Self-harm is common in adolescents in England
Question: What are the epidemiology and characteristics of self-harm in adolescents in England?
Population: In total, 5205 children and adolescents aged up to 18 presenting with self-harm to general hospital emergency departments. Self-harm was defined as intentional self-poisoning or self-injury, irrespective of motivation and degree of suicidal intent. It did not include events such as hair pulling, risk-taking behaviour or purging.
Setting: Six hospitals in Oxford, Manchester, and Derby, UK; 2000–2007.
Assessment: After presentation with self-harm, most individuals were assessed by specialist psychiatric clinicians. Demographic, clinical and clinical management data were collected by clinicians during the assessment. Data for individuals not having an assessment were extracted by research staff from medical records. Data extracted included age, gender, date and method of self-harm, alcohol involvement, time of presentation, psychiatric history, hospital admissions, psychosocial assessment and aftercare. Repeated self-harm episodes were identified and recorded.
Design: Longitudinal study.
Main results: During the study, 5205 children and adolescents presented with self-harm. Most of these individuals were aged 15–18 years (82.1%), with 17.8% aged 10–14 years old, and 0.1% aged under 10. Over half (53.3%) had previous self-harm, and 17.7% re-presented to the hospital with self-harm within 12 months. The annual rates of self-harm were highest in females aged 15–18 years (1423/100 000; 95% CI 1 to 346 to 1501), followed by males in the same age group (466/100 000; 95% CI 422 to 510), then females aged 10–14 years (302/100 000; 95% CI 269 to 335), and finally males aged 10–14 years (67/100 000; 95% CI 52 to 82). There were significant differences in the methods used for self-harm by gender (p<0.001). Most females (79.5%) used self-poisoning, while this was less common in males (72.9%). Self-injury was more common in males (22.7%) than in females (15.3%). Paracetamol was the most commonly used drug for self-poisoning (58.2%), followed by antidepressants (13.1%). The most common method of self-injury was cutting or stabbing (87.7%), followed by hanging (3.4%), jumping (2.7%), traffic-related acts (1.0%), carbon monoxide poisoning (0.6%) and drowning (0.3%). Alcohol was involved in more cases in males (38.5%) than females (32.7%; p=0.002), and was more commonly involved in the 14-year-old to 18-year-old age group (37.3%) than in the 10-year-old to 14-year-old age group (13.2%; p<0.001). After the introduction of national guidance in 2004 which recommended specialist psychosocial assessment in all patients with self-harm, this assessment occurred in 57% of child and adolescent cases. The guidance also recommended that all patients presenting with self-harm under the age of 16 should be admitted, and this was adhered to for 64.8% of cases in the under-16 age group at the two centres with reliable admission data.
Self-harm is common in children and adolescents in England, particularly in older adolescents. National guidance on self-harm in this age group needs further implementation.
‘If I had a world of my own, everything would be nonsense. Nothing would be what it is, because everything would be what it isn't.’1
When many adults, including clinicians, hear about or see an adolescent who engages in self-injury or self-harm, they are often perplexed with such behaviour, and feel they may have entered an Alice-in-Wonderland situation. Why would youth seek to hurt themselves? Unfortunately, this phenomenon among children, adolescents and adults is not rare and is found around the globe. Indeed, research notes that 5–8% of adolescents in Western countries report self-harm over the past year of surveys.
This survey by Hawton and colleagues looks at the epidemiology of self-harm in hospitalised children and adolescents from six hospitals in England between 2000 and 2007. It is a specific, non-generalisable group but fits in nicely with other epidemiological research of different groups with self-harm that are surveyed.
The authors point out a disturbing finding that only 57% of this ‘hospitalised’ group received a psychosocial evaluation. This is a saturnine state of affairs because it suggests the underlying issues for self-harm were not identified in many of the patients. This study can change clinical practice for many, if they become aware of the epidemiology of self-harm and the lack of much-needed behavioural assessment in so many.
Research does pinpoint many reasons for self-harm such as impulsivity, abuse, depression, low self-esteem, sense of persistent hopelessness, effects of school bullying, family dysfunction and/or others. Research ascertains that those who self-harm continue with their potential for self-harm and some eventually commit suicide if these underlying issues are not resolved. Society and clinicians must take all situations of self-harm seriously. This means psychiatric assessments on all those with self-harm and judicious follow-up to be sure these precious paediatric patients are receiving the behavioural or psychiatric care they require. Such patients should not be perceived through an Alice in Wonderland lens, but with the careful eye of a caring clinician to help them avoid a lifetime of dysfunction and/or suffer preventable suicide. Kudos to this study.