Self-harm in children and young people

How to recognise the signs and symptoms of self-harm in young people and the common psychiatric disorders associated with self harm.

Self-harm is a term used when someone intentionally causes injuries to their body, usually as a way of coping with overwhelming emotional distress. In the UK, common forms of self-harm include self-laceration and overdose.

Some young people who self-harm may also have thoughts of suicide. More than half of the young people who commit suicide have had a history of self-harm.

Young people can also self-harm by:

  • Burning (with cigarettes, lighters or matches)
  • Poisoning
  • Pinching, picking skin, or biting
  • Abusing alcohol or drugs
  • Deliberately starving themselves or binge eating
  • Excessive exercise
  • Persistent hair pulling, anywhere on the body
  • Strangulation
  • Excessive rubbing to create friction burns

How common is self-harm?

One in six young people have considered self-harm, and one in 10 young people have self-harmed. Some studies suggest that it is more prevalent in females than males.

Prevalence of self-harm may be under-estimated as figures are based on young people who report and receive treatment for their self-harm. However, many young people do not seek help after they self-harm, and may attempt to conceal it.

What are the signs of self-harm?

It is important to identify signs early and to take steps towards appropriate treatment. Most cases should be referred to secondary care. Possible indicators of self-harm in young people include:

  • Unexplained cuts or bruises, typically on the wrists, forearms, thighs, or chest
  • A young person who keeps themselves fully covered despite warm weather
  • A young person who appears withdrawn and isolates themselves from friends or family
  • Expressions of self-loathing and the desire to hurt and punish themselves
  • A young person who appears low in mood, and lacks interest in activities they once enjoyed
  • A young person who expresses a desire to take their own life
  • Low self-esteem and making statements of hopelessness and worthlessness
  • A young person who consistently blames themselves for problems that have occurred
  • Drugs or alcohol misuse
  • Pulling out eyelashes, eyebrows or hair
  • Unusual weight loss or weight gain, or changes in eating habits. A young person may try to hide this by wearing loose clothing or being secretive about eating

What are the causes?

The causes of self-harm are bio-psychosocial and multifactorial. There is no single factor that causes self-harm. Several factors can contribute to increase the likelihood of self-harm.

  • Family factors: difficulties in parent-child relationships, child and family adversity, maladaptive parenting, and parental divorce can be associated with self-harm.
  • Parental mental health disorders: exposure to self-harm in the family could model to a young person that it is a solution to overwhelming psychological distress.
  • Childhood physical and sexual abuse: there is a strong correlation between sexual and physical abuse and self-harm in young people.
  • Sexual orientation: research suggests that self-harm can be associated with adolescents’ concerns regarding sexual orientation. Estimates of risk for homosexual adolescents range from between two and six times that of heterosexual adolescents.
  • School: bullying is one of the main precipitating factors for young people who self-harm. This has become more common with the increase in bullying via social media.
  • Life stressors: young people who self-harm experience higher rates of exposure to stressful life events, such as socioeconomic difficulties, financial difficulties, peer-related stressors, social isolation, conflicts, and rejection.
  • Peer influence: group self-harm behaviour in young people can occasionally occur in settings such as schools and inpatient psychiatric units where young people are exposed to similar stressors, and modelling of self-harm behaviour within groups.
  • Media and internet: exposure and portrayals of self-harm in the media can increase the risk of it occurring in young people. Information can be gathered on methods used for self-harm and forums can infer that self-harm is an appropriate response to dealing with difficult emotions.
  • Substance misuse: some young people abuse alcohol or drugs as a short-term solution to a crisis. However, intoxication often leads to impaired judgement and reduces inhibition, thus facilitating self-harm behaviours.

Psychiatric disorders associated with self-harm

Common disorders associated with self-harm are the following.

  • Mood disorders: depression is the most prevalent mental health disorder associated with young people who self-harm.
  • Bipolar disorder: bipolar disorder has also been associated with increased rates of self-harm.
  • Psychosis: the risk of self-harm is increased in young people with psychotic disorders due to intrusive thoughts, or voices telling them to self-harm.
  • Anxiety disorders: anxiety disorders comorbid with depression have been identified as a risk factor for self-harm. Panic attacks have been associated with increased risk of self-harm in young people.
  • Eating disorders and body dysmorphic disorder: some young people have poor body image. Restricting their diet or starvation can be considered a form of self-harm.
  • Conduct disorder: antisocial behaviour is a risk factor for self-harm.

How to assess

Many young people who engage in self-harm do not seek formal help from professionals, but they are more likely to speak to friends or family.

Family GPs and clinicians in primary care settings play a significant role in the treatment process for young people who present with self-harm and/or suicidal ideation.

It is important to identify signs early and to conduct a comprehensive risk assessment, with an understanding of the frequency and severity of self-harm, and an understanding of the function of the behaviour, as well as consideration of appropriate treatment options.

Asking about self-harm does not increase the likelihood of self-harm.

When conducting an assessment consider the following:

  • Detailed history of self-harm
  • Details of helpful/unhelpful past interventions in a crisis
  • Brief developmental history
  • Physical examination of any wounds
  • Other psychiatric illnesses - for example, depression
  • Mental state examination
  • Assessment of risk of further self-harm or suicide
  • Insight/understanding of present mental health problems
  • Family history of psychiatric illness
  • Brief assessment of family situation (for example, have there been any recent bereavements, or a divorce?)
  • Medication history
  • Risk management plan

What is the treatment following self-harm?

Following assessment, consider referral to a secondary mental health team (CAMHS) to determine the level of support required. Treatment would ideally include further exploration and encouragement to talk about the young person’s feelings and worries. It is often helpful, if appropriate, to see the young person on their own.

Anyone who has taken an overdose, or tried to kill themselves, will need an urgent assessment by a doctor to check their physical health. This may mean attending the nearest accident and emergency department.

Cognitive-behaviour therapy (CBT) is the primary treatment for adolescent depression and affective disorders. CBT is a practical treatment based on the theory that thoughts, behaviours, emotions/mood, and some physical symptoms influence each other. It is therefore possible to modify the way a person feels by challenging and modifying thoughts and behaviour.

The primary aim of CBT is to focus on recognising cognitive thoughts that could lead to a depressed mood. Using problem-solving skills, behaviour activation, and emotional regulation techniques the young person is able to manage their depression.

Checklist of signs that a young person may be self-harming
  • Does the young person appear low in mood?
  • Have you noticed fresh cuts, scratches, bruises or other wounds?
  • Are they making an effort to conceal parts of their body?
  • Do they flinch during an examination?
  • Do they appear to be private or reserved?

Further reading

Self-Harm - Royal College of Psychiatrists. Information for parents, carers and professionals

Resources

National Self-Harm Network - UK charity offering support to people and families affected by self-harm

Selfharm.co.uk - a project dedicated to supporting young people who are affected by self-harm

First signs – user-led organisation to raise awareness about self-harm and provide support to people of all ages affected by self-harm

Young Minds - provides information and advice on child mental health issues Harmless- a user-led organisation for people who self-harm, and their friends and families

Samaritans - 24-hour emotional support for anyone feeling isolated, distressed or struggling to cope

TheSite.org - website by YouthNet UK, a charity that provides factsheets and articles on all of the key issues facing young people

  • Faiben Yemane is assistant psychologist and Dr Vibhav Shetty is consultant child and adolescent psychiatristat South Kent Child and Adolescent Mental Health Services, Sussex Partnership NHS Foundation Trust

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References

  1. Hawton K, Saunders K, and O'Connor R. Self-harm and suicide in adolescents. The Lancet 2012; 379(9834): 2373-82.
  2. Maalouf FT, Brent DA. Child and adolescent depression intervention overview: what works, for whom and how well? Child Adolesc Psychiatr Clin N Am 2012; 21: 299-312.
  3. Madge N, Hawton K, McMahon E et al. Psychological characteristics, stressful life events and deliberate self-harm: findings from the Child & Adolescent Self-harm in Europe (CASE) Study. Eur Child Adolesc Psychiatry 2011; 20(10): 499-508.
  4. National Institute for Health and Clinical Excellence: CG16 Self Harm: NICE Guideline (2004).
  5. Ougrin D, Zundel T, Ng A et al. Trial of therapeutic assessment in London: randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm. Arch Dis Child 2011; 96: 148-53.
  6. Rutter M, Bishop D, Pine D et al (2008). Rutter’s Child and Adolescent Psychiatry (Fifth edition). Oxford, Wiley-Blackwell.

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