According to NHS figures published in 2015, there was a 20 percent rise in the number of 10- to 19-year-olds admitted to hospitals across England, Wales and Northern Ireland, due to self-harm injuries. The number of teenagers taking their own lives has also hit a 17-year high, prompting the then Health Secretary, Jeremy Hunt, to announce a suicide prevention strategy in his speech at the Conservative Party Conference in October 2016.
This document offers guidance on the nature and causes of self-harm and suicidal behaviour, suggests some potential support strategies and outlines advice on managing injuries associated with self-harm.
What is self-harm?
Self-harm and suicidal behaviours are carried out by some young people to deliberately hurt themselves, in an attempt to cope with difficult and distressing feelings. Self-harm can include anything that causes an injury, but can also include risk-taking behaviours involving excessive drug or alcohol use, though this is often not acknowledged as a form of self-harm. Recognising such behaviours can be important as they may not be as obvious as others, such as self-cutting.
Some forms of self-harm include, but are not limited to, the following:
- Eating disorders
- Excessive exercising
- Taking a drug overdose
- Hitting or bruising
- Intentionally taking too much or too little medication
Although some young people who self-harm may be suicidal, self-harm can often be used as a way of expressing difficult emotions without being a suicide attempt, but can sometimes result in accidental death.
Signs of self-harm
Some of the signs of self-harm include, but are not limited to, the following:
- Unexplained cuts, bruises or burns
- Low mood, lack of interest in life or depression
- Clothing which provides maximum amount of coverage, even in hot weather
- Avoidance of swimming or other activities which require changing clothes around others
- Withdrawal or isolation from friends and family
- Self-loathing, blame of self for problems or expressing feelings of failure, uselessness, hopelessness or anger
- Low self-esteem
- Changes in eating habits or secretive eating
- Unusual weight-loss or weight-gain
- Signs of hair pulling
Reasons behind self-harm
Self-harm behaviours may manifest themselves for different reasons, some of which include, but are not limited to, the following:
- Management of extreme emotional distress
- Reduction of tension
- Expression of emotions such as hurt, anger or frustration
- Creation of physical pain to distract away from emotional pain
- An attempt to regain control over feelings or problems
- A form of escape
- Punishment of themselves or others
- An effort to elicit care from others
- A bid to identify with a peer group
- A suicide attempt
Some of the factors associated with self-harm and suicidal behaviour include, but are not limited to, the following:
- Depression, anxiety or low self-esteem
- Eating disorders
- Drug or alcohol abuse
- Poor parental relationships
- Drug/alcohol misuse in family
- Family history of self-harm or abuse
- Peer rejection
- Friends who self-harm
It has been reported that the first time a young person reveals their problem, they want to be treated with care and respect, but negative reactions can make their situation worse. It is vital that a pupil’s admissions are treated seriously, and not dismissed as attention seeking. If a pupil confides in you that they are self-harming, or you suspect that they are, it is important to observe the following principles:
- Remain calm and avoid judging their actions.
- Do not tell them to stop self-harming.
- Listen carefully and explain the limits to your confidentiality.
- Offer understanding and reassurance.
You could ask the following questions to gather more information:
- How long have you been coping in this way?
- How does it affect you?
- What help do you need?
- What would you like to happen next?
Alternative coping mechanisms
- Clenching an ice cube in the hand until it melts – sometimes it helps to tint the water red with food colouring beforehand, so that the cubes resemble blood.
- Snapping an elastic band against the wrist.
- Drawing on the skin with red pen or red paint instead of cutting.
- Taking part in sports activities.
- Using a punch bag.
- Hitting a pillow or a soft object.
- Listening to or creating loud music.
- Going for a walk or being close to nature.
- Practising mindfulness.
- Stroking or caring for a pet.
- Keeping a diary or a blog.
- Creating something: drawing, painting, writing, music, sculpture.
- Listening to soothing music.
Although there is no specific guidance on safeguarding and self-harm in the DfE’s statutory document ‘Keeping children safe in education’, schools have a responsibility to refer a pupil to their local children’s social care services when there is reasonable belief that a child:
- Has experienced significant harm, and/or;
- Is likely to experience significant harm and/or;
- Has developmental and welfare needs which need to be met through provision of family support services.
It is important that referrals are made with the agreement of the child’s parent/carer.
The most efficient way of referring a pupil to Child and Adolescent Mental Health Services (CAMHS) is to get involved with your school’s local health and wellbeing board, through the LA’s Director of Children’s Services or local Healthwatch organisation.
To build a clear picture of the severity of the pupil’s condition, it is important to:
- Use a clear process for identifying pupils in need for further support.
- Document evidence of the symptoms or behaviours that are a cause for concern.
- Encourage the pupil and their parent/carer to speak to their GP where appropriate.
- Consult CAMHS about the most effective ways to support the pupil in the interim.
More detailed information about the referral process can be found in the DfE guidance, ‘Mental health and behaviour in schools: Departmental advice for school staff’.
Managing serious injuries
If you are concerned that a pupil has seriously injured themselves or taken an overdose, it is vital that they get immediate medical treatment from A&E. In an emergency, do not hesitate to call for an ambulance and contact the pupil’s parent/carer.
Symptoms associated with serious poisoning or an overdose include, but are not limited to, the following:
- Being sick
- Breathing difficulties
- Uncontrollable restlessness or agitation
- Drowsiness or loss of consciousness
Helping someone who is conscious
If you think that a child has taken an overdose or poisoned themselves, and they are still conscious, ask them to sit still and stay with them while you wait for medical help to arrive.
Try to get them to spit out anything that is remaining in their mouth and try to find out the details of the harmful substance or medication that they have ingested. Pass this information on to the emergency services when they arrive.
Helping someone who is unconscious
If you think a pupil has swallowed a harmful substance or medication and they appear to be unconscious, try to wake them and encourage them to spit out anything left in their mouth.
Do not put your hand into their mouth and don’t try to make them sick.
While you are waiting for medical help to arrive, move the pupil on to their side with a cushion behind their back and their upper leg slightly forward, so they don’t fall on their face or roll backwards – this is known as the recovery position.
Wipe any vomit away from their mouth and make sure their head is pointing down, to allow any vomit to escape without them breathing it in or swallowing it. Ensure that the pupil is not left alone.
Try to find out what the pupil has taken - empty pill bottles or blister packs may be in the immediate area. Pass this information on to the emergency services when they arrive.
If the pupil is not breathing or their heart has stopped, ensure the first-aider begins CPR if they know how to.
How to help medical staff
When the paramedics arrive, or when you arrive, pass on as much of the following information as you can:
- Name the substance/medication you think the pupil may have ingested, or pass on any associated packaging, such as blister packs.
- How long ago they may have taken the substance.
- How it was taken e.g. swallowed or inhaled.
- How much was taken (if you know).
- Existing medical conditions and any known prescribed medication.
- Mention history of self-harm.
Managing less urgent injuries
For less urgent injuries, ensure that the pupil is assessed and treated by the school’s first aider.
Cuts and wounds
- Wash and dry hands thoroughly.
- Apply pressure to bleeding cuts using tissue or a clean bandage.
- Clean the wound under running tap water and apply a sterile adhesive dressing.
- Seek medical help if an existing wound has become infected (e.g. swelling, spreading redness or discharge has formed).
- A&E treatment will be required for:
- Bleeding that won’t stop.
- Bleeding from an artery – bright red blood that spurts with each beat of the heart and is hard to control.
- Loss of sensation near the wound.
- A potential foreign body that is still inside the wound.
- A very large wound or an injury that has caused a lot of tissue damage.
- Avoid moving anything that is stuck to the burned area.
- Cool with cold water for 10 to 30 minutes, then cover with cling film.
- Do not apply ice or any creams or greasy substances.
- A&E treatment will be required for:
- Large or deep burns bigger than the size of a hand.
- Any size burns that cause white or charred skin.
- Burns on the face, hands, arms, feet, legs or genitals that cause blisters.
Dan Whitworth (2015) ‘Schools 'struggling to cope' with students self-harming’, <http://www.bbc.co.uk/newsbeat/article/30695657/schools-struggling-to-cope-with-students-self-harming> [Accessed: 10 October 2016]
DfE (2016) ‘Mental health and behaviour in schools: Departmental Advice’
NHS (2015) ‘Burns and scalds’, <http://www.nhs.uk/conditions/Burns-and-scalds/Pages/Introduction.aspx> [Accessed: 10 October 2016]
NHS (2016) ‘Cuts and grazes’, <http://www.nhs.uk/Conditions/Cuts-and-grazes/Pages/Introduction.aspx> [Accessed: 10 October 2016]
NHS (2016) ‘Poisoning’, <http://www.nhs.uk/Conditions/Poisoning/Pages/Treatment.aspx> [Accessed: 10 October 2016]
North Yorkshire Safeguarding Board ‘Self-harm and Suicidal Behaviour’
University of Oxford (2016) ‘Coping with self-harm: A guide for parents and carers’