Khalid Karim, Consultant Child and Adolescent Psychiatrist and Sarah Baines, Specialist Nurse for Autism Spectrum Disorder at Leicestershire NHS Partnership Trust explore deliberate self-harm in autistic children and young people. They identify some of the stressors that may lead autistic children to engage in these behaviours, and highlight the risk factors and potential methods of identifying them.

Nationally and globally there has been considerable concern regarding the apparent increase in the number of young people under the age of 18 who self-harm. This is in comparison to rates of suicide in the UK which have which have remained fairly stable. For autistic children and young people there are concerns from parents, carers and professionals that self-harm is an even greater problem, but the extent is unclear due to limited research. Significantly however there are reports that suicidal ideation and suicide attempts are 28 times more common in autistic children than in non-autistic children.

Self-harm or self-injurious behaviour

Even the terminology applied to autistic children can sometimes be confusing, with self-harm and self-injury being used interchangeably and no consistency in the definition within literature. According to NHS Choices :

“self-harm is when somebody intentionally damages or injures their body. It is usually a way of coping with or expressing overwhelming emotional distress”.

This could however also be used to describe self-injury.

Although it is well documented that autistic children, especially those with a learning disability, can self-injure by, for example biting, hitting or scratching themselves, this is often different from self-harm. It tends to be seen in response to a physical stimuli such as pain or as a way of communicating a particular need often in the here and now while self-harm tends to have a longer term emotional basis.

The term self-harm is often used to describe young people who engage in diverse behaviour such as overdosing, cutting or burning, attempted hanging or other high risk activities which may result in injury or death. This behaviour may be to hurt themselves or to end their lives.

Identifying the stressors

Whichever term is used, the main principle to assessing and working with autistic young people is the recognition that although the self-harm in itself may be traumatic and stressful,  fundamentally it is a way of conveying the individuals distress at some factor or factors within their lives. Identification of these stressors is essential to reduce or prevent these actions.

While the risk of self-harm and suicidal ideation is greater in autistic children, the risk factors can be quite variable. These may include:

• underlying mental health problems (anxiety or depression)
• significant behavioural problems
• bullying
• increasing age
• male gender
• previous history of self-harm
• substance misuse
• social isolation and rejection
• poor problem solving
• impulsivity.

One of the most important factors to consider is whether the child has an underlying mental health issue as we know these occur so commonly in autistic children (Simonoff, E et al., 2008). If this is not identified and managed the chance of repeated self–harm is much greater, particularly for depressive illnesses.

While bullying can be an ongoing problem which can go unrecognised due to a number of factors including difficulties of seeking help, any unresolved stressor may be a risk and most often it is a combination of factors. Added to this is the difficulty many children can have in expressing their emotions - they instead express their frustration through these injurious behaviours.

Some self-harming has an impulsive quality so the presence of attention deficit hyperactivity disorder should be explored as it occurs so commonly (Simonoff, E et al., 2008). Although there has been little research on the issue, anecdotal evidence suggests that children who are considered higher functioning may be at higher risk of self-injury as they have more awareness of their isolation and perceived differences from their peers.

Supporting children and young people

When working with a child or adolescent it is useful when thinking about why the self-harm has occurred to consider not only the stress factors but also why did it occur at this time?

Sometimes it may be useful to divide the risk factors into different groups. Reasons for self-harm can be in one or more groups but it can help to clarify the situation:

• predisposing - the risk factors which underlie the problem especially mental health problems
• precipitating factors - the actual event which triggered the self-harm
• perpetuating factors - why the child may be continuing to self-harm

While the precipitating factor may be the most obvious it is equally or more important to find out why the young person was vulnerable at this time, in other words the predisposing factors for the behaviour.

If the self-harm is being repeated then again we need to look for unresolved problems. It is also important to examine parents/carers responses to the self-harm - some children may get sensory stimulation from their responses, e.g. raised voices and hugs.

Obviously prevention of self-harm would be the ideal situation and common to caring for autistic children is the need to identify the different stresses affecting the individual at any one time. This article has aimed to explore the terms self-injurious behaviour and self-harm, identify some of the stressors that may lead autistic people to engage in these behaviours and highlight the risk factors and potential methods of identifying these. Multiple interventions and the involvement of specialist mental health professionals may be required to address these harmful behaviours.