Self-Harm and Suicidal Behaviour

Many children and young people who come into foster care have experienced significant trauma in their lives and are often highly vulnerable. It is likely that these children will sometimes have multiple and complex needs and significant behavioural and emotional difficulties, which can lead to acting in ways that place themselves in situations of high risk including self-harm 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 another way and will need a supportive response to assist them to explore their feelings and behaviour and the possible outcomes for them.

The factors that increase the risk of a child taking actions to harm themselves or attempting suicide include life events such as bereavement (including knowing someone who has committed suicide), bullying at school or a variety of forms of cyber bullying, often via mobile phones, homophobic bullying, mental health problems, family problems, relationship difficulties or any previous child abuse. Recent research has also shown that children on the autistic spectrum are at increased risk.

The signs of the distress the child may be under can take many forms and can include:

• 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 themselves, swallowing or putting things inside body cavities;
• Staying in an abusive relationship;
• Taking risks too easily;
• Eating distress (anorexia and bulimia);
• Addiction for example, to alcohol or drugs;
• Low self-esteem and expressions of hopelessness.

An assessment of risk should be undertaken by the team around the child with your involvement at the earliest stage and should find out about and consider the child or young person's:

• Level of planning and intent;
• Frequency of thoughts and actions;
• Signs or symptoms of a mental health disorder such as depression;
• Evidence or disclosure of substance misuse;
• 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 by someone they trust such as the foster carer and/or social worker. Risk assessments should be regularly updated especially when there are significant changes in circumstances within the family or school setting. 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 they need to.

The research indicates that many children and young people have expressed their thoughts prior to taking action but the signs have not been recognised by those around them or have not been taken seriously.

In many cases the means to self-harm may be easily accessible such as medication or drugs in the immediate environment and this may increase the risk for impulsive actions. A plan for safe storage of medication in the household and other potential items which may be used by young people to self-harm should be made with the Fostering Service and you as the foster carer.

Good multi-disciplinary working is important and all health professionals including the GP should be aware of the child or young person's risk of self-harm to avoid prescribing medication without the foster carers knowledge or support.

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 care plan.

A supportive response demonstrating respect and understanding of the child or young person, along with a non-judgmental stance, are of prime importance. Note also that a child or young person who has a learning disability may find it more difficult to express their thoughts.

All reasonable measures should be taken to reduce or prevent the behaviour. This may include additional supervision, confiscation of materials that may be used to self-harm, or in an emergency as a last resort, use of physical intervention.

You should talk to the child or young person and establish:

• If they have taken any substances or injured themselves, if so, 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;
• Find out what is troubling them;
• 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.

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.

You should encourage the child to visit the GP, and speak to their social worker about making a specialist referral to the Looked after CYPMHS team.  You should seek immediate medical attention if a child or young person requires hospital treatment in relation to physical self-harm, or their mental health means they are at risk of significant harm to themselves of others.

You should support the child and young person at this time. If an alternative placement is needed to support the child or young person's mental health needs, the multi-disciplinary team around the child or young person will make decisions around consent issues and whether the young person needs to be detained to safeguard them.

You should keep good records of any concerns you have and share them with the child’s social worker.  Serious or persistent self-harming or attempted suicide must be notified to the child’s social worker (or Emergency Duty Team) within 24 hours. Your records should include any details of first aid administered, or medical advice sought. The team around the child will consider whether a child or young person in a particular situation is competent to consent or to refuse consent to sharing information with other agencies.

If there is any suspicion that the child may be involved in self harming or any attempts of suicide, the foster carer must notify the Fostering Service and the social worker must be informed as soon as practicable.

All self-harming must be recorded by the foster carer.

An Incident Report must also be completed.

If First Aid is administered, details must be recorded.

A risk assessment undertaken (if it does not already exist with a view to deciding whether a strategy should be adopted to reduce or prevent the behaviour) and that strategy should be included in the child's Placement Plan.

Consideration should be given by the Fostering Service to whether the incident is a Notifiable incident to Ofsted. See Significant Events and Notifications – When I need to tell other people about things Procedure.

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)

Self-harm: Assessment, Management and Preventing Recurrence NICE Guidance

Websites:

Mind

The Mix - Essential Support for Under 25s

National Self Harm Network

Papyrus

Young Minds