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

Risk on Demand? A Quantitative Content Analysis of the Portrayal of Risky Health Behaviors in Popular on Demand Content

Video on Demand (VOD) has become the most popular way for adolescent viewers to consume entertainment media, often without parental supervision. Given the potential for modeling, this study aims to investigate the prevalence and nature with which risky health behaviors are portrayed in popular VOD programs. A quantitative content analysis of trending programs (N = 529) from popular VOD-platforms investigated the prevalence, co-occurrence, tone, social context, and consequences with which alcohol use, tobacco use, drug use, unsafe sexual behavior, reckless behavior, and self-harm behaviors are portrayed in popular VOD programs. In addition, we analyzed the demographic characteristics of the characters who portrayed the risk behaviors Risk behaviors were portrayed frequently, with substance use behaviors (i.e. alcohol, smoking, drugs) being most prevalent and most likely to co-occur. Reckless behavior, self-harm behaviors, and explicitly unsafe sexual behaviors were much less common. Findings show that risk behavior was often portrayed in a normalized manner, with alcohol and smoking, in particular, being portrayed as neutral behaviors that rarely have consequences. Most risk-taking characters were (young) adult white males, mirroring the general overrepresentation of this demographic in popular media. Risk behavior was rarely problematized in popular on demand content. Potential consequences for adolescent viewers are discussed.

Interrupting the Self-Harm Continuum

Background: Nonsuicidal self-injury (NSSI) has increased rapidly and is frequently linked to suicidal behavior; it has been argued that these behaviors are key points on a self-harm continuum. Aims: The current research explored self-harm and help-seeking behaviors, with the aim of identifying possibilities for prevention of further harm, including suicide. Methods: An online survey of 304 New Zealanders was undertaken, with the majority being aged under 25 and female. Results: Nearly half of the sample had engaged in self-harm and most of those had experienced suicidal thoughts; close to a quarter had made a suicide attempt. NSSI was used as a way of dealing with emotional distress. Very few sought help of any kind, especially professional support; of those who did seek professional support, most found it helpful but did not necessarily stop self-harming as a result. Limitations: Men are under-represented in the sample - though this is in accordance with the population of people who engage in NSSI. Conclusion: Many participants engaged in NSSI and also had suicidal thoughts using NSSI as an emotion regulation strategy; some participants appeared to use NSSI rather than attempting suicide. Given a link between NSSI and suicidal thoughts and behaviors, reluctance to seek help and on-going injurious behavior among some who do seek help, there is a need for increased identification and proactive support specifically focusing on improving emotion regulation and targeted at injurious behavior.

A study of the interactive mediating effect of ADHD and NSSI caused by co-disease mechanisms in males and females

Background

Non-suicidal self-injury (NSSI), of which the predisposing factors are complex and diverse, profoundly affects the physical and mental health of young people. Therefore, this work established an NSSI intermediary network model considering the interaction of multiple factors. A mediating effect between attention-deficit/hyperactivity disorder (ADHD) and NSSI, considering the influence of comorbidities, such as depression, anxiety, and impulsive personality, was proposed based on sex differences.

Methods

A total of 2,689 middle school students in Ningbo City, Zhejiang Province, China, were randomly sampled and participated in this study. Data regarding their demographic characteristics, attention deficit, hyperactivity/impulsivity, NSSI, anxiety, depression, internet addiction, and other comorbid symptoms were collected and analyzed. After initially screening the data, variables were assessed for significance using a single-factor inter-group difference analytic method, and a binary logistic regression analysis was performed. The intermediary effect of factors influencing NSSI in males and females was also analyzed.

Results

The overall NSSI rate was 15.16%. The results showed that the impact of individual impulsivity characteristics (impulsiveness, the ADHD with hyperactivity/impulsivity subtype) on NSSI behavior was not significant (regression results, P > 0.05). The degree of association between ADHD with attention deficit and ADHD with comprehension deficit subtypes, and other comorbid symptoms (depression, anxiety, and internet addiction disorder) and NSSI, with odds ratios (ORs) of 7.6/6.42/436.68/3.82/1.86, and 95% bootstrap confidence intervals (CIs) of 4.64, 12.87/3.46, 12.67/137.42, 2659.13/2.32, 6.37/1.31, 2.82, respectively. The results also showed significant effects of ADHD subtypes on comorbid symptoms and the path effects of NSSI (P < 0.01). Among them, the mediating effect was the strongest when anxiety was the mediating variable, and the mediating effect of girls was higher than that of boys.

Conclusion

The results of this work demonstrated the influence of ADHD symptoms on NSSI behavior. Among patients with ADHD, patients with subtypes with obvious attention deficit characteristics were more likely to exhibit NSSI behavior, whereas the hyperactive impulse subtype had no direct impact on NSSI. We conclude that adolescent impulsivity may not be directly related to NSSI behavior and that impulsive characteristics jointly affect NSSI behavior through a series of NSSI comorbid symptoms. Notably, the probability of symptom onset and the degree of comorbidity was significantly higher in girls than in boys of the same age, and girls were more prone to NSSI behavior. These findings provide effective theoretical support for the prevention and treatment of adolescent NSSI behavior.

The Effect of Gender on Identification and Interpretation of Non-Suicidal Self-Injury

INTRODUCTION

Reported rates of non-suicidal self-injury (NSSI) differ by gender but may be under-reported and under-recognised in men. People engaging in NSSI rarely seek professional help without encouragement, so others play a key role in its identification and potential intervention. The current research investigated others' interpretations of NSSI, examining whether gender affects the likelihood of NSSI identification and views of how common and acceptable NSSI is.

METHOD

Participants (N = 429; 74.1% female, 23.3% male; please see below for further demographic information) responded to two vignettes describing a person self-injuring by punching a wall or by cutting themselves. The person's gender in each vignette was manipulated. Following each vignette, the participants rated the level to which they agreed the behaviour was common for the gender of the person described, as well as the level to which they agreed the behaviour was acceptable for the gender of the person described, on a 5-point Likert scale. Following both vignettes, participants were presented with a definition of NSSI and rated the level to which they agreed cutting and wall-punching were forms of NSSI on 5-point Likert scales. Independent-samples t tests and goodness of fit χ2 tests were conducted as appropriate.

RESULTS

Participants were more likely to identify wall-punching as common for men and cutting as common for women. However, there was no significant difference in whether wall-punching was identified as NSSI or considered to be an acceptable behaviour, regardless of the gender of the person engaging in it. That is, although research suggests that men are far more likely to engage in wall-punching as a form of NSSI than women, participants did not recognise this. Overall, the results indicated a gender-dependent difference in how acceptable and common NSSI is thought to be, but no noticeable difference in identification of a behaviour as NSSI. Wall-punching, typically a form of NSSI engaged in by males, tended not to be identified as such.

CONCLUSION

There is an effect of gender on how NSSI is interpreted, and it seems that men's NSSI is, and will continue to be, under-recognised. This has important implications for the treatment of men's NSSI, which is more likely to be seen as aggression and therefore deserving of punishment than an attempt at emotion regulation.

Brief Psychotherapeutic Intervention Compared with Treatment as Usual for Adolescents with Nonsuicidal Self-Injury: Outcomes over a 2-4-Year Follow-Up

INTRODUCTION

The "Cutting Down Programme" (CDP), a brief psychotherapeutic intervention for treating nonsuicidal self-injury (NSSI) in adolescents, was comparable to high-quality treatment as usual (TAU) in a previous randomized controlled trial (RCT).

OBJECTIVE

The aim of the study was to evaluate the long-term outcomes of the CDP over up to 4 years.

METHODS

Assessments of NSSI, suicide attempts, borderline personality disorder (BPD), depression, and quality of life took place 2 to 4 years (T3) after enrollment in a RCT. The evolution of NSSI, suicide attempts, depression, and quality of life was analyzed using (generalized) linear mixed-effects models. Ordered logistic regression was used for analyzing BPD diagnoses. Data from T0, T2, and T3 are reported.

RESULTS

Out of 74 patients, 70 (95%) were included in the T3 assessment. The frequency of NSSI events alongside with suicide attempts and depression further decreased between T2 and T3 and BPD between T0 and T3 in both groups. Quality of life remained stable in both groups between T2 and T3. Both groups received substantial but comparable additional treatment between T2 and T3. More treatment sessions during the follow-up period were linked to larger improvements of NSSI.

CONCLUSIONS

The CDP was found to be as effective as TAU in promoting recovery from NSSI and comorbid symptoms in the long term. Results suggest that treatment effects from a brief psychotherapeutic intervention may endure and even further improve after completion of the program. However, additional treatment seems to improve chances for recovery independent from CDP versus TAU.

The prevalence of self-injury in adolescence: a systematic review and meta-analysis

In the past 10 years, there has been a growing interest in self-injurious behavior (SIB) among adolescents. The lifetime prevalence of SIB is between 16 and 22% in community sample with females more likely to engage in SIB. There are conflicting results about the global distribution of the prevalence of SIB and whether the SIB has increased in the 21st century. Our aim in the current study was to conduct a systematic search of and meta-analysis on the prevalence of SIB in adolescents over the past 5 years' worth of published papers and to examine gender, continental, and year differences. We conducted a systematic search in June 2020 of six databases (PubMed, Scopus, Web of Science, OVID Medline, PsycINFO, EBSCO) with three main search terms: "self-injurious behavior," "prevalence," and "adolescence." Article inclusion criteria were (a) written in English; (b) published between January 1, 2015, and June 18, 2020; and (c) focused on a community sample. Titles and abstracts of the articles were screened first. Then, the relevant full texts were read, and those that met the inclusion criteria were collected. We used Comprehensive Meta-Analysis software was used to conduct the analyses. After the screening process 97, articles were included in the meta-analysis. The age of the samples ranged from 11.00 to 18.53 years. The overall average prevalence of nonsuicidal self-injury in the studies was 16%. There was a significant gender difference: females reported a higher prevalence than males (19.4% and 12.9%, respectively). A significantly higher prevalence was found among Asian articles than those from other continents (19.5% and 14.7%, respectively). The prevalence of SIB did not change significantly between 2013 and 2018. The current research draws attention to the high prevalence of SIB among adolescents, especially among females and those living in Asia. It is important to address this behavior, both in terms of prevention and intervention.

Symptomatic, Alexithymic, and Suicidality-Related Features in Groups of Adolescent Self-Harmers: A Case-Control Study

Non-suicidal self-injury (NSSI) is an increasing phenomenon among both clinical and nonclinical adolescent groups and is associated with several psychopathological symptoms, in addition to being one of the main risk factors for suicidality. Nevertheless, differences between clinical and nonclinical samples of self-harmers in symptom dimensions, alexithymia, suicidality, and NSSI-related variables are still scarcely investigated. The current study aimed to fill this gap by enrolling a sample of Italian girls (age range: 12-19 years) that included 63 self-harmers admitted to mental health outpatient services (clinical group), 44 self-harmers without admission to mental health services (subclinical group), and 231 individuals without an NSSI history (control group). Questionnaires investigating psychopathological symptoms, alexithymia, and NSSI-related variables were administered. The results highlighted that all symptom-related variables and alexithymic traits were more severe in the NSSI groups than in the control group; in particular, self-depreciation, anxiety, psychoticism, and pathological interpersonal relationships were distinguished between the clinical and subclinical groups. Compared to the subclinical group, the clinical group was characterized by higher NSSI frequency, NSSI disclosure, self-punishment as the main reason for engagement in NSSI, and suicidal ideation. These findings were then discussed in terms of clinical practice and primary and secondary prevention in the adolescent population.

Prevalence of mental health disorders in children and adolescents in the Republic of Ireland: a systematic review

Referrals to Child and Adolescent Mental Health Services (CAMHS) have increased in recent years. Services are already under-resourced and the adverse psychological impact of Covid-19 is likely to increase demand. Accordingly, an understanding of prevalence of mental health (MH) disorders among youth is imperative to help inform and plan services.

AIM

To establish prevalence of MH disorders among youth (under 18) in Ireland.

METHOD

A systematic review using pre-defined search terms in PubMed, PsycInfo, Embase and CINAHL was conducted. Empirical studies conducted in Ireland, in youth and focusing on MH disorders were included.

RESULTS

From a total of 830 papers identified, 38 papers met inclusion criteria. Significant variation in rates of MH disorders was evident based on study methodology. Screening questionnaires for general psychopathology reported rates of 4.8-17.8% scoring above clinical cut-offs, with higher rates for ADHD (7.3%). Studies examining depression ranged from 4% to 20.8%, while rates for 'current' MH disorder, determined by semi-structured interview, were 15.5%, while 'lifetime' rates varied from 19.9% to 31.2%. Fewer than half (44%) of those identified as 'in need' of specialist MH services were accessing CAMHS.

CONCLUSION

Data on MH disorders among Irish youth is limited, and studies showed significant variance in rates, making service planning difficult. There is an urgent need for serial epidemiological surveys, with clear operational criteria for clinically impairing MH difficulties. Such studies are essential to understand potential demand and service planning. This is most urgent given the expected increased demand post Covid-19.

Self-harm, in-person bullying and cyberbullying in secondary school-aged children: A data linkage study in Wales

INTRODUCTION

Although the evidence base on bullying victimization and self-harm in young people has been growing, most studies were cross-sectional, relied on self-reported non-validated measures of self-harm, and did not separate effects of in-person and cyberbullying. This study aimed to assess associations of self-harm following in-person bullying at school and cyberbullying victimization controlling for covariates.

METHODS

School survey data from 11 to 16 years pupils collected in 2017 from 39 Welsh secondary schools were linked to routinely collected data. Inverse probability weighting was performed to circumvent selection bias. Survival analyses for recurrent events were conducted to evaluate relative risks (adjusted hazard ratios [AHR]) of self-harm among bullying groups within 2 years following survey completion.

RESULTS

A total of 35.0% (weighted N = 6813) of pupils reported being bullied, with 18.1%, 6.4% and 10.5% being victims of in-person bullying at school only, cyberbullying only and both in-person bullying at school and cyberbullying respectively. Adjusting for covariates, effect sizes for self-harm were significant after being in-person bullied at school only (AHR = 2.2 [1.1-4.3]) and being both in-person bullied at school and cyberbullied (AHR = 2.2 [1.0-4.7]) but not being cyberbullied only (AHR = 1.2 [0.4-3.3]). Feeling lonely during recent summer holidays was also a robust predictor (AHR = 2.2 [1.2-4.0]).

CONCLUSIONS

We reaffirm the role of in-person bullying victimization on self-harm. Pupils were twice as likely to self-harm following in-person bullying as their nonvictimised peers. Interventions for young people that minimize the potential impacts of bullying on self-harm should also include strategies to prevent loneliness.

Revisiting Social Stigma in Non-suicidal Self-injury: A Narrative Review

Non-suicidal self-injury (NSSI) is highly prevalent in our community. Yet, there is a significant discrepancy between the number of individuals engaging in NSSI and those who seek treatment for NSSI. This discrepancy can be due to the high social stigma associated with the behavior. The impact of NSSI stigma is significant and can impair the quality of life in the individuals engaging in NSSI, delay help-seeking, reduce access to mental health care and further fuel misinformation. Even though the symptomatology, risks, and demographics of NSSI have received attention in terms of research, there is limited literature on NSSI stigma and its consequences. With that background set, this review provides a bird's-eye view of the different levels of stigma in NSSI (public, self, and health care), associated discrimination, the various aspects of such stigmatization (NSSI-related language, physical scarring, misinformation, the media), and, finally, the collaborative clinical-outreach interventions for mitigating NSSI-associated social stigma. If NSSI is indeed recognized as a clinical disorder, future research would need to focus on these constructs of stigma and treat them with the same importance as the one given to clinical studies of intervention and symptomatology in NSSI.

Support Seeking in the Context of Self-Injury Recovery: Perspectives From Individuals With Lived Experience

ABSTRACT

A sample of 229 university students responded to open-ended questions for the present study, which aimed to gain a deeper understanding of lived experiences of support seeking in the context of self-injury recovery. Inductive thematic analysis of the responses indicated themes from two domains: the benefits of support seeking and the barriers to support seeking. The first domain highlighted benefits from both professional sources (such as receiving diagnosis and referrals to therapy, learning emotion regulation strategies, and developing an improved understanding of self) and informal sources (such as receiving tangible aid, having a support system, and having a compassionate space). The second domain indicated that barriers could be both intrapersonal (such as desire to continue nonsuicidal self-injury, embarrassment and shame, establishing agency without others' support, and minimizing self-injury) and interpersonal (such as fear of being stigmatized, concern for others, and unhelpful prior experiences) in nature. Implications for future research, outreach efforts, and clinical practice are discussed.

Young Peoples' Perspectives on the Role of Harm Reduction Techniques in the Management of Their Self-Harm: A Qualitative Study

OBJECTIVE

Self-harm is a common phenomenon amongst young people, often used to regulate emotional distress. Over the last decade harm reduction approaches to self-harm have been introduced as a means to minimize risk and reinforce alternative coping strategies. However, there is a stark absence of research into the perceived usefulness of such techniques amongst adolescents, and previous studies have highlighted ethical concerns about advocating 'safer' forms of self-harm. This study aimed to investigate the perceived usefulness of harm reduction techniques for adolescents who self-harm.

METHOD

We purposively recruited current clients of a British early intervention program supporting young people in managing self-harm. We conducted semi-structured interviews and analyzed transcripts using thematic analysis.

RESULTS

Eleven interviews with service users aged 14-15 years identified three main themes: (1) Controlling the uncontrollable; (2) Barriers to practising safer self-harm; and (3) Developing a broad repertoire of harm reduction techniques. Participants expressed mixed views regarding the usefulness of such approaches. Some described greater competence and empowerment in self-harm management, whilst others described the utility of harm reduction methods as either short-lived or situation-specific, with the potential for misuse of anatomical knowledge to cause further harm to high-risk adolescents.

CONCLUSION

The findings from our sample suggest harm reduction techniques have a place in self-harm management for some individuals, but their usage should be monitored and offered alongside alternative strategies and therapeutic support. Our study highlights the need for further research on who would benefit from these techniques and how they can be implemented successfully.HIGHLIGHTSHarm reduction can help people who self-harm manage distress and maintain autonomyPeople who self-harm have a broad repertoire of harm reduction techniquesHarm reduction can help reduce long-term damage and frequency of self-harm.

A multi-environments-gene interaction study of anxiety, depression and self-harm in the UK Biobank cohort

The effects of gene-by-environment (G×E) interactions on complex diseases are significant, especially the superimposed effects of multiple environmental factors. However, research on the multi-environments-gene interactions of anxiety, depression, and self-harm is still limited. This study included white individuals (N = 66,041-74,482) from the UK Biobank. We fitted all environmental factors to a single environmental score (ES), and the estimated ES was used to calculate the multiplicative interaction effects between ES and genome-wide SNPs. Heritability was stratified by minor allele frequency (MAF) and linkage disequilibrium (LD). Our research found 10 loci with significant interaction effects, such as rs114830993 (PRICKLE2, P = 2.30 × 10^-8), rs151323364 (ASTN2, P = 2.71 × 10^-10) and rs536631793 (SYN3, P = 4.09 × 10^-8). In addition, we found that G×E heritability has a significant contribution to the depression of Patient Health Questionnaire-9 (PHQ-9) scores (h²_{G×E (female)} = 6.1%, h²_{G×E (male)} = 8.7%). Our research supported the important influence of multi-environments-gene interactions on anxiety, depression, and self-harm and provided clues for the prevention and etiological research of them.

Nonlinear relationship between sleep duration and non-suicidal self-injurious behaviour among Chinese adolescents

BACKGROUND

Previous studies have shown a positive association between sleep deprivation and non-suicidal self-injury (NSSI) among adolescents, but few studies have described the effects of oversleeping and weekend catch-up sleep on NSSI. The present study aimed to explore the nonlinear relationship between sleep duration and NSSI among Chinese adolescents.

METHODS

Data from China's National Adolescent Health Surveillance for the years 2014 to 2015 were collected from 15,713 students located across four provinces in China. A self-report questionnaire was used to assess sleep duration and 12-month NSSI. Binomial logistic regression models were used to examine the association between NSSI and sleep duration. The locally estimated scatter plot smoothing (LOESS) method was used to explore the associations of total NSSI number with sleep duration, and binomial regression analysis was used to test this relationship.

RESULTS

About 68.5% of adolescents reported sleeping less than 8 h on weeknights, while 37.8% of adolescents slept more than 10 h per night during weekends. The 12-month prevalence rate of NSSI was 29.4%. Compared to adolescents who reported weekend catch-up sleep of 0-1 h, those who slept < 0 h (adjusted odds ratio [aOR] = 1.38, 95% Confidence Interval [95% CI]: 1.16-1.64) had a higher risk of NSSI. Males who reported ≥3 h of weekend catch-up sleep had significantly increased odds of NSSI (aOR = 1.20, 95%CI: 1.01-1.42). Notably, a positive U-shaped association was observed between the sleep duration and the total NSSI number.

CONCLUSIONS

The findings reveal a nonlinear relationship between sleep duration and NSSI among Chinese adolescents. Therefore, it is necessary to be vigilant and screen for sleep duration among adolescents in NSSI treatment or prevention.

Experiences of Help From the Perspective of Finnish People Who Self-Harmed During Adolescence

Adolescent self-harm is a widespread phenomenon, and a significant problem worldwide. This study describes the experiences of help from the perspective of Finnish people who have suffered self-harm during adolescence. Data were collected from 27 participants as essays and interviews. Participants included both females and males with different backgrounds and treatment experiences. The data were analysed using inductive content analysis. Participants described having received help from other people in informal and formal ways, and they had both positive and negative experiences of help. The results show that several barriers exist for self-harming adolescents to access help, thus improvement in this area are necessary.

Exploring Lived Experiences of Adolescents Presenting with Self-Harm and Their Views about Suicide Prevention Strategies: A Qualitative Approach

Suicide is a serious global public health problem and the third leading cause of death in those 15-35 years old. Self-harm is the major predictor of future suicide attempts and completed suicide yet remains poorly understood. There is limited evidence on effective interventions for adolescents who present with self-harm. To identify and develop acceptable preventive and therapeutic interventions it is essential to understand the factors that contribute to self-harm and suicide in young people, in the context of their emotions, interpersonal difficulties, available support and prevention strategies. This qualitative study aimed at exploring the lived experiences of adolescents presenting with self-harm and their views about potential prevention strategies. Semi-structured interviews with 16 adolescents (12-18 years) presenting with a self-harm episode in a public hospital in Pakistan. A topic guide was developed to facilitate the interviews. The following themes emerged using the framework analysis; predisposing factors (interpersonal conflicts, emotional crisis etc.), regret and realization that self-harm is not the only option, perceived impact of self-harm, and suggestions for suicide prevention strategies (sharing, distraction techniques, involvement of family). This study may help in refining a contextual and culturally based explanatory model of self-harm in adolescents and in informing development of culturally acceptable interventions.

Rationalizing self-defeating behaviors: Theory and evidence

Why do individuals engage in self-defeating behaviors like self-harm, addiction, and risky sexual behaviors? Why do they experience the apathy of depression or inaction when trapped by multiple competing problems? We propose a framework for explaining these and other related behaviors based on the insight that individuals can only experience a limited number of latent stimuli to which they are exposed. We conduct an experiment to test this model and find that more than two thirds of the subjects behave consistent with our theoretical framework.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

"These Things Don't Work." Young People's Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approach

Although UK clinical guidelines make tentative recommendations for "harm minimization" strategies for repeated self-harm, this is in the absence of empirical evidence supporting their acceptability or effectiveness. We explore young people's views of harm minimization strategies (e.g., snapping elastic bands on skin, drawing on skin with red ink), as a proxy for self-harm. In this mixed methods study we examine data (secondary analysis) from: (1) an online questionnaire (N = 758) observing the frequency of these strategies being used as a form of self-harm, and as a form of alternative coping (viewed as distinct from self-harming), and (2) semi-structured interviews (N = 45), using thematic analysis to identify themes related to harm minimization. Predominant themes suggest that many young people viewed harm minimization strategies as a proxy for self-harm as ineffective. Where such strategies were reported as helpful, their utility was reported to be short-lived or situation-specific. Findings from both studies indicate that some young people described using harm minimization (e.g., elastic band snapping) as a form of self-harm (e.g., to break the skin). Harm minimization strategies should not be recommended in isolation and their use must be monitored. Further research is urgently needed to develop an evidence base that informs practice.

Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is associated with self-harm during adolescence and young adulthood, especially among females. Yet little is known about the developmental trajectories or childhood predictors/moderators of self-harm in women with and without childhood histories of ADHD. We characterized lifetime risk for nonsuicidal self-injury (NSSI), suicidal ideation (SI), and suicide attempts (SA), comparing female participants with (n = 140) and without (n = 88) childhood ADHD. We examined theory-informed childhood predictors and moderators of lifetime risk via baseline measures from childhood. First, regarding developmental patterns, most females with positive histories of lifetime self-harm engaged in such behaviors in adolescence yet desisted by adulthood. Females with positive histories of self-harm by late adolescence emanated largely from the ADHD-C group. Second, we found that predictors of NSSI were early externalizing symptoms, overall executive functioning, and father's negative parenting; predictors of SI were adverse childhood experiences and low self-esteem; and predictors of SA were early externalizing symptoms, adverse childhood experiences, and low self-esteem. Third, receiver operating characteristics analyses helped to ascertain interactive sets of predictors. Findings indicate that pathways to self-harm are multifaceted for females with ADHD. Understanding early childhood predictors and moderators of self-harm can inform both risk assessment and intervention strategies.

A Theory-Based Longitudinal Investigation Examining Predictors of Self-Harm in Adolescents With and Without Bereavement Experiences

BACKGROUND

Research has demonstrated that exposure to suicide can lead to increased vulnerability for self-harm or suicide. As a result, ideation-to-action models of suicide (e.g., the Integrated Motivational-Volitional Model of Suicide; IMV) recognise exposure as a significant risk factor which may be implicated in the translation of thoughts into actions. However, few studies have tested this theoretical link explicitly within an adolescent population, and examined how it compares to other types of bereavements.

METHODS

A 6-month prospective questionnaire study was conducted with 185 Scottish adolescents aged 11-17 (113 adolescents also completed the questionnaire at follow-up). The questionnaire included measures on experiences with bereavement and lifetime engagement in self-harm, as well as measures of defeat, entrapment, social support, coping, and other psychological variables.

RESULTS

At baseline, 12% of young people reported exposure to a suicide death, and 61% to a non-suicide death. In addition, 21% of pupils reported ever engaging in self-harm, while 23% had experienced self-harm ideation without engaging in it. Cross-sectional multivariate logistic regressions showed that family social support, glorifying/normalising beliefs about suicide, and family self-harm were significantly associated with self-harm group membership (control, ideation, or enactment groups). At follow-up, 10% of pupils reported exposure to a suicide death and 16% to a non-suicide death for the first time. A total of 26% of the sample reported self-harm at T2 (11% of participants for the first time), and 24% reported self-harm ideation without engaging in it. Multivariate analyses found that self-harm ideation and family self-harm at baseline were the only variables to predict self-harm group membership prospectively, in the expected directions. Bereavement experiences, whether by suicide or non-suicide, did not predict self-harm group status at baseline nor at follow-up.

CONCLUSIONS

This study provides support for the validity of a theoretical model of suicide, even though predictive ability over the 6-months period was limited. Although difficulties with recruitment may have limited the statistical power, this study provides insight into the prevalence and experiences of suicide bereavement among adolescents and the factors related to the onset and maintenance of self-harm.

[Development of an Online Intervention for Adolescents and Young Adults Engaging in Nonsuicidal Self-injury]

Development of an Online Intervention for Adolescents and Young Adults Engaging in Nonsuicidal Self-injury Nonsuicidal self-injury (NSSI) is a prevalent phenomenon in adolescence. Despite the existence of effective psychotherapeutic interventions, the majority of affected adolescents and young adults do not receive any treatment. Structural (e. g., no specific interventions, limited resources, limited accessibility) as well as individual factors (e. g., low help-seeking behavior) impede access to adequate clinical care for adolescent NSSI. Online interventions offer the possibility to provide specific interventions independent of one's location or local healthcare structures. Because of its high confidentiality and accessibility, the Internet also reaches adolescents with low help-seeking behavior. There is already evidence for online interventions concerning different mental health issues, like depression and anxiety. However, regarding NSSI, there are no effective, online interventions. Thus, we developed an online intervention based on an already evaluated short term program specific for adolescents and young adults with NSSI within the German STAR consortium (STAR: Self-Injury - Treatment, Assessment, Recovery). Within a randomised controlled trial, the intervention will be evaluated regarding its efficacy.

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.

Global Lifetime and 12-Month Prevalence of Suicidal Behavior, Deliberate Self-Harm and Non-Suicidal Self-Injury in Children and Adolescents between 1989 and 2018: A Meta-Analysis

OBJECTIVE

This meta-analysis aimed to estimate the global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents.

METHODS

A systematic search for relevant articles published between 1989 to 2018 was performed in multiple electronic databases. The aggregate 12-month and lifetime prevalence of suicidal behavior, deliberate self-harm, and non-suicidal self-injury were calculated based on the random-effects model. Subgroup analyses were performed to compare the prevalence according to school attendance and geographical regions. Results: A total of 686,672 children and adolescents were included. The aggregate lifetime and 12-month prevalence of suicide attempts was 6% (95% CI: 4.7-7.7%) and 4.5% (95% CI: 3.4-5.9%) respectively. The aggregate lifetime and 12-month prevalence of suicidal plan was 9.9% (95% CI: 5.5-17%) and 7.5% (95% CI: 4.5-12.1%) respectively. The aggregate lifetime and 12-month prevalence of suicidal ideation was 18% (95% CI: 14.2-22.7%) and 14.2% (95% CI: 11.6-17.3%) respectively. The aggregate lifetime and 12-month prevalence of non-suicidal self-injury was 22.1% (95% CI: 16.9-28.4%) and 19.5% (95% CI: 13.3-27.6%) respectively. The aggregate lifetime and 12-month prevalence of deliberate self-harm was 13.7% (95% CI: 11.0-17.0%) and 14.2% (95% CI: 10.1-19.5%) respectively. Subgroup analyses showed that full-time school attendance, non-Western countries, low and middle-income countries, and geographical locations might contribute to the higher aggregate prevalence of suicidal behaviors, deliberate self-harm, and non-suicidal self-injury. Conclusions: This meta-analysis found that non-suicidal self-injury, suicidal ideation, and deliberate self-harm were the three most common suicidal and self-harm behaviors in children and adolescents.

'There is no progression in prevention' - The experiences of mental health nurses working with repeated self-harm

Caring for people who self-harm is an everyday experience for mental health nurses and an important part of their role. How mental health nurses respond to and support those who self-harm can have a significant impact on the outcomes for service users and their intentions to seek help in the future. Repeated self-harm can be a particularly challenging phenomenon as it is often misunderstood and can have a negative impact on the therapeutic relationship. This qualitative descriptive study aims to explore how mental health nurses understand and work with repeated self-harm. Nine nurses working in a range of mental health settings within one service participated in semi-structured interviews which were analysed thematically. Findings are presented in two themes exploring participants' perceptions and understanding of repeated self-harm, and the process of learning to work with repeated self-harm, and are reported in accordance with the consolidated criteria for reporting qualitative research guidelines (COREQ). Participants reported that nursing practice relating to repeated self-harm remains largely focused on maintenance of safety and prevention of self-harm despite the identification that this often does not work. It was accepted that there is sometimes a lack of understanding about the function of self-harm; however, participants reported understanding increased following specific education about self-harm. Participants also identified the potential for more empowering and recovery-orientated responses, including the utilization of harm reduction approaches, to the care of those who repeatedly self-harm.

Prevalence and Clinical Correlates of Self-Harm Behaviors in Gilles de la Tourette Syndrome

Introduction: Major symptoms of Gilles de la Tourette syndrome (GTS) are tics, but in 90% of cases, psychiatric comorbidities occur. Self-harm behaviors (SHBs) could result from deliberate action and unintentional injury from tics. Methods: We examined 165 consecutive GTS patients aged 5 to 50 years (75.8% males). The median duration of GTS was 14 years (interquartile range, 9-22 years). The patients were evaluated for GTS and comorbid mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Self-harm behavior was diagnosed during the interview. To determine a direct relationship between SHB and clinical variables, we conducted two analyses, at the time of evaluation and lifetime. We also compared the group of children and adults with SHB. We also tried to distinguish between deliberate (non-tic-related SHB) and accidental (tic-related SHB). Results: Lifetime SHB was reported by 65 patients (39.4%), and in 55 of the cases, it was present at the time of evaluation. The age at the onset of SHB was reported in 55 of the cases (84.6%), and the median was 10 years (interquartile range, 7-13 years). In 30 of the patients (46.2%), SHB was evaluated as mild; in 26 (40%), as moderate; and in only 9 cases (13.9%), as severe. In the multivariable analysis for the predictor of lifetime SHB, attention-deficit/hyperactivity disorder (p = 0.016) and obsessive-compulsive disorder (OCD; p = 0.042) were determined as risk factors, while for current SHB, only tic severity (p < 0.0001) was statistically significant. When comparing predictors of SHB for children and adults, tic severity was determined as predictor for lifetime SHB in children (p < 0.0001), while the anxiety disorder was associated with lifetime SHB in adults (p = 0.05). Similarly, tic severity was a predictor of current SHB in the children group (p = 0.001), but this was not confirmed for adults. The group of patients with tic-related and non-tic-related SHB did not differ. Conclusions: Self-harm behavior appears mostly in children and adolescents and rarely begins in adulthood. Self-harm behavior is associated mainly with tic severity, obsessive-compulsive disorder, and attention-deficit/hyperactivity disorder. Clinical correlates of SHB are age related and differ at different points of life. Tic severity is the main factor associated with SHB in children. In the adult group, anxiety disorder and other psychiatric comorbidities may play the most important role.

Adolescent self-harm prevention and intervention in secondary schools: a survey of staff in England and Wales

BACKGROUND

Adolescent self-harm is a major public health concern. To date there is a limited evidence-base for prevention or intervention, particularly within the school setting. To develop effective approaches, it is important to first understand the school context, including existing provision, barriers to implementation, and the acceptability of different approaches.

METHODS

A convenience sample of 222 secondary schools in England and Wales were invited to participate in a survey, with a 68.9% (n = 153) response rate. One member of staff completed the survey on behalf of each school. Participants responded to questions on the existing provision of adolescent self-harm prevention and intervention, barriers to delivery, and future needs.

RESULTS

Adolescent self-harm is an important concern for senior management and teachers. However, emotional health and well-being is the primary health priority for schools. Health services, such as Child and Adolescent Mental Health Services, and on-site counselling are the main approaches schools currently use to address adolescent self-harm, with counselling cited as the most useful provision. Fifty-two per cent of schools have received some staff training on adolescent self-harm, although only 22% rated the adequacy of this training as high. Where schools do not have existing provision, respondents stated that they would like staff training, specialist student training, external speakers, posters and assemblies, although the latter four options were infrequently ranked as the most useful approaches. Key barriers to addressing adolescent self-harm were: lack of time in the curriculum; lack of resources; lack of staff training and time; and fear of encouraging self-harm amongst adolescents.

CONCLUSIONS

Adolescent self-harm is a priority for schools. Intervention might focus on increasing the availability of training to teaching staff.

Self-injury: Treatment, Assessment, Recovery (STAR): online intervention for adolescent non-suicidal self-injury - study protocol for a randomized controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) is a clinically significant behavior affecting approximately 18% of adolescents and young adults worldwide. The importance of NSSI is supported by its association with a broad spectrum of mental disorders. Despite its high relevance, evidence-based, specific, time-, and cost-effective treatment approaches are scarce. Cognitive behavioral therapy (CBT) seems effective in reducing the frequency of NSSI in adolescents and young adults. However, young people are often reluctant to seek professional help and effective interventions adressing NSSI are not sufficiently available across all regions of Germany. Research indicates that the majority of youth with risk behavior (including NSSI) prefer technology-based interventions. To date, effective interventions for adolescents and young adults with NSSI that are deliverd online are not available.

METHODS

The present project aims to develop and evaluate an online intervention for adolescents and young adults with NSSI based on the content of a recently evaluated face-to-face short-term program that includes elements of CBT and dialectical behavior therapy (DBT): "The Cutting Down Programme" (CDP). The efficacy of the new online CDP intervention will be tested in a randomized controlled trial (RCT) in which n = 700 youths engaging in repetitive NSSI will participate in either an online psychoeducation (n = 350) or online CDP (n = 350). Within a postline assessment four months after baseline (end of treatment; T1), and follow-up evaluations 12 and 18 months after baseline (follow-ups; T2 and T3), NSSI and comorbid symptoms as well as quality of life will be assessed. It is hypothesized that participants receiving online CDP report a greater reduction in the frequency of NSSI within the last three months at T2 (primary endpoint) compared to those receiving online psychoeducation. Exploratory analyses will focus on predictors of treatment outcome.

DISCUSSION

We report on the development and evaluation of an online intervention for adolescents and young adults engaging in NSSI based on the CDP. If supported by empirical evidence, an online-based intervention for NSSI might help to overcome the limited availability of adequate interventions for youth.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00014623 . Registered on 22 May 2018.

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.

A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care

OBJECTIVES

Young people in the public care system ('looked-after' young people) have high levels of self-harm.

DESIGN

This paper reports the first detailed study of factors leading to self-harm over time in looked-after young people in England, using sequence analyses of the Card Sort Task for Self-harm (CaTS).

METHODS

Young people in care (looked-after group: n = 24; 14-21 years) and young people who had never been in care (contrast group: n = 21; 13-21 years) completed the CaTS, describing sequences of factors leading to their first and most recent episodes of self-harm. Lag sequential analysis determined patterns of significant transitions between factors (thoughts, feelings, behaviours, events) leading to self-harm across 6 months.

RESULTS

Young people in care reported feeling better immediately following their first episode of self-harm. However, fearlessness of death, impulsivity, and access to means were reported most proximal to recent self-harm. Although difficult negative emotions were salient to self-harm sequences in both groups, young people with no experience of being in care reported a greater range of negative emotions and transitions between them. For the contrast group, feelings of depression and sadness were a significant starting point of the self-harm sequence 6 months prior to most recent self-harm.

CONCLUSIONS

Sequences of factors leading to self-harm can change and evolve over time, so regular monitoring and assessment of each self-harm episode are needed. Support around easing and dealing with emotional distress is required. Restricting access to means to carry out potentially fatal self-harm attempts, particularly for the young persons with experience of being in care, is recommended.

PRACTITIONER POINTS

Self-harm (and factors associated with self-harm) can change and evolve over time; assessments need to reflect this. Looked-after young people reported feeling better after first self-harm; fearlessness of death, access to means, and impulsivity were reported as key in recent self-harm. Underlying emotional distress, particularly depression and self-hatred were important in both first and most recent self-harm. Looked-after young people should undergo regular monitoring and assessment of each self-harm episode and access to potentially fatal means should be restricted. The CaTS would have clinical utility as an assessment tool Recruiting participants can be a significant challenge in studies with looked-after children and young people. Future research with larger clinical samples would be valuable.

Motivations for adolescent self-harm and the implications for mental health nurses

WHAT IS KNOWN ON THE SUBJECT?: Self-harm is a relatively common occurrence in adolescents; however, there remains a lack of understanding about the motivations behind adolescent self-harm, and this poor understanding can have a negative impact on how mental health professionals respond to young people who self-harm. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper identifies the reasons for self-harm in a community sample of young people and finds that the functions of self-harm differ for different people and that there may be multiple reasons for self-harm. Findings provide support for the affect-regulation model of self-harm which states that young people self-harm to regulate how they are feeling, but provides little support for the interpersonal influence model which proposes that self-harm is an attempt to influence how other people respond to them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Self-harm for most young people serves at least one specific function and is an indication of distress. There is a requirement for a non-pathologizing response towards young people who self-harm; self-harm should be understood as a meaningful behaviour rather than a symptom of an illness. Mental health nurses need to understand the multiple functions of self-harm. A better understanding of the individualized meaning behind self-harm can positively impact on attitudes towards young people who self-harm and provide for improved mental health service provision.

ABSTRACT

Introduction Although self-harm is a relatively common occurrence in adolescents, there is a lack of understanding about the motivations behind it. A poor understanding of self-harm contributes to negative perceptions about those who self-harm and a poor healthcare experience. Aim & Methods This study identifies motivations behind self-harm in school-based adolescents using a cross-sectional survey. Motivations behind self-harm were elicited using a scale and open-ended responses. Results Of the 856 adolescents who completed the survey across 11 postprimary schools, 103 reported a history of self-harm. The most commonly endorsed reason for self-harm was to 'get relief from a terrible state of mind' (79%). Open-ended responses were consistent with scale responses with most reporting that they self-harmed to relieve distressing emotions. Discussion Findings provide support for the affect-regulation model of self-harm with support also demonstrated for the self-punishment and antidissociation models. There was little support for the interpersonal influence model suggesting that the commonly held belief that self-harm is attention-seeking is one attributed by others to young people, and not widely reported by young people themselves. Implications for practice Mental health services need to be responsive to the needs of young people who self-harm which requires eliciting and understanding the individual and multiple meanings behind self-harm to best inform treatment options.

Health related quality of life and psychopathological distress in risk taking and self-harming adolescents with full-syndrome, subthreshold and without borderline personality disorder: rethinking the clinical cut-off?

BACKGROUND

Diagnostic standards do not acknowledge developmental specifics and differences in the clinical presentation of adolescents with borderline personality disorder (BPD). BPD is associated with severe impairments in health related quality of life (HRQoL) and increased psychopathological distress. Previously no study addressed differences in HRQoL and psychopathology in adolescents with subthreshold and full-syndrome BPD as well as adolescents at-risk for the development but no current BPD.

METHODS

Drawing on data from a consecutive sample of N = 264 adolescents (12-17 years) presenting with risk-taking and self-harming behavior at a specialized outpatient clinic, we investigated differences in HRQoL (KIDSCREEN-52) and psychopathological distress (SCL-90-R) comparing adolescents with no BPD (less than 3 criteria fulfilled), to those with subthreshold (3-4 BPD criteria) and full-syndrome BPD (5 or more BPD criteria). Group differences were analyzed using one-way analysis of variance with Sidak corrected contrasts or Chi-Square test for categorical variables.

RESULTS

Adolescents with subthreshold and full-syndrome BPD presented one year later at our clinic and were more likely female. Adolescents with subthreshold and full-syndrome BPD showed greater Axis-I and Axis-II comorbidity compared to adolescents with no BPD, and reported greater risk-taking behaviour, self-injury and suicidality. Compared to those without BPD, adolescents with subthreshold and full-syndrome BPD reported significantly reduced HRQoL. Adolescents with sub-threshold BPD and those with full-syndrome BPD did not differ on any HRQoL dimension, with the exception of Self-Perception. Similar, groups with sub-threshold and full-syndrome BPD showed no significant differences on any dimension of self-reported psychopathological distress, with the exception of Hostility.

CONCLUSIONS

Findings highlight that subthreshold BPD in adolescents is associated with impairments in HRQoL and psychopathological distress comparable to full-syndrome BPD. Findings raise awareness on the importance of early detection and question the diagnostic validity and clinical utility of existing cut-offs. Findings support a lower diagnostic cut-off for adolescent BPD, to identify those at-risk at an early stage.

Changes in parenting strategies after a young person's self-harm: a qualitative study

BACKGROUND

When faced with the discovery of their child's self-harm, mothers and fathers may re-evaluate their parenting strategies. This can include changes to the amount of support they provide their child and changes to the degree to which they control and monitor their child.

METHODS

We conducted an in-depth qualitative study with 37 parents of young people who had self-harmed in which we explored how and why their parenting changed after the discovery of self-harm.

RESULTS

Early on, parents often found themselves "walking on eggshells" so as not to upset their child, but later they felt more able to take some control. Parents' reactions to the self-harm often depended on how they conceptualised it: as part of adolescence, as a mental health issue or as "naughty behaviour". Parenting of other children in the family could also be affected, with parents worrying about less of their time being available for siblings. Many parents developed specific strategies they felt helped them to be more effective parents, such as learning to avoid blaming themselves or their child for the self-harm and developing new ways to communicate with their child. Parents were generally eager to pass their knowledge on to other people in the same situation.

CONCLUSIONS

Parents reported changes in their parenting behaviours after the discovery of a child's self-harm. Professionals involved in the care of young people who self-harm might use this information in supporting and advising parents.