1. Dr Michaela Swales Consultant Clinical Psychologist & Senior Lecturer

2. Describing the problem Self-injury includes: Self-poisoning Self-harm Important exclusions: Excessive consumption of alcohol or recreational drugs Mismanagement of physical health conditions Starvation in context of anorexia nervosa Body piercing

3. Methods of self-harm Broadly two types: self-poisoning and self-injury Assumptions cannot – and indeed should not – be made about motivation or intent of the behaviour based on the method Often people switch method or use more than one method at the same time in their life General population studies have shown self-injury to be more common than self-poisoning Cutting is the most common method of self-injury Less common methods: burning, hanging, stabbing, swallowing or inserting objects, shooting, drowning and jumping from heights or in front of vehicles

4. How common is self-harm? Meltzer et al (2001) 12, 529 children & young people 1.3% had tried to harm themselves – based on parental report Hawton et al (2002) 6,020 year 11 pupils 13.2% had at some point self-harmed, 6.9% in the last year Only 12% of those who had harmed had presented to hospital Rates vary between countries (Madge et al, 2008) Research in England, Canada & Australia report life-time rates of self-harm in school between 12-15% (2002-2005)

5. Outcomes of self-harm: Suicide Suicide rates are relatively low in young people 15-24 year olds: 0.86 and 0.30 per 1,000,000 in males and females respectively in England & Wales in 2010 BUT official suicide figures considerably underestimate likely rate of suicide in adolescents (Gosney & Hawton, 2007) Self-harm key risk factor for subsequent suicide Prospective longitudinal study across three centres in England Mortality across follow-up period of a median of 6 years was low (0.9%). Of these 51 deaths 49.0% were by suicide or probable suicide Self-cutting as means of self-harm was found to convey a greater risk of subsequent death by suicide than self- poisoning (Hawton et al, 2012)

6. Outcomes of Self-Harm: Repetition Repetition of self-harm is common. In hospital studies: Repetition rates within one year are between 15-20% Over longer periods repetition rates rise to 27-30%

7. Outcomes: resolution Recent study by Moran et al (2011) Longitudinal prospective study of 1943 adolescents across 7 waves of data collection between age 15 and 29 Substantial reduction in self-harm in late adolescence

8. Factors associated with self-harm Self-harm is common among the young – typical onset between 12-14 years – and more common among females Life events strongly linked with self-harm: Number and type of adverse events linked with self-harm Childhood sexual abuse, physical abuse and bullying Adverse interpersonal events (parents in younger adolescents, partners in older adolescents) frequently precipitate self- harm events Family history of self-harm has been shown to be a risk factor both in a twin study (Statham et al, 1998) and in a self-report study (Hawton et al, 2002)

9. Mental Health Foundation Report Bullied at school Not getting on with parents / siblings Parents getting divorced Worry about school work and exams Feeling isolated Bereavement Unwanted pregnancy Low self-esteem Physical, sexual or verbal abuse in the present or the past Self-harm or suicide of someone close to them Problems to do with sexuality Problems to do with race, culture or religion Feelings of rejection in the family or socially

10. Factors associated with self-harm Adolescents who self-harm in clinical samples – regardless of their intent – will in 90% of cases satisfy criteria for one or more psychiatric disorders Depression most common diagnosis Anxiety, conduct disorder, psychosis, high risk alcohol and drug use also associated Rates of psychiatric disorder unknown in non-referred samples

11. Factors associated with self-harm Psychological risk factors: impulsivity, poor problem-solving, hopelessness, self-criticism, perfectionism Sexual orientation: Lesbian, gay and bisexual people at heightened risk of self-harm compared to heterosexual people

12. Why do young people self-harm? Child and Adolescent Self-Harm in Europe (CASE) (Hawton & Rodham, 2006) Extensive study of self-harm in 15-16 year olds in the community covering seven countries Psychological pain motives most commonly endorsed “Wanting to get relief from a terrible state of mind” “Wanting to die” “Wanting to punish myself” “Wanting to show how desperate I was feeling”

13. The Developmental Challenge Adolescence a time of major physical and psychological change Rapid bodily changes can impact on self-esteem and sense of control Peer group become increasingly important in terms of identity Trajectory is to individuate from adults Brain and psychological changes impact on capacity to solve problems and to think about the future

14. Self-harm a problem for the adults Self-harm a solution for the young person

15. Problem Solving Model Illustration Intolerable Problem Option 3: Suicidal / Self-Harm Behavior Option 3: Suicidal / Self-Harm Behavior Individual Sees Only Three Problem Solving Options Option 1: Won’t Work Option 2: Resources Unavailable © Marsha Linehan & BTech LLC 2010

16. Population-based interventions Restriction of access to potentially lethal means Media guidance on reporting of self-harm and suicide Psychoeducation Training primary care workers in the screening and detection of people at risk

17. NICE Guidelines Two guidelines Short-term (48 hours) management Longer-term management

18. Longer-Term Management Guidance for Child & Adolescent Mental health Services on: Psychosocial assessment Interventions Psychological treatments