LEARNING TO HELP CHILDREN WHO HURT THEMSELVES

A desire to improve the treatment of adolescents who engage in deliberate self-harm motivated Professor Philip Hazell to carry out a research study testing the effectiveness of developmental group psychotherapy in preventing self-injury.

Why are kids hurting themselves?

Along with attempted suicide, deliberate self-harm (DSH) in children and adolescents can occur in many different ways. Examples include deliberate self-mutilation (such as wrist-cutting), head-banging, deliberate overdose of medication, burning, selfstrangulation, and jumping from heights. ‘About one in ten adolescent females and one in twenty adolescent males engage in self-harm’, Professor Hazell tells Scientia. ‘For many, it is a relatively benign behaviour which has minimal health consequences. For some, the problem becomes malignant, leading to disfigurement, frequent and problematic engagement with the medical system, and sometimes death. For these reasons, self-harm is an important public health issue.’ Community surveys looking at how often deliberate self-harm in children and adolescents actually occurs are just beginning to reveal the true magnitude of the problem. A 2010 community survey published in the Medical Journal of Australia showed that 1.1% of more than 12,000 Australians surveyed reported injuring themselves recently. For females, self-injury peaked in the 15–25 year-old age group, while in males, this peak occurred in 10–19 year-olds. Among those who reported selfharm, the most common method was cutting and the most common reason given was to control emotions. Rates of self-harm among adolescents have been rising since the 1960s and estimates of lifetime prevalence are as high as 14% in some countries. Self-injurers generally report being more psychologically distressed than noninjurers. They are also more likely to have trouble managing their emotions, have poor problem-solving skills, and often have difficulty with relationships in general. In children and adolescents who harm themselves, most attempts occur in their own homes. Statistics also show that one in five self-harm attempts is alcohol-related, while one in eight occurs under the influence of drugs. A 2008 Australian study found that self-harmers were also more likely to have a history of childhood abuse and neglect. Those same results show that less than half of all self-harmers actually seek professional help unless the self-harm attempt is particularly serious. However, most admitted to telling at least one person they knew about their self-harming. Whether this is a friend, family member or trusted teacher, being able to reach out and confide in someone can be a vital step in the healing process. For young people who don’t ask for help however, the outlook is often grim. Among adolescents who self-harm, the risk of further self-harm ranges from 10% in the six months following the first attempt to 42% within two years. Even for young people who do seek professional help however, finding the right kind of help is often a major challenge. Though general hospitals can deal with selfharmers on an emergency basis, providing them with help after they leave the hospital can be especially difficult.

Developmental group psychotherapy and self-harm

Treatment programs specifically aimed at helping self-harmers are still fairly rare. Most of the programs that are out there usually focus on related problems such as depression or substance abuse. This may explain why young people are often reluctant to seek treatment unless pressured to by medical doctors or family members. As for whether these different treatment options can actually help prevent future self-harm attempts, research studies tend to be pessimistic. But what about a group therapy program specially designed for adolescent selfharmers? Could such a program provide a better treatment alternative to prevent future self-harm attempts? One new program developed by a clinical team from the University of Manchester and Greater Manchester West Mental Health Foundation Trust, seemed particularly promising. Known as Developmental Group Psychotherapy (DGP), this program is specifically intended for young people between the ages of 12 to 17 who have a history of self-harm. Based on the principles of cognitive behavioural therapy, the DGP program also provides specialized training manual outlining different skills modules. These include social skills training, interpersonal psychotherapy and group therapy. By helping adolescents explore their relationships with family and friends, therapists encouraged them to become more pro-social. This means learning to overcome the isolation that can lead to self-harm. The first six program sessions focus on school and relationships, family problems, anger management, depression and self-harm, and worrying about the future. Following these first six sessions, adolescents then have the option of additional group sessions for up to twelve months. According to a 2001 study looking at the benefits of DGP, adolescents receiving group therapy had significantly fewer self-harm attempts after 29 weeks compared to the routine care received by the control group. While these results appeared promising, they were still based on a fairly small sample (69 adolescents in total). Unfortunately, a later research study by the Manchester researchers using a much larger sample (366 adolescents evenly divided between treatment and control conditions) failed to show any real effectiveness in preventing further self-harm attempts. Despite these conflicting results, developmental group psychotherapy remains one of the only real programs for helping adolescent self-harmers available. More research was definitely needed.

‘Self-harm, and concerns about risk of self-harm, are behind most of the afterhours calls I receive. Ever since my junior registrar days I have thought: “we can probably do this better”’

Bringing DGP to Australia

When asked about why he began researching adolescent self-harm, Professor Hazell replied ‘When I return home from a session in the surf, my wife usually asks me if I

caught any waves. Sometimes the answer is “no, but a few waves caught me”. Selfharm is like a wave that caught me. The issue is unavoidable; it is in my face’. Along with being Conjoint Professor of Child and Adolescent Psychiatry at Sydney Medical School, Professor Hazell is also Director of Child and Adolescent Mental Health Services for the Sydney Local Health District and Director of the Rivendell Child, Adolescent and Family Mental Health Service in New South Wales. ‘Self-harm, and concerns about risk of self-harm, are behind most of the after-hours calls I receive,’ Professor Hazell explains, ‘ever since my junior registrar days I have thought, “we can probably do this better”’. This motivated him to test the effectiveness of the Developmental Group Psychotherapy program in preventing selfharm in adolescents in an Australian setting, in a new research study in collaboration with a team of fellow researchers at the University of Newcastle and the University of Queensland. This new study, which has been published recently in the Journal of the American Academy of Child and Adolescent Psychiatry, looked at adolescents between the ages of twelve and sixteen who had least two self-harm episodes in the three months prior to the study. 138 adolescent selfharmers were referred by adolescent mental health agencies in three Australian cities. Of these, only 72 adolescents agreed to take part in the study. These participants were then randomly assigned to either the group therapy condition or the control condition. The 37 adolescents assigned to the control condition received routine care, including individual counselling, family therapy, and meetings with a case worker. For the group therapy condition, 35 adolescents received the same kind of programming described in the DGP treatment manual. This included an initial engagement phase with six one-hour group sessions conducted on a weekly basis. The groups were run by clinicians from community-based adolescent mental health services. Similar to the original Manchester study, adolescents who completed the six initial group sessions had the option to continue on with a more long-term group for up to twelve months. Adolescents in group therapy also received routine care from their local adolescent mental health service.

To make sure that the group therapy sessions were as close to the Manchester model as possible, a group therapist who had been involved in the original study helped to oversee the program and conducted ‘booster sessions’ as needed. Video conferencing also allowed the Australian therapists to consult with the British therapists about specific clinical concerns. All group sessions were videotaped and three British therapists rated them according to how closely they matched the DGP treatment manual. The program’s effectiveness was measured using assessments in four waves: immediately after being assigned to a treatment condition and then eight weeks, six months, and twelve months following assignment. Along with looking at whether or not there were any selfharm attempts, participants completed questionnaires measuring suicidal thinking, substance abuse, psychiatric symptoms, and overall level of functioning. Information on family issues, previous psychiatric history, home environment, and history of abuse was also collected by the researchers. The group therapy and control participants were fairly well-matched with no real differences that might distort the research findings. According to the research results, 97% of adolescent self-harmers reported cutting themselves while 71% also reported head-banging. Deliberately overdosing on medication was the third most prevalent method (57%) while other forms of self-harm, including jumping from a height, attempted drowning, poisoning, and strangling were less prevalent. Some of the adolescents participating in the study reported cutting themselves as often as once a week or more. While alcohol abuse was fairly common among self-harmers, drug abuse was not. Furthermore, half of all self-harmers live in two-parent households while about a third reported a history of sexual abuse. According to test results, there was no significant difference between the experimental and control group subjects in terms of depression, behaviour problems, or overall psychological functioning. In examining how effective the group treatment program was in preventing self-harm attempts, the results failed to support the positive results of the Manchester study. If anything, more of the participants attending group therapy harmed themselves during the follow-up period than the control participants did. Participating in the group program also had no apparent effect on depression or suicidal thinking. Taking the next step So why didn’t a group program that had seemed so promising when carried out by British researchers help Australian adolescents who harm themselves? In their article, Professor Hazell and his co-authors point out various differences between the adolescents in the two studies that may have played a role. Not only were there far more females in the Australian study than in the British study (91%) but they were more likely to be self-cutters as well. Also, the therapists conducting the groups in Australia had less experience with the DGP program than the British therapists who developed the program in the first place. This may have made them less effective in helping their patients.

‘About one in ten adolescent females and one in twenty adolescent males engage in self-harm’

Despite these disappointing results, Professor Hazell and his coauthors raise one important point: many of the young people who harm themselves did it on a regular or semi-regular basis. Even if group therapy doesn’t eliminate these attempts completely, they may make them less severe and encourage them to seek out help later on. When asked about his opinion on treatment for adolescent selfharmers, Professor Hazell remains optimistic. ‘As a clinician and medical administrator I am striving to develop better systems of care for young people who engage in self-harm’, he says. ‘My health service is presently bidding to be a site to evaluate a multi-component intervention to reduce self-harm and suicide. I am seeking ways to divert young people who self-harm away from hospital emergency departments. As a researcher I am still on a quest to identify an intervention that reduces repetition, or as I prefer to say it – hastens the attenuation of self-harm.’ Even though DGP remains unproven, at least in countries aside from where it was developed, further research may provide better clues about how to improve treatment services. While young people appear to be getting better at seeking treatment, more effective programs are still needed to ensure that children and adolescents find the resources they need to move on with their lives.

Meet the researcher

PROFESSOR PHILIP HAZELL
Professor Philip Hazell Thomas Walker Hospital (Rivendell) Hospital Rd, Concord West, NSW 2138 Australia

Professor Philip Hazell is Conjoint Professor of Child and Adolescent Psychiatry at the Sydney Medical School at the University of Sydney, Australia. He is also Director of Child and Adolescent Mental Health Services for the Sydney Local Health District and Director of the Rivendell Child, Adolescent and Family Mental Health Service in New South Wales. After obtaining his medical degree at the University of Otago and training as a psychiatrist at the University of Adelaide, he went on to earn his doctorate in medicine at the University of Newcastle. His long list of publications includes research on ADHD, youth suicide and deliberate self-harm, mood disorders, autism, children in out-of-home care, systematic reviews on treatment effectiveness and the evaluation of medical education. Professor Hazell was honored by the American Academy of Child and Adolescent Psychiatry with the Elaine Schlosser Lewis Award for Research in Attention Deficit Disorder in 2004. He is currently a co-investigator on funded longitudinal studies of children with Attention Deficit Hyperactivity Disorder and of determinants of health and wellbeing in adolescents in rural New South Wales. He is also a co-investigator on a funded clinical trial of fluoxetine for autism. Along with a lifetime of academic achievements, clinical appointments, and community service, he is also an accomplished violinist who has played in symphonies and an avid surfer.

CONTACT

E: philip.hazell@sswahs.nsw.gov.au T: (+61) 2 97362288 W: http://sydney.edu.au/medicine/people/academics/profiles/philip. hazell.php

KEY COLLABORATORS

Professor Keith Hawton and colleagues at the Centre for Suicide Research, University of Oxford Emeritus Professor Graham Martin and colleagues, University of Queensland Professor Katharine Steinbeck and colleagues, Academic Department of Adolescent Medicine, Children’s Hospital Westmead and University of Sydney Professor Jan Nicholson and colleagues, La Trobe University

REFERENCES

Hazell PL and Lewin TJ, Friends of adolescent suicide attempters and completers, Journal of the American Academy of Child and Adolescent Psychiatry, 1993, 32, 76–81. Hazell P, Martin G, McGill K, Kay T, Wood A, Trainor G, Harrington R, Group therapy for repeated deliberate self-harm in adolescents: Failure of replication of a randomized trial, Journal of the American Academy of Child and Adolescent Psychiatry, 2009, 48, 662–670. Martin G, Swannell S, Hazell P, Harrison J, Taylor AW, Self-injury in Australia: A community survey, Med J Aust, 2010, 193, 506–510. Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K, Pharmacological interventions for selfharm in adults, Cochrane Database of Systematic Reviews, Published Online 6 July 2015, DOI: 10.1002/14651858.CD011777 Hawton K, Witt KG, Taylor Salisbury TL, Arensman E, Gunnell D, Townsend E, van Heeringen K, Hazell P, Interventions for self-harm in children and adolescents, Cochrane Database of Systematic Reviews, Published online Dec 2015, DOI: 10.1002/14651858.CD012013