Paediatrics: Suicide and non-fatal deliberate self-harm

Suicide and non-fatal deliberate self-harm

Suicidal thoughts are common; they become abnormal when there is intent and/or plan when suicide is considered the only option.

·  Suicide is very rare in pre-pubertal children, but incidence rises through the teenage years. It is the fourth commonest cause of death in the 15–19-yr age group (UK, 4–8 per 100,000) with a male:female ratio of 4:1.

·  Non-fatal deliberate self-harm is far more common, with some 7% of those aged 15–16yrs having engaged in an act of deliberate self-harm in the previous year, and 10% in an act of deliberate self-harm in their lifetime. Actual self-harm is more common in females, with a female:male ratio of reported self-harm in the previous year of 4:1. Thoughts of self-harm are also more common in females, with a rate of 22.4% girls and 8.5% boys.

Predisposing characteristics to completed suicide include:

·  Psychiatric disorder (such as conduct disorder, depression, substance misuse, ADHD and psychosis).

·  Social isolation.

·  Physical illness.

·  Low self-esteem.

Relevant family factors include a family history of abuse and neglect or of psychiatric illness and suicide, and family dysfunction.

Methods of self-harm

Those who kill themselves use a range of methods, most commonly:

·  drug overdose;

·  inhaling car exhaust fumes;

·  hanging;

·  suffocating;

·  shooting (in countries where guns are easily accessible).

The majority of non-fatal deliberate self-harm is through overdosing, gen-erally with analgesics or prescribed drugs.

Cutting is very common, particularly amongst adolescent girls. Unless the cutting is deep and over the site of major blood vessels, it should not be seen as necessarily linked to suicide or attempted suicide. Those who cut describe it as easing a build-up of bad feelings, resolving emotional numbness, or sometimes as a form of self-punishment.

Assessment

Careful assessment should happen soon after the self-harm. It should include the young person, the family, and information from other sources such as the family doctor or social services. Initial assessment should identify:

·  Injuries from self-harm.

·  Likely/potential effects of ingestion of substance.

·  The child/young person’s capacity to consent to or refuse treatment.

·Presence or absence of mental illness.

·Risk of further episode of self-harm.

Appropriate medical treatment should be provided. A further separate interview should be conducted with the child once the acute situation is stable. Take a general history and address:

·History of act of self-harm.

·Circumstances leading up to self-harming behaviour.

·Degree of suicidal intent at time of deliberate self-harm.

·Intensity, frequency and duration of self-harm thoughts.

·Behaviour at time of overdose/self-harm.

·Impulsivity or planned nature of the self-harm episode.

·Help seeking or help avoiding behaviour.

·Ongoing plans for further self-harm or suicide.

·Previous history of self-harming behaviours.

·A full mental state assessment.

A clinical interview with the parents should include:

·A corroborative history of events surrounding self-harm episode.

·An exploration of parental response to the episode of self-harm.

·An assessment of family functioning and support for the child.

·Identification of symptoms suggesting a psychiatric disorder.

Management

First treat the physical effects of the self-harm episode and arrange a men-tal health assessment. Following risk assessment, make sure that appropri-ate levels of supervision are in place. Consider access to medication and other means of self-harm. If there are significant concerns about ongoing suicide risk, consider admission to an inpatient unit. If there are concerns about child protection, a referral should be made to social work. Treat any comorbid psychiatric disorder.

Management options for deliberate self-harm.

Aims of intervention

·Address self-esteem issues.

·Improve interpersonal skills and address relationship difficulties.

·Improve communication skills.

• Learn more helpful ways to communicate emotions.

Family work

Family support and counselling with more structured and intensive family therapy may be appropriate.

School based interventions

·Entire school programmes focusing on self-esteem peer relationships.

·Peer support programmes.

·Development and implementation of anti-bullying policies in school.

Prognosis 

10% of those who self-harm will repeat within a year. A sig-nificant proportion will kill themselves within 5yrs—4% of girls and 11% of boys.