Suicide and self-harming - advice
This advice provides information regarding the management of children who engage in self-harming behaviours or threats of suicide.
Document ID number 2407, version 4, 17 July 2020.
The purpose of this advice is to:
- provide a framework for self-harm and suicide risk management
- provide information about reducing the risks of injury or death and ensuring the safety and wellbeing of clients
- outline the reporting requirements
- reduce the level of uncertainty and stress for practitioners in managing clients who self-harm and express potentially suicidal behaviour.
This advice is not intended as a clinical or comprehensive assessment and intervention guide. See Adolescents and their families for further information.
Within the spectrum of children who are known to child protection, some are particularly vulnerable to risks from a range of actions and behaviours associated with self-harm. These include those who:
- threaten to self-harm, including threats of suicide
- actually self-harm
- engage in self-mutilation (self-cutting, blood letting)
- express suicidal ideation
- attempt suicide.
Often these types of actions and behaviours are associated with adolescence but they can also be displayed by younger children. Given the level of harm that can result from these actions and behaviours, working with and responding to these behaviours requires specific, intensive and strategic planning and casework. Two major considerations in responding to and managing self-harming behaviours and threats of suicide are harm reduction and duty of care.
Child protection clients have frequently experienced significant trauma in their lives and are often highly vulnerable. It is likely that these children will sometimes have multiple and complex needs and significant behavioural and emotional difficulties, which can lead to acting in ways that place themselves in situations of high risk. This can particularly apply where a child is placed in out-of-home care.
Children placed in residential care can be particularly vulnerable. These children may engage in self-harming behaviours or threats of suicide and have mental health diagnoses and higher levels of substance abuse than the general population. Residential care clients may lack age-appropriate skills necessary for independent living and may have increased levels of aggressive and challenging behaviour at younger ages.
Threats of self-harm and actual self-harm or suicide
Threats of self-harm and actual self-harm involve a range of actions, along a continuum, from statements to self-harm, to a display of self-harming behaviours, to suicide. In definition self-harm requires not only the threat or self-infliction of injury (to varying degrees of intent), but also importantly, an awareness of motive. The issue of awareness of motive is significant because it is what distinguishes self-harming behaviours from other types of behaviours often associated with and grouped as adolescent risk taking and experimental behaviours.
Children in the child protection system can present with significant behavioural and emotional difficulties and a lack of self-care. Experimental and risk-taking behaviours can frequently become extreme and result in significant levels of harm. This though does not equate to every child who engages in extreme risk-taking behaviour intentionally wanting to self-harm. Some displays of behaviours such as self-cutting, self-strangulation or deliberately placing oneself in harms way, can be relatively easy to define as an act of self-harm. Other types of high risk activities, which result in harm, may be more difficult to define as either intended acts of self-harm or experimental risk-taking behaviour, for example, substance use or reckless behaviours.
Assessing risk factors and developing management plans
The reasons children in the child protection system present with self-harming behaviours are often complex and varied but generally related to a combination of factors, including:
- past experience of and ongoing trauma
- significant and continuing stressors in their lives
- inadequate or poorly developed emotional or behavioural capabilities
- absence of self-care
- emerging or diagnosed psychiatric or psychological disorder
- lack of appropriate support networks
- lack of other coping mechanisms to moderate or address the behaviours.
For practitioners, identifying the potential likelihood or probability of self-harm requires an assessment of a range of factors indicating risk and need and an assessment of the risk opportunities. This assessment will form the basis for determining a risk management plan and if possible should include correctly identifying underlying causal factors. To formulate a risk management plan requires the coordinated and collaborative input of the whole care team and possibly other professionals who may be involved or have expertise to offer. See Adolescents and their families for further practice advice.
The composition of a care team will vary depending on the specific issues and needs of the child and family, however it will always include the child protection practitioner, agency placement worker, the child's case manager, the child's carer and parents (as appropriate). It prompts all parties involved to consider the things any good parent would naturally consider when caring for their own child.
Involvement of other agencies, professionals and CSOs – a multi-disciplinary approach
Children who display self-harming or suicidal behaviours may already have involvement with other services that have expertise to offer in addressing or reducing such behaviours. If a child is not involved with such services practitioners should consider making referrals or seek consultation with such services. Services such as intensive case management service (ICMS), child and youth mental health service (CYMHS), including intensive mobile youth outreach service (IMYOS) and crisis assessment and treatment team (CATT) and Take Two, each have specific expertise to offer in providing, assessment, therapeutic treatment services, case management or consultancy to address or reduce high risk behaviours. The involvement of these services on a consultancy basis or as part of the care team in developing intervention strategies and case management plans is essential to attaining the best outcomes for children involved with child protection. As part of the care team CSO placement services have a significant role in assisting to formulate intervention strategies and implementing agreed management plans.
Identifying factors indicating risk of self-harm or suicide
Factors which indicate risk of self-harm or suicide include:
- previous threats, attempts or acts of self-harm or suicide
- preoccupation with or idealisation of self-harm or suicide
- history of self-harm or suicide within the family
- ongoing and presenting psychological or emotional functioning, including marked changes in presentation such as depression, flat affect, mood deterioration (or elevation), high levels of anxiety or unrest, impulsivity
- psychological and psychiatric history
- stressors present in a child's life, including current events and occurrences
- lack of individual coping strategies and internal mechanism to deal with distressing or traumatic events
- withdrawal, isolation, separation or alienation from networks, for example, family, peers, social groups, school
- excessive involvement in high risk activities such as reckless actions endangering life, substance use
- sense of resignation, hopelessness or absence of a sense of future.
Identifying the opportunities for potential and actual harm
Opportunities for potential and actual harm include:
- whether there is a plan to self-harm or suicide
- where there are means available to carry out self-harm or suicide
- a significant event or incident occurred with which the child has not coped well with or, in the past has self-harmed as a response to such an event
- other factors present which could increase the possibility or desire to follow through with self-harm or suicide, such as access to substances or drugs, involvement with others who self-harm
- lack of or reduced contact and monitoring from regular supports
- comments indicating an intention to self-harm or suicide.
See Adolescents and their families for further practice advice.
Addressing risk factors in a child's case plan
Where it is known that a child engages in threats of self-harm or actual self-harm, the child’s case plan must identify the need for risk management and crisis prevention to respond to likely or actual episodes of self-harm or suicide. Detailed risk management and crisis prevention plans should occur in consultation with the care team. If a more detailed crisis plan is required, it should be recorded on CRIS where the plan can easily be accessed by other services such as, After Hours Child Protection Emergency Service (AHCPES), Streetwork Outreach Service (SOS), secure welfare services, out-of-home care providers.
Managing threats or acts of self-harm and suicide
On deciding a detailed management plan for self-harm behaviours, one model is to consider the actions or behaviours as either:
- situational or crisis driven or
- chronic and entrenched.
Within either of these two categories there may be similar features or characteristics but from identifying the possible factors that initiated or triggered the episode of self-harm, implementing different approaches, interventions and responses may be required to:
- ensure the immediate and ongoing safety of the child
- reduce the harm or prevent it from reoccurring
- provide the basis for a management plan which supports and promotes addressing harmful behaviours and the underlying causes.
Situational or crisis driven episodes of self-harm are those in which a specific external event or incident can be identified as precipitating or triggering the action or behaviour. They generally have a reactive time frame attached in which the likelihood of self-harming is high. A risk management plan to respond to such occurrences would follow a process of:
- identifying the event or anticipating likely events
- deciding whether the event can be resolved or ended, or whether the child can be separated from the event
- deciding whether the child can be supported through the event
- deciding whether the child can be safely maintained and supported in their current placement
- taking appropriate decision making action, such as consult with or report self-harming behaviour to the line manager, or care team members, or other involved professionals who can provide advice and direction.
Chronic or entrenched patterns of self-harming behaviours can be triggered by a specific event but are more likely to be related to psychological functioning. Often this internal component can make it more difficult to predict or map when an episode may occur. Where the self-harming behaviour may be chronic or ongoing there may be reoccurring behaviours or conduct in a child's presentation which signal a self-harming episode is imminent. A risk management plan in this case would include:
- identifying the signs that may indicate when an episode of self-harm is more likely
- utilising formulated assessment tools which may assist in gauging and monitoring behavioural patterns, for example, to ascertain when levels of anxiety or stress may be heightened. These tools may be provided by specialist services such as CYMHS, Take Two, ICMS
- developing strategies to reduce, prevent, or avoid the conditions and times in which the self-harming behaviours may regularly occur, that is, planned structured activities at those times
- developing a knowledge of what strategies could be employed to end the self-harming episode
- providing the client with alternative strategies if they feel they cannot stay safe, such as telephoning help-line numbers
- assessing if the client can be supported through the event
- deciding whether the client can be safely maintained and supported in their current placement
- taking appropriate decision making action, such as consult with or report self-harming behaviour to the line manager, or care team members or, other involved professionals who can provide advice and direction.
Risk management or crisis prevention implemented in conjunction with behaviour modification, 'bottom lines' and, consequences for actions provide one aspect of a comprehensive response.
The role of the practitioner is to coordinate the formulation of the plan with the care team (where relevant) and other involved professionals. All involved should agree to these plans. As these plans are the action plans to respond to incidents of self-harming and suicide behaviours, they often may need to be read and acted on by other services that may have a role in managing a client but have not necessarily been party to their formulation, such as AHCPES, SOS, SWS. Consequently the plans need to be kept up to date and should include:
- a relevant history
- current risk and needs assessment
- clear guidelines and instructions
- points of decision making and responsibility
- a list of services involved and relevant contact numbers
- recommendations for response
- updated plans or information.
Plans also need to be clearly marked and indicated in CRIS so other practitioners can easily locate them.
Risk management and crisis prevention planning for high-risk clients will require review on a frequent basis, sometimes daily or weekly depending on the degree of risk. In such cases it is likely that the care and placement planning process will need to include additional and frequent planning meetings held between the care team.
Reporting and recording requirements
Accurate and timely recording on CRIS of all incidents related to self-harm is important as this information assists in developing, formulating and reviewing the risk management plan for a child who engages in self-harm actions or behaviours. Where a child is listed on the high risk youth schedule, all incidents related to self-harm should already be included in the fortnightly high risk review and update. See procedure High-risk youth panels and schedules for tasks that must be undertaken.
Incident reporting is a Department of Health and Human Services requirement and involves completing an incident report as per the department's incident reporting instructions. Department staff and CSOs are required to complete the reports. Incidents are graded according to the actual impact on clients and staff and the potential risk to clients and the department. There are three categories of reportable incidents graded according to both the actual impact and apparent outcome for clients and staff. For further details, refer to Department of Health and Human Services incident reporting system.
Most incidents of actual self-harm or attempted suicide will require a critical incident report to be completed. All reports are to be completed according to the guidelines and within the specified timelines.
Child protection practitioners must ensure that incident reports are completed according to the guidelines and within specified timelines.
Strategies to address behaviours after hours should be highlighted on the client information system as a possible contact and discussed with the AHCPES. See procedure Possible contact to AHCPES for tasks that must be undertaken.
Secure Welfare Service
Where a child is exhibiting high-risk behaviours, which cannot be managed in a community setting, a placement in secure welfare may be appropriate. Secure welfare is a locked facility, which provides containment and time limited intervention.
The area operations manager/director, child protection or above may approve the placement of a young person on a family reunification, care by Secretary or a long-term care order at a secure welfare service, if they are placing themselves at high-risk and a mental health admission is not possible.
The Children's Court can make an interim accommodation order placing a young person at a Secure Welfare Service. See procedure Secure Welfare Service placement for tasks that must be undertaken.
Considerations for good practice
Self-harming behaviours and acts of self-harm by children can have a distressing and traumatic impact on all those involved in ensuring their safety and wellbeing. When working with children who self-harm or are at risk of suicide, practitioners should familiarise themselves with the services that are available to provide support and debriefing in the event of a critical incident. In situations where practitioners are involved with a child who is actively self-harming or suicidal, practitioners should, in consultation with other members of the care team, ensure there is a plan to manage the negative effects such as distress or grief, that an incident of self-harm or suicide may cause other workers, family members and other clients.