By Their Own Young Hand

Deliberate Self-harm and Suicidal Ideas in Adolescents

Keith Hawton, Karen Rodham

• Publisher: Jessica Kingsley Publishers
• Year: 2006
• Print ISBN: 9781843102304
• eBook ISBN: 9781846425295
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Self-harm in adolescents is an increasingly recognized problem, and there is growing awareness of the important role schools and health services can play in detecting and supporting those at risk. By Their Own Young Hand explores the findings of the first large-scale survey of deliberate self-harm and suicidal thinking in adolescents in the UK, and draws out the implications for prevention strategies and mental health promotion.

Six thousand young people were asked about their experiences of self-harm, the coping methods they use, and their attitudes to the help and support available. The authors identify the risk and protective factors for self-harm, exploring why some adolescents with suicidal thoughts go on to harm themselves while others do not, what motivates some young people to seek help, and whether distressed teenagers feel they receive the support they need. By Their Own Young Hand offers practical advice on how schools can detect young people at risk, cope with the aftermath of self-harm or attempted suicide, and develop training programmes for teachers. It also examines the roles of self-help, telephone helplines, email counselling, and walk-in crisis centres.

Packed with adolescents' own personal accounts and perspectives, this accessible overview will be essential reading for teachers, social workers and mental health professionals.

CHAPTER 1

Introduction and Overview

This book is about deliberate self-harm in adolescents. This is one of the most important social and healthcare problems for people at this stage of life. Deliberate self-harm includes any intentional act of self-injury or self-poisoning (overdose), irrespective of the apparent motivation or intention. The purposes of such acts include actual suicide attempts, a means of altering a distressing state of mind, a way of showing other people how bad a person is feeling, and an attempt to change the dynamics of an interpersonal relationship. This book provides an overview of the nature and extent of deliberate self-harm in adolescents, including causes and risk factors, and offers guidance on treatment and prevention. It is intended to be a practical and easily accessible resource.

In the UK, the extent of the problem measured in terms of hospital presentations of young people who have self-harmed has been recognised for a long time (Hawton and Goldacre, 1982; Hawton et al., 1982b; Kreitman and Schreiber, 1979; Taylor and Stansfeld, 1984a,b). Based on figures from deliberate self-harm monitoring systems, somewhere between 20,000 and 30,000 adolescents present to hospital each year in the UK because of self-inflicted overdoses or injuries. Deliberate self-harm represents one of the most common reasons for hospital presentation of adolescents. After deliberate self-harm was first recognised as a significant problem in the UK during the 1960s and 1970s, rates rose so rapidly that dire predictions were being made about the future demands that this phenomenon, especially self-poisoning by girls, would place on hospital resources (Kreitman and Schreiber, 1979). In the event, the rates levelled off, with signs of a small decrease during the early1980s (Sellar et al., 1990). However, there has been a further increase in rates in more recent years, particularly in girls (Hawton et al., 2003c; O’Loughlin and Sherwood, 2005).

During the 1970s and 1980s, reports of increasing numbers of adolescents presenting to hospitals after deliberate self-harm also started to appear from other countries, especially in Europe (Choquet et al., 1980), North America (Wexler et al., 1978) and Australia (Mills et al., 1974; Oliver et al., 1971). Particularly high rates of deliberate self-harm in adolescents resulting in hospital presentation (equivalent to those in the UK) have been identified in France (Batt et al., 2004), Ireland (Corcoran et al., 2004; National Suicide Research Foundation, 2004), Belgium (Van Heeringen and De Volder, 2002) and Australia (Reith et al., 2003).

Most acts of self-harm that result in a young person going to hospital involve overdoses rather than self-injuries (Hawton et al., 2003a; Hultén et al., 2001). In the UK, the drugs used most frequently in overdoses are analgesics, especially paracetamol (acetaminophen). In Oxford, in recent years approximately 60 per cent of overdoses by adolescents have involved paracetamol (Hawton et al., 2003a,b). This certainly reflects ease of availability – paracetamol is present in most households and can be bought over the counter in pharmacies and a wide range of other outlets. Other drugs used relatively commonly in overdoses include psychotropic agents, especially antidepressants and tranquillisers. Self-injury most frequently involves self-cutting, especially of the arm, but other methods include jumping from a height, running into traffic, hanging and self-battery.

What is the significance of deliberate self-harm in adolescents? Clearly it represents considerable current distress. In addition, long-term follow-up of adolescents who have self-harmed indicates a very high rate of suicide attempts in young adulthood (Fergusson et al., 2005b). Furthermore, deliberate self-harm is associated strongly with risk of future suicide, the risk of suicide in deliberate self-harm patients in general being elevated some 50–100 times that in the general population during the year after hospital presentation (Hawton and Fagg, 1988; Hawton et al., 2003d). Follow-up studies of adolescent patients have demonstrated that such people also have a greatly elevated risk of suicide (Goldacre and Hawton, 1985; Otto, 1972; Sellar et al., 1990). In a long-term follow-up study (mean follow-up period 11 years) of a very large sample of patients aged between 15 and 24 years, over half of all deaths were due to suicide or probable suicide (Hawton and Harriss, submitted). Studies of young people who have died by suicide also highlight the association between deliberate self-harm and suicide. For example, in an investigation of suicide in 174 young people aged between 15 and 24 years, 44.8 per cent were known to have a prior history of deliberate self-harm (Hawton et al., 1999a) – the true figure could have been even higher. Similarly, in psychological autopsy studies (which include interviews with relatives) of young people who have died by suicide, between one-quarter and two-thirds have been found to have carried out previous non-fatal acts of deliberate self-harm (Brent et al., 1993; Houston et al., 2001; Marttunen et al., 1993).

Attention to prevention of suicide in young people increased during the 1980s and 1990s, when it became apparent that suicide rates were rising in 15- to 24-year-olds, especially males, in several countries, including England and Wales (Hawton, 1992), Scotland and Northern Ireland (Cantor, 2000), New Zealand (Beautrais, 2003), Australia (Cantor, 2000), Scandinavian nations and the USA (Cantor, 2000). In more recent years several countries have witnessed a downturn in suicide rates, but rates remain higher than they were before the rise.

Young people have, therefore, been highlighted in national suicide-prevention strategies – indeed, increasing suicide rates in young people appear to have been a stimulus for development of such initiatives in several countries. Also, because of the extent of the problem of deliberate self-harm in young people, their specific needs have been emphasised in policy documents aimed at improving the hospital management of patients presenting with this problem (Royal College of Psychiatrists, 1998). For example, in the UK, the guide on self-harm produced by the National Institute for Clinical Excellence (2004) highlights the need for specialised services for adolescents. Guidelines for the management of adolescents following self-harm have been produced in other countries, such as the USA (American Academy of Child and Adolescent Psychiatry, 2001) and Australia and New Zealand (Australasian College for Emergency Medicine and the Royal Australian and New Zealand College of Psychiatrists, 2000).

For some years, it has been recognised that deliberate self-harm in adolescents is far more common than is reflected in hospital presentations. This evidence has come from school-based or community studies, such as in the USA, a large-scale biannual investigation, the Youth Risk Behavior Survey, which began in 1990. This showed, for example, that in 2003, 8.5 per cent of adolescents reported an act of attempted suicide in the preceding year. Only 2.9 per cent said that this had resulted in presentation to a doctor or nurse (Centers for Disease Control and Prevention, 2004). In a similar investigation in France, 9.2 per cent of adolescents reported having made a suicide attempt in their lifetime, only 21.9 per cent of episodes having resulted in hospital presentation (Pagès et al., 2004). In a systematic review of studies of this kind worldwide, we found that the average frequency of self-reported self-harm acts by adolescents in different time periods were as follows: suicide attempts – 6.4 per cent in the previous year and 9.7 per cent during their lifetime; deliberate self-harm – 11.2 per cent in the previous 6 months and 13.2 per cent during their lifetime. In addition, an average of 19.3 per cent of adolescents reported having had suicidal thoughts in the previous year and 29.9 per cent in their lifetime (Evans et al., 2005a).

Thus, it is clear that when studied at the community level, the incidence of deliberate self-harm is much more common than appears to be the case from hospital statistics. However, such information has been lacking for adolescents in the UK. Therefore, we decided to conduct a major survey of school pupils aimed at providing realistic information of this kind for England. We included a large number of schools, chosen to provide a reasonably representative sample of adolescents in terms of gender, ethnicity, socioeconomic characteristics, school type and school achievements. We adopted an anonymous self-report approach, since available evidence suggested that this would elicit the most accurate responses. We used a more thorough means of identifying deliberate self-harm episodes than had been the case in most other studies. We examined a wide range of potential factors that might contribute to self-harm, investigated help and treatment received after self-harm, and studied coping behaviours used by the adolescents. We focused the study primarily on 15- and 16-year-olds because at this age nearly all adolescents should be in education and, hence, available for study. We also reviewed all other studies that have been conducted regarding prevalence of self-harm behaviours and thoughts of such behaviours (Evans et al., 2005b), plus those relating to associated risk factors (Evans et al., 2004). This allowed us to put the findings of our schools study in a full international context.

All of this material has been used in the production of this book. The main reason we have written it is because we recognised the need for an up-to-date and easily accessible source of information on this topic. Thus, we have provided a detailed overview of the extent and nature of deliberate self-harm in adolescents, a thorough examination of risk factors for this behaviour, and detailed guidance on means of treatment and prevention. In particular, we wished to produce a very practical book that would assist readers in relation to their own needs and roles in this field. Although a major focus of the book is on deliberate self-harm in adolescents in the UK, the topic is considered fully in the international context, especially in relation to studies of a similar kind to our school-based study. Our systematic review of all the available studies worldwide has helped to ensure that our references to the international literature represent a balance of findings.

In the next chapter, we explain in more detail the reasons for our having conducted our schools study and describe how we carried out the investigation. This incorporates evidence about research methods that influenced our choice of approach.

In Chapter 3 we present the findings of the research concerning the extent of deliberate self-harm and thoughts of self-harm in the adolescents in our schools study. These results are compared with those from studies from other countries. We also examine the methods used for self-harm. We review the complexity of motivations that appeared to underlie the behaviour, contrasting the motives for overdose with those for self-injury, and also the motives chosen by boys compared with those chosen by girls. We address the question of whether the adolescents in our study presented to a general hospital (or other clinical services) after harming themselves, particularly in terms of factors that might have made hospital presentation more or less likely. The problem of repetition of deliberate self-harm is highlighted. Finally, we explore the impact of self-harm and suicide on family members and friends.

In Chapter 4, we address the important issue of what distinguishes adolescents who self-harm from other adolescents and what differentiates those with thoughts of self-harm from adolescents who do not have such thoughts. One of the most obvious differences is with regard to gender. We attempt to answer the question of why this might be. Other characteristics we consider are age and ethnic background. Subsequently, we examine a wide range of psychosocial and health risk factors, both from our schools study and from other studies in a range of countries. These risk factors include mental health and well-being, exposure to suicidal behaviour in others, such as peers and family members, and the media. We also examine the evidence for the influence of a range of other personal factors and experiences (e.g. sexual abuse, physical abuse, homosexual orientation), family characteristics and social factors.

Knowledge of help-seeking behaviours and coping strategies used by adolescents is crucial to understanding both the background to deliberate self-harm and the means of preventing the behaviour and providing effective help following deliberate self-harm. In Chapter 5, therefore, we explore help-seeking and coping in adolescents in general, and then go on to use the results of our schools study to compare adolescents who self-harm with other adolescents, including those with thoughts of self-harm that they have not acted on, and those reporting neither experience. We examine help-seeking in terms of whom adolescents feel able to turn to for advice and support, and both help-seeking and lack of it before and after acts of self-harm. We focus particularly on thoughts and attitudes that impede help-seeking.

In Part 2 of this book, we focus on the prevention of self-harm and assessment and treatment of those who have self-harmed. One extremely important aspect of prevention concerns what can be done in schools. This is the subject of Chapter 6. After examining the reasons for schools being a logical major focus for preventive efforts, we explore approaches in this setting in relation to three considerations. The first is what can be done to reduce the risk of self-harm, such as through educational initiatives aimed at changing attitudes, knowledge and coping skills. The second approach concerns identification and provision of help for adolescents identified as ‘at-risk’. Finally, there is the question of what help can be provided in schools for those who have engaged in self-harm, and what can be done to limit the negative impact of self-harm and suicide on others. We include detailed guidelines for school staff, which have been produced through a consensus process involving school staff, clinicians and researchers.

Self-harm often results in contact with health services. These have a vital role to play in prevention of self-harm. In Chapter 7, we first consider the important role of general practitioners (GPs), including how general practice care can be made more attractive to adolescents and how GPs can detect adolescents who may be at risk. We then turn to the role of hospital services, especially emergency department personnel and psychiatric services. We provide detailed guidance on psychosocial assessment of adolescents who present to hospital following deliberate self-harm. We then consider options for treatment of adolescents after self-harm. This includes a range of potential approaches, provided by personnel from various professional groups. Sources beyond statutory services need to be considered in the prevention and treatment of deliberate self-harm in young people. In Chapter 8, we begin by examining the role of self-help books and telephone helplines. We then turn to the Internet, which is attracting increasing attention in relation to its potential usefulness as a source of help for distressed youngsters and also as a potential source of danger, especially where young people might access sites about self-harm that do not necessarily have prevention of suicidal behaviours as a primary objective. Finally, we consider other types of media, especially literature, film, newspapers and music, and the roles they might have in encouraging suicidal behaviour as well as their potential usefulness in prevention.

In the final chapter, we summarise what we have covered in this book. We then turn to the future and look towards developments that could help tackle this important problem. These include initiatives at family, school, health service and other levels, such as the potential role of the media. In addition, we identify key research questions that need to be addressed.

As indicated earlier, we planned to write a very practical book that would be directly relevant to all concerned with deliberate self-harm in adolescents and one that would ultimately be a contribution to the prevention of this problem and to the provision of more effective care of those at risk or who have self-harmed. We are confident that after reading this book, the reader will know more about the phenomenon of deliberate self-harm. In addition, we hope that our more ambitious goals will also be realised.

Part 1

The Nature of Deliberate Self-harm in Adolescents

CHAPTER 2

Investigating Deliberate Self-harm in Adolescents

Introduction

This chapter focuses on the practical issues that we addressed when we were planning and implementing our study to determine how common deliberate self-harm and thoughts of self-harm are in adolescents in the general population, and the factors that are associated with these phenomena. In conducting such a study, it is essential that the design and methods are thought through carefully in order to ensure that the findings will provide an accurate picture of the problem. As the reader will see, given the focus of this study, this is not a straightforward task. We therefore had to consider several issues when designing the study.

We explain the decision-making process that we engaged in as we decided how best to collect the information from the adolescents. Having chosen to use a questionnaire, we describe how the questionnaire was developed and tested. Finally, we explore the issue of consent, before explaining in some detail the process of implementing the questionnaire study in the school context.

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Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• List of Figures
• List of Tables
• Acknowledgements
• Chapter 1: Introduction and Overview
• Part 1: The Nature of Deliberate Self-harm in Adolescents
• Part 2: Prevention and Treatment of Deliberate Self-harm in Adolescents
• Appendix I: Guidelines Used in the Schools Study for Categorising Respondents’ Descriptions of Deliberate Self-harm
• Appendix II: Information Sheet Given to Participants After Completing the Questionnaire
• Appendix III: Self-harm: Guidelines for School Staff
• Appendix IV: Robson’s Self Concept Scale (Short Version)
• Appendix V :Useful Contact Addresses in the UK for Young People with Problems, or their Friends or Relatives in Need of Advice.
• Appendix VI: Sources of Information about Deliberate Self-harm, Suicide and Mental Health Problems
• Appendix VII: Further Reading
• References
• Subject Index
• Author Index