By Their Own Young Hand of relatedinterest: Deliberate Self-Harm in Adolescence EditedbyClaudineFoxandProfessorKeithHawton ChildandAdolescentMentalHealthSeries ISBN1843102374 New Approaches to Preventing Suicide AManualforPractitioners EditedbyDavidDuffyandTonyRyan ISBN1843102218 Suicide TheTragedyof Hopelessness DavidAldridge ISBN1853024449 Hidden Self-Harm NarrativesfromPsychotherapy MaggieTurp ISBN1853029017 Promoting the Emotional Well Being of Children and Adolescents and Preventing Their Mental Ill Health AHandbook EditedbyKedarNathDwivediandPeterBrinleyHarper ForewordbyCarolineLindsey ISBN184310153X AMultidisciplinaryHandbookofChildandAdolescentMentalHealth for Front-line Professionals NishaDogra,AndrewParkin,FionaGaleandClayFrake ForewordbyPanosVostanis ISBN1853029297 Understanding and Supporting Children with Emotional and Behavioural Difficulties EditedbyPaulCooper ISBN1853026662 pb ISBN1853026654hb MentalHealthServicesforMinorityEthnicChildrenandAdolescents EditedbyMhemoodaMalekandCarolJoughin ForewordbyKedarNathDwivedi ISBN1843102366 Cannabis and Young People ReviewingtheEvidence RichardJenkins ISBN1843103982 By Their Own Young Hand Deliberate Self-harm and Suicidal Ideas in Adolescents Keith Hawton and Karen Rodham with Emma Evans Jessica Kingsley Publishers London and Philadelphia Firstpublishedin2006 byJessicaKingsleyPublishers 116PentonvilleRoad LondonN19JB,UK and 400MarketStreet,Suite400 Philadelphia,PA19106,USA www.jkp.com Copyright©KeithHawton,KarenRodhamandEmmaEvans2006 TherightofKeithHawton,KarenRodhamandEmmaEvanstobeidentifiedasauthors ofthisworkhasbeenassertedbytheminaccordancewiththeCopyright, DesignsandPatentsAct1988. Table3.3isadaptedfromRodham,K.,Hawton,K.andEvans,E.(2004) ‘Reasonsfordeliberateself-harm:comparisonofself-poisonersandself-cuttersinacommunitysampleof adolescents’.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry.Reproducedwithpermission fromLippincott,Williams&Wilkins. Table4.1isadaptedfromHawton,K.etal.(2002)‘Deliberateself-harminadolescents:selfreportsurveyin schoolsinEngland’.BritishMedicalJournal.Reproducedwithpermission fromtheBritishMedicalJournal. Table5.1andFigures5.1to5.4areadaptedfromEvans,E.,Hawton,K.andRodham,K.(2005)‘Inwhat waysareadolescentswhoengageinself-harmorexperiencethoughtsofself-harmdifferentintermsof help-seeking,communicationandcopingstrategies?’.JournalofAdolescence.Reproducedwithpermission fromElsevier. Allrightsreserved.Nopartofthispublicationmaybereproducedinanymaterialform(including photocopyingorstoringitinanymediumbyelectronicmeansandwhetherornottransientlyor incidentallytosomeotheruseofthispublication)withoutthewrittenpermissionofthecopyrightowner exceptinaccordancewiththeprovisionsoftheCopyright,DesignsandPatentsAct1988orunderthe termsofalicenceissuedbytheCopyrightLicensingAgencyLtd,90TottenhamCourtRoad,London, EnglandW1T4LP.Applicationsforthecopyrightowner’swrittenpermissiontoreproduceanypartofthis publicationshouldbeaddressedtothepublisher. Warning:Thedoingofanunauthorisedactinrelationtoacopyrightworkmayresultinbothacivilclaim fordamagesandcriminalprosecution. Pagesmarkedwith(cid:1)maybephotocopiedforuseasspecifiedonp.202withouttheneedtorequest permissionfromthepublisher. LibraryofCongressCataloginginPublicationData Hawton,Keith,1942- Bytheirownyounghand:deliberateself-harmandsuicidalideasinadolescents/KeithHawtonandKarenRodham, withEmmaEvans. p.cm. Includesbibliographicalreferencesandindex. ISBN-13:978-1-84310-230-4(pbk.:alk.paper) ISBN-10:1-84310-230-7(pbk.:alk.paper) 1. Self-destructivebehaviorinadolescence.2. Teenagers—Suicidal behavior.3. Youth—Suicidalbehavior. I.Rodham,Karen,1970-II.Evans,Emma,1975-III.Title. RJ506.S39H392006 616.85’8200835—dc22 2006013532 BritishLibraryCataloguinginPublicationData ACIPcataloguerecordforthisbookisavailablefromtheBritishLibrary ISBN-13:9781843102304 ISBN-10:1843102307 ISBNpdfeBook:1846425298 PrintedandboundinGreatBritainby AthenaeumPress,Gateshead,TyneandWear Contents Acknowledgements 10 Chapter 1 Introduction and Overview 11 Part 1 The Nature of Deliberate Self-harm in Adolescents Chapter 2 Investigating Deliberate Self-harm in Adolescents 21 Introduction 21 Clinicalversuscommunity-basedstudies 21 Therationaleforaschool-basedstudy 23 Aimsoftheproject 23 Choosinganappropriatemethodofdatacollection 23 Developingthequestionnaire 25 Testingthequestionnaire 33 Sampleofschoolpupils 33 Issuesofconsent 35 Howweimplementedthestudy 37 Safety-netarrangements 38 Summary 38 Chapter 3 The Nature, Prevalence and Impact of Deliberate Self-harm and other Suicidal Phenomena in Adolescents 40 Introduction 40 Deliberateself-harm 40 Attemptedsuicide 46 Thoughtsofself-harm 47 Suicidethreatsandplans 48 Methodsusedinactsofdeliberateself-harm 48 Themotivationbehinddeliberateself-harm 52 Premeditation 56 Repetitionofdeliberateself-harm 57 Hospitalpresentation 58 Impactofdeliberateself-harm 60 Summaryandimplications 62 Chapter 4 How Do Adolescents who Deliberately Self-harm or Have Thoughts of Self-harm Differ from other Adolescents? 65 Introduction 65 Gender 65 Age 67 Ethnicity 69 Internationaldifferences 70 Psychosocialandhealthcharacteristicsofadolescentswho deliberatelyself-harmorhavethoughtsofself-harm 71 Summaryandimplications 90 Chapter 5 Adolescents’ Help-seeking, Coping Strategies and Attitudes and their Relevance to Deliberate Self-harm 94 Introduction 94 Help-seeking,communicationandcoping 95 Recognitionofproblemsandtheneedforhelp 97 Copingstrategiesemployedbyadolescents 98 Talkingtoothers 102 Towhomdidadolescentswhoengagedindeliberate self-harmturnforhelp? 102 Whatstoppedadolescentsfromseekinghelp? 104 Didadolescentswhohadthoughtsofself-harm seekhelp? 106 Attitudestowardsyoungpeoplewhoengageindeliberate self-harm 106 Attitudestowardscontactinghelpingagencies 108 Summaryandimplications 110 Part 2 Prevention and Treatment of Deliberate Self-harm in Adolescents Chapter 6 Schools and Deliberate Self-harm 117 Introduction 117 Whybasepreventionstrategiesinschools? 118 Whatapproacheshavebeenusedinschools? 120 Primaryprevention 120 Secondaryprevention 126 Tertiaryprevention:dealingwiththeaftermath 129 Summaryandimplications 131 Chapter 7 The Health Service and Deliberate Self-harm 132 Introduction 132 Generalpractitionerservices 133 Generalhospitalemergencyservices 141 Assessmentofadolescentswhohavedeliberately self-harmed 144 Treatmentoptionsfollowingdeliberateself-harm 151 Summaryandimplications 157 Chapter 8 Self-help, Crisis Lines, the Internet and the Media and Deliberate Self-harm 160 Introduction 160 Self-helpbooks 160 Confidentialtelephoneservices 161 TheInternet 163 Themedia 168 Summaryandimplications 172 Chapter 9 Conclusions and Looking to the Future 174 Concludingcomments 190 Appendix I Guidelines Used in the Schools Study for Categorising Respondents’ Descriptions of Deliberate Self-harm 194 Appendix II Information Sheet Given to Participants After Completing the Questionnaire 201 Appendix III Self-harm: Guidelines for School Staff 202 Appendix IV Robson’s Self Concept Scale (Short Version) 224 Appendix V Useful Contact Addresses in the UK for Young People with Problems, or their Friends or Relatives in Need of Advice. 225 Appendix VI Sources of Information about Deliberate Self-harm, Suicide and Mental Health Problems 230 Appendix VII Further Reading 233 References 237 Subject Index 258 Author Index 261 List of Figures Figure3.1 Methodsofdeliberateself-harmdescribedbyadolescentsin ourschoolsstudywhoreportedharmingthemselvesinthe previousyear 49 Figure3.2 Methodsofdeliberateself-harmdescribedbyadolescentsin ourschoolsstudywhoreportedharmingthemselvesinthe previousyear,bygender 51 Figure3.3 Motivesfordeliberateself-harmreportedbyadolescentsin ourschoolsstudywhohadharmedthemselvesinthe previousyear 54 Figure3.4 Icebergmodelshowingthepercentageofadolescentsinour schoolsstudywhoreportedpresentingornotpresentingto hospitalfollowingtheirmostrecentactofdeliberateself-harm 59 Figure4.1 Frequencyofdeliberateself-harmbyageandgenderin12- to18-year-oldspresentingtothegeneralhospitalinOxford, 1990–2003 68 Figure4.2 Associationbetweendeliberateself-harmanddrugusein thepreviousyearinself-harmerscomparedwithother adolescentsinourschoolsstudy 76 Figure4.3 Associationbetweendeliberateself-harminthepreviousyear andalcoholuseinourschoolsstudy 77 Figure4.4 Associationbetweendeliberateself-harminthepreviousyear andsmokinginourschoolsstudy 78 Figure4.5 Associationbetweendeliberateself-harminthepreviousyear andhavingfriendswhohadalsoengagedindeliberateself- harminthepreviousyearinourschoolsstudy 85 Figure5.1 Copingstrategiesemployedbyadolescentsinourschools studywhenfacedwithstressfulsituations,accordingtohistory ofdeliberateself-harm,thoughtsofself-harmorneither 100 Figure5.2 Copingstrategiesemployedbyadolescentsinourschools studywhenfacedwithstressfulsituations,accordingtohistory ofdeliberateself-harm,thoughtsofself-harmorneither,by gender 101 Figure5.3 Peoplewithwhomadolescentsinourschoolsstudyfeltthatthey couldtalkaboutproblems,accordingtohistoryofdeliberate self-harm,thoughtsofself-harmorneither,bygender 103 Figure5.4 Sourcesofhelpapproachedbyadolescentsinourschools studyengagingindeliberateself-harm,bygender 104 FigureAIII.1Cycleofself-harm 206 List of Tables Table3.1 Prevalenceofdeliberateself-harminourschoolsstudy 41 Table3.2 Prevalenceofdeliberateself-harminourschoolsstudy, bygender 42 Table3.3 Prevalenceofdeliberateself-harminschoolpupilsin countriesparticipatingintheChildandAdolescentSelf-harm inEurope(CASE)study,bygender 45 Table3.4 Comparisonofthemotiveschosenbyself-cuttersandself- poisonersinordertoexplaintheiracts 55 Table4.1 Associationsbetweendeliberateself-harmintheprevious yearandanxiety,depression,impulsivityandself-esteemin ourschoolsstudy 72 Table5.1 Pupilswhoidentifiedthemselvesashavingseriouspersonal, emotional,behaviouralormentalhealthproblems:recognition ofneedforhelpandwhetherhelpwassought 99 Table5.2 Responsesofadolescentsinourschoolsstudytostatements aboutattitudestowardspeoplewhoharmthemselves(percent- agesinagreement),accordingtowhetherinthepreviousyear theyhadself-harmed,hadthoughtsofself-harmorneither 107 Acknowledgements MuchofthisbookisbasedonastudyweconductedinschoolsinEnglandin order to examine the prevalence of deliberate self-harm and thoughts of self-harminadolescents,andthefactorsassociatedwiththese.Thisstudywas madepossiblebyagenerousgrantfromtheCommunityFund.Thestudywas carried out in conjunction with Samaritans. We acknowledge the support of Simon Armson, Jackie Wilkinson and Su Ray from that organisation. We also thank other members of the advisory group for the study, including the late Richard Harrington and Nicola Madge. The study was conducted in collaborationwiththeChildandAdolescentSelf-harminEurope(CASE)study. Someoftheresearchmethodsusedforthestudyweredevelopedthroughthis collaboration.Theseniorcollaboratorsfromtheothercentresinvolvedinthat study are Ella Arensman, Diego De Leo, Sandor Fekete, Kees van Heeringen, ErikJandeWildeandMetteYstgard.NicolaMadgecoordinatedthisgroup.We thank Philip Robson for help with the development of our measure of self-esteem,LouiseHarrissforassistancewithsomeoftheanalyses,SueSimkin for helping us in the preparation of the book in several ways, Nicola Madge, Ann McPherson and Anne Stewart for their advice, Sarah Fortune for her commentsonpartofthemanuscriptandTaniaCastro-Martinezforsecretarial support. We also thank the Oxfordshire Adolescent Self-Harm Forum for permission to reproduce in adapted form its guideline for schools (Appendix III);Lippincott,WilliamsandWilkinsforgrantinguspermissiontoreproduce in modified form Table 3.3, which was originally published in Rodham, K., Hawton,K.andEvans,E.(2004)‘Reasonsfordeliberateself-harm:comparison ofself-poisonersandself-cuttersinacommunitysampleofadolescents.’Journal of theAmericanAcademyof ChildandAdolescentPsychiatry43,82–87;theBritish MedicalJournalforgrantinguspermissiontoreproduceinmodifiedformTable 4.1,whichwasoriginallypublishedinHawton,K.,Rodham,K.,Evans,E.and Weatherall,R.(2002)‘Deliberateselfharminadolescents:selfreportsurveyin schools in England.’ British Medical Journal 325, 1207-1211; and Elsevier for granting us permission to reproduce in modified form Table 5.1 and Figures 5.1,5.2,5.3and5.4,whichwereoriginallypublishedinEvans,E.,Hawton,K. and Rodham, K. (2005) ‘In what ways are adolescents who engage in self- harm or experience thoughts of self-harm different in terms of help-seeking, communicationandcopingstrategies?’Journalof Adolescence28,573–587.