What can schools actually do about tackling self-harm at primary schools? Sue Morris discusses this in her second article on self-harm and suicidal behaviour in primary school children

Depending on the size and demographics of your school, you may encounter very few or several pupils who engage in deliberate self-harm (DSH) as a coping strategy and, less frequently, children who become so desperate that they consider or even attempt to take their own lives when life appears intolerable to them. Generally the role of schools needs to be considered within the comprehensive child and adolescent mental health services (CAMHS). As illustrated in Figure 1, teachers and other school staff are positioned as ‘Tier 1’ mental health professionals within such services.

It is important to think about our own role within this broader canvas: we are not alone in our responsibilities, and need to make good use of the skills and resources that other services and agencies can provide.

A preventive approach: mental health promotion for all children
The University of Oxford Centre for Suicide Research and the Samaritans recommend that schools should play a more prominent role, arguing that ‘Since the vast majority of pupils who self-harm do not go to hospital, prevention needs to take place in the community, ideally within schools’. Through effective mental health promotion in our ‘Tier 1’ role, the risks that children will need to take recourse to DSH as a coping strategy or method of communication can be much reduced. Here policy is on our side: over recent years, the emphasis on personal, social and health education (PSHE) has been strengthened, and the new social and emotional aspects of learning (SEAL) initiative and resources, for example, are helpful in enabling schools to strengthen these aspects of pupils’ development and learning. In addition to curricular inputs to help develop children’s social problem-solving and emotional processing skills as means of preventing DSH and suicidal thinking and behaviour, we need to consider wider features of school culture and the school experience: for some children, school is part of the problem. As illustrated in Figure 1 in my previous article (‘In harm’s way’, Special Children 183, June/July 2008), worries about features of school life such as progress with work, assessments and peer relationships are very high indeed on children’s list of stressors. Moreover, studies have suggested that there is a significant minority of pupils who do not feel at all confident that support is available in school, and who believe that relatively few teachers can be depended upon to offer timely or effective help when they are anxious, unhappy or worried on their own or others’ behalf. We need to create a listening ethos, through use of circle time and other activities, and develop our relationships with the children, so all are confident they can approach teachers or teaching assistants for help and advice with any problems they may have. Finally, as children turn to their friends for help and advice, they will need help not only coping with their own emotional problems but also in recognising and helping friends in need. In this context, the establishment of peer support, ‘buddying’ and mentoring systems in schools is a helpful step.

Responding to disclosure
Children who have self-harmed frequently talk about their fears of how teachers will respond if they disclose self-harm or suicidal thinking, worrying that they will lose all control, and that their intimate secrets will be widely communicated and discussed. Of course, to some extent, these fears are well grounded, since school staff do have to balance the wishes and feelings of individual children, and respect for confidentiality, with health and safety requirements and child protection responsibilities. Staff to whom a disclosure of self-harm or suicidal thinking is made need to be prepared in advance for this eventuality. A few important points are worth reinforcing here:

  • Your own interpersonal approach to this crisis is critical: the isolation, powerlessness and low self-esteem that children who self-harm or feel suicidal so often feel, will be compounded by a judgemental or unsympathetic response. Staff need to be confident about what to do, and acknowledge the distress which the child is likely to be experiencing. It is paramount that staff do not, however, signal disgust or disapproval, although it is of course reasonable to show concern that the child is so distressed, and about the risk of harm.
  • The child will usually have chosen the adult they feel safe to approach. The adult needs to find a time and suitable place to listen, and then explain (in terms which the child can understand) that the disclosure will need to be shared with other staff and with parents/carers. Thereafter, the child can be given a ‘good listening to’.
  • If the child has injuries, has taken medication or ingested harmful substances, an immediate focus must be on ensuring the child’s safety. Immediate support may need to be sought from a qualified first-aider, while assessment and treatment from a medical practitioner is sought (in cases where the level of injury or uncertainty about what a child may have ingested so require).
  • Whatever the level of immediate physical harm and risk, the disclosure needs to be recorded and reported, within the school’s child protection/safeguarding procedures.
  • It is crucial that no staff member attempts to carry the burden of responsibility alone: disclosure should be a first step in a whole-school response.
  • A prompt multi-agency assessment needs to be set in place as a matter of urgency. This does not, however, prevent the provision of ongoing support for the child from trusted staff within the school.
  • Overall, attention needs to focus on the problem(s) for which the self-harm or suicide would be a solution, and to the identification of steps that can be taken to address or reduce the impact of the problem, to enhance coping strategies and/or the support available to the child. The focus should not normally be on stopping the self-harming behaviour.

Figure 1

Tier 4

Purpose

  • Access to day and inpatient units
  • Specialist complex interventions

Staff include

  • Child psychiatrists, neuropsychiatrists (inpatient specialist unit staff)
Tier 3

Purpose

  • Assessment and treatment of mental health disorders
  • Consultation to Tier 1/2
  • Research and development

Staff include

  • Clinical psychologists, psychiatrists, psychiatric social workers and psychotherapists
Tier 2

Purpose

  • Training and consultation for Tier 1
  • Outreach work
  • Assessment for Tier 3/4

Staff include

  • Clinical and educational psychologists, community paediatricians, child psychiatrists and nurses
Tier 1

Purpose

  • Promote mental health
  • Identify difficulties at an early stage
  • Offer general advice and treatment for less sever problems

Staff include

  • GPs, health visitors, social workers, school nurses, teachers and other school staff

Multi-agency support for schools
Schools need the support of other professionals, including health, social services and voluntary organisations. In fulfilling their responsibilities to support the promotion of mental health and to address mental distress and risks of deliberate self-harm suicidal thinking or attempted suicide, schools can draw on expertise from external services and agencies in the form of consultation and advisory support and contributions to staff training, in parallel to direct work with children and families. Voluntary agencies such as Samaritans and NCH Action for Children, alongside colleagues from the more traditional agencies – such as educational psychologists, education social workers, school nurses and other primary care workers – have an important part to play in supporting schools in meeting the needs of vulnerable children, and in contributing to school improvement initiatives that strengthen schools’ effectiveness in promoting children’s mental health and psychological wellbeing.

Risk assessment
In cases where self-harm or suicidal thinking are suspected, there is a need to initiate a prompt assessment of the level of risk this behaviour presents. This assessment needs to include an assessment of the child’s mental state, and the impact of any pattern of substance use. It is important here that assessment is initiated promptly by the ‘specialist’ tiers of the CAMHS, who are competent to undertake this assessment and to document and take forward the agreed crisis/contingency plan. Referral needs to be made on the same day that self-harm or suicidal thinking are discovered. Unless exceptional circumstances require otherwise, it will be appropriate to notify the child’s parents/carer immediately self-harm or suicidal thinking is noted in school, and to include parents in the early stages of the assessment and intervention planning.

The need for policy guidelines
It goes without saying that it is wise to be prepared with a contingency plan before the event: ideally the school should have policy guidelines in place, so that all staff know whom they should inform if DSH is suspected, which agency should be contacted, and what other steps need to be initiated. Such advance planning is essential in order to ensure a coordinated response can promptly and efficiently be set in motion, which includes provision of adequate support for the child, other children who have witnessed or know about the self-harm, and members of staff who may be experiencing significant shock or distress following a child’s disclosure or the discovery of self-harm or attempted suicide. DSH and/or suicidal thinking has much in common with, and indeed is sometimes included within, the safeguarding policy and procedures that schools follow in their child protection work. The duty of care is, as always, paramount. However, in responding to DSH or attempted suicide, there is normally no need for the ‘legalistic’ approach that can characterise other child protection referrals and cause delays in the provision of therapeutic support.

Training and support for school staff
The area of deliberate self-harm (DSH), attempted suicide and completed suicide promotes a high level of concern in schools, and is an area which most staff feel poorly equipped to address. The findings of the National Inquiry into Self-harm among Young People (2004-05), jointly run by the Camelot Foundation and the Mental Health Foundation, revealed that education professionals would value specific information and advice about these issues. Normally ‘Tier 2’ services such as the local authority educational psychology service and/or the ‘Tier 3’ CAMHS will welcome an invitation to contribute to staff training in your school in relation to this topic domain, as may local branches of voluntary agencies such as Samaritans, NCH Action for Children or Barnardo’s. Finally, of course, provision of professional supervision is paramount: teachers and other school staff who work to support children who experience mental distress and who engage in DSH and/or suicidal thinking are entitled to effective personal professional support. It is an essential component of a school’s responsibilities in mental health promotion and responding to the mental distress likely to be demonstrated by a significant number of children, that measures are in place to safeguard the wellbeing of staff, provide a safe forum in which staff can process the thoughts and feelings evoked by this work, and build on their experience to become increasingly confident and competent in this area of work. In this area too, schools need not ‘go it alone’, but would be well advised to seek training and support from external agencies.

Summary
This short article has aimed to signal that problems of DSH and suicidal thinking in school-aged children are increasingly prevalent, and that, within their wider responsibilities to promote children’s mental health and achieve the outcomes of the Every Child Matters agenda, these phenomena require attention in schools at the policy level, in staff support and training, in curriculum planning and in the area of pastoral casework. This is an area in which the school’s role within the comprehensive, multi-agency tiered CAMHS cannot be too strongly emphasised: schools have an important and distinctive contribution to make, but need to do this in partnership with other agencies and services within their locality.

Sue Morris is director of professional training in educational psychology at the University of Birmingham

References

  • Camelot Foundation and Mental Health Foundation (2005), Truth Hurts: Report of the National Inquiry into Self-harm among Young People.
  • Hawton, K, Rodham, K and Evans, E (2006), By Their Own Hand: Deliberate Self-harm and Suicidal Ideas in Adolescents. London: Jessica Kingsley
  • Hawton, K, Rodham, K, Evans, E and Weatherall, R (2002), ‘Deliberate self-harm in adolescents: self report survey in schools in England’. BMJ. 325, 1207–1211
  • Qualifications and Curriculum Authority (2001), Supporting School Improvement: Emotional and Behavioural Development. London: QCA
  • Social Care Institute of Excellence (2005) ‘Deliberate self-harm (DSH) among children and adolescents: who is at risk and how is it recognised?’ Research Briefing 16.
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