1. Child / young person who has self-harmed Child & Adolescent Psychiatry

2. A 14-year-old girl, 4 th of 5 children, who lives with her mother and siblings presents to Accident and Emergency having taken 10 tablets of paracetamol. Her blood paracetamol level indicates no need for N- acetylcysteine infusion. The rest of her physical examination and blood tests are unremarkable.

3. Learning Objectives By the end of the session you will be able to – Identify the common forms of self harm and some predisposing and precipitating factors – Describe key questions in the history to identify features of the self harm attempt that would suggest increased risk of repetition and suicide – Identify other psychiatric, social and demographic factors in the history associated with risk of self harm – Describe psychosocial treatment and risk management for children who have self harmed

4. Self-harm and Suicide 7%-9% of adolescents will have self-harmed at in the previous 12-months – 12% episodes will lead to hospital presentation 15% of older adolescents report having had suicidal thoughts in the previous year (3x more in girls) Actual suicide rates (15-24 year olds) 8 (males) and 2.3 (females) per 100,000 Psychological post-mortem studies of suicides show that a psychiatric disorder (usually depression) was present in most at the time of death

5. Self-harm and Suicide Self-poisoning makes up 90% of self-harm cases referred to hospital 30% of young people who self-harm report previous episodes and >10% will repeat within a year 25% of those committing suicide have previously carried out a non-fatal act

6. Features in history of the attempt suggestive of ↑ risk of repetition or suicide - “psychiatric red flags” Choice of violent potentially lethal method - e.g. massive overdose, hanging, jumping from height Belief about lethality of chosen method Clear unambiguous wish to die Final act in anticipation of death - e.g. suicide note or text Evidence of planning Efforts to avoid discovery Regretting that method failed Persisting suicidal intent Still hopeless Persistence of the trigger(s)

7. Other factors in the history associated with ↑ risk of actual suicide Older male (completed suicide) Psychiatric disorder – eg. depression, psychosis, etc Previous psychiatric admission Conduct problems Substance misuse Past history of self harm Social and emotional isolation

8. Bio-psychosocial framework for assessing risk for psychiatric adjustment in children Biological (e.g. physical illness, alcohol/drug intake; psychiatric family history) Social/Environmental (e.g. Life stresses & disappointments; family/peer models; poorly supportive environment ) Psychological (e.g. social isolation; pessimism) The likelihood of maladjustment increases cumulatively with more risk factors and less resiliency/protective factors in each additional domain Most risk of maladjustment with risk factors in all three domains

9. Assessment Systemic thinking – Contributing factors ‘Local’ community eg “ epidemic” Work/school and peers eg problems in peer relationships Family system eg family history, stresses, poor emotional support Individual eg genetics, physical illness, drug intake, pessimism, psychiatric disorder National Global

10. History of triggers predisposing & precipitating Individual to the child – Psychiatric disorder (depressive disorder in 50%) – Chronic physical problems – Relationship problems / Social isolation – Disciplinary problems – Substance abuse Broader environment – Peer relationship problems – Bullying in school or in the neighbourhood Family system – Parental psychiatric disorders – Family history of suicide or self-harm – Poor communication / Lack of support – Intra-familial l conflict – Broken homes, marital difficulties – Abuse and neglect

11. Screen for associated mental disorder Depression – low mood even before the self harm – anhedonia, social withdrawal – lethargy, reduced self esteem – excessive & unreasonable guilt, hopelessness – reduced sleep, appetite, concentration, energy…

12. Case A 14-year-old girl, 4 th of 5 children, who lives with her mother and siblings presents to Accident and Emergency having taken 10 tablets of paracetamol. Her blood paracetamol level indicates no need for N- acetylcysteine infusion. The rest of her physical examination and blood tests are unremarkable.

13. FORMULATION ProtectivePredisposingPrecipitatingMaintaining Individual to the child Family Broader social

14. What else would you like to know? The triggers? The overdose? Current mental state? Family & social history?

15. FORMULATION ProtectivePredisposingPrecipitatingMaintaining Individual to the child Cannabis use FamilyFamily history of suicide, personality disorder, drug abuse Disruption, Unsupportive Poor comunication Family unsupportive, arguments, poor communication Broader socialClose to grandmother Boy friend left Fight with friend School exclusion Lack of confident Depressive disorder, high suicidal risk, disrupted family

16. Management (1) Help keep her/him safe Convey the message that what has happened is serious Allow time for further psychiatric, psychosocial and risk assessments including social service referral and liaison with school – Admission to paediatric ward and psychiatric assessment Provide space and time for the acute crisis / emotional distress to dissipate – Admission to paediatric ward and psychiatric assessment

17. Management (2) Establish the nature of young person’s resources and supports, and how the family has tackled serious problems in the past Initiate psychological interventions e.g. problem solving and alternative coping strategies Extended admission to an adolescent psychiatric unit may be indicated for children at increased risk of suicide

18. Further treatment might include – problem solving – anger management – cognitive behaviour therapy – treatment of any underlying psychiatric disorder – family therapy – Environmental/social change such as temporarily alternative accommodation

19. Take home messages Self harm in childhood must be taken seriously Previous attempts and psychiatric disorder increase the risk for recurrence Careful history is needed to elicit the triggers and nature of the self harm and associated psychiatric and social circumstances; it is critical for adequate risk assessment and management A brief paediatric admission is helpful for the majority cases

20. Learning Objectives By now you will be able to – Identify the common forms of self harm and some predisposing and precipitating factors – Describe key questions in the history to identify features of the self harm attempt that would suggest increased risk of repetition and suicide – Identify other psychiatric, social and demographic factors in the history associated with risk of self harm – Describe psychosocial treatment and risk management for children who have self harmed