New survey findings suggest that self-harm among adolescents, especially young girls, is an increasing problem. Nerys Hairon finds out more about this behaviour
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The shocking statistic that around one-third of young girls have self-harmed highlights the importance of vigilance for signs of this behaviour and risk factors in patients.
A new survey has revealed that 32% of females aged 11–19 in the UK have tried to harm themselves. The survey, commissioned by mental healthcare specialist provider Affinity Healthcare, found a total of 22% of young people aged 11–19 admitted to self-harm (Affinity Healthcare, 2008).
As the survey results indicate that self-harm is becoming an increasing problem, it is vital that both practice nurses in primary care and those in acute care are aware of the issue and those most at risk. They also need to know signs that a person may be self-harming and management strategies.
The survey, carried out by Q Research in April this year, questioned 818 young people aged 11–19 across the UK (Affinity Healthcare, 2008). It found that 56% of all respondents admitted to knowing someone who had self-harmed. Of those who had self-harmed, 73% admitted to cutting, 48% to punching themselves, 14% to burning and 10% to self-poisoning.
The reasons for this behaviour were found to be wide-ranging and complex. Of those who admitted to self-harm, 43% said they had done so because they were depressed, 17% because they were angry, 10% as a result of relationship problems and 10% because they were stressed.
Following the results, Affinity Healthcare warns that self-harm among young people is becoming an increasing problem.
What is self-harm?
The National Children’s Bureau’s (NCB) Young People and Self-harm website (2008) states self-harm can take many forms, including:
Taking overdoses of tablets or medicines;
Throwing one’s body against something;
Pulling out hair or eyelashes;
Scratching, picking or tearing at the skin, causing sores and scarring;
Inhaling or sniffing harmful substances.
Mind (2008) explains that self-harm may also take less obvious forms, such as taking unnecessary risks, staying in an abusive relationship, an addiction to alcohol or drugs, or a person failing to look after their own emotional or physical needs.
The term self-harm (or deliberate self-harm) is preferred to ‘attempted suicide’ or ‘parasuicide’, because the various reasons for the behaviour include several non-suicidal intentions (Hawton and James, 2005). These researchers explained that although young people who self-harm may claim they want to die, the motivation for many has more to do with expressing distress and escaping from difficult situations. Even when death is the outcome, this may not have been the person’s intention.
Incidence and risk factors
The NCB (2008) says it is difficult to determine the exact prevalence of self-harm among young people due to the secrecy that often surrounds this behaviour. In addition, there is no standard definition used in research, and there are no national statistics at present.
The best evidence available suggests that self-harm is most common in children over the age of 11 and increases in frequency with age. It is rare in very young children, although there is evidence of children as young as five trying to harm themselves (NCB, 2008). Hawton and James (2005) reported that 7–14% of adolescents will self-harm at some point in their lives, and 20–45% of older adolescents say they have had suicidal thoughts at some time.
Self-harm is more common among girls and young women than among boys and young men. Research suggests that, among young people over 13, around three times as many females compared with males harm themselves (NCB, 2008). However, Mind (2008) points out the percentage of young men who self-harm appears to be rising.
Minority groups that experience discrimination are also at risk of self-harm. People with mental health problems, those with drug or alcohol misuse problems, and those facing major life difficulties, such as homelessness or poverty, are more likely to self-harm. Physical or sexual abuse may also be a factor. Young South Asian females in the UK appear to have an increased risk – it is suggested that intercultural stresses and consequent family conflicts may play a part in this (Hawton and James, 2005).
Evidence suggests that healthcare professionals may be missing opportunities to detect self-harm, with secrecy making it harder. Hawton and James (2005) found that as many as 30% of adolescents who self-harm report previous episodes, many of which have not come to medical attention.
Signs and symptoms
Signs of self-harm can include unexplained cuts, bruises or cigarette burns, usually on the wrists, arms, thighs and chest.
NHS Direct (2007) made the important point that people who self-injure are careful to hide the damage or scars. They will often hurt themselves in places that can be hidden by clothes, so that friends and family may be unaware of this behaviour. Another sign of possible self-harm is an insistence on covering up at all times, even in hot weather.
Hawton and James (2005) explained that it can be difficult for healthcare professionals to identify young people at risk of self-harm, even though many older adolescents at risk consult their GP before self-harming. These researchers added that acts of self-harm are often impulsive, and secrecy and denial are common. In order to prevent self-harm, multidisciplinary working with young people thought to be at risk is necessary, including those with severe psychiatric disorders.
NICE (2004) published guidance on the short-term physical and psychological management of this behaviour in both primary and acute care. Key priorities for implementation include: offering patients respect, understanding and choice; staff training; triage; treatment; assessment of needs and risk; and psychological, psychosocial and pharmacological interventions. For general principles of care in any setting, see box below.
General principles of care
Source: NICE (2004)
When managing self-harm in primary care, practitioners should urgently establish physical risk and mental state in a respectful way. They should assess risk of further self-harm, taking into account depression, hopelessness and suicidal intent. Other relevant staff and organisations should be informed of the outcome of this assessment.
NICE outlined criteria for referral to A&E for cases of self-injury and self-poisoning (www.nice.org.uk). When urgent referral to A&E is not necessary, healthcare professionals should consider whether urgent referral to secondary mental health services is needed. This decision should be based on risk and needs assessment, including:
Social and psychological aspects of the episode of self-harm;
Mental health and social needs;
Full details of assessment and treatments should be sent to the appropriate mental health team as soon as possible.
Affinity Healthcare’s survey suggests self-harm is an increasing problem among young people. Therefore practice nurses, mental health nurses and those working in acute care need to be increasingly vigilant for risk factors and self-harming signs.
Early intervention, sensitive management and, where necessary, prompt referral to specialist services will improve management of this complex behaviour.
Affinity Healthcare (2008) New survey Reveals Almost One in Three Young Females Have Tried to Self-harm. Press release, April 2008. www.affinityhealth.co.uk
Hawton, K., James, A. (2005) Suicide and deliberate self-harm in young people. British Medical Journal; 330: 891–894.
Mind (2008) Understanding Self-harm. www.mind.org.uk
National Children’s Bureau (2008) Young People and Self-harm. Information on Self-harm. www.selfharm.org.uk
NHS Direct (2007) Self-injury. www.nhsdirect.nhs.uk
NICE (2004) Self-harm: The Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care. www.nice.org.uk