Intentional self-harm and suicidal behaviour in children

About the examination

In 2014, the National Children’s Commissioner conducted an examination of intentional self-harm and suicidal behaviour in children and young people aged 0-17 years.

The examination involved national consultations, a public submission process, roundtables, analysis of key data and engagement with children and young people at risk through supported processes.

The findings of the examination are reported in the National Children’s Commissioner’s 2014 Children's Rights Report to federal Parliament.

Information available on this page includes:

• The key findings
• The recommendations of the examination 
• Developments since the 2014 report

Overview

Intentional self-harm and suicidal behaviour in children and young people is a significant public health challenge in Australia. It is also a human rights issue for children and young people. The Convention on the Rights of the Child includes a number of important rights to prevent intentional self-harm.

Article 6 of Convention, for example, guarantees children the fundamental right to life, and to survival and development to the maximum extent possible.
The Convention also guarantees children the right to protection from all forms of violence, under article 19, the right to the highest attainable standard of health, under article 24, and the right to an adequate standard of living, under article 27.

In 2014, the Australian Bureau of Statistics reported that intentional self-harm is the leading cause of death among Australian children and young people aged 15-24 years, with 264 deaths by males and 96 by females. (1).  Kids Helpline reported that in 2013-2014, 8,931 contacts aged 5-25 years were assessed by counsellors as experiencing current thoughts of suicide.  In the same year, 13,028 contacts were assessed by counsellors as having ‘current difficulties with self-injury’. (2) 

Available data reveals that some groups of children and young people are disproportionately affected by intentional self-harm and suicidal behaviour.
In 2014, the Australian Bureau of Statistics reported that Aboriginal and Torres Strait Islander males aged 15-24 were 3.9 times more likely to die due to intentional self-harm and for females the rate was 4.2 times more likely than non-Indigenous. (3) Data sourced from the National Coronial Information Centre (NCIS) revealed that Aboriginal and Torres Strait Islander children and young people who died due to intentional self-harm were younger than non-Indigenous children and young people.(4) Other groups that are disproportionately affected by intentional self-harm and suicidal behaviour include: children and young people in out-of-home care; children and young people with disability; children and young people from culturally and linguistically diverse backgrounds; and children and young people in rural and remote areas of Australia. (5)

In this context, the National Children's Commissioner chose to examine how the human rights of children and young people engaging in intentional self-harm and suicidal behaviour could be better protected.

Key Findings 

One of the key finding of the examination was that too much continues to be unknown and this is impeding us from predicting and preventing injury and death in children and young people due to intentional self-harm.

Definitional challenges and data issues

Many different terms are used to define intentional self-harm and suicidal behaviour. The distinctions between the terms used are not well understood, are not agreed upon, and are not clear. Research based on different definitions is difficult to compare and clinicians have difficulty in translating research findings into practical applications. 

The examination found that it is necessary to distinguish between non-suicidal self-harm and suicidal behaviour. Non-suicidal self-harm is different to suicidal behaviour. Differentiating between them is essential to building precise understandings about them. For example, data about death and hospitalisation due to intentional self-harm does not distinguish between intentional self-harm with suicidal intent and intentional self-harm without suicidal intent. This makes it hard to construct an accurate picture of what is actually occurring.

The availability of data is delayed due to the length of coronial investigations, which can take two years or more to finalise. There is also an underestimation of deaths due to intentional self-harm as a consequence of coroners not making a finding about intent. Confidentiality and privacy requirements limit the availability of data about death and hospitalisation due to intentional self-harm.

Finally, there is a dearth of research involving the direct participation of children and young people. Directly involving children and young people in research about intentional self-harm, with or without suicidal intent, is essential to understanding the causal factors involved.

Understanding risk factors

Understanding the multiplicity of risk factors related to self-harm and suicidal behaviour is central to effectively targeting and supporting children and young people. 

Research has predominantly focused on intentional self-harm with suicidal intent compared with non-suicidal self-harm. As a result, we know more about intentional self-harm with suicidal intent leading to death than we do about non-suicidal self-harm.

Distal risk factors that may predispose a child or young person to suicidal behaviours include:

• mental health problems
• alcohol and drug abuse
• child abuse, including physical and sexual abuse
• adverse family experiences, including poverty, domestic violence, parent with alcohol or drug dependency, parent in gaol, parent with a mental illness, person known to the child who died due to intentional self-harm
• previous suicide attempt(s)
• communicated suicidal intent
• intentional self-harm, with or without suicidal intent.

The vulnerability and consequent need for assessment is increased for children and young people who are exposed to multiple risk factors and who experience a lack of key protective factors. 

While there is a growing body of knowledge about the risk factors that increase the likelihood of suicidal behaviour and non-suicidal self-harm, much less is known about how or why children and young people engage in these behaviours. We do not know whether they develop as a result of multiple interrelated risk factors or only one or two predominant vulnerabilities, or whether specific combinations of risk factors can accurately predict intentional self-harming behaviour with or without suicidal intent. Research that simultaneously considers multiple risk factors is required.

Barriers to help seeking

A range of barriers were identified which prevent children and young people from seeking help. These include those experienced by the child or young person, those shaped by the parents and carers and those imposed by system constraints.

• Barriers experienced by children and young people included feelings of embarrassment and guilt, and fear of the response from parents and other sources of help.
• Barriers associated with parents and carers included limited awareness of available support services and worries about cost of services/treatments.
• Barriers as a result of system constraints included lack of appropriate and culturally sensitive support services and limited capacity of support services where there are waiting lists and motivation to seek support may have decreased by the time an appointment is available.

Particular barriers exist in relation to certain groups of children and young people. For example, language barriers exist for Aboriginal and Torres Strait Islander children and young people in remote communities and children and young people from culturally and linguistically diverse (CALD) backgrounds.

A particular barrier identified was that children and young people often receive a poor response from accident and emergency departments. Where children and young people present to an accident and emergency department, there is a genuine opportunity to connect with them and facilitate follow-up intervention. Further research is required to investigate the types of contact that children and young people have with professionals and where the missed opportunities for prevention lie.

Finding effective ways to encourage children and young people to access appropriate help or support for early signs and symptoms of difficulties must be a priority.

Recommendations

1. Establish a national research agenda for children and young people engaging in non-suicidal self-harm and suicidal behaviour through the new National Strategic Framework for Child and Youth Health. This should be supported by the soon to be established National Centre for Excellence in Youth Mental Health.
    
2. Strengthen and develop surveillance of intentional self-harm, with or without suicidal intent, through:

   a. The Australian Government funding an annual report on deaths due to intentional self-harm involving children and young people aged 0-17 years using the agreement reached between the Australian Bureau of Statistics; the Registrars of Births, Deaths and Marriages; and state and territory coroners on the dissemination of unit record data.
   b. The Australian Institute of Health and Welfare including a section using disaggregated data about hospitalisations for intentional self-harm involving children and young people aged 0-17 years in its regular series on hospitalisations for injury and poisoning in Australia.
   c. The Australian and New Zealand Child Death Review and Prevention Group continuing its work in relation to the development of a national child death database, in conjunction with the Australian Institute of Health and Welfare, and providing an annual progress report.
    

3. Collect national data on children and young people who die due to intentional self-harm through:

   a. The use of the standardised National Police Form, in all jurisdictions, by 2015. This should include an electronic transfer to the National Coronial Information System. A plan to monitor the outcomes of all jurisdictions using the standardised National Police Form should be developed, and the possibility of incorporating a range of demographic, psychosocial and psychiatric information specific to children and young people should be investigated.
   b. The Standing Council on Law, Crime and Community Safety putting the issue of standardisation of coronial legislation and/or coronial systems on its agenda. Standardisation should require that where all state and territory coroners find a death under investigation to be caused by an action of the deceased, the coroner must make a further finding of intent, based on the evidence, to clarify whether the deceased intended to take the action which caused his or her death; the deceased lacked capacity to recognise that his or her action would cause his or her death but death was a reasonably foreseeable consequence of the action; or it is not clear from the evidence whether the deceased intended to cause his or her death.
    

4. The Royal Australian and New Zealand College of Psychiatrists should review and, where appropriate, update its Guidelines for the Management of Deliberate Self Harm in Young People (2000).

Developments since the 2014 report

The Children’s Rights Report 2014 highlighted how Aboriginal and Torres Strait Islander children and young people are disproportionately affected by intentional self-harm and suicidal behaviour. 

Data provided by the Australian Bureau of Statistics in 2014 revealed that Aboriginal and Torres Strait Islander children and young people accounted for 28.1% of all the recorded deaths in children and young people under 18 years of age due to intentional self-harm.

The recommendations in the 2014 report highlighted the need for further research into the multiple interrelated risk factors and intervention strategies for Aboriginal and Torres Strait Islander children and young people.

Since 2015, The National Children's Commissioner has acted as a member of the National Advisory Committee for the Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP).

This project was established to evaluate suicide prevention programs operating in Aboriginal and Torres Strait Islander communities and to develop an evidence base for best practice in Aboriginal and Torres Strait Islander suicide prevention. ATSISPEP provided a final report to the Minister for Indigenous Affairs in September 2016, which details promising practices, recommendations for improvements to existing services and programs, and research and evaluation priorities. This report is available at the ATSISPEP website. 

In December 2016, Orygen, The National Centre of Excellence in Youth Mental Health released the 'Raising the bar for youth suicide prevention' report, calling for a reinvigorated suicide prevention response that specifically responds to the needs and experiences of young people.

The National Children's Commissioner has sought to raise awareness of this issue at national level by presenting at the 2015 and 2016 National Suicide Prevention Conference and continues to work closely with the Australian and New Zealand Child Death Review and Prevention group to promote better data collection. 

National Help and Counselling Services

If you are feeling distressed or would like to talk to someone, please contact:

Lifeline – 24 hour crisis support and suicide prevention

• Telephone: 13 11 14
• Website: www.lifeline.org.au

Kids Helpline – counselling service for children and young people aged between 5 and 25 years

• Telephone: 1800 55 1800
• Website: www.kidshelp.com.au

Headspace – counselling and referral service for young people aged 12 to 25 years

• Telephone: 1800 650 890
• Website: www.headspace.org.au
• Online chat: www.eheadspace.org.au

ReachOut.com – online youth mental health service

• Website: http://au.reachout.com

References 

(1) Australian Bureau of Statistics, 3303.0 – Causes of Death, Australia, 2014 (2016), Table 1.3, Line 40. At http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02014?OpenDocument (viewed 6 May 2016).

(2) Kids Helpline, Kids Helpline Insights 2014: National Statistical Overview (2015), Table 12, 50. At https://kidshelpline.com.au/upload/22973.pdf (viewed 6 May 2016).

(3) Australian Bureau of Statistics, 3303.0 – Causes of Death, Australia, 2014 (2016), Table 12.4, Lines 32 and 105. At http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3303.02014?OpenDocument (viewed 6 May 2016).

(4) Australian Human Rights Commission, Children's Rights Report 2014 (2014) 124. At http://www.humanrights.gov.au/our-work/childrens-rights/publications/childrens-rights-report-2014 (viewed 6 May 2016).

(5) Australian Human Rights Commission, Children's Rights Report 2014 (2014) 61-62. At http://www.humanrights.gov.au/our-work/childrens-rights/publications/childrens-rights-report-2014 (viewed 6 May 2016).