WHO Guide to Mental and Neurological Health in Primary Care
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Homepage :: Child & adolescent disorders :: Deliberate self-harm :: Assessment

Assessment

The diagnosis of deliberate self-harm in primary care settings is usually straightforward. However, some children and adolescents who have harmed themselves may try to conceal their true intent, claiming for instance that an overdose was accidental. Many others will conceal self-harm from parents and the practitioner.

Assessment is directed to four main issues:

  • assessment and management of the current episode.
  • identification and management of associated problems.
  • identification and promotion of the child and family's resources.
  • prevention of repetition.

Assessment and management of the current episode

  • All children and adolescents who have taken an overdose should receive prompt medical attention.
  • Suicidal intent should be assessed. Circumstances suggesting a high intent include the use of very dangerous methods, precautions to avoid discovery, and final acts such as leaving a note or giving possessions away.
  • The triggers of the current episode should be identified. These include arguments with family members, disciplinary crises at home or school, rows with peers, and breaking up with a boyfriend or girlfriend.
  • Cutting often occurs when the young person experiences strong feelings of tension, and the young person might report that cutting provides some temporary relief. Most young people who cut themselves have long-standing problems such as low self-esteem or substance abuse.

Identification and management of associated problems

  • Self-harm in adolescents is associated with depression, drug or alcohol abuse, behavioural problems, and physical illness.
  • There is often an association with family difficulties, including parental discord and violence, parental depression or substance abuse, role models of suicidal behaviour in the family, abuse of all kinds, and bereavement.
  • Other associated problems include bullying at school, peer role models of self-harm, models of self-harm in the media, and educational difficulties.

Identification and promotion of the child and family's resources

  • Factors in the child that protect them from self-harm, or from repetition of self-harm include being particularly good at something (eg a sport), positive peer relationships, good school attendance and academic achievement, and positive plans for the future.
  • Family factors that reduce the risk of self-harm include a close relationship with at least one positive role model, parenting styles that encourage rather than punish, and clear methods for communication within the family.

Prevention of repetition

  • This should begin with an assessment of the risk factors for frequent repetition or suicide - male gender, older age, use of dangerous methods, severe mental health problems (such as depression), high suicidal intent during the index episode of self-harm, and continuing suicidal intent.
  • Factors suggesting there is continuing suicidal intent include a clear statement that the young person intends to harm themselves again (such a statement should always be taken seriously), depression, unresolved personal or family problems (particularly if these appeared to precipitate previous self-harm), hopelessness, clear suicidal plans, easy access to dangerous methods, and frequent previous attempts.
  • Assessment of mental state and continuing suicidal intent will usually require that the young person be interviewed without the parent.
  • There is no evidence that encouraging children and adolescents to talk with professionals about suicidal feelings and suicidal plans precipitates self-harm.
  • The risk of repetition and suicide is not static, but changes over time, and may require regular assessment.

Last edited: 5/2/2004


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