1. Non fatal deliberate self harm ( 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)

2. Synonyms 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’

3. 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

4. NICE 2004 Guidelines re Deliberate Self Harm Focussed on respect, understanding, privacy Choice in their care Triage screening for and identifying physical and mental health needs Offering comprehensive psychosocial assessment to all

5. 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 Special issues for those under 16 Special issues for those under 16

6. CAMH professionals should –Be trained specifically to work with children and YP after self harm –Be skilled in the assessment of risk –Have regular supervision –Have access to consultation with senior colleagues Special issues for those under 16 Special issues for those under 16

7. Initial Management should include advising carers about removal of all means of self harm including medication. If repeated self harm consider developmental group psychotherapy for at least 6 sessions Special issues for those under 16 Special issues for those under 16

8. 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

9. 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

10. Adolescence associated psychosocial problems Conduct Disorder Depressive Disorder Psychosis Multi-impulsive Bulimia Incipient family breakdown Undisclosed abuse of all types Reaction to parental mental illness

11. In young people think about it as an event with meaning Particularly social or relational meaning Usually people who use DSH remain in contact with others, and there is an element of warning, or appeal for help from another Whether taken in context around others or not, there is always symbolic meaning to be made: ‘cutting the bad out of me’

12. Assessment Screening history and mental state for known factors associated with risk of repetition and completion At the same time asking the salient question…what is the significance of this person presenting to me, in this way, at this point in their life

13. Intent In the context of the assessment you have just made, what is your assessment of intention Assessment of intention in young people particularly important. It informs risk assessment Intention around the original act and ongoing intention What do they say about intention and what do their actions suggest