NICE guidelines for self-harm: a new school of thought

New NICE guidelines for the management of self-harm in the UK emphasise the important role of non-specialists. In this article, Holly Crudgington and Dennis Ougrin discuss this guidance, focusing on the new advice for schools and its implications.

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Self-harm – an umbrella term for any intentional self-poisoning or self-injury, irrespective of suicidal intent¹ – is a major public and clinical health challenge. Although people of all demographics self-harm, it is particularly common among adolescents. Prevalence estimates suggest that about 17% of young people have self-harmed in their lifetime, with the average age of onset around 12-13 years of age, and peak prevalence during mid-adolescence.^2,3 While reasons for self-harm are unique to individuals, many people self-harm to manage distress or emotional dysregulation.^4,5 But worryingly, few young people seek professional help for their self-harm or mental health.⁶

Despite recent advances in our understanding of the pathophysiology,⁷ impact of covid,⁸ and treatment of self-harm,⁹ the behaviour appears to be on the rise in high-income countries where most research has been undertaken. For example, among girls aged 13-16 years in the UK, a 68% increase in incidence of self-harm was recorded in primary care notes between 2011 and 2014.¹⁰ Similarly, a study comparing two population-based cohorts in the UK a decade apart observed a large increase in the prevalence of reported self-harm, from 11.8% in 2005 to 14.4% in 2015.¹¹ Given that self-harm peaks in adolescence, a time when the school environment is salient, should schools have some responsibility for addressing this growing problem?

Although schools may be in an unparalleled position to tackle self-harm and the barriers to help-seeking, evidence increasingly suggests that some schools feel ill-advised on how to help young people who self-harm.^12,13 Therefore, it could not be more timely that the UK’s body for setting clinical guidelines, the National Institute for Health Care and Excellence (NICE), have proposed updated guidance on identifying and helping to manage self-harm. This draft is the first update in over a decade,^1,14 and for the first time, NICE include advice for schools.

What are the updates?

The draft NICE guidelines highlight that addressing self-harm is the collective responsibility of all professionals working with young people, including healthcare professionals, social care practitioners, third sector organisation staff, criminal justice system workers and school staff. Irrespective of who identifies self-harm, guidelines emphasise that “at the earliest opportunity after an episode of self-harm, a specialist mental health professional should carry out a psychosocial assessment.”

For schools, the key new guidance includes:

• When a young person is found to self-harm, the professional (e.g., teacher) should (a) treat the young person with respect, (b) address any immediate physical health needs, (c) seek advice from a health or social care professional, (d) ensure the young person is aware of sources of support, and (e) address any safeguarding issues.
• Education settings should have guidance for staff to support students who self-harm and a designated lead responsible for ensuring that self-harm guidance is implemented.
• All education staff should be aware of the guidance for identifying and assessing the needs of students who self-harm.
• For students who have self-harmed, the designated lead should seek the advice of a mental health professional to develop a support plan with the student and their carers (as appropriate) for when they are in the educational setting.
• Education staff should consider how the student’s self-harm may affect their close friends and peer groups and provide appropriate support to reduce distress to them and the person.

“Key advice for schools includes having a designated lead responsible for ensuring self-harm guidance is implemented and considering how students’ self-harm may affect their wider peer network.”

Recommendations were informed by a review which found qualitative evidence that school staff want policies for how to respond to people who have self-harmed because they often feel unsure how to act and unsupported. The committee agreed that their new guidance would boost school staff confidence and competence, improving care for young people who self-harm.

Importantly, the guidance also highlights the need to consider how the young person’s self-harm may affect their close friends and wider peer group. Peer networks matter for self-harm: evidence suggests that young people who self-harm are more likely to hold certain positions within peer-networks (e.g., being in a bridging position that connects others¹⁵) and that the behaviour has the potential to be socialised in friendship groups.¹⁶ Similarly, suicidal behaviour has been associated with having a friend who died by suicide, being isolated or in densely connected peer networks.¹⁷ Considering peers is therefore an important addition to this NICE guidance.

Following consultation, the finalised guidelines are expected to be published in July 2022.

Implications

Including advice for schools in NICE guidelines for self-harm is a crucial step forward in tackling the problem. As committee member Professor Nav Kapur states, “self-harm can present to any setting, and its key that non-specialist settings know what to do”.¹⁸ School is an important part of life for most adolescents and a key setting where self-harm might be identified. The guidelines give clarity to schools about their responsibility for supporting young people who self-harm and how they can help. However, the uptake of the advice can only be as good as the resources that are available to schools. Schools often do not have the capacity to seek advice from mental health professionals in every case of self-harm. Schools are often frustrated by a lack of available mental health support often due to high thresholds for accepting referrals by child and adolescent mental health services. The only option is often to send the young person to an emergency department. Perhaps with greater confidence and training, educational professionals could help young people to engage with more appropriate and earlier support before emergencies occur. Ultimately, schools will also need increased access to these services, to provide better care for more young people.

“The guidelines give clarity to schools, but uptake of the advice can only be as good as the resources that are available to schools.”

Draft NICE Guidance

National Institute for Health Care and Excellence (2022) Self harm: assessment, management and preventing recurrence. In development [GID-NG10148].

References

1. National Institute for Health and Care Excellence (2011) Self-harm in over 8s: long-term management. Clinical Guideline CG133.
2. Gillies D et al. (2018) Prevalence and characteristics of self-harm in adolescents: meta-analyses of community-based studies 1990–2015. J Am Acad Child Adolesc Psychiatry, 57, 733–741.
3. Plener P et al. (2015) The longitudinal course of non-suicidal self-injury and deliberate self-harm: a systematic review of the literature. Borderline Personal Disord Emot Dysregul, 2, 2.
4. Madge N et al. (2008) Deliberate self‐harm within an international community sample of young people: comparative findings from the Child & Adolescent Self‐harm in Europe (CASE) Study. J Child Psychol Psychiatry, 49, 667–677.
5. Rodham K et al. (2004) Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents. J Am Acad Child Adolesc Psychiatry, 43, 80–87.
6. Rowe SL et al. (2014) Help-seeking behaviour and adolescent self-harm: a systematic review. Aust N Z J Psychiatry, 48, 1083–1095.
7. Cummins T M et al. (2021). Assessment of somatosensory function and self-harm in adolescents. JAMA Netw Open, 4, e2116853.
8. Ougrin D et al. (2021) Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study. Eur Child Adolesc Psychiatry, 7, 1–13.
9. Kothgassner OD et al. (2020) Does treatment method matter? A meta-analysis of the past 20 years of research on therapeutic interventions for self-harm and suicidal ideation in adolescents. Borderline Personal Disord Emot Dysregul, 7, 9.
10. Morgan C et al. (2017) Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care. BMJ, 359, j4351.
11. Patalay P & Gage SH (2019) Changes in millennial adolescent mental health and health-related behaviours over 10 years: a population cohort comparison study. Int J Epidemiol, 48, 1650–1664.
12. Evans R et al. (2019) Adolescent self‐harm prevention and intervention in secondary schools: a survey of staff in England and Wales. Child Adolesc Ment Health, 24, 230–238.
13. Heath NL et al. (2006) “I am not well-equipped”: high school teachers’ perceptions of self-injury. Can J Sch Psychol, 21, 73–92.
14. National Institute for Health and Care Excellence (2004) Self-harm in over 8s: short-term management and prevention of recurrence. Clinical guideline CG16.
15. Copeland M et al. (2019) Social ties cut both ways: self-harm and adolescent peer networks. J Youth Adolesc, 48, 1506–
16. Giletta M et al. (2013) Direct and indirect peer socialization of adolescent nonsuicidal self‐ J Res Adolesc, 23, 450–463.
17. Wyman PA et al. (2019) Peer‐adult network structure and suicide attempts in 38 high schools: implications for network‐informed suicide prevention. J Child Psychol Psychiatry, 60, 1065–1075.
18. Roxby P (2022) Self-harm guidance to include advice for schools and prisons. BBC News.

About the Authors

Holly Crudgington is an ESRC-funded PhD Student at the Centre for Society and Mental Health, King’s College London. Her PhD is focused on adolescent self-harm and the influence of gender and peer-friendship networks using data from the Resilience, Ethnicity and Adolescent Mental Health (REACH) study. Previously, she worked as a Research Worker in Paediatric Epilepsy at King’s College London and developed the first ever Core Outcome Set for childhood epilepsy research in collaboration with young people with epilepsy, their families, and health professionals. Holly completed an MSc in Clinical Mental Health Sciences at University College London in 2016 and worked as an Honorary Assistant Psychologist in the NHS alongside the course. Her experience in the NHS and working with young people with epilepsy has inspired her focus on adolescent mental health research.
(Image Via KCL)

Professor Dennis Ougrin is Professor of Child and Adolescent Psychiatry and Co-Director of the Youth Resilience Research Unit at Queen Mary University of London. He is also a Consultant Child and Adolescent Psychiatrist, leading intensive community care services. His main professional interests include the pathophysiology of self-harm in young people, effective interventions for self-harm in young people, and the prevention of borderline personality disorder. He has expertise in several research methodologies, including conducting randomised controlled trials. Professor Ougrin also leads a programme of global mental health studies aimed at developing community mental health services in Ukraine and other Low- and Middle-Income Countries, and previously led the MSc in Child and Adolescent Mental Health at King’s College London. He was also Editor-in-Chief of Child and Adolescent Mental Health, a key clinical journal in child and adolescent psychiatry, psychology and allied disciplines.

The authors declare no conflicts of interest in relation to this article.

Related links

• ACAMH Topic Guide: Self-harm & suicide.
• ACAMH Campfire: Literature review of support tools for school staff to respond to CYP self‐harm.
• ACAMH Podcast: School behaviour difficulties, school based interventions, and inclusive education, Alice Jones Bartoli.