Young people who practise self-harm intentionally

Review of recent research (2001-2004)

Dr L. F. Lowenstein, M.A.,DIP.PSYCH.,Ph.D

This paper examines recent research into children and adolescents who commit self-harm, and how this is related to suicide attempts. A future article will concern itself with adults.

Deliberate self-harm and its relationship to suicide is a particular challenge to nursing staff and professionals (Holdsworth et al, 2001). Deliberate self-harm is one of the most common reasons for emergency medical admission. A survey of those who practise self-harm has found that the medical personnel are rated as providing the most unsatisfactory support, while self-harm specialists are rated as providing the most satisfying support (Reid & Henry, 2002; Warm et al, 2002). There is currently much misunderstanding about what causes self-harm especially among psychiatrists and medical workers (Jeffrey & Warm, 2002; Hopkins, 2002).

The reason for this is probably a lack of research into deliberate self-harm (Blenkiron, 2003). There is therefore a need for up-to-date knowledge and proper training for counselling psychologists in how they can play a vital role in dealing with intentional self-harming (ISH) and in suicide prevention (Schwartz & Rogers, 2004).

Suicidal and self-harm behaviour are related. This is also the case for thoughts of ISH. These thoughts are likely to increase the odds of intentional suicide (Skegg et al., 2004). A useful definition of intentional self-harm is that by Isacsson & Rich (2001); “Deliberate self-harm is a behaviour not an illness. It is defined as an act by an individual with the intent of harming himself/herself physically. Deliberate self-harm has also been called “attempted suicide” or “parasuicide”. Suicide is a subcategory of deliberate self-harm when it has a fatal outcome.

What follows will consider the types of self-harming and the substances used, the incidence of this behaviour among the young, the causes of self-harm and the management, care and therapy involved in treating those who commit intentional self-harm.

One study assessed was of 60 young people who attended Accident and Emergency (A&E) Departments following deliberate self-harm over a 12 month period. The group was predominantly female and the self-harm mainly involved and overdosing with Paracetamol. A seasonal trend was detected with the rate of presentations falling off during the main school holiday periods (Clarke et al., 2001). In a study in Great Britain ( West London ) Bhugra et al. (2003) found overdoses were the commonest methods used for deliberate self-harm both among Asian and White adolescents. The second most common self-harming method as noted by Yip et al. (2002) was self-cutting.

Incidents of Intentional Self-Harming Among the Young

A study by James & Lawlor (2001) found that girls experienced greater problems than boys leading to intentional self-harming and were therefore at greater risk. 13% of the girls frequently thought of suicide and 7% had frequently thought of self-harm. This contrasted with none of the boys admitting to suicidal ideation and only 2.5% reporting thoughts of self-harm.

Deliberate self-harm was more likely to occur in White rather than Black or Asian persons and was of course greater in females than males. Among the contributing reasons, which will be discussed in the section on causes and associated features, are experiencing bullying in school and also physical and sexual abuse at home (Bhugra et al., 2002).

A study of suicidal ideation among Irish adolescents (Houghton et al., 2003) noted rates of suicidal ideation among 13 & 14 year old Irish school children of 44% at screening, and 29% at home interview. This was a disturbing statistic. Ireland is known to be a Catholic country where suicide is frowned upon most especially and yet there appears to be a high rate of youth suicide in Ireland .

Another study by Ross & Heath (2002) provided a comprehensive review of earlier reports and research on the frequency of self-mutilation. It was found that there was a relationship between self-mutilation, anxiety and depressive symptomatology. These adolescents hurt themselves on purpose and it was found that 13.9% of all students reported having engaged in self-mutilation behaviour at some time. Again, girls reported significantly higher rates of self-mutilation than did boys (64% versus 36% respectively). Self-cutting was found to be the most common type of self-mutilation, followed by self-hitting, pinching, scratching, and biting. These students also reported significantly more anxiety and depressive symptomatology that students that did not self-mutilate.

Causes and associated features

There is considerable information in the recent research literature concerning a number of associated causes interacting resulting in intentional self-harm. At its simplest level adolescents who practise self-harm, including self-poisoning, do this on impulse, often due to an argument with another boy or girl. The most common substance or type of self-harming is an overuse of Paracetamol and hence self-poisoning (Schmidt, 2001). There are currently only a few research data which involve psychoanalytic explanations such as separation, and conflict resulting from this as well as a sexual motive ( Gardner , 2001). An explanation based on psychotic illnesses is also relatively a rare explanation for intentional self-harming (Fagan, 2002).

More important as a reason for self-mutilation is a form of depersonalisation due to a negative family climate and the influences of this on the adolescent or child (Wolfradt et al., 2002). Parental mental health has also shown itself to be a predictor of repeated self-harm (Chitsabesan et al., 2003). Vermeiren et al (2002) observed the prevalence of community violence and the relationship between this and suicidal ideation and deliberate self-harm. Suicidal ideation was noted to be especially present when associated with actual behaviour of self-harming. Suicidal ideation was also seen as a direct cause of intentional self-harming as well as suicide attempts (Ferdinand et al., 2004; Penn et al., 2003).

It is unfortunate that many young people fail to receive an appropriate psychiatric or psychological assessment before being placed in residential settings (Dudley & Nirui, 2002). Such assessment might have revealed a considerable amount of antisocial or borderline personality disorders which in turn are likely to increase the risk of suicidal behaviour. This is most likely to occur when there is also a history of childhood sexual abuse (Links et al., 2003). One study of homeless and runaway youth also noted an increasing likelihood of self-harming and most especially self mutilation among such young people (Tyler et al., 2003).

Perhaps the most common risk factor related to intentional self-harming and suicide attempts is that of previous self-harming (Reith et al., 2003). Such self-harming is often considered to be an attention-getting device but this does not help to deal with the serious self-harmers who indeed are set on causing themselves to be victims often of inadvertent or desired suicide. Deliberate self-harm was also identified as a response to conflict of feeling distressed or angry (Crouch et al., 2004).

There is some lack of understanding as to why self-cutting patterns of behaviour and other forms of self-harming are more common in females than males. One explanation provided by Yip et al. (2003) is that repeated self-cutters for example carry out such behaviour for the purpose of releasing suppressed negative emotions based on interpersonal conflicts with peers, the family or in courtship. A combination of hostility and anxiety reduction models are suggested as reasons for self-harming also by Ross & Heath (2003). Matsumoto et al., (2004) in a comprehensive study considered a combination of factors resulting in intentional self-harming. These include suicidal ideation and suicide attempts, these being due to early separation from parents, bullying in school and sexual/physical abuse. It is wise not to rely on those who commit intentional self-harming as doing this as an attention-getting device. This leads to doing little or nothing to deal with it in the form of management or treatment (Nock & Prinstein, 2004).

The Relationship Between Intentional Self-Harming and Suicide Attempts

There is some uncertainty as to whether, self-harming ultimately is associated, or leads to, actual suicide attempts. Suicidal adolescents are characterised by more self-injurious and self-mutilative behaviours as well as a clear outward expression of anger. Results indicate that adolescent suicide attempters were particularly prone to earlier self-harm if they are between the ages of 13-17 (Zlotnick et al., 2003). As already stated previous deliberate self-harm (DSH) is the strongest predictor of suicide in the general population. Associated with this is suicidal ideation, especially of juvenile offenders, in custody. It has been noted that homosexual youths have a greater tendency than heterosexual youths of attempting self-harm and suicide (Morgan & Hawton, 2004; Crawford et al., 2003).

Bolognini et al. (2003) noted that there was a close association between suicidal attempts and self-mutilation. Such suicide attempts were greatest above all among abused or neglected adolescents (Zoroglu et al., 2003). It was noted that self-harm and suicidal behaviour frequently came from a background of aggressive families where children were provided with inappropriate care. This often led also to drug consumption. Ceverino et al. (2003) found it impossible to differentiate between the importance of environmental and genetic vulnerability leading to a pre-disposition to suicidal behaviour.

Attempts were made to differentiate between adolescents who had attempted suicide and those who engaged only in self-injurious behaviour. The object was to measure the degree of depression, suicidal ideation and attitudes towards life and death. Significant differences were found between those who attempted suicide and the self-harm group only. Most important in those who attempted and/or actually committed suicide was depression, suicidal ideation, and negative attitudes towards life (Muehlenkamp & Gutierrez, 2004).

Finally, Rodham et al. (2004) found that more adolescents that took overdoses than those who cut themselves had said they wanted to die (66.7% versus 40.2% ). Many had wanted to find out if someone loved them (41.2% versus 27.8%). Female self-cutters were more likely than male self-cutters to say that they had wanted to punish themselves (51% versus 25%) and had tried to get relief from a terrible state of mind (77.2% versus 60.9%). More self-cutters than self-poisoners had thought about the act of self-harm for less than an hour before hand (50.9% versus 36.1%). The often impulsive nature of these acts, (especially self-cutting) meant that prevention needed to focus on encouraging alternative methods of managing distress, problem-solving, and help-seeking before thoughts of self-harm developed.

Little is known at present as to the percentage of young people receiving help for their self-harming behaviour and those who fail to receive it. A comparison of group therapy with routine care of adolescents, who deliberately harm themselves on at least two occasions, indicates that group therapy shows promise as an effective treatment for adolescents who repeatedly harm themselves. However, larger studies are required to assess more accurately the efficacy of this intervention (Wood et al., 2001). In order to prevent suicide there are now a number of programmes in schools for this purpose. This involves school counsellors in the United States to a large degree (Capuzzi, 2002).

Another approach has been parent education groups to deal with their children who may be at risk of self-harming and suicide. These informal groups have taken place within schools. Results show that students in school intervention programmes tend to increase maternal care and reduced conflicts between parents and their children. It also reduces substance abuse and delinquency. Parent group members tended to be sole parents and it is these children that reported higher rates of substance use (Toumbourou & Gregg, 2002).

It has been established that older people who undertake self-harm are at a higher suicide risk than are younger persons. This is perhaps why older individuals are more likely to be admitted from A&E to general hospitals to receive specialist assessment and to be offered after care (Marriott et al., 2003). Those young persons, children and adolescents who practise self-harm need to be assessed by the child and Adolescent Mental Health Services. It is unfortunate that in two thirds of cases the young person is not admitted and one third are discharged without any discussion regarding assessment (Nadkarmi et al., 2003).

In order to prevent drastic results such as suicide there is a greater need than ever at prevention as well as treatment and most especially ongoing monitoring of such individuals. One study, that of Hawton et al., (2003) has found that there are fewer self-harming incidents during school holiday periods, and the largest number in term-times occur on Mondays due to study problems of such youngsters. Self-poisoning is involved in more than 90% of episodes. Paracetamol overdoses are especially present and also anti-depressant overdoses. True suicide intent is higher in males than females.

A study of nurses' and doctors' perception of young people who engage in suicidal behaviour by Anderson et al., (2003) has concluded that over the past 25 years suicidal behaviour in such young people has continued to be a major source of concern for health services around the world. More than three times as many females as males appear to deliberately self-harm and this is sometimes based on what friends have done or family members, as well as the lack of treatment being provided for a combination of drug use, depression, anxiety, impulsivity and low self-esteem (Hawton et al., 2002). These authors recommend more school-based mental health initiatives for the purpose of educating school pupils about mental health problems, and where to seek help.

Perhaps the most common approach to treatment is still the use of medication such as Fluoxetine (20mg) each morning. It was used in the case of an 11 year old boy who since toddlerhood had slowly chewed his right hand's third, fourth and fifth digits down to the second phalanges. Dysthymia and impulse control disorder was diagnosed. Some success was achieved using this medication as the boy stopped chewing his fingers when taking the medication. When not taking Fluoxetine he resumed chewing his fingers (Velazquez et al., 2000).

Another approach seen to be of value was the use of art therapy in groups. This was used with six young female patients who were involved with substance abuse, eating disorders and self-mutilation (Cooper & Milton, 2003). There is still however, limited research in examining what are likely to be effective treatment modalities (Stone & Sias, 2003). One thing is certain, it is vital to treat such youngsters for their depression and anxiety as a way of preventing future self-harming and suicide (Derouin & Bravender, 2004). There has been little research into the use of cognitive therapy and cognitive behaviour therapy to counteract ISH and suicide behaviour.

As may have been seen the incidence of self-harming in young people is certainly on the increase and yet little has been achieved in many cases as far as an appropriate treatment is concerned. There are still numerous successful suicides and serious self-harming among the young who have shown the inclination to carry out such behaviour through earlier self-harming demeanour. Multi-dimensional risk perspective must be the way to consider the aetiology of self-harming which often leads to suicidal behaviour. This includes biological, socio-cultural, family, psychological factors such as depression and hopelessness.

Too many children and adolescents still fall through the net and commit acts of self-destr uctiveness in the form of self-harming and suicide attempts and successful suicides, due to lack of being provided with effective care, management and treatment following a thorough psycho-diagnostic assessment. Matters are complicated by the fact that not all children and adolescents who self-harm are necessarily suicidal, but one never knows which are likely to carry out such a drastic final act. The important thing to realise is that self-harming is connected frequently to suicidal ideation and suicide acts.

As mentioned intentional self-harming behaviour includes cutting, burning, overdosing and jumping from high places etc. In some cases one must include such cases as anorexia nervosa and other eating disorders and being addicted to drugs. These behaviours should be viewed as indirect or long-term self-harming. It must be realised that these children and adolescents, on the whole, are fully aware of their desire to wish to die and to take steps towards this. After the age of 14 the likelihood of self-harming and suicide increases. It has been established that suicide becomes the third leading cause of death among adolescents and young adults. This is followed by accidents and homicides.

It is vital that such children and adolescents receive intensive care and treatment as early as possible and thereby to promote constructive thinking and behaviour. Such organisations as the Samaritans founded by the Reverend Chad Varah which provide 24 hour a day help are essential. Equally, children who are prone to self-harming need a considerable degree of 1-1 monitoring. This may infringe their personal liberty to some degree but personal liberty is of little value if the end product is their death. Such youngsters require among other things the following:

•  Promoting a positive relationship with an appropriate skilled adult in the treatment situation.

•  Helping the individual child to analyse the problems faced leading to self-harming and suicide attempts.

•  Being aware of the fact that it may be a cry for help or attention, but one never knows which young person is determined also in fulfilling the suicide intention.

•  It is vital always to act on the side of caution. Over-protection and intensive monitoring is preferable to not enough protection. This often requires monitoring within a residential setting for some considerable time until the child adopts a more positive and hopeful attitude to life.

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© L. F. Lowenstein