Self-harm in young people

Association of screen-based activities and risk of self-harm and suicidal behaviors among young people: A systematic review and meta-analysis of longitudinal studies

Emerging evidence suggests that screen-based activities are associated with self-harm and suicidal behaviors. This study aimed to examine these associations among young people through a meta-analysis. We systematically searched EBSCO pshyARTICLES, MEDLINE (via PubMed), EMBASE, and Web of Science from their inception to April 1, 2022, and updated on May 1, 2024. Longitudinal studies reporting the association between various screen-based activities and subsequent self-harm and suicidal behaviors in young people aged 10 to 24 were included. Nineteen longitudinal studies were included in the qualitative synthesis, and 13 studies comprising 43,489 young people were included in the meta-analysis, revealing that total screen use is significantly associated with the risks of self-harm and suicidal behaviors. Cyberbullying victimization was also related to these adverse outcomes. Subgroup analyses indicated that social media use and problematic screen use are significant risk factors for self-harm and suicidal behaviors. Study quality was appraised using the Newcastle-Ottawa Scale, and potential publication bias was deemed unlikely to affect the results significantly. These findings suggest that screen-based activities should be considered in the management and intervention strategies for self-harm and suicidal behaviors in young people.

Self-Harm in Eating Disorders (SHINE): a mixed-methods exploratory study

INTRODUCTION

Self-harm is highly prevalent among young people with eating disorders. However, why a young person may develop and continue to experience both an eating disorder and self-harm is unclear. This study will investigate the frequency, intensity, duration, function, context and processes of self-harm among people aged 16-25 diagnosed with an eating disorder. It will explore participants' perspectives on the genesis and functions of both their self-harm and eating disorder, as well as their support needs. The study was designed with the input of members of a Young Persons' Advisory Group, who will be key to study delivery and dissemination.

METHODS AND ANALYSIS

This exploratory study has a sequential mixed-methods explanatory design. Between 70 and 100 young people aged 16-25 with both an eating disorder diagnosis and self-harm thoughts and/or behaviours will be recruited from three NHS Eating Disorder outpatient services in England. Phase 1: a 14-day (six prompts per day) ecological momentary assessment (EMA) of participants' feelings, thoughts, motivations, behaviours and experiences of self-harm. Phase 2: 20-30 participants from phase 1 will be reapproached to take part in an in-depth qualitative interview on the psychological, emotional and social factors that underlie their self-harm and eating disorder as well as their support needs. EMA data from phase 1 will be analysed using descriptive and multilevel statistics. Qualitative interview data from phase 2 will be analysed using inductive and deductive thematic analysis. Results from both phases will be integrated using a mixed-methods matrix, with each participant's data from both phases compared alongside comparative analysis of the datasets as a whole.

ETHICS AND DISSEMINATION

The study gained ethical approval from the NHS HRA West Midlands-Black Country Research Ethics Committee (number: 296032). We anticipate disseminating findings to clinical, academic and lived experience audiences, at academic conferences, through peer-reviewed articles, and through various public engagement activities (eg, infographics, podcasts).

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.

Mental Health and Wellbeing in Young People in the UK during Lockdown (COVID-19)

This study aimed to assess the levels of mental wellbeing and potential for clinical need in a sample of UK university students aged 18-25 during the COVID-19 pandemic. We also tested the dose-response relationship between the severity of lockdown restrictions and mental wellbeing. We carried out a prospective shortitudinal study (one month between baseline and follow up) during the pandemic to do this and included 389 young people. We measured a range of facets of mental wellbeing, including depression, depressogenic cognition (rumination), wellbeing, stress and sleep disturbance. Our primary outcome was 'probable depression' as indexed by a score of ≥10 on the patient health questionnaire (PHQ-8). The prevalence of probable depression was significantly higher than pre-pandemic levels (55%) and did not decrease significantly over time (52%). Higher levels of lockdown severity were prospectively associated with higher levels of depressive symptoms. Nearly all students had at least one mental wellbeing concern at either time point (97%). The evidence suggests that lockdown has caused a wellbeing crisis in young people. The associated long-term mental, social, educational, personal and societal costs are as yet unknown but should be tracked using further longitudinal studies.

"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.

Mediating and moderating variables in the prediction of self-harm in young people: A systematic review of prospective longitudinal studies

BACKGROUND

Self-harm is widespread amongst young people. A growing body of research has explored factors that predict self-harm in young people, however, a systematic review of mediators and moderators of those factors has not yet been offered. This review aims to fill this gap by synthesising research about mediators and moderators of factors that prospectively predict self-harm in young people.

METHOD

A systematic review of research trials published up until 2018 was undertaken. Electronic databases Scopus (Elsevier), CINAHL, PsychINFO (EBSCO) and Medline were searched. Included studies utilised prospective longitudinal designs with participants aged 25 years or younger and self-harm outcome measures with published or reported psychometric properties. The aim of the review was to identify mediators and moderators of factors that predict self-harm in young people.

RESULTS

Of the 25 studies that met inclusion criteria, 22 reported at least one positive finding of a mediator or moderator. Specifically, 15 significant mediators and 20 significant moderators were identified in relation to a broad range of predictors of self-harm. Predictors were classified as adverse childhood experiences and parenting factors, psychological and psychiatric factors, social factors and intrapersonal factors. A number of potentially modifiable mediators and moderators were identified including interpersonal difficulties, impulsivity, self-esteem and self-compassion. Gender was the most commonly reported moderator.

LIMITATIONS

Included studies were assessed as limited by the heterogeneity of the mediators and moderators assessed, and by methodological factors including study durations, population characteristics, and the definition and assessment of self-harm. In addition, replication research was limited. Therefore it was difficult to integrate results and draw firm conclusions.

CONCLUSIONS

This review allowed us to explore diverse relationships between factors predictive of self-harm in young people and to identify a number of potentially modifiable mediators and moderators. Our findings have important implications for future research and treatment efforts as the identification of mediators and moderators is demonstrated to assist in identifying high risk individuals as well informing potential targets for treatment.

The psychic readiness for destruction among contemporary adolescents

AIMS AND OBJECTIVES

To verify the existence of psychic readiness for destruction among adolescent girls and to determine how psychic readiness for destruction is related to suicidal or violent behaviour in adolescence.

BACKGROUND

The psychic readiness for destruction can be treated as a generalised tendency (personality disposition) to behave in a way that increases the probability of negative consequences which directly and indirectly threaten one's life, health and its quality.

DESIGN

A retrospective cross-sectional study.

METHODS

The study involved 140 participants, aged 13-17, including 40 girls after suicide attempts (GS group), 40 girls using violence against others (GA group) and 60 girls without destructive behaviour at all (CG group). To measure psychic readiness for destruction, the polish adaptation of the Chronic Self-Destructiveness Scale (CS-DS) by Kelly was used.

RESULTS

No significant differences were found between the GS group and GA group. A significant difference was found between the girls who engage in interpersonal violence (GA) and the control group (CG). In this case, the results showed a significantly higher score among those participants who were involved in extremely aggressive behaviours. A similar trend was also observed when comparing the group of girls who attempted suicide (GS) with the CG.

CONCLUSIONS

Based on the conducted analyses, a clear trend was observed in consistency of destructive behaviours (tendency for destruction)-both active (seeking to violate norms, risky behaviours) and passive (omission, neglect) among the girls from both groups indicating even a single act of this kind (no significant differences between the groups).

RELEVANCE TO CLINICAL PRACTICE

Due to the complex nature of readiness for destruction and its negative consequences on health, it is imperative to investigate the risk factors for the tendency for destruction and to conduct health education among adolescents.

An interpretative phenomenological analysis of young people's self-harm in the context of interpersonal stressors and supports: Parents, peers, and clinical services

RATIONALE

Self-harm in young people is of significant clinical concern. Multiple psychological, social and clinical factors contribute to self-harm, but it remains a poorly understood phenomenon with limited effective treatment options.

OBJECTIVE

To explore young women's experience of self-harm in the context of interpersonal stressors and supports.

METHOD

Fourteen adolescent females (13-18 years) who had self-harmed in the last six months completed semi-structured interviews about self-harm and supports. Interpretative phenomenological analysis was undertaken.

RESULTS

Themes identified were: 1) Arguments and worries about family breakdown; 2) Unhelpful parental response when self-harm discovered and impact on seeking support; 3) Ongoing parental support; 4) Long-term peer victimization/bullying as a backdrop to self-harm; 5) Mutual support and reactive support from friends (and instances of a lack of support); 6) Emotions shaped by others (shame, regret and feeling 'stupid to self-harm'); and 7) 'Empty promises' - feeling personally let down by clinical services. These themes were organised under two broad meta-themes (psychosocial stressors, psychosocial supports). Two additional interconnected meta-themes were identified: Difficulties talking about self-harm and distress; and Impact on help-seeking.

CONCLUSION

Parents and peers play a key role in both precipitating self-harm and in supporting young people who self-harm. The identified themes, and the apparent inter-relationships between them, illustrate the complexity of self-harm experienced in the context of interpersonal difficulties, supports, and emotions. These results have implications for improving support from both informal and clinical sources.

Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm

We investigated public perceptions of, and responses to, adolescent self-harm-an under-researched topic, given that the majority of self-harm in this group is not disclosed to formal support services. Participants (N = 355, aged 18-67 years) were presented with 1 of 10 vignettes and completed self-report measures assessing perceived motivations for self-harm and helping/rejecting responses. Vignettes were manipulated across conditions for stated motivation, controllability of stated cause, and presentation format. Results indicate that stated motivation for self-harm, controllability of stated cause, and presentation format affect perceived motivations. Further, participants demonstrate an understanding of the complex nature of self-harm, indicating an appreciation that an individual may hold multiple motivations simultaneously. Perceived motivations for self-harm are associated with the endorsement of helping/rejecting behaviors. These relationships are important to explore, given the critical importance of initial responses to self-harm on subsequent disclosures and help-seeking.

Dealing with difficult days: Functional coping dynamics in self-harm ideation and enactment

BACKGROUND

Self-harm affords people a means of coping. However, little is known about how functional coping dynamics differ between stressful situations in which people self-harm (enactment), think about harming (ideation), or experience no self-harmful thoughts or behaviours.

METHODS

Participants (N = 1,157) aged 16-49 years (M = 18.21, SD = 3.24) with a recent history of self-harm (past 3 months) reported how they coped in response to their most significant recent stressor (3 months).

RESULTS

Almost 40% of participants, all of whom had self-harmed in the last 3 months, had no self-harm experience (thoughts or behaviours) in response to their most significant stressor in that time frame. In multivariate analysis, adjusting for symptoms of depression and anxiety, reappraisal coping was predictive of self-harm thoughts. Approach, emotion regulation and reappraisal coping were predictive of self-harm behaviour. Emotion regulation coping differentiated self-harm ideation and enactment groups.

LIMITATIONS

The cross-sectional design of the study precludes the ability to make inferences regarding causality. Further, there is no agreed definition of 'recent' self-harm.

CONCLUSIONS

Taken together, the findings suggest that functional coping dynamics may be differentially associated with self-harm ideation and enactment. This is important, given that understanding the transitions between ideation and enactment has been identified as a critical frontier in suicide prevention. Further, results indicate that seemingly innocuous events may have a profound impact as tipping points for enaction; this has implications for clinical practice, including the co-production of safety plans.

Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS)

BACKGROUND

Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm.

METHODS

Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams).

RESULTS

A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode.

LIMITATIONS

Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care.

CONCLUSIONS

The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.

Safety, Acceptability, and Use of a Smartphone App, BlueIce, for Young People Who Self-Harm: Protocol for an Open Phase I Trial

Background

Up to 18% of adolescents will engage in an act of self-harm before young adulthood, with the majority of acts occurring in private. Mobile apps may offer a way of providing support for young people at times of distress to prevent self-harm.

Objective

This is a proof-of-concept study designed to explore the safety, acceptability, feasibility, and usability of a smartphone app, BlueIce, with young people who are self-harming.

Methods

In this phase I open trial we will evaluate BlueIce, a smartphone app developed and coproduced with young people with lived experience of self-harm. BlueIce includes a mood-monitoring diary, selection of mood-lifting techniques based on cognitive behavior therapy and dialectical behavior therapy, and direct access to emergency telephone numbers. We will recruit young people (n=50) attending specialist child and adolescent mental health services with a current or past history of self-harm to trial BlueIce as an adjunct to their usual care. Questionnaires and interviews will be completed at baseline, postfamiliarization (2 weeks), and at follow-up (12 weeks after baseline) to assess safety, app use, and acceptability. Interviews will be undertaken with clinicians to assess the feasibility of BlueIce within a clinical setting.

Results

Recruitment occurred between May and November 2016. The recruitment target was 50, and by the beginning of November 54 young people had been referred.

Conclusions

This study is the first to evaluate an app specifically developed with young people for young people (under the age of 18 years) who self-harm. It will determine whether BlueIce is acceptable, how often it is used, and whether it is safe and does not have any unintentional adverse effects. This information will determine whether a feasibility trial to test recruitment, randomization, retention, and appropriate outcome measures should be pursued.

An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults

Six young adults (aged 19-21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.

Self-harm and life problems: findings from the Multicentre Study of Self-harm in England

PURPOSE

Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm.

METHODS

Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status.

RESULTS

Of 24,598 patients (36,431 assessed episodes), 57% were female and with a mean age of 33.1 years (SD 14.0 years), 92.6% were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (especially in those aged 35-54 years, and those who repeated self-harm). Those who repeated self-harm were more likely to report problems with housing, mental health and dealing with the consequences of abuse.

CONCLUSIONS

Self-harm usually occurs in the context of multiple life problems. Clinical services for self-harm patients should have access to appropriate care for provision of help for relationship difficulties and problems concerning alcohol and mental health issues. Individualised clinical support (e.g. psychological therapy, interventions for alcohol problems and relationship counselling) for self-harm patients facing these life problems may play a crucial role in suicide prevention.

Does drug treatment reduce the risk of further self-harm or suicide?

Self-harm is a significant social and healthcare problem, with substantial morbidity and healthcare costs. It has strong links to further self-harm and to suicide. The current review is one of three that investigate interventions in preventing recurrence of self-harm, and it focuses on pharmacological treatment. The conclusions are limited by the small number and size of trials identified, and the low quality of evidence. No benefit on recurrence of self-harm was detected in three small trials of antidepressants, but the types studied are ones that are now less commonly used. A small trial of flupentixol suggested a possible benefit on repetition, but this has not been replicated. One small trial of lithium showed no benefit, but this was in contrast to a recent large meta-analysis showing a significant anti-suicidal effect of lithium when used to treat mood disorder. The review highlights important areas for further research.

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.