The term self-harm used in this policy refers to any act of deliberate self-injury or self-poisoning carried out by an individual, irrespective of motivation.

Any child or young person, who self-harms or expresses thoughts about this or about suicide, must be taken seriously and appropriate help and intervention should be offered at the earliest point. Any practitioner, who is made aware that a child or young person has self-harmed, or is contemplating this or suicide, should talk with the child or young person without delay.

Defining Self Harm

Self-harm is a sign that a young person is experiencing significant emotional distress. Self-harm may include self-poisoning, hitting, cutting, burning, pulling hair, picking skin, head banging, self-strangulation. This policy does not cover other issues such as overeating/ food restriction or risk-taking behaviours such as consuming drugs/alcohol.

Helpful to know:

Self-harm in CYP is more common than many people realise: 12% of young people report that they occasionally self-harm as a coping strategy. (Source: Norfolk County Council)

Primary School Age Children

Self-harm is much less common in primary school age children (less than 1% - source: Nottingham City Council), behaviours include shallow cuts, hair pulling, head banging and deliberate self-grazing or scratching. Self-harm in younger children is often linked to family difficulties. In primary school age children we avoid using the label ‘self-harm’ and reframe a child’s behaviour as a demonstration of distress and/or help seeking behaviour’.

Young People with special educational needs

Young people with special educational needs may also engage in self-harm. It is estimated that about half of autistic people engage in self-injurious behaviour at some point in their life, and it can affect people of all ages.

Consider this statement:

“It important that as professionals we must not ask a young person to stop harming. There are many reasons for this. Firstly due to the addictive nature of self-harm, unless that method of coping is replaced with another in its place you are expecting that individual to give up their coping strategy. Without means to release/process the difficult emotion that they are struggling with, levels of distress will increase and some will move towards suicidal thoughts as they struggle to cope. Secondly, due to the nature of shame and guilt that an individual feels around their self-harm, they will not want to let you down and often unrealistically telling them to stop can drive the issue underground again as they go back to hiding the behaviour.”

Laura Haddow, Youthscape

Risk assessments

When making a risk assessment consider all factors “in the round”, for example:

• Frequency of harming behaviour

• Imminence of the next self-harm event (how likely and how soon is the CYP going to engage in another self-harm incident)

• Severity of incidents, e.g. does the self-injury require medical attention or is it typically manageable within the CYP’s environment

• What coping skills does the CYP have, and what external support do they have

Examples of risk categories:

Low risk

CYP with little or no history of self-harm, an amount of stress or life factors that the CYP feels is generally manageable, and at least some positive coping skills and some external support.

High risk

CYP with more complicated profiles – those who report frequent or long-standing self-harm practices; who use high lethality methods, and/or who are experiencing chronic internal and external stress with few positive supports or coping skills.

Taking Action when we learn that a CYP we are supporting has Self Harmed

Talking to the CYP in session

In a supportive and empathetic manner, try to establish the facts of the situation:

• What has happened? Have they have injured themselves or taken any substances;

• When did it happen? Explore how recent the incident was, and how many times it has occurred - and whether it is a regular pattern;

• Assess risk: understand how likely another self-harm incident is, whether there are any triggers, and try to understand the underlying causes that are causing the self harm

• Establish if the CYP is feeling suicidal: the question ‘Have you ever felt like ending your life?’ must also be asked. We know that asking about suicide does not put the idea into their mind, however some children may not disclose suicidal ideation until directly asked about this;

• Help and support: find out who is aware of the self harm, in particular the CYP’s parents/carers, school, and anyone else, and if possible, find out what help or support the CYP would wish to have;

• If possible, complete a Safety Plan in Session

SLACK POSTS

As soon as you are able to (ideally in session), write a post to the Slack channel:

#uk-nhs-crisis-channel

And tag:

• Boyana

• Daisy Butler-Gallie

Other things to explore (depending on the session)

• 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?

Informing and supporting Parents/Carers

We will need to have a conversation with the young person about sharing information with their parents/carers (unless this would put the CYP at risk of harm).

Sometimes young people have a preference of who they would like to be informed, e.g. Mum or Dad. If a young person is reluctant about informing their parents/carers, we will encourage them to think about the benefits of involving their family and how they could help.

Professional judgement must be exercised to determine whether a child or young person in a particular situation is competent to consent or to refuse consent to sharing information. Consideration should include:

• the child’s chronological age

• mental and emotional maturity

• intelligence, vulnerability and comprehension of the issues.

• Note: a child at serious risk of self-harm may lack emotional understanding and comprehension

It is good practice to give the young person choice in how their parents/carers are informed. Options could include:

• Which parent/carer is told

• Letting the young person inform their parent(s)/carer(s) first (with us following up subsequently)

• Parents/carers are informed with the young person present throughout the conversation

• Involving other adults in the conversation, for example a teacher or school nurse, to talk together with the young person

How urgently we make contact with the parents/carers will depend on the risk assessment. Generally, we would prefer to do so as soon as practicable (within 24 hours), however if the risk of further harm is low, we can wait (for example) until the following day, or after the weekend, especially if this would create a better environment for what is likely to be a difficult conversation, or in circumstances where the CYP expresses a desire to tell their parents/carers themselves.

Key points to consider (please read)

• Mindler has a strong preference that parents or carers are informed unless there is a clear reason not to. As remote service that only has weekly contact with the individual, it is generally safer if parents/carers are made aware of the self harm risk in a timely manner.

• For any child who is younger than 16 we will always want to inform their parents/carers about a self-harm incident. If the child says that their parents/carers are already aware, we should still speak to the parents/carers to confirm this.

• Informed consent from the CYP should be sought if possible. Good practice involves giving the CYP some choices about how this will be done.

• Therapists should be careful not to promise to keep our knowledge of the self harm confidential, because we are likely not to be able to do this.

If the CYP is over 16, and is adamant that they do not want their parents to be informed, we should contact the SSCB Safeguarding team to ask for advice regarding next steps. We should also consider if other adults (e.g. at school) could be informed.

Considering whether we are the best organisation to support the CYP going forward

Under the Sandbox NHS contracts, we do not have to support a CYP who is Self Harming, or one with suicidal ideation (SI). Therefore, if we feel that we cannot support the CYP safely in an online environment, we can speak to their local CAMHS team and arrange for them to be seen by them and discharged from the Sandbox.

However, because self-harm is so common in CYP mental health services, we are prepared to continue to support these individuals if we feel there is a clear plan in place to manage the risks involved.

This can be a really difficult judgement to make and is best made in consultation with other colleagues. We want therapists to feel supported when these moments happen.

Guiding principles

• We should put the best interests of the CYP first

• We should not try to persuade ourselves that we are the right service for the CYP because of waiting lists for NHS services (for example “the CAMHS waiting lists are so long, at least we can provide support now”)

• We should consult with other professionals where possible, in particular CAMHS, but also schools, GPs, Early Help or social services

Questions to consider:

• Does the CYP have suicidal ideation (SI) as well?

• Are the CYP’s parents able to support them in managing the risk of self harm?

• How frequent and risky is the nature of the self harm?

• How well is the CYP able to tackle difficult thoughts themselves?

• How is the CYP engaging in the therapy - have they expressed a strong desire to engage and make progress?

Sandbox Resources for CYP who are Self-Harming

• The Sandbox Academy iCBT course has a module on Self Harm that can be assigned to CYP.

• The Sandbox has a wide range of resources on Self Harm that can be sent to CYP or parents.

Further Reading

NICE Guidelines for Self Harm

https://www.nice.org.uk/guidance/ng225

National Autistic Society - Self Harm

https://www.autism.org.uk/advice-and-guidance/professional-practice/self-harm

Gillick Competence and Fraser Guidelines: NSPCC

https://learning.nspcc.org.uk/child-protection-system/gillick-competence-fraser-guidelines