Self-Harm and Suicidal Feelings

The States of Jersey set a Framework for Action 2015 – 2020, and the National Suicide Prevention Alliance – Thrive Jersey Platform. Suicide is a challenging and sensitive issue in any community, and all the more so in a small one. Suicide prevention in Jersey draws upon national policy and strategies. The Safeguarding Partnership Board (SPB) Jersey aims to provide guidance for practitioners which aligns with the Government's Framework and Thrive Jersey objectives to:

• Raise awareness throughout the community;
• Develop greater understanding of local factors linked to suicide;
• Improve mental health and wellbeing of children and young people;
• Reduce the stigma about suicidal feelings;
• Reduce the risk of suicide with high risk children and young people.

Definitions from the Mental Health Foundation:

Self-Harm

• Self-harm is when a child or young person hurts themselves on purpose, often when they are dealing with intense or overwhelming feelings and as a way of trying to cope.

The reasons children and young people self-harm will be different for everyone and they may not be able to name any on reason for their self-harming. Self-harm can be described as wide range of behaviours that someone does to themselves. Self-harm is often a hidden behaviour that can go on for a long time without being discovered. Many children and young people may struggle to express their feelings in any other way and need a supportive response to assist them to explore their feelings and behaviour and the possible outcomes for them.

Suicidal Feelings

Suicidal Feelings are described as confusing, frightening and complicated thoughts which range from not wanting to be here to planning about how and when to end their life, often along with an expression of wishing to stop pain as opposed to wishing to die.

Suicide

Self-harm, which results in death.

Suicide is complex with no single explanation. Often people who self-harm do not wish to die. However, self-harm is a common precursor to suicide. Children and young people who self-harm may kill themselves accidently or by misadventure. Some children and young people will express their thoughts prior to acting, and where a child has died, people say they had not recognised the signs or had not taken them seriously. Many children and young people find it hard to talk about suicidal feelings, because they are worried about how others will react if they really said what they were feeling.

The indicators that a child or young person may be at risk of self-harming can cover a wide range of life events such as experiencing depression, anxiety or eating problems, low selfesteem, feeling alone, bereavement, bullying at school or a variety of forms of cyber bullying, often via mobile phones, homophobic bullying, mental health problems including eating disorders, family problems such as domestic abuse or any form of child abuse as well as conflict between the child and parents (See further SPB Core Procedures and Practitioner Guidance on specific topics).

Anyone can have suicidal feelings, whatever their background or situation in life.  Where suicidal feelings have a wide range of potential causes, some common indicators are:

• Mental health;
• Neurodiversity;
• Anxiety including social anxiety;
• Bullying, prejudice and stigma related to race, gender, disability or identity;
• Different types of abuse (see recognising abuse);
• Life events such as bereavement, which includes losing a loved one to suicide;
• The end of a relationship;
• Long term ill health, pain or illness;
• Isolation or loneliness;
• Being put to prison;
• Feelings of inadequacy or failure;
• Substance use, including problematic substance use;
• Trauma and adverse childhood experiences;
• Societal, self or parental expectations around achievement;
• Cyber bullying, social media, internet targeting;
• Suffering from eating disorders;
• Obsessive or compulsive thinking and internet searching;
• Some  medication such as anti-depressants can cause some people to have suicidal thoughts.

For guidance on how to treat co-existing conditions that may relate to self-harm, such as alcohol misuse disorders, autism spectrum disorder, bipolar disorder, borderline personality disorder, learning disabilities, depression, eating disorders, generalised anxiety and panic disorder, mental health with learning disability, obsessive compulsive disorder, Post Traumatic Stress Disorder see National Institute for Care and Excellence (NICE 2022) guidelines here.

Signs of the distress can include:

• Covering up, wearing long sleeves in summer;
• Unexplained bruises, cuts, burns or bit marks on their body;
• Blood stains on clothing or finding tissues with blood;
• Becoming withdrawn, having angry outbursts and avoiding family and friends;
• Pulling out hair on head or eyebrows;
• Self-poisoning;
• Self-neglect, restricting eating or not eating;
• Direct injury such as scratching, cutting, burning, hitting themself, swallowing or putting things inside their bodies;
• Risk taking, trauma informed behaviours;
• Experimentation and substance use including alcohol and/or drugs. 

 If a child or young person is self-harming or feeling suicidal their feelings may become heightened if they:

• Drink alcohol or use substances;
• Have problems sleeping.

Practitioners should use The Continuum of Children’s Needs to support their practice decisions. The Continuum of Need will help practitioner decision making on which service level intervention is required.

An assessment of risk should be undertaken at the earliest stage and should consider the child or young person’s:

• Level of planning and intent;
• Frequency of thoughts and actions;
• Signs of depression;
• Signs of problematic substance use (including Alcohol);
• Previous history of self-harm or suicide in the wider family or peer group;
• Delusional thoughts and behaviours;
• Feeling overwhelmed and without any control of their situation.

Any assessment of risk should be talked through with the child or young person, where their parents/carers should be viewed as partners (unless to do so prejudices their welfare). Regularly updating as some risks may remain static whilst others may be more dynamic. 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.

The level of risk may fluctuate and a point of contact with a backup should be agreed to allow the child or young person to make contact if and when they need to.

If the young person is caring for a child or pregnant the welfare of the child or unborn baby should also be considered in the assessment (see Joint Protocol for Multi-Agency Pre-Birth Assessment and Referral Pathway).

Risk Factors Include:

• Previous suicide attempts or previous self-harm;
• Not in education, employment or training (NEET);
• Physical health problems including chronic pain;
• Living alone;
• Substance use, including problematic substance use;
• Having mental health problems.

The type of self-harm and/or suicidal feelings a child or young person has will be individual to them and will vary from person to person.

Assessment should include an understanding of:

• How intense their feelings are - some people will feel more overwhelmed than others, some will describe a build-up of feelings others may be intense from the start. They can be severe at different times of the day or night, they may be triggered by events, anniversaries or birthdays, and they may change quickly;
• How long they last – thoughts of self-harm and suicidal feelings can come and go; this may present as short intense feeling or more fleeting feelings or may be more prolonged;
• What they are searching on the internet and if what they are finding is helpful or harmful.

Where a child (including an unborn child) or young person presents with a health or development need) or where there is a  safeguarding Need (see Statutory Guidance - Levels of Need) practitioners must:

• Follow the SPB Child Protection Procedures, the SPB Children and Young People Safeguarding Referrals Procedure;
• Refer to the Children and Families Hub;
• In parallel refer an adult or young person with their consent to supportive domestic abuse services (see supportive agencies below);
• Where a child may have been physically abused, suffered neglect or sexual abuse consideration must be given to following the Child Protection Medical Pathway and/or the Child Sexual Abuse Pathway;
• Where there is an immediate risk of harm, practitioners must call the police on 999;
• Where domestic abuse is related to a vulnerable adult, practitioners must raise a safeguarding concern with referral to the Single Point of Referral for Adults at risk of harm.

Practitioners must:

• Seek immediate medical attention where required by calling emergency services – 999 and asking for an Ambulance where a child has already harmed themselves for example, have cut themselves, have taken medication or have ingested substances;
• Take immediate action to reduce high risk self-harm and suicide by calling the emergency services – 999 and asking for Police assistance where required;
• Where the means to self-harm is easily accessible, such as equipment to harm themselves - rope, knives, medication or drugs and there is cause to believe there is ongoing risk around impulsive actions, practitioners must take steps to reduce risks in the immediate environment by calling the emergency services on 999 and asking for police support.

Referrals should include information about the background history and family circumstances, the community context and specific concerns about the current circumstances for the child or young person where known.

Where a child or young person requires hospital treatment in relation to Self-harm or Suicidal Feelings. Self-Harm assessment, management and preventing recurrence practice guidance should be followed (National Institute of Health and Clinical Excellence (NICE) June 2022).

• There should be overnight admission to a Paediatric or Adolescent ward with detailed assessment the following day, with input from the CAMHS service;
• Referral must be made to Child and Adolescent Mental Health (CAMHS) where an age appropriate psychiatric practitioner or suitably skilled mental health practitioner will make assessment as soon as possible on attendance in ED or after admission;
• In parallel referral must be made to the Children and Families HUB to Safeguard their Welfare where required. Where children’s social care should take a collaborative approach with all agencies involved in the care of the child or young person;
• Triage, assessment and treatment should take place in a separate area of ED and on admission to hospital mental health and acute ward staff should jointly decide the need for close observation on a case by case basis;
• Children and young people admitted to a paediatric ward following an episode of self-harm should have access to a specialist from CAMHS, a joint daily review with both the paediatric and CAMHS team, daily access to their family members/carers, regular multi-disciplinary meetings between the general paediatric team and CAMHS to review their care needs;
• Wellbeing, health and development or safeguarding Assessment should include a full assessment of the family, their social situation, family history and child protection issues;
• Initial management should include advising carers of the need to remove all medications or other means of self-harm available to the child or young person who has self-harmed.

Any child or young person who refuses hospital admission where this is required to reduce the risk of harm or significant harm should be reviewed by a senior Paediatrician in Accident and Emergency, the on-call Child and Adolescent Psychiatrist where consideration around admission under mental health may be required.

Ensure continuity of practitioner care where possible.

Ensure there is collaborative work and care plans are made available to the multidisciplinary team caring for the child or young person.

Assess the safety of the child and young person’s environment, using the least restrictive measures possible. 
Consider removing items that may have been used to self-harm and involve the child or young person in this decision.

Hold multi-disciplinary meetings on a case by case basis to assess changes in circumstances to re-assess and understand strengths and risks.  

Practitioners should have access to regular Internal agency safeguarding supervision. Agencies Practitioners should also consider multi-agency reflective supervision where cases are complex, stuck or drifting. 

Professional challenge should be welcomed and partnership working depends on resolving professional difference and conflict as soon as possible. Where staff experience professional differences, they must follow the SPB Resolving Professional Difference/Escalation Policy.

The links relate to publications about self-harm and suicide with sections about children and young people as in the latest national strategy:

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:

The Mix – essential support for under 25s

Mind

www.firstsigns.org.uk

www.nshn.co.uk

www.papyrus-uk.org

www.getconnected.org.uk

Suicide Prevention: resources and guidance

The links relate to publications about self-harm and suicide with sections about children and young people as in the latest national strategy:

• Suicide prevention: resources and guidance (GOV.UK, 2017);
• Mental Health Foundation
• Mind
• Truth Hurts: Report of the National Inquiry into Self-harm among Young People.

Mental Health Foundation 2006.

• Hawton, K, Rodham, K and Evans, E (2006), By Their Own Hand: Deliberate Self harm and Suicidal Ideas in Adolescents. London: Jessica Kingsley.
• Royal College of Psychiatrists Managing Self-harm in Young People (2014);
• Guidance for Developing a Local Suicide Prevention Action Plan: Information for Public Health Staff in Local Authorities (2014).

Medical Practitioners:

• National Institute for Health and Care Excellence;
• Royal College of Psychiatrists Managing Self-harm in Young People (2014).

Managing the media:

• Media Guidelines for Reporting Suicide.

Websites:

• Self-Harm;
• National Self Harm Network
• Papyrus
• Get Connected