Abstract
Self-harm (SH) is not a diagnosis, but rather a way a young person can try to manage previous trauma, express difficult feelings or respond to an overwhelming situation. SH can involve an overdose, cutting, burning, punching, or any activity that deliberately harms the young person. It is complex, multifactorial, becoming increasingly prevalent and a major risk factor for suicide and mortality in young people. In April 2022, the charity Young Minds reported that the Children and Adolescent Mental Health Service faced an unprecedented crisis, and that the system was at breaking point. Due to these secondary care capacity issues, primary care is managing more cases of SH in young people. A survey of over 500 GPs from Pulse magazine found that 70% provided mental health support for children beyond their level of competence. This article will explore how SH presents, discuss a structured approach to the assessment of SH and help readers develop skills to promote the effective and safe management of SH.
Clinical case scenario
Julie attends the GP surgery with her 13-year-old daughter Amelia after noticing scars on her forearm. Amelia explained that she had self-harmed by cutting with scissors. She does this when agitated and has found this this calms her down.
You establish that cutting with these small scissors is the only method of self-harm, and the wounds look clean. Amelia last cut herself yesterday and she has been doing this occasionally for the past 2 months. Amelia does not have any feelings of wanting to end her life. You offer to talk to Amelia alone, but she is happy to speak in front of Julie.
Amelia feels different to everyone else; she enjoys watching cartoons which everyone else at school has grown out of, and she gets bullied for this activity. She does not have many friends at school, and she finds it hard to explain her feelings. She feels safe at home with her mother; her parents have recently divorced, and she sees her father at weekends.
A blank personalised safety plan is given to Amelia to fill out at home with Julie, and safety recommendations are discussed. You also speak to Julie alone; she is happy that she can keep her daughter safe and understands the safety plan.
Amelia is referred to the Children and Adolescent Mental Health Service (CAMHS) for possible autism with self-harm and you arrange a follow up appointment with Amelia and Julie 2 days hence.
Background
In 2019, the World Health Organization (WHO) found that mental health conditions accounted for 16% of the global burden of disease in 10–19-year-olds, and that suicide was the second leading cause of death in people aged 15–19. The UK Royal College of Psychiatrists estimates that around 1-in-10 young people in the UK will self-harm (SH) at some point.
The incidence of SH by a YP is greater in girls than in boys and more common in areas of high social deprivation (Morgan et al., 2017). Children and adolescents who harmed themselves were around nine times more likely to die unnaturally during follow-up compared with peers of the same age and sex without a history of self-harm.
There are a number or risk factors for SF and these can be categorised as social, genetic, biological, or psychological factors. Social factors include adverse childhood events such as parental separation or death, abuse, bullying, and drug and alcohol misuse. Biological risk factors include a family history of suicidal behaviour or female gender. Psychological risk factors include depression, anxiety, autism, and attention deficit hyperactivity disorder. Having a lesbian, gay, bisexual sexual orientation or identifying as a transgender person also increases the risk of SH.
Some studies have found a correlation between high internet use and SH. This may be because the internet can normalise SH and initiate competition amongst social media users (Marchant et al., 2017). An example of this includes trends such as the #labellochallenge on the social media platform TikTok in May 2022. Conversely, the internet and social media can benefit the YP by reducing isolation, connecting to outreach, and providing a source of therapy. Multiple charities, for example, MIND have helpful online resources specifically for young people, their friends and carers.
Assessment
GPs should take the disclosure of SH seriously, respond empathetically and listen to the YP with compassion. Disclosing SH to a professional can often be a significant step for the YP and an open, calm and thoughtful response can build rapport and be therapeutic by itself.
Explore why the YP SHs and what specific triggers lead them to this action. They can include feelings of worthlessness or hopelessness, emotional dysregulation, or so as to feel in control. The National Institute for Health and Care Excellence (NICE) guidance recommends a holistic psychosocial assessment, asking about home, social and school contexts. Social media, friendships, and if appropriate romantic relationships, should be asked about. Parents or carers should be involved in the care of the YP, where the YP has given consent. Safeguarding issues should be explored, for example, domestic abuse, violence or exploitation, ideally when the YP is alone.
A comprehensive risk assessment involves assessing the lethality, intention, and frequency of SH (Wood et al., 2021). A more violent method, increasing frequency or intent to end life increases the risk of future death. Research has shown that asking about suicidal intent does not increase the risk of future SH or suicide (Gould et al., 2005).
Management
NICE suggests that a referral to CAMHS should be made for young people who SH. This should be a priority when:
The person's levels of concern or distress are rising, high or sustained The frequency or degree of self-harm or suicidal intent is increasing The person providing assessment in primary care is concerned The person asks for further support from mental health services Levels of distress in family members or carers of children, young people and adults are rising, high or sustained, despite attempts to help (NICE 2022)
NICE recommends dialectic behavioural therapy for adolescents to treat SH in secondary care. This is typically a 16-week programme with both the YP and their family to develop skills, manage emotions and develop relationships. (Iyengar et al., 2018). Management of any underlying mental health condition should also be optimised. Continuity of care is important and primary care has a vital role in supporting the YP in the community, especially when waiting to access specialist treatment. Regular reviews can also help to identify a changing situation that may need to be escalated. Figure 1 illustrates the processes that take place in primary care during the assessment and management of a YP with SH issues.
Process chart for management of YPSH in primary care.
Safety planning
Safety planning is a personalised approach to help young people stay safe when they feel like they want to SH. Safety planning involves a conversation with the YP and ideally their family, to recognise when the YP is at risk of self-harming and specific actions to reduce the risk. Strategies include removing the methods available to SH, including locking away medications so that the YP cannot access them using a lockbox, removing knives and other sharp objects from where the YP can access them and the carer or parent increasing supervision. Box 1 shows an example of specific safety recommendations that are given to a patient. Safety recommendations.
Parents/carers are to remove all medication and sharp objects in the household and store them securely e.g. /kitchen knives, razors, and blades. Where possible have these in a locked box Parents/carers need to be mindful of harmful products that can be swallowed e.g. bleach, and any items/cords/cables that can be used to make a ligature Parents/carers will need to increase supervision and monitor your child where possible. If your child is in their bedroom, regular checks will be needed. Maybe have an open-door policy making it easier to keep a closer eye on your child Parents/carers need to know where your child is in the community and who they are with; if a crisis was to happen you need to be able to get in contact with your child and/or alert emergency services to where they are Parents/carers if you do not know your child’s whereabouts and you have been unable to contact your child you will need to report them as missing to the police, this is due to the potential risk of self-harm/suicide
This process requires the YP and their family to consider triggers to SH, behaviours which are early warning signs and current coping strategies. Practitioners should provide a physical copy of this agreed safety plan to the YP and parent or carer to aid its implementation during a crisis. Figure 2 shows an example personal safety plan and how it may be completed.
My safety plan.
Safety planning also involves safety netting, specifically detailing when and how the YP or parent or carer should seek help. Exact details will differ by locality, but could include telephone numbers for the local CAMHS crisis team or the Samaritans.
In addition, young people and their families should be signposted to charities that specifically deal with young people's mental health and suicide prevention. ‘Kooth’ is an online community that promotes mental well-being it can help the YP find a safe space to discuss how they are feeling. ‘Shout’ is a crisis service accessed by text instead of a call, reducing the social demand placed on the potential user.
Conclusion
When the YP discloses SH activity, a comprehensive, holistic assessment is required. A referral to CAMHS is likely to be needed and while the young person is waiting for specialist services a personalised safety plan, safety netting, regular follow-up and signposting to charities can be initiated in primary care.
Key points
When a young person discloses SH, respond empathetically and with compassion
Assess and treat the YP holistically, asking about the underlying biopsychosocial context
Assess risk by looking at lethality, intention, and frequency of SH
Create a personalised safety plan with the young person and ideally their parent or carer
Management does not end with a referral to CAMHS, regular follow-up in primary care with ongoing communication with secondary care is required
