AMA submission to the Inquiry into intentional self-harm and suicidal behavior in children
The Australian Medication Association (AMA) long supported calls for the establishment of the National Children’s Commissioner in Australia and now welcomes the opportunity to make a brief submission on the current inquiry into suicide and self-harm among children and young people, specifically those aged under 18 years. On many fronts Australian children and young people are relatively healthy and deemed to be doing well. Unfortunately intentional self-harm and suicide is a growing concern. The matter warrants significant attention and the AMA welcomes the National Children’s Commissioners focus on this area.
Hospital statistics for 2011-12 indicate that there were over 10,000 hospital admissions of people aged 15-24 years involving intentional self-harmi. This number is significant on its own but is particularly poignant in the context of estimates that only 10 per cent of individuals who self-harm present to hospital for treatmentii. Intentional self-harm is the leading cause of death among those aged 15-24 yearsiii. We also know that children aged younger than 15 years are engaging in self-harm and suicide but, for a range of reasons, exact estimates in the numbers are difficult to ascertain.
The AMA is the peak professional organisation representing medical practitioners in Australia. Medical practitioners have a significant role in identifying and treating mental health problems among all sections of the community. This includes mental health concerns in children and young people. The role of medical practitioners extends from early identification and prevention related activities through outreach and primary care to acute emergency treatment for children and young people who have engaged in life threatening acts of self-harm as well as those who require increased levels of mental health care. Medical practitioners are also involved in caring for those people (including friends and family members) who care for those children and young people who engage in self-harm, as well as those bereaved by suicide. It is worth noting that while the scope of the current inquiry is on children and young people, aged under 18 years, much of the relevant data and the provision of care and services aimed at ‘young people’ includes people aged up to 24 years, and therefore the recommendations made by the AMA are relevant to those aged under 18 years (as well as those aged from 18 through to 24 years).
The term ‘self-harm’ refers to a range of behaviors that involve deliberate physical injury to the body. In some cases self-harm is a maladaptive coping strategy that allows children and young people to express their emotional pain. In many cases self-harm is not intended to be fatal. While this idea may appear to be counter intuitive, non-suicidal self-injury (NSSI) is increasingly recognized as being distinct phenomena by clinicians. NSSI may not appear to pose immediate risk to health and wellbeing, but unfortunately it has been linked to more serious cases of self-harm and suicide.
Some young people engage in self-harm which is clearly associated with a level of distress and suicidal intent. In some instances, injuries may indicate the level of intent, but there are other instances, such as overdose and single vehicle accidents where intent may be less clear. As noted above, many young people who engage in self-harm do not present for medical treatment. When they do, it may be due to more severe and life threatening injuries. In emergency department settings, the assessment and management of both the physical trauma and underlying psychosocial issues are a common scenario.
Unfortunately, the reality is that self-harm can result in death. Youth suicide is a tragedy that affects not only the individual but also family, peers and the larger community and is often experienced as a personal failure by those who were in contact with the young person. iv While not everyone who has a mental illness attempts suicide, and not all of those who commit suicide have an established mental illness, it is clear that mental illness, self-harm, suicidal thoughts, attempts and completed suicides are all related. v
It is important that all children and young people who engage in self-harm are assessed by a medical practitioner in an appropriate setting within a reasonable time frame. Children and young people may face real and perceived barriers that prevent or delay their access to appropriate medical care. This is a problematic situation as general practitioners are highly trained and well placed to provide support to young people who are experiencing psychological distress, self-harm and suicidal thoughts. The AMA believes that more should be done to encourage young people to seek advice from their general practitioners. The AMA also believes that young people should be encouraged to have an ongoing medical relationship with a general practitioner, acknowledging that continuous, comprehensive care may improve the likelihood of identifying young people who are expiring high levels of psychological distress.
In addition to the recommendations about improving access to medical care for children and young people who self-harm, the AMA would also like to make comments in relation to the general points of interest noted in the associated background paper.
There must be continued research into intentional self-harm and suicide among children and young people in Australia. This research should incorporate continued focus on the identification risk and protective factors (including considerations of combinations of these factors that might pose significantly increased or reduced risk). Research should also incorporate some focus on groups of children and young people who are recognized to be at increased risk of self-harm and suicide, including (but not limited to) Aboriginal and Torres Strait Islander children and young people, children and young people in immigration detention, unemployed young people, sexually diverse children and young people, children and young people living in rural and remote settings, children and young people experiencing family breakdown and children and young people with a history of mental illness (essentially all children and young people experiencing high levels of psychological distress).
Australian and international research should inform appropriate policy responses to this important issue, including national awareness and education campaigns. Children and young people should be engaged during the development of these campaigns to ensure the messaging is appropriately targeted.
Efforts should also be made to support the various professionals who regularly interact with children and young people, and who might be able to identify early warning signs relating to self-harming behaviors and suicidal ideation.
Increasing health literacy among children and young people is an important goal. Health literacy and health education should include a specific focus on mental health and help seeking behaviours, so that children and young people not only know when to seek help, but how to go about accessing primary care services as well as emergency services in some instances.
There has been an increased financial commitment to the mental health of young people in recent years, specifically via the establishment of 65 Headspace services around the country that provide support for mild to moderate mental health problems for people aged 12 – 25 years. This investment is welcome, but should also extend to services providing acute mental health care for children and young people.
The AMA supports, in principle, the proposal to establish a national child death and injury database that includes a national reporting function. There are a number of benefits that extend beyond more accurate reporting of self-harm and suicide among children and young people. This information will help identify emerging risks to the health and wellbeing of children and young people in Australia.
The AMA welcomes reference to the impact of digital technology. While information and support may be provided via the internet, it is also important to recognise that excessive use and access to certain types of digital content may in fact be harmful to children and young people. The AMA has specific concerns about websites, social networks and other online communities that promote self-harm and suicidal activities. While it is difficult to prevent children and young people from accessing this content, the AMA believes it is an area worth continued investigation and monitoring.
As noted above, the AMA supports the National Children’s Commission’s current inquiry into self-harm and suicide among children and young people and appreciates the opportunity to make comments on a number of issues raised in the background paper.
i Australian Institute of Health and Welfare, Australian hospital statistics 2011-12, National tables for external causes of injury or poisoning (part 1), Catalogue Number HSE 134 (2013), tables 3 and 4.