Self-harm with and without suicidal intent in adolescence: causes and consequences in the ALSPAC cohort

Lead Research Organisation: University of Bristol
Department Name: Social Medicine

Abstract

Recent community studies indicate that up to 1 in 7 adolescents have self-harmed at some point in their lives, with the incidence rising rapidly between 10 and 16 years of age. These findings have led to concerns that more should be done to identify and treat young people who self-harm, but the clinical significance of community presenting self-harm is unclear. One quarter of self-harm episodes are carried out with expressed suicidal intent; whilst such episodes are a risk marker for later suicide attempts and suicide, most cases never reach medical attention and later health and social outcomes amongst adolescents who self-harm are uncertain.

To date, most studies of self-harm in adolescence have been based on small clinical samples - these are highly select groups, already known to medical services. The few population-based studies have generally measured risk factors and self-harm at one point in time, with few follow-up studies. The investigations that have been carried out are generally limited by small sample sizes and tend to have studied suicide attempts, rather than inter-relationships between self-harm with and without suicidal intent. Examining these latter relationships is important both to determine the clinical significance of non-suicidal self-harm in adolescence and to guide prevention and treatment strategies. Furthermore, knowing the health and social outcomes amongst adolescents whose self-harm does not come to medical attention will help determine the need for interventions in this group of people.

The proposed research is based on the Avon Longitudinal Study of Parents and Children (ALSPAC). ALSPAC is a long term study of over 13,000 children born in Bristol and the surrounding area in 1991-1992 who have been followed up since birth with regular questionnaires to parents, teachers and, more recently, the participants themselves. Study members have also been attending clinics every 1-2 years since the age of 7 years. They have provided information on suicidal thoughts and self-harm with and without suicidal intent at ages 11 and 16. The lifetime risk of self-harm was 1.6% at age 11, this had risen to 19% 16 years of age.

Our research will investigate whether there are differences in the characteristics and medium term outcomes between children who self-harm with and without suicidal intent in adolescence and in those who do and do not come to medical attention. Findings will be used to determine the clinical relevance of adolescent self-harm and whether there are sub-groups of self-harming adolescents who warrant particular attention. The principle outcomes we will investigate are a) mental health (assessed using the Clinical Interview Scale-Revised (CIS-R) at age 18) b) alcohol and cannabis abuse; c) educational performance (age 14: SATS; age16: GCSEs and age 18: A-levels and d) early employment record.

Two important issues when studying self-harm in ALSPAC are that it is possible that self-harm is under-reported by participants and that its prevalence (and risk factors) may differ between survey responders and non-responders. We will use recently established linkages between ALSPAC and national Hospital Episode Statistics data (all participants with relevant permissions) and the General Practice Research Database (GPRD) (5% of participants) to investigate these issues and assess their impact on the analyses in our proposed research and their implications for future research.

We have identified no other prospective studies that are in a position to answer these research questions.

Technical Summary

The prevalence of self-harm in adolescence is between 13 and 18%. Most adolescent self-harm is carried out with no suicidal intent and the majority of cases never come to medical attention. Current understanding of the causes and consequences of community presenting self-harm is limited. Furthermore, there is international uncertainty, exemplified by recent debates during the Diagnostic and Statistical Manual (DSM) revisions, of the diagnostic and clinical utility of distinguishing self-harm with and without suicidal intent. We propose investigating these issues in the ALSPAC cohort of over 13,000 children followed up since birth. Participants completed detailed interview/ questionnaires about self-harm at ages 11 and 16 years with n=905 participants reporting episodes of self-harm. Through regular follow-up they continue to provide information on their health and social circumstances.

We will investigate differences in risk factors (e.g. depression, substance misuse) and medium term health and social outcomes (to age 19 years) for community presenting self-harm with and without suicidal intent and for those cases known/not known to services, to test the hypotheses that these two behaviours differ in aetiology and outcome. The principle outcomes we will investigate in our prospective analyses are a) mental health (clinical interview scale-revised (CIS-R) at age 18) b) alcohol and cannabis abuse at ages 18 and 19; c) educational performance (ages 14, 16 and 18 and d) early employment record. We will perform a series of regression models to test the main hypotheses, and use multiple imputation to assess the impact of missing covariate data on the associations we identify. We will also use recently established linkages with GPRD and HES to carry out sensitivity analyses taking account of any random or systematic error associated with self-report data and non-response (n=6,400 respondents age 11 and n=5,000 age 16).

Planned Impact

Scientific advancement and impact upon the research community:

The research will lead to new knowledge concerning the appropriate classification of suicidal behavior and the health impact of different forms of suicidal behavior. This will inform future revisions of the Diagnostic and Statistical Manual (DSM) and the International Classification of Diseases (ICD) as well as contributing to the clinical management of children and adolescents who self-harm. Longitudinal studies of self-harm rarely distinguish between self-harm acts carried out with and without intent; the proposed research will provide guidance for the research community on whether such distinction is valuable. Furthermore, our linkages with HES and GPRD will provide a unique opportunity to assess the potential for bias in other studies of self-harm that rely on self-report or hospital presenting cases alone. This will allow researchers to make judgments about the impact of missing data and under-reporting on their findings.


Guidance for parents, the voluntary sector and other professional groups:

Parents, friends, teachers, school counsellors and healthcare professionals may all be affected by a young person's self-harming behaviour and want advice about how best to help the young person, the medium term risk associated with their child's self-harm and likely outcomes. Evidence in this area is currently limited. People often turn to organisations such as PAPYRUS (http://www.papyrus-uk.org/) or Samaritans; the proposed research will strengthen the evidence base for the advice these organisations can provide.

Contributing to increased public awareness about self harm and its risk factors will, we anticipate, reduce the stigma associated with self-harm / mental illness and increasing the likelihood that individuals will seek help and receive support from those from whom they seek help.


Impact on children's health and education:

Self-harm, and difficulties associated with it, are a cause of time off school in adolescence and this is likely to impact on children's academic achievement (we will investigate this in our proposed study). Improved knowledge to inform better prevention and treatment of this condition will likely improve children's educational performance and strengthen the UK's future workforce.


Clinical community:

There is a gap in knowledge concerning the causes and consequences of community-presenting self-harm and whether these differ for adolescents who self-harm with and without suicidal intent. Such information may improve risk stratification during clinical assessment and in prioritising referrals to Child and Adolescent Mental Health Services (CAMHS) teams. Improved knowledge in this area will therefore benefit both front-line clinicians / CAMHS teams as well as the NHS by allowing services to focus on those at greatest need. Further, there have been calls to screen for community presenting self-harm; by clarifying the medium-term health consequences of self-harm presenting and not presenting to health services our research will clarify the potential benefit of screening programmes.


Development of capacity and capability:

ALSPAC is one of the largest prospective studies capable of assessing the causes and consequences of self-harm in the current generation of young adults and the only such study to our knowledge in the UK. Improved knowledge about the aetiology and prognosis of self-harm with differing underlying motivations within ALSPAC will considerably enhance the value of ALSPAC for future studies of self-harm as well as informing future data collections and use of the ALSPAC resource by other researchers. The researcher employed on the study will develop skills through their analysis, write-up and presentation of study findings and workshop organization.

Publications

10 25 50
 
Description Data linkage paper (Arch Sui Research) was picked up as a case study by the Wellcome Trust understanding patient data taskforce
Geographic Reach National 
Policy Influence Type Citation in other policy documents
URL https://understandingpatientdata.org.uk/case-study/investigating-self-harm-young-people
 
Description AFSP Postdoctoral research fellowship
Amount $104,000 (USD)
Organisation American Foundation for Suicide Prevention 
Sector Charity/Non Profit
Country United States
Start 01/2016 
End 12/2017
 
Description Department of Health Policy Research Programme
Amount £234,496 (GBP)
Organisation Department of Health (DH) 
Sector Public
Country United Kingdom
Start 10/2013 
End 02/2016
 
Description Elizabeth Blackwell Institute Early Career Fellowship awarded to Dr Mars
Amount £26,613 (GBP)
Organisation Wellcome Trust 
Department Wellcome Trust Institutional Strategic Support Fund
Sector Charity/Non Profit
Country United Kingdom
Start 08/2014 
End 02/2015
 
Description Emotional dysregulation, self-harm and eating disorders: a mechanistic investigation
Amount £248,683 (GBP)
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 06/2019 
End 05/2020
 
Description Pathways to self-harm: biological mechanisms and genetic contribution
Amount £223,000 (GBP)
Funding ID MR/R004889/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start  
 
Description Collaboration with Dr Sarah Sullivan to examine the association between psychosis and self-harm 
Organisation University of Bristol
Country United Kingdom 
Sector Academic/University 
PI Contribution Academic / research expertise in self-harm and suicide
Collaborator Contribution Academic / research expertise in psychosis
Impact Paper submitted to PloS One entitled: The Longitudinal Association between Psychotic Experiences, Depression and Suicidal Behaviour in a Population Sample of Adolescents;
Start Year 2014
 
Description Collaboration with Paul Wilkinson 
Organisation University of Cambridge
Country United Kingdom 
Sector Academic/University 
PI Contribution Academic / research expertise on self-harm
Collaborator Contribution Gave a presentation on non-suicidal self-harm at the self-harm research day (see output in engagement section) Attended a meeting with doctoral and post-doctoral self-harm/suicide researchers to discuss current projects and future work Discussed his current research at a seminar in Bristol University
Impact Presentation given at the self-harm research day Advisor on AFSP fellowship application for post doc researcher (B Mars) Planned cross-cohort comparisons between ALSPAC and ROOTS, for example to examine associations with pulse and self-harm
Start Year 2013
 
Description Developing links with academics, voluntary sector organisations and individuals with lived experience 
Organisation Harmless
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Academic / research experience in self-harm
Collaborator Contribution Presentations given by invited speakers at the self-harm research day which show cased research findings from our project and put them in the context of existing knowledge Harmless and the self-harm organisation (SHO) provided stands at the research day which were well received by the delegates
Impact Presentations at the self-harm research day (see output in engagement section)
Start Year 2014
 
Description Developing links with academics, voluntary sector organisations and individuals with lived experience 
Organisation Sanofi
Department Genzyme Therapeutics Ltd
Country United Kingdom 
Sector Private 
PI Contribution Academic / research experience in self-harm
Collaborator Contribution Presentations given by invited speakers at the self-harm research day which show cased research findings from our project and put them in the context of existing knowledge Harmless and the self-harm organisation (SHO) provided stands at the research day which were well received by the delegates
Impact Presentations at the self-harm research day (see output in engagement section)
Start Year 2014
 
Description Developing links with academics, voluntary sector organisations and individuals with lived experience 
Organisation Self Harm Organisation
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution Academic / research experience in self-harm
Collaborator Contribution Presentations given by invited speakers at the self-harm research day which show cased research findings from our project and put them in the context of existing knowledge Harmless and the self-harm organisation (SHO) provided stands at the research day which were well received by the delegates
Impact Presentations at the self-harm research day (see output in engagement section)
Start Year 2014
 
Description Developing links with academics, voluntary sector organisations and individuals with lived experience 
Organisation University of British Columbia
Country Canada 
Sector Academic/University 
PI Contribution Academic / research experience in self-harm
Collaborator Contribution Presentations given by invited speakers at the self-harm research day which show cased research findings from our project and put them in the context of existing knowledge Harmless and the self-harm organisation (SHO) provided stands at the research day which were well received by the delegates
Impact Presentations at the self-harm research day (see output in engagement section)
Start Year 2014
 
Description 1 hour training session for regional GPs on self-Harm and suicide 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Dr Mars (project research assistant) took part in a training session for GPs with Salena Williams from Bristol's 'self-harm health integration team' (STITCH).

The GPs were informed about current self-harm research and the link between self-harm and suicide. We also identified current knowledge gaps, challenged stigma, discussed ways of managing self-harm patients, ways of minimising risk, and identified sources of help/referral pathways


Improved understanding of self-harm and suicide
Year(s) Of Engagement Activity 2014
 
Description Dr Becky Mars poster presentation at the FARR conference on the use of data linkage to investiagte bias in prevalence estimates of self-harm 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact poster presentation - discussion of study and results with peers

poster prize
Year(s) Of Engagement Activity 2015
 
Description Dr Becky Mars poster presentation to IASR/AFSP conference on the use of data linkage to investiagte bias in prevalence estimates of self-harm 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact poster presentation sparked discussion with peers

no known impacts
Year(s) Of Engagement Activity 2015
 
Description Dr Becky Mars presentation to ESSSB on risk factors and outcomes of self-harm with and without suicidal intent 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Delegates attending the 15th European Symposium on Suicide and Suicidal Behaviour (Tallinn, Estonia) attended the presentation, which sparked questions and discussion

no known notable impacts
Year(s) Of Engagement Activity 2014
URL http://esssb15.org/wp-content/uploads/2014/06/ESSSB-final-programme.pdf
 
Description Dr Becky Mars presentation to ESSSB on the use of data linkage to investiagte bias in prevalence estimates of self-harm 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Delegates at the 15th European Symposium on Suicide and Suicidal Behaviour (Tallinn, Estonia) attended the presentation, which sparked questions and discussion

no known notable impacts
Year(s) Of Engagement Activity 2014
URL http://esssb15.org/wp-content/uploads/2014/06/ESSSB-final-programme.pdf
 
Description Dr Mars poster presentation at the CLOSER conference on outcomes of self-harm with and without suicidal intent 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Poster presentation: discussed my results with peers. Learnt more about potential cohorts for future cross-cohort research

no known notable impacts
Year(s) Of Engagement Activity 2015
 
Description Dr Mars symposium presentation to ISSS conference on outcomes of adolescent self-harm with and without suicidal intent 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Part of a symposium on the longitudinal course of NSSI. Talks were followed by discussion of findings and future directions

Discussed possibility of future cross-cohort work with the ROOTS study (Cambridge) to examine the course of self-harm
Year(s) Of Engagement Activity 2015
 
Description Invited plenary at the Triple-i conference - Becky Mars 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact `Transitions from suicidal thoughts to suicide attempts' invited plenary at the Triple-I conference, Piran, Slovenia.
Year(s) Of Engagement Activity 2018
URL http://zivziv.si/triple-i-2018/#program
 
Description Local News Broadcast about Self-harm - Fixers project 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Professor Gunnell was interviewed about self-harm and this was broadcast on ITV regional news describing self-harm website development by a young person who has self-harmed.

Advice to website developer around self-harm - causes / incidence

Engagement with self-harm user audience - provision of information about self-harm.

Planning website development - website could be a good new source of information for service users.

Planning conference / workshop to launch our research findings
Year(s) Of Engagement Activity 2013
URL http://www.selfharmorganisation.org.uk
 
Description Press release for BMJ paper investigating the clinical and social outcomes of adolescent self-harm 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Press release issued by the University of Bristol to disseminate the research findings to the wider public

Press coverage included
Shanghai Daily: http://www.shanghaidaily.com/article/article_xinhua.aspx?id=248522
Financial Express (India): http://www.financialexpress.com/news/teenage-selfharm-linked-to-problems-in-later-life/1301154
Zee News (India): http://zeenews.india.com/news/health/health-news/teenage-self-harm-leads-to-mental-problems-in-adulthood_1488461.html
Xinhua (China): http://news.xinhuanet.com/english/health/2014-10/24/c_133738313.htm
Science Daily: http://www.sciencedaily.com/releases/2014/10/141021210724.htm (tweeted by Psychology News to 106k followers on Twitter)
Medical Daily: http://www.medicaldaily.com/self-harm-teenage-years-predicts-substance-abuse-lower-grades-and-difficulties-work-307610
Counsel and Heal: http://www.counselheal.com/articles/12298/20141022/teenage-self-harm-associated-problems-later-life.htm
Health Medicine Network: http://healthmedicinet.com/teenage-self-harm-linked-to-problems-in-later-life
Medical News today: http://www.medicalnewstoday.com/releases/284290.php (tweeted by Mental Health News to 17k followers)

There was also a blog on the Young Minds website: http://www.youngminds.org.uk/news/blog/2286_teenage_self-harm_can_lead_to_problems_as_adults (tweeted to 42.5K followers on Twitter).
Year(s) Of Engagement Activity 2014
URL http://www.bristol.ac.uk/psychiatry/news/2014/httpwwwbristolacuknews2014octoberself-harmhtml.html
 
Description Short course on data linkage for colleagues at the School of Social and Community Medicine, University of Bristol 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Linkage between self-harm and Hospital Episode Statistics was used as an exemplar project on the course. There was an activity designed around the findings from the paper

Increase in awareness of the processes surrounding record linkage and its potential use in research

The course was successful, and will be made available to the general public in the future
Year(s) Of Engagement Activity 2015
 
Description Talk at Self-harm organisation website launch 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Regional
Primary Audience Participants in your research and patient groups
Results and Impact Self-harm awareness forum 23 October 12-2PM

Media and self-harm users

Short presentation around self-harm with and without intent - facts, figures and myths

Dissemination of knowledge about needs for self-harm training.
Year(s) Of Engagement Activity 2013