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

1. Adolescent Self-harm
Origins, course and intervention
George Patton
VicHealth Professor of Adolescent Health Research
SPINZ Symposium Dunedin 28th-29th Nov 2006

2. Suicidal
Phenomena
Thoughts Behaviours

3. Suicidal
Phenomena
Thoughts Behaviours
Serious
Casual Thoughts Thoughts

4. Suicidal
Phenomena
Thoughts Behaviours
Serious
Casual Thoughts Thoughts
Thoughts Plans Threats

5. Suicidal
Phenomena
Thoughts Behaviours
Serious Attempted
Casual Thoughts DSH suicide
Thoughts
Thoughts Plans Threats

6. Suicidal
Phenomena
Thoughts Behaviours
Serious Attempted
Casual Thoughts DSH suicide
Thoughts
Thoughts Plans Threats

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. How common are 'suicide phenomena' in the teens?
30
25
20
15
10
5
0
Suicide Self-harm Suicidal
attempts thoughts
* meta-analysis Evans et al

9. How common are 'suicidal phenomena' in the teens?
30
25
20
15
10
5
0
Suicide Self-harm Suicidal
attempts thoughts
* meta-analysis Evans et al

10. Perspectives on Suicide Phenomena
A Socio-cultural
B Developmental
C Prevention
D Clinical responses

11. A Sociocultural
‘Anomie’
Contagion

16. Contagion & self-harm
• ‘Epidemics’ of self-
harm in institutions

17. Youth subcultures
• 10-fold higher rates of
self-harm in Goths!

18. CONTAGION
AND THE
INTERNET

19. Internet suicides
in Japan

20. INTERNET MESSAGE BOARDS
Creating a culture of
self-harm?

21. “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 the
pictures are extremely triggering,
I only looked at some like once and I only got
triggered (badly). They don’t help anyone and the people
who take pictures of their cuts are attention seekers and
just trying to see who can make worse cuts.
Do self injurers a favor and take the pictures down.“

22. B Developmental
Self-harm from a life course
perspective

23. 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

24. Female self-harm from 12 to 24 years
14
12
10
8
%
6
4
2
0
12 13 14 15 16 17 20 24

26. Pubertal Cascade
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche ? HPA axis

27. Pubertal Cascade
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche ? HPA axis
gonadarche HPG axis

28. Pubertal Cascade
8 9 10 11 12 13 14 15 16 17 18 years
adrenarche HPA axis
gonadarche HPG axis
Growth spurt GH/somatomedin axis
Oxytocin system ?

29. Frontal grey matter volume
240
235
230
225
220
215
210
4 6 8 10 12 14 16 18 20 22

30. Adolescent brain development
Prefrontal cortex maturation
• extends into the third decade
• impulse control
• planning
• emotional regulation

31. ‘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

32. 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

33. 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

34. 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)

35. 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)

36. Pubertal risks

37. Pubertal risks
Brain maturation

38. Early puberty
Pubertal risks
Brain maturation

40. Self-harm in early adolescence
Adjusted for Adjusted for
age & school ‘adult’ risks
grade
Pubertal stage
Pre/Early (n= 395) 1.0 1.0
Mid (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)

41. Fast track youth
Pubertal risks
Brain maturation

42. Fast track youth
Pubertal risks
Brain maturation

43. Prevalence of self-harm in adolescence and young
adulthood
20
15
10
5
0
Males Females Males Females
15 -17 years 21-24 years

44. 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

45. What predicts continuing?
• Females 8x
• Sexual abuse 3x
• Psychiatric morbidity 3x

46. C Prevention
Universal
Selective

47. Universal community-based strategies
Target Examples Requirements Potential
problems
Population • Restricting • Big enough risks • inclusion of
means • Understanding risk most at risk
• Reducing processes • ? harm direct
lethality or indirect
• Screening • Big enough risk • compliance
Individual • Suicide factors • ? harm direct or
education indirect

48. Limiting lethal means
Firearms
Paracetomol, Barbiturates
Restricting Access Toxic Domestic Gas
Agricultural Chemicals
Jumping Barriers

49. Limiting lethal means
Firearms
Paracetomol, Barbiturates
Restricting Access Toxic Domestic Gas
Agricultural Chemicals
Jumping Barriers
Vehicle emissions
Toxicity of antidepressants
Reducing Lethality Pits in train stations
Availability of N-acetylcysteine

51. Annette Beautrais

53. Scope for further regulation
of media?

54. Selective community-based prevention
Target Examples Requirements Potential
problems
Vulnerability • Family history • Capacity to • Reversibility
centred • Offenders promote resilience • Stigma
• Indigenous • ? Harm
Event • Adverse life • Capacity to debrief • Stigma
centred events • identifying event • ? Harm
• Common enough

55. 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

57. Death rates in male offenders aged 15-19 years
700
600
deaths/100,000
500
400
Male Offenders
300 Other males
200
100
0
All cause Drug Injury Suicide
Coffey et al BMJ 2003

58. Death rates in female offenders aged 15-19
years
2500
2000
deaths/100,000
1500
Female Offenders
1000 Other females
500
0
All cause Drug Injury Suicide
Coffey et al BMJ 2003

59. D Clinical Responses
1 Assessment
2 Treatment options
3 Pharmacological

60. 1 Assessment
• Suicide intent
• Social problems/ resources
• Concurrent psychiatric disorder
• Attitudes to help

61. 2 Treatment options
Strategy Examples Requirements Problems
Indicated • Psychological • Clinical resources • Sustainability
• Depressive • Effectiveness • Cases identifiable
symptom • Compliance • Labelling
• Screening • Certification of health
Treatment • Psychological • Accessibility • adverse effects
• Antidepressants • Clinical resources • level of non-response
• Effectiveness
Maintenance • Psychological • Clinical resources • Effect on disability
- prevention • Compliance • Complications?
of relapse

62. Problem solving not shown effective

63. Dialectical behavior therapy effective in one trial

64. 2 Treatment options
Strategy Examples Requirements Problems
Indicated • Psychological • Clinical resources • Sustainability
• Depressive • Effectiveness • Cases identifiable
symptom • Compliance • Labelling
• Screening • Certification of health
Treatment • Psychological • Accessibility • adverse effects
• Antidepressants • Clinical resources • level of non-response
• Effectiveness
Maintenance • Psychological • Clinical resources • Effect on disability
- prevention • Compliance • Complications?
of relapse

65. 3 Pharmacological
No pharmacological intervention
shown effective……..

66. Antidepressants not effective for DSH alone

67. 3 Antidepressants
If clear depression is present
but
Close monitoring

68. Scope for intervention
Promoting positive development
Family and school engagement
Reducing ‘adult’
risks
1st clinical
engagement
Specialised
treatments for
repeaters
Birth
10 20

69. Number of
young people
0
Low risk High risk
Level of self-harm
From Geoffrey Rose

70. Number of
young people
Suicide Level
0
Low risk High risk
Level of self-harm
From Geoffrey Rose

71. Number of
young people
Suicide Level
0
Low risk High risk
Level of self-harm
From Geoffrey Rose

72. High risk & treatment
Number of approaches
young people
Suicide Level
0
Low risk High risk
Level of self-harm
From Geoffrey Rose

73. Broad preventive strategy
High risk & treatment
Number of approaches
young people
Suicide Level
0
Low risk High risk
Level of deliberate self-harm
From Geoffrey Rose

74. Broad preventive strategy
High risk & treatment
Number of approaches
young people
Suicide Level
0
Low risk High risk
Level of deliberate self-harm
From Geoffrey Rose

75. Continuum theory
• 50% of young
suicides self-harm
• Self-harm and
suicide correlate

76. Continuum theory
• 50% of young • Most do not suicide
suicides self-harm • Most are not suicidal
• Self-harm and • changing age
suicide correlate relationship

77. WHO MATURES OUT AND
WHO DOES NOT?