Prof p hazell self harm in adolescents hanoi

Self harm in adolescents Professor Philip Hazell Rivendell Child Adolescent and Family Mental Health Service General considerations       Continuum of seriousness Continuum of intent to die (may be as low as 0.2%) Common precipitant is conflict with parents or significant others ‘Contagion’ effect Small group account for large proportion of repetitions Poor adherence to follow up, but those with greater risk of repetition more likely to attend Overlapping Terminologies       Non-suicidal self injury  Restricted to external injury, no suicide intent Deliberate self harm  Inclusive of internal injury ie ingestion, agnostic about suicide intent Parasuicide  As for DSH plus aimed at realising changes which the subject desired via the actual or expected physical consequences Attempted suicide  A more specific subcategory of parasuicide characterised by a strong intention to die Self poisoning, self mutilation, self battery, self immolation Self injurious behaviour Frequency of self-harm types Clinically referred sample 12-16 yrs Hazell et al J Am Acad Child Adolesc Psychiatry 2009;48:662-670         Cutting 97% Head banging 71% Medication overdose 57% Smothering 36% Strangling 25% Other poisoning 19% Jumping from height 17% Other 35% Method of self-harm by gender Madge et al J Child Psychol Psychiatry 2008;49:667-77 Four-week prevalence of non-suicidal self injury by age and sex Martin et al Australian National Epidemiological Study of Self Injury Rates of self-harm by gender in 15 and 16 yr olds Madge et al J Child Psychol Psychiatry 2008;49:667-77 Repetition (‘more than once’) Community aged 15-16 yrs Madge et al J Child Psychol Psychiatry 2008;49:667-77  Males 53.2%   Females 55.4% Cutting more likely than other methods to be associated with repetition Pattern of self-harm over 12 months Referred sample 12-16 yrs Hazell et al Presentation to AACAP meeting, Honolulu, Oct 2009 NC21 Yes No No Yes NC22 No No No No NC23 No Yes Yes NC24 Yes Yes Yes Yes NC25 Yes Yes Yes Yes 999 Yes Yes No No Yes No No interm i t No No No No No No No No atten Yes No No No No No No No atten Yes Yes Yes Yes persis t Yes Yes No 999 999 Yes Yes Yes 99 Yes 999 No Yes persis t Self injury   Age of onset  12-14 yrs (based on retrospective data) Course  Variable, most have ceased within yrs of starting 10 Special populations: Goths and Emos 25 Special populations: Children in immigration detention  25-100% of children in immigration detention engage in self harm  Human Rights and Equal Opportunities Commission (2004) A last resort? The national inquiry into children in immigration detention Canberra, ACT: HREOC 26 Hospitalisation     Limited RCT evidence in adults suggests hospitalisation does not influence repetition We are inclined to hospitalise for defensive rather than pro-active reasons Decision influenced by carer anxiety (“I’m not willing to take her home”) Hospitalisation may be deemed necessary as a child protection measure 27 Factors that influence clinicians to hospitalise       Problems with family support Depression Conduct disorder Substance abuse Previous attempts Suicidal behaviour in a relative Morrissey et al J Am Acad Child Adolesc Psychiatry 1995; 34: 902-11 28 29 Treatments for self injury     Effective  Dialectical Behaviour Therapy (in young adults with BPD) Uncertain benefit  Dialectical Behaviour Therapy (in adolescents)  Problem solving  Emergency card  Developmental group therapy Possibly harmful  Paroxetine, venlafaxine Unevaluated  Guided self help  Help lines  Peer support  Art therapy  Guided internet chat rooms (in young adults) 30 J Am Acad Child Adolesc Psychiatry 2001; 40:1246-53 31 Summary of outcomes Outcome Group Routine Significance Number sessions Median Median ? Individual support Median OR 0.3 (95% CI 0.1 to 1.0) Two or more self 2/32 harm 10/31 OR 6.3 (95% CI 1.4 to 28.7) Mean self harm 0.6 1.8 NS Dose effect Decrease Increase Median 32 J Am Acad Child Adolesc Psychiatry 2009;48:662-670 33 Repetition  By months    30/34 (88%) of the experimental group 23/34 (68%) of the routine care group ( χ2 = 4.19, p = 04) Interval 6-12 months   30/34 (88%) of the experimental group 24/34 (71%) of the routine care group (χ2 = 3.24, p = 07) 34 35 Self harm repetition     Group therapy n = 181 Routine care n = 183 No of repetitions 0-6 mths OR = 0.99 (CI 0.68 to 1.44) No of repetition 6-12 mths OR = 0.88 (CI 0.59 to 1.30) 36 Summary      Self harm is common in adolescents Peaks in older adolescent females Only a minority reach clinical care Motives more likely to be to manage internal stimuli than to communicate to others Associated with advance in puberty, and puberty’s association with depression, substance abuse and other correlates of self injury 37 Summary      Clustering due to assortive friendships and/or contagion The behaviour is recurrent in about a half of individuals but In about a half of clinic samples it will attenuate over 12 months There is no proven treatment to prevent recurrence or hasten attenuation in adolescents Hospitalisation not generally necessary 38 The way forward   Self esteem and self worth may be useful treatment targets in adolescents who self injure Hastening attenuation rather than preventing repetition should be the goal 39 ... Therapy (in adolescents)  Problem solving  Emergency card  Developmental group therapy Possibly harmful  Paroxetine, venlafaxine Unevaluated  Guided self help  Help lines  Peer support  Art... of self- harm The association with pubertal stage was evident in boys but appeared more striking in girls in whom self- laceration and selfpoisoning constituted the great proportion of self- harm. .. overlap in the friendship networks of friends of controls compared with friends of self harmers Forty-five percent of friends of self harmers harmed themselves during the follow-up period compared