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Child Health Guideline Identifier

Self harm

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Introduction

In a 2011 study of more than 8000 New Zealand teenagers, 20% reported that they had harmed themselves in some way - acute health services only see a fraction of these. Most will be female, usually with significant family and/or social difficulties.  Many will not have intended to die. Psychiatric disorders and substance abuse are commonly associated, and must be assessed for, as should safety issues including sexual and physical abuse.

Self-harming teenagers present challenges in the emergency department setting, and can trigger an emotional response from staff (eg irritation, hostility), as their behaviour can be interpreted as attention-seeking or time wasting. However self-harm is a communication, usually about an intolerable situation that the young person can't resolve by any other means, either because they don't have the emotional skills or because they don't have suitable supports. Various studies have shown that kindly, matter of fact and warm responses from staff increase the likelihood a young person will accept ongoing help.

Assessment

Assessment in an emergency setting must answer the following questions:

  • Was this a suicide attempt?
  • If so, how serious was it?
  • How safe are they now?
  • Do they have a psychiatric illness?
  • Do they have a substance abuse problem?
  • Are there other risks the young person is exposed to (such as physical/sexual abuse) or bullying?

Was This a Suicide Attempt?

The intent needs to be inquired for specifically, e.g. "What did you think would happen when you took the pills?"  or if the answer is unclear:  "Did you mean to die?"  Many teenagers take small overdoses in an attempt to escape a difficult situation but don't mean to kill themselves. Others harm themselves (eg by cutting) as a distraction from distressing emotions. Obviously, those who intended to die must be taken more seriously, but all self-harm must be considered dangerous behaviour.

How Serious Was It?

Health professionals often assume that the seriousness of an overdose is directly related to the number and type of tablets taken - i.e. the medical seriousness.  You have to be pretty determined to take more than 10 tablets.  However, this is only one factor to be considered.  In addition, the following need to be asked about:

Circumstances of the Self-Harm 

  • Was discovery inevitable or unlikely? (e.g. waiting until everyone was out versus taking an overdose in another room, while the family is home).
  • Was this spontaneous or pre-planned?
  • Was a note left?
  • Was the person intoxicated, therefore less in control of their behaviour?

Method Used 

Most teenagers will have taken small overdoses or cut themselves superficially. Some will be part of peer groups (on-line or in person) who inform and encourage each other to self-harm. Serious methods, e.g.: guns, hanging, jumping, carbon monoxide are related to a higher incidence of psychiatric disorder (e.g.: schizophrenia, depressive illness) or later completed suicide.

How Safe Are They Now? 

This includes the answers to questions 1 and 2 but also their attitude to "survival" i.e.: if they are disappointed that they are not dead, they must be considered a suicide risk.

This can be asked directly, e.g.: "How do you feel about still being alive?"  In practice most will say that they felt upset at the time of the attempt but are glad they are still alive.  In fact, embarrassment is quite common in teenagers presenting to the emergency department.  Equally important are the available social supports.  Is there someone - family, whanau, friend, who will be around to support the teenager or are they "on their own"?  (Often found in disrupted families).  Abuse issues should also be considered by asking the young person about bullying, physical assaults and sexual abuse.

Do They Have a Psychiatric Illness?  

Depressive Illness (most common)

Symptoms include:

  • Low or irritable mood most of the time for at least 2 weeks, not improved by usual activities.
  • Poor sleep (or excessive sleep sometimes)
  • Poor appetite and/or weight loss
  • Poor concentration/diminished ability to think clearly
  • Poor energy/psychomotor retardation - or agitation
  • Hopelessness about the future
  • Excessive thoughts of guilt or worthlessness
  • Suicidal thoughts or thoughts of death

Depressive illness is rare in childhood, but the incidence increases dramatically at puberty.

Schizophrenia (less common, but occasionally seen in ED)

Suicide attempts in young people with schizophrenia may be unusual in the method used or emotional response afterwards.  The main symptoms of schizophrenia are hallucinations (usually auditory), delusions, and decline in general function.  Young people often have a "florid" presentation with highly disturbed behaviour - including agitation and extremely bizarre ideas (sometimes bodily symptoms which may bring them to medical services).

Screening questions for schizophrenia include:

  • Do you ever hear sounds/people talking when there is no one there?
  • Has anything strange or unusual been happening to you?
  • Is there any problem with your thinking?

If the young person is very disturbed family/whanau will probably give a clearer history of unusual behaviour.

Do They Have a Substance Abuse Problem?

A high proportion of young people who self-harm also have substance abuse problems and may be intoxicated at the time of the attempt.  This can complicate assessment, especially if they are still under the influence of a substance when they present at ED.  Serious substance abuse is also a risk factor for completed suicide so needs to be identified.  Ask usual questions about types/amounts/frequency of substance use.

Assessment Summary

In the psychiatric assessment of self-harm, danger signs include:

Current Mental State

  • Current disordered mental state
  • Continued wish to die

The Suicide Attempt

  • The intention to die
  • Medically serious attempts
  • Violent attempts (guns, hanging, etc)
  • Planning an attempt so that it was likely to succeed
  • Leaving a note

History

  • Older males
  • Little social support
  • LGBT young people (several times risk of self harm) 
  • Psychiatric illness, especially depressive disorder or psychosis
  • Substance abuse
  • Prior suicide attempts

Management 

  • The assessment of suicidal young people requires a comprehensive evaluation, ideally by a clinician who is skilled in interviewing and working with children and adolescents.
  • Risk assessments should not be based on information from the young person alone. Information and input should always be drawn from several sources including the young person, their parents or guardians, and reports from other individuals close to the young person
  • Confidentiality is not absolute, and it may be necessary to contact whanau or other supports against the wishes of the young person (as spelt out in the Privacy Act (1993) and Health Information Privacy Code (1994) in order to ensure their safety.
  • It is possible to compel treatment or prevent the departure from ED of a person attempting suicide who does not wish to be treated, as long as they appear to be at imminent risk from self harm.  This is covered by the Crimes Act 1961 s41.
    Prevention of suicide or certain offences - Everyone is justified in using such force as may be reasonably necessary in order to prevent the commission of suicide, or the commission of an offence which would be likely to cause immediate or serious injury to the person or property of any one, or in order to prevent any act being done which he believes, on reasonable ground, would, if committed, amount to suicide or to any such offence.
  • A young person presenting following self harm should not be allowed to leave without assessment, and if they insist on leaving,  a clear plan for their safety involving other adults needs to be agreed on.
  • The above points are particularly critical with young people under 16 years, where clinicians may be acting "in loco parentis" in the absence of their parents/guardians. 
  • Self-harm among children <15 is rare but should be treated very seriously. Young children who self-harm have very high rates of abuse and family disruption, thus there should be a low threshold for social work referral and CYF involvement.

Actions 

  • Document all concerns and discussion about the self-harm behaviour
  • During 8.30-4.30 phone the Consult Liaison team Duty Phone on 021 492 403, or ext. 23303 and ask for the Duty Crisis staff member
  • After hours all children and adolescents who self-harm must be referred to the child psychiatric registrar on call (call ADHB switchboard), who may consult the on-call child & adolescent psychiatrist.  They will arrange follow-up with a Community Child and Adolescent Mental Health Team.
  • Few need psychiatric admission, most require outpatient treatment. Those who have higher risk factors or no suitable supports for supervision at home may need admission to Child and Family Unit or similar service to allow more space and time to sort out a plan: a child psychiatrist needs to approve admission.
  • If a child/young person needs medical admission a plan for their mental health monitoring needs to be developed with the help of mental health staff. Some may require a watch and occasionally the Mental Health Act may be required.

Notes  

Epidemiology and Risks of Suicide in New Zealand.

  • Most completed suicides occur between ages 17 and 24.
  • Males outnumber females in completed suicides by at least 2-3: 1.
  • Most suicides are due to falls, hanging, carbon monoxide (car exhaust), and firearms.  Overdosing is only occasionally "successful".
  • The risk before age 15 is very low (5 per year in NZ), 90% are male
  • Females greatly outnumber males in attempting suicide.
  • The immediate risk of suicide is very hard to predict even with expert assessment. Safety is enhanced by ensuring the young person feels as supported as possible and by engaging their family/whanau or other supports.

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Document Control

  • Date last published: 20 February 2017
  • Document type: Clinical Guideline
  • Services responsible: Consult Liaison Psychiatry
  • Author(s): Leah Andrews
  • Owner: Leah Andrews
  • Editor: Greg Williams
  • Review frequency: 2 years

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