Dr Sophia Morgan and Prof Carol Fitzpatrick look at deliberate self-harm in young people, examine the best ways to assess such an episode and indicate when to seek specialist treatment
The term deliberate self-harm (DSH) is used to describe ‘a nonfatal act in which an individual deliberately intended to cause self-harm through injury, ingestion of a substance in excess of the prescribed or therapeutic dose, ingestion of an illicit/recreational drug that was an act the individual regarded as self-harm or ingestion of a non-ingestible substance or object’ (Hawton et al, 2000).
Most commonly, DSH is a behaviour that is used to cope with difficult or painful feelings. Self-harm may be a strategy that appears attractive or effective to young people because it allows them to express their emotional pain and frustration without harming anyone else; it may be a way of communicating to people that one needs support; or it may offer a sense of control when they often feel they have none.
DSH is not a diagnosis but a dysfunctional behaviour, and as such is seen in a diverse range of patients, and is associated with a heterogenicity of psychological and psychiatric disorders.
Risk factors include: young age between 15-25 years; female gender; mental health problems of the child; and negative life experiences such as disrupted upbringing, parental problems and ongoing family relationship problems (Fox & Hawton, 2004).
Adolescent DSH has been linked to affective anxiety, substance abuse and eating disorders [Fortune & Hawton, 2005]. A consistent research finding is that a strong and direct link exists between adolescent DSH and depression.
Several personality and psychological variables have also been consistently linked to increased risk of suicidal behaviour in young people. These include: coping style; problem-solving deficits; cognitive distortions; affect regulation; self-esteem; irritability and impulsivity.
Finally, there is a well-documented association between DSH in adolescents and family dysfunction (Kerfoot et al, 1996). Impaired parent-child relationships, poor family communication styles and extremes of parental expectations and control have all been shown to be associated with adolescent DSH.
DSH is increasingly common in young people and is a serious public health problem in Ireland. In a recent study of 4,583 Irish adolescents, a history of DSH was reported by 9 per cent of respondents (National Suicide Research Foundation, 2004).
The most common methods used were cutting (66 per cent) and taking an overdose (35 per cent). Of those who had self-harmed, less than 12 per cent had attended medical services afterwards.
Levels of DSH are one indicator of mental health and well-being of young people in our society. Furthermore, a history of one or more acts of DSH is the strongest known predictor of repeated suicidal behaviour, both fatal and nonfatal (‘Reach Out – Irish National Strategy for Action on Suicide Prevention 2005-2014’).
Follow-up studies indicate that at least 1 per cent of patients presenting to general hospitals after DSH die by suicide within one year and 3-5 per cent do so within 10 years (Hawton & Fagg, 1998; Appleby, 1992). Considering this, it is imperative that effective means of identifying and managing self-harm in Irish adolescents be developed and resourced.
While there can be telltale signs (scars on arms or legs, a pattern of curious abrasions), equally often the signs are more subtle. Many young people who self-harm do so secretively, and this secrecy may be the only obvious red flag.
They may seem distracted, preoccupied or distant, and may retreat to a private space to self-harm. More overt signs may be the offering of vague or implausible excuses for wounds.
In an attempt to hide wounds, they might start wearing long sleeves/trousers in warm weather. More obvious still is the discovery of a hoard of implements (paper clips, razor blades, pieces of glass etc) stored in unusual locations.
Changes in behaviour may be noticed such as social withdrawal, sensitivity to rejection, difficulty handling anger or the showing of feelings of extreme shame or self-loathing. When pressed for details, the young person may grow guarded or anxious, and seem annoyed by the ‘intrusiveness’ of the questions. Other signs to look for are behaviours such as eating disorders, alcohol or drug abuse, which can accompany self-harm.
In the case of an acute self-harm episode, immediate assessment of the medical consequences of the self-poisoning or self-injury is needed, as well as a brief assessment of the patient’s psychiatric status and risk of further self-harm (consider depression, hopelessness and suicidal intent). Potential methods of self-harm should be removed and staff should be made aware of the possibility that the patient might leave before the psychiatric assessment has been conducted.
A referral to the emergency department should be made for all cases of suspected self-poisoning, and any case of self-injury that poses a significant risk to the young person. Arrangements should be made for an appropriate chaperone to accompany the young person, especially if there is a risk of further self-harm, risk of absconding or the young person is very distressed.
When urgent referral to the emergency department is not deemed necessary, an urgent referral to the local Child and Adolescent Mental Health Service (CAMHS) should be made. Parents should be advised to remove all means of self-harm, including medication, before the child or young person goes home.
In the non-acute scenario, consultation patterns indicate that most people who self-harm consult their GP soon after the episode. This consultation may provide an opportunity for preventing repeat self-harm and suicide (Gunnell et al, 2002).
The psychiatric assessment of the patient should ideally take place once any potential neuro-toxic/intoxication effects of the self-harm attempt have worn off. However, an urgent assessment is warranted if the patient is severely disturbed or at acute risk.
A comprehensive biopsychosocial assessment should be carried out, and should be supplemented by collaterals from other sources including parents, teachers or other professionals involved in their care.
The purpose of the psychiatric assessment is: to assess suicidal ideation and risk of acting on suicidal or self-harming impulses; to assess the young person’s overall mental health and development and determine whether they have a serious psychiatric disorder (psychosis, depression); assess their psychosocial situation; and, determine the ability of responsible adults to ensure their safety.
Decisions about referral, discharge and admission should be based on this comprehensive assessment, needs and risks. Where possible, the young person and their family should be involved in this decision-making process.
Typically, suicidal adolescents receive periods of intensive intervention following a suicide attempt, followed by intermittent low-intensity contact.
After their emergency department mental health assessment, the young person is usually discharged to the care of their parents or guardians, and a follow-up appointment is arranged in their local community mental health clinic. Young people who attempt suicide are particularly bad at complying with treatment. As a result, the aftercare of deliberate self-harmers can be problematic.
No one treatment has been found effective in stopping DSH among children and young people, but some interventions do positively affect other factors associated with self-harm in this population, such as depression and emotional control.
A number of treatment options that have shown promising results in individual studies including problem-solving therapy, cognitive-behavioural therapy, dialectic behavioural therapy, assertive outreach and family therapy (Fortune & Hawton, 2005).
Self-help groups and peer support programmes have also been proposed as potentially effective means of providing some sort of help to children and adolescents who self-harm.
However, as the existing research lacks robust methodology, and few intervention studies have specifically investigated this age group, there is little consensus regarding the most effective aftercare for treating young people with DSH.
Dr Sophia Morgan, Senior Registrar in Child and Adolescent Psychiatry and Prof Carol Fitzpatrick, Consultant Child and Adolescent Psychiatrist, St Frances’ Clinic, Children’s University Hospital, Temple Street.
The SPACE programme:
Parents and carers of self-harming young people experience a range of conflicting emotions including distress, anger, frustration, fear, vulnerability, anxiety and powerlessness. Families often need help coping with these emotions, as well as working out how to provide their child with the support that is needed.
The DSH Team in the Children’s University Hospital, Temple Street, was set up in 2002 in response to the growing number of cases of young people presenting to the emergency department following incidences of self-harm.
Through its experience with working with the families of these young people, the team identified a clear need to provide structured support for parents/carers of young people who have self-harmed.
The SPACE Programme was designed by the team as a support programme for parents and carers of children who have engaged in DSH.
It was developed following a focus group meeting with parents and carers of young people with DSH, and designed specifically upon their needs expressed.
As well as providing essential peer support, the programme includes: information and education around DSH; parenting, boundaries and communicating with adolescents; practical skills around dealing with episodes of DSH; and re-establishing family dynamics following DSH.
To date, eight cycles of the programme have been run with much success. On completing the programme, participants have reported lower levels of difficulties and distress, as well as increased parental satisfaction.
The next SPACE Programme will run on Tuesday evenings over a six-week period from October to November 2009, in Wynn’s Hotel, Lower Abbey Street, Dublin 1 from 7.30pm to 9pm.