Professional Documents
Culture Documents
DOI 10.1007/s00787-012-0269-6
ORIGINAL CONTRIBUTION
Received: 23 November 2011 / Accepted: 13 March 2012 / Published online: 25 March 2012
Springer-Verlag 2012
Introduction
Self-harm (intentional self-poisoning or self-injury, with or
without suicidal intent) in children and adolescents has
been identified as a major problem in several countries
[1, 2]. Much recent information on self-harm in young
people has been based on surveys, usually in schools [3, 4].
This has highlighted the extent of the problem at the
community level. Most individuals who gain access to
clinical care, however, have presented to hospital following
self-harm [5]. However, only a minority of individuals who
self-harm in the community present to hospital [3] or any
health facility [5]. Studies of children and adolescents
presenting to hospital have usually been based on single
hospitals [6, 7]. There is a need for data from multiple
centres to give a more representative picture of the extent
and nature of clinical demand.
In official clinical guidance on management of self-harm
there has been an understandable focus on children and
adolescents who self-harm. This includes, for example, the
National Institute for Clinical Excellence guides on selfharm published in the UK in 2004 [8] and 2011 [9] and
guidance from the Australian and New Zealand Colleges of
Psychiatrists and Emergency Medicine [10]. In addition,
national strategies on prevention of suicide include a focus
on self-harm patients [1113]. This is because of the risk of
suicide following self-harm [14], including in young people [6, 15].
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370
Method
Rates of self-harm
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Ethical approval
The monitoring systems in Oxford and Derby have
approval from local Health/Psychiatric Research Ethics
Committees to collect data on self-harm. Self-harm monitoring in Manchester is part of a clinical audit system and
has been ratified by the local Research Ethics Committee.
All three monitoring systems are fully compliant with the
Data Protection Act of 1998. All centres have approval
under Sect. 251 of the NHS Act 2006 to collect patient
identifiable information without patient consent.
Statistical analyses
Rates of self-harm and trends in rates were calculated
separately for each centre. The v2 test for trend (linear by
linear association, two-sided) was used to test the significance of changes over the period 2000 and 2007. Analyses
and calculations were performed with Microsoft Office
Excel 2003, SPSS v15.0 [23], and Stata v10.0. [24].
371
Results
Study population
A total of 5,205 individuals were included in the study,
three-quarters (74.6 %) of whom were female. During the
study period these individuals were involved in 7,150 selfharm episodes which resulted in presentation to the study
hospitals (Table 1).
Only four (0.1 %) of the individuals were under
10 years of age, 929 (17.8 %) were aged 1014 years, and
4,272 (82.1 %) 1518 years. The female to male ratio in
the 1014 years age group was 5.0, and in the 1518 years
age group, 2.7.
Nearly two-thirds of the individuals (2,847, 64.8 %)
were known to be students (either attending school or
higher education), with information on student/employment status missing for 15.6 % (814). Most were White
(88.5 %, N = 2,905), 3.5 % (115) Black, 2.6 % (134)
South Asian, and 2.5 % (130) from other ethnic groups
(information missing in 36.9 % (1,921) cases).
Rates of self-harm
In females, the annual person-based rates averaged over
the study period in 1518 year-olds were 4.7 times greater
than those in 1014 year-olds; in males they were 3.1
times greater (Table 2). There were no significant trends
in overall rates by gender during the 8-year study period.
However, there were changes in females aged
1518 years (v2 = 4.16, p = 0.04), with rates peaking in
2003 and subsequently declining. The overall female:male
rate ratio in age group 1014 years was 4.5 and varied
across the centres between 4.0 (Derby) and 5.8 (Oxford).
In age group 1518 years the overall female: male rate
ratio was 3.1 and varied between 2.5 (South Manchester)
and 3.4 (Oxford).
Rates rose in females with each year of age until age
1517 years (Fig. 1). Rates were significantly higher in
1518-year-old females in South Manchester than in the
other two centres. In males, rates rose more slowly with
age, and, except in Oxford (where rates appeared to peak at
age 16 years), were still rising at age 18 years (Fig. 2).
Rates in males aged 1518 years were significantly higher
in South Manchester than in the other two centres. Rates
were also significantly higher in females aged 1014 years
in South Manchester than in Derby.
Centres
Oxford N (%)
Manchester N (%)
Derby N (%)
N (%)
1,952
3,073
2,125a
7,150a
Males
397 (20.3)
812 (26.4)
532 (25.1)
1,741 (24.4)
Females
1,555 (79.7)
2,261 (73.6)
1,590 (74.9)
5,406 (75.6)
1,342
2,339
1,524a
5,205a
Males
311 (23.2)
630 (26.9)
383 (25.2)
1,322 (25.4)
Females
1,031 (76.8)
1,709 (73.1)
1,138 (74.8)
3,880 (74.6)
Episodes
Persons
a
Total
Table 2 Person-based annual rates of self-harm per 100,000 in the three centres, by gender and age group: average of years 20002007
Oxford
Rate
95 % CI
South Manchester
Derby
Rate
Rate
95 % CI
Combined
95 % CI
Rate
95 % CI
Males
1014 years
64
3592
95
52138
59
4078
67
5282
1518 years
410
334486
687
556817
428
371486
466
422510
Females
1014 years
369
1518 years
1,377
296442
1,2401,514
410
1,737
318502
1,5291,945
240
1,352
200279
1,2481,456
302
1,423
269335
1,3461,501
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372
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below total over 100 %. Paracetamol (including compounds) was by far the most frequent drug used for selfpoisoning (58.2 %, N = 3,343), followed by antidepressants (13.1 %, N = 752). Drugs used relatively infrequently included salicylate (including compounds; 6.9 %,
N = 399), benzodiazepines (2.5 %, N = 150), major
tranquillisers (2.1 %, N = 122) and co-proxamol (1.9 %,
N = 105). Other drugs (e.g., NSAIDs, opiates, antibiotics)
were used in 43.0 % (N = 2,474) episodes. During the
study period there was a significant decrease in self-poisoning with salicylate and compounds (v2 = 9.44,
p = 0.002) and co-proxamol (v2 = 30.45, p \ 0.001). The
use of other drugs for self-poisoning significantly
increased during this period (v2 = 28.02, p \ 0.001).
Self-injury By far the most common method of selfinjury was self-cutting or stabbing (87.7 %, N = 1,364),
followed in frequency by hanging (3.4 %, N = 53),
jumping (2.7 %, N = 42), traffic-related acts (1.0 %,
N = 16), carbon monoxide poisoning (0.6 %, N = 10) and
drowning (0.3 %, N = 4). Self-injury involving other
methods occurred in 4.2 % (N = 66). There were gender
differences in methods of self-injury (v2 = 31.65, df = 6,
p \ 0.01), with cutting/stabbing occurring in a greater
proportion of episodes by females (90.5 vs. 81.3 %) and
hanging/asphyxiation in more episodes by males (6.0 vs.
3.2 %). There were no significant differences, however, in
the methods of self-injury by age groups (1014 years vs.
1518 years).
Alcohol Whether or not alcohol was involved in episodes of self-harm was known in 3,451 (84.8 %) assessed
episodes. Alcohol was more often involved in episodes by
males (38.5 %, N = 327) than females (32.7 %, N = 851;
v2 = 9.98, p = 0.002). Involvement of alcohol did not
change significantly during the study period in either
gender. Alcohol was more often involved in episodes by
adolescents aged 1518 years (37.3 %, N = 1,118) than
1014 year-olds (13.2 %, N = 60; v2 = 101.1, p \ 0.001).
Time of day
The time of presentation for self-harm showed marked
diurnal variation with lowest numbers between 6.00 a.m.
and 9.00 a.m. and then increasing numbers until a peak was
reached between 10.00 p.m. and 1.00 a.m. (Figure 3).
Involvement of alcohol showed a similar pattern, except
that increasing proportions of episodes involving alcohol
occurred between 1.00 am and 5.00 a.m. (Fig. 3).
Previous psychiatric history
Of the 3,077 individuals who had a psychosocial assessment at their first episode in the study period, 28.0 %
(N = 689) had received previous psychiatric treatment
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Discussion
We have used data from the Multicentre Study of Selfharm in England to provide information on the epidemiology, characteristics and aftercare of a large sample of
children and adolescents who presented to hospital over an
8-year period following self-harm. While some individuals
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374
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difference relates to the greater likelihood that self-poisoning in adolescents will result in presentation to hospital
(and to any clinical service) compared with self-cutting [5,
30].
Alcohol use and problems appeared to be related to selfharm in many cases, including in some of the younger
adolescents. Strategies to tackle youth drinking patterns,
including under-age drinking [31] may have beneficial
effects on self-harm.
The diurnal variation in self-harm hospital presentations
found in this study, including alcohol-related self-harm,
with a peak at night, are relevant to availability of clinical
services for young self-harm patients. Admission of all
children and adolescents who present with self-harm at
night to allow opportunity for full recovery and psychosocial assessment, as is recommended for all those aged
16 years and under [8], would seem sensible.
Over half of the children and adolescents in this study
were repeaters of self-harm, yet only just over a quarter had
a history of psychiatric treatment, highlighting the fact that
much self-harm in the community does not result in clinical
care [5]. Also, repetition of self-harm resulting in hospital
presentation within 1 year following a first episode in the
study period was common, occurring in 17.7 %.
As found in other studies [3234], relationship problems
predominated among the difficulties the children and adolescents were facing at the time of self-harm, with problems with families and friends being especially common in
females. Problems with alcohol, drugs and legal issues
were more common in the males. There were differences in
the nature of problems individuals faced at the time of selfharm, with problems with boyfriends/girlfriends, alcohol,
drugs, bereavement, finances and housing being more
common in 1518 year-olds, and more 1014 year-olds
facing problems with friends. We did not have systematic
information on psychiatric disorders in the children and
adolescents in this study, but other studies have shown that
the majority of those presenting with self-harm are likely to
have disorders, especially depression [35, 36]. Effective
therapeutic interventions are therefore likely to include a
combined focus on life problems and mental health [1]. At
present, unfortunately, evidence of effective interventions
for children and adolescents based on randomised controlled trials is lacking [3739].
The fact that psychosocial assessment occurred in only
57 % of presentations in this study, even though the three
centres involved have well-established specialised selfharm services, demonstrates the extent to which hospitals
fall short of implementing the national guideline recommendation that all self-harm patients should receive a
specialist assessment. As non-assessment may have several
causes (e.g., self-discharge, patient refusal, unavailability
of staff, emergency department policy), this requires
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Conclusions
Using data collected systematically in multiple hospitals
in England on self-harm presentations by children and
adolescents, we have shown that self-harm becomes more
common with age, especially after the age of 12 years and
in females, and that rates of self-harm remain high,
especially in older adolescents. We have highlighted a
continuing problem of use of paracetamol for self-poisoning and the important role that alcohol has in selfharm. There is a clear diurnal pattern in numbers of
hospital presentations, with a preponderance at night,
especially for alcohol-related self-harm. Problems facing
children and adolescents who self-harm often include
relationship difficulties, especially for females. Repetition
of self-harm is common. Implementation of the national
guidance that psychosocial assessment should be conducted with all patients presenting to hospital with selfharm clearly presents a challenge.
This study demonstrates the value of multicentre collection of information on self-harm in children and adolescents. The findings also emphasise the need for large
scale longitudinal studies and for development of effective
aftercare interventions.
Acknowledgments For assistance with data collection we thank
Deborah Casey, Elizabeth Bale and Anna Shepherd in Oxford, Elizabeth Murphy, Iain Donaldson, Maria Healey and Stella Dickson in
Manchester, and Carol Stalker in Derby, and members of the general
hospital psychiatric and other clinical services, and hospital administration staff in all three centres. KH is a National Institute for Health
Research Senior Investigator. NK is also supported by the Manchester
Mental Health and Social Care Trust. We acknowledge financial
support from the Department of Health under the NHS R&D Programme (DH/DSH2008). The Department of Health had no role in
study design, the collection, analysis and interpretation of data, the
writing of the report, and the decision to submit the paper for publication. The views and opinions expressed herein do not necessarily
reflect those of the Department of Health.
Conflict of interest
of interest.
Appendix
See appendix Table 3.
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376
Table 3 Problems identified in
assessed individuals, aged
1018 years (N = 3077), by
gender
Males N (%)
Females N (%)
v2
281 (39.1)
1027 (46.2)
10.9
216 (29.9)
623 (28.1)
0.86
0.368
Study/employment
169 (23.5)
507 (22.8)
0.15
0.703
88 (12.3)
378 (17.0)
Alcohol
88 (16.0)
144 (8.0)
30.4
<0.001
11.5
0.001
0.001
0.002
Housing
77 (10.7)
151 (6.8)
Mental health
73 (10.1)
163 (7.3)
Drugs
62 (11.3)
76 (4.2)
Financial
53 (7.4)
104 (4.7)
7.68
0.006
Bereavement
42 (5.9)
132 (6.0)
0.01
0.925
Consequences of abuse
38 (5.3)
177 (8.0)
5.76
0.016
Physical health
31 (4.3)
82 (3.7)
0.57
Legal
33 (4.6)
30 (1.4)
Other problems
96 (13.4)
343 (15.5)
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