Young People and Self-Harm

This document is designed to support professionals in Greater Manchester, to respond to disclosures of self-harm made by young people in an empathic, non-judgemental and effective way. It contains details around self-harm including practices, triggers and potential indicators. It explains how to respond to young people in a supportive way and details pathways which must be followed.

All professionals and / or agencies should respond consistently and empathically using appropriate reporting procedures. Regular monitoring should take place.

It’s important to acknowledge that, for some young people, self-harm may have become an important way of coping with their emotional pain or distress and it would therefore be inappropriate to request that they “stop self-harming”, or to instruct them to do so. However, initiating a conversation about safer ways to cope may be appropriate, this decision should be considered on an individual basis.

• Most cases of self-harm in young people can be managed without recourse to hospital treatment or other medical intervention;
• Hospital emergency departments should only be accessed in cases of medical emergency;
• In the majority of cases, young people can be very effectively cared for by a professional known to them offering low-level, supportive interventions in a familiar location;
• Long waits in emergency departments could be detrimental to young people’s wellbeing when emergency treatment is not required.

Self-harm is the term used to describe an individual carrying out a behaviour with the intent to cause some physical harm, injury or pain to themselves.

Examples include:

• Cutting;
• Burning;
• Banging or scratching;
• Breaking bones;
• Hair pulling;
• Ingesting toxic substances or objects;
• Ligature strangulation;
• Pro self-harm sites - claim to offer a supportive community of people who self-harm. In reality they tend to be unhelpful and may be dangerous as they encourage making comparisons of injuries which can lead to more serious acts of self-harm / causing self-injury;
• Evidence shows that some young people anonymously bully themselves online, sometimes called ‘self-trolling’, by setting up multiple online profiles and posting abusive content about themselves. This behaviour is psychologically very complex.

• Self harm in children and adolescents is a major public health problem in many countries;
• In a large population based cohort study from Australia, for example, 8% of adolescents aged less than 20 years reported harming themselves at some time;
• Self harm is highly correlated with the presence of anxiety disorders and depression, with prolonged poor psychological health in childhood linked to the onset of common mental illnesses in adulthood;
• Non-fatal self harm is also the strongest risk factor for subsequent suicide, which is the second most common cause of death among 10-24 year olds worldwide after road traffic incidents;
• In the United Kingdom (UK), the definition of suicide is a death with an underlying cause of intentional self-harm or an injury or poisoning with undetermined intent. The Office for National Statistics in 2020, provided the most recent data per age group. According to the National Child Mortality Database the number of child/young person death notifications received by CDOPs assessed as highly or moderately likely to be due to suicide, year ending 31 March 2020 were 108 children;
• Half of adolescents who die by suicide have a history of self harm. In addition, there has been an increase in reports of mental health problems, including self harm, from teachers and from charity based or third sector organisations in frontline contact with children and adolescents;
• In the UK, the national suicide prevention strategy recently expanded its scope by aiming to reduce self harm rates as a common precursor to suicide;
• In 2021, The University of Cambridge research into self-harm in England found that between 1 in 5 and 1 in 7 adolescents self-harm; While self-harm is a significant risk factor for subsequent suicide attempts, many do not intend suicide but face other harmful outcomes, including repeatedly self-harming, poor mental health, and risky behaviours like substance abuse;
• For some young people self-harm may be an indicator they are having thoughts of suicide; however, for the majority self-harm would mean something different; for example - a desire to escape from intolerable emotional pain, a way of reducing tension, an expression of low self-worth;
• Self–harming is always an expression of emotional pain and should, therefore, be taken seriously.

(Morgan, 2017)

• Statistics show young people who identify as female are at least four times more likely to self-harm than those who identify as male;
• Young people of Asian heritage are at increased risk of engaging in self-harming behaviours;
• Young people in the following vulnerable groups are also found to be at greater risk of self-harming behaviours:
  • Young offenders;
  • Care experienced young people;
  • Diagnosed with emotional, conduct or hyperkinetic disorders (demonstrating neuro diversity).

Other factors which have the potential to increase the risk of young people engaging in self-harming behaviours have been identified below:

Individual Factors

• Young people experiencing mental health challenges like depression, anxiety, low mood, low self-esteem, loneliness, feelings of hopelessness;
• Those who demonstrate poor communication or problem-solving skills;
• Current or historical engagement in misuse of drugs and / or alcohol.

Family/Social Factors

• Experiencing abuse: physical, sexual, emotional, bullying, neglect or exploitation;
• Difficult relationships with friends or family;
• Have family members or friends who engage in risky behaviours;
• Living in a deprived area or as part of a low income household.

A number of factors could trigger a self-harm incident, including:

• Family relationship issues (a common trigger for younger adolescents);
• Peer relationship issues e.g. romantic relationships ending (a common trigger for older adolescents);
• Incidences of bullying;
• Trauma e.g. bereavement, abuse;
• Personally difficult dates e.g. anniversaries;
• Problems in school or with the police;
• Exam pressure;
• Transitions e.g. moving from school to college, parental separation/divorce.

Changes in other behaviours observed in the young person, particularly those associated with emotional challenges could be described as self-harm warnings signs. For example:

• Changes in eating/sleeping habits;
• Increased isolation / becoming socially withdrawn;
• Changes in mood / activity levels;
• Lowering of academic grades;
• Talking about self-harm or suicide;
• Misuse of drugs or alcohol;
• Giving away possessions;
• Risk taking behaviour;
• Medication non-compliance (e.g. declining insulin for diabetes).

However, there may be no warning signs at all.

Self-harm behaviours may be transient in young people particularly where it is triggered by individual stresses and may be resolved fairly quickly. It could, also, be more of a long-term behaviour possibly associated with serious emotional difficulties. Where a number of underlying risk factors are present, the risk of continuing self-harm is greater.

Young people may get caught up in mild repetitive self-harm, such as scratching. This can be a coping skill learned as part of a friendship group. In these cases, it would be helpful to take a warm, accepting and low-key approach which avoids escalation and maintains the interpersonal relationship allowing ongoing observation of any increasing risk.

Frequency of self-harm behaviours may increase during difficult periods and reduce once that difficulty has passed.

Once a self-harming behaviour is established, it can be difficult to stop. Self-harm can have a number of functions and might be an effective way of coping, for a young person.

For example, where it provides:

• A reduction in tension;
• A distraction from problems;
• A feeling of having escaped;
• An outlet for anger and / or rage;
• An opportunity to feel real / not feel numb;
• A method of self-punishment;
• A way of taking control;
• A way to manifest emotional pain physically;
• A way to avoid attempting suicide.

When a person inflicts pain upon themselves, their body produces endorphins, which can give some temporary relief or a feeling of peace. This result could be described as addictive making it difficult for a young person to stop engaging in self-harming behaviours. Some young people who self-harm have said the physical pain caused by the behaviour is easier to endure than the emotional pain which initially triggered the self-harm.

Self-harm isn't always a sign of mental illness or of something being 'wrong' with a person

All sorts of people self-harm, even people in high-powered jobs. It's a sign that something is bothering and upsetting someone, not that they are mad. You may not have met anyone else who self-harms and may find it upsetting or shocking. There's a lot of secrecy about self-harm, but many thousands of people cope in this way for a while. Approximately 1 in 12 young people self-harm at some point.

Fact: Other things can be 'self-harm' too. Things like starving, overeating, drinking too much, risk-taking, smoking and many others are also types of 'self-harm'. Some coping methods (like burying yourself in work) may be more socially acceptable, but can still be harmful.

People stop self-harming

Many people stop self-harming - when they are able to. Their issues may be resolved and / or they find different ways of coping with their feelings. It can take a long time and they may require support to achieve this.

People self-harm for a reason

Self-harm is often a way of coping with painful experiences and trying to gain a sense of control; this may indicate a feeling of lacking control in other areas of their life.

Manchester Children's Safeguarding Partnership Self-Harm Pathway

Stockport-specific Pathway

Oldham-specific Pathway

Trafford-specific Pathway

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

The Truth About Self-harm, The Mental Health Foundation

Suicide Prevention: Resources and Guidance, GOV.UK

Suicide by Children and Young People 2017, (HQIP)

Websites

Mind

The Mix - Essential Support for Under 25s

Childline – Mental Health

National Self Harm Network

Papyrus

Young Minds

Kooth

Support Options

Shout - 24/7 text support

Greater Manchester Mental Health Crisis Café - an out of hours friendly and supportive community space open to anyone from Manchester, Bolton, Salford and Trafford, experiencing a mental health crisis

Bluesci at Night Crisis Café - 7 days a week out of hours support for anyone in emotional distress or experiencing a mental health crisis

Greater Manchester Mental Health Urgent Response Team

Pennine Care CAHMS

Pennine Care Safe Zones - part of the Greater Manchester crisis care pathway for children and young people.

NHS Non-emergency number 111

• Young people may present to any member of staff, including first-aid or reception staff. It is, therefore, essential that frontline staff are aware that injuries may be self-inflicted, that they have access to this guidance and are able to access support / guidance with identifying appropriate actions;
• When visible signs of distress are present, it would be important to give the young person the opportunity to talk about how they are feeling in a safe space;
• What is important for many young people is having someone to talk to who listens properly and does not judge;
• Confidentiality is a key concern for young people, and they need to know that it may not be possible for you to offer this however strongly they express this. If this is explained at the outset of any meeting, then the young person can make an informed decision as to how much information they wish to share. Deciding together who are the best people to inform would be essential;
• If you consider that a young person is at serious risk of harming themselves or others, then information needs to be shared and the young person informed;
• Resist the temptation to tell them not to do it again, or promise you that they won’t do it again;
• It is important that all attempts of suicide or deliberate self-harm are taken seriously. All mention of suicidal thoughts should be noted and the young person listened to carefully;
• Take a non-judgmental attitude towards the young person exploring their reasons for carrying out self-harm. Whilst offering reassurance that you are trying to understand their feelings and behaviours;
• Discuss with the young person any worries they have about sharing this with their caregivers and how we can support that conversation;
• If a young person has a self-inflicted injury (but has not taken medication / an overdose), they should not be sent to a hospital Emergency Department (ED) unless a first-aider has confirmed that the young person has injuries requiring emergency medical treatment, or this has been advised by a CAMHS team member or other medical practitioner. Injuries that require emergency medical treatment include: burns that are blistering or red, cuts that are deep and / or bleeding profusely, where the young person has lost consciousness or has recently overdosed or ingested harmful liquids;
• In the case of a non-recent overdose of tablets and where the young person is conscious and alert, advice must still be obtained from a medical practitioner, but it may not be necessary for the young person to attend ED. The designated officer should try to obtain advice from the duty officer at CAMHS – 0161 419 2062 – or the school nursing team. If this is not possible, the young person should get a same-day appointment with their GP or go to the nearest hospital Emergency Department;
• Follow your local pathway in all cases of actual or intended self-harm.