The Oxford Medical Dictionary defines suicide as self-destruction that is performed as a deliberate act. Although it is strongly linked to self-harm, it is noteworthy that self-harm is often not a suicide attempt, but actually a parasuicide -when self-harm is carried out for other reasons other than killing oneself. Deliberate self-harm refers to “a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning, and superficial self-cutting in response to intolerable tension” (Skegg, 2005).
According to The National Institute of Clinical Excellence (NICE), self-harm is an expression of personal distress, and is not in itself, and illness. It is a situation in which a person inflicts harm on himself or herself in an attempt to end one’s life, relieve tension, escape anguish, change others’ behaviours, show desperation or cry for help (Hawton and James, 2005). Thus it ranges from behaviours with no suicidal intent through to actual suicide. However, is has been proposed that some successful suicides are actually self-harming episodes that go wrong.
Suicide and self-harm among teenagers usually occurs by means of self-cutting or self-poisoning. Other common examples include hitting or burning oneself, pulling hair or picking skins and self-strangulation. Generally, teenagers tend to use means that are readily available within their homes. Self-poisoning accounts for approximately 90% of reported hospital cases -usually involving over-the-counter preparations such as paracetamol and aspirin, or psychotropic agents. Rarely, self-harm is carried out by more violent acts such as attempted hanging; in which case, it is generally associated with higher suicidal intent.
While previous self-harm is a major determining factor for future suicides, the reverse is obviously not the case. Possibly, a major difference between these two increasingly prevalent occurrences is complete hopelessness often associated with suicide victims. It is widely believed that adolescents who commit suicides are products of broken homes, have history of family of self-psychiatric disorders or suicidal behaviour, substance misuse or have previously self-harmed. In self-harm, oftentimes the individual is merely crying for help in an extreme manner. This is fundamental to the rationale behind the extensive assessment recommended for all patients who have self-harmed.
Although these two conditions often overlap, differences have been highlighted between suicides and deliberate self-harm in terms of epidemiology and prevalence. While suicide rates increase with age, the majority of deliberate self-harm occur in people under 35 years of age. Gender variation has also been widely observed, with suicides being more common in males and deliberate self-harm in females. Also, differences arise in the psychiatric status of the patients. Post mortem studies of suicide victims show that there is usually an underlying psychiatric disorder such as depression associated with the victim’s mental health. This is not always the case with self-harm patients. Although there could be a history of depressive illness, self-harm is frequently an impulsive act, probably enhanced by alcohol or drug consumption (Hawton and James, 2005).
Self-harm is a serious public health problem and young people are particularly affected by it (Mental Health Foundation, 2006). A case of a patient who has self-harmed is a chance for the health services to effectively evaluate and address any relevant underlying problems and is an opportunity to successfully avert potential future suicides.
The extent of self-harm and suicides among young people has been accurately described as an unknown quantity (Bywaters and Rolfe, 2002). Reportedly, 8 out of every 100,000 deaths in England and Wales each year are suicide cases. There are an estimated 25,000 adolescent self-harm presentations annually in hospitals in England and Wales (Hawton et al, 2000) and government research report that as many as 1 in 17 young people have attempted to harm themselves. Suicide is the second most common cause of death among 15- to 34-year olds. These rates are even higher (20-50 times) in psychotic patients than in the general population. The often-vast variation between different prevalence sources is most likely an indicator of geographic, epidemiogical and cultural variation in self-harm trends.
Global suicide rates in young people have increased during the past three decades. According to the Office of National Statistics (1999), 1.3% of 5-10 year olds have tried to harm, hurt or kill himself/herself. More than four times this proportion (5.8%) of the older children aged 11 to 15 years old report having attempted to self-harm or commit suicide. Most child and adolescent mental the health services take the school-leaving age of 16 as their upper limit. Thus most available statistics are only for children up to the age of 16. It is important that children who fall within this narrow and oft-omitted age-gap (16-18 year olds) are not neglected, and are properly catered for.
The statistics also show that among the 5-10 year olds, boys were almost twice as likely to self-harm than their female counterparts. Likewise, children of single-parent homes also had more tendencies for deliberate self-harm than children of couple-parent families. Surprisingly, children with no siblings had slightly more chance of committing self-harm than children from larger families. 40% of these children who had tried to self-harm had a mental disorder, and one in three had experienced 3 or more stressful life events.
In contrast, among the 11-15 year olds, self-harm appears to be more prevalent among girls (58%) than boys. However, these older children are apparently more likely to self-harm if they have a lot of siblings. 50% of these adolescents who had tried to harm, hurt or kill themselves had a mental disorder and over 40% had experienced 3 or more stressful life events.
Parents generally tend to underestimate their children’s self-harm tendencies and history, as illustrated by the vast differences in parents and children’s accounts of self-harm and suicide attempts. This gives an insight into the level of shrouding and secrecy that is associated with these phenomena and casts doubts on the validity and reliability of these widely accepted statistics. Stigmatisation and ostracization commonly associated with suicide and self-harm victims and families is the most likely reason behind under-reporting and denial. In addition, prevalence of suicides is largely underestimated because of reluctance of coroners to classify cause of death as suicides, especially in children. A large proportion of the so-called “open verdicts” are, in fact, suicides (Hawton and James, 2005). Self-harm techniques such as self-cutting usually go unnoticed. As the most common method of DSH by teenagers, the implications are that the rates of self-harm amongst adolescents are grossly under-reported. Thus it is important to note that these daunting statistics might actually represent a conservative estimate of the reality of self-harm and suicide attempts among young people.
Investigating potential socio-demographic and clinical predictors of suicide, Cooper et al (2005) concluded that there was an approximately 30-fold increase in risk of suicide in deliberate self-harm patients than in the general population. Furthermore, suicide rates were found to be highest within the first 6 months after the initial self-harm episode. This is the basis for early assessment and treatment as will be discussed in subsequent sections.
Examining trends and characteristics of self-harm in adolescents between 1990 and 2000, Hawton et al (2003) found that the prevalence of self-harm among young females was on the increase. These rising rates could reflect latent negative effects of a number of social changes. Possible reasons for this increase include increased rates of family breakdowns, increasing rates of substance misuse, media influences and common peer behaviours.
In a self-report survey, Hawton et al (2002) studied the prevalence of deliberate self-harm in adolescents aged 15 and 16 years old, and the factors associated with it. In this age group, females were more likely to self-harm than males. Ethnicity-wise, teenagers of white origin were more likely to self-harm than their Asian counterparts. Black young people were the least likely to self-harm. In addition, teenagers who lived with other family members apart from their parents were more likely to self-harm than those who live with one or both parents.
Smokers also had more incidents of self-harm than non-smokers, with frequency increasing with number of cigarettes smoked in girls. Similar trends were observed with young people who consumed alcohol. Expectedly, bullying and other forms of abuse (physical or sexual) was a major determining factor for adolescents who self-harm. Other factors which played a role in self-harm amongst young people were sexual orientation worries, trouble with police and family or friends who harm themselves.
Although self-harm is observed in all age-groups, it has an average age of onset of 12 years old (Fox and Hawton, 2004). Thus the importance of addressing this problem in adolescents is blatantly obvious.
Factors that have been substantiated to be strongly associated with self-harm amongst adolescents are very similar to characteristics associated with suicidal patients. These include:
In an ecological and person-based study, Hawton et al (2001) investigated the influence of the economic and social environment on deliberate self-harm and suicide. Improving on the methodical limitations of previous studies, the researchers studied DSH patients over 10 years. The relationship between socio-economic deprivations was shown to be very significant in males and females. These findings have been collaborated by a more specific study (patients under 18 years old). Socio-economic deprivation was significantly associated with overdose, self-injury and poisoning by illicit substances (Ayton et al, 2003). Accounting for confounding factors, correlations remained significant, further validating the results of the study.
Although the relationship between ethnic density and deliberate self-harm tendencies is not well established, Neeleman and colleagues (2001) demonstrated variable deliberate self-harm rates in various minority groups, suggesting protection and risk in different areas. This is a gap in the literature for future research. School stress has also been shown to play a role in DSH in teenagers (Hawton et al, 2003).
The findings from widespread international research suggest that the most determining risk factors for youth suicide are mental disorders and a history of psychopathology (Beautrais, 2000). Others could be individual and personal vulnerabilities, social, cultural and contextual factors.
Possible motives for self-harming behaviour other than death are highlighted below (Hawton and James, 2005):
Furthermore, research has provided a useful insight into the factors that can influence repetitive self-harm behaviours despite aftercare and treatment. This is important in the assessment of patients who have self-harmed to identify those who are likely to self-harm again and prevent such episodes. Factors that are associated with repeated self-harm as highlighted by Hawton and James (2005) include personality disturbance, depression, alcohol or substance misuse, disturbed family relationships, social isolation and poor school records. Hawton et al (1999) demonstrated that self-harm repeaters differed from the non-repeaters in having higher scores for depression, hopelessness and trait anger, and lower scores for self-esteem.
Specific reasons that have been cited for self-harm by young people, as highlighted by the National Inquiry (2006) include:
· Strained relationships with parents
· Parental divorce
· Unwanted pregnancy
· Worry about academic performance
· Childhood abuse (sexual, physical or emotional)
· Low self-esteem or rejection
· Problems to do with race, culture or religion
2. Responding To Young People Who Self-Harm
2.1 Guidelines And Evidence For Good Practice
The National Institute for Clinical Excellence (NICE, 2004) has proposed guidelines for the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. In addition, The Royal College of Psychiatrists (RCPSYCH) also provides guidance on managing young people up to the age of 16 who deliberately harm themselves. Such guidelines are readily applicable to the Health service i.e. Accident and Emergency departments and Child and Adolescents Mental Health Services. Integrating these treatment guidelines and the findings of related research, the management of these young self-harm patients will be extensively discussed under the following sub-titles:
A comprehensive child and adolescent mental health service needs to take all the above facets into consideration when treating this group of extremely vulnerable patients. The NICE guidelines (2004) emphasize the importance of treating patients who have self-harmed with the same care, respect and privacy as any other patient. In fact, the likely distress associated with self-harm may necessitate additional care and tact when dealing with these patients.
Also, health services are urged to provide appropriate training to all staff (clinical and non-clinical) that has any form of contact with the patients to fully equip them with the necessary skills and knowledge to effectively understand and care for people who have self-harmed. Ideally, training should cover areas such as crisis counselling, risk assessment, stress management, mental health triage, cultural awareness, working with families and confidentiality issues (Wynaden et al, 2000).
Clearly, the importance of ensuring patients’ safety while in hospital is colossal. These patients should be offered an environment that is safe, supportive and minimises any distress. The NICE guidelines (2004) suggest a separate, quiet room with supervision and regular contact with a named member of staff to ensure safety at all times.
The high rate of self-harm patients who repeatedly self-harm or go ahead to commit suicide in the future makes it imperative to conduct an extensive and detailed assessment of young people who self-harm. Young people who have self-harmed in a potentially serious or violent way should be assessed either by a child and adolescent psychiatrist, a specialist mental worker, a psychologist, a psychotherapist or a psychiatric nurse (Hawton and James, 2005). The NICE guidelines propose that all people who have self-harmed should be offered this preliminary assessment at triage, regardless of the severity of the attack. Apart from the obligatory emergency physical assessment, this will give an insight into the patient’s mental health, the level of distress and their willingness to co-operate with the medical team. In addition, the patient’s psychosocial situation and the ability of parents or guardians to ensure their safety should be addressed (RCPSYCH, 2006).
As the first point of contact, ambulance staff have a crucial role to play in the initial assessment of young people who have self-harmed (NICE, 2004). The Australian Mental Health Triage Scale is a validated comprehensive assessment scale that provides a means of efficiently rating clinical urgency so that patients can be seen in a timely manner. This scale has been shown to improve staff confidence and attitudes in dealing with clients with mental health problems, thus improving patients’ outcomes in the long-run (Broadbent et al, 2004).
Research has shown the importance of cultural, ethnic and racial awareness and sensitivity in the assessment process. Some cultures regard suicide attempts as taboo, and it is always good practice to take such factors into consideration. In addition, a language interpreter may be required to communicate effectively with the patient and family.
2.1.2 Treatment Planning
Following the preliminary assessment, it is considered good practice to have an action or treatment plan (Hawton and James, 2005). The treatment plan should take into account all aspects of the patient’s management in hospital, ranging from treatment options to pharmacological and psychological interventions to discharge planning.
2.1.3 Admission To Hospital
At this point, temporary admission should be considered especially for patients who are who are very distressed, for people who may be returning to an unsafe or harmful environment and for people in whom psychosocial assessment proves too difficult for any number of reasons (NICE, 2004). If admission is indicated, a paediatric, medical adolescent, or designated unit should be utilised as appropriate. Despite the NICE guidelines, some schools of though believe that regardless of the toxicological or physical state of the young person, hospital admission is desirable, so that adequate further physical and psychosocial assessments can be carried out, and management/crisis interventions can be planned and initiated (Hawton and James, 2000). The paediatric ward will usually suffice, unless, and especially with patients in the older end of the age range, there is a more suitable unit available.
Waterhouse and Platt (1990) investigated the difference in outcomes between self-harm patients who were admitted to hospital and those were discharged as outpatients. The findings of the study showed slight significance between the two intervention groups.
It is the role of the admitting staff to obtain agreement for the mental health assessment of the patient from parents or relevant guardians, and to alert all members of staff of each young person’s needs. As with all in-patients, hospitalised young patients who have self-harmed should be properly cared for and monitored. In addition, responsibilities of staff of the mental health team will include providing consultation to the young person and his/her family, the paediatric team and staff of the social services and education departments.
The Crisis Recovery Unit at the Bethlem Hospital in London, a national specialist unit for people of 17 years and above who repeatedly self-harm, have a different and slightly radical approach to the in-patient treatment of these patients (Mental Health Foundation, 2006). Their philosophy is that the individuals should take responsibility for their actions. This practice-supported technique focuses on helping young people realise for themselves that self-harm is not an effective strategy for dealing with their problems. It encourages these patients to talk about their problems and explore alternative coping strategies, including strategies for dealing with the urge to self-harm. However, the effectiveness of such an intervention in younger patients (11-16) is not certain, as these children might not be mentally mature for such self-realisation tactics.
2.1.4 Treatment Options
Treatment options for adolescents who have harmed themselves could be individual-based, family-based or group-based. Individual-based interventions include but are not limited to problem-solving, cognitive behavioural therapy and anger management. Family therapy could be in the form of problem-solving or structural or systemic therapy, and group therapy could involve any of these techniques performed in teams or groups.
Problem-solving therapy or brief psychological therapy as it is otherwise known, is a brief treatment that is aimed at helping the young patient to acquire basic-problem solving skills to identify and prioritise their problems (Mental Health Foundation, 2006). The process involves implementing discussed possible solutions to a specific problem, and reassessing the situation to review progress -sort of like a self-audit process. The basics of problem-solving therapy as identified by Hawton and James (2006) are highlighted below:
· Identifying and deciding what problems to tackle first
· Agreeing goals of therapy with the patient as much as is possible
· Working out steps to achieve goals
· Deciding how to tackle the first step
· Reviewing progress
· Dealing with psychological factors that obstruct progress
· Working through subsequent steps
This method of problem-solving therapy appears to improve depression, hopelessness and general problems in deliberate self-harm patients significantly more than control therapy (Townsend et al, 2001). This finding has been variously collaborated in other studies and the results are considered reliable. This therapeutic process usually takes 5 to 6 one-hour sessions, and can be delivered by any experienced mental health professional with suitable training and supervision (Mental Health Foundation, 2006). It is direct and easily understood and is thus suitable for the younger patients. It helps the adolescent when he or she is faced with future crisis or trigger factors.
Cognitive Behavioural Therapy
This form of psychotherapy is based on the belief that psychological problems are the product of an individual’s faulty way of viewing the world. In this case, the therapist aims to modify the patients’ cognitive processes and beliefs using techniques that are similar to those described above (problem-solving therapy), but with behavioural techniques.
Although widely used adopted in psychotherapy in the treatment of depression, cognitive behavioural therapy (CBT) has limited evidence of use in self-harm patients. Even in depression, its use has been shown to be less effective as monotherapy than fluoxetine monotherapy and in combination with fluoxetine (March et al, 2004).
Dialectical Behaviour Therapy
Dialectical Behaviour Therapy (DBT) is an intensive therapeutic technique that was introduced to help those who repeatedly harm themselves. It could involve as long as a full year of individual therapy, group sessions, social skills training and access to crisis contact (Mental Health Foundation, 2006).
Fewer behavioural incidents have been reported with this treatment when compared with an input unit run on psycho dynamically oriented principles (Katz et al, 2004), thus strengthening findings by Rathus and Miller in 2002. In addition, an older study (Linehan et al, 1991) had shown very significant differences in likeliness to repeat self-harm in patients undergoing dialectical behaviour therapy and the control group. The NICE guidelines (2004) suggest the use of dialectical behaviour therapy in self-harm patients who have a diagnosis of borderline personality disorder, but stress that this should not preclude the use of other strongly validated psychological treatments with vast evidence-based support.
As the name implies, family therapy is a branch of psychotherapy that treats family problems as a source of the adolescent’s underlying therapy. Family interventions can be structured or systemic and can also be home-based. Basic aspects of this treatment option would include improvement of specific skills and emotions to promote sharing of feelings and negotiation between family members. Elements of assessment of families of self-harm victim should include (Hawton and James, 2005):
· Family structure and relationships
· Recent family life events, e.g. death, relocation, divorce e.t.c.
· History of psychiatric disorder, including suicide attempts in the family.
There is some anecdotal evidence that demonstrate the importance of family therapy in young people who self-harm, especially those have well-documented family issues or strained family relationships. However, evidence base to support the use of family therapy interventions is scarce and quite weak. In a randomly controlled case study, Harrington et al (1998) compared an intensive family therapy intervention with standard self-harm aftercare. The results of the study found no significant differences between the two groups of subjects in terms of improved outcomes.
Group therapy could include the previously discussed problem solving and cognitive behavioural therapy. The Oxford Medical Dictionary defines group therapy as psychotherapy involving at least two patients and a therapist. Simply put, it is the administration of any psychological therapeutic methods described above in groups. Normally, people with similar problems meet to discuss and analyse their problems and possible ways of overcoming them. Although this intervention could be time-saving, the possibility of confrontation and tension between the group members is a potential barrier to its effective implementation. Also, the negative connotation of suicide and self-harm might prevent patients from effectively participating in such group sessions.
In a small-randomised parallel trial in Manchester, England, Wood et al (2001) strove to evaluate the effectiveness of group therapy for repeated deliberate self-harm in adolescents by comparing combination of routine care and group therapy with routine care alone. Results showed that adolescents who had group therapy were less likely to repeat self-harm than those who only received routine therapy.
Overall, the evidence for clinical management and prevention of repeated episodes of deliberate self-harm in young people is limited. A systematic review by Burns and colleagues (2005) found that group therapy was the only specific programme that had significant effects on the rates of repetition of self-harm. Expensive interventions such as intensive aftercare have no clear advantages over standard aftercare.
2.1.5 Medical And Surgical Management
Clearly a person who has harmed himself/ herself will have some form of injury, whether superficial or systemic. Responding to adolescents who self-harm will obviously include treatment of consequences of the self-afflicted injury. The treatment of self-injury would be the same as for any other injury, taking into account the level of distress and emotional disturbance experienced by the patient (NICE, 2004).
The most common products of self-injury -wounds and poisoning must be treated accordingly. Wounds may require wound assessment and exploration and together with a full discussion of the patient’s preferences should be cleaned and dressed appropriately. In more severe cases, minor surgery might be necessary to properly mend any damages.
Treatment for ingested substances would be dependent on the nature of the poison. Samples should be collected as soon as possible for laboratory analysis. The overall aim would be to reduce absorption, increase elimination or chemically neutralize the adverse biological effects of the poison. The guidelines proposed by the National Institute of Clinical Excellence emphasizes the consideration of gastro-intestinal decontamination only in self-harm patients who present early, are fully conscious with a protected airway, and are at risk of significant harm as a result of the poisoning. Activated charcoal could be administered 1 to 2 hours after ingestion. Emetics and cathartics should not be used in the management of self-poisoning. Recommendations by TOXBASE or the National Poisons Information Service (NPIS) should be followed to prevent further complications and harm. Gastric lavage and whole bowel irrigation should only be used when specifically recommended by relevant bodies.
2.1.6 Pharmacological Interventions
Generally, the use of pharmacological agents in treating adolescents who have self-harmed is built on the basis that depression is an underlying problem in these patients. Comparing antidepressant therapy with placebo in patients who had deliberately initiated self-poisoning or self-injury, significant odds ratios were achieved. Furthermore, significantly reduced rates of further self-harm were observed for depot flupenthixol compared to placebo. The current controversy over selective serotonin reuptake inhibitors in children and adolescents (Wong et al, 2004), especially those with suicidal ideation must be taken into account when prescribing for this group of patients. Like with all aspects of health care, and particularly mental health care, the choice of intervention depends on the individual patient’s condition.
Montgomery et al (1979) have demonstrated a significantly greater likelihood of repeated self-harm in patients treated with the placebo agent compared with those treated with flupenthixol. Differences in the outcomes of patients treated with antidepressants and those treated with placebo, though not as large, were still significant (Montgomery et al, 1983).
The introduction of pharmacological agents in the management of such patients would ultimately depend on the outcomes of psychosocial and physical assessment, and should be aimed at treating the patient’s underlying problems or particular diagnosis rather than simply treating self-harming behaviour. Whatever, therapeutic decisions are made, clinicians should ensure that the patient (or where not possible, parents or guardians) are made aware of the treatment options available, including the likely advantages and disadvantages, and involved in making a choice.
2.1.7 Referral and Discharge Following Self-Harm
Referral and discharge of an adolescent after self-harm would depend on the outcomes of the extensive assessment that would have been previously conducted (section 2.1.1). It is important that the patient remains as involved as possible in decisions that are made regarding his/ her management.
Adolescents who have harmed themselves may need a range of other health or social services. Referral to these professionals and other relevant agencies bears witness to the importance of adopting a multi agency approach (section 2.3). Proper documentation of all relevant interventions and conversations will ensure a seamless transfer from one health service to another and culminate in improved quality of care and better outcomes.
2.1.8 Family Support
This is quite different from family therapy as discussed under treatment options (section 2.1.4). Rather than attempt to resolve underlying family problems in a bid to address the source of the adolescent’s problems like the latter, family support refers to moves that could be taken to help parents and siblings deal with the traumatic experience of self-harm in the family.
Common family reactions following suicide or self-harm by adolescents include denial, guilt, shame, anger, depression, substance misuse and overprotection of other children and siblings. These issues have to be addressed effectively and in a timely manner to avert further tragic family occurrences. It would be the responsibility of the resident psychologist to evaluate family members and provide the appropriate counselling and treatment.
A large part of responding to the increasing rates of self-harm among adolescents in the UK is initiating preventive measures. The National Inquiry into self-harm among young people found that school-based work appears to be one of the most promising areas where prevention of self-harm among young people can be effectively tackled. Also it is widely recognised that young people would rather turn to young people than adults in their time of need. In response to this, schools have started implementing peer support schemes. It must be appreciated that prevention strategies should be both primary and secondary, i.e. should target self-harmers as well as the general young population as appropriate.
Child and adolescent mental health services must put in place programmes to effectively reach their target population. Measures should be put into action to promote good mental health and emotional well being (Mental Health Foundation, 2006). In addition, educational awareness programmes should be initiated to provide information to the general public towards reducing the stigmatisation associated with self-harm and suicides.
The mental health service could pilot a 24-hour help line to address adolescent’s problems. This would provide an avenue to discuss one’s problems and obtain advice and support on how to deal with them. 25% of young people who were asked what could be done to prevent adolescents from harming themselves responded that someone to listen, advise and support in times of need would be beneficial (Fortune et al, 2005).
Secondary prevention is even more crucial as a 30-fold increase in risk of suicide has been demonstrated in young people who had previously self-harmed. Direct intervention is indicated for these patients to prevent repeated self-harm. Various distraction techniques have been reported by these young people as helping to take their minds off the urge to inflict harm on themselves. These include physical exercise, writing negative feelings on paper and ripping it up, using a red felt-pen to mark instead of cut, hitting a punch bag to vent anger and frustration, writing in a diary and talking to a friend (Mental Health Foundation, 2006).
Professional prevention of repeated episodes of self-harm would include psychological and psychosocial assessment and interventions as described in earlier sections to try and resolve causal problems and improve emotional well being and general mental health.
2.2 Assessing The Needs And Risks of Young People Who Have Self-Harmed
Psychosocial assessment in patients who have self-harmed can be classified broadly into assessment of need and assessment of risks. Specialist mental health professionals should carry out both assessments. Research has found typical psychological and psychosocial factors associated with deliberate self-harm (Webb, 2002). However, the breadth and sensitivity of tools and methods utilised in these studies mean that psychosocial factors have been less consistently measured. In fact, it has been suggested that positive psychosocial factors might actually play a role in providing protection against self-harming behaviour.
Assessment of Needs
Needs assessment should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the individual’s act of self-harm, current suicidal intent and hopelessness (NICE, 2004). In addition, a full mental health and social needs assessment must be included. As always, all conversations and interventions must be clearly documented in the patients’ notes to ensure seamless transition from one healthcare professional to another, and to enable follow-up.
Assessment of Risks
This should include identification of the main clinical and demographic characteristics that are potential risk factors for repeated self-harm or suicide (NICE, 2004). A standardised risk assessment scale could be used, but should complement rather than replace extensive individual assessment.
Psychosocial assessment is important because it provides an insight into the longer-term needs and risks of the patient and forms a basis for therapeutic decisions.
2.3 The Multi Agency Approach To Management of Adolescents Who Self-Harm
The involvement of multiple agencies or services in the care of patients who have self-harmed is crucial to obtaining good outcomes. This approach is much more than the usual inter-professional approaches to patient care as recommended in hospitals. Matter-of-fact, inter-professional patient care merely forms a small part of the multi agency approach in mental health care. The Royal College of Psychiatry (2006) emphasizes the importance of a full and longer-term approach to providing care for self-harm patients that will require the co-ordinated activities of local and health authorities together with an awareness of the important role that non-statutory sector agencies play.
The nature of these episodes of self-harm and the age group being considered necessitates the involvement of a wide range of professionals in health and non-health sectors in order to address all aspects of the incidence appropriately. Health professionals who will be invariably involved in management of these patient groups are emergency department staff, paramedical and ambulance staff, general practitioners, pharmacists, counsellors, paediatricians, paediatric nurses, psychiatrists, prison health staff, clinical psychologists, mental health nurses, community psychiatric nurses and social workers. Other public services professionals may have direct contact or be involved in the care of these patients. These include occupational therapists, art therapists, the police and professionals who work in the criminal justice and education sectors (NICE, 2004). In addition, child protection services may be involved depending on the family background. Thus it is clear that the full range of resources and interventions required by young people who harm themselves span the responsibilities of a range of agencies and sectors of care (RCPSYCH, 1998).
Paramedical and Ambulance Staff
As the first health care contacts that an adolescent will have after a self-harm episode, ambulance staff and paramedics have an increasingly important role in early assessment and treatment of self-harm. Urgently needed at this point is an assessment of physical risk to ascertain the extent of the injury and provide first-aid treatment at once. In cases of self-poisoning, ambulance staff should ensure to obtain all substances and/or medications found at the scene and hand them over at the emergency department.
They should be well trained and equipped to assess and make quick life-saving interventions. Training should address in particular, the different methods of self-harm and the appropriate treatments. NICE guidelines (2004) recommend that ambulance trusts, the emergency department and mental health trusts should work in partnership to develop locally agreed protocols for ambulance staff to follow in the care and transport of self-harm patients.
Emergency Department Staff
The accident and emergency (A&E) staff in the hospital are probably the main care-providers for these patients at this acute stage. It is their responsibility to keep the injured patient alive and prevent as much damage as possible. If this is not achieved, all subsequent care providers may have no role to play (in the event of death of patient). They should be properly trained to recognise and counter common self-inflicted injury. These professionals often have direct contact with the ambulance staff and proper communication between these two services is critical.
General Practitioners and Paediatricians
Effective communication between primary and secondary care is necessary in order to allow continuity of care for these patients. Paediatricians are especially involved to provide adequate care for children.
Mental Health Services
The role of mental health professionals such as psychiatrists, psychologists, and mental health nurses in providing care to self-harming young people is very evident. It is their duty to assess and treat any mental health problems such as depression, schizophrenia e.t.c. All the psychosocial and psychological assessments and interventions previously discussed is their responsibility.
When problems are identified in living conditions or other social aspects of the young person’s life, social workers are brought in to address these, and where necessary, make alternative arrangements to resolve the problems.
In the infrequent case of illegal activities associated with the incidence of adolescents’ self-harm, members of the police force or other criminal justice professionals are required to resolve these issues. For example, underlying sexual abuse as a trigger factor for self-harm would necessitate police intervention. Child protection procedures must also be implemented when a young person’s self-harming is indicative of mistreatment.
Children and adolescents spend most of their time in school, and thus the school staff could have a major role to play in taking care of young people who have self-harmed. Caution should be applied when dealing with children. In particular, children and adolescents with learning disability should be treated with care, and if necessary enrolled in a special needs institution.
Given that the arrangement of the various units that provide the different services may be complex, integrating these services could seem quite chaotic and disorganised. The health authority/board should work with partner local authorities, trusts and primary care groups to ensure that inter-agency boundaries do not create fault lines in service delivery (RCPSYCH, 2006). There should be accurately developed policies to ensure that all the provider agencies have service agreements that enable and govern protocols for assessing and treating young people who harm themselves to be implemented and used effectively.
The fundamental idea of a comprehensive child and adolescent mental health service provider is the takes a multi agency approach and is not restricted solely to a psychiatric service (Morley and Wilson, 2001). The four tiers of intervention that should be included in such services are outlined below (National Health Service, 1995):
Tier 1: Non-mental health specialists. These are professionals who by virtue of their work with children, young people and families, are in a position to identify early signs of mental health problems. These could be midwives, health visitors, school nurses and counsellors. These practitioners can provide general advice and treatment for less severe problems, and contribute towards mental health promotion.
Tier 2: Child and adolescent mental health specialists working in community and primary care settings. E.g. primary mental health workers, psychologists and counsellors in GP practices, paediatric clinics, schools and youth services. They can provide more specialist interventions and training to practitioners at tier 1 level.
Tier 3: At this stage, the multi-disciplinary and multi agency specialist child and adolescent mental health professionals work as team, as appropriate to provide extensive assessment and treatment to children and young people with more complex and persistent disorders.
Tier 4: In-patient and highly specialised child and adolescent mental health services, including specialist and forensic units usually offering services across several areas. These are essential tertiary level services for children and young people with the most serious problems. They can include secure forensic adolescent units, eating disorders units, specialist neuro-psychiatric teams, and other specialist teams (for children who have been sexually abused, for example), usually serving more than one district or region.
3. General Discussion
The reality of self-harm in adolescents paints a grim and depressing picture. The vulnerable nature of the patient group makes management and treatment interventions even more difficult to implement effectively. With increased access to televisions, the Internet and other sources of information and entertainment, young people today are exposed to all sorts of negative influences that could hamper mental health and emotional well being. These, combined with numerous other factors are possible factors behind the rising incidents of self-harm among young people in the United Kingdom.
Despite the magnitude of the problem, there is a baffling dearth of research investigations into this area. Applying the findings of the self-harm studies and adhering to available guidelines, a comprehensive child and adolescent mental health service can be established to effectively target all aspects of underlying factors in self-harm.
Ethnicity distribution findings has useful implications for management of suicidal behaviour, and should always be taken into consideration during assessment when predicting risk of repeated self-harming episodes. Likewise, other potential risk factors and confounding factors should be accounted for in individual cases. Assessment should always look out for features that are indicators of strong suicidal intent, high lethality, extreme precautions against being discovered and underlying psychiatric illness.
Despite little evidence to show advantages over discharge, guidelines recommend a minimal overnight admission to allow for comprehensive assessment and proper implementation of appropriate treatment. Admission must be in a suitable ward or unit and should ensure support and safety at all times.
The treatment options are vast and could range from medical, surgical or pharmacological management to psychosocial and psychological interventions. Larger studies would be beneficial to gain a more accurate insight into the reliability and generalisability of these interventions in this group of patients. There appears to be more research and information in the literature for psychological and psychosocial interventions such as problem-solving, cognitive behavioural therapy, dialectical behaviour therapy and group therapy, than for pharmacological management e.g. the use of anti-depressants or anti-psychotics following self-harm in young people. Ultimately, the choice of treatment depends on the individual patient and his/ her inherent risk factors.
Assessment of needs and risks (psychosocial assessment) must be carried out before discharge to ascertain the patients’ ability to cope and the extent of their suicidal ideation. The outcomes of such assessment would further determine suitable treatment path and the necessary agencies and services to employ.
For a comprehensive child and mental health service to efficiently respond to the rising incidents of self-harm among young people, there is need to appreciate the importance of inter-professional collaboration within the hospital setting. Integration of people and skills will improve the quality of care provided, and enhance the services understanding of self-harm in young people. In addition to this the importance of external multi-agency involvement is noted, as the full range of interventions required by these highly susceptible patient group necessitates the input of a wide range of agencies and sectors of care. Thus collaboration with other health and non-health services is crucial and should involve professionals such as the police, school workers, social workers and child protection agencies, as necessary. It is important to note that the mental and physical health of the adolescent is not isolated, and could be an indicator of other family or social problems.
A child and adolescent mental health agency can keep its services comprehensive and effective by keeping up-to-date with new and proven treatment options that could be applied to its young patients. Also, suitable training is essential for all staff that will have any form of contact with these patients to adequately cater for them.
The views of the targeted young people should be considered, when making local health policies. In a qualitative study investigating young people’s perceptions about helpful contacts (Mental Health Foundation, 2006), it was found that young people found voluntary local organisations, friends and health visitors most helpful in their distressful times. Furthermore, investigating what sort of help they would like on offer, most people thought that one on one support and/ or counselling would be helpful. Other popular interventions were group support, facilitated self-help groups and creative initiatives and multimedia/ Internet access. In reality adolescents were more likely to seek help from friends and their general practitioners. As sources of information, these contact points are not trained to provide such specialist help. Young people should be made aware of services provided by child and adolescents mental health agencies to educate them on the available benefits of reaching out to them in time of need.
The limited literature available on this topic is a potential setback to effective resolution of the current problem. Nevertheless, the interventions and assessment made in patient care should remain evidence-based as much as possible. It must be understood that the treatment of young people who self-harm should not be just solely psychiatric, and should adopt the recommended multi agency approach in order to effectively target all latent aspects of the problem.
Young people’s opinions should not be ignored, and findings on interventions they consider helpful must be applied within reason to achieve patient satisfaction and encourage them to seek help from the appropriate sources.
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