Self Harm & Risk Assessment

1. Self Harm&Risk Assessment

2. Definitions • Self Harm - self-poisoning or injury, irrespective of the apparent purpose of the act (NICE 2004) • DSH - A deliberate non-fatal act, whether physical, drug over dosage or poisoning, done in the knowledge that it was potentially harmful, and in the case of drug over dosage, that the amount taken was excessive’( Morgan 1979)

3. Definitions • Parasuicide: ‘any act deliberately undertaken by a patient which mimics the act of suicide but which does not result in a fatal outcome’ ( Kreitman 1988) • Attempted suicide : ‘an act of self damage inflicted with the intention of self destruction’

4. Self Harm • cutting • burning • scalding • banging or scratching one’s own body • breaking bones • hair pulling • ingesting toxic substances or objects.

5. Scale of problem • DSH among top 5 causes of hospital admission in the UK • Most common reason for medical admission of females (Hawton 2007) • Suicide is the most common cause of death in men <35 • Suicide rate highest in 45-74yr age group • DSH commoner in younger age and women

6. Prevalence (YP) • 1 in 15 of young people self harm • Maybe 1 in 10 (Hawton et al 2003) • Self cutting is most common type of DSH • F:M = 4-6.5 : 1 • Asian females (15-35) 2-3x more likely to SH • Suicide is very rare under the age of 12 yrs • Suicide in 10-14yrs = 0.9/100,000 in 15-19yrs = 6.9/100,000

7. Risk factors • Girls • Psychiatric disorder • Hx of abuse • School, home or work problems • Alcohol & drug misuse • Lack of supportive family relationships • Parental mental illness

8. Management …NICE 2004 • The management of DSH in young people is a joint endeavour between A and E, Paediatrics and CAMHS • Joint Royal College ( Paediatrics and Psychiatry) recommendations • Admit all cases overnight irrespective of apparent seriousness of attempt • Next working day assessment • Local joint working protocols • Protocols to be NICE compliant

9. NICE guidelines DSH Special issues for those under 16 Triage, assess and treat in separate area Nurses trained in assessment and early management of young people who have self harmed All should be admitted overnight to Paediatric ward and assessed the next day Admit to a ward for adolescents if over 14 Paediatrician should have overall responsibility for those admitted Obtain parental consent for mental health assessment Staff to be trained in the particular issues related to consent and capacity in this age group Special attention to confidentiality, consent, capacity, parental consent, mental health act and children act CAMHS should undertake assessment and provide consultation to family and other agencies/staff groups as appropriate

10. Particular focus on adolescence • Untreated depression • Limited repertoire of strategies of coping • Impulsive traits • Substance Misuse • Access to irreversible methods • Together these factors are a potent and risky combination

11. Risk factors for repeat attempt and for suicide completion • Male gender • Increasing age • Living alone • Steps to avoid detection • Past attempts • Mood disorder • Substance Misuse (particularly males over 16) • Depression, hopelessness • Agitation

12. Remember • SH is not the core problem – it is a sign & symptom of an underlying emotional difficulty/pain • not usually triggered by one isolated event but rather a set of circumstances “I don’t really like school and nick off as much as I can. There’s always arguments at home so I go out and hang around with a group of lads and lasses. We all drink a bit; sometimes I cut my arm with a bit of broken glass. It feels good, but then I regret it the next day when I see the scar.” (Dimmock, 2008:45)

13. Risk Assessment Risk Originally a sailing term from Portuguese 'sailing into uncharted waters'.

14. Risk ‘the possibility of beneficial and harmful outcomes and the likelihood of their outcome in a stated timescale danger vs risk Danger is the damage or harm that may occur from an event Risk is the likelihood of the event

15. Risk is not static, it is dynamic. Risk assessment is a cross-sectional view but may take changing factors into consideration We are not proficient at quantifying risk( one study suggests we're wrong 95% of the time‘ Thankfully wrong by overstimation in the main

16. Types of adverse outcome Harm to self Self-mutilation Suicidal acts Self neglect and starvation Harm to others Emotional abuse and violence Physical abuse and violence Harm from others Emotional abuse and exploitation Physical Sexual Harm from healthcare system Harm to staff in the work

17. Overdose Assessment Separate up into groups and take 10 minutes Perform a risk assessment and devise a management plan

18. 16 year old girl Overdose of 10 paracetamol Did not know about potential lethality Taken when angry Immediately told mother Came to hospital without resistance Regrets action No major history of emotional disturbance But hx of SH & 2 previous OD after relationship break Parental support

19. Are you worried Would you let her home What advice would you give her and her mother

20. 16 year old girl Overdose 90 paracetamol Taken with the intention of dying. Planned for 2 weeks Church in the evening, quietly made her peace with friends Went home Mother drunk Went upstairs, took the tablets alone and sober No direct trigger Knew mother would not disturb her until the Tuesday (college day) Mother found her unconscious on Tuesday Phoned ambulance, only got into it for her mother Risk assessment psychol

21. Are you worried Will you send her home What might steer you to allow her home

22. Remember We cannot read the future Human nature is impossibly complex Risk assessment is highly inexact Risk management does not equal risk elimination Responsibility is not a binary issue