Sue Morris looks at self-harm and suicidal behaviour in primary school children, including the definitions, prevalence rates and the factors that increase and reduce risk

In the past two to three decades there has been a disturbing increase in suicidal behaviour among children and adolescents. This type of behaviour includes non-fatal behaviours such as attempted suicide or deliberate self-harm (DSH) and completed suicide.

Such behaviours by children and young people may be frightening and even incomprehensible to their peers, and inevitably evoke powerful emotional responses in adults, who can find it disturbing that a young person finds their life so unbearable that they wish to end it or put it at risk.

oreover, parents and staff in schools are often very unsure of how best to respond in cases where they suspect or know a child is self-harming or talking about suicide, fearing that they might make a bad situation worse, and increase rather than reduce risks to
the safety and wellbeing of the child.

Illustrative of the scale of the problem is a recent media article (Daily Telegraph, 6 May 2008), headed ‘Self-harm and eating disorders on rise among under-10s’, based upon research for The Children’s Society Good Childhood Inquiry and 2006-07 statistics from the Department of Health (DH). The article claimed that, ‘The unhappiness of British children has been reflected in figures showing that hundreds of girls and boys under 10 are going into hospital with self-inflicted injuries and eating disorders such as anorexia and bulimia’ and it went on to cite DH data indicating that, during this one-year period, more than 15,000 children had been admitted to hospital for self-inflicted injuries, of whom 169 had been under the age of 10 (and here it must be recognised that hospital admissions account for only a very small minority of affected children).

This article will briefly summarise some of the research evidence about the prevalence of deliberate self-harm and suicidal behaviour in children and young people, factors that increase and decrease the risks of such behaviour, and steps which primary schools can take to address these risks and support vulnerable children. First, though, a shared understanding of terminology is required to ensure clarity of communication.

The Mental Health Foundation suggests the following definitions:

  • Suicide: Self-harm that results in death.
  • Attempted suicide: Self-harm motivated by the intent to end life, which results in non-fatal injury.
  • Deliberate self-harm: Self-harm that has no suicidal intent, which results in non-fatal injury.

The University of Oxford Centre for Suicide Research recommends a more comprehensive definition of DSH that states that while DSH is not suicidal in its intent, there must be the intention to cause harm, either explicitly or by implication. By way of contrast: most of us engage to some degree in behaviour that we know to be potentially harmful to our wellbeing (such as eating unhealthily, drinking alcohol above recommended level, or driving too fast); but while this behaviour may be reckless and irresponsible, it would not be categorised as DSH unless our primary motivation for the behaviour were to inflict pain or injury upon ourselves.

A further phenomenon worthy of note is suicidal thinking or suicide ideation – terms that apply when a person is thinking and perhaps talking about suicide as a response to problems in life. Although suicide ideation will not lead to attempted suicide in the majority of cases, evidence of suicidal thinking should never be ignored as ‘attention-seeking’ behaviour, but should always be taken seriously and listened to, prompting evaluation of risk and provision of support.

The extent of the problem

Across all age groups, completed suicides are three to four times more common in males than in females, a trend very different from that which characterises suicidal thinking and DSH, all of which occur far more frequently among females.

In 2004, the last year for which data is currently available, the rate of completed suicides was approximately 16.5 for every 100,000 of the population, with a figure of 12.5 for men and 4.0 per 100,000 for women. In recording and reporting statistics, the Office of National Statistics categorises deaths of children and young people within two age categories: 0-14 years and 15-24 years.

In 2004, the death by suicide of 14 boys and nine girls within the 0-14 year age range, and 495 young men and 140 young women within the 15-24 year age range, was recorded. It is apparent therefore that completed suicide in the younger (0-14 years) age group is, thankfully, very rare.

However, for the past three decades, suicide has consistently been one of the three major causes of premature death in childhood and adolescence. Every case of completed suicide represents a devastating tragedy in human terms, leaving an appalling sense of loss, wasted potential and guilt among the families, friends and communities from which these young people come. Moreover, overall reported levels of prevalence are likely to underestimate the scale of the problem, since coroners remain reluctant to ascribe premature deaths to suicide in cases where there is any room for doubt that the child or young person did indeed end their life intentionally.

Prevalence of deliberate self-harm

As far as DSH is concerned, research undertaken in 2005 indicated that one in 15 young people in Great Britain harm themselves, with:

  • most young people who harm themselves aged between 11 and 25 years
  • 12 being the age at which most young people begin to harm themselves
  • some children as young as seven, or under, engaging in self-harm.

Moreover, some research suggests that the UK has the highest rate of self-harm in Europe.
The prevalence rate for girls who self-harm is approximately four times higher than the rate for boys. However, the severity of the problem in boys should not be overlooked, in part because the rate is rising, and because boys often employ methods that are more hazardous, such as hitting themselves or breaking their own bones, with the contingent risk that the cause of their injuries may be put down to fights or accidents.

In 2000, Samaritans commissioned research into DSH in young people, which was carried out by Dr Keith Hawton and colleagues from the University of Oxford Centre for Suicide Research (Youth and Self Harm: Perspectives – A Report). This was an important epidemiological study, in that a representative cross-section of young people formed the sample, rather than solely those presenting at hospital accident and emergency departments. The results indicated that some 10% of young people had self-harmed, while 15% reported suicidal thinking but no deliberate self-harm over the preceding year – prevalence levels considerably in excess of those that had been expected.

Primary-age children

There is very little research into deliberate self-harm, suicidal thinking, attempted or completed suicide in primary-age children. However, there is evidence that, in common with many social ills and threats to the social and emotional wellbeing of children, such as eating disorders or involvement as perpetrators or victims of violent crime, increasingly young children resort to self-harm at times of stress, and that growing (but thankfully still very small) numbers contemplate or attempt to take their own lives. A briefing paper published by the Social Care Institute of Excellence (SCIE) in August 2005 presents results from a national survey of more than 10,000 children, noting that the prevalence of DSH among five- to 10-year-olds occurred at a rate of:

  • 0.8% among children with no known mental health difficulties
  • 6.2% among children with a diagnosed anxiety disorder
  • 7.5% in cases where children had a diagnosed conduct, ‘hyperkinetic’ or other forms of chronic mental distress.

While rates are considerably lower than those for the 11-15 year age band there are no grounds for complacency amongst those of us who work with primary-age children.

Why should we be concerned about DSH in primary-age children?

As noted above, DSH is predictive of later attempts at suicide. DSH is a clear indicator of mental distress and poorly developed coping skills. There is unequivocal evidence that prevalence rates are rising. For example, the number of children disclosing DSH to ChildLine counsellors has risen steadily over the past decade, with a 65% increase in the two-year period from 2002-04 alone.

Younger children lack the cognitive maturity and life experience to handle problems with the effectiveness and sophistication of adults or even adolescents. They lack the time perspective necessary to appreciate that pain will pass. They are not yet capable of the abstract thinking skills that can enable them to think hypothetically and weigh alternative courses of action, and so feel hemmed in by the moment. Their egocentricity and ‘faulty thinking’ may lead them to blame themselves for situations for which they are not responsible, such as domestic violence or parental separation. They lack the power to effect change in their lives and escape adversity. Depending on their age, they will have a very incomplete understanding of the finality of death, although fortunately this is offset by the fact that they will also, more often than not, lack the means to kill themselves. Overall, however, younger children must certainly be considered a population highly vulnerable to the effects of stress and unhappiness.

If we can support children’s development of social problem-solving skills, emotional processing and resilience in the early years of their lives, we can reduce their vulnerability to mental ill-health and long-term suicide risks. The exponential increases in DSH and suicidal thinking in later childhood in adolescence and youth are by no means inevitable consequences of getting older. 

Why are some children at more risk of DSH/suicidal thinking?

This is a complex question, and it is widely accepted that there are no simple cause and effect relationships, just as there is no single ‘golden bullet’ solution. We have already seen that girls are more susceptible to DSH and suicidal thinking, while boys are more likely to end their lives through acts of suicide, and that risk increases as a result of mental distress and with increased age. Research literature has identified a number of factors as increasing or reducing risks that children may resort to DSH or attempted suicide (see Figure 1). It is generally accepted that risks are multiplicative, in that the higher the number of risk factors, the greater their impact. It is a mistake to look for a single ‘cause’ of DSH or suicidal intent: there may be an immediate trigger which precipitates the behaviour at a particular time, but, almost without exception, children who resort to such desperate measures will be characterised by a complex web of risks, which interact to disrupt their emotional equilibrium and engender a sense of hopelessness or unbearable distress.

Figure 1: Factors linked to an increased/decreased risk of DSH

  Risk factors Protective factors

Characteristics of the individual child

  • low self-esteem
  • male (suicide)
  • increasing age
  • poor coping skills
  • difficult temperament
  • mental distress or illness, eg anxiety/depression
  • alcohol/substance misuse
  • stress or worries about school work or peers
  • history of similar behaviour in the past
  • past or current experience of abuse
  • feeling isolated
  • recent bereavement
  • high self-esteem
  • female
  • higher ability/attainment
  • outgoing personality
  • good coping skills
  • positive school experience
  • secure attachment
  • resilience
  • knowledge of where to seek support

Features of the immediate context

  • access to means of causing self-harm
  • being alone
  • social exclusion
  • alcohol and drugs
  • access to social support
  • social inclusion
Family factors
  • family members who self-harm
  • family conflict
  • parental separation and divorce
  • single parent family
  • parental illness
  • parental drug/alcohol misuse
  • sexual/physical abuse
  • poverty/low socio-economic status
  • supportive adult relationship
  • harmonious family relationships
  • low level of material or social hardship
  • good role models within family
Peer group
  • arguments with friends
  • bullying
  • friends who self-harm
  • stable and secure friendship group
  • pressure from school to perform well
  • supportive adult
  • inclusive/incorporative ethos
  • strong commitment to PSHE and mental health promotion
  • establishment of peer support systems
Wider culture and community
  • minority status
  • problems in relation to race, culture or religion
  • problems regarding sexual orientation or identity
  • media: portrayals glamorise DSH or suicide ‘victims’ and elicit ‘copy-cat’ responses by vulnerable children and young people

What functions does DSH serve?
As with talk of suicide, the widespread notion that DSH is ‘attention-seeking’, and that it must therefore be ‘ignored’ for fear of reinforcing undesirable behaviour, is generally ill-founded. Research suggests that the most common reason children and young people take recourse to DSH is ‘to gain relief from a terrible state of mind’, because they wish to die, or to punish themselves (Hawton et al, 2002).

In some cases the behaviour does represent a form of communication, serving to show how desperate they are feeling, to test whether someone cares about them or, sometimes, as a protest, to frighten someone or get their own back in some way. In most cases, DSH is a way of coping with distress.

Responding to DSH

Where children are suspected or known to self-harm, intervention needs to focus on:

  • keeping the child safe
  • providing opportunities to explore the pressures and stresses that evoked the distress to which the DSH was the solution, with a view towards identifying steps that can be taken to address these pressures at source
  • helping the child develop more effective coping strategies and/or providing enhanced support.

It is rarely appropriate to focus on extinguishing the DSH, since this is often the best coping strategy which the child has available.

In the case of both attempted suicide and DSH, there are significant risks of contagion effects: the role model afforded by, and the attention given to, the child who self-harms may serve to recruit other vulnerable children to self-harm as a response to adversity. This adds to the challenges we all face in responding effectively and with sensitivity to the needs of children who self-harm, while safeguarding the wellbeing of the wider school community.

What are some of the warning signs?

In general, children who have faced adversity in their lives are more likely to resort to DSH and to think about suicide as a way out. The Mental Health Foundation publication, The Truth About Self-harm, notes that it is usually very difficult to tell whether someone is self-harming, since this is most often a shameful secret for those who take recourse to this behaviour. Moreover, many of the characteristics that often indicate emotional distress (appearing unhappy, ‘washed out’, lacking in energy, becoming more withdrawn or more emotionally volatile, for example), can also be indicators of self-harm.
Of course, in cases where a child is cutting, burning, or pulling out hair, there may be physical evidence, but children will usually take steps to hide this, and offer plausible alternative explanations.

In cases of completed suicide in childhood, bullying or friendship difficulties are often implicated. Often though, the suicide comes as a shock: even with hindsight the warning signs can be hard to identify.

In general, our role in schools is not to take positive action to screen and identify children who self-harm and/or feel suicidal. Rather, it is our job to:

  • monitor the social and emotional wellbeing and development of all our pupils, and have a range of differentiated provisions in place to help pupils with difficulties
  • give prominence to mental health promotion and supporting pupils’ social and emotional development in school, taking full account of the risks as well as the opportunities that school life can present to children
  • be confident and effective in our response when a child discloses that s/he or a friend has self-harmed, or is talking about suicide
  • be aware of and prepared for the probability that many children in any school will experience serious mental distress about which we, as adults, may know very little. We need to acknowledge that some of these children will resort to self-harm or think about suicide because they have no better ways of coping.

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