Interventions for self-harm in children and adolescents

108 Pages·2016·0.95 MB·English

Interventions for self-harm in children and adolescents
(Review)
Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Townsend E, van
Heeringen K, Hazell P
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2015,Issue12
http://www.thecochranelibrary.com
Interventionsforself-harminchildrenandadolescents(Review)
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
ADDITIONALSUMMARYOFFINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 29
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis1.1.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome1RepetitionofSHpost-intervention. . . . . . . . . . . . . . . 86
Analysis1.2.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome2FrequencyofSHpost-intervention. . . . . . . . . . . . . . . 87
Analysis1.3.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome3Numberofindividualpsychotherapysessionsattended. . . . . . . . 88
Analysis1.4.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome4Numberoffamilytherapysessionsattended. . . . . . . . . . . . 89
Analysis1.5.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome5Numbercompletingfullcourseoftreatment. . . . . . . . . . . . 90
Analysis1.6.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome6Depressionscorespost-intervention. . . . . . . . . . . . . . . 91
Analysis1.7.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome7Hopelessnessscorespost-intervention. . . . . . . . . . . . . . 92
Analysis1.8.Comparison1Dialecticalbehaviourtherapy/mentalisationforadolescentsvs.Treatmentasusualorother
routinemanagement,Outcome8Suicidalideationscorespost-intervention. . . . . . . . . . . . . 93
Analysis2.1.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome1
RepetitionofSHatsixmonths. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis2.2.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome2
RepetitionofSHat12months. . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Analysis2.3.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome3
Depressionscoresatsixmonths. . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Analysis2.4.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome4
Depressionscoresat12months. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Analysis2.5.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome5
Suicidalideationscoresatsixmonths. . . . . . . . . . . . . . . . . . . . . . . . . . 97
Analysis2.6.Comparison2Group-basedpsychotherapyvs.Treatmentasusualorotherroutinemanagement,Outcome6
Suicidalideationscoresat12months. . . . . . . . . . . . . . . . . . . . . . . . . . 98
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Interventionsforself-harminchildrenandadolescents(Review) i
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 105
Interventionsforself-harminchildrenandadolescents(Review) ii
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Interventions for self-harm in children and adolescents
Keith Hawton1, Katrina G Witt2, Tatiana L Taylor Salisbury3,4, Ella Arensman5, David Gunnell6, Ellen Townsend7, Kees van
Heeringen8,PhilipHazell9
1Centre for Suicide Research,University Departmentof Psychiatry, Warneford Hospital, Oxford, UK. 2Departmentof Psychiatry,
UniversityofOxford,Oxford,UK.3CentreforGlobalMentalHealth,LondonSchoolofHygiene&TropicalMedicine,London,UK.
4InstituteofPsychiatry,King’sCollegeLondon,London,UK.5NationalSuicideResearchFoundationandDepartmentofEpidemiology
andPublicHealth,UniversityCollegeCork,Cork,Ireland.6SchoolofSocialandCommunityMedicine,UniversityofBristol,Bristol,
UK.7Self-HarmResearchGroup, Schoolof Psychology, University of Nottingham, Nottingham, UK.8Unit for Suicide Research,
Department of Psychiatry and Medical Psychology, Ghent University, Ghent, Belgium. 9Discipline of Psychiatry, Sydney Medical
School,ConcordWest,Australia
Contactaddress:KeithHawton,CentreforSuicideResearch,UniversityDepartmentofPsychiatry,WarnefordHospital,Oxford,OX3
7JX,[email protected].
Editorialgroup:CochraneCommonMentalDisordersGroup.
Publicationstatusanddate:Edited(nochangetoconclusions),publishedinIssue1,2016.
Reviewcontentassessedasup-to-date: 30January2015.
Citation: HawtonK,WittKG,TaylorSalisburyTL,ArensmanE,GunnellD,TownsendE,vanHeeringenK,HazellP.Interventions
for self-harm in children and adolescents. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD012013. DOI:
10.1002/14651858.CD012013.
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Self-harm(SH;intentionalself-poisoningorself-injury)iscommoninchildrenandadolescents,oftenrepeated,andstronglyassociated
withsuicide.ThisisanupdateofabroaderCochranereviewonpsychosocialandpharmacologicaltreatmentsfordeliberateSHfirst
publishedin1998andpreviouslyupdatedin1999.Wehavenowdividedthereviewintothreeseparatereviews;thisreviewisfocused
onpsychosocialandpharmacologicalinterventionsforSHinchildrenandadolescents.
Objectives
Toidentifyallrandomisedcontrolledtrialsofpsychosocialinterventions,pharmacologicalagents,ornaturalproductsforSHinchildren
andadolescents,andtoconductmeta-analyses(wherepossible)tocomparetheeffectsofspecifictreatmentswithcomparisontypesof
treatment(e.g.,treatmentasusual(TAU),placebo,oralternativepharmacologicaltreatment)forchildrenandadolescentswhoSH.
Searchmethods
ForthisupdatetheCochraneDepression,AnxietyandNeurosisGroup(CCDAN)TrialsSearchCo-ordinatorsearchedtheCCDAN
SpecialisedRegister(30January2015).
Selectioncriteria
Weincludedrandomisedcontrolledtrialscomparingpsychosocialorpharmacologicaltreatmentswithtreatmentasusual,alternative
treatments,orplacebooralternativepharmacologicaltreatmentinchildrenandadolescents(upto18yearsofage)witharecent(within
sixmonths)episodeofSHresultinginpresentationtoclinicalservices.
Interventionsforself-harminchildrenandadolescents(Review) 1
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Datacollectionandanalysis
Two reviewers independently selectedtrials, extracted data, and appraised study quality, with consensus. For binary outcomes, we
calculatedodds ratios (OR)and their95% confidence intervals (CI). For continuous outcomes measured using the same scale we
calculatedthemeandifference(MD)and95%CI;forthosemeasuredusingdifferentscaleswecalculatedthestandardmeandifference
(SMD)and95%CI.Meta-analysiswasonlypossiblefortwointerventions:dialecticalbehaviourtherapyforadolescentsandgroup-
basedpsychotherapy.Fortheseanalyses,wepooleddatausingarandom-effectsmodel.
Mainresults
Weincluded11trials,withatotalof1,126participants.Themajorityofparticipantswerefemale(mean=80.6%in10trialsreporting
gender).Alltrialswereofpsychosocialinterventions;therewerenoneofpharmacologicaltreatments.Withtheexceptionofdialectical
behaviourtherapyforadolescents(DBT-A)andgroup-basedtherapy,assessmentsofspecificinterventionswerebasedonsingletrials.
Wedowngradedthequalityofevidenceowingtoriskofbiasorimprecisionformanyoutcomes.
TherapeuticassessmentappearedtoincreaseadherencewithsubsequenttreatmentcomparedwithTAU(i.e.,standardassessment;n=
70;k=1;OR=5.12,95%CI1.70to15.39),butthishadnoapparentimpactonrepetitionofSHateither12(n=69;k=1;OR
0.75,95%CI0.18to3.06;GRADE:lowquality)or24months(n=69;k=1;OR=0.69,05%CI0.23to2.14;GRADE:lowquality
evidence).Theseresultsarebasedonasingleclusterrandomisedtrial,whichmayoverestimatetheeffectivenessoftheintervention.
ForpatientswithmultipleepisodesofSHoremergingpersonalityproblems,mentalisationtherapywasassociatedwithfeweradolescents
scoringabovethecut-offforrepetitionofSHbasedontheRisk-TakingandSelf-HarmInventory12monthspost-intervention(n=
71;k=1;OR=0.26,95%CI0.09to0.78;GRADE:moderatequality).DBT-Awasnotassociatedwithareductionintheproportion
ofadolescentsrepeatingSHwhencomparedtoeitherTAUorenhancedusualcare(n=104;k=2;OR0.72,95%CI0.12to4.40;
GRADE: low quality). In the latter trial, however,theauthors reportedasignificantly greater reduction over time in frequency of
repeatedSHinadolescentsintheDBTcondition,inwhomtherewerealsosignificantlygreaterreductionsindepression,hopelessness,
andsuicidalideation.
Wefoundnosignificanttreatmenteffectsforgroup-basedtherapyonrepetitionofSHforindividualswithmultipleepisodesofSHat
eitherthesix(n=430;k=2;OR1.72,95%CI0.56to5.24;GRADE:lowquality)or12month(n=490;k=3;OR0.80,95%
CI0.22to2.97;GRADE:lowquality)assessments,althoughconsiderableheterogeneitywasassociatedwithboth(I2=65%and77%
respectively).WealsofoundnosignificantdifferencesbetweenthefollowingtreatmentsandTAUintermsofreducedrepetitionof
SH:complianceenhancement(threemonthfollow-upassessment:n=63;k=1;OR=0.67,95%CI0.15to3.08;GRADE:very
lowquality),CBT-basedpsychotherapy(sixmonthfollow-upassessment:n=39;k=1;OR=1.88,95%CI0.30to11.73;GRADE:
verylowquality),home-basedfamilyintervention(sixmonthfollow-upassessment:n=149;k=1;OR=1.02,95%CI0.41to2.51;
GRADE:lowquality),andprovisionofanemergencycard(12monthfollow-upassessment:n=105,k=1;OR=0.50,95%CI0.12
to2.04;GRADE:verylowquality).Nodataonadverseeffects,otherthantheplannedoutcomesrelatingtosuicidalbehaviour,were
reported.
Authors’conclusions
TherearerelativelyfewtrialsofinterventionsforchildrenandadolescentswhohaveengagedinSH,andonlysingletrialscontributed
toallbuttwocomparisonsinthisreview.ThequalityofevidenceaccordingtoGRADEcriteriawasmostlyverylow.Thereislittle
supportfortheeffectivenessofgroup-basedpsychotherapyforadolescentswithmultipleepisodesofSHbasedontheresultsofthree
trials,theevidencefromwhichwasofverylowqualityaccordingtoGRADEcriteria.Resultsfortherapeuticassessment,mentalisation,
anddialecticalbehaviourtherapyindicatedthattheseapproacheswarrantfurtherevaluation.DespitethescaleoftheproblemofSH
inchildrenandadolescentsthereisapaucityofevidenceofeffectiveinterventions.Furtherlarge-scaletrials,witharangeofoutcome
measuresincludingadverseevents,andinvestigationoftherapeuticmechanismsunderpinningtheseinterventions,arerequired.Itis
increasingly apparentthatdevelopmentofnewinterventionsshouldbedoneincollaborationwithpatientstoensurethattheseare
likelytomeettheirneeds.Useofanagreedsetofoutcomemeasureswouldassistevaluationandbothcomparisonandmeta-analysis
oftrials.
PLAIN LANGUAGE SUMMARY
Interventionsforchildrenandadolescentswhoself-harm
Whyisthisreviewimportant?
Interventionsforself-harminchildrenandadolescents(Review) 2
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Self-harm(SH),whichincludesintentionalself-poisoning/overdoseandself-injury,isamajorprobleminchildrenandadolescentsin
manycountriesandisstronglylinkedtoriskoffuturesuicide.ItisthereforeimportantthateffectivetreatmentsforSHpatientsare
developed.
Whowillbeinterestedinthisreview?
CliniciansworkingwithyoungpeoplewhoengageinSH,policymakers,youngpeoplewhothemselveshaveself-harmedormaybeat
riskofdoingso,andtheirfamiliesandrelatives.
Whatquestionsdoesthisreviewaimtoanswer?
ThisreviewisanupdateofapreviousCochranereviewfrom1999whichfoundlittleevidenceofbeneficialeffectsofinterventionsfor
SHaimedspecificallyatchildrenandadolescents.Thisupdateaimstofurtherevaluatetheevidencefortheeffectivenessofpsychosocial
andpharmacologicaltreatmentsforchildrenandadolescentswhoengageinSHwithabroaderrangeofoutcomes,particularlywith
regardstoinvestigatingwhethertherearespecifictreatmentsforchildrenandadolescentswhoSHwhichhavegreaterbenefitcompared
toroutinecareintermsoftreatmentadherenceandimprovementsinpsychologicalwell-being.
Whichstudieswereincludedinthereview?
Tobeincludedinthereview,studieshadtoberandomisedcontrolledtrialsofeitherpsychosocialorpharmacologicaltreatmentsfor
childrenandadolescentsupto18yearsofagewhohadrecentlyengagedinSHandpresentedtoclinicalservices.
Whatdoestheevidencefromthereviewtellus?
TherehavebeensurprisinglyfewinvestigationsoftreatmentsforSHinchildrenandadolescents,despitethesizeofthisproblemin
many countries. Providing therapeuticassessmentmayimproveattendance atsubsequent treatmentsessions. Onlyone therapeutic
approach-mentalisation-wasassociatedwithareductioninfrequencyofrepetitionofSH.Howeverthiseffectwasonlymodestand
thetrialwassmall,whichpreventsusfrombeingabletomakefirmconclusionsabouttheeffectivenessofthistreatment.Therewas
noclearevidenceofeffectivenessforcomplianceenhancement,individualcognitivebehavioraltherapy(CBT)-basedpsychotherapy,
home-basedfamilyintervention,orprovisionofanemergencycard,norwasthereclearevidenceforgrouptherapyforadolescentswith
ahistoryofmultipleepisodesofSH.
Whatshouldhappennext?
Therapeuticassessment,mentalisation,anddialecticalbehaviourtherapywarrantfurtherinvestigation.Whileinasinglesmallstudy,
individual CBT-basedpsychotherapyappearedineffective,furtherevaluationofthistreatmentisalsodesirablegiventhefavourable
resultsfoundinadultswhoSH.GiventheextentofSHinchildrenandadolescents,greaterattentionshouldbepaidtothedevelopment
andevaluationofspecifictherapiesforthispopulation.
Interventionsforself-harminchildrenandadolescents(Review) 3
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
CopInte SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
yright©rvention
2s
016for CBT-basedpsychotherapycomparedtotreatmentasusual
Tse
helf-h Patientorpopulation:childrenandadolescentswhoengageinSH.
Ca
ocrm Settings:outpatient.
hrain Intervention:individualCBT-basedpsychotherapy.
neCchild Comparison:treatmentasusual.
ollaren
boan Outcomes Illustrativecomparativerisks*(95%CI) Relativeeffect Numberofparticipants Qualityoftheevidence Comments
ration.dadole (95%CI) (studies) (GRADE)
Publishscents Assumedrisk Correspondingrisk
ed(Re Treatmentasusual CBT-based psychother-
bv
yie apy
Jow
h)
n
W Repetition of SH at six Studypopulation OR1.88 39 ⊕(cid:13)(cid:13)(cid:13) Quality was downgraded
iley months (0.3to11.73) (1RCT) VERYLOW1,2 as information on allo-
&
cation concealment, par-
S
o
n ticipantblinding,outcome
s
,
L assessor blinding, and
td
. selectiveoutcomereport-
ing was not adequately
described. The trial was
further downgraded as
the same therapists de-
livered both theinterven-
tion and control treat-
mentsleadingtopossible
confoundingwhichcould
111per1000 190per1000
haveledtoareductionin
(36to595) thedemonstratedeffect
*Thebasisfortheassumedrisk(e.g.themediancontrolgroupriskacrossstudies)isprovidedinfootnotes.Thecorrespondingrisk(andits95%CI)isbasedontheassumedriskinthe
comparisongroupandtherelativeeffectoftheintervention(andits95%CI).
CBT:cognitivebehaviouraltherapy;CI:confidenceinterval;OR:oddsratio;RCT:randomisedcontrolledtrial;SH:self-harm.
4
CIn
opte
yright©rvention GRADEWorkingGroupgradesofevidence
2s Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
016for Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychangetheestimate.
Tse
helf-h Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.
Cocarm Verylowquality:Weareveryuncertainabouttheestimate.
hraneCinchild 1RaisnkdosfebleicastivweaosurtcaotemdeasreVpEoRrtiYngSEwRaIsOUnoStaasdeinqfuoarmtealytiodnesocnribaellodcraatiisoinngcothnecepaolmsseibnitl,itypaortficsieplaencttiobnlinbdiiansg,,poeurtfcoormmaenacsesebsiasso,rdbeltinedctiniogn,
ollaren bias,andreportingbias.Giventhatthesametherapistsdeliveredboththeinterventionandcontroltreatmentsinthistrial,thereisalso
ba
orand thepossibilityofconfoundingwhichcouldhaveledtoareductioninthedemonstratedeffect.
tion.adole 2ImprecisionwasratedasSERIOUSowingtothewideconfidenceintervalassociatedwiththeestimateoftreatmenteffect.
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5
BACKGROUND particularlythoseofhighincome(Hawton2012b;Sheen2002).
InamulticentrestudyofchildandadolescentSHpresentations
to hospitals in England, three-quarters of individuals were girls
Descriptionofthecondition andself-poisoningoccurredinjustoverthree-quartersofepisodes
(Hawton2012b).Self-cuttingisthenextmostfrequentmethod
Theterm‘self-harm’isusedtodescribeallintentionalactsofself-
forthosewhopresenttohospital.Inthecommunity,however,self-
poisoning(suchasoverdoses)orself-injury(suchasself-cutting),
cuttingandotherformsofself-mutilationarefarmorefrequent
irrespectiveofdegreeofsuicidalintentorothertypesofmotiva-
thanself-poisoning(Madge2008).
tion(Hawton2003).Thusitincludesactsintendedtoresultin
SH(andsuicide)inadolescentsistheresultofacomplexinter-
death(‘attemptedsuicide’),thosewithoutsuicidalintent(forex-
playbetweengenetic,biological,psychiatric,psychosocial,social,
ample,tocommunicatedistress,totemporarilyreduceunpleasant
andculturalfactors(Hawton2012a).Relationshipproblemsare
feelings), and those with mixed motivation (Hjelmeland 2002;
common in adolescentswhoengage in SH,especiallyproblems
Scoliers2009).Theterm‘parasuicide’wasintroducedbyKreitman
with family members. Relationship problems with partners are
1969toincludethesamerangeofbehaviour.However,‘parasui-
morecommoninolderadolescentsthaninyoungeradolescents
cide’hasbeenusedintheUSAtoreferspecificallytoactsofself-
(Hawton2012b);theremayalsobeahistoryofemotional,phys-
harmwithout suicidal intent(Linehan1991),andthetermhas
ical,orsexualabuse(Madge2011).Bullying,includingcyberbul-
largely falleninto disuse in the UK and other countries. In the
lying,canalsoincreasetheriskofSH(Hinduja2010).Psychiatric
fifthversionoftheDiagnostic andStatisticalManual ofMental
disordersarecommoninadolescentswhopresenttohospitalbe-
Disorders(DSM-5;AmericanPsychiatricAssociation2013),two
causeofSH,withdepression,anxiety,ADHD,andeatingdisor-
typesofself-harmingbehaviourareincludedasconditionsforfur-
dersbeing particularly frequent (Hawton 2013). Whileperson-
therstudy,namely“Non-SuicidalSelfInjury”(NSSI)and“Suici-
alitydisordersshouldnotbediagnosedinadolescents,emergent
dalBehaviorDisorder”(SBD).Many researchersandclinicians,
pathologicalpersonalitytraitsmaybeapparentduringthisphase
however,believethistobeanartificialandsomewhatmisleading
of development, with traits similar to those in adult borderline
categorisation(Kapur2013),andrecentresearchhasshownahigh
personalitydisorderbeingfoundinsomeadolescentswhoengage
levelofco-occurancebetweenNSSIandattemptedsuicide,inpar-
infrequentrepetitionofSH(Crowell2012).Pooremotionregu-
ticularamongyoungpeople(Andover2012).Wehavetherefore
lationabilitiesorpooremotionalintelligencemayalsocontribute
usedtheapproachfavouredintheUKandsomeothercountries
totheriskofSHinthispopulation(Mikolajczak2009).
of conceptualising all intentional self-harmin a single category,
SHinadolescenceoftenhasa’contagious’quality,andexposureto
namelyself-harm(SH).
SH(andsuicide)infriendsandfamilymemberscanbeastrongin-
SH is a major problem in children and adolescents (Hawton
fluence(Hawton2002;McMahon2013;O’Connor2014).Ado-
2012a).Unlikesuicide,inmostcountriesSHinyoungpeopleoc-
lescentsarealsovulnerabletomediainfluences;SHinbothtradi-
cursfarmorecommonlyinfemalesthanmales(Evans2005).SH
tionalmedia,suchasfilmsandtelevisionsoaps,andnewmedia,
isuncommonbelowtheageof12years(Hawton2003);fromage
especially theInternet and social networking (Daine 2013), are
12yearsonwards,SHbecomesincreasinglyfrequentingirlssuch
important.
thatthe female:maleratio between 12 and 15 yearsof age isas
PsychologicalinfluencesonSHinyoungpeopleincludefeelings
highasfiveorsixtoone.Thisisthoughttobeduetotheincreased
ofentrapment,lackofbelonging,andperceivingoneselfasabur-
prevalenceofdepressioninyoungadolescentfemales,andalcohol
den(O’Connor2012).Deficienciesinproblem-solvingskillsmay
consumptionandengagementinsexualactivityinbothgenders
alsoberelevant(Speckens2005).Othercontributorsincludeper-
(Patton 2007). The gender ratio decreases in the older teenage
fectionism,lowself-esteem,socialisolation,impulsivity,hopeless-
yearsasthebehaviour becomesmorefrequentinboysandrates
ness,andpoorparent-childattachment(Hawton2012a).Onthe
leveloffingirls.SHismorefrequentinadolescentsfromlowerso-
other hand, social attachment to family (Carter 2007), friends,
cioeconomicgroups(Burrows2010).IntheUK,SHhasbecome
andschoolmaybeprotective(King2008;Stallard2013).
morecommoninadolescentsinrecentdecades,atleastasreflected
RepetitionofSHiscommoninadolescents,with15-25%ofin-
in hospital presentations (Hawton 2003). However, only about
dividualswhopresenttohospitalfollowingSHreturningtothe
one in eight adolescents in the community who self-report en-
samehospitalfollowingarepeatepisodewithinayear(Hawton
gaginginSHeverpresentstohospital(Hawton2002;McMahon
2008b).Theremayalsobeotherrepeatepisodesthatdonotresult
2014;Ystgaard2009).Infact,ithasbecomeincreasinglyapparent
inhospitalpresentation.Repetitionisalsocommoninadolescents
thatSHinadolescentsinthecommunity(withouthospitalpre-
whodonotpresenttoclinicalcare(Hawton2002).
sentation) isextremelycommon (Hawton 2012a;Madge 2008;
Whilesuicideisrelativelyuncommoninyoungeradolescents,SH
McMahon2014),althoughlessisknownabouttheseindividuals.
generallyincreasestheriskoffuturesuicide,especiallyinadoles-
In children and adolescents who present to hospital, the most
cent males. Risk is also increased in those who repeat SH and,
commonmethodofSHisself-poisoning,withoverdosesofanal-
contrary to clinical opinion, possibly in those who cut them-
gesics(especiallyparacetamol)beingcommoninsomecountries,
Interventionsforself-harminchildrenandadolescents(Review) 6
Copyright©2016TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
selves(comparedtothosewhoengageinself-poisoning)(Hawton self-esteem,increasingasenseofsocialconnectedness,andreduc-
2012c). ingimpulsivity,aggression,andunhelpfulreactionstodistressing
Ofparticularconcernregardingafter-careofadolescentswhoen- situations.
gage SH and whopresent to hospital is the factthatadherence
torecommendedtreatmenttendstoberelativelypoor;between
Cognitivebehaviouraltherapy-basedpsychotherapy
25%and50%ofadolescentswillnotattendanyfollow-upses-
sions(Granboulan2001;Taylor1984). This intervention includes both cognitive behavioural therapy
(CBT)andproblem-solvingtherapy(PST).CBThelpspatients
identifyandcriticallyevaluatethewaysinwhichtheyinterpretand
evaluatedisturbingemotionalexperiencesandevents(Westbrook
Descriptionoftheintervention
2011), and aims to help them change the ways in which they
Treatment forSHinchildrenandadolescents mayinvolve psy- dealwithproblems.Thisisachievedinthreesteps:first,patients
chosocialinterventions,pharmacologicalinterventions,oracom- arehelpedtochangethewaysinwhichtheyinterpretandevalu-
binationofthetwoapproaches. atedistressingemotions;second,patientslearnstrategiestohelp
themchangethewayinwhichtheythinkaboutthemeaningsand
consequencesoftheseemotions;finally,withthebenefitofmodi-
Psychosocialinterventions
fiedinterpretationofemotionsandevents,patientsarehelpedto
Giventheroleofpsychologicalinfluences,andparticularlyprob- changetheirbehaviouranddeveloppositivefunctionalbehaviour
lem-solvingdeficits(Speckens2005),inchildrenandadolescents (Jones2012).
whoengageinSH,psychologicalapproachesusedinthetreatment PST, which is an integral part of CBT, assumes thatineffective
of these individuals typically involve brief individual or group- andmaladaptivecopingbehavioursmightbeovercomebyhelp-
basedpsychologicaltherapy(suchascognitive-behavioural ther- ingpatientslearnskillstoactively,constructively,andeffectively
apyorproblem-solvingtherapy),familytherapy,andcontactin- solvetheproblemstheyfaceintheirdailylives(Nezu2010),and
terventions;enhancedassessmentinterventionsmayalsobeused. thatthiswillreduceSH.PSTconsistsofencouragingpatientsto
Treatmentmayvaryintermsofinitialmanagement,locationof consciously and rationally appraise problems, reduce or modify
treatment,continuity,andintensityorfrequencyofcontactwith thenegativeemotionsgeneratedbyproblems,anddeveloparange
therapists.Thereisalsoconsiderablevariationamongcountriesin ofpossiblesolutionstoaddressproblems(D’Zurilla2010).Treat-
theavailability ofservicestoprovidesuchinterventions. Conse- ment goals include helpingpatients todevelopa positive prob-
quently,thereisnostandardpsychosocialtreatmentforSHinchil- lem-solving orientation, use rational problem-solving strategies,
drenand adolescents. However,in highincome countries treat- reducethetendencytoavoidproblem-solving,andreducetheuse
mentgenerallyconsistsofacombinationofassessment,support, ofimpulsiveproblem-solvingstrategies(Washburn2012).Home-
involvementofrelatives,andindividualpsychologicaltherapies. workassignmentsareanessentialcomponentofCBT-basedpsy-
chotherapy.
Pharmacologicalinterventions
InterventionsforpatientswithmultipleepisodesofSHor
Given the prevalence of depression in children and adolescents
emergingpersonalityproblems
who present to hospital following an episode of SH (Hawton
2013),pharmacologicaltreatmentsmayincludeantidepressants.
Otherpharmacologicalagents,suchasbenzodiazepinesandother
Dialecticalbehaviourtherapy
anxiolytics,mayalsobeprescribed.However,treatmentwithphar-
macologicalagentsisgenerallylesscommonthantreatmentwith Dialecticalbehaviourtherapy(DBT)inadultscombinesproblem-
psychosocialinterventions,partlyduetoconcernsabouttherisk solving training, skillstraining, cognitive modification training,
ofexacerbatingsuicidality(Miller2014). andmindfulnesstechniques(Washburn 2012),encouraging pa-
tientstoaccepttheirthoughts,feelings,andbehaviourswithout
necessarily attempting tochange, suppress, or avoid theseexpe-
riences(Lynch 2006).Within thisframework, theaimof DBT
Howtheinterventionmightwork
istohelppatientsbetterregulatetheiremotions,achieveasense
ofinterpersonaleffectiveness,becomemoretolerantofdistressing
thoughts or feelings, and become better at managing their own
Psychosocialinterventions
thoughtsandbehaviours(Linehan1993;Linehan2007).Thepri-
The mechanisms of action of psychosocial interventions might mary treatmentgoals ofDBT arethereforethreefold:toreduce
includehelpingadolescentsimprovetheircopingskillsandtackle SH,behavioursthatinterferewiththesuccessoftreatment(such
specific problems, overcoming psychiatric disorders, improving as treatment non-adherence), and any other factors which may
Interventionsforself-harminchildrenandadolescents(Review) 7
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