needs assessment of young people who self-harm: insights from two scottish studies robert young...
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Needs assessment of young people who self-harm: Insights
from two Scottish studies
Robert Young
Medical Research Council, Social & Public Health Sciences Unit, University of Glasgow
Lanarkshire self-harm health needs assessment: stakeholder consultation meeting Hamilton, 16 July 2008
Overview & Outline
• BASICS/MEASURMENT:Measuring need in self-harm: Problems & Definitions. Why focus on the
needs of young people who self-harm?
• RISK/NEEDS:Who is at greatest need? High risk-groups, high risk schools, different
motives so different need for different people
• AWARENESS/SERVICE-USE:Who is aware of the needs of YP who self-harm? Service use and who do
YP confide in. What are professionals who deal with young peoples needs & experience?
• INTERVENTION/MEETING NEED:Who can and how can we address YP needs: Interventions & reasons for
cessation
MEASURING NEED IN SELF-HARM:PROBLEMS & DEFINITIONS.
Deliberate self-harm
Non-fatal self-harm Self-destructive behaviour
Repeated self-harm
Cutter
Self-mutilation
Self-injury
Para suicide
Harm to self
Attempted suicide
Suicidal gesture
Various terms used in self-harm research
Non-fatal suicide
self-harm
Suicidal behaviour
70% not at risk
20-30% Depressed mood-symptoms
20% Suicidal thoughts
3-6%
Attempted suicide
< 4/10,000 Completed suicide7-14 % lifetime self-harm
1-2% currently self-harming
3/100 Complete suicide in next 15-years
Prevalence “suicidal behaviours & cognitions” & relationship with self-harm
Scottish Need Assessment Study (SNAP):
Qualitative study of professionals experience of working with YP.N= 1049, (25% experienced YP
who self-armed)
11-16 study region:Quantitative study of
YP, age-19N=1256, 89 self-harm
Sample: 1727 15-year old school children from Central
Clydeside Conurbation
49% No history of suicide-risk
41.5% Morbid thoughts
about death and dying
9.1%
Attempted or seriously
thought about suicide
6.1% attempted suicide
Prevalence suicidal-risk within age-15 year olds in West of Scotland in 1999
52
37
2721 19
12 10 95
0
10
20
30
40
50
60
Anger
Forget
som
ethin
g
Anxie
ty
Kill-s
elf
Not s
ure
punish
-sel
f
mak
e oth
ers
notic
e
Other
upset o
ther
s% E
nd
ors
ing
re
as
on
fo
r S
elf
-ha
rmReason for self-harm (ordered by frequency)16+ study (1256 base, 89 cases self-harm)
Crudely two self-harmers clusters
CHRONIC/REPEATING• Repeated self-harm• Internalising behaviours• Female• Teenagers• Require professional help• Sexual abuse• Depression• Family difficulties• Externalising behaviour• Internal “trigger” for self-
harm
TRANSIENT• One-off event• Reaction to temporary
stressful circumstances• Few long-term problems• Few psychiatric
problems• External trigger
SAME LEVEL OF SUICIDAL IDEATION
BUT VERY DIFFERENT NEEDS
INEQUALITIES IN RISK & NEEDS
0
1
2
3
4
5
6
7
16-24 25-34 34-44 44-54
% A
ttem
pte
d s
uic
ide
/ no
n-f
atal
sel
f-h
arm Attempted suicide Non-fatal Self-harm
UK Age distribution of lifetime rates of self-harm & attempted suicide(UK National statistics, 2002: n=8580)
12
6
11
1718
10
35
27
0
5
10
15
20
25
30
35
40
45
GPs
Health
Vis
itor
Paedi
atrici
ans
Resid
entia
l work
ers
Volunta
ry s
ecto
r wor
kers
Teach
ers
School n
urse
s
Social
Work
ers
% in
volv
ing
sel
f-h
arm Last case
SNAP (2003), Young person with mental-health need: last & most worrying case involving self-harm.(1049 professionals working with young people)
25
10
2223
31
15
43
33
0
5
10
15
20
25
30
35
40
45
GPs
Health
Vis
itor
Paedi
atrici
ans
Resid
entia
l work
ers
Volunta
ry s
ecto
r wor
kers
Teach
ers
School n
urse
s
Social
Work
ers
% in
volv
ing
sel
f-h
arm
Most worrying case
SNAP (2003), Young person with mental-health need: last & most worrying case involving self-harm.(1049 professionals working with young people)
RISK/NEEDS:High-risk groups & risk
factors
Who is at greatest need:Risk factors & high-risk groups
• Female• Depression• Personality disorder• Alcohol & drug problems• Stress Exam/academic pressure• Major Life Events (bereavement,
divorce/family break-up)• “Minor” life events (bullying,
relationship problems)• Age• Impulsivity• Media/triggers?• Friends/family who self-harm
(risk/support network)?• Isolation• Deprivation (life-events)• Poor coping skills
• LGBT• Offenders (Prison &
delinquency)• Goths & alternative youth• Ethnic minorities
2.6
4.45.0
6.1
9.9
13.313.8
14.2
0.6
6.5
0
2
4
6
8
10
12
14
16
Death re
l/frie
nd
Serio
us inju
ry
police/c
ourt
Bullied
Viole
nce at
wor
k
expe
lled
Run away
sexu
al ab
use
No eve
nts
6+ e
vents
Lif
e e
ve
nt
an
d
% r
ate
of
Se
lf-h
arm
Life-events and self-harm(UK National statistics, 2002: n=8580)
Life-events specific to young people
0
10
20
30
40
50
60
70
80
90
100
8 9 10 11 12 13 14 15 16 17 18 19
Age
% s
elf
-ha
rmAge (Cumulative) at which young people started to self-harm (89 young people)
So 13-18 seems to be the age of most need
6%
8%7% 7%
5%7%
17%
0%2%4%6%8%
10%12%14%16%18%20%
Mal
e
Femal
e
Non-man
Man
ual
FT-Edu
Work
Nonlabour
% L
ife
tim
e S
elf
-ha
rm
Lifetime self-harm as a function of gender, social class and labour market position
1%2% 2%
1% 1% 1%
7%
0%1%2%3%4%5%6%7%8%9%
10%
Mal
e
Femal
e
Non-man
Man
ual
FT-Edu
Work
Nonlabour
% C
urr
en
t S
elf
-ha
rm
Current self-harm as a function of gender, social class and labour market position
0
5
10
15
20
25
Percentage suicide attempt or ideation
for 43 WoS secondary schools (Age 15)
Least MostSchool levelSuicide-risk
Average Suicide-risk
High-risk/need schools?
low-risk/need schools?
1 1.5 2 2.5 3
School-engagement
(low)
School-rating(nurses)
Increased odds of Suicide-attempt/ideation
Boy Girls All
Suicide-risk by School predictors
*
School-pupil perceptions
*
*
*= statistically significant predictor
School-level effect
*
19%
23%
7%
36%
6%
23%
44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Mal
e
Femal
e
Non-m
an
Man
ual
FT-Edu
Work
Nonla
bour
Sel
f-h
arm
to
Kil
l se
lfReason (kill self) for self-harm as a function of gender, social class and labour market position
Hi-rate of the Unemployed &
manual background self-harm to kill self
14%
37% 36%
21%
40%
16%
22%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Mal
e
Femal
e
Non-M
anual
Man
ual
FT-Edu
Work
Nonla
bour
% S
elf-
har
m t
o r
elie
ve a
nxi
ety
Reason (relieve anxiety) for self-harm as afunction of gender, social class and labour market position
Hi-rates for females, students & middle class background use self-harm to manage stress
AWARENESS/SERVICE-USE:
17
11
9
4
00
2
4
6
8
10
12
14
16
18
20
Any Parent/Friend GP Mental HealthSpecialist
Uni/Work
Nu
mb
er
aw
are
Young person currently self-harming (who knows)
GP & informal networks aware of
need
Specialist & formal networks unaware of
need
7% 6%
22%
36%
40%
44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Anx/Dep Behav/External Substance
DS
M-I
V V
oic
e-D
ISC
dia
gn
os
is a
ge
-18
-20
No self-harm Self-harm
Rates of psychiatric disorder for self-harmers vs. non-self-harmers
39.9
14.6
3.82.5 2.1
1.1
50.6
24.7
7.9
31.5
14.6
7.9
0
10
20
30
40
50
Casuality (age-11+)
In-patient (age-11+)
GP(year) Psych (age-11+)
Social Work(age-11+)
Child-Panel
% U
se o
f se
rvic
es s
ince
ag
e-11
Non-self-harmer Self-harmer
Use of services since age-11, except GP (16+, n=1256, of which 89 self-harm)
Heavy use of specialist services
0 0
8
0
18
3
99
8
29
0
18
8
4
0
5
10
15
20
25
30
GPs Paediatricians Residentialworkers
Voluntarysector
workers
Teachers Schoolnurses
SocialWorkers
% N
eed
Pro
f H
elp
Last case Most worrying case
Self-harm case, Last & most worrying case: Need professional help (SNAP)
Residential workers & Teachers want
professional help
6
8
0 0
8
11
00 0
19
0
20
87
0
5
10
15
20
25
GPs Paediatricians Residentialworkers
Voluntarysector
workers
Teachers Schoolnurses
SocialWorkers
% G
oo
d/B
ad o
utc
om
eGood Bad
Self-harm case, Most worrying case: Good or bad outcome (SNAP, n =209)
Residential workers & Teachers want see
poor outcome
44
33
29
12
35
13
41
19
8
5
0
6
11
00
5
10
15
20
25
30
35
40
45
GPs Paediatricians Residentialworkers
Voluntarysector
workers
Teachers Schoolnurses
SocialWorkers
% N
ot/
Sat
isfi
ed w
ith
oth
er s
ervi
ce
Satisfied Not satisfied
Self-harm case, Most worrying case:Satisfied with service (SNAP,n=209)
Focus of needs assessment: filling the gaps: Tentative results
Source of meeting needYoung People
Professionals
Use Aware Dissatisfied with
Services
Need prof-help
Poor outcome
Hospital-based/inpatient ? ? ?
Primary care: GP -Social work, residential workers
-
Psychological services
? ? ?
Education: Teachers/School-nurses
- -
Informal: (e.g. peers, family)
? ? ?
Work/University/College 0 0 ? ? ?Specialist Self-harm services ? ? ?
INTERVENTION/MEETING NEED:Effective interventions & reasons
for cessation
NICE conclusions regarding Psychosocial interventions for Self-harm: 2004“The evidence reviewed here suggests that
there are surprisingly few specific interventions for people who have self-harmed that have any positive effect. The GDG came to the conclusion that, at the present time, there was insufficient evidence to support any recommendation for interventions specifically designed for people who self-harm.”
Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, p177
11.4 11.7 12.7
0
10
20
30
40
50
60
70
80
90
100
Initial 3-months 6-months 12-months
Nu
mb
er
of
ca
se
s w
ho
se
lf-h
arm
Self-harm at 3, 6 & 12-monthfollow-up (63 cases, pilot study)
20% typically self-harm repeat rate at 1-year
(n=1982) Bennewith, et al, 2002
37
2625
12
0
5
10
15
20
25
30
35
40
Realised harm toself and family or
“stupidity”
“one off” or temporarily phase
Coped or felt betteror found purpose
Got help,professional, family
or friends
% E
nd
ors
ing
re
as
on
sto
pin
g s
elf
-ha
rmReason for Stopping self-harm (ordered by frequency)
Thanks to my colleagues and co-authors
Patrick West, Medical Research Council, Social & Public Health Science Unit
Helen Sweeting, Medical Research Council, Social & Public Health Science Unit
Michael van Beinum, Medical Research Council, Social & Public Health Science Unit
Eileen McCafferty, Glasgow Nurse-led Self-harm Service, NHS Glasgow
Judy Furnivall, Institute for Residential Child Care, University of Strathclyde
Philip Wilson, Dept of general practice, University of Glasgow