1. Self Harm Cases Presenting to BC Children’s Hospital 1997-2002 Mhairi Nolan, CHIRPP Coordinator, Health Canada, BCIRPU Kate Turcotte, Social Science Researcher, BCIRPU Ian Pike, Director, BCIRPU

2. Introduction Describe the circumstances and means by which children & youth (5-19 years) are harming themselves, as presenting to BC Children's Hospital emergency department (1997-2002)

3. Ranking of cause of death among youth, by age group, BC, 1998-2002. (VISTA) Age Group (years) 5-910-1415-1920-24 Transport Neoplasms Intentional Injury Unintentional Injury CongenitalIntentional InjuryNeoplasms Endocrine & MetabolicCongenitalCirculatory System Nervous System Intentional InjuryCirculatory SystemCongenitalSigns/ Symptoms Infectious & ParasiticEndocrine & MetabolicRespiratory SystemEndocrine & Metabolic Circulatory SystemRespiratory SystemEndocrine & MetabolicCongenital Digestive SystemSigns/ SymptomsBloodRespiratory System

4. Five-year age specific mortality rates (per 100,000 population) due to suicide, BC, 2000-2004 (VISTA)

5. Five-year age specific hospital separation rates (per 100,000 population) due to suicide/self harm, BC, 1996/1997-2000/2001 (BC Health Data Warehouse)

6. Hospital separations rates (per 100,000 population) due to self harm among male youth, by age group (years), BC, 1989/90-2000/01. (BC Health Data Warehouse)

7. Hospital separations rates (per 100,000 population) due to self harm among female youth, by age group (years), BC, 1989/90-2000/01. (BC Health Data Warehouse)

8. Aim To continue the investigation of intentional injury among children and youth aged 5-19 years in BC, including: –suicide gestures –suicide attempts –self harm by ingestion, cutting, and burns & hanging

9. Methods Using the BC CHIRPP database, cases coded as intentional self harm were selected and analyzed for the years 1997 to 2002, ages five years and over Descriptive analysis provided for the dataset as a whole, as well as subdivided into the following five categories: –Suicide gestures –Suicide attempts –Ingestion –Cutting –Burns & Hanging

10. Limitations CHIRPP data is: – self reported by the patient, or reported by proxy by a parent or guardian –taken from the chart Older teens do not always present at paediatric hospitals –age group above 15 years is under represented Cases presenting to BC Children’s Hospital are not representative of a specific geographic area –no trends can be suggested

11. Results - Overall Age GroupSex (years)MaleFemaleTotal 5-1427 (10.5%)86 (33.5%)113 (44.0%) 15-1927 (10.5%)117 (45.5%)144 (56.0%) Total54 (21.0%)203 (79.0%)257 (100%)

12. Percentage of self harm by type, ages 5-19 years, CHIRPP 1997-2002

13. Percentage of self harm by type, excluding hangings and burns, by age group (years), CHIRPP 1997-2002

14. Suicide Gestures Age GroupSex (years)MaleFemaleTotal 5-14* 9 (34.6%) 15-19*10 (38.5%) Total7 (26.9%)19 (73.1%)26 (100%)

15. Suicide Gestures Location: –Predominantly at home (61.5%) –Unspecified for 26.9% Mechanism of Injury: –Ingestion (73.1%), 26.3% of these acetaminophen –Cutting (26.9%), using razors/shavers, safety pins, nails/screws/bolts/ tacks, glass or mirrors

16. Suicide Gestures 69.2% classified as poisoning or toxic effect 19.2% classified as open wounds of the wrist or lower leg Remainder included superficial injuries or no injury detected

17. Suicide Attempts Age GroupSex (years)MaleFemaleTotal 5-1412 (12.9%)27 (29.0%)39 (41.9%) 15-199 ( 9.7%)45(48.3%)54 (58.1%) Total21 (22.6%)72 (77.4%)93 ( 100%)

18. Suicide Attempts Location: –Predominantly at home (49.5%) –Unspecified or missing (39.8%) Mechanism of Injury: –Ingestion (75.3%), 30.0% of these acetaminophen alone –Cutting (14.0%), using knives (46.1%), razors/shavers and scissors –Strangulation (5.4%), involved belts, clothing, rope/string and pet supplies

19. Percentage of suicide attempts by ingestion, by substance, ages 5-19 years, CHIRPP 1997-2002

20. Suicide Attempts 80.6% of attempted suicides classified as poisoning or toxic effect 12.9% classified as open wounds of the forearm or wrist

21. Ingestions Age GroupSex (years)MaleFemaleTotal 10-148 ( 8.9%)32 (35.6%)40 (44.4%) 15-1910 (11.1%)40 (44.4%)50 (55.6%) Total18 (20.0%)72 (80.0%)90 (100%)

22. Ingestions Location: –Predominantly at home (41.1%) –Other/unspecified (36.7%) –Remaining in other homes, institutional homes/hospital, school, and on highway/other road (5.6% each)

23. Ingestions Ingested predominantly: – multiple medications (23.4%) including combinations with acetaminophen – acetaminophen/ ASA alone (21.1%) –psychoactive medications (20.0%) Other products include antifreeze, cleaning products, liquid/solid fuels, topical medication, small rocks/stones/gravel, and unknown

24. Percentage of ingestion-related cases by ingested substance, ages 10-19 years, CHIRPP 1997-2002

25. Cuttings Age GroupSex (years)MaleFemaleTotal 10-14*18 (43.9%) 15-19*23 (56.1%) Total* 41 (100%)

26. Cuttings Location: –Predominantly at home (31.7%) –Institutional home (19.5%) –Hospital (17.1%) –Unspecified (17.1%)

27. Cuttings Cutting Implement: –Razor/shaver (36.6%) –Knife (26.8%) –Other (17.1%), including pins/needles, scissors and glass

28. Percentage of cutting cases by body part, ages 10-19 years, CHIRPP 1997-2002

29. Burns & Hanging 6 hangings ≤ 5 burn cases

30. Visit Disposition Of all BC CHIRPP self-harm cases, patients were most likely to be admitted to hospital for: –Suicide attempts (60%) –Ingestions (50%) –Suicide gestures (31%) –Cutting (17%)

31. Discussion Deliberate self-harm is recognized as a distinct set of practices separate from suicide attempts or gestures Variously defined as the deliberate and voluntary infliction of physical harm to one’s own body that is not life threatening and is without any conscious suicidal intent

32. Continuum of self-destructive behaviour (Laye, 2003) NormalCompleted Suicide Suicidal behaviour and/or Attempted Suicide Direct self-harm Active Visible Indirect self-harm Passive Secondary and invisible Self-mutilationSelf-injurySubstance Abuse Eating Disorder SmokingRisky Behaviours Self Destructive Behaviour

33. Discussion Deliberate self-harm behaviour typically originates in adolescence There are demonstrated differences in their distributions according to sex –Males at all ages are consistently more likely than females to commit suicide –Deliberate self-harm is more common among females than males

34. Discussion Success of male suicide can be accounted for by their tendency to use more lethal and irreversible methods such as hanging and firearms Females tend toward the use of poisons, gases, and drugs

35. Discussion This study determined that deliberate self- harm acts among adolescents presenting to the BC Children’s Hospital were predominately: – suicide attempts (36%) –ingestion (35%) Of all suicide attempts, 75% were by ingestion

36. Discussion Ingestion was predominately through the use of acetaminophen/ASA and psychoactive medication Most common place chosen for the attempt was the young person's home (41%)

37. Conclusions Hospital separation data indicate that self harm among males aged 15-24 years have declined over the past 12 years, from approximately 140 to 60 per 100,000 The trend among females aged 15-19 years declined from approximately 350 to 175 per 100,000

38. Conclusions Further investigation is warranted to determine the full extent of the problem in BC, as well as to explore prevention and treatment options for youth and support for their families