MANAGEMENT AND SUPPORT OF CHILDREN AND YOUNG PEOPLE WHO DELIBERATELY SELF-HARM
- Definition of children and young people who self harm
- Self harming behaviour
- Roles and responsibilities of agencies
- Staff training
a.This protocol is a result of a multi-agency working group established by British Forces Germany Safeguarding Board (SB) Policies, Procedures and Publicity Sub-group with all agencies that are represented on the SB. This protocol applies to all eligible children, and young people within British Forces Germany area of responsibility.
b.All agencies must demonstrate a duty of care to promote the use of this Protocol in helping staff assess risk and take appropriate action for the benefit of children and young people. All self-harm needs to be regarded seriously, properly assessed by trained practitioners working under supervision and subject to a joint action plan.
2.DEFINITION OF CHILDREN AND YOUNG PEOPLE WHO DELIBERATE SELF-HARM^
a.A deliberate act by a child/young person under 18 years with intent to cause harm or injury to him/herself.
b.Methods of self-harm include overdosing, swallowing items, hitting and bruising, cutting, burning oneself, hair pulling, self-strangulation or suffocation and excessive alcohol or substance use. It may also include behaviours that have serious clinical consequences, e.g. food refusal.
a.Self-harm is a highly emotive topic and can cause considerable anxiety for parents, carers or professionals. Although sometimes thought to be attention-seeking, the behaviours are often carried out secretly and the effects concealed from view.
b.There are many different theories about why the behaviour occurs and how best to respond to it. The most prevalent view evidenced by self-reports is that acts of self-harm (notably cutting) have the effect of helping the young person to manage feelings they are unable deal with by other means. The acts are often triggered by feeling of self-directed anger or loathing and may be associated with unpleasant subjective experiences of being emotionally numb or cutoff; commonly the young person may not be seeking to achieve anything in particular apart from the subjective sensation of temporary relief or respite that it seems to bring.
c.Young people who self-harm are more likely to have been bullied or abused, or to have problems with their family or boy / girl friends; some people find the pressure of exams too much, some have low self-esteem. It is more common in girls (4:1) but boys are more likely to cause bruising than cut and it may not be so apparent. Mental illness, particularly depression and anxiety, social adversity, poor parenting practice and child abuse, marital discord and divorce, worries about sexual orientation and gender uncertainties and perfectionist personality traits are additional risk factors. Overall, genetic, psychological, cultural, cognitive and interpersonal factors all play a part in the onset and continuation of the behaviour.
Occasionally the behaviour is a result of a serious intent to die, but most children and young people who self-harm do not want to end their lives.
d.How common is this problem?
Many people self-harm, it is estimated that as many as 15 to 25% of teenagers have self-harmed at some point. The most common age for people to self-harm is 11-25 years. It has increased over the past 30 years, particularly among girls. It is rarely reported before secondary school age and spikes in frequency around puberty in girls, with the rate in boys rising later.
Half of young people report multiple episodes and at least 1 in 7 who present to hospital will represent within a year. Repeated hospital contact is more common with overdose than with cutting. Of those who are admitted to hospital, most will have a diagnosable psychiatric disorder, usually depression or anxiety, but also ADHD (impulsivity is a relevant factor) and conduct disorder as well as substance and alcohol misuse. In this group, key risk factors are a family history of suicide or self-harm, previous self-harm or contact with others who do so, suicidal intentions, plans and access to means and a lack of social support.
Self-Harm and Suicide?
Most self-harm behaviours cease in late adolescence, particularly in boys. For those who present to hospital, there is a 100 fold increase in the suicide risk over the next 20 years. This risk is greater with repeated episodes, psychiatric admissions and in males.
e.All evidence of self-harming behaviour must be regarded seriously and handled in a manner that reduces risk of further episodes, escalation or damage to health. Self-harm is a behaviour, not an illness; commonly it indicates a need for specialist professional help to enable the young person to develop more effective coping strategies for dealing with whatever feelings predisposed them to act in this way.
f.Such behaviour is symptomatic of the young person’s sense of discomfort or distress; the causes are rarely straightforward and may contain multiple factors.
A child or young person who self harms should be recognised potentially as a child in need who may be at risk of actual or likely significant harm, and should, therefore, fall within the safeguarding children procedures. However, existing procedures are based on the assumption that the child is at risk from another person, normally a parent/carer who inflicts harm (acts of commission) or fails to prevent harm (acts of omission). In relation to children who self-harm, there is often not the clear correlation between parental action and the child’s self-harming behaviour. These multi-agency procedures intend to address this issue. (For a summary of current research in relation to self-harm, see Appendix 4).
4.1Initial Assessment of the Situation
a.If a child or young person presents with actual or suspected self-harm, staff should seek advice from a senior manager or supervisor within their own organisation. In schools, the staff member should contact the Designated Senior for child protection advice. Specialist health advice should be sought from the child / young person’s General Practitioner (GP) and / or from the Child and Adolescent Mental Health Service (CAMHS). All discussions, decisions and referrals must be documented (See Appendix 1).
b.An assessment by a healthcare professional will need to consider the immediate consequences of the risk taking and to assist understanding of what is behind the behaviour.
c.At all stages parents should be involved. Children and young people under 18 should be advised that confidentiality can be breached if s/he is considered to be a risk to themselves or others. The capacity and competence of the child / young person to make decisions must be considered and a careful assessment of risks and rights needs to be made as part of the overall assessment.
4.2Risk to Life^
a.If there is serious injury or a risk to life, staff in Germany should arrange emergency admission to hospital by dialling 112, asking for a Notarzt ambulance. If admission is to the nearest non Designated German Provider Hospital, the referrer must notify the Hospital Hotline of the admission and the reason for admission. In other commands, staff should contact the appropriate emergency services.
4.3Admissions to Hospital^
a.In Germany, if a child or young person is admitted to Designated German Provider (DGP) hospital following an incident of self-harm, the Patient Support Services (PSS) should inform the child / young person’s GP, who should make a referral to CAMHS. Out of hours, the PSS should telephone BFGHS Telephone Advisory Service (TAS) who will ensure that the child / young person’s GP is informed as soon as possible the next working day. If the child / young person is admitted to a non-DGP, the above procedure is to be followed as soon as Clinical Referral Mangers are aware of the admission through the daily bed state reports. . British Forces Social Work Service (BFSWS) Central Referral Team (CRT) should be contacted by the GP / CAMHS team as soon as they are aware of the admission so that a decision about the need for a strategy meeting can be reached. This is to ensure any previous information about the child and family can be shared. CAMHS nurses in Germany must also contact the designated Child and Adolescent Mental Health Psychiatrist for support and advice, particularly in cases where there may be a requirement for admission to a psychiatric unit. See Appendix 2 for a flowchart, depicting these requirements. In other commands, liaison with secondary care and primary care services should be established and local procedures followed to support the child / young person and family.
b.In Germany, a mental health assessment by a member of the CAMHS team should take place within one working day of the child / young person being medically fit for assessment. This assessment will take priority over normal planned clinical duties. The nurse will undertake a mental health and risk assessment and develop plans for ongoing care with the young person and family/carers; these must be discussed with the GP and Consultant Child & Adolescent Psychiatrist and other agencies as appropriate. A follow-up appointment will be offered by a (ideally the same) member of the CAMHS team within seven days (or earlier if required or recommended by the treating clinician or CAMHS Psychiatrist) of discharge from hospital. In other commands, close liaison with available mental health services should be held, according to local procedures.
c.BFSWS will convene and chair a strategy meeting if required, inviting all the appropriate health, education (School and Pupil and Family Services), and welfare agencies. In some instances, police involvement may be necessary, particularly if there are concerns about a possible crime having been committed. All professionals must attend this meeting as high priority in order that the immediate and future needs of the child / young person can be properly assessed, and an appropriate action plan put in place. The strategy meeting may be held whilst the child is in hospital or as soon as possible following discharge.
4.4Referral to British Forces Germany Central Referral Team / Social Work Services in other commands^
a.If the act of self-harm is associated with one of the four categories of abuse then Section 47 enquiries should be initiated. The four categories of abuse are physical abuse, emotional abuse, sexual abuse and neglect. Section 47 enquiries are undertaken or directed by British Forces Germany Social Work Service when it is suspected that a child is at risk of actual or likely significant harm.
b.Neglect would include failure of the child’s carers to intervene or to be involved in any plan to protect the child from further harm.
c.A strategy meeting should be convened between police and social work service, and where appropriate, representatives from agencies involved with the child / young person and their family, e.g. Service Children’s Education (including School and Pupil and Family Services), Youth and Community Workers, Health Service. Where safeguarding concerns are identified, the BFGHS Named Dr and Nurse should be informed by health staff.
4.4.2Child in Need
a.If abuse or neglect is not immediately evident but self harming behaviour continues and is either severe and/or persistent, and a number of risk factors have been identified then any one of the agencies/professionals who are involved with the child or young person can refer the concerns to British Force Social Work Service via the Central Referral Team to request a Child in Need meeting.
b.Best practice would recommend that all children / young people who have self-harmed need to be assessed by health and social care practitioners experienced in this field. This assessment should include a full assessment of the child, family and social situation, bearing in mind that there may be child protection issues. The Social Work Service should undertake an assessment in accordance with Working Together to Safeguard Children 2013.
c.The child in need meeting must consider a risk assessment, a risk management plan and a date for a review.
5.ROLES AND RESPONSIBILITIES OF AGENCIES^
a.Appendix 3 details the generic roles and responsibilities of key staff involved with children and young people.
a.Managers of services need to ensure that training, supervision and support for staff who have contact with people who self-harm is available. Managers need to identify key staff within their agencies to receive training in the management of self harm, e.g. Designated Seniors in schools, SCE School Nurses Youth and Community staff, health staff involved in supporting children and young people.
b.Each member agency of the SB is required to ensure wide distribution of this protocol within their area of responsibility.
A.Deliberate Self- Harm among Children and Young People: The Mental Health Foundation Vol 4 Issue 16 2003.
B.The Samaritans Key Facts: Young People and Suicide (Ewell 2001)
C.Look Beyond the Scars: Understanding and Responding to self-injury and self harm. NCH 2002.
D.NHS National Institute for Clinical Excellence. Clinical Guideline 16: Self Harm- The short-term physical and secondary prevention of self-harm in primary and secondary care July 2004
E.Kaplan, T. (Editor) Emergency Handbook Children and Adolescents with mental health problems 2009 Royal College of Psychiatrists
F. NHS National Institute for Clinical Excellence. Self-harm (longer term
management): NICE guideline
G.Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children: DfE, 2013
H.Young people who self-harm: implications for public health practitioners. NSPCC, March 2009
I.Hawton, K and Rodham, K and Evans, E, Samaritans; University of Oxford Centre for Suicide Research (2003) Youth and Self Harm: perspectives. A report, Oxford, Samaritans.
Useful web sites:
www.rcpsych.ac.uk Royal College of Psychiatrists
www.lifesigns.org.uk Voluntary organisation lead by people with personal experience of self-injury. Very useful section on “Creating a School Self-Injury Policy”
www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf NICE guideline 16
www.nice.org.uk/guidance/CG133/NICEGuidance Nice Guideline 133
- Care Pathway for Children / Young People who Self-harm
- Procedure to follow when a child / young person is admitted to hospital following self harm
- Roles and responsibilities of professionals involved in the care of children and young people
- Research findings
In Germany, TAS can be contacted out of hours through dialling any Medical Centre number.
CARE PATHWAY FOR CHILDREN AND YOUNG PEOPLE WHO SELF HARM^
PROCEDURE TO FOLLOW WHEN A CHILD / YOUNG PERSON
IS ADMITTED TO DESIGNATED GERMAN PROVIDER HOSPITAL FOLLOWING SELF-HARM (for other commands, follow local procedures)^
ROLES AND RESPONSIBILITIES OF PROFESSIONALS INVOLVED IN THE CARE OF CHILDREN AND YOUNG PEOPLE^
Army Welfare Service (Community Support)
In cases of actual or suspected self-harm, AWS staff will note any concerns and provide on-going support to the child / young person. Staff will inform the child / young person of the requirement to share their concerns with their professional Line Manager. A record of all relevant information will be kept on the Community Support Incident Report Form (CSIRF). The Line Manager will discuss the level of risk and needs of the child / young person with the worker and ensure that the agreed action is taken and recorded on the CSIRF.
British Forces Social Work Service
The British Social Work Service (BFSWS), provides a statutory social service in accordance with the Children Act 1989, specifically Section 17 (children and families in need), Section 47 (protection of children), Section 20 (voluntary accommodation of children), and the Children Act 2004. As lead agency in safeguarding children, it is the statutory duty of the BFSWS to investigate child protection referrals and to provide services for children and families in need.
BFSWS is staffed by professionally qualified and HCPC registered social workers employed as Senior Social Work Practitioners (SSWP). It is supported by administrative staff and located throughout BFG. The Head of Service is based at Bielefeld with the Service Manager (Operations) and the Learning and Development Manager. There are 2 Family Support teams managed by 2 Social Work Team Managers (North and South) with the SSWPs located within their respective areas.
Based in Gutersloh the Joint Response Team is co-located with three members of the Special Investigation Branch (SIB) of the Military Police. This team handles all initial child protection inquiries, whether from BFG or ESG, under Home Office Guidance and UK law. They provide the out of hours service dealing with the emergency protection of children.
In addition, BFSWS has Senior Social Work Practitioners in Fostering, Adoption and Additional Needs and Disability covering the whole of BFG.
All referrals to BFSWS are made via its Central Referral Team (see below)
Central Referral Team
By calling Civilian: (0049) 0800 724 3176 you will connected to the BFSWS Central Referral Team (CRT). The CRT will take calls from BFG or ESG units and offers an advice and consultation service to users. Professional agencies will be asked to complete a Multi Agency Referral Form to ensure full and correct details and reasons for referral are made. Referrals are sent to the appropriate Family Support Team (North or South) for allocation, or may be dealt with by the Joint Response Team if there are child protection concerns.
Outside of normal working hours, in cases of emergency, a Duty Senior Social Work Practitioner supported by a duty Team Manager can be contacted on the same numbers as those for the office hours.
Child and Adolescent Mental Health Service (CAMHS)
The CAMHS team in Germany comprises of specialistRegistered Mental Healthnurses and a visiting Consultant Child and Adolescent Psychiatrist from the South London and Maudsley NHS Foundation Trust (SLaM). The role of CAMHS is to offer therapeutic intervention in a variety of ways to children and young people who are referred. CAMHS offer individual therapy, family work and in some areas group work, working closely with other allied agencies such as SCE, Primary Health Care colleagues and BFSWS. CAMHS staff lead the mental health assessment, care and discharge planning and contribute to strategy discussions if children / young people are admitted to hospital. They will advise, in conjunction with local hospital psychiatrists, if further assessment or treatment of mental illness is necessary. Clinical Governance is through SLaM. In cases of self harm requiring admission to hospital, the CAMHS team are required to be the point of contact with the treating clinicians in hospital and the young person, family and GP, in order to provide a clear communication pathway.
Community Children’s Nurse (CCN)
The Community Children’s Nurse acts as liaison between secondary health care and the primary health care team, offering support to children and young people whilst in hospital and as a resource for signposting to other agencies. In the community setting, they offer nursing support to Paediatricians and to families with children with additional needs and chronic illnesses. In the cases of self harm requiring hospital admission, they can liaise with the Paediatrician in cases where the child / young person is already known to the Paediatric service.
The principal role of the Community Paediatrician in relation to self-harming children and young people who are admitted to hospital is to support children with existing or consequential medical needs. Close liaison with hospital and primary and community clinicians is required in such cases.
General Practitioner (GP)
The General Practitioners would act in support of children / young people who have self-harmed through consultation and onward referral to appropriate services, i.e. CRT; hospital; CAMHS. When the child / young person has been discharged from hospital, they are able to prescribe medication recommended by a Consultant at the hospital. This request would need to be conveyed by facsimile marked “Urgent” and the dose of medication should be clearly stated. The BFGHS G.P. would not be able to immediately authorise medication that is not listed in the British National Formulary for Children (BNFC).
School Public Health Nurse (SPHN)
A School Public Health Nurse is a registered general nurse (working for British Forces Germany Health Service) who has undertaken further training to qualify as a health visitor or school health practitioner. They have two key responsibilities:
- To assess, protect and promote the health and well-being of children and young people of school ages; and
- To offer advice to individual and groups of children, young people, their carers and teachers.
They are responsible for a group of schools within a geographical area and they are generally located in medical centres.
School Public Health Nurses are key personnel for supporting young people with mental health issues providing a link between health and education. They also work in partnership with local communities and other agencies to deliver an integrated service to children and young people who self harm or at risk of self-harming.
Service Children’s Education (SCE)
SCE prioritises the well being of all children and young people. All settings and schools have a structured approach whereby concerns are dealt with confidentially and appropriately through named staff who are trained and supported in their work. SCE fully endorses all multi agency and inter disciplinary approaches to meeting the needs of children and young people.
- All SCE staff complete mandatory safeguarding training. All schools also have a named Designated Senior who have undertaken more advanced, SB approved, safeguarding training as well as completing regular awareness updates. The task of the designated senior is to ensure that all school staff are aware of their roles and responsibilities with regard to safeguarding, and to ensure that there is safe and effective collaborative working with other key agencies and professionals.
The designated person should ensure that all school-based staff are aware of the SB policy on self-harm. Safeguarding is not simply an administrative task and it is essential that all staff are actively aware of the signs and potential symptoms of self harm as well as understanding how to make best use of the policy so as to take the most appropriate course of action.
The first priority of the school is to ensure the young person who self-harms, or is at risk of self harm, receives prompt and appropriate support with the initial emphasis being on safety and therefore being the need for medical attention; in cases where the young person is thought to be at risk of significant harm the school will also refer directly to the Joint Response Team. The response by the school will be proportionate and in accordance with the SB policy.
- HQ SCE maintains a Pupil and Family Services (P&FS) Team which is multi disciplinary and includes Educational Psychologists (EPs), Education Social Workers (ESWs) and Specialist Teachers.
Pupil and Family Services (P&FS) has a set of priorities and responsibilities which link to the wider agenda of the well being of children and young people. This involves working in partnership with SCE staff based in schools and other settings as well as with other agencies; P&FS staff are based in a number of garrison based offices. P&FS EPs and ESWs should be consulted in all cases of self-harm.
The Education Social Work Service is professionally responsible within SCE for ensuring that all SCE staff comply with safeguarding requirements. The Service is also responsible for ensuring that all SCE policies and practices with safeguarding implications (e.g. safer recruitment, complaints against staff) are in accordance with best practice and kept under regular review.
Education Social Workers are all registered members of the Health and Care Professions Council and engage in regular supervision. They also have specialist training and experience in systemic work both with families and with schools, maintaining their skills through conjoint work with the other specialist disciplines.
- The Educational Psychology Service has lead responsibility within SCE for behaviour and psychological wellbeing of children and young people. The Service provides governance for branch interventions based on applied psychology and thereby contributes at several different levels both directly and in support of other professional disciplines.
Educational Psychologists are registered practitioner members of the Health and Care Professionals Council and must meet mandatory governance requirements. They have specialist training and experience in assessment and research; this includes individual and systemic (family, school and community) aspects of human development. They are also qualified to undertake additional training to deliver specialist forms of intervention and supervision.
- Service Children’s’ Education employs nurses to work in the secondary schools in British Forces Germany which have a boarding facility. These nurses are registered general nurses who provide the day-to-day support for children and young peoples’ medical needs in the absence of their parents in each school setting. This is an important role as they aim to deliver a holistic high quality service, in partnership with other agencies-signposting and referring as necessary. .
Service Police are responsible for investigating and alleged offences and reporting to the chain of command.
Evidence shows that acts of self-harm may start at an early age. It is more common in girls than in boys, although there has been a recent steep rise in occurrence among young men. Government research published in 2001 suggests that as many as 215,000 eleven to fifteen year olds in Great Britain, one in 17, may have harmed themselves. The average age for a child to start to self-harm is thirteen but it is not unknown for children to self-harm as young as 7yrs.
Traumatic events during child hood and early teenage years may be factors in self-harm. Sexual, physical and emotional abuses all increase the risk of self-harming behaviours.
Research also reveals that there are a number of social and psychological reasons for self- harming behaviour. These may include being bullied, high parental expectation, parental separation, bereavement, discrimination, exclusion and pre-menstrual tension. Some children reported that self-harming had become a habit.
When episodes of self-harm have a raised profile it is not uncommon for the issue to have resonance for other vulnerable young people that may be susceptible to this type of behaviour. Studies suggest that those who self-harm most commonly have a friend that is engaging in similar behaviour.
Young people that self-harm are frequently unhappy with adult responses that seek to theorise or jump to conclusions about why they may have done it. Such approaches can deter self-referral to seek help and result in disengagement from further appointments.
Self-harm is more common amongst young people with a history as victims of personal abuse (physical, emotional or sexual) than in the general population.
Self-harm has been more common amongst certain youth sub-cultures that attract like-minded young people
Self-harm and suicide are associated, although the two types of behaviour are different. Self-harm is described as having an element of coping and containment when dealing with persistent and powerful emotions, with patients indicating that in some ways it helps them feel better, albeit temporarily. As a means of temporary relief it also has an addictive quality, but it suggests a desire to cope. Suicide is more often an expression of despair and a feeling that the person no longer wishes to continue coping.
Children who self-harm are at greater risk of suicide than the general population. Many who attempt suicide have a prior history of self-harm; the majority of those that self-harm do not attempt suicide.
Self-harm is commonly undetected, with the patient actively seeking to conceal the behaviour and its effects. As a result it is difficult to obtain accurate figures on incidence but the Royal College of Psychiatrists estimates the figure for young people that self-harm at some point can be as high as 1 in 10 amongst the general population.
Girls are more likely to self-harm and to attempt suicide than boys; the behaviour amongst boys tends to involve activities with a higher level of risk and when boys attempt suicide it is more likely to be fatal. Some with a propensity to self-harm find outlet through other forms of high-risk behaviour.
Compared to the general population, gay and bisexual young people seem to be more likely to self-harm.
One of the key objectives of treatment and support for those who self harm is to enable them to learn more effective strategies for addressing the powerful emotions that they are having difficulty with.
BFSWS British Forces Social Work Service
CAMHS Child and Adolescent Mental Health Service
CRT Central Referral Team
DGP Designated German Provider Hospital
GP General Practitioner
SCE Service Children’s Education
SSWP Senior Social Work Practitioner