5.5.2 Self Harm and Suicidal Behaviour |
RELATED CHAPTERS
This chapter should also be read in conjunction with Safeguarding Children Abused Through Sexual Exploitation Procedure.
AMENDMENT
Appendix 3: Legislation and Guidance was revised and updated in September 2018.
This chapter is currently under review.
Contents
- Introduction
- Principles Underpinning the Guidance
- The Aims of this Guidance
- Training - Safeguarding Children
- Definitions to Support the Guidance
- The Risk Assessment Process
- Baseline Risk Assessment Tool: Questions and Guidance
- Levels of Risk and Suggested Actions
- Do's and Don'ts
- Consent Issues
- Child Protection
- Further Risk Assessment Stage
- Further Assessment of Risk to Determine Referral
- Direct Referral Route to Specialist or Emergency Care
- Ongoing Support Systems
Appendix 1: Self Harm Care Pathway
Appendix 2: Guidance on Sharing Information
Appendix 3: Legislation and Guidance
Appendix 4: Useful Organisations/Contacts
Appendix 5: Key Contacts in Hertfordshire
1. Introduction
Self harm and suicidal behaviour among children and young people has increased dramatically over the past twenty years. Research evidence reviewed by the National Inquiry into Self-harm among Young People suggests one in 12 young people have self-harmed in the UK, and that rates of self-harm are higher than anywhere else in Europe.
This guidance is intended for use and the risk assessment completion by anyone working with children and young people up to the age of 18 or 25 for those with learning difficulties or disabilities in Hertfordshire.
It has been developed via a multi agency working group and aims to offer an informed and systematic approach to addressing the needs of children and young people at risk of self- harm or suicide. It also sets out to ensure that children and young people gain appropriate support, and are assessed and referred appropriately where needed.
This guidance document recognises that children and young people who self-harm are doing so as a coping mechanism, and that telling them to stop does not work. It also seeks to support staff in working with children and young people to reduce the potential harm self-harm can cause to both the young person's physical body and to their mental well-being, e.g. self-esteem.
2. Principles Underpinning the Guidance
- Recognising self-harm as a real and sensitive issue;
- Each young person to be respected and listened to;
- Ensure the implementation of equal opportunities;
- Young people to be made aware of the local Confidentiality & Information Sharing policy;
- To work towards minimising harm and give coping strategies where appropriate;
- Recognising the young person may be part of a family unit;
- Support to be offered to families;
- Where staff feel intervention is necessary, this will be achieved through ongoing communication with the young person;
- Follow local organisation's self harm policy - within Hertfordshire's framework.
3. The Aims of this Guidance
- To improve the quality of support, advice and guidance offered to young people who self- harm, or maybe at risk of committing suicide;
- Offer consistent support to children and young people no matter what point of contact, to standardise the response of agencies regardless of what type of agency;
- To increase knowledge, skills and competence of staff to recognise the signs and respond appropriately when working with a young person who self-harms, and/or knows of someone who self-harms;
- To meet a locally identified need by service providers & commissioners.
4. Training - Safeguarding Children
Hertfordshire Safeguarding Children Partnership (HSCP) offers/delivers training on safeguarding that is available to people across the children's and young people's workforce.
Stage 1 training - All staff who are in regular contact with children and young people must, as a minimum, undertake stage 1 introductory training on safeguarding children and promoting their welfare, as per local policy requirements.
Staff in this category are in a position to identify concerns about maltreatment, including concerns, which may arise from implementing the Family First Assessment.
Stage 2 training - Staff who work regularly with children and young people, and who may be asked to contribute to an assessment of a child or young person in need, should also attend stage 2 multi agency training. This training will provide a higher minimum level of expertise and a better understanding of working together to safeguard children effectively.
Operational managers who supervise staff at this level and have strategic responsibility for the provision of services to children and young people should also attend stage 2 training.
Stage 3 training - Is for named and designated safeguarding children leads across all agencies who need to have a thorough understanding of working with complex or serious cases and have a particular responsibility for safeguarding children.
5. Definitions to Support the Guidance
Self-harm*
Self-harm describes a wide range of things that people do 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. Self-harm can involve:
- Attempted hanging;
- Overdosing of tablets or medicines;
- Cutting, often to the arms using razor blades, broken glass or knives;
- Burning using cigarettes or caustic agents;
- Punching and Bruising;
- Inserting or swallowing objects;
- Head banging;
- Pulling out hair or eyelashes.
Self Injury
Self injury is any act which involves deliberately inflicting pain and/or injury on the body, but without suicidal intent. Self injury is seen as a coping mechanism with the aim of relieving emotional distress.
NB Although self-harming behaviour is relied on as an attempt to cope and manage and may not be intentionally suicidal, it must be recognised that the emotional distress that leads to self harm can also lead to suicidal thoughts and actions.
Suicide
Suicide is an intentional, self-inflicted, life-threatening act resulting in death from a number of means.
Suicidal-intent
This is indicated by evidence of premeditation (such as saving up tablets), taking care to avoid discovery, failing to alert potential helpers, carrying out final acts (such as writing a suicide note) and choosing a violent or aggressive means of deliberate self harm allowing little chance of survival.
*The term self-harm is often used as an all encompassing term referring to suicidal thoughts and attempted suicide.
6. The Risk Assessment Process
First Contact - Baseline Risk Assessment Stage A child, a peer or a parent may directly contact a member of staff. Equally a worker may notice a change in the child's behaviour or appearance that leads to a cause for concern, as such any frontline worker should be able to complete the risk assessment. The following table lists behaviours and situations that could indicate risk of deliberate self harm or suicide in young people. This list is offered as a guide and not as a diagnostic tool.
Click here to view The Risk Assessment Process Table.
An early baseline assessment of self harm should take place to ensure that the child or young person gets timely and appropriate support.
All frontline workers need to feel confident to make an early baseline assessment via a number of basic but important questions. See below:
A designated member of staff should also be identified who can provide advice and support to workers, e.g. the school/college nurse.
If the risk assessment is completed, then this should be documented in all records and case files.
7. Baseline Risk Assessment Tool: Questions and Guidance
| Setting up the contract with the child or young person |
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| Initial questions |
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| Responses |
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| Further Questions |
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The Hertfordshire Self Harm Toolkit is a landing page which provides links to a range of other tools and information to support schools and other professionals in relation to self harm. Click here to view the Self Harm Toolkit. Please note, you need to be logged in to access the resources. Hertfordshire professionals: click here to register.
8. Levels of Risk and Suggested Actions
The following link provides a table/tool to help professionals identify levels of risk and possible actions Click here to view Levels of Risk and Suggested Actions Table The following table also identifies possible support services available for different levels of risk
Risk |
Services Available |
Low Risk |
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Raised Risk |
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High Risk |
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9. Do's and Don'ts
| Do's |
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| Don'ts |
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At this stage it is strongly recommended that the professional should ask the young person who else is aware of the young person's circumstances or has been involved to avoid risk assessment duplication.
CAMHS services can be accessed via the Single Point of Access (SPA) – 0300 777 0707.
There is also Step 2 which is Tier 2 early intervention Child and Adolescent Mental Health Service which aims to help children and young people with low level mental health impairments manage their difficulties at the earliest possible stage, so they can look forward to an emotionally healthy future. Step 2 consists of a small team of mental health professionals (nurses, psychologists, counsellors) trained in using a number of therapeutic talking therapies. They firstly offer an Initial Assessment where they meet with the referred client and their parents and assess their needs. Sometimes their difficulties can be resolved within the first session, by talking it through, offering some useful advice or by signposting the client to more appropriate organisations for their needs. In other cases, the Step 2 Advisor in partnership with the client and family may decide that it is appropriate to offer some short term therapeutic treatment. This can be up to six sessions.
In addition, Step 2 provides unnamed telephone advice to professionals working within schools and can offer some limited training too. The contact number to Step 2 is 01438 730 570 - Please note, this number is for professionals only, not parents or young people.
If there is also drug and alcohol misuse happening you may also want to make a referral to the Change Grow Live CGL
Responses to the risk assessment questions together with an assessment of the appearance and behaviour of the child or young person will lead to:
- An increased awareness of the child's or young person's needs but no further action, or
- An increased awareness of the child's or young person's needs and an on-going support and potential re-assessment system being put in place locally, or
- A recognised need for the child or young person to be referred on for a more in-depth assessment and support.
10. Consent Issues
If a young person is deemed to need support from other professionals the worker supporting the individual will:
- Seek consent from the young person to share information (See Appendix 2: Guidance on Sharing Information, Section 5);
- Tell the young person what information will be shared, why it should be shared and the consequences of sharing (See Appendix 2: Guidance on Sharing Information).
Sometimes concerns of significant harm may lead to referral being made without consent.
However, it is highly recommended to seek consent where possible.
11. Child Protection
After the baseline risk assessment, or at any stage of the care pathway, if a professional is concerned that the child is in need of protection, they should call the Customer Call Centre on 0300 123 4043 For out of hours service (after 8 pm) calls will automatically be diverted to an agency, who can contact the Children's Services Out of Hours Service (SOOHS) on your behalf (except textphone/minicom, callers need to redial 01992 632150).
The usual child protection procedure should then be followed whereby a section 47 enquiry / core assessment will be carried out by Children's Social Services in consultation with the Police and other agencies.
If an urgent referral is required schools can contact CAMHS* via the school nurse, TAS (the Targeted Advice Service) on 01438 737511 or Children's Services on 0300 123 4043. Alternatively, parents/carers can request a referral to CAMHS via their child’s GP. In the case of self inflicted injuries needing treatment, when substances or tablets have been ingested, or a child or young person is at imminent risk of suicide, an emergency referral to A&E would be required, usually via a 999 call for an ambulance.
CAMHS can also be contacted through the Single Point of Access (SPA) contact number 0300 777 0707
12. Further Risk Assessment Stage
At the Further Risk Assessment stage a number of key workers will be in a position to offer a more in-depth risk assessment and thus determine whether the child or young person needs further support.
Assessment at this stage using the proforma in Section 8, Levels of Risk and Suggested Actions will lead to one of the following outcomes:
- An increased awareness of the child's or young person's needs but no further action;
- An increased awareness of the child's or young person's needs and an on-going support and potential re-assessment system being put in place;
- Identification of a high risk of need leading to either emergency admission or referral to any of those stipulated in the Referral Routes box within the Self Harm Care Pathway (Appendix 1: Self Harm Care Pathway). Also refer to questions in Section 7, Baseline Risk Assessment Tool: Questions and Guidance.
This staged risk assessment approach ensures that staff are supported where uncertainty arises, and that children and young people receive timely and appropriate support and assessment.
13. Further Assessment of Risk to Determine Referral
Please remember that risk factors are not, nor can they ever be, tools for prediction. Also, any risk assessment can only be valid for the moment at which it is carried out and so may need to be repeated at suitable intervals according to professional judgement or advice. Risk of self-harm is not the same as risk of mental illness, and one does not need to be mentally ill to self-harm, although there may be links (see list of Risk factors).
Bear in mind that some information can be obtained from the young person, but not all, which may need to come from other sources, such as parents or carers, peers, or other professionals. The order of the factors in the list is not necessarily significant, as they are all worthy of consideration.
14. Direct Referral Route to Specialist or Emergency Care
Some staff at the 'Baseline Assessment Stage' might decide to directly refer to the professionals in the 'referral route' box. For example, a General Practitioner may refer directly to the Child and Adolescent Mental Health Service.
It is also possible that the first time any community health or education professionals learn of a child or young person in need may be after attempted suicide or deliberate self-harm that has resulted in assessment in Accident and Emergency or admission to hospital. Irrespective of the entry point on to the Referral Pathway, where a child or young person's has been deemed to need an assessment it is essential that we do not lose sight of that person post assessment.
15. Ongoing Support Systems
On-going support systems need to be put in place irrespective of the level of risk based on the-going notion that the level of perceived risk could change at any time.
On going support may take many forms and may be offered via numerous sources and will be dependent on the child or young person's needs and wishes (see table below).
Where the baseline assessment does not lead to referral for more in depth assessment it is essential that communication with the young person remains strong and that an appointed professional remains in contact with the young person on a regular basis.
If a young person has been admitted to hospital the locality Child and Adolescent Mental Health Service might continue to offer support, but equally the school/college nurse, the child's GP, or in some cases the child's social worker, may be best placed to offer on going support. One key worker should be named and identified to offer an on going point of contact for that child, with an alternative person stipulated should the key worker not be available. This needs to be agreed locally between key professionals and in consultation with the family and young person. A planning meeting may need to be convened for this purpose, and further review meetings where requires.
It is also acknowledged that parents / carers, staff and other pupils may require support themselves when supporting young people at risk of self harm. Key contact numbers for staff are available within Appendix 5: Key Contacts in Hertfordshire.
| Risk | Services Available |
| Low Risk |
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| Raised Risk |
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| High Risk |
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Appendix 1: Self Harm Care Pathway
Click here to view Appendix 1: Self Harm Care Pathway.
Appendix 2: Guidance on Sharing Information
This is concise guidance for sharing recorded information about children or young people who harm themselves or are perceived to be at risk of self-harm including suicide.
| 1. | Purpose of Sharing InformationThe purpose of sharing information is to ensure young people in need and in particular young people who harm themselves or are perceived to be at risk of self harm including suicide are given the help and support they are entitled to. |
| 2. | What will be shared?Information shared will be no more than is necessary. All information will be handled with respect and care. Unrecorded observations, which may not at first seem significant, will be freely shared on a need to know basis within statutory agencies and between partners in the interests of meeting the statutory functions of the partners. Information should be recorded if it is significant. |
| 3. | ConsentPartners will record the competent child's consent to share recorded information. Fresh consent should be sought if the existing consent does not cover the proposed sharing or there has been a break in involvement. The child should be told what information may be shared and why it would be shared and the consequences of sharing. |
| 4. | Sharing without ConsentInformed consent should be sought from the competent child to share recorded information unless;
If consent to sharing recorded information is refused by the competent child, or can/should not be sought from the child, information should still be shared in the following circumstances;
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| 5. | When is a child "competent" to give consent?Anyone under the age of 18 is a child. A judgement must be made as to whether a particular child in a particular situation is competent to consent or 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 (Fraser guidelines should be used). |
| 6. | Sharing InformationPartners who request or refer information should state;
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| 7. | FamiliesPartners should keep parents informed and involve them in the information sharing decision even if a child is competent or over 16. However, if a competent child wants to limit the information given to his 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 with parental responsibility should give consent unless the circumstances for sharing without consent apply. |
| 8. | Partners:Children's ServicesProbation, Youth Offending Team Youth Connexions, Hertfordshire Children's Trust Partnership employees and contractual partners Hertfordshire Community Health Services Hertfordshire Partnership Foundation Trust Further Education Colleges |
Appendix 3: Legislation and Guidance
| 1. | Children Act 1989 Section 17A child is defined as 'in need' by Section 17 of the Children Act (1989) if:
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| 2. | Children Act 1989 Section 47Where a local authority has reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child's welfare. 'Harm' is defined as Ill treatment, which includes sexual abuse, physical abuse and forms of ill-treatment which are not physical, for example:
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| 3. | Mental Health Act 1983The Mental Health Act 1983 is the principal Act governing the treatment of people with mental health problems in England and Wales. The Mental Health Act covers all aspects of compulsory admission and subsequent treatment. Besides these emergency procedures, there are other sections of the Act under which a person can be detained in hospital without their consent.(In November 1999 the Government issued a White Paper called 'Reforming the Mental Health Act', which was intended to act as the basis for a new Act. In June 2002 this was superseded by a draft Mental Health Bill). The Mental Health Act of 1983 covers the detention of people deemed a risk to themselves or others. It covers four categories of mental illness: severe mental impairment, mental impairment, psychopathic disorder and mental illness. The first two are generally interpreted as people with learning difficulties who have aggressive tendencies. Psychopathic disorder relates to people who have a "persistent disorder or disability of the mind" which leads to aggression. Mental illness itself is not defined by the Act. However, it does state what it does not cover, which includes people who may be deemed to be mentally ill "by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs". The Act allows people considered to be mentally ill to be detained in hospital and given treatment against their will. They do not have to commit a crime or have harmed anyone. They are usually detained because it is considered in their interests and for their own safety, but they may be held because they are deemed a risk to others. |
Mental Capacity Act 2005
The Mental Capacity Act 2005 for England and Wales come into force in 2007. The Act will generally only affect people aged 16 or over and provides a statutory framework to empower and protect people who may lack capacity to make some decisions for themselves, for example, people with dementia, learning disabilities, mental health problems, stroke or head injuries who may lack capacity to make certain decisions. It makes it clear who can take decisions in which situations and how they should go about this. It enables people to plan ahead for a time when they may lack capacity. The Act covers major decisions about someone's property and affairs, healthcare treatment and where the person lives, as well as everyday decisions about personal care (such as what someone eats), where the person lacks capacity to make the decisions themselves.Guidance and Further Reading
Northumberland Families and Children's Trust. Deliberate Self Harm and Suicide: Care Pathway for Children and Young People in Northumberland (2008)
MIND. 'Understanding Self-Harm'.
Department of Health and Social Care 2004. Case Study: Integrated Pathway for Children and Young People who Self harm
North East Regional Interagency Procedures Project 2005. Deliberate Self-harm and Suicide: Safeguarding Children and Young People
Cambridgeshire and Peterborough NHS Foundation Trust: Understanding and responding to children and young people who self-harm: a guide for practitioners (2009)
NSPCC Inform. Dealing with Self Harm. Services for Children and Young People (2008)
Social Care Institute of Excellence (2005) 'Deliberate self-harm (DSH) among children and adolescents: who is at risk and how is it recognised?' Research Briefing 16.
The truth about self-harm – The Mental Health Foundation
Suicide prevention: resources and guidance GOV.UK
Suicide by Children and Young People 2017 (HQIP)
Appendix 4: Useful Organisations/Contacts
Childline
Tel: 0800 1111
Website: Childline
British Association for Counselling and Psychotherapy (BACP)
email: bacp@bacp.co.uk
Website: bacp
Mindinfoline
Tel: 0845 766 0163
Mind is the leading mental health organisation in England and Wales, providing a
unique range of services. Mindinfoline is
Mind's helpline and information service.
Samaritans
Tel: 08457 909090
Website: Samaritans
Befriending service for anyone going through a personal crisis who is at risk of suicide.
Self-harm Alliance
PO Box 61, Cheltenham, Gloucestershire GL51 8YB
Helpline: 01242 578 820
Website: Self harm resources and publications, self-harm links
and websites
A national survivor-led voluntary group
Mental heath and counselling organisations
NHS Choices, A guide to mental health services in England
YoungMinds
parents information service: 0800 018 2138
Website: YoungMinds
For anyone concerned about a child's mental health
Websites
Other websites for staff, parents, children and young people about health, wellbeing and selfharm:
- Prevention of Young Suicide;
- Life Signs;
- National Self Harm Network;
- Talks and teaching resources from Samaritans in schools;
- Childline;
- Mind;
- The Mix;
- Young Minds.
Advice and guidance for professionals and parents/carers is also available from Hertfordshire Partnership NHS Foundation Trust (HPFT) via their Single Point of Access on 0300 777 0707 between 0800 and 1900 hours or 01438 843322 between 1700 and 0800 hours.
Hertfordshire Partnership (NHS) - Get help.
Appendix 5: Key Contacts in Hertfordshire
If an urgent referral is required then this should be direct to the child's GP, Children's Services or local CAMHS Service. In the case of self inflicted injuries needing treatment or when substances or tablets have been ingested then an emergency referral to A&E would be required, usually via a 999 call for an ambulance.
| Telephone Number | |
| CAMHS Clinics Borehamwood and Potters Bar Hemel Hempstead Hoddesdon Bishop's Stortford St. Albans (Kingsley Green) Stevenage Watford Welwyn and Hatfield |
0208 3598540 01442 259132 01992 465042 01279 827399 01923 289050 01438 781406 01923 470610 01707 351800 |
| Customer Service Centre | 0300 123 4043 |
| Customer Service Centre Out of Hours (After 8 pm) | 0300 123 4043 |
| Counselling in Schools Service | 01992 588796 |
| Family Lives (previously Parentline Plus) | 0808 800 2222 |
| Parental Drug Awareness Service (PDAS) | 01707 393934 |
| School Nurses | Contact your
school nurse
direct or via 01462 427113 |
| Youth Connexions | 0800 389 3258 |
| Target Advice Service – Practitioner Consultations | 01438 737511 |
| Police Operation Halo Team | 01707 355383 |
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