The 2019 Jack Tizard Memorial Lecture and National Conference focused on ‘Helping young people in crisis: gender identity, personality problems, and complex trauma.’
This is the Jack Tizard Memorial Lecture: Professor Keith Hawton ‘Self-harm in children and adolescents: a major health and social problem of our time’.
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About the speaker
Self-harm in children and adolescents: a major health and social problem of our time
Keith is Professor of Psychiatry and Director of the Centre for Suicide Research at Oxford University; Consultant Psychiatrist with Oxford Health NHS Foundation Trust. For more than 40 years he and his research group have been conducting investigations concerning the causes, treatment, prevention and outcome of suicidal behaviour. He has published more than 500 papers and chapters and 15 books. He has received the following awards: Stengel Research Award from the International Association for Suicide Prevention; Dublin Career Research Award from the American Association of Suicidology; Research Award of the American Foundation for Suicide Prevention; Life Achievement Award presented at the European Symposium of Suicide & Suicidal Behaviour in Israel; Morselli Medal from the International Association of Suicide Research; Finnish Psychiatric Association Medal. He is a Fellow of the Academy of Medical Sciences. Professor Hawton has a particular interest in epidemiology and clinical management of self-harm, suicide and self-harm in adolescents, media influences on self-harm and evaluation of suicide prevention initiatives.
Well, thank you very much Stephen for that introduction and thank you to the association for giving me the honour of giving the Jack Tizard Memorial Lecture. It truly is an honour to do so. Many of you will be aware or all you will be aware of the problems that have recently been highlighted in terms of self-harm and suicide in young people is one we [inaudible 00:00:47] through a couple of years ago. There’s another one about self-harm, and yes there’s been a very major increase in self-harm particularly in young girls. And then some of you will have seen the releases of the week before last, I think it was, about this paper in The Lancet Psychiatry where data from the adult psychiatric morbidity study we presented over three periods from 2000 up to 2014 suggesting that there had been a massive increase in non-suicidal self-harm… This is using the American definition of NSSI… from 6.5 percent in 2000 to 20 percent in 2014 in females, with a particular increase in self-cutting.
So what I’d like to do is talk a bit about the epidemiology in trends in both… I can talk about both suicide and self-harm. I think it’s important to consider both together, so I’m going to talk about epidemiology in trends in children and adolescents, say a bit about the onset of self-harm and its timing, and then going to review some of the complexity of factors that contribute to both suicide and self-harm in young people. I’m going to tell you about some new work on the association between self-harm and subsequent suicide. I’m going to try and address some of the points about prevention and treatment, and finally I’m going to end by saying a bit about the impact of self-harm in particular on families.
First, the epidemiology. We find it really useful to think in terms of this iceberg model of self-harm and suicide where you have suicide obviously is the worst outcome of self-harming behaviour, and then self-harm, which presents to clinical services. I’ll be particularly referring to hospital services. And then it’s called the iceberg because of this huge amount of relatively hidden self-harm that’s occurring in the community in young people, much of which does not come to clinical attention. Our estimates would be somewhere between one in eight and one in ten cases come to clinical attention, although, of course, families and friends may be aware of the self-harm in many cases.
In terms of suicides, so taking the peak of the iceberg, globally these are somewhat old data from Patton’s group, but they’re the latest we have. It’s the second most common cause of death in 15 to 19 year olds after road traffic accidents. Interestingly in females it’s the most common cause of death, although numerically it’s much less common in females than in males, but males have a much higher incidence of road traffic accidents and other violent causes of death, and so that pushes it down to the third most common cause in males. What about trends in suicide? These are national data for England from the Office of National Statistics from 2000 up to 2017. Males are shown in red, females in blue, and a darker blue for the overall trend. You can see that they follow a relatively similar pattern. If we look at the recent period since 2010, 2011, you’ll see there’s been a very major increase in suicide in males and in the females. Although, interestingly, if you track back to the beginning of the century, we actually had high rates, relatively high rates at that time. Now the pattern is that we’re almost back to the what can have slightly… well equivalent rates of suicide in 12 to 19 year olds as we had at the beginning of the century, but of course we’ve got this upward trend, and indeed the females have overtaken the rates that they had at the beginning of the century.
Turning to self harm, just to clarify what we mean by self harm, this is the definition we use: intentional non-fatal poisoning, self-poisoning or self-injury, irrespective of the degree of suicidal intent or even absence of suicidal intent, really with a distressed state of mind and so on, so including overdoses, self-cutting, attempted hanging, jumping, etcetera. And in terms of national trends, these are data from a Bristol group looking at hospital and primary care data; males are here, females here. And you can see that the main change that’s happened has been this massive increase, a doubling, in the incidence of self-harm in girls aged 13 to 16. Little shift in the other patterns, although possibly a little bit of an increase in the very, very young. So there’s something going on in the teenage years that’s reflected in an increase in self-harm, as I showed in that media release at the beginning, particularly in girls and in younger teenagers, and also an increase in suicide rates.
So getting back to the iceberg model, we tried to put numbers to the compartments to this model a couple of years ago. Actually these were data from 2011 to 13, so these are annual numbers, estimated numbers, although accurate numbers for suicides. The suicide data came from the Office for National Statistics and the hospital presented self-harm estimates came from our Multicentre Study of Self-harm in England, and the community self-harm figures came from a school survey conducted in… a large-scale school survey in Gloucestershire. And you can see these numbers now will be quite a lot higher for suicides, but you can see the gender ratio over two to one male to female, whereas with self-harm, it’s always very much reversed. For hospital presented self-harm we estimated over 20,000 individuals in the 12 to 17 age range presenting with self-harm in hospitals each year, with a four to one gender ratio. For community self-harm this figure will be a considerable underestimate because it was based on young people saying, yes, I self-harmed in the last year and giving a description of what they did and it fitting our criteria, and very often, even those who said they self-harm, didn’t give a description of what they’d done, so this would be an underestimate, but it shows again a very high female to male ratio.
So, I mean, what these numbers obviously illustrate is that we clearly need preventative interventions and most people look to the schools for this, and I’ll say a bit more about this later, and possibly online preventative intervention. And of course, it’s obvious to say the need for good quality hospital based clinical services and community treatment services for young people who self-harm.
So I have to say a little bit about the onset of self-harm. These are again data from our Multicentre Study for Self-harm in England, based on data from Oxford, Manchester and Derby. And this shows the number of individuals by gender and individual years of age, from ten upwards to 18, females in red in this slide. And you can see that things take off around age 12, and the gender ratio then is very high in terms of female to male, four to one, and gets even higher, up to six to one at age 14, and then gradually decreases as the males start to catch up with the numbers of females. Of course they never do catch up in the teenage years.
There’s been some interesting work done on the relationship between puberty and the onset of self-harm. This slide summarises data from a study from Patton again, which is based on school surveys in Australia and America, looking at 3,000 school students, school pupils, and they used the Tanner scale to look at the association between risk of self-harm and pubertal stage. And what this shows quite clearly is a very strong association between later or completed puberty and the onset or the risk of self-harm with a sort of titration effect through the phases of puberty. And they found that the association with pubertal stage was particularly strong in girls and also for self-cutting, and other independent factors that were associated with risk of self-harm were depression, alcohol use, and the onset of sexual activity.
There’s some recent work, not yet published, from the ALSPAC study showing that the risk of self-harm increases the earlier the onset of puberty. So there’s some very interesting findings around the relationship of puberty to the beginning of self-harming behaviour. We’ve been doing some work… This is unpublished work… looking at self-harm in very… in young children. Again these are data from our Multicentre Study of Self-harm. And this basically shows the numbers of individuals. The numbers are relatively small when you consider we’re looking at a 14-year study period here. Males are shown in black. The interesting thing is that the gender ratio is the opposite way in the very younger… in the younger children who are self-harming. And then at age 11, it reaches parity and then you have this sudden increase at age 12 in girls self-harming. One of the other important findings here was there was a relatively high incidence in both genders, but particularly boys, of self injury in the very young age group, and including particularly attempted hanging and suffocation, which are obviously particularly dangerous methods.
Okay, I’d now like to review some of the complexity of findings that are associated with or contribute to self-harm and suicide in children and adolescents. And I’ll go through these fairly rapidly because there’s a wide range of factors that have been shown to be associated, not all necessarily causal, with self-harm and suicide. One is socio-economic deprivation. We know that rates of self-harm in children and adolescents are higher in those who live in areas of relative socio-economic deprivation and also it’s associated with poor educational achievement. And then, of course, there are all the family history and diversity factors, which are well known to be associated with self-harm and suicide: parental separation, divorce, parental death, family history of suicidal behaviour, which seems to act beyond just transmission of psychiatric disorder, but also parental mental disorder where there’s problematic parental relationship, and then, of course, as you well know, and we’ll be hearing more about it today, adverse child experience, childhood experiences, physical or sexual abuse, bullying, and, of course, interpersonal difficulties. In younger adolescents it’s mostly about family relationship problems; in older adolescents it’s often… the interpersonal difficulties are often with boyfriends and girlfriends.
And then, of course, there’s the whole question about mental disorder as part of the contributory picture. We did a psychological autopsy study some years ago of young people who die by suicide, and we found something over 80 percent had evidence of psychiatric disorders, based on the family’s clinical records, etcetera. And we also did a systematic review a few years ago of studies using research diagnostic criteria of young people who presented to clinical services with self-harm. I think we found nine studies in children and adolescents, and the figures were very similar. Around about 80 percent, just over 80 percent, with evidence of psychiatric disorder, particularly depression, anxiety, including PTSD, ADHD. In both these studies, autism spectrum disorder wasn’t examined, so that’s missing from these data. We know that that’s another important association.
Drug and alcohol misuse, alcohol misuse is probably the more important factor contributing to both self-harm and suicide, particularly in older adolescents. And then, of course, the emergence of borderline personality traits, again we know are well associated with self-harm, particularly repetition of… multiple repetition of self-harm. And then there’s the question of impulsivity. We talk a lot about people being impulsive. I think that is often a misleading term because I think it’s often that individuals have difficulty solving problems they’re facing and do something just to lower their arousal rather than always be people who respond rapidly to things, but certainly the association with impulsivity. As you’d expect with the figures with depression, which we found in 50 percent of those in our psychological autopsy study, low self-esteem, hopelessness, some evidence that more problem solving skills may increase risk of self-harm and a lot of interest lately in the role of perfectionism, particularly Stephen mentioned university student suicides, and to what extent, I don’t think we know, but it’s often said that perfection is a major contributing factor in that group.
Lately, a lot of interest in the role of sleep disorders in self-harm. Here’s one illustration; this is a study from the USA of a community mood disorders clinic in which over 200 11 to 19 year olds who were attending this clinic were examined, and 65 percent of them had severe nightly sleep problems and half of them had a history of non-suicidal self-injury, using the American definition; 30 percent suicide attempts. Obviously quite a lot of them did both. And what was found in this study was that severe sleep disturbance is associated with more frequent self-harm, suicide attempts and suicidal ideation.
And, of course, there’s the important influence of social media and the use of mobile phones on sleep. The UK study indicated that almost half of teenagers were checking their mobile phones during the night and very worrying figure, one in ten checking them at least ten times at night, which obviously doesn’t help with sleep or other problems, and may be adding to the stress in young people and contributing to self-harm.
Also an interest recently in mood instability, by which we mean where there’s rapid changes in affect with and particularly controlling their behavioural consequences. And in another American study of 250 young males and females aged 18 mood instability identified at age 18 was found to predict borderline personality disorder, including self-harm, repetition of self-harm at age 20.
We know that contagion self-harm behaviour can be a particular problem in young people. We know that exposure to friends’ self-harming can be an important risk factor. In a schools based study we did some years ago we found this was particularly true for girls and for self-cutting. We know that also clustering of self-harm and suicide occurs in young people much more commonly than in adults and also that media influences self-harm and suicide are particularly strong in young people. And many of you will remember the sad story of the cluster, the large number of suicides that occurred in young people in Bridgend just over ten years ago. And here’s some of the awful newspaper reporting of those events, including on front page headlines photo galleries, photos of the young people who died, the method of suicide mentioned in the title, and indeed in the text there was much more detail about the particular method the girl in this case used for suicide. And we know that those sorts of… the way suicide is reported can have an influence on the likelihood of subsequent suicides. There’s some very elegant work from Madelyn Gould in the USA a few years ago showed this quite clearly.
And then, of course, there’s the whole problem of internet sites which may portray methods of self-harm. The next slide I’m going to show is something you would say is triggering for people at risk of self-harm, so maybe you want to close your eyes for a moment. So this sort of picture is easily accessible on the internet. We did a review a couple of years ago… it was published last year… looking at what evidence there was regarding internet sites and self-harm, and the evidence from the studies, studies we were able to look at it all together, showed that, first of all, young people often accessed the internet sites related to self-harm prior to harming themselves, that pro- suicide sites, in other words sites which tend to encourage self-harming behaviour or even suicide, are very easy to access, that detailed methods of self-harm and suicide are very easily available. In terms of… There’s a lot of discussion about social networking sites, do these contribute to self-harm? The evidence we found from the study seemed to go both ways, suggesting that some people found that… who were self-harming found them useful; in other cases there was evidence they may have actually contributed to self-harm.
And then there’s the issue of cyber bullying, online bullying. And of course, the problem with this is it can happen 24 hours a day. A person can be alone and be bullied by peers. And again, we did a review with Ann John’s group in Wales of the impact of cyber bullying or being cyber bullied on risk of self-harm, and this is just summarising all the studies. And basically a doubling of the risk of self-harm in those who were being cyber bullied, although it is very difficult to distinguish cyber bullying from face to face bullying as well because often people were experiencing both. Interestingly people who were actually doing the bullying also had an increased risk of self-harm.
What about factors that may be protective against self-harm? Well, we didn’t have a lot… We can obviously look at the inverse of all the risk factors, but that’s not very helpful. But these are the findings as I’m aware of them. Firstly, that social connectedness, the sense of being part of a peer group, being attached to peers, may be protective, feeling part of the school community may be protective, and limited evidence that more adaptive problem solving skills may be protective.
So let’s turn now to the issue of suicide following self-harm. And I’m going to refer to data from our Multicentre Study with data collected on self-harm in Oxford, Manchester and Derby. This is a website for our group. And again, this again, this is unpublished data. It’s the follow-up study we’ve done of over 9,000 ten to 18 year olds who presented to hospital between 2000 and 2013, so a 14 year period, followed up for death, which everybody’s flagged in our Multicentre Study for death anywhere in the UK, so we’ve got data from ONS for any deaths that occurred up to the end of 2015. And this is the methods used for self-harm at first presentation in the over 9,000 individuals. The majority, over three quarters, self-poisoning, particularly common in the females, self-injury more common in the males, and with a small group that used both self-poisoning and self-injury in the same episodes. And what we found at the end of 2015 was that 124 individuals had died. Nearly 45 percent of the deaths were suicides. Just over one in five were recorded as accidental deaths, although one or two of these may have been possible suicides, particularly where there was accidental… recorded accidental poisoning with psychotropic drugs, and then just over a third with deaths from other causes, natural causes in other words, mainly.
So focusing on the suicides, the 55 individuals who died by suicide, these are the methods involved in their actual deaths. And you can see a very different pattern to what I’ve showed you in terms of methods at the time of self-harm presentation, with 45 of them, of the 55, involving self- injury, and self-injury being particularly common in the males who died by suicide. So there was major method switching from self-harm to suicide, and this shows the switching methods from the last episode of self-harm in those who repeated, or the first episode in those who didn’t, to their suicide, you can see the big switch from self-poisoning to self- injury, particularly hanging and asphyxiation. A large number… 12 out of the 17 who self-injured used self-injury in their suicide, although some switched to self-poisoning, interestingly, and all of those before that had used both methods in their last episode of self-harm died by self-injury. So it was major method switching, and particularly a switch to hanging and asphyxiation with 57 percent of them died using this method.
One of the interesting things about doing a long-term follow up is if you look at the deaths that occur well after the incidence of self-harm. And what this shows is that the vast majority, three quarters of the deaths, occurred after age 18. So in those ten to 15, four out of the 11 who died were in this age range; those 16 to 18, just nine out of 44 in this age range. The vast majority of deaths occurring later on. So just to summarise that, nearly half the deaths in this study were due to suicide, over half of them involved hanging or asphyxiation, involved evidence of method switching. The majority of the suicides occurred in adulthood, and indeed, what we found is that the risk seemed to be maintained over time, whereas in adults you see a rapid drop off in risk after the first year. There was a pretty strong indication that risk of suicide, although much lower than in adults, was maintained over time. And importantly, there was an association of increased risk where self- injury occurred, and no difference in the risk of suicide where the last message of self-harm had been self-cutting or overdose, and that’s contrary to what a lot of clinicians believe, makes that an important point.
Good. In prevention and treatment, one approach has been gatekeeper training, training of schoolteachers to recognise youngsters at risk. I think the evidence of effectiveness at this is not strong. It doesn’t mean that it doesn’t work. I think the evidence is not strong. Screening was very popular in the USA where individuals completed questionnaires and those who scored above a certain cut off were then interviewed clinically in terms of whether they were potentially at risk. This has now been dropped, largely because it wasn’t that effective, and one problem was young people being screened, the screen was negative, and dying subsequently by suicide, resulting in legal action by parents against school, so that has now been dropped.
But much more positive has been the results of school educational programmes. Here’s one which is the Saving and Empowering Young Lives in Europe study or the SEYLE project, in which there was training in mental health awareness for school pupils, role play, working in groups, booklets about mental health, and also training on this sort of whole school approach to prevention. And in a study involving ten countries and a very large number of schools there was evidence that this was associated… this programme was associated with an actual reduction in risk of subsequent self-harm. It wasn’t conducted in this country, unfortunately. And I do think it needs verification in further work, but at least there is something positive there. And there are other programmes that have been shown to show encouraging results.
Always when we’re thinking about prevention we should be thinking about restriction of access to means. The very best evidence of impacts on suicide, in particular, come from changes in the availability of particular means to suicide. In this country I’m thinking about smaller packs of paracetamol seem to be important that are not being followed in all outlets. Some outlets are offering large amounts, relatively large amounts of paracetamol relatively cheaply.
And then there’s a question of what interventions work following self-harm. We did a Cochrane Review some years ago… I think three years ago… and we’ve added some study or adding some studies to this. In terms of therapies where there are more than one trial showing evidence of efficacy using randomised trials then the best evidence comes for the dialectical behaviour therapy. And we found three trials where when there’s a comparison with treatment as usual, DBT was shown to have benefits in terms of reducing frequency of self-harm and also reducing the reduction of depression, hopelessness, and suicidal ideation. There are some single trials which offer encouragement. Dennis Ougrin, who’s here, his therapeutic assessment approach, seemed to offer positive results in terms of engagement in therapy. And there’s some evidence that mentalisation may be beneficial in reducing repetition of self-harm. But not a lot go on relative to the situation in adults.
Obviously, we need to do our work to try and tackle problems in media reporting. Things have greatly improved in this country in terms of newspaper reporting and other media reporting and portrayal. I think the Samaritans, in particular, have done a fantastic job with their media guidelines and also their monitoring and feedback, where there’s poor reporting or portrayal of suicidal behaviour. But every now and again, we get a bad example. There’ve been some recently in relation to university student suicides. The government is very committed to sanctioning internet issues, particularly websites which seem to encourage self-harm, and that is important. The problem is one can really only tackle websites originating in this country, and of course, that isn’t always the case. And then there’s the question of whether internet web based interventions are going to be effective. There’s a lot of work going on the internet based interventions, but we still need to see the positive results from these. At the moment I don’t think there’s good evidence of effectiveness. It doesn’t mean they don’t work of course. We’re just waiting for better evidence to accumulate.
So I’d like to end by saying a bit about the impact of self-harm on families, and I’m going to refer to a study we did a few years ago, which was a qualitative interview study with 37 parents of young people who were self-harming, mostly mothers. As in so often, and many of you will be aware, it’s very difficult to recruit fathers for studies like this, and we found the same, and we just had five fathers. But we did have a range of participants from across the UK, a very poor ethnic minority representation as well, although we did try to specifically target ethnic minority parents. And in terms of the young people who’d been self- harming, the sons or daughters, they’d used a range of self-harm methods. They would tend to be towards the more severe end in that a lot of them were in or had been in psychiatric care.
So I’m going to show you some clips from a health talk website that we developed based on the thematic analysis of these interviews. So I’ve just got six minutes of clips to show you of these.
My daughter’s 17 now, and when she was 13 one of her friends told her dad that she’d been cutting herself with glass that she’d been collecting somehow, and she said that she knew… She told my daughter she was going to tell us and obviously she tried to persuade her not to, but her friend being a sensible girl and obviously cared about her said, no, I’m going to tell them because it’s the right thing to do. First feeling was my stomach dropped and I felt sick, and I thought, oh no, it’s really that bad. What’s happened that’s that bad? Why has she felt the need to do this? What have I done? Why didn’t I notice a signal? Why couldn’t she come to me? Why couldn’t she talk about it? What could I have done to make things different so that she hadn’t felt the need?
Total lack of control. Total lack of understanding and not knowing. Don’t worry, everything will be all right. Don’t worry, I’ll look after that. I’ll sort it out and suddenly you can’t.
At some stage, I can’t remember how old she was, but I do remember she explained it very coherently. If your head is hurting with emotional pain, if you’re unhappy, if you’re really, really hurting so badly in your head to harm yourself on the skin, to give yourself other pain, stops the feelings in your head. And she’s always been very coherent at explaining the things that she’s done. And I could…even though I can’t really understand why anyone would do that, I understood that. It’s deferring that pain away.
I’ve since found out it is a lot more common than what we think it is and speaking to the community mental health nurse, she says she’s just inundated with children that are self-harming, and it’s almost as if it’s a bit of a craze, but in my daughter’s case it was not a craze. This was to help her overcome or get through the trauma that she’d been through. So to me, there seems like there’s two forms of self-harm. There is this craze going round, but there is also the very disturbed who are using it just to get through.
Do you tell people? Do you keep it quiet? Who do you tell? Do you feel embarrassed? Do you feel humiliated? Do you feel… What do you feel? What do you say to people when they say they haven’t seen your daughter for a while? There are all these things. It’s… You kind of like you’re skating on ice. You don’t know how to be.
I think it… being female it helps me to talk. Men are not so good at talking on the whole. That’s a generalisation, but… And I think that’s one of the things that’s so difficult for my son because his father was very much, men don’t cry and men don’t this, whereas I’ve always enforced, reinforced or whatever the word is, actually it takes more of a man to cry, and he does at times.
The important thing is finding reliable, researched information. It’s very easy to look for anything and get onto a website that’s got a forum, that is just people chit chatting and spreading their opinions. It’s much more difficult to find somewhere that has got researched knowledge and background, as well as people talking, and talking about their experiences.
Clinician, listen to the parents, please, please, please. Nobody has spoken to us enough. We’re the ones that know about our children and we’re the ones that can help you to help our children. So please talk to us more because sometimes our children won’t talk to you, but we can tell you a lot more, especially about their background, about when they were younger, and more needs to be found out about the person they were treating through the parent and it’s not.
Don’t ever be ashamed of admitting what you’re going through because I’ll guarantee you, there’s about 50 other folk out there in the same boat. And if by doing this, I can at least help one person raise awareness or help them understand better or help them to acknowledge what’s going on, then I’ll be happy.
I think also looking after yourself, looking after your own mental and physical health is really, really important. And I sought help myself and have some counselling.
I think you have to take a longish term view of this. You can’t rush them to stop it immediately, which is what you’d like to do, well I wanted to do at the beginning. You can’t despair of them and turn your back on them. I think you have to find a way together to talk about things, to find out their triggers for it, to try and reduce it, to take a longer term view and to keep hopeful and supporting them until they no longer need it.
I would just say to people to remain hopeful. It might be a long, long journey and it might feel at times where your terror and fear is going to completely overwhelm you, but just remain hopeful, remain strong and realise that nothing stays the same.
Professor Keith Hawton
Okay, so those are just some extracts from the website, which you can find online. It’s the healthtalk.org website. Just a quick summary of key findings that parents tended to react to their discovering their child’s self-harm, confusion, disbelief. But it also often had very negative effects on the parents’ emotional state. Several of them actually had treatment themselves for mental disturbance following the discovery of the self-harm, a lot of them financial issues particularly where young people had to be transported or for aftercare or where parents had to travel long distances where some of them might be in in-patient care. There were major impacts on parenting, including not just the young person’s self- harming, but impacts on parenting of siblings and often impacts on the wider family, including marital relationships, and social isolation was an issue for some parents, particularly because of the perceived stigma associated with self-harm, not wanting to talk to others about it. As I’ve said, parenting strategies were often affected and they clearly considered the attitude of clinicians to be important and there were particular comments about not wanting clinicians who were assessing their son or daughter to be using [inaudible 00:46:00]. Young people were saying to them they didn’t want them using a tick box approach to assessment but really active listening to them, that they wanted, as you can see from a couple of the comments here, to be involved in a treatment, and they considered, again as you will have heard, the practical information through resources and also guidance were considered important.
And as a result of this, we developed, first of all, the healthtalk website, where there’s about 240 video… mostly video extracts… arranged thematically around all the issues related to young people’s self-harm. And then together with the Charlie Waller Trust we produced a guide for parents and carers, which is available both freely online and in hard copy from the Charlie Waller Trust. I think at the last count thousand 48,000 copies had been distributed of that. And more recently, we produced this guide for school staff, also available from Charlie Waller Trust. And both of these, there’s some copies upstairs in the coffee area on the Charlie Waller Memorial Trust desk that people can look at. And lastly, we produced the summary of our findings for clinical staff.
So just to summarise what I’ve said, there is clear evidence of increased rates of suicide in teenagers, a very worrying upward trend in rates of suicide, but also particular increase in self-harm in young adolescent girls. Much self-harm, as illustrated from the iceberg model, doesn’t come to clinical attention. A very wide range of factors can contribute to self-harm. It’s truly multi factorial. I’m not going to go through them all> I’ve listed them there. And obviously when thinking about intervention therapy one needs to consider what is important in individual cases. There’s an important association between self-harm and subsequent suicide, often including a change in method of suicide, with the risk extending well into young adulthood. And, as I said, because of the highly multifactorial nature of self-harm and suicide, a wide range of therapeutic and preventive measures are required, although at the moment the evidence about what really works is still sadly rather limited. And that prevention of self-harm and suicide clearly in the young people presents a major challenge, with school based and possibly, hopefully internet based approaches probably being the best option. And lastly, the impact of self-harm and of course suicide on families is extremely substantial and must be addressed in terms of management of young people who are self-harming. So thanks very much for your attention. Thank you.
Thank you. Can you hear me? Yes, thank you Keith for a fantastically comprehensive talk about really putting the field in context, and showing those very moving videos of the parents. It’s often a difficulty I find showing other people [inaudible 00:50:02], so thank you. So we’ve got ten minutes, so who would like to start? There are some people roaming around with microphones. Yes?
I wondered if…
Can you say who you are?
Oh, Marian Mintova. I wonder if you could say something about self-harm and eating disorders?
Professor Keith Hawton
Well, we know that… Yes, there’s certainly a strong association between self-harm and both anorexia and bulimia, talking about specific disorders. And, of course, it’s well recognised that the highest risk for suicide in any psychiatric disorder is with anorexia. So there’s a major association there. In bulimia, repetitive self-harm, self-mutilation is often a common part of the picture. Somebody was asking me last night about the nature of the association, why is it that there is this association? I think often it’s about self-control and break through from self-control for both binges and self-cutting or other self-harm, but of course, self-harm itself may also provide… Well, I think often the motive is self-punishment, reflecting the dislike of the self, body image and so on, and that’s often, I think, the motive for self-mutilation or self-cutting in eating disorders, although it may also be about tension release.
Thank you very much. I have a few questions, but the first one would be… or the main one would be around your opinion on the use of safety planning with young people after self-harm? I know there’s a lot of enthusiasm about it, but whether there’s a research base in your opinion?
Professor Keith Hawton
Well, no, I think what we’re always seeing, both in adults and in clinical practices with adults and young people is a move away from this idea of risk assessment. There are numerous studies which now show we cannot identify individuals who are specifically at risk and we should stop kidding ourselves if we can do that, and although trusts very much still want us to do it I think it’s often about protecting the trusts rather than the patients, but that’s another issue. And a move towards thinking, well, any individuals who’ve got… or any group of individuals with psychiatric disorders will have an increased risk of self-harm and suicide. It’s just that we can’t identify the, if you like, needle in the haystack. So we need to be thinking about safety planning in all individuals. And I think this is a really positive move, as long as the management can go along with it, my trust management, that is. And the evidence is not strong. There’s some evidence from a trial in the US in adults that safety planning in youngsters with… Sorry, in individuals who are self-harming… seem to have beneficial effects. There’s a lot of work going on here at the moment, both in adults and in young people, but we’re waiting for the evidence. But I can’t help but feel it’s a positive way forward. So this is where you develop a safety plan with the individual about what they do or will do if they get into another crisis, about their personal resources they can use, who they can turn to and so on and so forth, plus other aspects in terms of restriction of access to thinking about access to methods of self-harm and suicide, sharing of information, although it’s a controversial area, with families, and having a clear communication with the clinicians, families and the individual as well. So I think it’s a really positive way forward.
My name’s Isla. I just wanted to see if there was any research indicating why there’s a strong link between puberty and early self-harm? I was just wondering if there’s a prevalence of disorders like premenstrual dysphoria or something that might be causing that prevalence of it?
Professor Keith Hawton
Well, there’s an interesting question. I think we still don’t know specifically why there’s this… with this association, but we do know from other evidence that menstrual disturbances can be, obviously in females, can be associated with the increased risk of self-harm. But I think we’re quite a long way from understanding really why there’s this particular association, but I think it really is an important topic clinically to be aware of. But sorry, I don’t… Maybe someone else here does.
Hello, Clare Stafford from the Charlie Waller Trust. Thank you for that. Was excellent. You mentioned poverty and deprivation; certainly in our work we’re hearing very clearly from schools that they feel that they’re picking up on the deficits in community services, youth services, social services. The other factor that keeps coming up regularly is the exam system, the education system, the crushing pressure of exams earlier, more. Maybe there’s a link with perfectionism. I just wondered if you’d observed at all whether that is a factor, maybe particularly amongst young girls who tend to be a little bit more conscientious about that and may then have self-harming behaviour as a result?
Professor Keith Hawton
Well, certainly in the study, I think I just touched on earlier on about problems young people were facing preceding their self-harm, studying problems came out second or third after interpersonal difficulties. What we don’t have from that… Those data are fairly crude in the sense of just knowing that where they identify as having a study problem we don’t know the nature of those problems with study. And obviously it needs looking at more. But as you say Clare, the younger girls, it is a particular issue, so I agree. It’s certainly an important.
Thank you. Just sorry, Sonia. NHS Trust. I jus wondered if you had any thoughts about the management of self-harm with an open inpatient setting? Obviously they’re now actually trying to get the people out of hospital fairly quickly, the ever-increasing demand of keeping people safe and restrictions, restricting access to means etcetera.
Professor Keith Hawton
Well, here I need to make a confession. I’m not a child or adolescent psychiatrist. I’m a suicide researcher and that’s it, a self-harm and suicide researcher. But yes, it is a difficult dilemma, isn’t it? Because we know that in an institutional setting, particularly inpatient settings, the risk of contagion around self-harm, is particularly strong, and can cause major distress obviously for staff and so on, and that ideally you want to take individuals out of that more contagious environment. But striking the balance between safety and what might be seen as a desirable intervention, I think is often a very difficult one. And as we know in this… I was going to say game. It’s the wrong word for their clinical practice, but taking risks is what we’re doing every day. I think one’s preference should be towards working with young people in the community, if at all possible, and really keeping inpatient care down to a minimum. But it is a really, really difficult balance. I’m sure a clinician would be able to answer this much more fully than I can, but I agree the balance there is really tough.
Isobel Hayman. Thank you for the wonderful review. My question’s actually sort of related, which one of the things that came over most strongly to me was this mismatch between knowing what’s happening and knowing what to do about it. And in some settings, for example, in liaison with Child and Adolescent Mental Health, almost all resource is being used up on trying to keep on top of this problem because the ultimate outcome is so devastating. And I just wondered if you had something to say broadly about the direction of travel as how services go about organising what they do about this in terms of how much resource to put into this problem? Because the perceived risk is so great and people are so risk averse, all we can actually do and know what to do is so limited, so the temptation is to do absolutely everything you can, but that means one can end up not being able to do much else.
Professor Keith Hawton
Well, certainly in terms of where young people are actually self-harming, clearly we’ve got to put resources into good quality psychosocial current assessment to make sure we fully understand as well as possible what’s going on in terms of the relationships with young people and then to identify what potentially might be therapeutic, including obviously involving families. I tend to feel, reviewing the literature on interventions, what we really need are simple, brief interventions that work. And I don’t think we know at the moment what those best are, such that we can say to clinicians confidently this is a good way to go. I tend to favour problem solving types of interventions, but the evidence, again, is not… in terms of young people… is not really strong. And of course those do demand time. And I think… and I’ve talked about the evidence for dialectical behaviour therapy, well the problem is you’re talking there about fairly intensive treatment, three to four months at least group or individual work. But of course, doing it in groups provides some economy in terms of time. I think we’ve got to really move towards thinking more about prevention. And I really do think we’ve got to take this very seriously and start trying to do in schools, using the evidence that’s out there to try and develop interventions that are… preventative approaches, which are going to show some benefits. That to me is where the real need is. But I recognise the impact on clinical services where the youngsters are actually self-harming is enormous. And somebody commented last night, that self-harm is taking over… In a sense, it’s taking a lot of resources away from other problems, some of which may be more serious in terms of impacts on young people and their outcomes. Sorry, it’s not a very…
No, those are all the things I was thinking about.
Okay, I’m afraid there are lots more questions, but we’ve got to stop. We’re out of time. Keith will be around here in the tea break for further questions, so thank you very much.