4.24 Self-Harm and Suicidal Ideas

1. Definitions and Risk Factors

Self-harm is a term used when someone injures or harms themselves on purpose rather than by accident. Common examples include ‘overdosing’ (self-poisoning), hitting, cutting or burning oneself, pulling hair or picking skin, or self-strangulation (Royal College of Psychiatrists).

Some of the reasons children may self-harm include:

• expressing or coping with emotional distress;
• trying to feel in control;
• a way of punishing themselves;
• relieving unbearable emotional distress;
• a request for help;
• a response to intrusive thoughts;
• peer influence;
• suicide challenge, otherwise known as a ‘group of death’ or ‘cult’.

Sometimes the reason is unknown. The reasons can also change over time and will not be the same for everybody.

Suicide is when a child ends their own life. There is no single reason why a child dies by suicide; social, psychological and cultural factors can contribute to someone being at greater risk of suicide.

Research by the Health Quality Improvement Partnership (HQIP) found that over half of young people who die by suicide have a history of self-harm and that, although there are many antecedents of suicide in young people, self-harm is a crucial indicator of risk and should always be taken seriously, even when the physical harm is minor.

Common themes in suicide by children and young people include:

• family factors such as mental illness;
• abuse and neglect;
• bereavement and experience of suicide;
• bullying;
• suicide-related internet use;
• academic pressures, especially related to exams;
• social isolation or withdrawal;
• physical health conditions that may have social impact;
• alcohol and illicit drugs;
• mental ill health, self-harm and suicidal ideas.

Suicide-related internet / social media platform use was defined by the HQIP as:

• searching the internet for information on suicide methods;
• visiting website(s) that may have encouraged suicide;
• communicating suicidal ideas online;
• being a victim of online bullying prior to suicide.

Internet safety is an important component of suicide prevention in young people, particularly in the under-20s (see also Internet Safety chapter).

2. Safeguarding Response

Principles for initial assessment and care by healthcare professionals and social care practitioners

When a health care or social care practitioner becomes aware of a child following an episode of self-harm, the practitioner should:

• treat the child with respect, dignity and compassion, with an awareness of cultural sensitivity;
• establish the means of self-harm and take immediate steps to keep the child safe;
• assess whether there are concerns about capacity and consent (see Section 3, Mental Capacity and Consent);
• liaise with other agencies and those involved in the child’s care (including family members and carers, as appropriate) to gather and share information to understand the context of and reasons for the self-harm (see Section 4, Information Sharing);
• establish the following as soon as possible:
• the severity of the injury and how urgently medical treatment is needed;
• the child’s emotional and mental state, and level of distress;
• whether there is immediate concern about the child’s safety;
• whether there are any safeguarding concerns. If so they should consult their safeguarding lead and make a referral to children’s social care (see Referrals chapter). If necessary take steps to ensure the immediate safety of the child – see Immediate Protection chapter;
• if there is a need to refer the child to a specialist mental health service for assessment.

2.1 Principles for initial assessment and care by non-healthcare professionals

When a child 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 child with respect, dignity and compassion, with an awareness of cultural sensitivity;
• address any immediate physical health needs resulting from the self‑harm; if necessary, call 111 or 999 or other external medical support;
• seek advice from a healthcare professional or social care practitioners, which may include referral to a healthcare or mental health service;
• address any safeguarding issues, or refer the person to the correct team for safeguarding.

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 child’s emotional and mental state, and level of distress;
• whether there is immediate concern about the child’s safety;
• whether there are any safeguarding concerns;
• if there is a need to refer the child to a specialist mental health service for assessment.

In line with NICE Self-harm Quality Standard, children who have self‑harmed will have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and immediate concerns about their safety, and receive a psychosocial assessment. A mental health professional experienced in assessing children and young people who self-harm should carry out the psychosocial assessment. They should ask about:

• the child’s social, peer group, education and home situations;
• any caring responsibilities;
• use of social media and the internet to connect with others and the effects of these on mental health and wellbeing;
• any child protection or safeguarding issues.

Children and young people who have been admitted to a paediatric ward following an episode of self-harm should have:

• access to a specialist child and adolescent mental health service (children and young people’s mental health services – CYPMHS) or age appropriate liaison psychiatry 24 hours a day;
• a joint daily review by both the paediatric team and children and young people’s mental health team;
• daily access to their family members or carers;
• regular multidisciplinary meetings between the general paediatric team and mental health services.

Following referral to children’s social care, a multi-agency safeguarding response will include assessment of the child’s situation and whether the child is in need of services under section 17 Children Act 1989 or whether the child is at risk of significant harm requiring further child protection enquiries to be made under section 47 Children Act 1989 (see Section 47 Enquiries chapter). Social care practitioners should foster a collaborative approach with all agencies involved in the child’s care, as well as their family members and carers as appropriate.

3. Mental Capacity and Consent

Assessment may be needed of the child’s mental capacity to give informed consent to medical interventions, which depends on their age. Where the child is aged 16 or over, capacity is assessed in line with the principles of the Mental Capacity Act 2005 (MCA).  A child is considered unable to make a decision if they cannot:

1. understand information about the decision to be made (‘relevant information’);
2. retain that information in their mind;
3. use or weigh that information as part of the decision making process; or
4. communicate their decision (by talking, using sign language or any other means); and
5. that inability is due to an impairment of, or a disturbance in the functioning of, their mind or brain.

Where the child is under the age of 16, the MCA does not apply and an assessment is based on whether they are ‘Gillick competent’. Where a child is assessed as being Gillick competent to make the particular decision or give the particular consent at the relevant time, they are able to give a valid consent or make a valid decision without the requirement for additional consent by a person with parental responsibility.

There is no set of defined questions to assess Gillick competency. Practitioners need to consider several things when assessing a child’s capacity to consent, including:

• the child’s age and maturity;
• their understanding of the issue and what it involves – including advantages, disadvantages and potential long-term impact;
• their understanding of the risks, implications and consequences that may arise from their decision;
• how well they understand any advice or information they have been given;
• their understanding of any alternative options, if available;
• their ability to explain a rationale around their reasoning and decision making.

Note that capacity can fluctuate, particularly if the child is in a state of emotional distress,

For further information see Mental Capacity and Consent chapter.

4. Information Sharing

A multi-agency approach is important to gain a rounded understanding of the child’s situation. Working Together to Safeguard Children sets out that no single practitioner can have a full picture of a child’s needs and circumstances so effective sharing of information between practitioners, local organisations and agencies is essential for early identification of need, assessment, and service provision to keep children safe.  Practitioners should be proactive in sharing information as early as possible to help identify, assess, and respond to risks or concerns about the safety and welfare of children.

Whilst it is good practice to be transparent and inform children and their parents / carers that information will be shared for these purposes, it is not necessary to seek consent to share information for the lawful purpose of safeguarding and promoting the welfare of a child.

For further information see the procedures on Information Sharing and Data Protection chapters.