Paediatric medicine - Self-harming in young people

Self-harm should be taken seriously as there is an increased risk of suicide, explains Dr Alice Shiner.

The signs caused by self-harm are often concealed by the individual (Photograph: SPL)
The signs caused by self-harm are often concealed by the individual (Photograph: SPL)

Self-harm is increasingly prevalent among young people in the UK. It is estimated around 10 per cent of 11 to 25-year-olds will self-harm, with an average age of onset of 12 years.

For some people it is an isolated occurrence, but for others it becomes a regular behaviour.

Few cases are brought to GPs' attention as most individuals conceal their behaviour.

Self-harm is defined as a deliberate non-fatal act which an individual carries out in the knowledge that it will cause them harm.

It most frequently takes the form of self-injury, including cutting or burning the skin.

However, the act of self-poisoning is more likely to lead to contact with doctors; overdose accounts for 90 per cent of known episodes of self-harm (see box below for the types of self-harm).

Causes of self-harm
Most self-harm is not an attention-seeking behaviour or a failed suicide attempt.

More commonly it occurs as part of a maladaptive coping strategy employed when trying to manage a difficult emotional transition to adulthood.

It is used as a means of achieving emotional release when other strategies have not yet been learned. Often it is a symptom of underlying problems that result in emotional distress, such as breakdown in family relationships, bullying, abuse or stress about school work.

Signs
The physical signs of self-harm are often concealed. Wounds from self-inflicted cuts may be seen, most frequently, on the wrists, upper arms, thighs and chest.

Evidence of burns, scalds, self-insertion of foreign objects or hair pulling may also be apparent. However, few physical signs exist for self-poisoning.

Psychological signs of self-harm are generally related to the underlying cause. A depressed young person may be withdrawn and become isolated from family and friends.

Bullying at school may lead to poor school attendance or truanting. An abusive situation may be suggested by a variety of signs including abnormal interactions between the young person and their abuser.1

Questions to ask
Self-harming behaviour is rarely disclosed so when GPs have a high index of suspicion in relevant cases they should gently question the patient, adopting a sensitive and non-judgmental approach.

All self-harm that is disclosed should be taken seriously, as there is an increased risk of eventual suicide. Questions should be asked about:

  • The events leading up to self-harming.
  • What happened during the episodes, including methods used for self-harming and the consequences.
  • Future intentions. A previous history of self-harming, mental ill-health, disturbed family relationships and social isolation increase risk of further events.
  • Suicide risk assessment can be problematic as it may be difficult to determine suicidal intent; tools developed for use in children can be used to make a more accurate assessment.2
  • The psychosocial needs of the individual. Any existing support and the inclination of the patient to utilise this should be established.
  • The presence of substance misuse.

Managing the situation
In tandem with assessment, the immediate need for medical care should be addressed.

Recent superficial wounds may be dressed in the surgery, but deeper wounds or significant overdose often requires referral to secondary care.

Urgent referral to the Child and Adolescent Mental Health Services (CAMHS) is required if assessment reveals a high risk of suicide.

Longer term strategies usually centre on a harm reduction policy.

CAMHS and other agencies, including schools, educational psychologists and health visitors, can be involved.

Strategies include:

  • Distraction techniques (marking the skin with a pen rather than cutting).
  • Individual or group self-help.
  • Peer support.
  • Cognitive behavioural therapy.
  • Problem-solving therapy.
  • Psychotherapy.
  • Websites and telephone helplines.
  • Antidepressants - initiated by mental health specialists.

Involving parents or guardians
If parents or guardians are unaware of a young person's self-harming, the possible benefits and harms arising from disclosure should be considered.

The GMC position is that information should be disclosed if necessary to protect the young person from serious harm or death, including cases where abuse is possible or the young person is involved in risky behaviour such as self-harm.3

Child protection
Sometimes, a GP's assessment raises concerns about child maltreatment either as the underlying cause of self-harm or as a differential diagnosis for signs of physical injury.

In any case of this nature, it is important that child protection procedures are promptly implemented.

Long-term outlook
Self-harming behaviour can be difficult to treat and often only resolves once there has been a change in the life circumstances which initiated it. GPs should assist young people in managing emotional distress and support harm reduction strategies.

  • Dr Shiner is a GP in Norwich
Types of self-harm
Self-injury
  • Cutting
  • Burning (cigarettes)
  • Scalding
  • Banging or scratching
  • Breaking bones
  • Hair pulling
  • Picking at the skin
  • Inserting foreign objects inside the body

Self-poisoning
  • Overdosing on medications
  • Ingesting toxic substances

Wider definitions
  • Eating disorders
  • Substance misuse

References
1. NICE. When to suspect child maltreatment. CG89. London, NICE, 2009. http://guidance.nice.org.uk/CG89/Guidance/pdf/English

2. Kingsbury S. PATHOS: A screening instrument for adolescent overdose: a research note. J Child Psychol Psychiatry 1996; 37(5): 609-11.

3. GMC. 0-18yrs: Guidance for all doctors. 2007. www.gmc-uk.org/guidance/ethical_guidance/children_guidance_index.asp

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