Deliberate self-harm in adolescents: comparison between those who receive help following self-harm and those who do not

Factors associated with informal and formal help-seeking among Asian adolescents with nonsuicidal self-injury

Although nonsuicidal self-injury (NSSI) is prevalent among adolescents and is associated with an increased risk of adverse outcomes, many adolescents with NSSI do not seek help. However, there is a lack of research on the factors that may increase the likelihood of help-seeking, especially within Asia. To address this gap, the present study examined whether certain factors were associated with informal and formal help-seeking - specifically gender, severity of NSSI, functions of NSSI and authoritative parenting. 121 adolescents (Mage = 16.2 years, 71.1% female) were recruited from specialist outpatient clinics and inpatient psychiatric wards from a public hospital in Singapore. One caregiver per adolescent was also recruited. Data from self-report questionnaires were analysed using logistics regression analyses. The results suggest that the severity of NSSI increases the likelihood of informal help-seeking, while adolescents who have parents with more authoritative parenting style are less likely to seek informal help. Gender and functions of NSSI were not found to be associated with help-seeking. The findings from this study can guide professionals in their efforts to encourage help-seeking within Asian populations, as well as inform prevention and treatment programs for Asian adolescents with NSSI.

Self-harm by single- and multi-agent medication poisoning in a retrospective analysis of a Poison Control Center database from January 2018 to December 2022

PURPOSE

Medication poisoning is the most common method of self-harm. Longitudinal studies incorporating pre- and post-COVID-19 pandemic data are required to describe the phenomenon and to evaluate the long-term impact on mental health.

METHODS

Calls to the Poison Control Center of Policlinico Umberto I Hospital - Sapienza University of Rome, Italy, were analyzed retrospectively for characteristics and clinical presentation of cases of interest from January 2018 to December 2022.

RESULTS

A total of 756 cases of self-harm by medication poisonings were recorded in the study period. A reduction in rate of cases in 2020 was followed by a return to pre-pandemic levels by 2021. When separately analyzing single- and multi-agent cases, occurrence of cases involving just one medication increased since early 2021, with a peak in 2022 (7.8% of total calls, 95% CI 6.2-9.5, from 4.9%, 95% CI 4.1-5.8 in 2018). This increase in the rate of cases, mostly of none or mild severity, was driven by youth aged 12-21, in which the relative proportion of single- versus multi-agent cases showed an increasing trend since 2020 (from 42.6% in 2018 to 78.6% in 2022). Acetaminophen was the medication most frequently involved and benzodiazepines the largest class. A psychiatric background was increasingly seen in 2022, especially in age group 12-21.

CONCLUSION

Single-agent medication self-harm may be an increasingly prevailing phenomenon. Young adolescents with a psychiatric background might be most vulnerable to this behavior in the COVID-19 pandemic aftermath. Healthcare professionals should expect favorable clinical outcome and improve both counseling and psychotherapy supervision in individuals at risk.

Predictors of self-harm and emergency department attendance for self-harm in deprived communities

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18-24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18-24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services.

Impact of Parental Mental Health and Help-Seeking on Adolescents' Suicidal Ideations and Help-Seeking Behaviors

This study aimed to evaluate the impact of parental mental health on adolescent offspring. Data regarding 6512 families from the 2010-2021 Korean National Health and Nutrition Examination Survey were analyzed; among them, 428 were placed in the suicidal ideation (SI) group and 421 were placed in the matched control (MC) group. This number was selected for the use of the propensity score matching method. The findings highlighted significant associations between parental mental health and adolescent suicidal ideation, with mothers in the SI group having higher odds of Diagnosed Depression (OR 2.109, 1.023-4.350 95% CI), Depressive Mood (OR 2.155, 1.224-3.793 95% CI), and Suicidal Ideation (OR 2.532, 1.322-4.851 95% CI) compared to the MC group. Regarding the fathers, paternal Suicidal Ideation (OR 4.295, 1.747-10.599 95% CI) was the only significant factor for adolescent suicidal ideation. In contrast, maternal depressive symptoms and help-seeking behavior significantly impacted adolescent help-seeking; Maternal Depressive Mood increased with adolescent Help-Seeking (OR 4.486, 1.312-15.340 95% CI) while Maternal Suicidal Ideation reduced the probability of Help-Seeking in the SI group (OR 0.15, 0.031-0.721, 95% CI). Chronic and severe depressive symptoms in mothers could make adolescents less likely to seek help for their suicidal ideations. Therefore, clinicians working with adolescents should prioritize a family-oriented approach.

Self-harm in immigration detention: political, not (just) medical

Self-harm within immigration detention centres has been a widely documented phenomenon, occurring at far higher rates than the wider community. Evidence suggests that factors such as the conditions of detention and uncertainty about refugee status are among the most prominent precipitators of self-harm. While important in explaining self-harm, this is not the entire story. In this paper, we argue for a more overtly political interpretation of detainee self-harm as resistance and assess the ethical implications of this view, drawing on interviews with detainees from Australia's offshore system. Self-harm by detainees is not only a medical 'condition' arising in response to oppression but a form of political action to lessen or contest it. We first establish how self-harm could be conceptualised as resistance. We then discuss its political purpose, noting it serves at least three functions: intrinsic, instrumental and disruptive or coercive. Viewing detainee self-harm as political resistance is a supplement to (rather than a substitute for) a medical approach. However, conceptualising self-harm this way has several advantages, namely, moving away from the idea that such behaviour is 'maladaptive', recognising detainees as political agents, combatting government claims of 'manipulation' and 'blackmail' and clarifying the duties of healthcare workers who work in detention.

Twelve-month service use, suicidality and mental health problems of European adolescents after a school-based screening for current suicidality

Suicide is one of the leading causes of death in adolescents and help-seeking behaviour for suicidal behaviour is low. School-based screenings can identify adolescents at risk for suicidal behaviour and might have the potential to facilitate service use and reduce suicidal behaviour. The aim of this study was to assess associations of a two-stage school-based screening with service use and suicidality in adolescents (aged 15 ± 0.9 years) from 11 European countries after one year. Students participating in the 'Saving and Empowering Young Lives in Europe' (SEYLE) study completed a self-report questionnaire including items on suicidal behaviour. Those screening positive for current suicidality (first screening stage) were invited to an interview with a mental health professional (second stage) who referred them for treatment, if necessary. At 12-month follow-up, students completed the same self-report questionnaire including questions on service use within the past year. Of the N = 12,395 SEYLE participants, 516 (4.2%) screened positive for current suicidality and were invited to the interview. Of these, 362 completed the 12-month follow-up with 136 (37.6%) self-selecting to attend the interview (screening completers). The majority of both screening completers (81.9%) and non-completers (91.6%) had not received professional treatment within one year, with completers being slightly more likely to receive it (χ2(1) = 8.948, V = 0.157, p ≤ 0.01). Screening completion was associated with higher service use (OR 2.695, se 1.017, p ≤ 0.01) and lower suicidality at follow-up (OR 0.505, se 0.114, p ≤ 0.01) after controlling for potential confounders. This school-based screening offered limited evidence for the improvement of service use for suicidality. Similar future programmes might improve interview attendance rate and address adolescents' barriers to care.

Pandemic-related emergency psychiatric presentations for self-harm of children and adolescents in 10 countries (PREP-kids): a retrospective international cohort study

To examine the differences in hospital emergency psychiatric presentations for self-harm of children and adolescents during the covid-19 lockdown in March and April 2020 compared with the same period in 2019. Retrospective cohort study. We used electronic patient records from 23 hospital emergency departments in ten countries grouped into 14 areas. We examined data on 2073 acute hospital presentations by 1795 unique children and adolescents through age 18. We examined the total number of emergency psychiatric hospital presentations and the proportion of children and adolescents presenting with severe self-harm as our two main outcome measures. In addition, we examined sociodemographic and clinical characteristics and clinical management variables for those presenting with self-harm. To compare the number of hospital presentations between 2020 and 2019 a negative binomial model was used. For other variables, individual participant data (IPD) meta-analyses were carried out. Emergency psychiatric hospital presentations decreased from 1239 in 2019 to 834 in 2020, incident rate ratio 0.67, 95% CI 0.62-0.73; p < 0.001. The proportion of children and adolescents presenting with self-harm increased from 50% in 2019 to 57% in 2020, odds ratio 1.33, 1.07-1.64; p = 0.009 but there was no difference in the proportion presenting with severe self-harm. Within the subpopulation presenting with self-harm the proportion of children and adolescents presenting with emotional disorders increased from 58 to 66%, odds ratio 1.58, 1.06-2.36; p = 0.025. The proportion of children and adolescents admitted to an observation ward also decreased from 13 to 9% in 2020, odds ratio 0.52, 0.28-0.96; p = 0.036. Service planners should consider that, during a lockdown, there are likely to be fewer emergency psychiatric presentations. Many children and adolescents with psychiatric emergencies might not receive any service. A focus on developing intensive community care services with outreach capabilities should be prioritised.

Social and life skills in adolescents who have self-harmed: analysis of survey responses from a national sample of adolescents in Norway

OBJECTIVE

Social and life skills (SLS) may be important in the prevention and treatment of self-harm, but few studies have described this relationship. We examined three components of SLS in adolescents who reported self-harm that was, according to themselves, diagnosed by a clinician.

DESIGN

Cross-sectional.

SETTING

National screening prior to military service.

PARTICIPANTS

176 284 residents of Norway born in 1999-2001 received a declaration of health. We included 171 486 individuals (84 153 (49%) women and 87 333 (51%) men) who were 17 (n=1 67 855) or 18 years of age (n=3631) when they completed the declaration.

OUTCOME MEASURE

The main outcome was clinically diagnosed self-harm, defined as self-harm that the adolescents themselves stated had been diagnosed by a clinician. Components of SLS were social interactions; coping strategies; and emotional regulation/aggression. The association between SLS and self-reported clinically diagnosed self-harm was assessed in hierarchical multiple regression models controlling for sex; school absence; and feelings of emotional pain.

RESULTS

Three percent (n=5507) of the adolescents reported clinically diagnosed self-harm. The three components of SLS together added little to the prediction of clinically diagnosed self-harm (∆R²=0.02). After controlling for school absence and emotional pain, emotional regulation/aggression was the only SLS-component that was independently associated with clinically diagnosed self-harm (OR 1.33, 95% CI 1.31 to 1.36). The young men who said they had been clinically diagnosed for self-harm scored slightly worse on social interactions (Hedge's g (g) = -0.13, p<0.001) and emotional regulation/aggression (g = -0.18, p<0.001) than the young women in this group.

CONCLUSION

Young women and young men who reported clinically diagnosed self-harm had more problems with emotional regulation/aggression than other adolescents, but did not have worse social interactions or coping strategies.

Help-seeking duration in adolescents with suicidal behavior and non-suicidal self-injury

Prompt access to appropriate professional care for adolescents with self-harm thoughts and respective behaviors (suicidal behavior and non-suicidal self-injury [NSSI]) is crucial as both are associated with an increased risk of suicide in later life. The present study aimed to describe the duration from initial onset of thoughts and incidents of self-harm until first clinical presentation in children and adolescents and to identify factors affecting help-seeking duration. Onset of self-harm thoughts and behaviors, time of first clinical presentation, and psychiatric and demographic variables were obtained from n = 672 adolescents (11-19 years) from the Germany-based AtR!Sk (Ambulanz für Risikoverhalten & Selbstschädigung) cohort-study at an outpatient clinic for risk-taking and self-harm behaviors. In 22% of overall cases, the first self-harm thoughts and behaviors occurred after contact to professional care was already established. Focusing on actual help-seeking delay only, it took between M = 0.99 years (after first suicide attempt) and M = 1.98 years (after first thoughts of NSSI) until participants sought professional help. Overall, help-seeking duration and help-seeking delay were longer for participants with more severe psychopathology (i.e., BPD, depressive symptoms, general symptom severity). The findings revealed a substantial delay of receiving appropriate professional care in adolescents with self-harm thoughts and behavior. The correlation between treatment latency and higher psychopathology may emphasize the need of prompt treatment. A better understanding of barriers and facilitators to professional help will contribute to enhance measures of tailored support for young patients in their help-seeking process.

Risk factors of suicidality among married adults: A cross-sectional survey in Rajshahi City, Bangladesh

Background

Suicide is a serious public health concern all over the world including Bangladesh. About 9% of the patients admitted with suicidal ideation (SI) or suicide attempt (SA) later complete suicide. To understand and prevent suicide, the study of SI and SA is necessary but research in this area is scanty in Bangladesh. Therefore, we studied suicidality (SI and SA) among married adults in Rajshahi City, Bangladesh.

Methods

This was a household cross-sectional study. A total of 708 married adults were selected for this study using a multi-stage random sampling. Suicidality was measured based on two factors: (i) suicidal ideation, and (ii) suicide attempt. Frequency distribution, Chi-square test and multiple binary logistic regression model were used in this study according to our objectives.

Results

The prevalence of suicidal ideation, suicide attempt, and suicidality was 5.8%, 3.4%, and 8.3% respectively among married adults. A multiple binary logistic regression model provided the following risk factors of suicidality: (i) joint family (AOR = 0.310, p<0.01), (ii) ≥26 years of age at the first marriage (AOR = 0.379, p<0.05), (iii) twice or more marriage (AOR = 0.214, p<0.01), (iv) conjugal life of ≥16 years (AOR = 0.410, p<0.05), (v) having no child (AOR = 6.343, p<0.01) and (vi) having 1–2 children (AOR = 6.190, p<0.01), (vii) medical comorbidity (AOR = 0.421, p<0.01), (viii) mental comorbidity (AOR = 0.253, p<0.01), (ix) stress-anxiety (AOR = 0.311, p<0.01), (x) family history of mental disorders (AOR = 0.059, p<0.01), (xi) family history of suicide/suicide attempt (AOR = 0.009, p<0.01), (xii) substance abuse (AOR = 0.065, p<0.01), (xiii) poor relationship with spouse (AOR = 0.209, p<0.01), and (xiv) poor relationship with other family members (AOR = 0.347, p<0.05).

Conclusion

The prevalence of suicidality is remarkable in Rajshahi city, Bangladesh. The government and non-government agencies can use the findings of this study to identify the vulnerable groups and undertake measures for preventing and reducing suicidality.

General practitioners' training and their attitudes towards young people who self-harm: A cross-sectional survey

AIM

Self-harm is common among adolescents and young adults and carries increased risk of suicide and other negative outcomes, yet only a small proportion will seek professional help. General practitioners (GPs) are a potentially valuable source of help as most young people visit their GP regularly for other reasons. The primary aim of this research was to explore GPs' empathy and attitudes towards young people who self-harm and how these are related to GP specialist training.

METHOD

GPs completed questionnaires regarding their training, levels of empathy, perceived knowledge and attitudes towards young people who self-harm. The cross-sectional design included a random sample of 178 GPs and 47 GPs-in-training in the Republic of Ireland. Bootstrapped mediation analysis using structural equation modelling (SEM) was applied to explore the pattern of relationships among GP-training, empathy, perceived knowledge of self-harm and attitudes towards youth who self-harm.

RESULTS

The SEM results revealed that the model had a very good fit to the data. Empathy was the strongest predictor of attitudes towards self-harm even if GPs had received youth mental health training and fully mediated the effect of youth mental health training on perceived knowledge of self-harm. Specialized training in self-harm was a stronger predictor of perceived knowledge than empathy but had no association with negative attitudes.

CONCLUSIONS

The findings emphasize positive outcomes associated with GP training and highlight potential differences in the effects associated with specific vs general training in youth mental health. These differences may be used to inform the design and implementation of continuing professional development.

Children and young people who die by suicide: childhood-related antecedents, gender differences and service contact

BACKGROUND

Worldwide suicide is commonest in young people and in many countries, including the UK, suicide rates in young people are rising.

AIMS

To investigate the stresses young people face before they take their lives, their contact with services that could be preventative and whether these differ in girls and boys.

METHOD

We identified a 3-year UK national consecutive case series of deaths by suicide in people aged 10-19, based on national mortality data. We extracted information on the antecedents of suicide from official investigations, primarily inquests.

RESULTS

Between 2014 and 2016, there were 595 suicides by young people, almost 200 per year; 71% were male (n = 425). Suicide rates increased from the mid-teens, most deaths occurred in those aged 17-19 (443, 74%). We obtained data about the antecedents of suicide for 544 (91%). A number of previous and recent stresses were reported including witnessing domestic violence, bullying, self-harm, bereavement (including by suicide) and academic pressures. These experiences were generally more common in girls than boys, whereas drug misuse (odds ratio (OR) = 0.54, 95% CI 0.35-0.83, P = 0.006) and workplace problems (OR 0.52, 95% CI 0.28-0.96, P = 0.04) were less common in girls. A total of 329 (60%) had been in contact with specialist children's services, and this was more common in girls (OR 1.86, 95% CI 1.19-2.94, P = 0.007).

CONCLUSIONS

There are several antecedents to suicide in young people, particularly girls, which are important in a multiagency approach to prevention incorporating education, social care, health services and the third sector. Some of these may also have contributed to the recent rise.

Community Based Support for People at Risk for Suicide and Those Who Care for them - Areas for Improvement

To systematically review the quality of evidence regarding the effectiveness of supports for people affected by suicide. EMBASE, MEDLINE, and PsychINFO were searched for evaluations of community-based supports for people affected by suicide. Outcomes included suicide-related behavior, depression, grief, quality of life, caring ability, and qualitative experiences. Fifteen studies evaluated 15 supports of various modalities. Study quality was generally poor; most studies examined bereaved individuals with mixed findings. Few reduced suicide-related behavior, half improved depression, and grief, while studies of caring ability, quality of life, or qualitative experiences reported positive effects. Supports associated with better outcomes connected peers with similar experiences, were provided over a period of months, and involved veteran rather than novice facilitators. Supports for people affected by suicide may be effective for improving suicide-related behavior, psychological adjustment, quality of life and caregiving, but require further evaluation.

Understanding the Needs of Young People Who Engage in Self-Harm: A Qualitative Investigation

Self-harm is common and associated with adverse outcomes. Research about the risk factors for self-harm has informed the field with regard to clinical interventions that should be delivered for young people who engage in self-harm. Missing is an in-depth understanding of what the triggers of an urge to self-harm might be, including in young people being treated with a clinical intervention. Therefore, there is little knowledge about what techniques young people find helpful to deal with urges to self-harm when they occur. This qualitative study engaged seven young people with lived experience of self-harm in semi-structured interviews about the immediate triggers of the urge to self-harm, and helpful strategies to manage this urge. Thematic analysis using a general inductive approach revealed distressing emotions and a sense of isolation as key themes, with other triggers associated with their induction. Highlighted was the wide range of situations and emotions that can be triggering, such that a further key theme was the idiosyncratic nature of the self-help strategies young people found helpful. Interventions that are developed to support young people who self-harm must address this complexity and findings highlight the need for young people to maintain some autonomy and control while being supported to connect with others for support. This research adds to the literature on self-help strategies to support young people in moments when they are experiencing distressing emotions, feel isolated, and have an urge to self-harm providing important insight to the prevention and intervention for self-harm among young people.

Understanding the Experience and Needs of School Counsellors When Working with Young People Who Engage in Self-Harm

Self-harm rates are increasing globally and demand for supporting, treating and managing young people who engage in self-harm often falls to schools. Yet the approach taken by schools varies. This study aimed to explore the experience of school staff managing self-harm, and to obtain their views on the use of guidelines in their work. Twenty-six pastoral care staff from New Zealand were interviewed. Interviews were analyzed and coded using thematic analysis. Three themes emerged: The burden of the role; discrepancies in expectations, training, and experience; and the need for guidelines to support their work. This research, therefore, demonstrated a need for guidelines to support school staff to provide support around decision making and response to self-harm in the school environment.

Resource Intensity for Children and Youth: The Development of an Algorithm to Identify High Service Users in Children's Mental Health

Children’s mental health care plays a vital role in many social, health care, and education systems, but there is evidence that appropriate targeting strategies are needed to allocate limited mental health care resources effectively. The aim of this study was to develop and validate a methodology for identifying children who require access to more intense facility-based or community resources. Ontario data based on the interRAI Child and Youth Mental Health instruments were analysed to identify predictors of service complexity in children’s mental health. The Resource Intensity for Children and Youth (RIChY) algorithm was a good predictor of service complexity in the derivation sample. The algorithm was validated with additional data from 61 agencies. The RIChY algorithm provides a psychometrically sound decision-support tool that may be used to inform the choices related to allocation of children’s mental health resources and prioritisation of clients needing community- and facility-based resources.

Patterns of self-harm methods over time and the association with methods used at repeat episodes of non-fatal self-harm and suicide: A systematic review

BACKGROUND

The risk of self-harm repetition and suicide may be influenced by self-harm method choice. However, there are mixed findings regarding whether there is a discernible pattern in self-harm methods over successive episodes of non-fatal self-harm, and if so, how these may be associated with self-harm repetition and/or suicide.

METHODS

A systematic review of five electronic databases was undertaken until 31 May 2018 to identify cohort studies on patterns of self-harm methods and their association with methods used either at repeat self-harm episodes and/or suicide.

RESULTS

15 studies were included reporting data on of 127,371 participants. Over an average follow-up period of 2.8 years, one-third (33.3%) switched methods between episodes of self-harm, most commonly from self-injury to self-poisoning. For suicide, almost one-half (42.1%) switched methods over an average follow-up period of 11.2 years.

LIMITATIONS

Studies were characterised by a moderate study quality. Studies tended to group all methods into self-injury and/or self-poisoning with little consideration as to the diverse range of self-harm methods included within these broad categories and the likely differences in potential lethality between these methods. Few investigated the role of alcohol and/or drug dependence and mental illness on self-harm method choice.

CONCLUSIONS

Given the frequency of method switching observed, and the lack of discernible patterns over time, all patients should be routinely assessed for risk and needs irrespective of the method used at the index episode of non-fatal self-harm.

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.

"They aren't all like that": Perceptions of clinical services, as told by self-harm online communities

Self-harm is a critical public health issue, with strikingly low rates of attendance to clinical services. By offering support, anonymity, and open discussions, online communities hold useful insights into the factors which influence help-seeking behavior. We explore the perceptions of clinical services in three self-harm online communities to understand which services are being used and why. Message threads from each community were extracted randomly until saturation, providing 513 messages across 60 threads. A thematic analysis was performed resulting in four key themes: access to appropriate services during an episode of self-harm, service preference, fears surrounding disclosure, and support.

Attitudes toward adolescent self-harm and its prevention: The views of those who self-harm and their peers

PROBLEM

Adolescent self-harm is a common phenomenon; however, little is known about young peoples' attitudes toward self-harm and what they believe can be done to prevent it. This study aimed to identify adolescents' attitudes about self-harm and their perspectives on preventing it.

METHODS

A cross-sectional anonymous survey was administered to 856 post-primary school students across 11 schools in Dublin, Ireland. Attitudes toward self-harm were captured through a five-item scale and views on prevention of self-harm were captured through an open-ended survey question. Responses from those who self-harmed and those who did not were compared to identify differences.

FINDINGS

Significant differences were identified between those who self-harmed and their peers. Those who self-harmed were less likely to believe that self-harm was carried out to get attention or was a result of loneliness or depression; they were more likely to believe that self-harm was impulsive. Findings demonstrated that a majority of young people believed that self-harm could be prevented and a number of preventative strategies were identified.

CONCLUSIONS

It is important that the views of adolescents are incorporated into the design and delivery of youth-friendly services and that there is a focus on increasing awareness of the youth-orientated services that currently exist.

Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care

Objectives To examine temporal trends in sex and age specific incidence of self harm in children and adolescents, clinical management patterns, and risk of cause specific mortality following an index self harm episode at a young age.Design Population based cohort study.Setting UK Clinical Practice Research Datalink-electronic health records from 647 general practices, with practice level deprivation measured ecologically using the index of multiple deprivation. Patients from eligible English practices were linked to hospital episode statistics (HES) and Office for National Statistics (ONS) mortality records.Participants For the descriptive analytical phases we examined data pertaining to 16 912 patients aged 10-19 who harmed themselves during 2001-14. For analysis of cause specific mortality following self harm, 8638 patients eligible for HES and ONS linkage were matched by age, sex, and general practice with up to 20 unaffected children and adolescents (n=170 274).Main outcome measures In the first phase, temporal trends in sex and age specific annual incidence were examined. In the second phase, clinical management was assessed according to the likelihood of referral to mental health services and psychotropic drug prescribing. In the third phase, relative risks of all cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning were estimated as hazard ratios derived from stratified Cox proportional hazards models for the self harm cohort versus the matched unaffected comparison cohort.Results The annual incidence of self harm was observed to increase in girls (37.4 per 10 000) compared with boys (12.3 per 10 000), and a sharp 68% increase occurred among girls aged 13-16, from 45.9 per 10 000 in 2011 to 77.0 per 10 000 in 2014. Referrals within 12 months of the index self harm episode were 23% less likely for young patients registered at the most socially deprived practices, even though incidences were considerably higher in these localities. Children and adolescents who harmed themselves were approximately nine times more likely to die unnaturally during follow-up, with especially noticeable increases in risks of suicide (deprivation adjusted hazard ratio 17.5, 95% confidence interval 7.6 to 40.5) and fatal acute alcohol or drug poisoning (34.3, 10.2 to 115.7).Conclusions Gaining a better understanding of the mechanisms responsible for the recent apparent increase in the incidence of self harm among early-mid teenage girls, and coordinated initiatives to tackle health inequalities in the provision of services to distressed children and adolescents, represent urgent priorities for multiple public agencies.

Repeated self-harm in young people: a review

OBJECTIVES

This paper provides a review of the rates of self-harm and repeated self-harm among young people. It describes some of the risk factors associated with these behaviours and summarises some of the barriers to delivering optimal treatment.

CONCLUSIONS

The review concludes that there is an urgent need for the delivery of respectful and evidence-based practice to all young people who present with self-harm. In addition, improved monitoring of self-harm presentations to hospitals across Australia is required in order that robust data are collected and the impact of practice change can be reliably assessed.

Concurrent adversities and deliberate self-harm among indigenous Sami and majority Norwegian adolescents: the Norwegian Arctic Adolescent Health Study

Background:

Few studies have investigated proximal relationships between deliberate self-harm (DSH) and concurrent adversities.

Objective:

We aimed to investigate these relationships in a community population of 4881 indigenous Sami and majority Norwegian adolescents, 15 to 16 years old, and related to ethnicity and gender.

Methods:

Youth with and without self-reports of DSH last year were compared on 12 concurrent adversities, on scales measuring family and peer functioning, and on sociodemographic conditions.

Results:

DSH last year was reported by 22.3% of the adolescents, and by more girls (28.8%) than boys (15.9%). All 12 concurrent adversities were related strongly to DSH last year. Deliberate self-harmers reported twice as many concurrent adversities as non-DSHs, and a large effect size (Cohen’s d = 0.80) indicated a strong multiple additive relationship, but among DSHs no ethnic or gender differences were found. Multivariately, among Sami youth sexual abuse [odds ratio (OR), 8.4] was strongly related to DSH, whereas among majority Norwegians sexual abuse (OR, 3.9) and violence (OR, 4.5) were identified as the strongest predictors. Similarly, among boys violence from adults (OR, 8.8) was associated most strongly with DSH, whereas among girls sexual abuse (OR, 4.3) was the most robust predictor. DSHs reported more conflicts with parents, less family support and involvement, and more peer problems than non-DSHs, and DHS girls had more difficulties in these relationships than DHS boys. Only small ethnic differences were found.

Conclusion:

Adolescent DSHs reported twice as many concurrent adversities as non-DSHs, sexual abuse and violence were strongly related to DSH. Ethnic and gender differences in risk factors were found. Clinicians should inquire about traumatic experiences such as sexual and physical abuses, and should have a family, peer, and gender perspective in their work.

Is there a difference between hospital-verified and self-reported self-harm? Implications for repetition

OBJECTIVE

Repeated intentional self-harm (SH) is associated with economic costs and increased risk of suicide. Estimates of repetition vary according to method of data capture and are limited by short periods of follow-up observation. Some sources use hospital records and others self-reported SH (SRSH). Our aim was to examine the relationship between SRSH and hospital-verified SH (HVSH) and later repetition of SH (predictive validity). We also aimed to examine whether rates of SH repetition differ between first-time presenters and non-first-time presenters using either definition of SH.

METHOD

We conducted a large prospective study tracking SH attempts through an Accident and Emergency (A&E) department within the United Kingdom. We took a representative sample of 774 patients (30% of total who reported SH) and followed them for 5.6 years on average. The index episode of SH was recorded at the time of referral to staff in A&E. Prior episodes of SH were determined from an electronic search of A&E patient database, and in addition, recollection of prior SH as reported by the patient to their clinician at the time of index presentation was recorded.

RESULTS

Across the whole sample 32.0% of patients repeated SH within 1 year, which rose to 54.1% at completion of follow-up. Repetition rates were considerably higher in patients with a prior SH history than those presenting with a first SH episode after 1 year (47.9% vs. 19.6%) and by the end of follow-up (73.8% vs. 39.4%) (P<.001). Of 411 with self-reported first presentations, 45.2% repeated over the study period. In terms of predictive validity, 65.2% of those with previous SRSH repeated vs. 73.8% with previous HVSH (P<.001). There was low agreement between SRSH and HVSH (Kappa=0.353, 95% confidence interval 0.287-0.419, low).

CONCLUSIONS

We found relatively poor agreement between hospital-defined and self-reported SH. A total of 62.8% of those who denied SH actually had a hospital-verified previous episode. Patients with recorded prior SH and those who recall previous SH have significantly higher rates of repetition, but the two samples imprecisely overlap and predictive validity is stronger for HVSH.

The treatment of suicidality in adolescents by psychosocial interventions for depression: A systematic literature review

OBJECTIVE

Given depression is a significant risk factor for suicidal behaviour, it is possible that interventions for depression may also reduce the risk of suicide in adolescents. The purpose of this literature review is to determine whether psychological interventions aimed to prevent and/or treat depression in adolescents can also reduce suicidality.

METHODS

We conducted a systematic review of psychological interventions aimed to prevent and/or treat depression in adolescents in which outcomes for suicidality were reported, using five databases: PsycINFO, Embase, Medline, CINAHL and Scopus. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

A total of 35 articles pertaining to 12 treatment trials, two selective prevention trials and two universal prevention trials met inclusion criteria. No studies were identified that used a no-treatment control. In both intervention and active control groups, suicidality decreased over time; however, most structured psychological depression treatment interventions did not outperform pharmaceutical or treatment as usual control groups. Depression prevention studies demonstrated small but statistically significant reductions in suicidality.

LIMITATIONS

Analysis of study quality suggested that at least 10 of the 16 studies have a high risk of bias. Conclusive comparisons across studies are problematic due to differences in measures, interventions, population differences and control groups used.

CONCLUSIONS

It is unclear whether psychological treatments are more effective than no treatment since no study has used a no-treatment control group. There is evidence to suggest that Cognitive Behavioural Therapy interventions produce pre-post reductions in suicidality with moderate effect sizes and are at least as efficacious as pharmacotherapy in reducing suicidality; however, it is unclear whether these effects are sustained. There are several trials showing promising evidence for family-based and interpersonal therapies, with large pre-post effect sizes, and further evaluation with improved methodology is required. Depression prevention interventions show promising short-term effects.

Does emergency department use and post-visit physician care cluster geographically and temporally for adolescents who self-harm? A population-based 9-year retrospective cohort study from Alberta, Canada

BACKGROUND

Clustering of adolescent self-harming behaviours in the context of health care utilization has not been studied. We identified geographic areas with higher numbers of adolescents who (1) presented to an emergency department (ED) for self-harm, and (2) were without a physician follow-up visit for mental health within 14 days post-ED visit.

METHODS

We extracted a population-based cohort of adolescents aged 15-17 years (n = 3,927) with ED visits during 2002-2011 in Alberta, Canada. We defined the case as an individual with one or more ED presentations for self-harm in the fiscal year of the analysis. Crude case rates were calculated and clusters were identified using a spatial scan.

RESULTS

The rates decreased over time for ED visits for self-harm (differences: girls -199.6/100,000; p < 0.01; boys -58.8/100,000; p < 0.01), and for adolescents without a follow-up visit within 14 days following an ED visit for self-harm (differences: girls -108.3/100,000; p < 0.01; boys -61.9/100,000; p < 0.01). Two space-time clusters were identified: (1) a North zone cluster during 2002-2006 (p < 0.01) and (2) a South zone cluster during 2003-2007 (p < 0.01). These clusters had higher numbers of adolescents who presented to the ED for self-harm (relative risks [RRs]: 1.58 for cluster 1, 3.54 for cluster 2) and were without a 14-day physician follow-up (RRs: 1.78 for cluster 1, 4.17 for cluster 2). In 2010/2011, clusters in the North, Edmonton, and Central zones were identified for adolescents with and without a follow-up visit within 14 days following an ED visit for self-harm (p < 0.01).

CONCLUSIONS

The rates for ED visits for adolescents who self-harm and rates of adolescents without a 14-day physician follow-up visit following emergency care for self-harm decreased during the study period. The space-time clusters identified the areas and years where visits to the ED by adolescents for self-harm were statistically higher than expected. These clusters can be used to identify locations where adolescents are potentially not receiving follow-up and the mental health support needed after emergency-based care. The 2010/2011 geographic cluster suggests that the northern part of the province still has elevated numbers of adolescents visiting the ED for self-harm. Prospective research is needed to determine outcomes associated with adolescents who receive physician follow-up following ED-based care for self-harm compared to those who do not.

A Pilot Study on the Efficacy of Volunteer Mentorship for Young Adults With Self-Harm Behaviors Using a Quasi-Experimental Design

BACKGROUND

Studies have shown that postdischarge care for self-harm patients is effective in reducing repeated suicidal behaviors. Little is known about whether volunteer support can help reduce self-harm repetition and improve psychosocial well-being.

AIM

This study investigated the efficacy of volunteer support in preventing repetition of self-harm.

METHOD

This study used a quasi-experimental design by assigning self-harm patients admitted to the emergency departments to an intervention group with volunteer support and treatment as usual (TAU) for 9 months and to a control group of TAU. Outcome measures include repetition of self-harm, suicidal ideation, hopelessness, and level of depressive and anxiety symptoms.

RESULTS

A total of 74 cases were recruited (38 participants; 36 controls). There were no significant differences in age, gender, and clinical condition between the two groups at the baseline. The intervention group showed significant improvements in hopelessness and depressive symptoms. However, the number of cases of suicide ideation and of repetition of self-harm episodes was similar for both groups at the postintervention period.

CONCLUSION

Postdischarge care provided by volunteers showed significant improvement in hopelessness and depression. Volunteers have been commonly involved in suicide prevention services. Further research using rigorous methods is recommended for improving service quality in the long term.

A Systematic Review of Social Media Use to Discuss and View Deliberate Self-Harm Acts

Objective

To conduct a systematic review of studies of social media platforms used by young people to discuss and view deliberate self-harm.

Study Design

11 electronic databases were searched from January 2000 to January 2012 for primary research; in June 2014 an updated search of Medline was conducted. Grey literature sources were also searched. Search results were screened by two reviewers. Data were extracted by one reviewer and verified by another. Methodological quality was assessed using the Mixed Methods Appraisal Tool.

Results

Due to heterogeneity in study objectives and outcomes, results were not pooled; a narrative analysis is presented. 26 studies were included. Most were conducted in Canada or the UK (30.8% each), used qualitative designs (42.3%), and evaluated discussion forums (73.1%). Participants were most often aged 19–21 years (69.2%), female (mean 68.6%), and 19.2% had a documented history of depression. The social media platforms evaluated were commonly supportive and provided a sense of community among users. Support included suggestions for formal treatment, advice on stopping self-harming behavior, and encouragement. Harms included normalizing and accepting self-harming behavior; discussion of motivation or triggers, concealment, suicidal ideation or plans; and live depictions of self-harm acts.

Conclusions

Although this evidence is limited by its descriptive nature, studies identify beneficial and detrimental effects for young people using social media to discuss and view deliberate self-harm. The connections users make online may be valuable to explore for therapeutic benefit. Prospective, longitudinal investigations are needed to identify short- and long-term potential harms associated with use.

Relations between Nonsuicidal Self-Injury and Suicidal Behavior in Adolescence: A Systematic Review

Nonsuicidal self-injury (NSSI) and suicidal behaviors, both important issues in adolescent health care, are frequently associated and possibly clinically related. Our objective was to explore the views of relations between nonsuicidal self-injury and suicidal behaviors during adolescence and young adulthood (11–25 years) expressed in the scientific (medical and psychological) literature. We adopted a textual approach to the process of synthesis to tell the story of the findings from the included studies. Our narrative systematic review of 64 articles found that they share the same risk factors. Integrated models envision nonsuicidal self-injury as a gateway enabling teens to acquire the capability for suicide. Because suicidal behavior short-circuits thought, it is difficult to conceive an intention to die during adolescents' acts of self-injury. Intention is constructed by the narrative of the act, influenced by numerous elements from the psychopathologic, cultural, religious, and philosophic context. Techniques of mentalizing-based treatments and work on the meaning that adolescents attribute to their behaviors might improve care.

Beyond medicalization: Self-injuring acts revisited

For too long, medical/psychiatric and psychological studies, with focus on emotional sensitivity, personality traits, and correlation with psychopathology, have dominated research on self-injuring acts. The phenomenon thus has been defined as a predominantly medical issue. However, a large body of community prevalence studies show self-injuring acts to be a common phenomenon in society, and most of those who self-injure are unknown in psychiatric or other clinical settings. This article describes and analyzes the medicalization of self-injuring acts and argues a need to move research on self-injuring acts out of the medical paradigm. There is a need to explicitly explore the impact of social, cultural, structural, and gendered factors surrounding and influencing self-injuring acts. A non-medical approach, beyond the limits of the medical perspective, would feed research forward and create a more nuanced view on this widespread social phenomenon.

Why Do Adolescents Self-Harm?

BACKGROUND

Given the high rates of self-harm among adolescents, recent research has focused on a better understanding of the motives for the behavior.

AIMS

The present study had three aims: to investigate (a) which motives are most frequently endorsed by adolescents who report self-harm; (b) whether motives reported at baseline predict repetition of self-harm over a 6-month period; and (c) whether self-harm motives differ between boys and girls.

METHOD

In all, 987 school pupils aged 14-16 years completed a lifestyle and coping questionnaire at two time points 6 months apart that recorded self-harm and the associated motives.

RESULTS

The motive "to get relief from a terrible state of mind" was the most commonly endorsed reason for self-harm (in boys and girls). Interpersonal reasons (e.g., "to frighten someone") were least commonly endorsed. Regression analyses showed that adolescents who endorsed wanting to get relief from a terrible state of mind at baseline were significantly more likely to repeat self-harm at follow-up than those adolescents who did not cite this motive.

CONCLUSION

The results highlight the complex nature of self-harm. They have implications for mental health provision in educational settings, especially in relation to encouraging regulation of emotions and help-seeking.

Using Data Linkage to Investigate Inconsistent Reporting of Self-Harm and Questionnaire Non-Response

The objective of this study was to examine agreement between self-reported and medically recorded self-harm, and investigate whether the prevalence of self-harm differs in questionnaire responders vs. non-responders. A total of 4,810 participants from the Avon Longitudinal Study of Parents and Children (ALSPAC) completed a self-harm questionnaire at age 16 years. Data from consenting participants were linked to medical records (number available for analyses ranges from 205-3,027). The prevalence of self-harm leading to hospital admission was somewhat higher in questionnaire non-responders than responders (2.0 vs. 1.2%). Hospital attendance with self-harm was under-reported on the questionnaire. One third reported self-harm inconsistently over time; inconsistent reporters were less likely to have depression and fewer had self-harmed with suicidal intent. Self-harm prevalence estimates derived from self-report may be underestimated; more accurate figures may come from combining data from multiple sources.

Risk factors for suicide attempts and hospitalizations in a sample of 39,542 French adolescents

BACKGROUND

The high frequency of suicide attempts during adolescence is a serious public health concern. In particular attempts leading to hospitalization, often due to their severity, require careful consideration.

METHODS

Participants were drawn from a large adolescent general population survey conducted by the French Monitoring Center for Drugs and Drug Addiction and the National Service department. The final sample included 39,542 adolescents aged 17. Participants were surveyed during the "one-day session of civic and military information" using a pen and paper self-administered questionnaire.

RESULTS

Depressive symptoms, family socio-economic status, familial situation, relationship with parents, school situation, substance use and body image were significant independent predictors of lifetime suicide attempts. Among suicide attempts, hospitalization was independently predicted by daily smoking in both genders, school dropout, grade repetition, absence of relationship with the mother, regular cannabis smoking and lifetime other illicit drug use in girls.

LIMITATIONS

The main limitation of the present study is the absence of a thorough assessment of psychiatric disorders, depressive symptomatology being the only indicator of mental health status at the time of the survey. Second, the survey was cross-sectional thus limiting the interpretation of the findings.

CONCLUSIONS

The variables associated with suicide attempts and among them, those associated with hospitalization should be used to identify and provide additional services to adolescents at risk for serious suicidal behavior. Primary prevention in the field of parenting and family support, as well as intervention tackling normative beliefs related to body image should be considered.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews; this review is focused on psychosocial and pharmacological interventions for SH in children and adolescents.

OBJECTIVES

To identify all randomised controlled trials of psychosocial interventions, pharmacological agents, or natural products for SH in children and adolescents, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who SH.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (30 January 2015).

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial or pharmacological treatments with treatment as usual, alternative treatments, or placebo or alternative pharmacological treatment in children and adolescents (up to 18 years of age) with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, extracted data, and appraised study quality, with consensus. For binary outcomes, we calculated odds ratios (OR) and their 95% confidence intervals (CI). For continuous outcomes measured using the same scale we calculated the mean difference (MD) and 95% CI; for those measured using different scales we calculated the standard mean difference (SMD) and 95% CI. Meta-analysis was only possible for two interventions: dialectical behaviour therapy for adolescents and group-based psychotherapy. For these analyses, we pooled data using a random-effects model.

MAIN RESULTS

We included 11 trials, with a total of 1,126 participants. The majority of participants were female (mean = 80.6% in 10 trials reporting gender). All trials were of psychosocial interventions; there were none of pharmacological treatments. With the exception of dialectical behaviour therapy for adolescents (DBT-A) and group-based therapy, assessments of specific interventions were based on single trials. We downgraded the quality of evidence owing to risk of bias or imprecision for many outcomes.Therapeutic assessment appeared to increase adherence with subsequent treatment compared with TAU (i.e., standard assessment; n = 70; k = 1; OR = 5.12, 95% CI 1.70 to 15.39), but this had no apparent impact on repetition of SH at either 12 (n = 69; k = 1; OR 0.75, 95% CI 0.18 to 3.06; GRADE: low quality) or 24 months (n = 69; k = 1; OR = 0.69, 05% CI 0.23 to 2.14; GRADE: low quality evidence). These results are based on a single cluster randomised trial, which may overestimate the effectiveness of the intervention.For patients with multiple episodes of SH or emerging personality problems, mentalisation therapy was associated with fewer adolescents scoring above the cut-off for repetition of SH based on the Risk-Taking and Self-Harm Inventory 12 months post-intervention (n = 71; k = 1; OR = 0.26, 95% CI 0.09 to 0.78; GRADE: moderate quality). DBT-A was not associated with a reduction in the proportion of adolescents repeating SH when compared to either TAU or enhanced usual care (n = 104; k = 2; OR 0.72, 95% CI 0.12 to 4.40; GRADE: low quality). In the latter trial, however, the authors reported a significantly greater reduction over time in frequency of repeated SH in adolescents in the DBT condition, in whom there were also significantly greater reductions in depression, hopelessness, and suicidal ideation.We found no significant treatment effects for group-based therapy on repetition of SH for individuals with multiple episodes of SH at either the six (n = 430; k = 2; OR 1.72, 95% CI 0.56 to 5.24; GRADE: low quality) or 12 month (n = 490; k = 3; OR 0.80, 95% CI 0.22 to 2.97; GRADE: low quality) assessments, although considerable heterogeneity was associated with both (I(2) = 65% and 77% respectively). We also found no significant differences between the following treatments and TAU in terms of reduced repetition of SH: compliance enhancement (three month follow-up assessment: n = 63; k = 1; OR = 0.67, 95% CI 0.15 to 3.08; GRADE: very low quality), CBT-based psychotherapy (six month follow-up assessment: n = 39; k = 1; OR = 1.88, 95% CI 0.30 to 11.73; GRADE: very low quality), home-based family intervention (six month follow-up assessment: n = 149; k = 1; OR = 1.02, 95% CI 0.41 to 2.51; GRADE: low quality), and provision of an emergency card (12 month follow-up assessment: n = 105, k = 1; OR = 0.50, 95% CI 0.12 to 2.04; GRADE: very low quality). No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

There are relatively few trials of interventions for children and adolescents who have engaged in SH, and only single trials contributed to all but two comparisons in this review. The quality of evidence according to GRADE criteria was mostly very low. There is little support for the effectiveness of group-based psychotherapy for adolescents with multiple episodes of SH based on the results of three trials, the evidence from which was of very low quality according to GRADE criteria. Results for therapeutic assessment, mentalisation, and dialectical behaviour therapy indicated that these approaches warrant further evaluation. Despite the scale of the problem of SH in children and adolescents there is a paucity of evidence of effective interventions. Further large-scale trials, with a range of outcome measures including adverse events, and investigation of therapeutic mechanisms underpinning these interventions, are required. It is increasingly apparent that development of new interventions should be done in collaboration with patients to ensure that these are likely to meet their needs. Use of an agreed set of outcome measures would assist evaluation and both comparison and meta-analysis of trials.

A meta-analysis on the relation between peer victimization and adolescent non-suicidal self-injury

Several studies suggest that there are relations between children's or adolescents' self-injurious behaviors and peer victimization. In the current study, a meta-analysis was performed to study the relations between non-suicidal self-injury and peer victimization. Non-suicidal self-injury focuses on self-injurious behaviors without suicidal intent, that result in immediate tissue damage and are not socially sanctioned within one's culture or for display. Using a meta-analysis, effect sizes of existing studies can be statistically summarized, and publication bias and moderators can be analyzed. The databases PsycINFO, MEDLINE, ERIC and ProQuest were searched for relevant articles. Articles were only included if they focused on children or adolescents, if they focused on non-clinical samples, and if they focused on self-injuring behaviors as opposed to thoughts or ideation. We found nine studies with fourteen independent samples and a total of 20,898 adolescents and children reporting on the relation between peer victimization and non-suicidal self-injury. Our analysis showed positive and significant relations between non-suicidal self-injury and peer victimization. Further analyses showed an absence of publication bias. Younger children that were victimized reported significantly more non-suicidal self-injury than older children. By preventing peer victimization we may potentially prevent non-suicidal self-injury in children and adolescents.

Self-harm in young people: Prevalence, associated factors, and help-seeking in school-going adolescents

Adolescent self-harm is recognized as a serious public health problem; however, there is little reliable comparative data on its prevalence or characteristics, or on the extent of help-seeking for self-harm. The aims of the present study were to determine the prevalence and associated factors of adolescent self-harm in an urban region in Ireland, and to investigate help-seeking behaviours for self-harm. This was a cross-sectional study of 856 school-going adolescents, employing an anonymous self-report questionnaire. A lifetime history of self-harm was reported by 12.1% of adolescents. Factors independently associated with self-harm included exposure to self-harm of a friend/family member. Professional help-seeking was uncommon prior to (9%) and after (12%) self-harm. Furthermore, only 6.9% of adolescents presented to hospital as a result of their last self-harm act. These findings indicate that self-harm is common in adolescents; however, seeking professional help is not a common phenomenon, and those who present to hospital represent the 'tip of the iceberg' of adolescent self-harm. Identifying the prevalence of self-harm and associated factors, in addition to help-seeking behaviours, in young people is important to determine the preventative programmes to target 'at-risk' groups. Mental health nurses have an important and increasing role to play in such school-based initiatives.

Cannabis use in children with individualized risk profiles: Predicting the effect of universal prevention intervention

AIM

To study the effect of a universal prevention intervention targeting cannabis use in individual children with different risk profiles.

METHODS

A school-based randomized controlled prevention trial was conducted over a period of 33 months (n=1874 sixth-graders, baseline mean age 11.82). We used a two-level random intercept logistic model for panel data to predict the probabilities of cannabis use for each child. Specifically, we used eight risk/protective factors to characterize each child and then predicted two probabilities of cannabis use for each child if the child had the intervention or not. Using the two probabilities, we calculated the absolute and relative effect of the intervention for each child. According to the two probabilities, we also divided the sample into a low-risk group (the quarter of the children with the lowest probabilities), a moderate-risk group, and a high-risk group (the quarter of the children with the highest probabilities) and showed the average effect of the intervention on these groups.

RESULTS

The differences between the intervention group and the control group were statistically significant in each risk group. The average predicted probabilities of cannabis use for a child from the low-risk group were 4.3% if the child had the intervention and 6.53% if no intervention was provided. The corresponding probabilities for a child from the moderate-risk group were 10.91% and 15.34% and for a child from the high-risk group 25.51% and 32.61%. School grades, thoughts of hurting oneself, and breaking the rules were the three most important factors distinguishing high-risk and low-risk children.

CONCLUSIONS

We predicted the effect of the intervention on individual children, characterized by their risk/protective factors. The predicted absolute effect and relative effect of any intervention for any selected risk/protective profile of a given child may be utilized in both prevention practice and research.

The impact of attitudes as a mediator between sense of autonomy and help-seeking intentions for self-injury

BACKGROUND

Self-injury is a complex issue, further complicated by the fact that up to half of young people who self-injure do not receive help. Young people who do receive help for self-injury claim they prefer to access family and friends over more formal sources of help. This original research set out to examine the influence of negative attitudes to professional help and a sense of autonomy on help-seeking intentions.

METHODS

A cross-section of 220 university students and young adults from the community (Students = 131, other participants = 89; mean age = 24.64) completed anonymous online questionnaires measuring self-injurious behaviour and mental health related problems, attitudes toward seeking professional mental health help, autonomy, and intentions to seek help for self-injury. Two separate mediation models were tested using a bootstrapping approach to investigate intentions to seek help - one on mental health problems, and one specifically on self-injury.

RESULTS

More positive attitudes to help-seeking were significantly associated with greater intentions to seek help, while higher perceived autonomy was associated with lower intentions to seek help. Attitudes fully mediated the negative relationship between autonomy and willingness to seek help for self-injury. The model also maintained partial mediation for willingness to seek help for other mental health problems, beyond self-injury. Current self-injurers expressed significantly more negative attitudes toward help-seeking compared to past self-injurers and those with no history of self-injury. Similarly, current self-injurers reported being less likely to seek help from anyone compared to both other groups.

CONCLUSIONS

This study appears to be the first to set out to compare self-injurers' attitudes to help-seeking directly with those of non-self-injurers, and the first to show that attitudes mediate the relationship between autonomy and help-seeking. The findings provide evidence that will assist development of interventions targeting negative attitudes toward seeking professional help, in order to increase help-seeking among self-injurers who would otherwise not receive treatment.

Does Insurance Matter? Implementing Dialectical Behavior Therapy with Two Groups of Youth Engaged in Deliberate Self-harm

This paper presents the outcomes of a Dialectical Behavior Treatment (DBT) program, implemented in intensive outpatient care with two groups of adolescents (n = 55 and n = 45), ages 12-18, who engaged in deliberate self-harm (DSH) but had different insurance/funding sources and risk backgrounds. This pre-post study examined variability in clinical functioning and treatment utilization between the two groups and investigated moderating risk factors. Findings support DBT's effectiveness in improving clinical functioning for youth with DSH regardless of insurance type. However, lower rates of treatment completion among youth without private insurance call for extra engagement efforts to retain high-risk youth in DBT.

The healing journey: help seeking for self-injury among a community population

Help seeking is known to be a complex and difficult journey for people who self-injure. In this article, we explore the process of help seeking from the perspective of a group of people living in Northern Ireland with a history of self-injury. We conducted 10 semistructured interviews and employed a grounded theory approach to data analysis. We created two major categories from the interview transcript data: (a) "involution of feeling," which depicts participants' perspectives on barriers to help seeking; and (b) "to be treated like a person," in which participants communicate their experiences of help seeking. The findings pose important implications for policy, practice, theory, and future research, including the need to increase the uptake of follow-up care among people who arrive at hospitals as a result of self-injury, self-harm, or suicidal behaviors.

Help-seeking behaviour following school-based screening for current suicidality among European adolescents

PURPOSE

To screen and clinically interview European adolescents reporting current suicidality (suicidal ideation and suicide attempt) and investigate attendance at the clinical interview.

METHODS

The Saving and Empowering Young Lives in Europe (SEYLE) Project was carried out in 11 European countries. A baseline questionnaire was completed in school by 12,395 adolescents (mean age 14.9; SD 0.9). Those who screened positive for suicidality (attempting suicide and/or serious suicidal ideation or plans) in the past 2 weeks were invited to a clinical interview with a mental health professional.

RESULTS

Of the 12,395 adolescents, 4.2 % (n = 516) screened positive for current suicidality. The prevalence ranged from 1.1 % in Hungary to 7.7 % in Israel (p < 0.001). 37.6 % (n = 194) of those who screened positive subsequently attended the clinical interview. Female students were more likely to attend for interview (42.0 % versus 30.6 %, p = 0.010). The attendance rate varied considerably across countries, from 5.7 % in Italy to 96.7 % in France (p < 0.001). Improved attendance was associated with using school as the only interview setting (Mean attendance rate, MAR = 88 vs. 31 %, p = 0.006) and arranging the interview within 1 week of contacting the student (MAR = 64 vs. 23 %, p = 0.013). The greater the travel time to interview, the lower the attendance rate (Pearson's r = -0.64, p = 0.034). Independent of the variation by country, at the individual level, adolescents with more depressive symptoms and a recent suicide attempt more often attended for interview.

CONCLUSION

A high rate of current suicidality was found amongst European adolescents. However, the majority of these displayed limited help-seeking behaviour. Future studies should investigate ways of making screening programmes and other interventions more acceptable and accessible to young people, especially young males.

Help-seeking behaviour and adolescent self-harm: a systematic review

OBJECTIVE

Self-harm is common in adolescence, but most young people who self-harm do not seek professional help. The aim of this literature review was to determine (a) the sources of support adolescents who self-harm access if they seek help, and (b) the barriers and facilitators to help-seeking for adolescents who self-harm.

METHOD

Using a pre-defined search strategy we searched databases for terms related to self-harm, adolescents and help-seeking. Studies were included in the review if participants were aged 11-19 years.

RESULTS

Twenty articles met criteria for inclusion. Between a third and one half of adolescents who self-harm do not seek help for this behaviour. Of those who seek help, results showed adolescents primarily turned to friends and family for support. The Internet may be more commonly used as a tool for self-disclosure rather than asking for help. Barriers to help-seeking included fear of negative reactions from others including stigmatisation, fear of confidentiality being breached and fear of being seen as 'attention-seeking'. Few facilitators of help-seeking were identified.

CONCLUSIONS

Of the small proportion of adolescents who seek help for their self-harm, informal sources are the most likely support systems accessed. Interpersonal barriers and a lack of knowledge about where to go for help may impede help-seeking. Future research should address the lack of knowledge regarding the facilitators of help-seeking behaviour in order to improve the ability of services to engage with this vulnerable group of young people.

The iceberg of suicide and self-harm in Irish adolescents: a population-based study

PURPOSE

Suicide is a leading cause of death among adolescents. Self-harm is the most important risk factor for suicide, yet the majority of self-harm does not come to the attention of health services. The purpose of this study was to establish the relative incidence of adolescent suicide, hospital-treated self-harm and self-harm in the community.

METHODS

Annual suicide rates were calculated for 15-17 year-old in the Cork and Kerry region in Ireland based on data from the Central Statistics Office. Rates of hospital-treated self-harm were collected by the Irish National Registry of Deliberate Self-Harm. Rates of self-harm in the community were assessed using a survey of 3,881 adolescents, the Child and Adolescent Self-harm in Europe study.

RESULTS

The annual suicide rate was 10/100,000. Suicide was six times more common among boys than girls. The annual incidence rate of hospital-treated self-harm was approximately 344/100,000, with the female rate almost twice the male rate. The rate of self-harm in the community was 5,551/100,000, and girls were almost four times more likely to report self-harm. For every boy who died by suicide, 16 presented to hospital with self-harm and 146 reported self-harm in the community. For every female suicide, 162 girls presented to hospital with self-harm and 3,296 reported self-harm.

CONCLUSIONS

Gender differences in relative rates of self-harm and suicide are very large, with boys who have harmed themselves at particularly high risk of suicide. Knowledge of the relative incidence of self-harm and suicide in adolescents can inform prevention programmes and services.

Self-poisoning with medications in adolescents: a national register study of hospital admissions and readmissions

OBJECTIVE

To examine characteristics of hospital admissions and risk factors associated with rehospitalization for self-poisoning with medications in adolescents aged 10-19 years.

METHOD

This study used data from the Norwegian Patient Register from 2008 to 2011. The main outcome was hospital readmission within the observation period. A complementary log-log regression model was used to assess the effect of characteristics at index hospital admission on readmission.

RESULTS

Of 1497 patients, 76.4% were females and 89.8% were aged 15-19 years. At their first hospital admission, about one third received a secondary psychiatric diagnosis. Females (47.5%) were registered with an E-code for intentional self-harm more often than males (33.7%), and females were more often than males discharged to further treatment (27.8% vs. 21.5%). As many as 18.4% were rehospitalized for self-poisoning by medications. Significant predictors for hospital readmission were female sex [hazard ratio (HR) = 2.4, 95% confidence interval (CI) 1.7-3.6], discharge to further treatment (HR = 2.3, 95% CI 1.8-2.9) and psychiatric secondary diagnoses (HR = 1.5, 95% CI 1.2-1.9).

CONCLUSION

This national study demonstrated significant sex differences in adolescents treated in hospital for self-poisoning with medications. Psychiatric secondary diagnoses had a strong predictive effect on readmission, which indicates the importance of psychiatric/psychosocial assessment of adolescents who are admitted to hospital for self-poisoning with medications.

Student help seeking from pastoral care in UK high schools: a qualitative study

BACKGROUND

Little is known about high school students' perceptions of school-based pastoral support. This study aimed to explore this in the context of a high school-based emotional support project.

METHODS

Qualitative interviews explored perspectives on help seeking of students (N = 23) and staff (N = 27) in three UK high schools where a pastoral project was introduced. Data were analysed thematically.

RESULTS

Student peer groups perceived help seeking as a sign of weakness. However, students valued learning skills in managing emotions and friendships. Staff expressed concerns about students' ability to help seek proactively, and highlighted organisational influences on pastoral support.

CONCLUSIONS

Increasing student control over the process, and involving trusted staff, could encourage help seeking in high school. It is possible to access the views of students who do not help seek, to improve understanding of help-seeking behaviour.