Dr Claire Strauss | Dr Gayle Hann
Self-harm (often called ‘deliberate’ self-harm – although this term is used less nowadays as it can sound like an accusation) is:
Some people who self-harm have a mental health problem – but don’t assume this is always the case. People who self-harm are, however, likely to have strong negative feelings of emotional distress, or self-loathing, disgust or shame. Self-harm is a sign that something is wrong rather than a disorder in itself. An act of self-harm is not necessarily an attempt at suicide, and not necessarily a sign someone is having suicidal feelings. In fact, to the person who has self harmed, it can sometimes be a form of self-preservation.
Cutting and burning are common self-harm methods (but there are lots of other things we see, including head-banging, tying ligatures, taking overdoses and attempted hanging). Teenagers might use risky behavior as a form of self-harm (getting drunk, taking drugs, jumping off things and putting themselves in unsafe situations). Younger children may scratch or bite themselves.
A young person might come to hospital purely because of an episode of self-harm – or it could be picked up during an assessment for some unrelated problem.
Self harm and paediatrics
Self-harm is common. In the UK we have one of the highest rates of self-harm in Europe (400 episodes per 100000 people). Among 15–16 year olds, it’s estimated that more than 10% of girls and 3% of boys have self- harmed in the previous year. So… it’s sadly unsurprising that we see so much self-harm in acute paediatrics.
Self-harm can indicate a serious mental health or social problem. These patients need to have a detailed assessment and should receive the best help available – unfortunately this isn’t always the case. Self-harm is often stigmatized, and poorly understood, even by healthcare professionals. This means that some patients experience attitudes which make them feel more guilty or ashamed – and less likely to seek help in the future.
A positive experience can make a huge difference in starting on the road to recovery, particularly following the first attempt to seek help (15% of adolescents further self-harm within the first year). Someone who self-harms is 50-100 times more likely to eventually die by suicide, so a hospital attendance is an unmissable opportunity to intervene.
The Paediatrician’s Role:
- Overall responsibility for a child or young person presenting with self-harm.
- Performing a risk assessment before the patient is admitted to the paediatric ward – do they need constant observation or a RMN?
- Referring to mental health services, usually Child and Adolescent Mental Health Service (CAMHS).
- Treating any medical issues e.g. injuries or overdoses (check Toxbase for guidance)
- Ongoing medical care
- Caring for co-existing medical conditions
- Recognising self-harm in patients who are in hospital for another reason
- Escalating safeguarding concerns
How to discuss self-harm
Talking about self-harm can be very difficult. It might be the first time the young person has spoken about it, to anyone. Either that – or they may have had to repeat their story again and again (and again) and find this very frustrating (and potentially traumatic). They may have come across judgemental attitudes and now be reluctant to talk. There might be a lot of shrugs and ‘don’t knows’ as it can be difficult to put such difficult thoughts into words. This doesn’t mean they aren’t distressed – it can just be impossible to put things into words. Although the injuries or overdose may not seem significant the emotional distress behind them could be severe.
It is important to have enough time for this conversation, ideally without distractions, and for it to take place somewhere private.
Don’t project your own judgement, blame or frustration (which are common feelings in health professionals who see the patient as the cause of their own harm). Young people are very sensitive to these. Showing compassion and taking the young person seriously is the best way to encourage them to talk to you.
It’s not helpful to simply tell a young person ‘not to’ self-harm. Self-harming may be their only way to cope with the distress they are feeling. Sometimes it helps to acknowledge this.
The young person may not feel comfortable talking about their self-harm with their parents. They should be able to talk to you alone – but it is important to tell them about the limits of confidentiality and not promise secrecy. If you feel they are at significant risk of harm, parents may need to be made aware. Ideally encourage the young person to talk to their parents about their current difficulties. Otherwise – find out exactly what the patient does not their parents to know and aim to keep their confidence as much as possible. For example, a teenager may be happy to disclose their self-harm to their parent but not that it is due to issues around their gender identity or sexuality.
Your priority has to be physical needs (managing an overdose, major blood loss, burns or trauma). However, NICE recommends that ‘a psychosocial assessment should not be delayed until after medical treatment is complete’.
The history; acute event
- What was the method of self-harm (there may have been several)?
- If they took an overdose; what was taken? how much? what time? with any alcohol or drugs?
- Was this a suicide attempt?
- Where did they injure themselves?
- Did they tell anyone?
- Was there a trigger for it? e.g. an argument with friends, a bereavement or a perceived failure?
- How did they feel afterwards?
- When did they start self-harming?
- Which methods have they used?
- What was the trigger to start self-harming?
- What purpose does it serve, how does it make them feel?
- How often do they self-harm?
- Is there a pattern e.g. a time of day or common triggers?
- Is it getting worse or more frequent?
- Have they told anyone?
- Have they had any help from, or had contact with, mental health services?
- Have they had a diagnosis?
- Do they want to stop?
- Is there a family history of mental health problems?
- Is there a history of suicide (attempted or completed) in the family?
If there was suicidal intent, the seriousness of the attempt should be assessed:
Did they expect the method of attempted suicide to work?
Are they surprised that it didn’t work?
What preparation had they done? (e.g. stockpiling medications)
How long had they been considering suicide? Or was this impulsive?
Had they written a suicide note?
Had they made any preparations for death?
Had they told anyone about their suicidal feelings?
What was the likelihood of anyone finding them? e.g. Had they locked the door? Gone somewhere far away?
It is really important to ask about ongoing suicidal intent.
- How do they feel now that the suicide attempt failed?
- Do they have ongoing active or passive suicidal feelings?
- Do they want to try again?
- Do they have the means to try again?
- Is there anything which will stop them trying again?
Mental state assessment
A useful tool is HEEADSSS – outlined below with some examples of questions which can be adapted.
Red Flags: Is the young person at significant risk of further harm?
- Significant suicidal ideation
- Violent methods of self harm
- Significant escalation of self harm (frequency or severity)
- Associated mental health disorder – depression, anxiety, eating disorder
- Disengagement from servivces
- Absence of an effective support system
- Absence of a safety plan in the case of urges to hurt themselves
Examining self-harm injuries can feel intimate and uncomfortable. It’s usually best to wait until you have some rapport with the young person – or they might prefer someone else to examine them – which you should offer. Ideally, examine them fully (not just the current injury) to see the extent of their self-harm, including any previous injuries.
Be wary of any injuries which might not have been self-inflicted – are there safeguarding concerns?
Negative Attitudes and Misconceptions
NONE of these are true!
Treat wounds in the same way you would treat accidental wounds. Give appropriate pain relief and local anaesthesia. Ask whether the young person thinks they are likely to interfere with wound healing (this might guide your choice of sutures or glue). Be careful of using bandages, which can be used as ligatures.
Admission to the ward – how can you make the environment as safe as possible? One-on-one supervision might be necessary, possibly by a registered mental health nurse (RMN). Your hospital may have a protocol on whether a patient should be searched for self-harm implements when they are admitted to a ward.
If a patient already has a social worker, you need to let them know about their admission. If they are not known to social services – consider making an urgent referral.
Next – who is going to make the referral to CAMHS? Make sure this isn’t delayed or forgotten. Tell the patient and their parents about any referrals you make.
CAMHS will carry out a detailed psychological and risk assessment – they can also arrange any follow up. Ideally the paediatric and mental health teams should be in close contact to ensure the plan for admission and discharge is understood by everyone.
Things to consider before discharging a patient include:
- Medical and psychological fitness: both the medical and mental health teams need to agree that they are safe to leave.
- Place of discharge: are they going to a safe place? Are they going back to a supportive environment or one which might trigger further self-harm?
- Follow up plans: What is being put in place to change the circumstances which have led to self-harm? Are the mental health services going to remain involved and review the patient quickly?
- Safety netting: Make sure patients and parents know that if they are struggling, particularly if the young person is feeling unsafe, it is ok to come back for help.
- Support: What support does the young person have? Parents, family, friends, school or professionals? Is there someone that they feel comfortable going to if they need to talk? Do they have a way of reaching out in an emergency?
- Safeguarding: Have any safeguarding concerns been addressed? If necessary have social services been contacted?
- Access to further methods of self-harm: It’s impossible to remove every single possible method of self-harming, or for a young person to be constantly supervised. However – parents should be advised to keep medications locked away to discourage impulsive overdoses.
Dr Claire Strauss, Paediatric Registrar, North Middlesex Hospital, London
Dr Gayle Hann, Paediatric Consultant and Named Doctor for Child Protection, North Middlesex Hospital, London
Useful guidance for professional treating patients who self-harm
Resources for patients and parents
Childline 0800 1111
Young Minds: Parents’ Helpline 0808 802 5544.
Samaritans 08457 90 90 90