SCIE research briefing 17: Therapies and approaches for helping children and adolescents who deliberately self-harm (DSH)

Published August 2005

What is the issue?

This section introduces and defines the scope of the briefing and the topic.

A SCIE Research briefing provides up-to-date information on a particular topic. It is a concise document summarising the knowledge base in a particular area and is intended as a 'launch pad' or signpost to more in-depth investigation or enquiry. It is not a definitive statement of all evidence on a particular issue. The briefing is divided into the different types of knowledge relevant to health and social care research and practice, as defined by the Social Care Institute for Excellence (SCIE) (1). It is intended to help health and social care practitioners and policy-makers in their decision-making and practice.

This briefing focuses on other therapies or measures to help children and young people who deliberately self-harm (DSH). The aim of the therapy is either to reduce the amount they self harm or to stop them self-harming completely. The population covered by this briefing are children and adolescents up to the age of 19 who live in the community. The characteristics of self-harm, and the psychological and psychosocial factors associated with self-harm among children and adolescents are covered in a previous briefing in this series (2). This earlier briefing also covers the problems of identifying young people who self-harm. The interventions described in the current briefing are therefore for children and adolescents who have been identified as self-harming or who have approached professionals or services seeking some sort of help or support. A great deal of the research and policy literature on these interventions does not distinguish between self-harm with the intention of committing suicide or self-harm without that intention, sometimes called self-injury or self-mutilation. The interventions described here are also principally designed for use with people who self-harm repeatedly and have done so over a long period, rather than those who have self-harmed on a single occasion. Although this briefing recognises that self-harm, specifically self-injury or mutilation, and attempted suicide have very different motivations, the term "self-harm" is used throughout the briefing to denote both self-injury or mutilation and attempted suicide (2). The focus of this briefing therefore is non drug-based interventions to prevent or limit self-harm, including suicide, among people who repeatedly self-harm.

Why is it important?

Paracetamol overdose and cutting are the two most common forms of self-harm reported for children and young people (3-7). Self-harm becomes more common after the age of 16, but is still prevalent among younger children and adolescents. Although it is generally difficult to provide accurate prevalence figures for self-harm, partly because of the various possible definitions of this concept, as described above, but also because it may not be reported, some numbers can still be given. It is estimated that about 19,000 adolescents under 16 years of age are admitted to emergency hospital care each year in England and Wales after attempting suicide (8). A national survey of more than 10,000 children found that the prevalence of self-harm among 5-10 year-olds was 0.8% among children without any mental health issues, but was 6.2% among those diagnosed with an anxiety disorder and 7.5% if the child had a conduct, hyperkinetic or less common mental disorder (9). These figures increase dramatically for the 11-15 year-old age group, with the prevalence of self-harm being 1.2% among children without any mental health issues, but 9.4% among those diagnosed with an anxiety disorder, and 18.8% if the diagnosis is depression. The prevalence was between 8 and 13% for children with conduct, hyperkinetic or less common mental disorders (9).

A survey found that more than 60,000 young people aged 12-24 presented to A&E departments with recognised self-harm in 1996-1997, half of whom were admitted as in-patients (10). The number of children disclosing self-harm to ChildLine counsellors has risen steadily since the mid-1990s, with a 65% increase between 2002 and 2004, although increased awareness of the issue by both children and counsellors may be responsible for some of the increase (5). However, self-harming is usually a private act, and many people who self-harm, including children and young people, may not seek medical assistance or approach health services. For example, in a self-report survey of adolescents, less than 13% of reported episodes of self-harm had resulted in presentation to hospital (11). This may be because cutting usually does not require medical assistance (11). The numbers may therefore be much higher (12,13). There is no difference in prevalence between adolescents from the white or black or ethnic minority communities (7,14).

Research has also shown that self-harm is often not a singular occurrence, but is commonly repeated and can go on for many years (4,5,13,15). A self report survey of more than six thousand pupils aged 15-16 found that almost 400 (6.9%) had self-harmed in the previous year (11). According to a survey of self-harming among participants of NCH projects, 27% of those who reported self-harming did so at least once a week, and 41% at least once a month (13). Self-harming is therefore often performed regularly and persistently. Children and adolescents under 16 years of age account for about 5% of all self-harm episodes presenting to hospital, and 10-15% of these cases are repeaters with a history of self-harm (16). It has been found that rates of repeated self-harm are increasing, rates of first-episode of self-harm have not reduced, and that the resulting pressure on services is affecting the response to the assessment and treatment of self-harm episodes (6). A history of self-harm is also a significant risk factor for suicide (6,17-19), with repeated episodes of self-harm relatively more likely to result in suicide than single episodes (20). There is no really effective primary prevention for identified self-harm. Interventions for helping children and young people who repeatedly self-harm usually have to be available to them for long periods because no one-off or short-term therapy has been found to be effective.

What does the research show?

Organisational knowledge

This section lists and briefly summarises documents that describe the standards that govern the conduct of statutory services, organisations and individuals in relation to the parents of disabled or chronically ill children.

Department of Health (2005). National Suicide Prevention Strategy for England: Annual report on progress
This document provides information about how the national suicide prevention strategy is to be implemented by Development Centres in each region of the England, including some specific plans for adolescents and looked after children. Self-harm is explicitly included in the strategy because it is a risk factor significantly associated with suicide.

National Institute of Clinical Excellence (2004). Self-harm. The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (PDF)
This is good practice guidance for primary and secondary health care professionals working with people who self-harm. The guidance focuses on what professionals should do in terms of immediate medical treatment, assessment, referral and admission or discharge. There is a small section specifically on special issues relating to children and young people (8-16 years). However, the guidance does not make recommendations regarding the longer-term management of self-harm. Only Dialectical Behavioural Therapy (DBT) is cited as a potential treatment for people with borderline personality disorder who self harm.

Department of Health (2004). National Service Framework for Children, Young People and Maternity Services: The mental health and psychological well-being of children and young people
This best practice guidance defines the standards on child and adolescent mental health which form part of the National Service Framework for Children, Young People and Maternity Services. It addresses the responsibilities of CAMHS and other services, and the provision of appropriate support or help for children with mental health needs. Although self-harm is not covered specifically, there is a clear association between self-harm and the presence of mental health issues (9,21-23).

Mental Health Act 1983
Staff involved in the assessment and treatment of young people who self-harm need to understand when and how the Mental Health Act can be used. The issue of consent and young people is also covered by this Act.

Policy community knowledge

This section summarises documents describing proposed structural models and guidance for the delivery of policy and improved practice. These documents are published by public policy research bodies, lobby groups, think tanks and related organisations.

Women's Aid (2004). Principles of good practice for working with women with mental health issues (PDF)
The aims of this good practice guidance are to increase safe choices for women and children who experience domestic violence, to raise awareness in refuges, outreach and other organisations, and to encourage joint working between domestic violence organisations and mental health professionals.

Dow P. (2004). "I feel like I'm invisible". Children talking to ChildLine about self-harm(PDF). ChildLine.
This document reports the findings of an 18-month inquiry conducted by the Mental Health Foundation and Camelot Foundation. It aims to connect research and practice, raise awareness and make policy recommendations. This document suggests that practitioners need to know why children self-harm and what the triggers are (eg. bullying); that there needs to be better training and sources of advice for professionals, including teachers; and that young people need direct-access to well-resourced mental health services.

Richardson G., Partridge I. (2003). Child and Adolescent Mental Health Services: An Operational Handbook. London, Gaskell.
This book describes "in operational terms" how Child and Adolescent Mental Health Services (CAMHS) should be developed and delivered in line with the National Service Framework (NSF) for Children, Young People and Maternity Services. Specific examples are given for each of the four tiers of service provision. Click here for a review.

Bywaters P., Rolfe A. (2002). Look Beyond the Scars. Understanding and responding to injury and self-harm (PDF)
This reports the findings from interviews with a group of people who self-harm or who have self-harmed in the past, and some of their partners. It was commissioned by the NCH. The report concludes by making extensive recommendations to policy makers, commissioners, service providers, and staff in social care, health and education. The recommendations include ensuring that services focus on the whole family and not just the child who is self-harming, a reconsideration of institutional placements for adolescents, more support for self-help, and for relevant staff to be understanding and sympathetic.

Royal College of Psychiatrists (1998). Managing Deliberate Self-harm in Young People. Council Report CR64.
This report sets down the prerequisites for developing protocols for assessing and managing self-harm among young people, and outlines the roles and responsibilities of consultant child and adolescent psychiatrists.

Practitioner knowledge

This section describes studies carried out by health and social care practitioners, documents relating their experiences regarding the topic, and resources produced by local practitioner bodies to support their work.

Young People and Self-harm, National Children's Bureau. Self-harm projects database
This is a database of self-harm projects, including those with protocols, in the UK.

The Basement Project
This local Welsh project provides training, consultation and supervision for workers in community and mental health services.

42nd Street
42nd Street is a Manchester-based mental health service which provides suicide/self-harm training in the form of one-day workshops to other organisations.

Clarke T, Sherr L., Watts C. (2000). Young People and Self-harm. Pathways in Care. (PDF)
This is an audit undertaken for Barking and Havering Health Authority into the delivery of services to young people who self-harm. The report concludes with recommendations on the development of care pathways for this client group.

Research knowledge

This section summarises the best available research literature. The focus is on studies undertaken in the United Kingdom, so that the findings are as relevant as possible to the intended audience of the briefing.

The limitations of the research
There is very little research on interventions specifically for or involving younger people (5,15,24-26). The largest studies have all been conducted on adult populations, usually above the age of 16 (27-34). Adults have also been the focus of exploratory research, such as the effectiveness of self-help groups (35). Some of the findings are also based on participants' own self report about their continuing self-harm, which may not be a reliable measure.

The research below only considers interventions that seek to affect personal emotional and psychosocial factors that are associated with self-harm in this age group. Interventions that aim to address the needs of children or adolescents with mental health problems generally tend to focus on promoting resilience, which is predicated on self esteem. This can be an effective strategy for helping all young people following adverse or abusive experiences (36). However, this briefing only considers interventions investigated specifically for self-harm. Also, it does not seek to examine interventions to address broader social and economic factors known to be significantly associated with self-harm, such as socio-economic deprivation, living in care, and a disrupted or disruptive home life.

Therapy usually seeks to address the factors which are associated with self-harm. These include depression, anxiety, impulsivity, feelings of hopelessness, and negative perspectives on problem-solving. The principal aim of most of therapies for self-harm is therefore to help participants to adapt perspectives and to develop alternative coping strategies and ways of expressing their feelings. The interventions tend to focus on developing problem-solving and coping skills which are seen to be an effective alternative to self-harm. There has been a number of randomized trials of treatments to reduce rates of deliberate self-harm among adults populations, but relatively little comparable research specifically on children and adolescents. Dialectical Behavioural Therapy (DBT) is the only therapy known to be effective in reducing self-harm among certain adult populations (those with borderline personality disorder), but developmental group therapy and multi-systemic therapy (MST) are both known to reduce rates of deliberate self-harm among children and adolescents (24,37,38). Larger, more powerful randomized trials of these two potentially effective interventions are needed to confirm and develop the findings of the existing exploratory studies. Other interventions are known to have a positive effect on factors associated with self-harm, such as depression and suicidal thoughts, although they do not significantly affect rates of self-harm themselves. Also, none of the interventions has been evaluated for their long-term effectiveness. It is noteworthy that three of the four randomized studies of therapies for self-harm among adolescents have been published within the last year (24-26,38). This reflects an appreciation of the need for more research in this area.

Therapies for children and adolescents
A group therapy programme for adolescents who repeatedly self-harmed found that this therapy was more effective at reducing future instances of self-harm than routine care (24,37). Also, the more group sessions attended by participants, the fewer the number of incidents of deliberate self-harm. However, the effect was not very strong and the sample was very small, so the authors of the study have urged caution in accepting its findings. The therapy involved both problem-solving and cognitive-behavioural therapy (CBT) and was based on themes which are known to be associated with self-harm, such as hopelessness, problems with family and school relationships, depression, guilt and anger. The Royal College of Psychiatrists define CBT as " a talking treatment that emphasises the important role of thinking in how we feel and what we do. The treatment involves identifying how negative thoughts affect us and then looks at ways of tackling or challenging those thoughts". The routine care was the conventional care provided to adolescents who self-harm, such as non-specific counselling and family sessions. The therapy also improved school attendance and led to reduced use of routine care, but did not affect depression, which is a key factor in self-harm among children and adolescents (24).

An arguably very local-specific US study has compared hospitalization and routine community aftercare with multi-systemic therapy (MST) (38). MST involves the development of a plan with the young person's family to eliminate the means and triggers of self-harming behaviours. MST was significantly more effective than hospitalization and routine care at reducing rates of self-harm, according to the report of the adolescent participants. However, the study population was not composed exclusively of individuals who self-harmed, but also included some who only had psychosis or homicidal thoughts. The population was therefore not entirely consistent with the outcome being examined. A US study of cognitive and problem-solving skills therapy, given over a period of 3-6 months, for adolescents who had attempted suicide found that depression and suicidal thoughts (suicidal ideation) were positively affected by the treatment, but rates of self-harm remained unaffected (25).

Dialectical behavioural therapy (DBT) combines measures to change behaviour with efforts to make participants accept negative feelings. It aims to teach better coping mechanisms, impulse control, self-awareness and emotional regulation or control. This therapy is usually given to certain inpatient populations only, but has been found by one Canadian study to be potentially effective in reducing self-harm, depression and suicidal thoughts in the short term, up to one year, among children and adolescents (26). The therapy was given during an initial two-week stay in hospital. By contrast, an outpatient study of DBT for adolescents with borderline personality disorder conducted in the US had no effect on the number of repeated suicide attempts when compared with routine psychodynamic therapy (39). However, this form of DBT did have a positive impact on the adolescents' suicidal thoughts, general psychiatric and personality disorder symptoms.

A family-based approach has been suggested by a systematic review, which found that poor family communication was an important factor in self-harm by adolescents (21). Such family-based therapy has been examined and found to improve depressive symptoms significantly among certain adolescents, but to have no real effect on rates of self-harm when compared to routine care (15). The therapy consisted of home visits by social workers to conduct "family problem-solving sessions".

An audit of calls received by ChildLine found that many young people phoned the service to ask about how they could help friends who were self-harming (5). Given the possibility that some children and adolescents who self-harm are more likely to talk to friends than either family or professionals, "peer support programmes in schools" have been suggested as offering a viable means of helping these young people (5). One UK survey of the incidence of self-harm found that rates dropped during school holidays, reinforcing the link between self-harm and pressures at school (40). This suggests that more support should be provided by schools for children who self-harm. A US review has made some recommendations on how school counsellors can develop strategies for helping and managing students who self-injury (41). However, US research has also raised the ethical and legal issue of education professionals and counsellors disclosing self-harm by a student to other parties (42). Art therapy has also been investigated as a possible intervention, but there is very little research into its effectiveness for adolescents who self-harm (43).

It is perhaps noteworthy that all of the interventions which did not significantly reduce the number of repeated self-harm episodes did significantly reduce symptoms of depression and suicidal ideation for as long as 1 year after treatment (25,26). However, treatments which did positively affect repeat rates of self-harm had no such significant effect on these secondary outcomes (24,38). This underlines the complex, multi-faceted nature of the dynamics behind self-harm. Interventions which successfully addressed factors known to be associated with self-harm, such as depression, hopelessness and suicidal thoughts, had no independent effect on rates of self-harm. The causal relationship between these factors and self-harm is clearly very complex. This is one of the reasons why predicting self-harm, and repeated self-harm, has been found to be very difficult (44).

Therapies investigated for adults
There is much more research on therapies to treat self-harm among the adult population, aged 16 and above. Dialectical behavioural therapy (DBT) has been found to be effective in reducing self-harm and thoughts about suicide in the short term, up to one year, among adult women with borderline personality disorder (30,31). However, it is an intensive and expensive course of therapy involving group sessions, social skills training and the availability of crisis contacts (45). Several other studies on adults who self-harm and have borderline or impulsive "personality disturbance" have compared standard psychiatric treatment with manual-assisted cognitive therapy (MACT) (27-29,46). This used group sessions and self-help booklets based on the principles inherent in DBT. Compared to treatment as usual, such as short-term counselling, psychotherapy, or referral to voluntary groups or a GP, the MACT group had significantly lower rates of suicidal acts and better self-rated depressive symptoms, although the proportion of people continuing to self-harm was the same in both groups (27,29). The therapy also significantly improved positive-thinking among both groups (46). The therapy was also significantly more cost-effective than usual treatments (33,34). An Indian study of cognitive-behavioural therapy (CBT) for forty adults who deliberately self-harmed found that the therapy was effective in managing most factors associated with self-harm, except impulsivity (32). However, it did not prevent repeated self-harm.

A series of four interpersonal therapy sessions given to patients in their own homes has been found to reduce rates of self-reported self-harm among adults who had been hospitalised for self-poisoning, compared to patients who had "treatment as usual" provided by their GPs (47). The interpersonal therapy aimed to "identify and resolve interpersonal difficulties that caused or exacerbated psychological distress" (47). Treatment as usual involved patients being referred to their GP and approaching them if there was anything wrong. One primary care intervention, again for adults, involved GPs actively inviting people who had presented to A&E with self-harm to come to a consultation with them. They then treated or counselled the patient using a set of guidelines on the management of self-harm developed for the study (48). The intervention had no effect on repeated incidents of self-harm.

Self-help groups have only been the subject of exploratory studies, and there is no evidence that they stop repeated self-harm among participants, although some have reported that the group helped them to reduce the frequency and severity of the self-harm (35). However, like many of the other interventions, there were other positive effects of the therapy. Participants did not feel they were being judged, but rather felt accepted and valued, and also felt better for being able to help others. However, some participants became concerned about the well-being of other members, and some also experienced distress due to hearing about others' self harm (35).

User and carer knowledge

This section summarises the issues raised by young people who self-harm, both as described by the literature and as defined through local consultation.

How do children and young people view health and support services?
Young people have said that having someone to talk to who showed understanding and respect was extremely helpful (13,49,50). The majority of adolescents in one study said having someone to talk to was an important part of their treatment and care, and one quarter stated that they wished they had had access to such support before they overdosed (51). The National guidance on self-harm also recommends that children and adolescents who self-harm should always be treated with understanding and respect by professionals (52). Young people's personal experience of health professionals is mixed. They consistently say that staff in hospitals, social services and residential care need to show genuine interest and sympathy, and not be judgemental, and that it can be useful to speak to other people who self-harmed because they knew that their experiences would be understood (13,50,53-55). However, only one third of those asked said they would attend a self-help or support group because they would not feel comfortable discussing their own experiences in a group and may be distressed by others' experiences (13).

Some feel that emergency care staff have positive attitudes towards them (13), especially in hospitals where there are psychiatric services (56), but the majority have reported that emergency care staff can be judgmental, unhelpful and unwilling to understand (13,49,55). One group of young women said that those professionals with whom they were able to communicate most effectively were non-judgemental and sympathetic (54). A small study of adolescents' views about the care they had received for an incident of self-poisoning found that about half thought it was good, but one third considered it to be poor (51). Young people have therefore suggested that there should be more training programmes for staff to improve their understanding of self-harm and to develop greater empathy with people who do self-harm (13,49,57). The provision of appropriate training is also a recommendation of national guidance (52).

Young people who received treatment in psychiatric wards and residential children's homes have said that it is unhelpful for self-harm to be treated as a routine event when in care, something that was not worthy of special attention (13). They have also said that being monitored, or having their means of self-harming taken away from them, does not prevent them from self-harming. This is because they often find alternative means, such as not eating, and can feel more distressed because they feel they have lost a means of control and have had responsibility for their own actions taken away from them (13). Some young people have also said that talking with professionals can be difficult and unhelpful because it can mean addressing painful memories and speaking about personal issues with strangers (13). National guidance recommends that people should be allowed to choose the gender of professionals involved in their treatment and assessment (52).

In one study, half of the adolescents who had self-poisoned felt, as a result of the treatment, that they were less likely to overdose again in future, but half felt the treatment had had no effect (51). The young people interviewed for another study also admitted that stopping self-harm completely was not a likely outcome of any of the help they had received, and they were reluctant to say they had stopped self-harming or would stop completely (13). The small number in this study who had stopped cited stability and a supportive environment, as well as "having something to lose", especially children, as important factors in ceasing to self-harm (13).

Finally, the divergent attitudes of young people to self-harm, especially the view that self-harm can be seen as something which is helpful and not needing of any intervention, raises legal and ethical issues for professionals. However, there is currently no research on this issue.

Useful links

This section lists sources of information relevant to professionals who work within this field, and may also be of value to service users.

ABC of Adolescence. Suicide and Deliberate Self Harm in Young People
This is the tenth in a series of twelve brief overviews published by the British Medical Journal of findings on adolescence health and well-being. It is written by Keith Hawton and Anthony James.

Bristol Crisis Service for Women
This is a national voluntary organisation that supports women in emotional distress, especially women who harm themselves.

British Psychological Society
This organisation makes available a number of documents relating to DSH.

ChildLine
ChildLine is the free 24-hour confidential helpline for children and young people in the UK. Children and young people can call this helpline about any problem, at any time.

Mental Health Foundation
This web site provides access to information about mental illness, including a fact sheet on self-harm

Mind
Mind is a charity which that promotes and protects good mental health for all, and treats people with experience of mental distress fairly, positively, and with respect. The organisation also provides a leaflet aimed at people who self-harm and who can help.

National electronic Library on Mental Health
This national specialist library provides information on self-harm and suicide.

National Institute of Clinical Excellence. Understanding NICE guidance. Self-harm: short-term treatment and management(PDF). Information for people who self-harm, their advocates and carers, and the public (including information for young people under 16 years)

This document has sections written specifically for professionals, children and adolescents, and parents and carers, both about self-harm in gerenal, and about what should be expected in terms of treatment, assessment and referral.

National Self-harm Network
This national charity aims to provide support to people that self-harm and the people affected by self-harm, including family and professionals.

NCH
The NCH is a charity which provides services to support some of the UK 's most vulnerable and excluded children and young people. The web site provides a list of FAQs on self-harm by children and young people

Samaritans
The Samaritans provides a confidential help service for people who want to discuss issues or problems in their lives.

Trust for the Study of Adolescence
This organisation offers training and related resources for professionals working with young people who self-harm.

Young Minds
This is the principal online information resource designed for young people who are experiencing personal or emotional problems. It has a section specifically on self-harm among young offenders

Young People and Self-harm
This is the principal web resource for children and young people who self-harm. It is maintained by the National Children's Bureau (NCB).

Young People and Self-harm: a National Inquiry
This website provides access to the findings and documents of three national inquiries into self-harm among young people.

Related SCIE Research briefings

Deliberate self-harm (DSH) among children and adolescents: who is at risk and how is it recognised?

The Health and Well-being of Young Carers

ADHD: Background, assessment and diagnosis

ADHD: How it is treated

Acknowledgements

Thank you to experts and service users for their contributions to this briefing.