Key learning points:
– A significant proportion of children and young people self-harm, and this group is becoming increasingly visible in a range of settings, including primary care
– Good mental health care and support is premised on effective communication and interpersonal skills
– It is more important that practitioners are child-centred, approachable, good listeners and trustworthy than whether they have specific mental health training
Around one-fifth of children and young people experience mild-to-moderate mental health problems, with as many as one-in-10 experiencing more serious problems.1-4 Among the more serious problems is self-harm. Estimate rates of self-harm in young people vary but rates are typically between eight and 13%.5-7 It is a somewhat escalating public health issue: self-harm hospital admissions among children are at a five-year high8 and, while it used to be relatively rare for a young person under 12 to present with self-harming behaviour, its prevalence appears to be increasing in the primary school population.9
Self-cutting is the most frequent form of self-harm among young people, although self-poisoning is also relatively common.5 Self-harm tends to recur, with more than half of young people reporting multiple events and 15% presenting again within a year of a first episode.10
Despite the relatively high prevalence of self-harm among young people, there is little robust evidence regarding effective treatments.11 While hospitalisation may be an option, current mental health policy4,12 has tended to re-emphasise the value of mental health promotion, early intervention and mental ill-health prevention in young people’s mental health. This is not only because of the significant costs associated with secondary and tertiary mental health care but also because of the stigma associated with mental health services.13 The focus on preventative approaches means primary care professionals, including practice nurses, health visitors and school nurses are increasingly likely to play a role in managing young people who self-harm. Moreover, because of the growing public awareness of self-harm among young people, increasing demand from families for help and support, and overstretched and underfunded specialist child and adolescent mental health services (CAMHS), young people and indeed children who self-harm are becoming more visible in primary care.
Having the confidence to help
Nurses generally have excellent communication skills but in nurses without specialist mental health knowledge or training these skills tend to get overshadowed by anxieties over specific and seemingly alarming mental health conditions like self-harm. Thus most nurses will have the underlying competence to help children and young people who self-harm but they often lack the confidence. In this context, it is worth noting that research1,14,15 seems to indicate that children with a variety of mental health problems and their families tend to prioritise health care practitioners ability to listen, and their accessibility, approachability and child-centredness over whether they have mental health expertise or not. In addition, listed below are several other observations and practical tips that non-specialist nurses are likely to find useful when working with children and young people who self-harm:
· Children and young people frequently have different views from adults about what matters in their care; it is therefore important that the child or young person is able to speak freely and openly in a safe environment and this generally means they should be seen separately from parents or carers.
· Peer relationships may be more important to older children than parents and asking about this may be helpful to establish context for any presenting problems. Assessments also needs to include a discussion of the young person’s ‘digital life’, i.e. their internet use and online relationships.16
· Safeguarding children and young people is paramount, but if other people need to know about a child or young person’s situation, nurses need to think about how others will be told and the implications for trust. It is essential to be clear about confidentiality and why, when and how information will be shared with professionals and parents.
· A positive or strengths-based approach is less stigmatising and defeatist than one focusing on problems and deficits. As well as risks, nurses need to look for protective factors in a young person’s life or within the family such as, an extremely good relationship with a grandparent, enjoyment of school, good coping skills or having several close friends.
· No subject is taboo in mental health; it is okay to ask about self-harm, suicidal thoughts, substance use, sexual or other abuse, eating behaviour and so on, as long as these subjects are broached sensitively.
The case example in Box 1 illustrates some of these points in action.
It is also worth noting that specialist CAMHS are usually more than willing to offer support and guidance to their primary care colleagues, although there is some variance in the degree of support individual CAMHS are able to offer. Some of the more well resourced services may have a mental health liaison worker or a primary mental health worker who can provide specific training and advice for primary care professionals,17 while others may merely be able to offer telephone support.
Additional sources of support for non-specialists include third sector organisations like YoungMinds and Place2Be and the recently established MindEd website funded by the Department of Health.
Perhaps the most difficult aspect for primary care practitioners is when to refer on to CAMHS. This is an important consideration for two main reasons. The first is that overstretched mental health services frequently complain of ‘inappropriate’ referrals from primary care which can undermine the good relationships between primary and secondary care that are needed for effective services.18
The second is that referral to CAMHS carries a risk of stigmatisation which can be more damaging to a child or young person in the long run because it can deter them from getting the support they need.4,5,13 Ultimately, the question of whether to refer or not is mainly about risk. And while risk assessment in mental health can be more of an art than a science, there are some principles that might be useful in helping non-specialist nurses assess risk:
· Risk assessment involves exploring individual factors (academic success/failure, physical illness/disability or substance misuse), family factors (family stability/breakdown, parental criminality or domestic abuse) and community and environmental factors (discrimination or homelessness).1
· Medical emergencies do occur in children’s mental health (for example; taking an overdose) and they should be treated as such, with immediate action including calling an ambulance if necessary.6
· High levels of distress in the young person or her/his carers and unresponsiveness to any previous treatments suggest increased risk,6 as does repeated self-harm.10,11
· As mentioned earlier, protective factors can mitigate against risk.
· Also as mentioned before, risk assessment can be enhanced by asking the child, young person or parent direct questions. For example, the young person should be asked whether the purpose of the self-harm act was to end their life or to communicate their distress.
Many non-specialist nurses working in primary care settings lack confidence when it comes to supporting children and young people when self-harm is a feature. This lack of confidence is often borne out of a fear of saying the ‘wrong’ thing, or a belief that it is difficult to help someone who self-harms without being an expert, or from the tendency to confuse the seriousness of a situation with how frightening it appears.
The confidence of practice and other non-specialist nurses can be boosted, by appreciating that most nurses already possess the communication and interpersonal skills needed to support children and young people with these kinds of problems. To a large extent this means treating children and young people who have mental health problems the same as if they had any other health problem – that is by listening and asking direct, open and honest questions, with compassion, sensitivity, and with the child or young person’s interests at heart.
· McDougall T, Armstrong M, Trainor G. Helping Children and Young People who Self-harm: An Introduction to Self-harming and Suicidal Behaviours for Health Professionals. London: Routledge; 2010.
· Royal College of Psychiatrists. Managing self-harm in young people: www.rcpsych.ac.uk/files/pdfversion/CR192.pdf
· MindEd – www.minded.org.uk
· Place2Be – www.place2be.org.uk
· YoungMinds – www.youngminds.org.uk
1. CAMHS Review. Children and Young People in Mind: The Final Report of the National CAMHS Review. London: Department for Children, Schools and Families/Department of Health; 2008.
2. Meltzer H, Gatward G, Goodman R, Ford T. Mental Health of
Children and Adolescents in Great Britain. London: The Stationery Office; 2000.
3. Green H, McGinnity A, Meltzer H, Ford T, Goodman R. Mental Health of Children and Adolescents in Great Britain, 2004. Basingstoke: Palgrave MacMillan; 2005.
4. Lemer C. Our Children Deserve Better: Prevention Pays, Annual Report of the Chief Medical Officer 2012. London: Department of Health; 2013.
5. National Inquiry into Self-harm among Young People. Truth Hurts: Report of the National Inquiry into Self-harm among Young People. London: Mental Health Foundation; 2006.
6. National Institute for Health and Care Excellence (NICE). Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (CG16). 2004. www.nice.org.uk/guidance/cg16
7. National Institute for Health and Care Excellence (NICE). Self-harm: longer-term management (CG133). 2011. www.nice.org.uk/
8. Kotecha S. Self-harm hospital admissions among children ‘at five-year high’. www.bbc.co.uk/news/health-30414589 (accessed: 12 December 2014)
9. NSPCC. Under Pressure. ChildLine Review: What’s affected children in April 2013-March 2014. www.nspcc.org.uk/globalassets/documents/annual-reports/childline-review-... (accessed 10 June 2015)
10. Hawton K, Saunders K, O’Connor R. Self-harm and suicide in adolescents. The Lancet 2012;379:2373-82.
11. Pryjmachuk S, Trainor G. Helping young people who self-harm: perspectives from England. Journal of Child and Adolescent Psychiatric Nursing 2010;23:52-60
12. Department of Health. No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. London: Department of Health; 2011.
13. YoungMinds. Stigma: A Review of the Evidence. London: YoungMinds. 2010. www.youngminds.org.uk/assets/0000/1324/stigma-review.pdf (accessed 2 July 2015)
14. Pryjmachuk S, Graham T, Haddad M, Tylee A. School nurses’ perspectives on managing mental health problems in children and young people. Journal of Clinical Nursing 2012;21:850-9.
15. Pryjmachuk S, Elvey R, Kirk S, Kendal S, Bower P, Catchpole R. Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study. Health Service and Delivery Research 2014;2(18).
16. Royal College of Psychiatrists. Managing self-harm in young people (College Report 192). 2014. www.rcpsych.ac.uk/files/pdfversion/CR192.pdf (accessed 2 July 2015)
17. Atkinson M, Lamont E, Wright B. NFER Review: The role of primary mental health workers in education. Slough: National Foundation for Educational Research. 2010. www.nfer.ac.uk/publications/PMH01/PMH01.pdf (accessed 2 July 2015)
18. Pettitt B. Effective Joint Working between Child and Adolescent Mental Health Services (CAMHS) and Schools. [Research Report RR412 for the Department for Education and Skills]. 2003. London: Mental Health Foundation
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