In this blog for researchers, Dr Katrina Witt, who works in a new cross-cutting role for Cochrane Common Mental Disorders as a joint Senior Editor for both the Suicide and Self-Harm Satellite and Children & Young People’s Satellite of CCMD highlights the need to have a ‘youth lens’ in this field, with input from Professor Ann John and Associate Professor Sarah Hetrick who lead these satellites respectively. This blog is one of a series on Evidently Cochrane, #YoungMindsMatter.
Self-harm is a complex issue; it is driven by significant distress and we begin this blog by acknowledging the lived experience of those who have engaged in self-harm and those who care for people who engage in self-harm. We know it is prevalent, and of concern are indications that it is becoming more so, particularly in young people. We are using the definition of self-harm that includes self-injury and self-poisoning irrespective of motivation and degree of suicidal intent, and suicidal behaviour.
Worldwide, an estimated 18.0% of young people aged 11-18 years have engaged in self-harm in their lifetime, whilst 16% have attempted suicide . We report these figures knowing that they represent individuals and those who care for them, and again acknowledge the impact for these people. Because we know that self-harm and attempted suicide are important, and modifiable, risk factors for suicide , we are keen to see ongoing investment in safe and effective treatments that target these risk factors in young people .
Are there youth-specific interventions?
A number of interventions have been developed and tested for their effectiveness in preventing repeat self-harm in young people [3,4]. However, the effectiveness of these interventions has often been disappointing; particularly when compared to those observed for similar treatment interventions in adults . One possibility for this disparity, and that deserves more attention, is that many of the interventions that have been tested in young people were originally designed for adults, with little or no modification to meet the developmental needs and challenges of young people at risk of suicide [3,6].
Self-harm results from a myriad of genetic, biological, psychiatric, psychosocial, social, cultural, and other factors. However, for young people, there may be particular factors tied to their unique developmental stage that should be considered. Factors such as exposure to self-harm in others (both family and peers) as well as portrayals in traditional media (film, television), and new media (social media), may play a role. In terms of social media, cyberbulling is important (adding to traditional bullying that has always been a factor in this age group), as is the constant invitation to compare oneself with others, and the pressure to remain online late into the night to engage with others, resulting in disrupted sleep (a further risk factor for suicidal ideation, self-harm, and suicidal behaviour). Disruptions to existing relationships and social networks may also have strong influence .
What do young people say?
Our Group’s Joint Coordinating Editor and Child and Youth Psychologist, Sarah Hetrick has worked with young people who engage in self-harm to explore some of the issues they think are important contributors . Young people often talk about the pressure they feel to do well or be the best in education, and in other areas like sport, and how the stress of performing well or not achieving can be a trigger for self-harm. These anxieties may be related to increasing uncertainty about whether they will be able to find a job and financial stability in current political and economic climates. Young people also talk about difficulties in relationships being a trigger and the incredible sense of disconnection and isolation they can feel. Some young people are facing substantial discrimination and the impacts of this, and for Indigenous young people, the impacts of colonisation and ongoing impacts of this trauma are substantial.
Traditional psychological interventions, however, often focus on generic factors, such as emotion regulation, and relationship functioning with family (but not typically with peers or relationships in the age of social media)with little specific youth-focused content. As a consequence, we are likely missing valuable opportunities to really understand, and engage with, the reasons young people engage in self-harm and suicidal behaviour. Additionally, we may also be missing opportunities to offer treatment in a format likely to be more desirable to young people, such as through digital platforms and social media . This might include using different mediums to deliver interventions, such as via mobile telephone applications and social media platforms including (but not limited to) YouTube.
Working with young people for better interventions?
Our work in the CCMD Children and Young People satellite has highlighted how creative and insightful young people are in terms of thinking about interventions that are likely to be effective for them. We should turn to young people and engage them in the co-design of interventions to address some of these issues. Sarah Hetrick reflects on this: “One thing that has continued to strike me in this work is the number of times young people say that they simply want someone who understands where they are coming from, is kind, and listens. Obviously, there is more that might be required, particularly where there are multiple and complex issues that need to be addressed, but surely this should be an easy thing to ensure is in place across all settings where young people are present – clinical, educational, home, sports, community and online?”
As is often the case with children and young people, there are already far fewer studies of interventions to prevent self-harm . There is enormous scope for innovation and development, but it is also true that greater co-design of interventions is required, where young people are involved from the inception, to the design, implementation, and evaluation of future interventions. Co-design of such interventions should pro-actively include more marginalised young people such as Indigenous young people, those from ethnic minorities, asylum seekers and refugees and those from the LGBTQ+ community to ensure they address issues of inequalities and access’. This is where Cochrane can play a valuable guiding role to future trialists.
Tell us what you think
We are currently designing the outcomes for a series of Cochrane In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More about interventions for self-harm. We have run several co-design workshops with young people who have told us we should measure things like: burdensomeness, hopelessness, depression, willingness to seek help, self-esteem, as well as self-harm. Let us know what you think we should measure that would help us to understand if and how our interventions for youth self-harm are effective. You can do so by leaving a comment on the blog.
Join in the conversation on Twitter with @Cochrane_CCMD @CochraneUK #YoungMindsMatter or leave a comment on the blog. Please note, we will not publish comments that link to commercial sites or appear to endorse commercial products.
Katrina Witt’s biography appears below.
The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Common Mental Disorders Group. Disclaimer: The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the UK National Health Service, the NIHR, or the UK Department of Health and Social Care.
Disclosure of interest
Katrina Witt reports grants from the National Health and Medical Research Council. Sarah Hetrick reports grants from Royal Society of New Zealand, grants from Faculty Research Development Fund-Faculty of Medical and Health Sciences, University of Auckland, during the conduct of the work; grants from Auckland Medical Research Foundation Douglas Goodfellow Repatriation Fellowship, outside the submitted work. She is also the joint co-ordinating editor of the Cochrane Common Mental Disorders Group and take responsibility for the Child and Young Person Satellite. Ann John reports grants from the Medical Research Council, MQ and the Wolfson Foundation during the conduct of the work. She is co-Director of the Cochrane Suicide and Self-harm satellite.