Deliberate self-harm in adolescents in Oxford, 1985-1995

An exploration of family dynamics in adults who self-harm

OBJECTIVES

The aim of the present study was to explore how adults who self-harm experience family relationships.

METHODS

A phenomenological design was employed to examine the dynamic relationship between self-harm and family systems. Semi-structured interviews were conducted with six female adults who attend a community mental health service and engage in self-harm. Transcripts were analysed using Interpretative Phenomenological Analysis (IPA).

RESULTS

Four superordinate themes emerged from the data and two subordinate themes emerged within each superordinate theme: family interactive patterns (subordinate themes: enmeshed patterns and culture of 'getting on with it'), searching for meaning (subordinate themes: expressing emotional turmoil and engrained worthlessness), relating to others (subordinate themes: guilt and feeling misunderstood) and journey towards life without self-harm (subordinate themes: acceptance and family support).

CONCLUSIONS

Findings emphasise the role of family systems in understanding self-harm in adults. The study highlights the need for family-based interventions for family members who support adults that self-harm.

Prevalence of Depression and Predictors of Discharge to a Psychiatric Hospital in Young People with Hospital-Treated Deliberate Self-Poisoning at an Australian Sentinel Unit

OBJECTIVE

Hospital treated deliberate self-poisoning is common in young people. Internationally, estimates of rates of depression in this population are very wide (14.6% to 88%). The aims of this study were to determine the prevalence of depression and the independent predictors of referral for psychiatric hospitalisation in young people (aged 16 to 25 years) following an index episode of hospital treated deliberate self-poisoning.

METHOD

A retrospective cohort study design (n = 1410), with data drawn from a population-based clinical case register. Unadjusted and adjusted estimates of predictors of referral for psychiatric admission (after-care) used logistic regression models.

RESULTS

Prevalence of any depression diagnosis was 35.5% (n = 500); and 25.4% (n = 358) were referred for a psychiatric admission. The adjusted estimates for predictors of psychiatric inpatient referral were: high suicidal level (OR 118.21: CI 95% 63.23-220.99), low/moderate suicidal level (14.27: 9.38-21.72), any depression (2.88: 1.97-4.22), any psychosis (4.06; 1.15-14.36), older age (1.12: 1.04-1.21), and number of support people (0.88: 0.78-0.98).

CONCLUSION

Depression was diagnosed in more than a third and was an independent predictor of psychiatric inpatient referral, so service providers need to account for this level of need in the provision of assessment and after-care services. Evidence-based guidelines for psychiatric inpatient after-care for deliberate self-poisoning and/or depression in young people are limited. Our explanatory model included suicidal level, depression, psychosis, older age, and available support persons, suggesting that the treating clinicians were making these discharge decisions for admission in keeping with those limited guidelines, although the balance of benefits and harms of psychiatric hospitalisation are not established. Future research examining patient experiences, effectiveness of psychiatric hospitalisation, and alternatives to hospitalisation is warranted.

Paracetamol: unconventional uses of a well-known drug

OBJECTIVES

To describe and map what is known about unconventional uses of paracetamol through a scoping review of published literature by adopting adopted a PRISMA systematic approach methodology.

KEY FINDINGS

Four themes for unconventional uses of paracetamol emerged: (a) use of paracetamol in sleep (a-1) positive effect of paracetamol on sleep (n = 9) or (a-2) neutral or negative effect of paracetamol on sleep (n = 9); (b) use of paracetamol in sport (n = 13); (c) mixing paracetamol with drinks, waterpipe and illicit drugs (n = 5); and (d) miscellaneous uses (n = 4). Forty records were reviewed and charted. Available literature supports concern around the potential of harmful or non-medical use of paracetamol, especially among patients with a history of substance use, parents of young children or athletes.

SUMMARY

Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever. It is considered remarkably safe if used within instructions. However, there is growing evidence that paracetamol, is sometimes used outside approved indications or abused (i.e. used for non-medical reasons). This review highlights the need for enhanced pharmacovigilance and surveillance of non-medical paracetamol use and raising general public awareness of its potential dangers especially in higher than recommended doses.

Predicting self-harm within six months after initial presentation to youth mental health services: A machine learning study

BACKGROUND

A priority for health services is to reduce self-harm in young people. Predicting self-harm is challenging due to their rarity and complexity, however this does not preclude the utility of prediction models to improve decision-making regarding a service response in terms of more detailed assessments and/or intervention. The aim of this study was to predict self-harm within six-months after initial presentation.

METHOD

The study included 1962 young people (12-30 years) presenting to youth mental health services in Australia. Six machine learning algorithms were trained and tested with ten repeats of ten-fold cross-validation. The net benefit of these models were evaluated using decision curve analysis.

RESULTS

Out of 1962 young people, 320 (16%) engaged in self-harm in the six months after first assessment and 1642 (84%) did not. The top 25% of young people as ranked by mean predicted probability accounted for 51.6% - 56.2% of all who engaged in self-harm. By the top 50%, this increased to 82.1%-84.4%. Models demonstrated fair overall prediction (AUROCs; 0.744-0.755) and calibration which indicates that predicted probabilities were close to the true probabilities (brier scores; 0.185-0.196). The net benefit of these models were positive and superior to the 'treat everyone' strategy. The strongest predictors were (in ranked order); a history of self-harm, age, social and occupational functioning, sex, bipolar disorder, psychosis-like experiences, treatment with antipsychotics, and a history of suicide ideation.

CONCLUSION

Prediction models for self-harm may have utility to identify a large sub population who would benefit from further assessment and targeted (low intensity) interventions. Such models could enhance health service approaches to identify and reduce self-harm, a considerable source of distress, morbidity, ongoing health care utilisation and mortality.

A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial

BACKGROUND

Self-harm in adolescents is common and repetition rates high. There is limited evidence of the effectiveness of interventions to reduce self-harm.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of family therapy (FT) compared with treatment as usual (TAU).

DESIGN

A pragmatic, multicentre, individually randomised controlled trial of FT compared with TAU. Participants and therapists were aware of treatment allocation; researchers were blind to allocation.

SETTING

Child and Adolescent Mental Health Services (CAMHS) across three English regions.

PARTICIPANTS

Young people aged 11-17 years who had self-harmed at least twice presenting to CAMHS following self-harm.

INTERVENTIONS

Eight hundred and thirty-two participants were randomised to manualised FT delivered by trained and supervised family therapists (n = 415) or to usual care offered by local CAMHS following self-harm (n = 417).

MAIN OUTCOME MEASURES

Rates of repetition of self-harm leading to hospital attendance 18 months after randomisation.

RESULTS

Out of 832 young people, 212 (26.6%) experienced a primary outcome event: 118 out of 415 (28.4%) randomised to FT and 103 out of 417 (24.7%) randomised to TAU. There was no evidence of a statistically significant difference in repetition rates between groups (the hazard ratio for FT compared with TAU was 1.14, 95% confidence interval 0.87 to 1.49; p = 0.3349). FT was not found to be cost-effective when compared with TAU in the base case and most sensitivity analyses. FT was dominated (less effective and more expensive) in the complete case. However, when young people's and caregivers' quality-adjusted life-year gains were combined, FT incurred higher costs and resulted in better health outcomes than TAU within the National Institute for Health and Care Excellence cost-effectiveness range. Significant interactions with treatment, indicating moderation, were detected for the unemotional subscale on the young person-reported Inventory of Callous-Unemotional Traits (p = 0.0104) and the affective involvement subscale on the caregiver-reported McMaster Family Assessment Device (p = 0.0338). Caregivers and young people in the FT arm reported a range of significantly better outcomes on the Strengths and Difficulties Questionnaire. Self-reported suicidal ideation was significantly lower in the FT arm at 12 months but the same in both groups at 18 months. No significant unexpected adverse events or side effects were reported, with similar rates of expected adverse events across trial arms.

CONCLUSIONS

For adolescents referred to CAMHS after self-harm, who have self-harmed at least once before, FT confers no benefits over TAU in reducing self-harm repetition rates. There is some evidence to support the effectiveness of FT in reducing self-harm when caregivers reported poor family functioning. When the young person themselves reported difficulty expressing emotion, FT did not seem as effective as TAU. There was no evidence that FT is cost-effective when only the health benefits to participants were considered but there was a suggestion that FT may be cost-effective if health benefits to caregivers are taken into account. FT had a significant, positive impact on general emotional and behavioural problems at 12 and 18 months.

LIMITATIONS

There was significant loss to follow-up for secondary outcomes and health economic analyses; the primary outcome misses those who do not attend hospital following self-harm; and the numbers receiving formal FT in the TAU arm were higher than expected.

FUTURE WORK

Evaluation of interventions targeted at subgroups of those who self-harm, longer-term follow-up and methods for evaluating health benefits for family groups rather than for individuals.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN59793150.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 12. See the NIHR Journals Library website for further project information.

Population attributable risk of factors associated with the repetition of self-harm behaviour in young people presenting to clinical services: a systematic review and meta-analysis

The repetition of hospital-treated self-harm by young people is common. However, little work has summarised the modifiable factors associated with this. A thorough understanding of those factors most strongly associated with repetition could guide the development of relevant clinical interventions. We systematically reviewed four databases (EMBASE, Medline, PubMed and PsycINFO) until 15 April 2016 to identify all observational studies of factors for the repetition of self-harm or suicide reattempts (together referred to as 'self-harm behaviour') in young people. We quantified the magnitude of association with odds ratios (OR) and 95% confidence intervals (CIs) and calculated the population attributable risk (PAR) and population preventable fraction (PPF) for modifiable factors to provide an indication of the potential impact in reducing subsequent self-harm behaviour in this population. Seventeen studies were included comprising 10,726 participants. Borderline personality disorder (OR 3.47, 95% CI 1.84-6.53; PAR 42.4%), any personality disorder (OR 2.54, 95% CI 1.71-3.78; PAR 16.3%), and any mood disorder (OR 2.16, 95% CI 1.09-4.29; PAR 42.2%) are important modifiable risk factors. Severity of hopelessness (OR 2.95, 95% CI 1.74-5.01), suicidal ideation (OR 2.01, 95% CI 1.43-2.81), and previous sexual abuse (OR 1.52, 95% CI 1.02-2.28; PAR 12.8%) are also associated with repetition of self-harm. We recommend that clinical services should focus on identifying key modifiable risk factors at the individual patient level, whilst the reduction of exposure to child and adolescent sexual abuse would also be a useful goal for public health interventions.

Deliberate Self-harm among Young People Begins to Increase at the Very Early Age: a Nationwide Study

BACKGROUND

Suicide in young people is one of most common cause of death; and deliberate self-harm (DSH) is important indicator of suicide. It is currently unclear how old the rate begins to increase or when it reaches to the same level with adults. The purpose of this study was to find beginning age of DSH and compare their characteristics with adults.

METHODS

This study retrospectively reviewed 5 years of nationwide prospective registry named Emergency Department-based Injury In-depth Surveillance (EDIIS) registry composed of all injured patients who were admitted to twenty tertiary university hospital emergency departments. Injured patients aged 29 years or younger from January 1, 2011 to December 31, 2015 were included. Incidence rate of DSH in all age was described. Patients were stratified by age: early teenage (11-15 years), late teenage (16-19 years), and early adulthood (20-29 years). Data of early teenage group were compared to those of other groups for examining their characteristics.

RESULTS

Among 588,549 injury patients, 8,400 patients reported DSH. The rate began to rise at age 11 and reach at age 16 which was equivalent to that of age 20 to 29. Early teenage had significantly higher excess mortality ratio based injury severity score (EMR-ISS) and had almost same level without significant difference in operation incidence or mortality compared to late teenage and early adulthood.

CONCLUSION

DSH rate began to rise at age 11, reaching adulthood level at age 16 in Korea.

Online discussion forums for young people who self-harm: user views

Aims and method

To explore what young people who self-harm think about online self-harm discussion forums. SharpTalk was set up to facilitate shared learning between health professionals and young people who self-harm. We extracted themes and illustrative statements from the online discussion and asked participants to rate statements.

Results

Of 77 young people who participated in the forum, 47 completed the questionnaire. They said they learned more about mental health issues from online discussion forums than from information sites, found it easier to talk about self-harm to strangers than to family or friends, and preferred to talk online than face-to-face or on the telephone. They valued the anonymity the forums provided and reported feeling more able to disclose and less likely to be judged online than in ‘real life’.

Clinical implications

Mental health professionals should be aware of the value of anonymous online discussion forums for some young people who self-harm, so that they can talk about them and assess their use with their patients.

Explicit Motives, Antecedents, and Consequences of Direct Self-Injurious Behaviors

BACKGROUND

Self-injurious behaviors in adolescence are a serious public health concern.

AIMS

The current study aims to expand our understanding of motives for direct self-injurious behaviors (D-SIB). We examined the explicit motives but also the actual antecedents and consequences of D-SIB over time.

METHOD

As part of the Saving and Empowering Young Lives in Europe (SEYLE) study, adolescents between the ages of 14 and 18 years from Israel completed self-report questionnaires at baseline, 3-month, and 12-month follow-ups.

RESULTS

Decreases in social support predicted later increases in D-SIB, an effect mediated by negative affect. Both peer and parental support also exerted quadratic effects on D-SIB. Thus, low as well as high support predicted subsequent D-SIB. In turn, D-SIB was followed by increased peer and parental support.

LIMITATIONS

Our methodology relies on self-reports, affected by social desirability and recall biases.

CONCLUSION

The findings support a causal path for the development of D-SIB: from interpersonal distress to emotional distress and then to D-SIB. They also point to interesting avenues regarding subgroupings of adolescents who self-injure depending on their motives. Finally, our results reveal that D-SIB, although of negative import, might paradoxically be effective in serving certain functions such as gaining support from parents and peers.

Socioeconomic position and self-harm among adolescents: a population-based cohort study in Stockholm, Sweden

BACKGROUND

Understanding the association between parental socioeconomic position and self-harm in adolescence is crucial due to its substantial magnitude and associated inequality. Most previous studies have been either of cross-sectional nature or based solely on self-reports or hospital treated self-harm. The aim of this study is to determine the association between parental socioeconomic position and self-harm among adolescents with a specific focus on gender and severity of self-harm.

METHODS

A total of 165,932 adolescents born 1988-1994 who lived in Stockholm at the age of 13 were followed in registers until they turned 18. Self-harm was defined as first time self-harm and severity of self-harm was defined as hospitalized or not. Socioeconomic position was defined by parental education and household income. Cox proportional hazards regression were used to estimate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Analyses showed an association between parental socioeconomic position and self-harm. Among adolescents with parents with primary and secondary education compared to tertiary parental education the HR were 1.10 (95% CI 0.97-1.24) and 1.16 (95% CI 1.08-1.25) respectively. Compared to the highest income category, adolescents from the lower income categories were 1.08 (95% CI 0.97-1.22) to 1.19 (95% CI 1.07-1.33) times more likely to self-harm. In gender-stratified analyses, an association was found only among girls. Further, restriction to severe cases eliminated the association.

CONCLUSIONS

This study suggested that low parental socioeconomic position is associated with self-harm in adolescence, predominantly among girls. The desertion of an association among severe cases may be explained by differences in suicidal intent and underlying psychiatric diagnosis. Efforts to prevent self-harm should consider children with low parental socioeconomic position as a potential target group.

Association Between Deliberate Self-harm and Violent Criminality

IMPORTANCE

Individuals who self-harm may have an increased risk of aggression toward others, but this association has been insufficiently investigated. More conclusive evidence may affect assessment, treatment interventions, and clinical guidelines.

OBJECTIVE

To investigate the association between nonfatal self-harm and violent crime.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort study, conducted from January 1, 1997, through December 31, 2013, studied all Swedish citizens born between 1982 and 1998 who were 15 years and older (N = 1 850 252). Individuals who emigrated from Sweden before the age of 15 years (n = 104 051) or immigrated to Sweden after the age of 13 years (ie, <2 years before the beginning of the follow-up; n = 22 009) were excluded. Data analysis was performed from April 21, 2016, to June 4, 2016.

EXPOSURES

Receipt of self-harm-associated clinical care.

MAIN OUTCOMES AND MEASURES

Conviction of a violent crime according to the Swedish penal code.

RESULTS

The study cohort consisted of 1 850 525 individuals (950 382 males and 900 143 females), and the mean (SD) follow-up time was 8.1 (4.7) years (range, 0-17.0 years; minimum age, 15 years; maximum age, 32 years). During a mean follow-up period of 8.1 years, 55 185 individuals (3.0%) received clinical care for self-harm. The crude hazard ratio was 4.9 (95% CI, 4.8-5.0) for violent crime conviction in exposed individuals compared with the unexposed group. Women who self-harm were at particularly high risk for expressing violent behaviors. After adjustment for relevant psychiatric comorbidities and socioeconomic status, an almost doubled hazard of violent offense remained (hazard ratio, 1.8; 95% CI, 1.8-1.9).

CONCLUSIONS AND RELEVANCE

Self-harm is associated with an increased risk of conviction for a violent offense in both sexes. The risk of violence, as well as the risk of suicide and self-harm, should be assessed among offending and self-harming individuals.

Impulsivity and self-harm in adolescence: a systematic review

Research supports an association between impulsivity and self-harm, yet inconsistencies in methodology across studies have complicated understanding of this relationship. This systematic review examines the association between impulsivity and self-harm in community-based adolescents aged 11-25 years and aims to integrate findings according to differing concepts and methods. Electronic searches of EMBASE, MEDLINE, PsychINFO, CINAHL, PubMed and The Cochrane Library, and manual searches of reference lists of relevant reviews identified 4496 articles published up to July 2015, of which 28 met inclusion criteria. Twenty-four of the studies reported an association between broadly specified impulsivity and self-harm. However, findings varied according to the conception and measurement of impulsivity and the precision with which self-harm behaviours were specified. Specifically, lifetime non-suicidal self-injury was most consistently associated with mood-based impulsivity-related traits. However, cognitive facets of impulsivity (relating to difficulties maintaining focus or acting without forethought) differentiated current self-harm from past self-harm. These facets also distinguished those with thoughts of self-harm (ideation) from those who acted on thoughts (enaction). The findings suggested that mood-based impulsivity is related to the initiation of self-harm, while cognitive facets of impulsivity are associated with the maintenance of self-harm. In addition, behavioural impulsivity is most relevant to self-harm under conditions of negative affect. Collectively, the findings indicate that distinct impulsivity facets confer unique risks across the life-course of self-harm. From a clinical perspective, the review suggests that interventions focusing on reducing rash reactivity to emotions or improving self-regulation and decision making may offer most benefit in supporting those who self-harm.

Adolescent Admissions to Emergency Departments for Self-Injurious Thoughts and Behaviors

The objective of the present study was to describe the incidence and the characteristics of Self-Injurious Thoughts and Behaviors (SITBs), among adolescents aged 11–18 admitted, over a two year period, to all the Emergency Departments of a Region of North-eastern Italy through a comprehensive analysis of medical records. A two-step search was performed in the regional ED electronic database. First, we identified the cases that had been clearly diagnosed as SITBs by an Emergency Department physician. Secondly, suspect cases were detected through a keyword search of the database, and the medical records of these cases were hand screened to identify SITBs. The mean annual incidence rate of SITBs was 90 per 100,000 adolescents aged 11–18 years. Events were more frequent in females. Drug poisoning was the most frequently adopted method (54%). In 42% of cases a diagnosis of SITB was not explicitly reported by the physician. In 65% of cases adolescents were discharged within hours of admission. Only 9% of patients started a psychiatric assessment and treatment program during hospital stay. This research confirms the high incidence of SITBs among adolescents and highlights the difficulty in their proper diagnosis and management. Such difficulty is confirmed by the fact that only a few patients, even among those with a clear diagnosis, were sent for psychiatric assessment. Correct identification and management of SITB patients needs to be improved, since SITBs are an important public health problem in adolescence and one of the main risk factors for suicide.

“I Am Not Well-Equipped”

Fifty teachers completed a survey to investigate knowledge, self-perceived knowledge, and attitudes regarding self-injury (SI). Teachers were aware of basic facts concerning SI; however, 78% underestimated prevalence, and only 20% felt knowledgeable. Attitudes were mixed, with 48% finding the idea of SI horrifying; however, 68% disagreeing that SI was “often manipulative.” Principal components analysis indicated that perceived knowledge emerged as a separate construct from attitude s toward SI. Years of teaching experience was related to self-perceived knowledge, but not to attitudes. In addition, 74% of teachers reported having a personal encounter with SI, and 62% felt that SI is increasing in the schools. Qualitative analysis of open-ended questions revealed a strong desire for further knowledge and training. Results indicate that teachers’ perceptions are not consistent with studies of SI in clinical settings but are consistent with recent research in community and school samples. The need for teacher education about SI is emphasized.

A Social Semiotic Interpretation of Suicidal Behaviour in Young People

This article presents a study of nurses’ and doctors’ perceptions of young people who engage in suicidal behaviour. A contemporary view of grounded theory is used to guide the collection and analysis of qualitative data from nurses and doctors working with young people in an accident and emergency department, paediatric medicine and child and adolescent mental health services (adolescent inpatient unit). The analysis of 45 semi-structured interviews generated the category: Processes of communication and associated meanings: Another voice, Complex messages and Seeing and using the social environment. A social semiotic framework is used to explore the way in which nurses and doctors perceive young people who engage in suicidal behaviour. The article concludes by considering the implications for policy and practice.

Trends in Self-Harm in Kuala Lumpur, 2005-2011

Acts of self-harm are not routinely tracked in Malaysia. The present study investigates the prevalence of self-harm in Kuala Lumpur, Malaysia, over a 7-year period. The aims were to: (a) assess the prevalence of self-harm; (b) examine any changes over a period of 7 years, and (c) identify correlates of methods of self-harm. Data were extracted from the hospital records of Kuala Lumpur Hospital to review trends in self-harm between 2005 and 2011. There were 918 episodes of self-harm across the 7-year period, with a significant peak in 2007-2009. The average rate of self-harm (7.7 per 100,000 population per year) was similar or lower than the rate of suicide (6-8 or 8-13 per 100,000) suggesting that genuine cases of self-harm are often attributed to other causes. Nevertheless, over-representation of young people, women and Indians suggest areas in which resources to prevent self-harm might usefully be targeted. Estimating rates of self-harm are fraught with problems and further research is needed to understand the economic and cultural barriers around seeking treatment for self-harm, reporting self-harm and classifying self-harm.

Non-Suicidal Self-Injury among Adolescents in Amman, Jordan

While previous research has demonstrated cross-national differences in non-suicidal self-injury (NSSI), most studies to date have taken place in North America. The present study investigated the prevalence and characteristics of NSSI in a sample of 952 Jordanian adolescents (49.8% female) between the ages of 11-19 years. Participants completed a screening measure to assess occurrence of NSSI and its characteristics. Results indicate an overall lifetime prevalence of 22.6% (n = 215), with significantly more males (26.98%, n = 129) than females (18.14%, n = 86) reporting having engaged in NSSI at least once in their lifetime. This study provides empirical evidence that adolescent engagement in NSSI occurs at similar prevalence levels in Jordan, relative to North American samples, whereas gender comparisons of prevalence and characteristics revealed several differences.

Suicidal tendency in a sample of adolescent outpatients with adjustment disorder: gender differences

BACKGROUND

Although Adjustment Disorder (AD) is a prevalent diagnosis in adolescent mental health services and linked to suicidal tendency in adolescence, little research exists examining prevalence and gender differences of suicidal symptoms among AD patients using standardized instruments.

AIMS

The present study aims to assess the presence of suicidal tendency in a clinical sample of Spanish adolescents with AD analyzing gender differences.

METHOD

Ninety-seven adolescents with AD were recruited at a public mental health center and included in the AD sample; they were administered the Inventario de Riesgo Suicida para Adolescentes (Suicide Risk Inventory for Adolescents-IRIS) and the Millon Adolescent Clinical Inventory (MACI). Ninety-nine community adolescents were recruited and administered the IRIS inventory. The community sample works as a contrast group.

RESULTS

Girls with AD show higher levels of suicidal symptoms than boys on both the IRIS Suicidal Ideation and Intention scale (t=8.15, p<.001) and the MACI Suicidal Tendency scale (t=6.6, p<.001). Girls with AD scored significantly higher than girls from the community contrast group sample in the IRIS Suicidal Ideation and Intention scale, but boys with AD presented no differences with regard to boys form the community contrast group sample. Compared with normative clinical samples of the MACI, no differences in the Suicidal Tendency scale scores were found between AD and normative girls, but AD boys showed significantly lower mean scores than normative boys. Suicidal symptoms were presented by 27% of girls and 18% of boys, although only 6% of the girls and none of the boys presented clear suicidal tendencies.

CONCLUSIONS

Considering suicidal tendencies in adolescents with Adjustment Disorder is important-especially in girls, who present high suicidal tendencies in relation both to boys and to community peers and the normative clinical population.

Adolescents with suicidal behaviour: attendance at A&E and six month follow-up

Objectives: To review the clinical presentation, and Accident and Emergency Department clinical response to 14-20 year olds in suicidal crisis in inner city Dublin and to carry out a six month follow up of these young people.

Method: A retrospective review of the case notes of all 14-20 year olds who had attended the Mater Hospital A&E department between June 2001 and May 2002 with suicidal behaviour or ideation was carried out in order to establish socio-demographic information, type of suicidal or self-harming behaviour, intervention in the A&E department, and discharge plan. Active outreach attempts were made to trace, contact and interview these young peoples at least six months after the initial presentation. Quantitative measures of psychological functioning at follow-up included the General Health Questionnaire, The Beck Depression Inventory and The Scale for Suicidal Ideation. A qualitative interview covered their recall of the reasons for their deliberate self harm, their view of their current psychological functioning and personal relationships, reported repetition of deliberate self harm, and their views of what type of services would be useful for young people with suicidal ideation or behaviour.

Results: A total of 89 young people aged 14-20 years (male: female ratio = 2:3) presented to the Mater A&E department between June 2001 and May 2002 with deliberate self-harm, deliberate self-poisoning and/or suicidal ideation, and accounted for 108 presentations. They showed high levels of psychosocial disadvantage. Almost half had a history of previous contact with mental health services, while the same proportion had a history of previous deliberate self-harm. Drug overdose using paracetamol was the most common method used. Psychiatric assessment was documented in 66% of cases, and documented follow up recommendations were made in 60% of cases. Two thirds of the 89 young people who formed the study population were traced. Half of those contacted agreed to be interviewed and half refused. The majority of those interviewed described themselves as functioning better psychologically than at the time of the index attendance at the A&E department The quantitative measures supported this. One third of those interviewed reported repeated deliberate self-harm since their index attendance, for which most did not seek medical intervention. Many of the young people had clear views about the importance of talking to someone when in crisis. They described a service, which was informal, accessible on a 24-hour basis, and staffed by people with experience of mental health, alcohol and drug related disorders.

Conclusions: This is a particularly vulnerable group of patients from a socio-demographic and mental health perspective. Their attendance at the A&E department provides a unique opportunity for an in-depth psychosocial assessment, which should be recorded in a systematic way to assist clinical audit, facilitate strategic mental health planning and may confer some therapeutic clinical benefit to at risk young people. An easily accessible, active DSH team specifically tailored for young people in the A&E department could provide assessment and short-term follow-up. This is the approach recommended by young people in suicidal crisis, whose views need to be heard.

Deliberate self-harm in young people: attendance at a paediatric emergency department

OBJECTIVES

Deliberate self-harm (DSH) is the strongest predictor of suicidal behaviour. This retrospective study reviewed all DSH presentations to our Paediatric Emergency Department between 2002-2006.

METHOD

Using database and medical records we profiled these presentations. Data was coded and statistically analysed.

RESULTS

There were 253 DSH attendances. Twenty-four percent were living in care, 15% were under 12 years and 14% presented more than once. Overdoses (61%) were more common than cutting (16%) and 56% had a psychiatric condition.

CONCLUSIONS

DSH presents an ongoing challenge to child and adolescent mental health services and those working in suicide prevention. Identifying the characteristics of these young people is essential to providing appropriate treatment for this high-risk group.

Sociocultural context of suicidal behaviour in the sundarban region of India

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their "intention to die," and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.

Parents of young people with self-harm or suicidal behaviour who seek help - a psychosocial profile

BACKGROUND

Deliberate Self-Harm (DSH) is a common problem among children and adolescents in clinical and community populations, and there is a considerable amount of literature investigating factors associated with DSH risk and the effects of DSH on the child. However, there is a dearth of research examining the impact of DSH on parents, and there are few support programmes targeted at this population. This cross-sectional study examines the profile of a sample of parents of young people with DSH who participated in a support programme (Supporting Parents and Carers of young people with self-harm: the SPACE programme), with the goal of investigating pre-test parental well-being, family communication, parental satisfaction, perceived parental social support, and child strengths and difficulties.

METHODS

Participants were 130 parents who attended the SPACE programme between 2009 and 2012, and who completed six questionnaires at baseline: the General Health Questionnaire-12, Strengths and Difficulties Questionnaire, Kansas Parenting Satisfaction Scale, General Functioning Scale of the McMaster Family Assessment Device, Multidimensional Scale of Perceived Social Support, and a demographic questionnaire.

RESULTS

The majority of parents met criteria for minor psychological distress (86%) and rated the quantity and severity of their children's difficulties as being in the abnormally high range (74%) at baseline. A majority of participants (61%) rated their perceived social support as being poor. Lower parental well-being was significantly correlated with poorer family communication, poorer parenting satisfaction, and a greater number of difficulties for the child. Perceived social support was not significantly correlated with parental well-being. Parents whose children were not attending school at baseline had significantly lower well-being scores than those whose children were. Parents whose children had received a formal diagnosis of a mental health disorder also had significantly lower well-being scores than those whose children had not.

CONCLUSIONS

Parents of young people with DSH behaviours face considerable emotional and practical challenges; they have low levels of well-being, parenting satisfaction, social support, and experience poor family communication. Given the importance of parental support for young people with DSH behaviours, consideration should be given to the need for individual or group support for such parents.

Deliberate self-harm in adolescents aged 12-18: a cross-sectional survey of 18,104 students

Little is known about accurate prevalence and associated factors of deliberate self-harm (DSH) among adolescents in Asian countries. In this study, the prevalence and associated factors of DSH among adolescents in Japan were examined. Data were derived from a cross-sectional survey using an anonymous self-report questionnaire and enrolling 8,620 adolescents aged 12-15 and 9,484 aged 15-18. DSH in the previous 12 months was reported by 3.3% (95% CI, 2.9-3.7) of junior and 4.3% (3.9%-4.7%) of senior high school respondents. The prevalence was more than four times as high among girls as among boys for both age groups. DSH was further strongly associated with having suicidal thoughts, having depression/anxiety symptoms, and having used recreational drugs. These associated factors were similar for both sexes and for both older and younger teenagers. A substantial minority of adolescents present with DSH, even among those aged 12-15. The prevalence of DSH in Japan was in the lower ranges of those reported for Western countries. The identified associated factors were not dissimilar from those reported in the West.

Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England

We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5,205 individuals (7,150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0 and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres. In females they averaged 302 per 100,000 (95 % CI 269-335) in 10-14 year-olds and 1,423 (95 % CI 1,346-1,501) in 15-18 year-olds, and were 67 (95 % CI 52-82) and 466 (95 % CI 422-510), respectively, in males. Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a year). Relationship problems were the predominant difficulties associated with self-harm. Specialist assessment occurred in 57 % of episodes. Self-harm in children and adolescents in England is common, especially in older adolescents, and paracetamol overdose is the predominant method. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.

Deliberate self-harm in children and adolescents: an 11-year case note study

OBJECTIVE

To retrospectively examine the case-notes of all children and adolescents admitted with deliberate self-harm (DSH) or suicidal ideation during the study period 1993-2003. The study aimed to identify underlying reasons why children and adolescents engage in DSH, and to identify common psychiatric, psychosocial and familial factors which may predispose or contribute to an individual's engagement in such behaviour.

METHOD

All children presenting to the hospital with DSH or suicidal ideation were identified and data collected from their case notes. A study specific questionnaire was designed to collect demographic details, details on clinical presentation, past attempts, comorbid psychiatry disorders, family history and family circumstances. Information was also recorded on hospital stay and discharge planning.

RESULTS

During the 11-year period, 231 children presented with suicidal ideation or behaviour. The mean age was 12.85 with an age range from 6-17 years, with a female:male ratio of 2.5:1. Overdose was the most common method (81.2%) and paracetamol most commonly the drug of choice. More than half of the group (55.7%) expressed a wish to die. More than half (51.8%) had expressed suicidal ideation in the past, 31% had made a previous attempt, and 11.7% had been previously admitted. Of the children 8% presented with suicidal behaviour more than once over the study period. There was a family history of completed suicide in 6.6%.

CONCLUSION

Deliberate self-harm in young people is a significant public health problem in Ireland. During the period of this study, rates have continued to increase. There is an urgent need for national bodies such as the National Suicide Review Group to extend their focus to include those under age 18 and for services to be developed that might reduce DSH behaviours. More research is needed in the area of childhood suicidal behaviour.

Attempted suicide in mental disorders in young adulthood

BACKGROUND

Nationwide general population study establishes the prevalence of suicide attempts in different mental disorders among young adults and their sociodemographic correlates. Current psychiatric symptoms are also examined.

METHODS

A random sample of 1,894 young Finnish adults aged 20-34 years were approached to participate in a questionnaire containing several screens for mental health interviews. All screen positives and random sample of screen negatives were invited to an SCID interview. Altogether 546 subjects participated in the interview. Diagnostic assessment and lifetime history of suicide attempts were based on all available systematically evaluated information from the questionnaire, the interview and/or case records.

RESULTS

The lifetime prevalence of suicide attempts was 5.6% in men and 6.9% in women. Both mental disorders and poor educational and occupational functioning were associated with lifetime suicide attempts. Lifetime history of suicide attempts was associated with current psychological distress, problems related to substance use and other psychiatric symptoms, even after taking current Axis I disorder into account. Suicide attempts were most common in persons with psychotic disorders (41%).

CONCLUSIONS

These results suggest that continued efforts are needed to outreach and treat effectively young adults with serious mental disorders. Young people who make a suicide attempt should be offered treatment. It seems also important to prevent psychosocial alienation of young people by providing them with adequate education and work possibilities.

Group therapy for adolescents with repeated self harm: randomised controlled trial with economic evaluation

OBJECTIVE

To examine the effectiveness and cost-effectiveness of group therapy for self harm in young people.

DESIGN

Two arm, single (assessor) blinded parallel randomised allocation trial of a group therapy intervention in addition to routine care, compared with routine care alone. Randomisation was by minimisation controlling for baseline frequency of self harm, presence of conduct disorder, depressive disorder, and severity of psychosocial stress.

PARTICIPANTS

Adolescents aged 12-17 years with at least two past episodes of self harm within the previous 12 months. Exclusion criteria were: not speaking English, low weight anorexia nervosa, acute psychosis, substantial learning difficulties (defined by need for specialist school), current containment in secure care. Setting Eight child and adolescent mental health services in the northwest UK.

INTERVENTIONS

Manual based developmental group therapy programme specifically designed for adolescents who harm themselves, with an acute phase over six weekly sessions followed by a booster phase of weekly groups as long as needed. Details of routine care were gathered from participating centres.

MAIN OUTCOME MEASURES

Primary outcome was frequency of subsequent repeated episodes of self harm. Secondary outcomes were severity of subsequent self harm, mood disorder, suicidal ideation, and global functioning. Total costs of health, social care, education, and criminal justice sector services, plus family related costs and productivity losses, were recorded.

RESULTS

183 adolescents were allocated to each arm (total n = 366). Loss to follow-up was low (<4%). On all outcomes the trial cohort as a whole showed significant improvement from baseline to follow-up. On the primary outcome of frequency of self harm, proportional odds ratio of group therapy versus routine care adjusting for relevant baseline variables was 0.99 (95% confidence interval 0.68 to 1.44, P = 0.95) at 6 months and 0.88 (0.59 to 1.33, P = 0.52) at 1 year. For severity of subsequent self harm the equivalent odds ratios were 0.81 (0.54 to 1.20, P = 0.29) at 6 months and 0.94 (0.63 to 1.40, P = 0.75) at 1 year. Total 1 year costs were higher in the group therapy arm (£21,781) than for routine care (£15,372) but the difference was not significant (95% CI -1416 to 10782, P = 0.132).

CONCLUSIONS

The addition of this targeted group therapy programme did not improve self harm outcomes for adolescents who repeatedly self harmed, nor was there evidence of cost effectiveness. The outcomes to end point for the cohort as a whole were better than current clinical expectations. Trial registration ISRCTN 20496110.

Coping with depression and vulnerability to mania: A factor analytic study of the Nolen-Hoeksema (1991) Response Styles Questionnaire

OBJECTIVES

To assess the factor structure of the Nolen-Hoeksema (1991) Response Styles Questionnaire (RSQ), and to investigate the relationship between coping with depression and other measures of affective symptomatology in a student sample.

DESIGN

A factor analytic study of the RSQ followed by an investigation of the relationship between RSQ scale scores and measures of affective symptomatology.

METHOD

Five hundred twenty-eight undergraduate students completed a battery of questionnaires comprising the RSQ, Beck Depression Inventory, Hypomania Personality Questionnaire, Positive and Negative Affect Scale and the Dysfunctional Attitudes Scale. Factor analysis of the RSQ was performed and correlational and regression analyses were conducted on the data from the other four questionnaire measures.

RESULTS

Factor analysis revealed a meaningful 3-factor solution which measured coping styles characterized by (i) rumination; (ii) pleasant distraction and problemsolving; and (iii) risk-taking. Rumination and risk-taking were independently associated with both depression and hypomania scores, and hypomania was associated with both depression and dysfunctional attitudes. Additional relationships between coping and the other measures are also reported.

CONCLUSIONS

The results support the validity of the coping styles concept and suggest their natural separation into three distinct strategies. Abnormal coping is discussed as a potential contributing factor to affective symptoms, including symptoms of bipolar disorder.

Adolescents’ Willingness to Access School-Based Support for Nonsuicidal Self-Injury

Nonsuicidal self-injury (NSSI) is a prevalent behaviour among youth. School is an opportune setting for intervention with this population, but it is unknown how many youth who engage in NSSI would be willing to access school-based support. The current study surveyed 7,126 middle and high school students. Those that indicated that they engaged in NSSI ( n = 654; 168 boys, 486 girls) responded to follow-up questions regarding the behaviour and willingness to participate in a school-based support program for NSSI. Self-injurers who responded that they would be willing to access help at school ( n = 88; 13.5% of the sample) and a matched group of those who would not be willing were compared on a number of variables. Willingness to access school-based support did not differ by gender or ethnicity but differed between middle and high school students. On indices of NSSI and worries about safety, the adolescents willing to access support reported that they used more methods of injury as well as increased worries about safety in their neighbourhood and sexual harassment.

Epidemiological trends in attempted suicide in adolescents and young adults between 1996 and 2004

BACKGROUND

Notwithstanding the epidemiological studies indicating an increased risk of attempted suicide among adolescents and young adults, there is a scarcity of international studies that examine long-term epidemiological trends in rates and characteristics of this vulnerable group.

AIMS

This article describes the results of a 9-year monitoring study of suicide attempts in adolescents and young adults referred to the Accident and Emergency Department of the Gent University Hospital (Belgium).

METHODS

Between January 1996 and December 2004, trends, sociodemographic, and methodrelated characteristics of suicide attempts were assessed by a psychiatrist on data sheets.

RESULTS

Attempted suicide rates declined from 1996 to 2001 and then rose until 2004, but did not exceed previous rates. During the 9 years of monitoring, there was a preponderance of female suicide attempters, except for 1997. Rates of attempts and of fatal suicide were negatively correlated. Significantly more males than females deliberately injured themselves. Younger attempters, especially females, significantly more often poisoned themselves with analgesics. In nearly one in five attempts, alcohol was used in combination with other methods, and alcohol intake was more commonly observed in older suicide attempters. Nearly half of the adolescents were identified as repeaters.

CONCLUSIONS

The results of this study warrant further monitoring of trends and characteristics of young suicide attempters.

A pilot study evaluating a support programme for parents of young people with suicidal behaviour

BACKGROUND

Deliberate self harm (DSH) is a major public health concern and has increased among young people in Ireland. While DSH is undoubtedly the result of interacting factors, studies have identified an association between DSH and family dysfunction as well as the protective role of positive family relationships. Following a focus group meeting held to identify the needs of parents and carers of young people with DSH, a support programme (SPACE) was developed. The aims of the current study are to evaluate the effectiveness of the SPACE programme in decreasing parental psychological distress, reducing parental report of young peoples' difficulties, increasing parental satisfaction and increasing parents' ratings of their own defined challenges and goals.

METHODS

Participants were recruited from a Mental Health Service within a paediatric hospital, Community Child and Adolescent Mental Health Teams and family support services. All services were located within the greater Dublin area in Ireland. Forty-six parents of children who had engaged in or expressed thoughts of self harm attended the programme and participated in the evaluation study. The programme ran once a week over an 8-week period and included topics such as information on self harm in young people, parenting adolescents, communication and parental self-care. Seventy percent (N = 32) of the original sample at Time 1 completed measures at Time 2 (directly following the programme) and 37% (N = 17) of the original sample at Time 1 completed them at Time 3 (6 months following the programme). A repeated measures design was used to identify changes in parental wellbeing after attendance at the programme as well as changes in parental reports of their children's difficulties.

RESULTS

Participants had lower levels of psychological distress, increased parental satisfaction, lower ratings of their own defined challenges and higher ratings of their goals directly after the programme. These changes were maintained at 6-month follow up in the 37% of participants who could be followed up. Furthermore the young people who had engaged in or expressed thoughts of self harm had lower levels of difficulties, as reported by their parents, following the programme.

CONCLUSION

These findings suggest that the SPACE programme is a promising development in supporting the parents of young people with suicidal behaviour. The programme may also reduce parental reports of their children's difficulties. Further evaluation using a randomized controlled trial is indicated.

Psychological subtyping finds pathological, impulsive, and 'normal' groups among adolescents who self-harm

BACKGROUND

Research to date suggests that as many as 12-15% of young people engage in self-harm behaviour; however, the current understanding of the psychological basis of adolescent self-harm is limited. The objective was to determine whether adolescents who self-harm are a psychologically homogenous group. It was hypothesised that psychological subtypes would exist and these groups would report different rates of self-harm.

METHOD

Nine hundred and forty-four school students aged 11 to 19 and 166 first-year psychology students aged 21 or younger completed a self-report questionnaire. Participants were aged 11 to 21 (mean = 15.4, SD = 2.1). Sixty-two percent of the sample were female (n = 692). Students were allocated to psychologically distinct groups. Rates of self-harm were compared for the psychological subtypes of self-harmers.

RESULTS

Two hundred and thirty-four participants reported lifetime self-harm (21.1%; 95% CI 19-23%) and 78 reported recent self-harm (7.0%; 95% CI 6.7-7.3%). The present study identified three psychologically quite distinct groups of adolescents within those who reported self-harm - a psychologically pathological group, a psychologically 'normal' group, and an impulsive group. The pathological group reported the highest rate of recent self-harm (50.9%); the psychologically 'normal' and impulsive groups reported similar rates of self-harm (28.7% and 24.6%, respectively).

CONCLUSIONS

Adolescents who self-harm are not a psychologically homogenous group. One pathological subtype of self-harmers appears to most closely reflect a number of the psychological and social factors previously associated with self-harm. However, a large proportion of the sample was allocated the psychologically 'normal' subtype. This finding highlights the importance of psychological screening of adolescents presenting for treatment for self-harm as subtypes of self-harmers may require disparate strategies for intervention. Further research is required in order to identify appropriate treatment strategies for each subtype.

Analysis of accident and emergency doctors' responses to treating people who self-harm

Self-harm is a prevalent phenomenon regularly faced by doctors and nurses working in accident and emergency (A&E) departments. We argue that the treatment decisions A&E doctors make are fundamental to decreasing the high risk of suicide among this group. In this article we present a qualitative study exploring how doctors working in A&E respond to treating people who self-harm. In total, five A&E doctors were interviewed and the data were analyzed using interpretative phenomenological analysis. Three main themes were extracted: treating the body, silencing the self, and mirroring cultural and societal responses to self-harm. Within these themes, we identified both facilitative and unhelpful aspects of the relationships between people who self-harm and A&E doctors. We consider the clinical implications of these findings within the context of A&E doctors having limited opportunities to address the relational nature of the care they offer to this group.

Clinical diagnoses, characteristics of risk behaviour, differences between suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injury

OBJECTIVE

Self-injury (SI), self-injurious behaviour (SIB), including suicidal or non-suicidal self-injury (SSI, NSSI) represent an increasing problem among teenagers amounting to a 6-17% prevalence rate in adolescence, yet little data exists on detailed characteristics and associated factors of SI reaching clinical severity. There is also a scarcity of data distinguishing between suicidal and non-suicidal subsamples of self-injuring patients, i.e. showing which predictors contribute to develop self-injurious behaviour with a previous suicidal history (SSI).

METHOD

Clinical diagnoses and characteristics of risk behaviour were examined in a crosssectional design in suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injurious behaviour. From the total pool of 708 new patients consecutively referred with various psychiatric problems in five regional child psychiatric centres in Western-Hungary over an 18-month period, 105 adolescent outpatients suffering from self-injurious behaviour participated in the study (28 males and 77 females aged from 14 to 18 years, mean age 15.97, SD 1.05). The Ottawa/Queen's self-injury questionnaire (OSI) was used to measure the characteristics of risk behaviour, while the comorbid clinical diagnoses were confirmed by the M.I.N.I. Plus International Neuropsychiatric Interview. Descriptive statistics presented the frequencies of the characteristics of SI, bilateral comparisons were used to reveal relevant items to differentiate between sex, duration of practice and SSI versus NSSI and logistic regression was performed to identify significant predictors of suicidal subtype of self-injuring practice.

RESULTS

A total of 60% of the clinical SI population experienced a present or past episode of major depression. The motivation of patients to resist impulses and to discontinue malpractice was low. Cutting and scratching was the most common self-injuring methods. Two-thirds of the sample practised the impulsive type of SI, while 30% practised premeditated SI having an incubation time from 30 min to days and weeks before carrying out SI. Although duration of SI did not distinguish the sample in important aspects, girls and boys differed in several aspects of SI practice. SSI adolescents differed from their NSSI peers in a number of important characteristics including the frequency of actions, injured areas, methods, specific stresses and motivations. SSI adolescents were more likely to favour cutting of the lower leg and drug overdose as modes of SI. SSI adolescents were more likely to report addictive features than their peers with no suicidal motivation. From the aspect of self-injurious practice, logistic regression analysis found only two significant predictors for the combined pathology.

Rates of non-suicidal self-injury in high school students across five years

It is believed that the rate of non-suicidal self-injury (NSSI) among high school students is increasing. However, no known research has examined the rates of NSSI among non-clinical, high school samples of adolescents across several years. The current study utilized archival data from five academic years [2001 to 2005 (N = 1393)] to address this limitation by examining the lifetime prevalence rates of NSSI in urban high school students within the Midwestern United States. Results indicate a significant difference in rates across years by gender. Females showed a significant increase in their rates of NSSI compared to males, who showed a significant decline, during the last 3 years of the study. Implications of these findings for school personnel and directions for future research discussed.

Non-suicidal self-injury and eating pathology in high school students

Although past research has explored self-injurious behaviors and disordered eating among adults in clinical settings, little research has been conducted examining nonsuicidal self-injury (NSSI) and eating pathology in community samples of adolescents. Four hundred and 40 students were screened for the presence of NSSI; a prevalence rate of 13.9% was found. Those who indicated that they engaged in NSSI (n = 59) and a comparison group of non-self-injurers (n = 57) completed the Eating Disorders Inventory. Results indicate that students who engage in NSSI display significantly more eating pathology than their non-NSSI peers, including poor interoceptive awareness; difficulties with impulse regulation; an increased sense of ineffectiveness, distrust, and social insecurity; and increased bulimic tendencies and body dissatisfaction. Relationships were found between increased lifetime frequency of NSSI behaviors and poor impulse control and deficits in affective regulation. In addition, adolescents who had stopped self-injuring reported comparable rates of eating pathology as did adolescents who continued to self-injure. The theoretical connection between NSSI and eating pathology are discussed with reference to enhancing knowledge regarding the characteristics of NSSI.

Adolescent alcohol involvement and suicide attempts: toward the development of a conceptual framework

The present article provides a conceptual framework of the relation between alcohol involvement (A) and suicide attempts (S). This framework can be broadly construed to reflect two dimensions: directionality (direction of causality; A-->S, S-->A, or a spurious relation) and temporality (distinguishing between proximal and distal effects of both behaviors). We review and evaluate the evidence on the association between A and S among adolescents using this conceptual framework as a guide. The extant data suggest that this relation is complex and not fully understood. Further, it seems unlikely that a single approach will be found to determine direction of causality, and the specification and validation of hypothesized mechanisms will involve a variety of different types of evidence. Suggestions for additional research using informative designs are discussed.

Deliberate self-harm in children and adolescents: a qualitative study exploring the needs of parents and carers

Deliberate Self-harm (DSH) is a serious public health problem and is becoming more prevalent among young people in Ireland. Research tends to focus on the DSH patient. However, parental involvement is recognized as an important factor in their child's prognosis. This study aimed to describe parents' and carers' experiences of self-harm in their child in order to identify their support needs. A focus group methodology was used to generate qualitative data. Representative participants whose children had engaged in suicidal behaviour were recruited from the Paediatric Emergency, Child and Adolescent Mental Health Teams and Family Support Services. Twenty-five participants attended the focus group meeting. A transcript-based conceptual analysis was conducted to identify and explore emerging themes. Participants expressed the need for support; information about suicidal behaviour in young people; skills for parenting an adolescent; and advice on managing further incidents. Parents described significant difficulties in family communication, in parent-child relationships, and in the area of discipline following self-harm. These findings support current research that identifies the need for service development and information for parents/carers of young people who self-harm.

Self-poisoning by drugs and chemicals: variations in demographics, associated factors and final outcomes

OBJECTIVE

Drug overdose exposures were compared with chemical poisoning in terms of demographics, associated factors and final outcomes.

METHOD

Deliberate self-poisoning (DSP) cases admitted to Penang General Hospital during the years 2000-2004 were studied. Chi-square, independent t-test and binary logistic were used whenever applicable.

RESULTS

Indian patients were more likely to use household products, whereas Malay and Chinese patients were more likely to take drug overdoses (P=.001). Drug overdose victims experienced more socioeconomic problems (P=.05) and were more likely to be admitted to the intensive care unit (P=.052). Chemical poisoning patients presented earlier (P=.011), were hospitalized for shorter time (P=.001) and had a higher rate of mortality (P=.01).

CONCLUSION

The present study has identified a unique ethnic variation in the choice of suicide attempts from toxic substances. DSP associated with drug overdose showed significant morbidity, but increased mortality was seen in chemical poisoning.

Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study

BACKGROUND

Deliberate self-harm among young people is an important focus of policy and practice internationally. Nonetheless, there is little reliable comparative international information on its extent or characteristics. We have conducted a seven-country comparative community study of deliberate self-harm among young people.

METHOD

Over 30,000 mainly 15- and 16-year-olds completed anonymous questionnaires at school in Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway. Study criteria were developed to identify episodes of self-harm; the prevalence of self-harm acts and thoughts, methods used, repetition, reasons given, premeditation, setting for the act, associations with alcohol and drugs, hospitalisation, and whether other people knew, were examined.

RESULTS

Self-harm was more than twice as common among females as males and, in four of the seven countries, at least one in ten females had harmed herself in the previous year. Additional young people had thought of harming themselves without doing so. More males and females in all countries except Hungary cut themselves than used any other method, most acts took place at home, and alcohol and illegal drugs were not usually involved. The most common reasons given were 'to get relief from a terrible state of mind' followed by 'to die', although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime.

CONCLUSIONS

Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally.

Pathways from adolescent deliberate self-poisoning to early adult outcomes: a six-year follow-up

BACKGROUND

Prospective studies show that the adult outcomes of adolescents who deliberately harm themselves are marked by high rates of adversity and psychiatric disorders. The goal of this study was to identify pathways linking childhood risk factors to early adult outcomes of suicidal adolescents.

METHODS

A clinical sample of 158 adolescents who deliberately poisoned themselves was followed up six years later. Eighty per cent of the cohort (n = 126) were interviewed in early adulthood using a battery of standardised measures of psychopathology and social functioning.

RESULTS

Multivariate mediation path analysis identified four pathways linking child and adolescent risk factors to adverse outcomes in early adulthood. Family dysfunction, conduct disorder and hopelessness contributed to the risk of high adversity in early adulthood indirectly through its effect on other risk domains, including dropping out of school and adopting adult roles at a younger age. Hopelessness not only predicted dropping out of school but also independently contributed to the risk of chronic major depressive disorder in early adulthood. Child sexual abuse independently predicted high adversity and chronic major depression over and above the influence of hopelessness. Juvenile onset major depression independently predicted chronic major depression in early adulthood. A substantial proportion of the effects of child sexual abuse and hopelessness on the risk of deliberate self-harm in early adulthood was mediated by high adversity and the duration of major depression. However, chronic major depression was the only risk factor independently associated with deliberate self-harm in adulthood once correlation with adversity was taken into account.

CONCLUSIONS

Chronic major depressive disorder is central to deliberate self-harm repetition. However, adult outcomes of suicidal adolescents are also dominated by the accumulating effects and consequences of other childhood risk factors, including child sexual abuse and adolescent hopelessness.

A survey of school nursing provision in the UK

AIM

This paper is a report of a study to map school nursing provision across the health and education sectors in Wales to identify the number, age, qualifications, terms of employment, location, functions and access to continuing professional development and clinical supervision of school nurses.

BACKGROUND

School nurses are important in promoting the health of school-aged children. Increased demands have arisen from changes in patterns of health, illness and lifestyles.

METHODS

An interview survey was conducted with a purposive sample of school nursing/health visiting managers from 13 healthcare sector providers, senior personnel officers from 22 Local Education Authorities and 45 head teachers/school nurses from independent schools. Data were collected between March and June 2004 and the overall response rate exceeded 80%.

RESULTS

A total of 249 school nurses were identified: 90% employed by the healthcare sector and 10% by the education sector. An ageing, under-developed and under-resourced service was identified. Disparity in practice within and across the sectors was evident, resulting from lack of policy direction regarding the scope and content of school nursing services. Workforce size, age and educational profile pose challenges for service delivery.

CONCLUSION

Investment in recruitment and education is required if school nurses are to meet increasing demands and fulfil their public health role. The low percentage of school nurses aged under 30 years may reflect lack of a career pathway and understanding of school nursing. The findings enable national and international comparisons in terms of numbers, size of caseload, age, qualifications, terms of employment and activities and functions.

Risk factors associated with suicide attempts and other self-injury among Hong Kong adolescents

This study examined 1,361 Chinese adolescents who reported self-injurious behaviors. Groups A and B both acknowledged deliberate self-injury, but only Group A had made a suicide attempt. Group C reported accidental self-injury. Deliberate self-injurers (Groups A and B) were more frequently girls, older, and with more suicidal ideation. Group A had more psychopathology, environmental and suicide-related risk factors than group B and C. Group C had higher depressive symptoms than noninjured controls. The study clarifies differences among self-injurious behavior groups based on expressed deliberate self-injury and self-reported suicide attempt. These three groups appear to present a continuum of risk.

The national suicide prevention strategy for England: the reality of a national strategy for the nursing profession

Suicide is recognized as a global phenomenon and many countries now have national suicide prevention strategies. International guidance on suicide prevention and accepted epidemiological and treatment-based research underpins healthcare policy relating to suicide reduction. There has been an established comprehensive strategy in England since 2002. However, the rate of suicide continues to be a concern and nurses hold a key role in the implementation of national, regional and local policy into practice. The aim of this paper is to consider the current implications of the national suicide prevention strategy in England for nursing. This discussion paper draws upon both empirical evidence-based literature, governmental guidance and policy-related documentation. The national suicide prevention strategy for England currently continues to have a multifaceted impact on the nursing profession. This ranges from clinical practice issues such as risk assessment through to broader public health responsibilities. If nurses and allied health professionals are to be effective in their role within suicide prevention, they will need to be supported in building awareness of the wider context of the national policy. In particular, this will mean working effectively and collaboratively with the voluntary sector, service users and other non-medical agencies.

The virtual cutting edge: the internet and adolescent self-injury

The 2 studies reported here use observational data from message boards to investigate how adolescents solicit and share information related to self-injurious behavior. Study 1 examines the prevalence and nature of these message boards, their users, and most commonly discussed topics. Study 2 was intended to explore the correlations between content areas raised for discussion. Both studies were intended to shed light on the role of message boards in spreading information about self-injurious practices and influencing help-seeking behavior. More than 400 self-injury message boards were identified. Most are populated by females who describe themselves as between 12 and 20 years of age. Findings show that online interactions clearly provide essential social support for otherwise isolated adolescents, but they may also normalize and encourage self-injurious behavior and add potentially lethal behaviors to the repertoire of established adolescent self-injurers and those exploring identity options.

Self-injurious behaviors in a college population

OBJECTIVE

The goal was to assess the prevalence, forms, demographic and mental health correlates of self-injurious behaviors in a representative college sample.

METHODS

A random sample of undergraduate and graduate students at 2 northeastern US universities were invited to participate in an Internet-based survey in the spring of 2005. Thirty-seven percent of the 8300 invited participants responded.

RESULTS

The lifetime prevalence rate of having > or =1 self-injurious behavior incident was 17.0%. Seventy-five percent of those students engaged in self-injurious behaviors more than once. Thirty-six percent reported that no one knew about their self-injurious behaviors and only 3.29% indicated that a physician knew. Compared with non-self-injurers, those with repeat self-injurious behavior incidents were more likely to be female, bisexual or questioning their sexual orientation. They were less likely to be Asian/Asian American and >24 years of age. When controlling for demographic characteristics, those with repeat self-injurious behavior incidents were more likely to report a history of emotional abuse or sexual abuse, ever having considered or attempted suicide, elevated levels of psychological distress, and > or =1 characteristic of an eating disorder. A dose-response gradient was evident in each of these areas when single-incident self-injurious behaviors were compared with repeat-incident self-injurious behaviors.

CONCLUSIONS

A substantial number of college students reported self-injurious behaviors in their lifetimes. Many of the behaviors occurred among individuals who had never been in therapy for any reason and who only rarely disclosed their self-injurious behaviors to anyone. Single self-injurious behavior incidents were correlated with a history of abuse and comorbid adverse health conditions but less strongly than were repeat self-injurious behavior incidents. The reticence of these clients to seek help or advice renders it critical that medical and mental health providers find effective strategies for detecting and addressing self-injurious behaviors.