ARTICLE IN PRESS

Current Paediatrics (2005) 15, 120–126

www.elsevier.com/locate/cupe

Assessment of adolescent self-harm

Quentin Spendera,b,

a
Child and Family Service for Mental Health, Orchard House, Chichester PO19 6PQ, UK
b
St George’s Hospital Medical School, Tooting, London SW17 ORE, UK

KEYWORDS Summary This practitioner review suggests an approach to adolescents who harm
Deliberate self- themselves, principally by self-poisoning or self-cutting. Such adolescents frequently
harm; pass through the care of paediatricians, who may feel they are not trained
Self-destructive be- adequately to help them. Self-harm presents an important opportunity for secondary
haviour; prevention of subsequent self-harm and suicide. To achieve this, all professionals in
Self-injurious beha- contact with such adolescents need to be aware of the pain and distress that lead
viour; them to a position where self-harm seems the only option. The practicalities of
Adolescent; engagement, history-taking, observation and what to do next are discussed.
Overdose; Although informed by the latest guidelines, research and psychiatric understanding,
Risk assessment; the review is intended to be a practical guide based on personal experience.
Impulse control dis- & 2005 Elsevier Ltd. All rights reserved.
orders

Practice points
 Young people who self-harm deserve caring
curiosity about what has made them do this
 The paediatric role includes engagement,
assessing suicidal intent and preparing the
family to work with a mental health service
 Paediatricians who come across young peo-
ple who cut themselves should be aware of
the need to attend to the feelings giving rise
to the cutting in preference to the cuts
themselves
Child and Family Service for Mental Health, Orchard House,
Chichester PO19 6PQ, UK. Tel: +441243 815514;
fax: +441243 815499.
E-mail addresses: quentin.spender@btinternet.com,
spender@sghms.ac.uk (Q. Spender).
Introduction
Self-harm can be defined as ‘self-poisoning or
injury, irrespective of the purpose of the act’.1 In
children under the age of 8, this is most often
accidental, but from the age of 12 onwards, it
becomes common for the self-harm to be deliber-
ate. Self-harm in this latter sense is rare under the
age of 10.2 Common forms are overdosing and self-
cutting, but many other activities may have the
same significance in terms of communicative or
suicidal potential. Examples include: jumping from
a height, running in front of a car, attempted
hanging, or self-burning.
Many young people are admitted to hospital with
excessive alcohol ingestion. They can be divided
into two groups. The most common group consists
of those who drink experimentally with their
friends and have more than they are used to. More

0957-5839/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cupe.2004.12.009
 ARTICLE IN PRESS
Assessment of adolescent self-harm 121

rarely, adolescents may drink with intent to harm

themselves, perhaps in combination with other In a school-based study
potentially harmful chemicals; these should be of 15–16-year-olds
treated in the same way as others who self-harm. questioned about the last year:
The female pronoun is used in what follows, as
self-harm is commoner in females than males.
However, it is more serious in males, as it is more
likely to lead at some stage to completed suicide.
It is easy to think that self-harm is not a problem 21% reported
worthy of precious medical and nursing time, or suicidal thoughts
that people who self-harm are a nuisance.3 Profes-
sionals who are honest about their feelings will be
aware at times of a certain irritation with young
people with self-inflicted damage.4 Such negative
feelings are less likely in staff who rate themselves Of these, 1 in 3 acted:
as effective with this group of patients.5 The UK 11% of the total girls
National Institute of Clinical Excellence guideline1 3% of the total boys
emphasises the importance of treating such pa-
tients with respect. Adolescents who harm them-
selves usually have a lot to cope with and scant
support to do so, although they may not necessarily
tell you the half of it.

Self-poisoning: 2% Self-cutting: 4%
Epidemiology of total sample of total sample

Self-harm becomes commoner with increasing age

up until at least 17 years.2 Girls outnumber boys,
more so with younger than with older adolescents.6
Figure 1 shows the results of a community study on
self-harm.7 Those who present to hospital are
clearly a minority.
The repetition rate for adolescent self-harm is
15% in the first year, roughly equal in each gender,6
so the first episode presents a vital opportunity for
secondary prevention. The suicide rate for adults
with self-harm seen in hospital is 0.5% in the first
year8 and the risk persists.9
The context for assessment
Self-cutting and self-poisoning are the two most
common forms of self-harm, the other varieties
being small in number. These two forms have
different origins and require different manage-
ment. What follows is mainly about self-poisoning;
self-cutting is discussed separately later.
Most adolescents with self-harm who get as far as
hospital are seen in Accident and Emergency. Some
will be assessed initially by a general practitioner
(GP), by NHS direct, or by the ambulance service.
Current best practice is that under-16’s with self-
poisoning are admitted to a paediatric bed at least
overnight.10,11 Those who cut themselves should
Of these, 23% were Of these, 6% were
seen in hospital seen in hospital
Figure 1 Epidemiology of self-harm.
generally not be admitted. Admission after self-
poisoning is recommended in order to emphasise
the psychological seriousness of the self-poisoning,
irrespective of the physiological seriousness: an
overdose of five paracetomol tablets may result
from more serious suicidal intent than ingestion of
20. Admission can provide valuable temporary
respite for the adolescent from the situation that
led them to self-harm. It also allows a more
thorough assessment than may be possible in
Accident and Emergency: this is usually completed
by a member of the adolescent mental health
service. The exact timing of this varies from one
service to another. Over-18’s are generally seen in
Accident and Emergency by adult mental health
services and may be discharged with follow-up
unless their medical status precludes this. The
policy for those between their 16th and 18th
birthdays may be somewhere between these two
 ARTICLE IN PRESS
122
alternatives, and shows wide geographical varia-
tion, but may in time be standardised in the UK
through the National Service Framework. If ad-
mitted, they are likely to be more appropriately
cared for in the adolescent bay of a paediatric ward
than on an adult ward.
Decisions to be made in Accident and Emergency
may include:
 How urgent should mental health assessment be?
 Is there a need for specialist nursing or observa-
tion?
 What should be done if the young person refuses
admission?
All three of these hinge on the severity of suicidal
intent. This needs to be part of the overall
assessment, which is usually begun in Accident
and Emergency and continued on the paediatric
ward. The success of the assessment depends on
establishing an adequate rapport with the young
person.
Establishing a working relationship
A young person is unlikely to tell you much of
relevance if she senses you are in a hurry and think
that she is wasting your time. Even if both of these
things are true, it is possible to give the impression
that you have enough time and act in a respectful
way. Ensure the room for the interview is suffi-
ciently private—a multi-bedded ward will never be
adequate: there must be an interview room or
cubicle. Choose a suitable position in which to sit,
usually at a diagonal rather than opposite, and try
to find the most comfortable distance, depending
on the room. Explain what is going on and the
purpose of asking questions. A bit of non-problem
chat at the beginning may help—but make sure you
are going to understand the answers if you ask
about the latest musical trend or skateboarding
technique. Try to be empathic and interested in
how she is experiencing life at the moment.
As with all interviewing, try to start with open-
ended questions and only if these do not get the
answers you think might be lurking, proceed to
closed questions. Tailor the choice of questions to
the individual (and family). If you miss out an
important question, you can usually go back and
ask it later (or perhaps leave it to someone else
to ask!).
Do not be deterred by the ‘I don’t know’ answer,
or the silent shoulder-shrug. These are common
teenage parlance. If you feel you are asking too
Q. Spender
many questions (which can happen if you follow a
guideline such as this too rigidly), try summarising
what you do know and then checking that you have
got it right. A nod will do. You could even hazard a
guess at some feelings, such as: ‘It seems as if you
may have been feeling pretty hopeless about things
recently?’ Then a nod or a shake of the head
becomes even more valuable information.
You cannot promise to keep everything confiden-
tial (detailed guidelines below), but you can make
a point of asking what she does not want shared
with her carers and keeping as much as possible of
this from them.
After speaking to the adolescent, ensure you
know who has parental responsibility. Select the
most appropriate amongst these to talk to (this may
be a grandparent or social worker rather than
a parent).
Confidentiality
There are certain circumstances in which it is right
to break a young person’s confidence. In general, it
is best to tell them that you have no choice but to
tell other people before you do this. They usually
respect the fact that you are subject to rules just as
they are:
 The information is life threatening or about
potential danger, for instance, she is going to
steal her father’s shotgun and shoot herself. (This
may sound outlandish, but a depressed patient of
mine actually said this to me. I suggested to her
father that he should lock up his large collection
of guns, of which I had no previous knowledge,
and which he had not thought of doing.)
 There is a revelation of sexual or physical abuse:
J In the case of ongoing abuse in an under-16-
year-old, you have to tell social services.
J With past sexual or physical abuse in an over-
16-year-old, she can veto your telling social
services, providing she is no longer at risk and
providing there is no one else at risk.
J With past sexual abuse in an under-16-year-
old, you should usually tell social services
unless it is clearly pointless: for instance, rape
2 years ago in a holiday camp abroad by
someone whose name she cannot remember.
In practice, you can usually discuss these thorny
issues with a more experienced colleague before
deciding whom to tell what: but it helps to have
some idea while talking to the young person. It also
 ARTICLE IN PRESS
Assessment of adolescent self-harm
illustrates how dangerous it may be to promise
absolute confidentiality.
A linked point is that, in relation to anyone under
18, you do not need their consent to tell an adult
with parental responsibility about an act of self-
harm. You merely need to be able to justify your
actions by assessing the young person as being at
risk. Thus, you might agree not to tell carers about
superficial cutting unless it becomes more danger-
ous, but it would be inappropriate not to tell carers
about an overdose with suicidal intent.
History
Included in both the paediatric history and the
mental health assessment should be:
(1) A factual account of what has happened: This
should cover what tablets were taken, the
circumstances of the overdose, who was told
first, how long after the overdose and who
called the ambulance. Was there any attempt
to avoid detection? Was there a suicide note?
Did the urge to self-harm build up over a period
of time?
(2) Has anything happened recently that might
have affected you? Examples include: house
move, death of a relative, split from boyfriend,
accident, assault, abuse, etc. Does any of this
help explain the current predicament?
(3) Past history as appropriate: Medical conditions
in the past and present, prescribed medication,
and past mental health history, especially self-
harm. If you wish to ask about abuse, it is
probably best left until a late stage of the
interview, once rapport has developed.
(4) What is the current family situation? This
should include everyone living at home, plus
all siblings and all parents, wherever they are.
Who is the young person’s main confidant within
the family, if any? Who is doing the parenting?
Are siblings supportive? Is there a lot of conflict
with—or between—parents?
(5) Current schooling situation: Is school a positive
place to be? Are peers friendly or do some of
them bully? (Not excluded by a ‘No’ answer.)
How is academic work going? Is there pressure
at school? When are SATs/mocks/GCSEs? Are
teachers sympathetic?
(6) Current friendship network: Are there friends
who can be confidants? Close friends of same
sex? Close friends of opposite sex?
(7) Use of non-prescribed drugs: For instance
(arranged roughly in order of increasing harm-
123
fulness): cannabis, cigarettes, Ecstasy, alcohol,
amphetamines, cocaine, heroin, etc.
Observation
You may learn as much from non-verbal clues as
verbal statements. This, for instance, will give you
information about mood, self-esteem and hope-
lessness. How is eye contact? Does she appear open
or is she reluctant to say anything? Interaction with
parents (and between parents) is also useful
evidence: is there mutual warmth or impenetrable
antagonism?
Paediatric nursing observations are also impor-
tant, providing valuable information on:
 The mood of the young person.
 Her relationships with staff and visitors.
 Her capacity to express her feelings.
 The acceptability of her behaviour.
Suicidal intent
Asking about suicide does not make it more likely to
occur. There is no harm in asking ‘Did you want to
die?’ and ‘Do you still?’ Other questions that you
might find useful include:
 What did you hope would happen?
 Did you think it would kill you?
 For how long did you plan this, or was it an
impulse?
 What was in your mind as you did it?
 Did you leave a note?
 Did you try to avoid being found out?
 When and whom and why did you tell?
 What would have happened if you had died?
 Who would have minded most if you had died?
Often you will find that an overdose was an
attempt to escape from a situation that felt
impossible, or was an expression of emotions that
felt unbearable, rather than anything much to do
with wanting to die. Young people (before their
first overdose) often do not have much medical
awareness and often think the tablets will just send
them to sleep. They may not think much beyond
that, particularly if the self-harm was impulsive.
Table 1 (adapted from Fox and Hawton2) shows
some possible motivators for self-harm: the first
three are mainly inward motives, the next three
mainly outward and the last two both.
 ARTICLE IN PRESS
124
You should now be in a position to form an
opinion about the level of suicidal intent. Using the
information gathered, you can fill in a checklist
(Table 2)12 to help summarise your interview, but it
is intended as a supplement to, not a substitute for,
a clinical assessment, which should cover the
content of all five questions. There is no cut-
off score, but the higher the score, the greater
the risk.
Formulation of the problem
A helpful way of gaining an understanding of an
overdose or other act of self-harm is to think of it as
a form of communication (often muted and
ineffective). It is worth wondering what would
have happened if the communication could have
been made some other way. Often self-harm occurs
because the right person is not there to talk to, or
because talking does not feel possible.
A way of summarising your interview (in addition
to filling in checklists) is to construct a diagnostic
formulation. This should be based on the four P’s:
 Predisposing factors, such as:
J Family discord.
J Abuse of any sort.
J Previous self-harm or psychiatric disorder.
 Precipitating factors, such as:
J A row with a boyfriend.
J Bullying at school.
J The loss of a beloved relative or pet.
Table 1 Reported motivators for self-harm.
To escape from a situation
To escape from unbearable anguish
To get inner relief
To get outside help
To show desperation to others
To change the behaviour of others
To get back at other people/make them feel guilty
To die
Table 2 PATHOS questionnaire.
‘Have you had Problems for longer than one month?’
‘Were you Alone in the house when you overdosed?’
‘Did you plan the overdose for more than Three hours?’
‘Are you feeling Hopeless about the future—that things won’t get much better?’
‘Were you feeling Sad for most of the time before the overdose?’
Score one point for each item present, and total out of five.
Q. Spender
 Perpetuating or maintaining factors, such as:
J Impaired communication within the family.
J A difficulty putting feelings into words (alex-
ithymia).
J Hopelessness.
 Protective factors or resilience, such as:
J A confidant within the family.
J A confidant who is a friend.
J A capacity to bounce back from setbacks.
What happens next?
Talking to carers
This may be necessary to supplement the interview
with the young person and to help move things
forward. Negotiate with the adolescent what she
does not want you to share with her carers and
whether she wants to be present when you see
them or not.
In addition to further history-taking, seeing the
carers can help them begin to understand their
child’s predicament. If they feel ashamed or cross,
it is important to nudge them in the direction of
being concerned. If they are not sufficiently
anxious about the potential consequences of self-
harm, they need to be made more anxious.
Reassurance is not usually appropriate.
Hospital referral to the adolescent mental
health service
Families often resent being referred to a mental
health service, but parents are more likely to
accept that this is necessary once they have
accepted the severity of the situation and adoles-
cents are more likely to accept this if they have felt
heard and understood. Seeing the adolescent
mental health service should be presented as part
of the routine of what happens after an overdose.
If an adolescent or their carers choose not to stay
for this, then it is important to explain that they
are not getting the service the adolescent needs. If
the young person has been assessed as being of high
[P]
[A]
[T]
[HO]
[S]
 ARTICLE IN PRESS
Assessment of adolescent self-harm
suicidal risk, then (in the UK) use of the 1983
Mental Health Act should be considered (there is no
lower age limit). After agreeing to admission, a
young person may change her mind and seek
discharge: she can then be kept in against her will
by using Section 5(2), which can be completed by a
consultant paediatrician and a duty hospital admin-
istrator, giving 72 h for psychiatric assessment and a
decision about a 28-day compulsory admission
(Section 2). If self-discharging from Accident and
Emergency, she can be brought back by the police
using Section 136, which should be followed as soon
as possible by a psychiatric decision about compul-
sory admission. Use of the Act should not, in
general, be necessary if someone with parental
responsibility agrees to the appropriate course of
action and can, in turn, persuade the adolescent to
follow this course.
Outpatient referral to the adolescent mental
health service
Discharging adolescents from Accident and Emer-
gency with a follow-up appointment for someone
they have not yet seen is a dangerous practice, as
they seldom attend such appointments. This has led
some to recommend home-visiting for follow-up.13
Outpatient follow-up after admission should ideally
be with the same person who did the assessment, in
order to preserve continuity and increase the
chance of attendance, although this may not
always be possible. Attendance at follow-up ap-
pointments is generally poor, so it is important to
do as much as possible within the hospital admis-
sion, while anxiety levels are still high enough
to make changes in attitude and behaviour
more likely.
Table 3 When to worry about self-cutting.
You do not need to worry
Superficial cutting, leading to little bleeding and
scars that heal quickly
Nothing to indicate past abuse
No other self-harm
No history of bingeing, vomiting or distorted body
image
A sensible attitude to experimentation with drugs and
alcohol
Mood changes are transient
125
Self-cutting
Self-cutting tends to be different in school-age
adolescents compared to adults. It is increasingly
reported in girls aged 12–15,14 in whom it is usually
superficial and of mainly cosmetic importance. The
left forearm is a common site, but any accessible
part of the body can be incised, with a variety of
sharp objects.
The differences between self-poisoning and
cutting have been shown in the same sample
referred to in Fig. 1.15 Fewer adolescents who cut
themselves than those who took overdoses said that
they had wanted to die or had wanted to find out if
someone loved them. More self-cutters than self-
poisoners had thought about the act of self-harm
for less than an hour beforehand. Also, female self-
cutters were more likely than male self-cutters to
say that they had wanted to punish themselves or
had tried to get relief from a terrible state of mind.
Table 3 shows when to be concerned about
cutting and when not. Some individuals may move
from the left-hand column to the right-hand
column; the risk factors for this progression are
unclear.
How should we understand the phenomenon of
self-cutting? Reports from young people who cut
are varied, but there are some common themes,14
as shown in Table 4. It can be seen as a
communication, to oneself or to others, and as a
strategy for managing difficult feelings of the sort
that are very common in adolescence.
Management of cutting
The behavioural approach is insufficient on its own.
Merely withholding attention can lead, in some
Indications for concern
Deep scars, some needing stitching
A known history of sexual abuse or rape; promiscuous
sexual activity; or wildly unpredictable behaviour
Associated with overdosing
Associated with an eating disorder
Use of drugs or alcohol that is potentially dangerous
Persistent symptoms of depression or anxiety
 ARTICLE IN PRESS
126
Table 4 Self-cuttingy
Can be a release of anger or other powerful
emotion
Can transform emotional pain into more
manageable physical pain
Can relieve unbearable tension
Can be a way of exercising control for young people
who feel their lives are out of control
Can be an alternative to suicide or overdose
cases, to an escalation of the cutting behaviour.
The least possible attention should be given to the
cuts themselves; inpatient admission is generally
best avoided. At the same time, if you come into
contact with such a young person, it is important to
pay attention to any distress (or other feeling)
underlying the cutting. Very often the young person
cannot put this into words: if she could, she might
not need to cut! But this does not mean there is no
feeling there. Helping carers to worry less about
the cutting and more about the possible underlying
feelings can nudge things in the right direction.
In cases of recurrent self-harm, or the first
(reported) instance of cutting, it is often helpful
to predict relapse, for instance, by saying that it
may be difficult for her to prevent herself cutting
again. I try to frame this as positively as possible,
saying that it does little harm if it remains super-
ficial, is less dangerous than taking an overdose and
may be a way of regulating feelings (like slamming
doors or shouting). This is a win–win situation for
the doctor: if it continues, you are right; if it stops,
your paradoxical intervention has worked.
At the same time, it is important to maintain a
certain level of concern within the family (as
opposed to blame) and it is worth emphasising that
there are healthier ways of communicating what-
ever the feelings are. Encouraging the young person
to talk to her friends or family may facilitate this.
Acknowledgements
I have received helpful advice about earlier drafts
of this paper from Dr Avril Washington, Consultant
Paediatrician at Homerton University Hospital; Dr
Karina Lambrenos, Consultant Clinical Psychologist,
Q. Spender
Alder Hey Children’s Hospital, Liverpool; and an
anonymous service-user.
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