1. Juvenile Self-Harm as it Relates to Thinking Impairment, Age, and Abuse.
Amanda Moen, Katrina Poppert, and Laura Hasemann
University of Nebraska - Lincoln
Results (continued)
with mild Thinking impairment than for those with minimal or no impairment. Juveniles in age group 3 (14.72 years years) with minimal or no impairment had a significantly lower mean Self-Harm score than both other impairment categories, with the larger difference being found in comparison to those with moderate impairment. In concordance with the research hypothesis, those who were only physically abused in age group 1 had a significantly higher mean Self-Harm scale score when they exhibited moderate levels of Thinking impairment, such that a larger effect was found when comparing mild and moderate scores. Also is support of the research hypothesis, juveniles in age group 2 with minimal or no impairment had a significantly lower mean Self-Harm score than both other impairment categories, with the larger difference being found in comparison to those with moderate impairment. Contrary to the research hypothesis, in age group 3 mean Self-Harm scores did not significantly differ across levels of Thinking impairment. Contrary to the research hypothesis, those children who were only sexually abused in age group 1 with minimal or no Thinking impairment exhibited a significantly greater mean self-harm score than those who were mildly impaired. In partial concordance with the research hypothesis, juveniles in age group 2 with mild Thinking impairment had a significantly higher mean Self-Harm score than those with minimal or no Thinking impairment, with no significant difference in either level with those in the moderate Thinking impairment condition. Contrary to the research hypothesis, the mean Self-Harm scores of those in age group 3 did not significantly differ across levels of Thinking impairment. Among children who were both physically and sexually abused, in partial support of the research hypothesis, those in age group 1 with minimal or no impairment had significantly lower mean Self-Harm scores than those in the other two conditions, with there being no significant difference in mean Self-Harm scores between mild and moderate impairment. Partially in concordance with the research hypothesis, in age group two, the mean Self-Harm scores of those with mild
Introduction
Empirical studies have examined the risk factors associated with deliberate self-harm in children and adolescents. Two common factors that are repeatedly shown to be related to self-harming behaviors are prior physical abuse and sexual abuse (Boudewyn & Liem, 1995; Raj, Kumaraiah, & Bhide, 2000; Uchida, 1995). Sexual abuse has been specifically identified as an associate of self-harm in juveniles (Fanous, Prescott, & Kendler, 2004; Fliege, et al., 2009; Morgan & Hawton, 2004; O’Connor, Rasmussen, & Hawton, 2009).
Studies have also looked at the association of age and self-harm, with the majority of prior research having been conducted on adolescent populations. While the results are mixed, it has been commonly found that deliberate self-harming behaviors increase between the age of 12 and 13 (Hawton & Harriss, 2008; Sourander, et al., 2006). Furthermore, Sourander, et al. (2006) found that the difference in self-harm levels between males and females decreases after 14 years of age, with the females aged engaging in more self-harm than their same-aged male counterparts. In older adolescents the same trend was found, although there was a general decrease in the amount of self-harming behaviors, with female levels dropping more drastically than male levels.
Additionally, prior research has demonstrated that psychosocial impairment in children is related to self-harm. Self-harming behaviors among juveniles have been linked to poor relationship quality (Boudewyn, & Liem, 1995; Laukkanen, et al., 2009; Morgan & Hawton, 2004), and feelings of hopelessness (Hjelmeland & Grøholt, 2005; Kinyada, Hjelmeland, & Musisi, 2005). Further studies have linked other psychosocial factors, such as depressed mood (Boudewyn & Liem, 1995; Fliege, et al., 2009; Laukkanen, et al., 2009) and low self-esteem (Boudewyn & Liem, 1995; Hjelmeland & Grøholt, 2005) to self-harm in juveniles.
The purpose of the current study was to assess the relationship of age, history of physical, history of sexual abuse, and Thinking subscale scores to Self-Harm subscale scores at pre-treatment. It was hypothesized that older youths who were physically or sexually abused, especially sexually abused, and who exhibited high levels of impairment on the Thinking subscale would show significantly greater impairment on the Self-Harm subscale. It was also hypothesized that those with no history of either type of abuse, but with higher levels of impairment on the Thinking subscale, would exhibit higher Self-Harm subscale scores. This study seeks to understand further the relationship of all of theses variables so as to better comprehend the complex nature of self-harming behaviors in juveniles.
Results (continued)
impairment were significantly greater than the scores of those with minimal or no impairment, or moderate impairment. In concordance with the research hypothesis, those in age group 3 with moderate impairment had the highest mean Self-Harm scale scores, with the significant mean difference being greater for those with minimal or no impairment than those with mild impairment.
There was a significant main effect of Thinking scale impairment, F(2, 425) = , p < .001, MSe = See Figure 4. In concordance with the research hypothesis, further examination of cell means, using LSDmmd = 2.147, yielded an overall positive and successively increasing linear trend, such that with each successive level of Thinking impairment severity, Self-Harm scores increased. See Figure 2. This main effect is misleading, however, because successive increases in mean Self-Harm scores as severity of Thinking impairment increases is not descriptive for any level of age at any combination of abuse history. The main effect was partially descriptive of the 4-way, based on LSDmmd = In partial support of the research hypothesis, in age group 1, for those who had been only physically abused, mean Self-Harm scores were not significantly different for those with minimal or no impairment and those with mild impairment. Juveniles in age group 1 with moderate impairment had significantly higher mean scores than either other group with a larger difference found when comparing minimal or no impairment to moderate impairment. Contrary to the research hypothesis, for those with no history of abuse in age group 1, there was no significant mean score difference across Thinking impairment conditions. In partial support of the research hypothesis, juveniles with both types of abuse and minimal or no Thinking impairment had significantly lower mean Self-Harm scores than either other group, with age group 2 and 3 having the same Self-Harm score. In concordance with the research hypothesis, those in age group 2 with only physical abuse and minimal or no Thinking impairment had significantly lower mean Self-Harm scores than either other group, with a larger difference with moderate rather than mild impairment, and the mean Self-Harm scores of age groups 2 and 3 not being significantly different. In partial concordance with the research hypothesis, juveniles with no history of abuse and moderate Thinking impairment in age group 2 had a significantly greater mean Self-Harm score than the other Thinking impairment conditions, with a larger difference found with mild impairment, and with no significant difference in mean scores between minimal or no impairment and mild impairment. In partial support of the research hypothesis, those in age group 2 who had experienced sexual abuse and either history of physical abuse, with minimal or no impairment had significantly lower mean Self-Harm scores than those with mild impairment, but did not have significantly different mean scores than those with moderate impairment. Contrary to the research hypothesis, for those with both types of abuse in age group 2, mild impairment had a significantly greater mean Self-Harm score than those with moderate impairment, whereas for those with only physical abuse, there was no significant difference in mean scores when comparing mild impairment to moderate impairment. In partial support of the research hypothesis, among juveniles in age group 3, those with minimal or no thinking impairment, regardless of combination of abuse or no abuse, did not have significantly different scores from those with mild impairment, except for in those children without a history of abuse, such that those with mild impairment had greater Self-Harm scores than those with minimal or no impairment. In support of the research hypothesis, those in age group 3 who had experienced physical abuse, for either level sexual abuse history, with mild impairment had significantly lower mean Self-Harm scores than those with moderate impairment. Contrary to the research hypothesis, those who had not experienced physical abuse, for either level of sexual abuse history, had no significant mean difference in Self-Harm scores between mild impairment and moderate impairment groups. And in partial support of the research hypothesis, all those in age group 3, regardless of abuse history, with moderate impairment had significantly greater mean Self-Harm scores than those with minimal or no impairment, except for those who had not experienced either type of abuse, such that there was no significant difference in the mean scores of those with minimal or no impairment and moderate impairment.
No other interactions or main effects than the two aforementioned were significant.
Table 1. Mean Self-Harm Subscale Scores
Figure 1. Mean Self-Harm Subscale Scores
Method
Participants
Participants consisted of 460 juvenile delinquents recruited from the state of Nebraska, as part of an Omni Behavioral Health contribution to a state wide evaluation of alternative behavioral treatments. The youths ranged in age from 3.81 to years (M = , SD = 3.434), and for the purposes of this study, participants were separated by age into 3 equal groups, with those from 3.81 years to11.76 years of age being in age group 1, those from years to years of age being in age group 2, and those from years to years of age being in age group 3. The majority of participants were male (69.0%), and the bulk of the sample consisted of European Americans (81.6%), with the remainder being classified as non-white (18.4%).
Measures
Child and Adolescent Functioning Assessment Scale (CAFAS) – The CAFAS is a scale composed of eight subscales that assess youth impairment. The scales are: School/Work (functions acceptably in a group education environment), Home (performs age appropriate tasks and follows rules), Community (acts lawfully towards others and their property), Behavior Toward Self and Others (suitability of youth’s everyday behavior), Self-Harmful Behavior (extent to which youth is capable of coping without employing self-harmful behaviors or verbalizations), Substance Abuse (Youth’s substance abuse and how inappropriate or disruptive it is in nature), and Thinking (ability of the youth to utilize rational thought processes) (Hodges, K. Doucette-Gates, A., & Kim, C., 2000). Each subscale is comprised of a set of behavioral descriptions (e.g., failing most classes) that are grouped into levels of impairment. Each level is allocated a numerical value: severe impairment (30), moderate impairment (20), mild impairment (10), and minimal or no impairment (0). The rater administering the scale identifies items that illustrate the youth’s severest functioning during a specific time period, and the youth’s score for each subscale is determined by the level of severity in which the items appear (e.g., failing most classes is severe impairment on the School/Work subscale). For each subscale there is a corresponding set of goals and strengths relevant to each domain. A total score for the CAFAS is generated by combining the scores of each of the eight scales, and ranges from 0 to 240. A higher score indicates a greater level of impairment in functioning. (Hodges, K., Xue, Y, & Wotring, J., 2004).
Procedure
Participants received treatment at the cost of the State of Nebraska, with no extra compensation. Youths completed the CAFAS at pre-treatment, mid-treatment (6 months) and post-treatment (12 months). Age, ethnicity and other child characteristics were acquired through a demographic questionnaire administered at pre-treatment. The scores on the Thinking scale were used to assess their relationship to Self-Harm scale scores, in combination with age and history of sexual and physical abuse. For the purpose of this study, the severe Thinking impairment condition was removed from the analysis due to a lack of participants.
Discussion
The present study examined how age, physical abuse history, sexual abuse history and Thinking impairment are related to Self-Harm subscale scores. Contrary to the research hypothesis, the oldest children with either type of abuse experience (or both) and moderate Thinking impairment did not exhibit significantly greater mean Self-Harm scores, except in 2 conditions: for those with no abuse history at all, such that a significant difference between age groups 1 and 3 was found, and for those with both types of abuse history, such that age group 2 having a significantly lower mean Self-Harm subscale score. Past research has not examined all of these variables together, so future research should replicate this study and examine if any patterns might be found in different populations.
Contrary to the research hypothesis, and prior research, which suggests that sexually abused children would have greater Self-Harm subscale scores, the current model suggests that there is no greater impact of sexual abuse over physical abuse (Fanous, Prescott, & Kendler, 2004; Fliege, et al., 2009; Morgan & Hawton, 2004; O’Connor, Rasmussen, & Hawton, 2009). This model even suggests that both types of abuse, by themselves or in conjunction, have no significant impact on Self-Harming behaviors, which was unexpected given the findings of prior literature that abuse has a significant impact on Self-Harming behaviors (Boudewyn & Liem, 1995; Raj, Kumaraiah, & Bhide, 2000; Uchida, 1995).
It was also hypothesized that those without a history of abuse who had higher levels of Thinking impairment would exhibit higher Self-Harm subscale scores. Prior research has demonstrated that Thinking impairment is related to Self-Harm scores (Boudewyn, & Liem, 1995; Fliege, et al., 2009; Hjelmeland & Grøholt, 2005; Kinyada, Hjelmeland, & Musisi, 2005; Laukkanen, et al., 2009; Morgan & Hawton, 2004), and in this model, those with moderate Thinking impairment in age group 2 had significantly greater Self-Harm scores than the other two conditions, and those with mild and moderate impairment had significantly higher levels of Self-Harm scores than those with minimal or no impairment. Future studies should address why those in age group 1 with the highest level of thinking impairment did not have greater levels of Self-Harming behaviors.
In partial support of prior studies, which found that Self-Harming behaviors generally peak around 12 or 13 years of age and drop off during adolescence (Hawton & Harriss, 2008; Sourander, et al., 2006), this model found that Self-Harming behaviors increased as the level of Thinking impairment became more severe. The significance here, along with the lack of significance of other interactions and main effects, suggests that Thinking impairment has a very important relationship to the prevalence of Self-Harming behaviors. Future research should concentrate on analyzing the impact of Thinking impairment, and perhaps examine gender differences, since one gender or another may be more prone to have greater levels of Thinking impairment, putting them at risk for performing more Self-Harming behaviors.
Future research should replicate the current study, but extend to include all levels of Thinking impairment so as to get the most complete representation of the relationship between Thinking impairment and Self-Harm subscale scores. The study would also assess the impact of gender. There some differences between the genders that could have an impact on which sex might perpetrate more self-harm, and it would be interesting to investigate how gender inter-relates with other variables in the relationship to self-harm.
*-There were no participants in this condition. The results were examined using a Type IV Sum of Squares and still found to be significant.
Figure 2. Main Effect of Thinking Impairment Subscale Scores for Self-Harm Subscale Scores
Results
A 4-way between groups ANOVA was used to examine the main effects and interactions of age, Thinking scale impairment, physical abuse history and sexual abuse history as they relate to Self-Harm scale scores. Figure 1 and Table 1 illustrate the mean Self-Harm scale score for each of the design conditions.
There is a significant 4 way interaction, F(3, 425) = 2.82, p = .039, MSe = Examination of the cell means (LSDmmd = 7.437), reveals that partial support of the hypothesis. Children who were not physically or sexually abused and were in age group 1(3.81 years years) did not show any significant mean difference in Self-Harm scale scores across levels of Thinking impairment. Those in age group 2 (11.77 years years) exhibited a significantly greater mean Self-Harm scale score when they had moderate Thinking impairment, with the effect being larger for those