1.4.34 Self Harm
SCOPE OF THIS CHAPTER
This guidance has been written to help practitioners support young people who have self harmed, who or who may be at risk of self harming. It explains some of the ways in which young people may harm themselves and the reasons why they do this. It contains useful advice on how to respond to a young person who has self harmed, as well as links to local and national sources of support and specialist advice / interventions.
1 in 3 people  who self-harm will do it again within a year. People who self-harm are 50 times more likely to kill themselves. It is almost impossible to say how many young people self-harm. This is because very few teenagers tell anyone what's going on, so it's incredibly difficult to keep records or have an accurate idea of scale. It is thought that around 13% of young people  may try to hurt themselves on purpose at some point between the ages of 11 and 16, but the actual figure could be much higher.
Any child or young person who self-harms, or expresses thoughts about this, 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 should talk to the child or young person without delay.
Self-harm, is defined in NICE guidance as:
"an expression of personal distress, usually made in private, by an individual who hurts him or herself. The nature and meaning of self-harm, however, vary greatly from person to person. In addition, the reason a person harms him or herself may be different on each occasion, and should not be presumed to be the same."
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.
3. Types of Self Harm
Self-harm includes any act of self-poisoning (often with medication) or self-injury irrespective of motivation. It can involve:
- Cutting, often to the arms using razor blades or knives;
- Burning or scalding;
- Inhaling or sniffing harmful substances;
- Head banging;
- Punching or hitting themselves;
- Pulling out hair or eyelashes;
- Ingesting toxic substances or objects;
- Inserting or swallowing objects;
- Misusing alcohol or drugs; or
- Deliberately starving themselves (anorexia nervosa) or binge eating (bulimia nervosa).
Understanding the motivations behind self-harm, which are often complex, wide-ranging and dependent on each individual case, is important. Self harm can be a way of obtaining relief from a difficult and otherwise overwhelming situation or emotional state. It can also be a coping mechanism to dull mental distress with the aim of preserving life, which can be a difficult concept to understand. Despite this clear distinction, young people who self-harm are known to be in a high risk group for suicide although suicidal feelings are likely to originate from the issues behind the self-harm rather than the self-harm itself. The level of a young person's self-injury (even where it is described as 'superficial') is not indicative of the level of risk of suicide. In some cases, death occurs as a result of self-harm but is not the intention.
See also Suicidal Behaviour Procedure.
4. Understanding why Children and Young People Self Harm
In most cases, people who self-harm do it to help them cope with overwhelming emotional distress, which may be caused by:
- Social problems – including being bullied (both in person or on-line), experiencing difficulties at work or school, having difficult relationships with friends or family, coming to terms with their sexuality if they think they might be gay or bisexual, or coping with cultural expectations, such as an arranged marriage, living with domestic abuse and having a parent or close family member who has died as a result of suicide;
- Trauma – including the impact of physical, sexual, emotional abuse and neglect, the death of a close family member or friend, poor parental relationships and arguments and the loss of a pregnancy through miscarriage;
- Psychological causes – mental health problems which can include repeated thoughts or voices telling a person to self-harm, disassociating (losing touch with who they are and with their surroundings), or borderline personality disorder;
- Alcohol and/or substance misuse;
- Expressing low self-esteem and hopelessness;
- Taking risks too easily in daily life;
- Individual factors – such as poor mental health, poor communication skills, low self-esteem, poor problem solving skills.
These issues can lead to a build-up of intense feelings of anger, guilt, hopelessness and self-hatred. The person may not know who to turn to for help and self-harming may become a way to release these pent-up feelings.
Self-harm is linked to anxiety and depression. These mental health conditions can affect people of any age. Self-harm can also occur alongside antisocial behaviour, such as misbehaving at school or getting into trouble with the police.
While you may feel that it is not part of your job role to carry out formal risk assessments in relation to self harm, all workers have a responsibility to talk to a child/young person who is experiencing difficulties in order to keep them safe and to help them to access the support that they need.
If a child/young person tells you that they have self-harmed you may be the first person that they have confided in. Young people have reported that the first time they speak to a professional they want to be treated with care and respect, but sometimes the response they receive can actually make their situation worse, for example if they are told to simply stop self-harming or if suicidal thoughts are dismissed as attention seeking.
6. Signs or Indicators of Self Harm
Signs of self harm can present in the following forms:
- Unexplained cuts, bruises or cigarette burns, usually on their wrists, arms, thighs and chest;
- A child or young person who keeps themselves fully covered at all times, even in hot weather;
- Signs of depression, such as low mood, tearfulness or a lack of motivation or interest in anything;
- Self-loathing and expressing a wish to punish themselves;
- Becoming very withdrawn and not speaking to others;
- Changes in eating habits or being secretive about eating, and any unusual weight loss or weight gain;
- Signs of low self-esteem, such as blaming themselves for any problems or thinking they're not good enough for something;
- Signs they have been pulling out their hair;
- Evidence of drug or alcohol misuse;
- Changes in eating/sleeping habits;
- Increased isolation from friends and family;
- Lowering of academic grades; and
- Talking about self harm and suicide.
You may feel anxious about asking a child/young person if they are self-harming; however it is important to talk about it, even if you find it uncomfortable. It is a myth that you may put the idea into their head.
Any assessment of risks should be carried out 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.
As the level of risk may fluctuate a point of contact (with a backup) should be agreed to allow the child or young person to make contact if they need to.
In many cases the means to self-harm may be easily accessible such as medication or drugs in the immediate environment and this can 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.
7. Protective and Supportive Action
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:
- If they have taken any substances or injured themselves;
- What is troubling them;
- How imminent or likely self-harm might be;
- What help or support the child or young person would wish to have;
- Who else may be aware of their feelings.
The following should be explored in a private environment, not in the presence of other pupils or patients depending on the setting:
- A full picture of the young person's life
- How long they have felt like this?
- Are they at risk of harm from others?
- Are they worried about something?
- Are they experiencing any issues with their own health and/or other problems such as relationship difficulties, abuse and sexual orientation issues?
- What other risk taking behaviour they have been involved in?
- What have they been doing that helps?
- What they are 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 they are feeling generally at the moment?
- What needs to happen for them to feel better?
- What are their strengths and vulnerabilities?
Depending on the responses received from the young person, practitioners should consider an Early Help assessment and/or a referral to Children's Social Care Services.
It is important not to:
- 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.
8. Information Sharing and Consent
Confidentiality is a key concern for young people and they need to know that it may not be possible to maintain complete confidentiality.
The best assessment of the child or young person's needs and the risks they may be exposed to requires information to be gathered in order to analyse and plan the most appropriate support services. In order to share and access information from the relevant professionals the child or young person's consent will be needed; however, 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. In making this judgement, consideration should be given to the child's chronological age, mental and emotional maturity, intelligence, vulnerability and comprehension of the issues.
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 able to make their own decisions 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 / carer with parental responsibility should give consent unless the circumstances for sharing without consent apply.
9. Support Agencies
Any child or young who requires an intervention or assessment by a Child and Adolescent Mental Health Services (CAMHS) practitioner will be treated with dignity and respect. The CAMHS practitioner will use a number of tools (for example a comprehensive assessment/ Sainsbury's risk assessment) to determine, in a timely and appropriate manner, the support and intervention that the child/ young person may require.
West Yorkshire CAMHS Contact Information
Studies (e.g. Social Work and Social Media: Online Help-seeking and the Mental Well-being of Adolescent Males, British Journal of Social Work) have shown adolescents are more likely to seek help and support online, some favouring social networks and search engines over quality health sites. Young males who sought help from friends online recorded higher levels of mental health wellbeing. Professionals need to recognise this generational shift in help-seeking behaviour.
- The Mix – Essential Support for Under 25s;
- National Self Harm Network;
- Papyrus UK – Suicide Prevention Project;
- Samaritans – Self Harm;
- For a wide range of support services for gay, lesbian, bisexual and trans people: LGBT Foundation.
- Mind in Bradford;
- Kirklees - Access to CAHMS;
- Leeds - Self Harm and Suicidal Behaviour – working with children and young people in Leeds;
- Mindmate - Advice and Support for Young People in Leeds;
- Wakefield Safeguarding Children Partnership Self Harm and Supporting Young People with Suicidal Thoughts - Guidance for Professionals Working in Universal Services.
Many voluntary sector agencies offer support for young people in non-clinical settings, such as counselling or drop-in sessions. Many children and young people value the person centred support from such agencies – see the local mental health directory or contact Public Health department for information about local services.
10. Reports and Further Information
These links relate to publications about self-harm with sections about children and young people as in the latest national strategy:
- Truth Hurts: Report of the National Inquiry into Self-harm among Young People. Mental Health Foundation 2006;
- Chief Medical Officer Report;
- Hawton, K, Rodham, K and Evans, E (2006), By Their Own Hand: Deliberate Self-harm and Suicidal Ideas in Adolescents. London: Jessica Kingsley;
- Self Harm (Nice Guidance).