Deliberate Self-Harm (DSH): A Follow-up Study of Irish Children C Cassidy, F McNicholas, R Lennon, B Tobin, M Doherty, N Adamson Department of Child Psychiatry, Our Lady’s Children’s Hospital, Crumlin, Dublin 12 Abstract This study aimed to look at rates of repetition in children presenting with Deliberate Self-Harm (DSH) to a paediatric A&E department. Children presenting with DSH to a paediatric A&E between 2000 and 2005 were invited to participate in the study. Telephone interviews collected information on demographic details and mental health functioning, including repetition of DSH. Data was obtained from 39 parents and 10 children (31 girls and 8 boys, mean age 15) 1 in 5 females (20%) had made a repeat attempt of DSH and 1 in 10 (10%) had repeated more than once. No males repeated self-harm. On going parental concern rather than clinician risk assessment at index episode predicted subsequent DSH. Given the poor predictive value of clinician risk assessment, all attempts of DSH must be taken seriously, especially those associated with ongoing parental concern. Introduction Deliberate self-harm (DSH) is a common problem, accounting for over 11,000 1 presentations to general hospitals in Ireland in 2003 . The highest rate (600 per 100,000 population) was found in 15-19 year old females. In a recent Irish survey of 2 15â..17 year olds, 12.2% reported a lifetime history of DSH . Following an episode of DSH, repetition is common. Studies in adults report repetition rates of 15% after 3 1 year . Higher repetition rates have been found in adolescents, up to 45.9% in one 2 questionnaire based Irish study , and 42% in a Norwegian study of adolescents admitted to hospital post DSH. DSH is a major risk factor for completed suicide. 5The increased risk persists for two decades after the index episode . The youth suicide rate (15-24 year olds) in Ireland was 5th highest in the EU in 2004, a rate 1 of 15.7 per 100,000 population , and is the leading cause of death in young men. Given the high suicide rates in the Irish population, and the significance of past DSH as a risk factor for completed suicide, this study was conducted to examine rates and risk factors for repetition of DSH in Irish children who had previously attempted DSH and had presented to a hospital setting. Method All children who had presented to a tertiary paediatric centre between 2000 and 2005 with DSH, who were under 18 years old at the time of the follow up study, were eligible to participate. Approval was granted by the hospitalâ..s Ethics Committee. Telephone interviews were conducted with consenting parents and children. A study specific questionnaire enquired about the childâ..s level of satisfaction with their current mental health status, quality of life, and any repeat episodes of DSH. Parental satisfaction with their childâ..s mental health and childâ..s ability to cope with stress was rated on a Likert scale of 1- 10 (1= very dissatisfied and 10= very satisfied). Any recent stressful life event was recorded as was level of parental concern regarding ongoing suicidal risk. Data pertaining to their index DSH presentation was collected from their hospital case files and included demographic details, details of the index presentation and subsequent discharge plan. Descriptive and inferential statistics (Chi Square tests) were conducted on all variables using the SPSS 12 programme. Results 112 children presented with Deliberate Self-Harm during the study period. 16 children were aged over 18 years at the time of the study and were excluded as per Ethics committee recommendations. Of the 96 families eligible to participate, only 66 families were traceable. 39 parents/guardians (59%) and 10 children agreed to participate in the study. Details of Index Episode The mean age at index presentation was 13.28 years (range of 8-15years). The majority were living at home (95% n=37) and attending secondary school (79%, n=31). Two children were in care. Overdose was the most common method of self-harm (n=27, 70%), typically following a stressful life event (n=35, 89%). 5 (13%) had a family history of DSH and two had a family member who had died by suicide. Clinicians rated the index attempt as â..impulsiveâ.. in 80% of cases and the level of risk as high (10%), moderate (51%) or low (39%). Post index presentation, 97% of the children (38) were offered a referral to community child psychiatry teams for follow-up. Follow-up Data The mean age at follow-up was 15.46 years (range: 10-18years). Interviews were conducted with 34 biological parents, 2 adoptive parents and 3 guardians resulting in follow-up of 8 males and 31 females. Duration of follow-up ranged from 1-6 years. The majority of children were still in school (87%, n= 34) 2 were in employment and 3 were unemployed. Three females (7.7%) reported now having children themselves. Of those referred to CAMHS at time of index presentation, 21% (n=8) did not take up the appointments offered. 25% of parents/guardians reported regular alcohol use in children and 8% reported drug use. Of the 10 children interviewed, 4 reported regular alcohol use (40%) and 1 reported drug use (10%). One in 5 children (20%), all female, had made a repeat attempt at deliberate self-harm (n= 8) with 1 in 10 (10%) repeating more than once (n=4). Of the 8 children who had repeated self-harm, 5 had received a psychiatric diagnosis. However, the relationship between psychiatric diagnosis and repeat DSH was not significant (X2 = .2365 p>.05). Twenty seven participants declined to partake in this study. A comparison was made between responders and non-responders based on clinical information at index presentation. Non responders were less likely to be living at home, more likely to have had a past episode of DSH and more likely to have had a family member with DSH or completed suicide. Satisfaction with Mental Health Participants rated their level of satisfaction with their childâ..s mental health and their ability to cope with stressors on a Likert scale of 1(poor) -10 (excellent). Most parents were satisfied with their childâ..s mental health, with a mean score of 8.3 (SD= 1.5) Dividing the group into those scoring above the mean (most satisfied) and below (least satisfied), revealed a correlation between satisfaction with mental health, ability to cope with stress and repeat DSH. Parents who reported being least satisfied with the childâ..s mental health and ability to cope with stress had children who were more likely to repeat (U=67.5 N1=8 N2=31 p=.043 two tailed). Children whose initial DSH act was deemed as â..impulsiveâ.. were more likely to rate their mental health more positively (X2=8.87, df=4, p<0.05, Ø=0.477). Similarly, children whose initial DSH act followed a recent stressful event, were also more likely to rate their mental health positively (X2=5.51, df=4, p<0.05, ˆ.=0.376). The relationship between repeated DSH and ongoing parental worry regarding repetition was also significant (X2 = 4.11 p<.05, ˆ.=0.325) Of the 8 children who repeated DSH, 4 (50%) parents reported ongoing worry that the child may self-harm again. Discussion This is a small follow up study of Irish children who presented to a paediatric centre with Deliberate Self-Harm. It aimed to identify rates of repetition of DSH. Twenty three children (64%) were rated as having a good outcome, ie not having repeated DSH, being in school or employment, not having children and being satisfied with their mental health and coping ability. Thirteen (36%) had a poorer outcome. Despite a relatively short follow up (mean follow-up period 2 years, range 1-6 years) 20% of young people had repeated DSH and 1 in 10 had repeated more than once. Other studies have reported higher results. An Irish community survey and a 2,4Norwegian follow-up study found rates of repetition of almost 50% . In the latter study, the follow-up period was 9 years after the index episode. It is acknowledged that the longer the FU period, the higher the rate of repetition. A longer period of follow up in this study might well have revealed higher rates of repetition. As only 10 young people were interviewed, information on repetition rates is mainly based on report from parents who may not be fully aware of all repeat episodes of DSH. Of the 10 children who responded, only one reported a repeat DSH attempt as did their parents. However, the smaller number of children compared to parents may well have led to an under-reporting of repetition rates. Another source of error to be Deliberate Self-Harm (DSH): A Follow-up Study of Irish Children 1 considered is responder bias. It is possible that parents were more likely to participate if their child was doing well and they were happy with their childâ..s mental health. In fact, the analysis between responders and non responders at index episode confirms that non responders were more at risk, having already had more past DSH attempts and a higher rate of DSH in family members. They were also more likely to be living outside of the family home. These factors alone would make it likely to increase their risk of subsequent attempts and an overall higher rate of repeat DSH upon FU. In our sample, all of those repeating DSH were female. This is consistent with previous studies which indicate higher rates of self harm and repetition in females 6 . The level of suicide risk as rated by the clinician at the time of DSH was not predictive of repeat DSH, with those rated as low suicide risk at the index episode just as likely to repeat as those rated high risk. This is consistent with a previous study which attempted to establish risk factors for repeat self-harm. The sensitivity of their predictive model was found to be low with the majority of those going on to repeat self-harm having been classified as â..low riskâ.. even those deemed to be at low risk at index episode are at risk of repetition and 7. Therefore require thorough assessment and follow-up. It was noted that where both child and parent were interviewed, there was a high correlation between the parent and child perception of the childâ..s emotional well-being. Parents appeared to be attuned to their childâ..s mental state. Parental worry or satisfaction with their childâ..s mental health and coping ability was strongly predictive of future attempts. Eliciting parental concern and engaging parents is an important way of accessing and assessing the mental state in children who might be reluctant to converse. There is growing concern about the rate of alcohol and substance misuse amongst Irish adolescents. The European Schools Project on Alcohol and Other Drugs self-administered questionnaires, reported regular alcohol use (consuming alcohol 20 8 using a times or more in the past 12 months) in 39% of girls and 31% of boys. Our study showed similar high levels, with 25% of parents and 40% of children reporting alcohol use. It is of interest that the presence of a stressful life event prior to the index episode was significantly related to high satisfaction with mental health at follow-up, as was the attempt being defined as â..impulsiveâ... This may suggest that these children had responded impulsively to an acute stressor, in the absence of a psychiatric diagnosis, and once the stressor resolved, showed a good outcome. There are a number of positive aspects to the study. Firstly all of those followed-up had received a psychiatric evaluation at time of presentation to A&E. This is consistent with NICE guidelines on the management of Deliberate Self-Harm in young people. Almost all (97%) were referred to local Child & Adolescent Mental Health Services and unlike previous concerns in the literature about lack of attendances, the majority attended for follow-up. Of those who repeated self-harm at follow up, all had taken up the referral to local services. None of those who did not take up referral to local services had repeated self harm. This may indicate that those who were deemed most at risk are more likely to attend for follow-up, and those without any psychiatry illness or other risk factors, perhaps the â..impulsiveâ.. attempts post life events, chose not to attend. This study highlights the difficulties in the follow-up of children who have self-harmed. A significant proportion of our sample (33%, n=30) was lost to follow-up. 41% of those contacted did not wish to participate and baseline data from the index episode showed that these non-repsonders were more at risk. The study raises the issue of the ethical considerations in tracing those who are lost to follow-up. In this study, parents were contacted initially by letter and subsequently by each of the telephone numbers provided at the childâ..s index presentation. Due to concerns over breaches of confidentiality, ethical approval did not allow us contact the family GP or catchment area CAMHS to try and ascertain correct contact details. While contacting CAMHS services would provide valuable and accurate information on the childâ..s diagnosis, repetition of self-harm and attendance at services post index episode, the importance of confidentiality was felt to out weight the benefits of data collection. Additionally concern was expressed about contacting individuals who at the time of FU would be over the age of 18. This had a negative impact on the study in terms of duration of FU and the inclusion of over 18 year olds. Obtaining consent from parents and adolescents at index episode to be contacted in the future with regard to possible research studies should have a positive effect on recruitment. It may also improve the recording of contact details and hence reduce numbers lost to follow-up. Due to the small sample size and data collection by telephone interview rather than clinical assessment, this study can only be regarded as a pilot study. More research is needed in this area. Despite their young age, 1 in 5 children repeated DSH over a brief period of time, and 1 in 10 had repeated more than once. In this study, clinician assessment of risk status at index episode did not predict subsequent attempts. It is imperative that all clinicians are aware of the seriousness of any suicidal behaviour or ideation and that a full mental health assessment is carried out. Parental concern is predictive of risk and needs to be considered carefully. Correspondence: F McNicholas Department of Child Psychiatry, Our Lady’s Children’s Hospital, Crumlin, Dublin 12 Email: fiona.mcnicholas@sjog.ie References 1. Central Statistics Office 2006 2. National Suicide Research Foundation 2004. Young Peopleâ..s Mental Health- A report of results from Lifestyle and Coping Survey. 3. Owens, D., Horrocks, J.& House, A.(2002). Fatal and non-fatal repetition of self-harm. British Journal of Psychiatry 181, 193-199. 4. Groholt, B.,Ekeberg, O., Haldorsen, T. (2006) Adolescent suicide attempters: what predicts future suicidal acts. Suicide & Life Threatening Behaviour. 36:638-650 5. Jenkins,G. et al (2002) Suicide rate 22 years after parasuicide: cohort study. British Medical Journal 325: 1155. 6. Hawton,K. et al (2003) Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1999-2000. Journal of Child Psychology and Psychiatry. 44:8 1191 7. Chitsabesan,P et al (2003). Predicting repeat self-harm in children. European Journal of Psychiatry 12:23-29. 8. European Schools Project on Alcohol and Other Drugs Report 2003. Comments:
Deliberate Self-Harm (DSH): A Follow-up Study of Irish Children