Responding to non-suicidal self Responding to non-suicidal self injury & suicidality in the school injury & suicidality in the school

settingsettingMay 2013May 2013

Lydia SenediakLydia Senediak (Senior Clinical Psychologist: CAMHS Hornsby Ku-ring-gai) (Senior Clinical Psychologist: CAMHS Hornsby Ku-ring-gai)

NSSI: definitionNSSI: definition

The direct, The direct, deliberate deliberate destruction of destruction of body tissue body tissue without lethal without lethal intentionintention

(Nock, 2009)(Nock, 2009)

Non-suicidal self-injury (NSSI)Non-suicidal self-injury (NSSI)

Usually in the context of:Usually in the context of:– Mental health problemsMental health problems

especially especially depressiondepression

– Situational stressSituational stress

____________________________________________– To numb/ anaesthetize To numb/ anaesthetize [disconnect][disconnect]

– To feel/ control To feel/ control [connect][connect]

PatternsPatterns GenderGender::

- females - females generallygenerally 2 – 4 x higher 2 – 4 x higher (depending on method)(depending on method)

MethodsMethods:: – Cutting (incl. scratching)/ picking skinCutting (incl. scratching)/ picking skin– Self-hitting/ biting/ burning Self-hitting/ biting/ burning – Inserting objectsInserting objects

TransmissionTransmission::

- Peer contagion- Peer contagion

- Electronic communication/ social media- Electronic communication/ social media ComorbidityComorbidity::

– Depressive symptoms (80%)Depressive symptoms (80%)

Moran et al Moran et al (Lancet, 2012)(Lancet, 2012)

N = 1802 (community sample) N = 1802 (community sample) [15y - 29y][15y - 29y] 7 waves of FU from middle teens to late 20s7 waves of FU from middle teens to late 20s One in 12 adolescents self harm (8%) One in 12 adolescents self harm (8%)

but only a tenth continue to late 20s but only a tenth continue to late 20s Of the 14 yp who continued self Of the 14 yp who continued self

harming, 13 = femaleharming, 13 = female Adolescent symptoms of depression Adolescent symptoms of depression

and anxiety are associated with on-and anxiety are associated with on-going self harm in 20s (6x more likely)going self harm in 20s (6x more likely)

Teen depression Teen depression : the facts: the facts Up to two-fifths of adolescents suffer from Up to two-fifths of adolescents suffer from

depressed mood depressed mood in any 6 month periodin any 6 month period

Five percent of young people suffer from a Five percent of young people suffer from a clinical clinical depressiondepression

About 48% of young people with a About 48% of young people with a diagnosis of depression will have another diagnosis of depression will have another episode within 2 yearsepisode within 2 years

About 75% will have another episode within About 75% will have another episode within 5 years5 years

Epidemiology NSSI Epidemiology NSSI (community studies)(community studies)

Approx. 3 - 12% in past 12 monthsApprox. 3 - 12% in past 12 months

Life-time prevalenceLife-time prevalence:: 8 - 15% often cited8 - 15% often cited

““It works. I get to feel something real, and It works. I get to feel something real, and when everything else seems so crazy and when everything else seems so crazy and

out of control, it’s the only thing I can out of control, it’s the only thing I can control.. Without it I may not be here” control.. Without it I may not be here”

AndrewAndrew

What we see…What we see…

Struggle to regulate emotions & responsesStruggle to regulate emotions & responses ReactiveReactive Maladaptive coping strategiesMaladaptive coping strategies Unhelpful view of world & selfUnhelpful view of world & self

________________________________________________

History of loss/ traumatic experiencesHistory of loss/ traumatic experiences Unhealthy view/ engagement in relationshipsUnhealthy view/ engagement in relationships Often reluctant to involve parents ++Often reluctant to involve parents ++

Age of onset….Age of onset….

• Majority begin between 12 and 15 years of Majority begin between 12 and 15 years of ageage

• Occurs in approx. 5 – 8% of Primary Occurs in approx. 5 – 8% of Primary School children (Barrocas et al, 2012)School children (Barrocas et al, 2012)

• Approx. 20 -25% of the self-harmers say Approx. 20 -25% of the self-harmers say they started in the 6they started in the 6thth Grade or earlier Grade or earlier (Ross and Heath, 2002)(Ross and Heath, 2002)

““I don’t feel the pain until the next day. I’m I don’t feel the pain until the next day. I’m not sure what I feel when I cut, but not sure what I feel when I cut, but

afterwards it’s like a relief” afterwards it’s like a relief” Heather

Signs to look for……Signs to look for…… NSSINSSI Overly secretive behaviour (e.g. when changing clothes; Overly secretive behaviour (e.g. when changing clothes;

excessive time in bathroom). Isolation ++excessive time in bathroom). Isolation ++

Refusal to participate in activities revealing DSH (e.g. Refusal to participate in activities revealing DSH (e.g. swimming)swimming)

Inappropriate clothing for the weather (e.g. constantly Inappropriate clothing for the weather (e.g. constantly wearing long sleeves, etc.)wearing long sleeves, etc.)

Blood stained clothingBlood stained clothing

Unexplained scars, bruising, cuts (or bandages/ covers)Unexplained scars, bruising, cuts (or bandages/ covers)

Possession (hoarding) of implements (e.g. razors, Possession (hoarding) of implements (e.g. razors, lighters, knives, etc.)lighters, knives, etc.)

Cessation factorsCessation factors Developing a sense of self and finding ‘your Developing a sense of self and finding ‘your

own voice’ – own voice’ – feeling validatedfeeling validated– individuationindividuation

Safe, predictable environmentSafe, predictable environment

Ability to identify and express feelings more Ability to identify and express feelings more appropriatelyappropriately

Impulse control/ maturityImpulse control/ maturity

NNSI and Suicide riskNNSI and Suicide risk Vast majority child and adolescent self-Vast majority child and adolescent self-

harmers have little suicidal intent harmers have little suicidal intent

However, self harm (with or without However, self harm (with or without suicidal intent) is a strong predictor of suicidal intent) is a strong predictor of later suicide (present in histories of later suicide (present in histories of some 40 – 60% of suicides) some 40 – 60% of suicides)

(e.g. Cavanagh et al, (e.g. Cavanagh et al, 2003)2003)

Rate of suicide attempt increases as Rate of suicide attempt increases as frequency of NSSI increasesfrequency of NSSI increases

Self-injury as an ‘adaptive’ mechanismSelf-injury as an ‘adaptive’ mechanism

DSH serves a function in their livesDSH serves a function in their lives

Helpful responses from staffHelpful responses from staff

Viewing the self-harm as one way of trying Viewing the self-harm as one way of trying to to cope/ express meaningcope/ express meaning

Repeatedly, people who self-injure list Repeatedly, people who self-injure list compassionate, non-shaming compassionate, non-shaming listening and calm interest as most listening and calm interest as most helpful” (Alderman, 1977; Wise, 1999; helpful” (Alderman, 1977; Wise, 1999; Hyman, 1999)Hyman, 1999)

Youth Suicide: Youth Suicide: Frequency (Australia)Frequency (Australia)

Each year approx. 400 young people Each year approx. 400 young people (aged 15-24 years) die from suicide(aged 15-24 years) die from suicide

Rates for 15 – 24 year olds fell by 56% Rates for 15 – 24 year olds fell by 56% between 1997 & 2006 between 1997 & 2006

Most common method is hangingMost common method is hanging

In 15-19 year olds, for every suicide by In 15-19 year olds, for every suicide by a female there are approx. 3 – 4 suicidesa female there are approx. 3 – 4 suicides by a male by a male [f[females make many more emales make many more suicide attempts]suicide attempts]

Indicators of greater suicide risk:Indicators of greater suicide risk:Be more concerned ifBe more concerned if::

MarkedMarked problems with sleep/appetite and social problems with sleep/appetite and social withdrawalwithdrawal

Increased risk-taking behaviourIncreased risk-taking behaviour

Giving away possessions/ rituals around Giving away possessions/ rituals around goodbyesgoodbyes

Increased alcohol/ substance useIncreased alcohol/ substance use

Direct/Indirect comments containing Direct/Indirect comments containing hopelessness/ suicidal thoughtshopelessness/ suicidal thoughts

________________________________________________

Hallucinations or delusions (extra concern)Hallucinations or delusions (extra concern)

PreventativePreventative interventions: interventions:plan AHEAD for WELL-BEINGplan AHEAD for WELL-BEING

School management responseSchool management responseClear Clear management protocols (separate NSSI and management protocols (separate NSSI and suicidal behaviour). suicidal behaviour). Develop re-entry plansDevelop re-entry plans

Defined Defined staff rolesstaff roles

Open about your limitations (incl. boundaries re: Open about your limitations (incl. boundaries re: confidentiality)confidentiality)

Inform/ guide parentsInform/ guide parents

Seek mental health assessment and treatment Seek mental health assessment and treatment

Limit possible contagion to othersLimit possible contagion to others

Contacting parentsContacting parents

When (? clinical threshold): clarify When (? clinical threshold): clarify with studentwith student

Who contacts….Who to contact?Who contacts….Who to contact?

Cultural sensitivityCultural sensitivity

Possible contra-indicationsPossible contra-indications

Take home messagesTake home messages Most get better with maturityMost get better with maturity

Seek mental health assessment:Seek mental health assessment:– Assess comorbidityAssess comorbidity– Review suicidal intentReview suicidal intent– Explore relevant Hx and triggersExplore relevant Hx and triggers

Involve parents in collaborative planning whenever Involve parents in collaborative planning whenever possiblepossible

Enhance well-being & help-seeking across the Enhance well-being & help-seeking across the school community. TEAM APPROACHschool community. TEAM APPROACH

“ “ Our greatest glory is not in never falling, Our greatest glory is not in never falling, but in rising every time we fall” but in rising every time we fall”

ConfuciusConfucius

Thank you. Best wishes for the future!Thank you. Best wishes for the future!