Self Harm and Suicidal Behaviour

Definitions from NICE guidance, Self-harm: assessment, management and preventing reoccurrence:

• Intentional self-poisoning or injury, irrespective of the apparent purpose of the act. 

The term is purposefully broad and includes: 

• Self-Harm or non-suicidal self-injury: acts where the intent is to cope with distress, punish oneself, or relieve tension without the intent to die. 
• Suicidal attempts: acts where there is some degree of intent to end one's life.

The term self-harm, rather than deliberate self-harm, is the preferred term as a more neutral terminology recognising that whilst the act is intentional, it is often not within the young person's ability to control it.

Self-harm is a common precursor to suicide and children and young people who deliberately self-harm may kill themselves by accident.

Self-harm can be described as a wide range of behaviours that someone does 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. Many children and young people may struggle to express their feelings in other ways and will need a supportive response to help them explore their feelings, behaviour, and possible outcomes.

The indicators that a child or young person may be at risk of taking actions to harm themselves or attempt suicide can cover a wide range of life events and circumstances. These can include racial discrimination, disability, mental health problems, bullying, family dynamics, bereavement, domestic violence and caring responsibilities for their parents or siblings.

Groups of young people who are particularly at risk include:

• LGBTQ+ Young people.
• looked after children.
• Neurodivergent young people.

It is also important to consider the impact on children and young people who have experienced trauma historically and the current influence on their wellbeing.

• Cutting behaviours.
• Other forms of self-harm, such as burning, scalding, banging, hair pulling.
• Self-poisoning.
• Not looking after their needs properly emotionally or physically.
• Direct injury such as scratching, cutting, burning, hitting yourself, swallowing or putting things inside.
• Unexplained injury if the behaviours are not witnessed such as unexplained bruises, cuts or cigarette burns.
• Staying in an abusive relationship.
• Taking risks too easily.
• Eating distress (for example anorexia, bulimia or binge eating disorder).
• Addiction for example, to alcohol or drugs.
• Low self-esteem and expressions of hopelessness, lack of motivation, self-loathing and withdrawal from things that were important to them.
• Always keeping themselves fully covered, regardless of temperature (when there are no cultural considerations).

Practitioners must remain professionally curious and vigilant for any indications in behaviour and language and consider the impact of the child's history.

For children or young people with a learning disability, sensory disability or those who are neurodivergent.

Self-injury and repetitive harming behaviour could be a form of communication about both their immediate and wider environment. Practitioners should take a specialist approach to what the child is saying, what physical, environmental or emotional changes have occurred, the physical soothing the behaviour could bring, and whether an immediate solution can be implemented.

There is evidence to conclude that many individuals who act on self-harm or suicidal impulses can have no plans or intentions to do so, even minutes beforehand. Both the NICE guidance for Self-harm: assessment, management and preventing recurrence and the NHS England Staying safe from suicide guidance emphasise that suicide prediction tools, scales and stratification should not be used and that a psychosocial approach should be taken.

The NHS Staying Safe from Suicide best practice guidance noted that 80% of people in contact with mental health services who died by suicide are assessed as low or no risk at their last contact.

The 10 key principles, within the NHS Guidelines, staying safe from suicide, give guidance on the overarching principles that should be used as a framework when working with children and young people and that attention to safety should be part of a wider, holistic approach to mental health care. 

Adopting a warm and empathic approach, active listening, and open communication supports the building of a safe space for the child and nurtures a collaborative relationship.

If a child has a sensory or learning disability, how they communicate must be learned to ensure they have been understood.  If they communicate without language, any Positive Behaviour Support (PBS) plans should be studied, and observations should be undertaken at different times of the day to support understanding of their reactions to environmental stimuli, informing their likes and dislikes and what makes them happy and sad. Those who know them best should be involved in helping them understand their means of communication throughout the planning process.

Practitioners should talk to the child or young person in a private space and explore topics that are relevant to their age which could include:

• If they have taken any substances or injured themselves, the severity of this and whether medical treatment is needed.
• Find out if there is an immediate concern for the child or young person's safety.
• If they are experiencing any delusional thoughts or behaviours.
• Find out what is troubling them and if they feel they are overwhelmed or have control over their current situation.
• Explore how imminent or likely self-harm might be.
• Find out what help or support the child or young person would wish to have.
• Find out who else may be aware of their feelings.
• If they have peers or are experiencing social isolation.
• Find out what changes the child or young person has gone through.
• If they are experiencing physical issues such as prolonged pain or infection that could impact wellbeing and behaviour such as UTI.
• If there is any history or family history regarding self-harm or suicide ideation.
• If there any signs or symptoms of a mental illness such as depression or anxiety?
• Do they have an AI companion? These companions differ from more generalised task-oriented AI chatbots such as ChatGPT and Alexa. They are programmed to emulate emotional intelligence, emotional support and companionship. It is important to remain professionally curious and try to understand what topics they discuss with these companions. These topics may direct the AI to algorithms that could expose them to harmful AI behaviour, which in turn could compound their issues (This is a rapidly evolving and under-researched area, and guidance on this topic is likely to change).
• If they use social media, forums, chat rooms etc and how these make them feel. Consider whether the Online Safety Act 2023 has affected their internet use and whether it has had any positive or negative impact.
• They should explore.
• How long have they felt like this?
• Are they at risk of harm from others?
• Are they worried about something?
• Ask about the young person's health and any other problems such as relationship difficulties, abuse and sexual orientation issues?
• What other risk-taking behaviour have they been involved in?
• What have they been doing that helps?
• What are they 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 are they feeling generally at the moment?
• What needs to happen for them to feel better?

Summarise with the child to clarify your understanding of what they have shared.

Consider:

• Self-harming can be secretive and often associated with guilt and embarrassment. This can present challenges when trying to approach the subject of self-harm with a young person.
• It is important that the adult checks their own feelings and thoughts before asking any questions. If the feelings and thoughts are negative in any way, they will be communicated non-verbally to the young person, which may hinder the helping process.
• It is important for young people to have someone to talk to who listens properly and does not judge.
• Take a non-judgmental attitude towards the young person. Try to reassure them that you understand that the self-harm is helping them to cope at the moment and you want to help.

Do not:

• 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.

This information should serve as the basis for a safety plan. As a minimum the three 'Ps should be included the presenting problem and the precipitating and protective factors.

The NHS Guidelines, Staying Safe from Suicide Guidance breaks down the activity and framework for the Safety assessment and formulation of the safety management planning into;

1. Assessment - practitioners should listen, engage and validate the child or young person with acceptance. They should gather risk information from the past and present, assess the future, and support them with realistic hope. Information should be evidence based.
2. Safety formulation - A shared understanding of current problems and what makes situations better or worse; and
3. Safety management and planning - What immediate actions are needed? The plan should be finalised collaboratively to manage future changes and to be reviewed dynamically as and when needed.

The focus of the plan should be on the child or young person's needs and on how to support their immediate and long-term psychological and physical safety. Practitioners should be assured that any access to items that can be used to self-harm is acknowledged and addressed. For example, access to medication within the home and making stakeholders aware, such as the prescribing GP.

The plan should be clear, state who to contact and at what point, depending on the presenting risk level. It should be reviewed as and when needed and clearly outline the next steps to be taken and by whom. The safety planning process should be discussed with the child or young person in an accessible way, and the child should, as far as practicable, understand what the plan means for them. Their challenges and feelings should be acknowledged and positive steps should be explored with them to develop realistic hope. If the young person is caring for a child or is pregnant, the welfare of the child or unborn baby should also be considered within the planning.

Referral to Children's Social Care:

The child or young person may be a Child in Need of services (s17 of the Children Act 1989), which could take the form of an early help assessment or a support service or they may be likely to suffer significant harm, which requires child protection services under s47 of the Children Act 1989.

The referral should include information about the background history and family circumstances, the community context, and, if available, the specific concerns about the current circumstances. If appropriate, discuss the referral with the child and provide information on the supportive actions that could occur.

If any concerning information arises regarding the child's home environment, then, depending on risk, either a police call should be made if in immediate danger (or any other children or vulnerable adults are in danger on the property) or a safeguarding alert should be made to the children's safeguarding team.

Where hospital care is needed:

Where a child or young person requires hospital treatment in relation to physical self-harm, practice should be as follows, in line with the National Institute of Health and Care Excellence (NICE) (see NICE website):

Triage, assessment and treatment should be undertaken by paediatric nurses and doctors trained to work with children and young people who self-harm in a separate area of the emergency department for children and young people.

Special attention should be given to:

• Confidentiality.
• Young person's consent (including Gillick competence), with a clear outline of how the clinician has balanced this with any presenting risk consideration.
• Parental consent.
• Child protection issues.
• Use of the Mental Health Act and the Children Act.
• Admission.

All children and young people should normally be admitted into a paediatric ward under the overall care of a paediatrician and assessed fully by an age-appropriate liaison psychiatry professional or suitably skilled mental health professional at every attendance after self-harm, and that children admitted to a paediatric ward should have access to a specialist CAMHS or liaison psychiatry service 24 hours a day, with a joint daily review by both the paediatric and mental health teams.

Alternative placements may be needed, depending on:

• Age.
• Circumstances of the child and their family.
• Time of presentation.
• Child protection issues.
• Physical and mental health of the child or young person.
• Occasionally, an adolescent psychiatric ward may be needed.

After admission, the paediatric team should obtain consent for mental health assessment from the child or young person's parent, guardian or legally responsible adult.

During admission, the CYPMHS team should:

• Provide consultation for the young person, their family, the paediatric team, social services, and education staff.
• Undertake assessment addressing needs and risk for the child (similar to adults, see assessment of needs and assessment of risk), the family, the social situation of the family and young person, and child protection issues.

For all children and young people, advise carers to remove all means of self-harm, including medication, before the child or young person goes home.

Any child or young person who refuses admission should be discussed with a senior Paediatrician and, if necessary, their management discussed with the on-call Child and Adolescent Psychiatrist.

The best assessment of the child or young person's needs and the risks requires useful information to be gathered to analyse and plan the support services. In order to share and access information from the relevant professionals the child or young person's consent will be needed.

Professional judgement must be exercised to determine whether a child or young person in a particular situation is competent to consent to, or refuse, the sharing of information. Consideration should include the child's chronological age, mental and emotional maturity, intelligence, vulnerability and comprehension of the issues. Any available history regarding the previous ability to consent should be sought.  A child at serious risk of self-harm may lack emotional understanding and comprehension, and the Gillick Competences should be used. Advice should be sought from a Child and Adolescent Psychiatrist if the use of the Mental Health Act may be necessary to keep the young person safe.

Informed consent to share information should be sought if the child or young person is competent, unless:

• When you have a safeguarding concern, wherever it is practicable and safe to do so, engage with the child and/or their carer(s), and explain who you intend to share information with, what information you will be sharing and why. You are not required to inform them, if you have reason to believe that doing so may put the child at increased risk of harm (e.g., because their carer(s) may harm the child, or react violently to anyone seeking to intervene, or because the child might withhold information or withdraw from services). 
• You do not need consent to share personal information about a child and/or members of their family if a child is at risk or there is a perceived risk of harm. You need a lawful basis to share information under data protection law, but when you intend to share information as part of an action to safeguard a child at possible risk of harm.
• Consent may not be an appropriate basis for sharing. It is good practice to ensure transparency about your decisions and seek to work cooperatively with Professionals should keep parents informed and involve them in decisions about sharing information, even if a child is competent 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 with parental responsibility should give consent unless the circumstances for sharing without consent apply.

See: Information Sharing. Advice for practitioners providing safeguarding services for children, young people, parents and carers for further guidance.

The links relate to publications about self-harm and suicide with sections about children and young people:

NICE guidance for Self-harm: assessment, management and preventing recurrence

NHS England: Staying safe from suicide guidance

Self-harm in Young People: Information for Parents, Carers and Anyone Who Works with Young People, Royal College of Psychiatrists

Suicide Prevention: Resources and Guidance, GOV.UK

Suicide in Children and Young People. National Child Mortality Database

Greater Manchester Suicide Prevention Strategy 2025 - 2030

Child mental health: learning from case reviews - NSPCC Summary of risk factors and learning for improved practice for professionals working with children struggling with their mental health 2023.

Websites

Mind

The Mix - Essential Support for Under 25s

National Self-Harm Network

Papyrus

Young Minds

Feeling Suicidal? Find Hope and Support

Understanding Child Self-Harm & Keep Them Safe | NSPCC

Self-Injurious Behaviour - CAMHS

Get help - free, 24/7, confidential mental health text support service | Shout 85258

Self Injury Support

Resource Hub - Harmless