• Direct injury such as scratching, cutting, burning, hitting yourself, swallowing or putting things inside;
• Staying in an abusive relationship;
• Taking risks too easily;
• Eating distress (anorexia and bulimia);
• Addiction, for example, to alcohol or drugs;
• Low self-esteem and expressions of hopelessness.
• Withdrawal from usual activities

(As per  NICE Guidance Self-harm: assessment, management and preventing recurrence (NG225 

When a person who has self-harmed presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should:

•  treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity
• work collaboratively with the person to ensure that their views are taken into account when making decisions
• address any immediate physical health needs resulting from the self-harm, in line with locally agreed policies; if necessary, call 111 or 999 or other external medical support (The Sussex Mental Health line can be contacted via 111 option 2)
• seek advice from a healthcare professional or social care practitioners, which may include referral to a healthcare or mental health service
• ensure that the person is aware of sources of support such as local NHS urgent mental health helplines, local authority social care services, Samaritans, Combat Stress helpline, NHS111 and Childline, and that people know how to seek help promptly
• respond to safeguarding issues such as indicators and or disclosures of abuse or neglect and make onward safeguarding referral.

When a person presents to a non-health professional, for example, a teacher or a member of staff in the criminal justice system, the non-health professional should establish the following as soon as possible:

• the severity of the injury and how urgently medical treatment is needed
• the person's emotional and mental state, and level of distress
• whether there is immediate concern about the person's safety
• whether there are any safeguarding concerns
• a recognition of protective factors and the network around the young person.
• whether the person has a mental health care and safety plan, this can be established by contacting the Young person's local CAMHS team.
• if there is a need to refer the person to a specialist mental health service or Emotional Wellbeing being service for assessment, this is via a Single Point of access in some areas of Sussex CAMHS (sussexcamhs.nhs.uk).

(NICE Guidance Self-harm: assessment, management and preventing recurrence (NG225)

When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should:

• treat the person with respect, dignity and compassion, with an awareness of cultural sensitivity
• establish the means of self-harm and, if accessible to the person, discuss removing this with therapeutic collaboration or negotiation, to keep the person safe
• assess whether there are concerns about capacity, competence, consent or duty of care, and seek advice from a senior colleague or appropriate clinical support if necessary; be aware and accept that the person may have a different view and this needs to be taken into account
• seek consent to liaise with those involved in the person's care (including family members and carers, as appropriate) to gather information to understand the context of and reasons for the self-harm
• discuss with the person and their families or carers (as appropriate), their current support network, any safety plan or coping strategies.

When a person presents to a healthcare professional or social care practitioner following an episode of self-harm, the professional should establish the following as soon as possible:

• the severity of the injury and how urgently medical treatment is needed
• the person's emotional and mental state, and level of distress
• whether there is immediate concern about the person's safety
• whether there are any safeguarding concerns
• a recognition of protective factors and the network around the young person.
• whether the person has a mental health care and safety plan, this can be established by contacting the Young person's local CAMHS team.
• if there is a need to refer the person to a specialist mental health service or Emotional Wellbeing being service for assessment, this is via a Single Point of access in some areas of Sussex CAMHS (sussexcamhs.nhs.uk).

Carry out concurrent physical healthcare and the psychosocial assessment as soon as possible after a self-harm episode.

Specific guidance in Primary care, care by ambulance staff and paramedics and social care are available in Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE

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 Guidance Self-harm: assessment, management and preventing recurrence (NG225) September 2022.

Initial assessment or Triage should establish the following as soon as possible:

• the severity of the injury and how urgently physical treatment is needed
• the child/young person's emotional and mental state and level of distress
• whether there is immediate concern about the child/young person's safety
• whether there are any safeguarding concerns
• the person's willingness to accept medical treatment and mental health care
• the appropriate nursing observations level
• whether the child/young person has a mental health care and safety plan

Before discharge ensure that:

• a plan for further management has been drawn up with all appropriate agencies and people
• a planning meeting with all appropriate agencies and people has taken place and
• arrangements for aftercare have been specified, including clear written communication with the primary care team

There should be an age appropriate assessment by a mental health professional as soon as possible after arrival to complete a psychosocial assessment. (See section 7 Psychosocial Assessment, below)

Any child or young person who refuses psychosocial assessment or admission should be reviewed by a senior Paediatrician in Accident and Emergency and, if necessary, their management discussed with the on-call Child and Adolescent Psychiatrist,  and CAMHS liaison.

This should be done with reference to the National Institute of Health and Clinical Excellence NICE Guidance Self-harm: assessment, management and preventing recurrence (NG225) September 2022 - Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE

Assessment should be undertaken by healthcare practitioners experienced in this field.

Assessment should follow the same principles as for adults who self-harm, but should also include a full assessment of the family, their social situation (including peer group and education), family history, the use of social media and the internet to connect with others and the effects of these on mental health and wellbeing, any caring responsibilities, child protection and issues.

Do not delay the psychosocial assessment until after medical treatment is completed.

The psychosocial assessment should explore the functions of self-harm for the person and the strengths, vulnerabilities and needs. Including adverse childhood experiences.

Mental health professionals should undertake a risk formulation as part of every psychosocial assessment including considering if social care need to be part of this assessment.

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 as should a consideration if this person is a young carer.

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 support service or they may be at risk of  significant harm, which requires child protection services under s47 of the Children Act 1989.

The referral should include information about the background history and family circumstances, the community context and the specific concerns about the current circumstances, if available.

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 Gillick competence 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/carers informed and involve them in the information sharing decision even if a child is competent or over 16 as part of the triangle of care. Care and Safety plans should be shared with schools and social care if possible. However, if a competent child wants to limit the information given to their parents/carers or other 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.

Acute hospital trusts in Sussex should follow their internal trust pathway for self-harm and contact the Named Professionals within the trust for advice as required.

Please see - 8.51 Response to a suspected suicide | Sussex Child Protection and Safeguarding Procedures Manual.

Please see - 8.50 Responding to a potential cluster of suicides for children and young people aged under 18 | Sussex Child Protection and Safeguarding Procedures Manual

Royal College of Psychiatrists Managing Self-harm in Young People

Guidance for Developing a Local Suicide Prevention Action Plan: Information for Public Health Staff in Local Authorities NICE guideline [NG225] Published: 07 September 2022 Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE

• 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);

Websites:

• CAMHS (sussexcamhs.nhs.uk)
• Mind;
• firstsigns.org.uk;
• nshn.co.uk;
• papyrus-uk.org;
• getconnected.org.uk.