Understanding self-harm in children and young people is made difficult partly because of the very contradictory way in which self-harm can be on the one hand an obvious visible expression for the child of something that is troubling them whilst at the same time it is not at all obvious what the difficulties or motivation to self-harm might be. Sometimes self-harm is a very hidden expression and other times it is intended to be almost obvious.
Another factor which makes this such a difficult area to discuss is that self-harm in children evokes strong feelings in the adult / carer role which again may lead to us not knowing exactly what to do. How should the adult / carer respond when we might ourselves feel very confused and have a range of feelings from wanting help ourselves to feeling angry, or even punished by the child?
Self-harm also confronts us with a continuum of harm that might well be superficial but can also include having to be aware of children’s vulnerability to commit suicide. Just because someone is self-harming it does not mean they are suicidal. But also children that commit suicide do not necessarily start off with superficial self-harm and work their way up. It is important not to become complacent around risk, but equally important to not over amplify expressions of self-harm by assuming the child is attempting suicide when they may be using superficial self-harming as a way to manage their own complex emotional and psychological development.
Added to this there has been a growing trend in superficial self-harm within adolescence, which is both puzzling and disturbing. Sometimes this type of expression can almost appear to be like a ‘rite of passage’ and an attempt for vulnerable children to try and fit in. The self-harm is intended to be obvious and almost conveys a sense of confidence. For others self-harm might be a way to fit in or find a way to locate one’s own emotional expression within a group.
For some cutting is a way in which they can almost see a painful and confusing emotional expression, this is often the case for children and young people with a social and communication difficulty. Other children may impulsively self-harm and may have almost no control over this. There is no doubt that there is a national trend to self-harm within childhood and adolescence. It is not at all clear why this is the case. At a national picture NHS CAMHS (Child and Adolescent Mental Health Service) and in-patient adolescent psychiatric units are at stretching point – but this is the more severe end of the spectrum where self-harm may also have links to psychiatric disorders. Self-harm in and of itself is not a mental health condition. However, when self-harm and psychiatric presentations such as Depression or Post Traumatic Stress Disorder are linked then special care around that child is essential.
Self-harm can be understood in many different contexts. Until you spend time assessing a child it will not always be clear as to what the motivation or purpose is behind their own self harm. It may also be the case that the child themselves has no idea what is motivating them to do this. In some ways this is why telling a child not to self-harm may be counter-productive. However, it can be equally puzzling to children that adults say nothing at all, and they may feel that no one can keep themselves safe from their own emotional difficulties and their expression of self-harm.
The key areas in assessing risk are to do with intent, planning, impulsivity and internal state of mind. Take your time in assessing and understanding what is going on, as this is a very helpful way in which as an adult in the child’s mind you are modelling a strong and robust way in which these difficult thoughts and feelings can begin to be understood and processed.
If you are concerned about a child and their expressions of self-harm then it is important to seek professional advice and support, generally this is done via a visit to your GP and a referral to a local CAMHS team. Young people who are concerned themselves can talk to their School Nurse who will be able to make a referral or make an appointment with their GP. YoungMinds is an excellent website with helpful resources for children and adolescents to use. In the longer term it might be helpful to seek out psychological support for your child.
Psychological Services for Schools is able to deliver training to staff and also offer support to vulnerable students, please contact us if you are concerned about a student. However, we are not an emergency service and if you are very worried about someone then your GP is the best place to go initially.