Children Who Self-Harm

Self-harm, suicide threats and gestures by a child must always be taken seriously and may be indicative of a serious mental or emotional disturbance. The frequency of self-harming behaviours in young people from middle childhood onwards is significantly increasing with adolescence being a key period of vulnerability. Whilst girls are more likely to present with impulsive and planned overdoses, often over the counter medication and easily available tablets, boys are at greater risk of completed suicide with few warning signs prior to the act of self-harm.

There is no agreed definition of self-harm. Self-harming behaviours include choices which range from low key acts by a young person to establish his/her identity and sense of personal control to serious attempts to end one's life. At one end of the spectrum is the young person's ability to choose to undergo piercings and tattoos; the other end of the spectrum could include even serious attempts to commit suicide involving knives and guns.

Self-harming behaviours are varied but include attempts to restrict weight gain by calorie restriction or bingeing and purging eating patterns, acts of self-harm by cutting with razor blades or burning the skin with cigarettes, the use of non-prescribed substances and alcohol, the inappropriate use of prescribed medication e.g. in diabetes, the use of ligatures, the swallowing of non-digestible objects e.g. batteries and attempts at hanging. Self-harming behaviours such as repeated cutting on various parts of the body including the forearms, thighs and abdomen may represent an unhelpful coping strategy for managing emotions such as anger or a sense of isolation from family and peers. Young people who self-harm habitually may also take overdoses at times of markedly low mood or when overwhelmed by thoughts of suicidal intent. Many boys especially, engage in activity such as joy riding or involvement in gangs, apparently reckless as to their safety.

Many young people experience significant stress related to academic pressures and difficulties within their peer group including bullying in school, in the community and online. Young people often experience marked anxiety in relation to their weight and appearance. Young people are vulnerable to pressures at home including physical illness and death in close family members, financial difficulties and unemployment within the household, parental mental illness and adult relationship breakdown. Young people are vulnerable to sexual exploitation and may be placed under pressure to experiment with drugs and alcohol.

The possibility that self-harm, including a serious eating disorder, may have been caused by a form of abuse or neglect should not be overlooked but young people may require considerable time and support to develop trusting relationships with professionals involved in their care before they are able to disclose their concerns. The initial presentation of a young person with an episode of self-harm at A&E requires careful and sensitive exploration as many young people self-harm on a number of previous occasions before formally seeking help from family, friends or professionals, including teachers and youth workers. Repeated presentations with self-harm should be viewed with considerable concern by the professionals involved generating a clear plan for further risk assessment based on a multi-agency assessment approach and close inter-agency communication.

This may justify a referral to Children's Social Care for an assessment as a Child in Need and/or in need of protection see the Referral, Investigation and Assessment Procedure.

Liverpool Self-Harm Multi-Agency Practice Guidance and Tool Kit has been developed in consultation with colleagues from across the LSCP Partnership. This work will be further developed to include a Training Programme which will be delivered on both LSCP and CYPMHS Training Calendar.

See Liverpool Multi-Agency Self-Harm Guidance and Toolkit 2021.

It is good practice, whenever a child or young person is known to have either made a suicide attempt or been involved in self-harming behaviour, to undertake a multi-disciplinary risk assessment, along with an assessment of need.

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 focus of the assessment should be on the child or young person's needs, and how to support their immediate and long term psychological and physical safety.

Any child or young person admitted to A&E should be first medically assessed in relation to concerns about any impairment of physical well-being and then, when fit, the young person should undergo formal mental health assessment alongside discussion with the adult(s) holding Parental Responsibility for the young person, exploring the capacity of the family and wider system to provide support and safety on discharge from hospital.

Where a child has been admitted to hospital as a result of self-harming behaviour, any discharge should involve co-ordinated planning between Children's Social Care and Children and Young People’s Mental Health Services (CYPMHS).

In the case of older adolescents there may be a need for negotiation between child and adult services in both social care and mental health services regarding appropriate provision.