Adolescent Self-harm

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Dr George Patton. Presentation to SPINZ Symposium, Dunedin, Nov. 28, 2006. http://www.spinz.org.nz

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Adolescent Self-harm

  1. 1. Adolescent Self-harmOrigins, course and intervention George Patton VicHealth Professor of Adolescent Health Research SPINZ Symposium Dunedin 28th-29th Nov 2006
  2. 2. Suicidal PhenomenaThoughts Behaviours
  3. 3. Suicidal Phenomena Thoughts Behaviours SeriousCasual Thoughts Thoughts
  4. 4. Suicidal Phenomena Thoughts Behaviours SeriousCasual Thoughts Thoughts Thoughts Plans Threats
  5. 5. Suicidal Phenomena Thoughts Behaviours Serious AttemptedCasual Thoughts DSH suicide Thoughts Thoughts Plans Threats
  6. 6. Suicidal Phenomena Thoughts Behaviours Serious AttemptedCasual Thoughts DSH suicide Thoughts Thoughts Plans Threats
  7. 7. Are suicidal phenomena increasing? • 30% increase in reports to Childline in UK in 2004 • 30% increase in A&E self- harm decade to Millenium in Oxford
  8. 8. How common are suicide phenomena in the teens?3025201510 5 0 Suicide Self-harm Suicidal attempts thoughts * meta-analysis Evans et al
  9. 9. How common are suicidal phenomena in the teens?3025201510 5 0 Suicide Self-harm Suicidal attempts thoughts * meta-analysis Evans et al
  10. 10. Perspectives on Suicide Phenomena A Socio-cultural B Developmental C Prevention D Clinical responses
  11. 11. A Sociocultural ‘Anomie’ Contagion
  12. 12. Contagion & self-harm • ‘Epidemics’ of self- harm in institutions
  13. 13. Youth subcultures• 10-fold higher rates ofself-harm in Goths!
  14. 14. CONTAGION AND THE INTERNET
  15. 15. Internet suicides in Japan
  16. 16. INTERNET MESSAGE BOARDSCreating a culture of self-harm?
  17. 17. “Don’t get me wrong, I love this site.But geez, take down the pictures.As a fourteen year old cutter I will tell you that thepictures are extremely triggering,I only looked at some like once and I only gottriggered (badly). They don’t help anyone and the peoplewho take pictures of their cuts are attention seekers andjust trying to see who can make worse cuts.Do self injurers a favor and take the pictures down.“
  18. 18. B DevelopmentalSelf-harm from a life course perspective
  19. 19. Male self-harm from 12 to 24 years 8 7 6 5 4% 3 2 1 0 12 13 14 15 16 17 20 24
  20. 20. Female self-harm from 12 to 24 years 14 12 10 8% 6 4 2 0 12 13 14 15 16 17 20 24
  21. 21. Pubertal Cascade8 9 10 11 12 13 14 15 16 17 18 years adrenarche ? HPA axis
  22. 22. Pubertal Cascade8 9 10 11 12 13 14 15 16 17 18 years adrenarche ? HPA axis gonadarche HPG axis
  23. 23. Pubertal Cascade8 9 10 11 12 13 14 15 16 17 18 years adrenarche HPA axis gonadarche HPG axis Growth spurt GH/somatomedin axis Oxytocin system ?
  24. 24. Frontal grey matter volume240235230225220215210 4 6 8 10 12 14 16 18 20 22
  25. 25. Adolescent brain development Prefrontal cortex maturation • extends into the third decade • impulse control • planning • emotional regulation
  26. 26. ‘Adult’ problems commoner from puberty • depression - anxiety syndromes • deliberate self-harm • substance abuse • eating disorders • psychosis • pain syndromes • type 1 diabetes • obesity and cardiovascular risk
  27. 27. Deliberate self harm by early and late pubertal stage 10 8 6% 4 2 0 I-III IV/V I-III IV/V Males Females
  28. 28. Self-harm types in early vs late puberty in girls 3.5 3 2.5 2% Early Puberty 1.5 Late Puberty 1 0.5 0 Cutting Overdose Other
  29. 29. Self-harm in early adolescence Pubertal stage Pre/E arly (n= 395) 1.0 M id (n=1239) 2.1 (0.7, 6.3) Late/C om plete (n=1893) 4.3 (1.3, 14) A ge 0.51 (0.34, 0.78) G rade 9 (vs. 7) M ales (n=850) 1.3 (0.4, 1.6) Fem ales (n=902) 3.0 (1.1, 7.8)
  30. 30. Self-harm in early adolescence Pubertal stage Pre/E arly (n= 395) 1.0 M id (n=1239) 2.1 (0.7, 6.3) Late/C om plete (n=1893) 4.3 (1.3, 14) A ge 0.51 (0.34, 0.78) G rade 9 (vs. 7) M ales (n=850) 1.3 (0.4, 1.6) Fem ales (n=902) 3.0 (1.1, 7.8)
  31. 31. Pubertal risks
  32. 32. Pubertal risks Brain maturation
  33. 33. Early pubertyPubertal risks Brain maturation
  34. 34. Self-harm in early adolescence Adjusted for Adjusted for age & school ‘adult’ risks gradePubertal stagePre/Early (n= 395) 1.0 1.0Mid (n=1239) 2.1 (0.7, 6.3) 1.3 (0.5, 3.6)Late/Completed 4.3 (1.3, 14) 1.9 (0.6, 5.6) (n=1893)
  35. 35. Fast track youthPubertal risks Brain maturation
  36. 36. Fast track youthPubertal risks Brain maturation
  37. 37. Prevalence of self-harm in adolescence and young adulthood201510 5 0 Males Females Males Females 15 -17 years 21-24 years
  38. 38. Report of young adult self-harm by teen harm 18 16 14 12 10% 8 6 4 2 0 No teen Teen harm No teen Teen harm harm harm Males Females
  39. 39. What predicts continuing?• Females 8x• Sexual abuse 3x• Psychiatric morbidity 3x
  40. 40. C PreventionUniversalSelective
  41. 41. Universal community-based strategiesTarget Examples Requirements Potential problemsPopulation • Restricting • Big enough risks • inclusion of means • Understanding risk most at risk • Reducing processes • ? harm direct lethality or indirect • Screening • Big enough risk • complianceIndividual • Suicide factors • ? harm direct or education indirect
  42. 42. Limiting lethal means Firearms Paracetomol, BarbituratesRestricting Access Toxic Domestic Gas Agricultural Chemicals Jumping Barriers
  43. 43. Limiting lethal means Firearms Paracetomol, BarbituratesRestricting Access Toxic Domestic Gas Agricultural Chemicals Jumping Barriers Vehicle emissions Toxicity of antidepressants Reducing Lethality Pits in train stations Availability of N-acetylcysteine
  44. 44. Annette Beautrais
  45. 45. Scope for further regulation of media?
  46. 46. Selective community-based preventionTarget Examples Requirements Potential problemsVulnerability • Family history • Capacity to • Reversibilitycentred • Offenders promote resilience • Stigma • Indigenous • ? HarmEvent • Adverse life • Capacity to debrief • Stigmacentred events • identifying event • ? Harm • Common enough
  47. 47. Selective prevention: Who is at high risk?• Marginalised youth – indigenous youth – young offenders – young mentally ill – same sex attracted youth – ethnic minority youth? (eg Arabic speaking)• Family history of suicidal behaviour
  48. 48. Death rates in male offenders aged 15-19 years 700 600deaths/100,000 500 400 Male Offenders 300 Other males 200 100 0 All cause Drug Injury Suicide Coffey et al BMJ 2003
  49. 49. Death rates in female offenders aged 15-19 years 2500 2000deaths/100,000 1500 Female Offenders 1000 Other females 500 0 All cause Drug Injury Suicide Coffey et al BMJ 2003
  50. 50. D Clinical Responses1 Assessment2 Treatment options3 Pharmacological
  51. 51. 1 Assessment• Suicide intent• Social problems/ resources• Concurrent psychiatric disorder• Attitudes to help
  52. 52. 2 Treatment optionsStrategy Examples Requirements ProblemsIndicated • Psychological • Clinical resources • Sustainability• Depressive • Effectiveness • Cases identifiable symptom • Compliance • Labelling• Screening • Certification of healthTreatment • Psychological • Accessibility • adverse effects • Antidepressants • Clinical resources • level of non-response • EffectivenessMaintenance • Psychological • Clinical resources • Effect on disability- prevention • Compliance • Complications?of relapse
  53. 53. Problem solving not shown effective
  54. 54. Dialectical behavior therapy effective in one trial
  55. 55. 2 Treatment optionsStrategy Examples Requirements ProblemsIndicated • Psychological • Clinical resources • Sustainability• Depressive • Effectiveness • Cases identifiable symptom • Compliance • Labelling• Screening • Certification of healthTreatment • Psychological • Accessibility • adverse effects • Antidepressants • Clinical resources • level of non-response • EffectivenessMaintenance • Psychological • Clinical resources • Effect on disability- prevention • Compliance • Complications?of relapse
  56. 56. 3 PharmacologicalNo pharmacological intervention shown effective……..
  57. 57. Antidepressants not effective for DSH alone
  58. 58. 3 AntidepressantsIf clear depression is present but Close monitoring
  59. 59. Scope for intervention Promoting positive development Family and school engagement Reducing ‘adult’ risks 1st clinical engagement Specialised treatments for repeaters Birth 10 20
  60. 60. Number of young people 0 Low risk High risk Level of self-harmFrom Geoffrey Rose
  61. 61. Number of young people Suicide Level 0 Low risk High risk Level of self-harmFrom Geoffrey Rose
  62. 62. Number of young people Suicide Level 0 Low risk High risk Level of self-harmFrom Geoffrey Rose
  63. 63. High risk & treatment Number of approaches young people Suicide Level 0 Low risk High risk Level of self-harmFrom Geoffrey Rose
  64. 64. Broad preventive strategy High risk & treatment Number of approaches young people Suicide Level 0 Low risk High risk Level of deliberate self-harmFrom Geoffrey Rose
  65. 65. Broad preventive strategy High risk & treatment Number of approaches young people Suicide Level 0 Low risk High risk Level of deliberate self-harmFrom Geoffrey Rose
  66. 66. Continuum theory• 50% of young suicides self-harm• Self-harm and suicide correlate
  67. 67. Continuum theory• 50% of young • Most do not suicide suicides self-harm • Most are not suicidal• Self-harm and • changing age suicide correlate relationship
  68. 68. WHO MATURES OUT AND WHO DOES NOT?

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