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Understanding why young people harm themselves

Nicola Madge
BA MSc PhD
Assistant Research Director
National Children's Bureau
London
E:nmadge@ncb.org.uk

Understanding why young people harm themselves can be difficult for everyone. Children and adolescents themselves may wonder why they behave as they do and wish they could stop; their friends and parents may ask how they can help and whether they are in some way to blame; and professionals (such as teachers, social workers, doctors - or even nurses) can feel bewildered and unsympathetic. Greater knowledge can help to promote understanding, and the relaunched "Young People and Self-Harm" website at the National Children's Bureau provides a first port of call for all those looking for information and advice in this area (see Resources).

The scale of the problem
The large numbers of young people known to harm themselves, as well as others who injure themselves without anyone knowing, point to the seriousness of the issue and the need to provide effective services and guidance aimed at reducing and alleviating the problem. This is particularly important as single episodes frequently lead to repetition,(1,2) as self-harm may be a precursor to ­attempted or completed suicide,(3) and as it usually reflects personal and interpersonal problems and difficulties that need to be addressed.
In the UK, deliberate self-harm is one of the top five reasons for acute medical admissions,(4) and it has been estimated that around 300 per 100,000 males and 700 per 100,000 females, aged between 15 and 24 years, will be admitted to hospital for this reason each year.(1) In addition, there are many more young people who remain "hidden" within the community and do not necessarily need medical attention. The National Children's Bureau is coordinating the Child & Adolescent Self-harm in Europe (CASE) Study, and this is providing clear evidence from seven countries (Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway) that many young people who carry out these acts do so in secret. Findings from the English part of the study show that only about half the young people who reported episodes of self-harm told someone beforehand, and fewer than a quarter sought help after the event.(2) Furthermore, the vast majority did not attend hospital for their injuries.

What is meant by self-harm?
Self-harm is not easy to define and can mean many different things. Generally speaking, it is an act that is carried out intentionally with the expectation that it is likely to cause physical injury. In practice, the forms it may take include an overdose of pills or tablets, self-cutting, burning, self-battery, jumping from a high place, and some behaviours involving drugs and alcohol. Self-harm can also occur as part of certain medical and developmental conditions, such as Cornelia de Lange's syndrome, Prader­-Willi syndrome, fragile X syndrome and Cri du Chat syndrome.(5)

Patterns of self-harm
There is no typical profile for young self-harmers, but there are some quite striking patterns. First, the vast majority are female. This is true of both those who do and those who do not go to hospital after an episode. Second, age is important. Although there is little evidence to suggest that small children commonly harm themselves, some parents have reported that their children as young as 5-7 have tried to harm, hurt or even kill themselves.(6) Among older groups, age appears to increase the risk of self-harm.
Early findings from the CASE Study indicate that personal characteristics such as low self-esteem, anxiety and depression also increase the risk of self-harm among young people.(2) Indeed, self-harm usually arises amid difficulties of some kind. A recent systematic review of population-based studies looking at suicidal phenomena in adolescents (the definition of which included self-harm) suggests that a wide range of factors may be implicated,(7) such as:

  • Mental health difficulties.
  • A history of physical and sexual abuse.
  • Exposure to similar behaviour shown by others.
  • Conflict and poor communication at home.
  • An absence of good peer relations.

What makes a young person want to self-harm?
Even when young people have serious problems and difficulties in their lives, the reasons they give for their self-harm can be surprising. Some may have made a serious suicide attempt, but most see their behaviour as a means of coping and "surviving". The Royal College of Psychiatrists is among those to point out how self-injury can be a way of dealing with difficult feelings, particularly if there is nowhere to turn.(8) It can also relieve tension when things get so bad that a young person feels they might explode. Or it may be a way of feeling alive when otherwise numb and detached from the real world.

Prevention and intervention
The primary goals of prevention and intervention are to offer help and support to young people who are harming themselves or are at risk of doing so, to assist in resolving any difficulties they may be facing, and to reduce or eliminate reliance on self-injury. Another goal is to encourage and empower all those in contact with these young people, whether family, friends or professional workers, to provide appropriate help and support. Yet another is to raise awareness and increase acknowledgement of the problem more generally. This means getting people to realise that self-harming behaviour is not rare and that it signals a young person who is struggling to cope. It is also about providing people with better knowledge and understanding of self-harm among young people, including its prevalence, visibility and associated risk factors, to enable them to better support, manage and prevent such behaviour.
At a policy level, self-harm among young people is highlighted as of concern within the National Suicide Prevention Strategy for England.(9) Many bodies, including the Royal College of Psychiatrists, also provide guidance aimed at health authorities, NHS trusts, primary care trusts, local authorities, psychiatrists and other practitioners. In addition, the National Institute for Clinical Excellence is developing guidelines for staff working in accident and emergency departments, pointing out that "health service staff frequently have a negative attitude towards those who carry out acts of self-harm, ­particularly those who harm themselves repeatedly".
Children and Adolescent Mental Health Services (CAMHS), the statutory service with responsibility in this area, are currently underresourced. Additional funding should, however, make them much more widely available from 2004. This is a significant development as local initiatives have demonstrated the effectiveness of community adolescent mental health teams if these are sufficiently resourced, able to reach the target adolescents and able to intervene quickly.(10)
Different types of strategy have been adopted and attempted at a practice level. Providing information and support through face-to-face groups, the internet, written and aural/visual materials and telephone helplines is one approach. Medical and psychiatric treatment is another. The scarce evaluation of such interventions has suggested that some may be more promising than others.(11) A third general strategy focuses on general population groups and is likely to be school-based. Peer support group and peer mentoring schemes fall within this category, as do curriculum-based programmes. In general, these aim to boost young people's self-esteem and encourage them to develop effective coping strategies. They also encourage pupils to "look out" for each other and offer support as needed.

The "Young People and Self-Harm" website
There is no substitute for direct, one-to-one support for young self-harmers seeking help, but the National Children's Bureau's relaunched self-harm website has an important role to fill. As well as contributing to the general acceptance and understanding of self-harm among young people, it can reach a wide range of groups seeking practical advice - including young people who are harming themselves in secret and do not know where else to turn. It provides an anonymous source of information and is likely, as such, to appeal to boys as well as girls.(12) It is also a forum for researchers to share their findings and an arena for the dissemination of new policy and practice initiatives. It will have served its purpose if it makes even a small dent in the incidence of self-harm among the young.

Practice pointers

  • Be aware that young people under stress may be at risk of ­harming ­themselves
  • If detected, always take a young person's self-harm ­seriously
  • Follow ­guidance on managing ­deliberate self-harm (eg, as issued by the Royal College of Psychiatrists and under ­development by the National Institute for Clinical Excellence)
  • Make sure that support is ­available to young people who self-harm, whether from a ­professional, a family member or a friend
  • Ensure that any appropriate ­referrals are made, such as to mental health services

References

  1. Hawton K, Fagg J, Simkin S, Bale E, Bond A. Deliberate self-harm in adolescents in Oxford, 1985-1995. J Adolesc 2000;23:47-55.
  2. Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002;22:1207-11.
  3. Safinofsky I. Repetition of suicidal behaviour. In: Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. London: Wiley; 2000.
  4. NHS Centre for Reviews and Dissemination. Deliberate self-harm. York: University of York; 1998.
  5. Hewitt A. Young people who self-harm. London: National Children's Bureau; 2003
  6. Meltzer H, Harrington R, Goodman R, Jenkins R. Children and adolescents who try to harm, hurt or kill themselves. London: National Statistics Office; 2001.
  7. Evans E, Hawton K, Rodham K. Suicidal phenomena in adolescents: a systematic review of population based studies. Oxford: University of Oxford; 2002.
  8. Royal College of Psychiatrists. Deliberate self-harm in young people. Factsheet 30, for parents and teachers. London: RCP; 2002.
  9. Department of Health. National suicide prevention strategy for England. London: Department of Health; 2002.
  10. Kaplan T and the SAFE team. From a short-life project to a ­mainstream service: convincing commissioners to fund a community adolescent mental health team. Child Adolesc Ment Health 2002;7:114-20.
  11. Wood A, Trainor G, Rothwell J, Moore A, Harrington R. A randomised trial of group therapy for repeated deliberate self harm in adolescents. J Am Acad Child Adolesc Psychiatry 2001;40:1246-53.
  12. Madge N, Franklin A. Change, ­challenge and school nursing. London: National Children's Bureau; 2003.

Resources
National Children's Bureau
W:www.ncb.org.uk
The Young People and Self-Harm website
W:www.selfharm. org.uk
National Institute for Clinical Excellence (NICE)
W:www.nice.org.uk