newsGP – Adolescent repeat self-harm risks highlighted by study – RACGP

Jolyon Attwooll
Jolyon Attwooll
Analysis of NSW hospital presentations for self-harm underline the need for youth-specific early intervention, according to researchers.
A new NSW study has highlighted the significant possibility of repeat episodes among young people admitted to hospital for self-harm, as well as the cohort’s elevated risk of suicide.
Researchers from UNSW’s Black Dog Institute considered data from self-harm hospital admissions among 10–29 year-olds between 2012 and 2019 in NSW.
There were 48,547 individuals captured in the study, including 19,180 (39.5%) aged 15–19.
The analysis linked emergency department data, patient records and cause of death data to track the incidence of repeat self-harm and suicide.
According to the study authors, these were significantly higher in the year after the initial self-harm presentation, with repeat self-harm recorded at a rate of 188.84 per 1000 person-years, and suicide at 3.3 per 1000 person-years.
This declined steeply after five years to 14.51 and 0.28 per 1000 person-years respectively.
The study also reported that 6055 children aged 10–14 visited an NSW emergency department for self-harm over the study period, including 2276 for a repeat incident.
‘Adolescents and young adults with self-harm presentations were at a high risk of subsequent repeat self-harm and suicide death, especially the first year after presentations,’ the authors wrote.
‘Youth-specific early intervention and long-term management should be delivered accordingly, especially for those at early adolescence.’
Their findings were published this month in the Journal of Affective Disorders.
Lead author Dr Jiahui Qian, from the Black Dog Institute and UNSW Medicine and Health, says the figures likely under-represent the reality.
‘We only looked at self-harm presentations to an emergency department but there will be many more young people in the community who self-harm but don’t go to a hospital and so aren’t represented in this study,’ she said.
While the research recorded a significantly higher number of females presenting with self-harm at hospital, it found males are more likely to engage in a repeat episode, as well as die by suicide.
For Dr Andrew Leech, a GP with a special interest in paediatrics, the study is pertinent to general practice for a number of reasons.
He says he is seeing increasing numbers of self-harm presentations among young children.
‘We haven’t necessarily been taught about self-harm in younger children, therefore this is a relatively new concept for GPs to work through,’ he told newsGP.
‘We are seeing younger presentations than ever before. I have personally seen children expressing self-harm thoughts as young as eight, banging their head on a wall, scratching their skin or writing letters to their parents that they want to “die” for example.
‘It can be tough, even overwhelming, to hear this from a child.’
While Dr Leech questions whether children recognise the significance of what they are saying at this age, he says it is important to assess risks and the reasons behind the feelings.
‘This is a sign of the distress young people are facing and the lack of positive coping mechanisms that are taught to them or made available,’ he said.
He believes a number of factors may be involved, including increased social media use and screen time, the impact of COVID-19, more drug and alcohol use, as well as family violence or trauma, such as bullying.  
‘Young children are not developmentally able to self-regulate when under immense stress and tend to either learn behaviours from their peers or demonstrate their pain by turning to physical means such as self-harming,’ he said.
‘They might have heard it from another child, or seen it on a phone app such as TikTok or YouTube – these apps can normalise dangerous behaviours.
‘As a GP I see this as a red flag for serious underlying mental health concerns and an urgent prompt to help them.’
The researchers write that better, and more widespread, evidence-based programs in schools would draw welcome attention to coping strategies, as well as raise awareness and help those affected to seek the right support.
‘Self-harm is fundamentally a maladaptive coping behaviour, so we need to find ways to stop young people from getting to the point of engaging in suicidal behaviour and shift them to adaptive coping behaviours,’ Dr Michelle Tye, a senior author of the study, said.
Dr Tye also called for improvements to clinical assessment following hospital admission and said regular psychosocial assessments could help reduce the risk of repeat self-harm and suicide.
She said the elevated risk in the first month after a self-harm episode shows the importance of immediate patient support.
‘Ideally, all young people should have access to ongoing support through coordinated aftercare approaches, particularly in those first few weeks after their presentation to hospital, to protect against repeat self-harm,’ Dr Tye said.
Dr Leech agrees with the article’s recommendations for more school-based education on mental health, resilience, coping with stress and dealing with the risks of social media. 
‘As GPs we can offer simple strategies to redirect the thoughts of self-harm, that might be going for a walk, speaking to a loved one, mindfulness apps such as Smiling Mind, or using a fidget toy or squishy ball to help express the emotional feeling in a physical way,’ he said.
‘I remind all my younger patients that there is nothing you can’t handle with a little bit of support and working through it.’  
He says he suggests Kids Helpline and the headspace platform for after-hours support, and also recommends close follow-up and a psychology referral for the child, and potentially the parent too.  
‘Children at more serious level of risk should be assessed more urgently either in the emergency department or by the child/adolescent mental health service,’ he said.
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