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PAPERS: Keith Hawton, Karen Rodham, Emma Evans, and Rosamund Weatherall Deliberate self harm in adolescents: self report survey in schools in England BMJ 2002; 325: 1207-1211 [Abstract] [Full text]

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Association between adolescent deliberate self harm and suicide has been overstated

Bobby P Smyth   (10 December 2002)

Association between adolescent deliberate self harm and suicide has been overstated 10 December 2002
Bobby P Smyth, Specialist Registrar in Child & Adolescent Psychiatry Knowsley CAMHS, The Wellcroft Centre, Wellcroft Rd., Huyton, Merseyside, L36 7TA Send response to journal: Re: Association between adolescent deliberate self harm and suicide has been overstated	Editor, The demonstration by Hawton et al that deliberate self harm is a common event among 15 and 16 year old school children is a helpful finding[1]. They found that 3.2% of boys and 11.2% of girls had harmed themselves in the previous year and 55% of these had repeated self harm. Deliberate self harm and suicide are frequently discussed in a rather seamless manner, the assumption being made that they differ in only quantitative terms, the former being a lesser variant of the latter. The data presented by Hawton et al suggests that this view is simplistic. When contrasted with the suicide rates in this age group, it emerges that the ratio of girls who engage in self harm to suicide victims is 8615 to one[2]. Among boys, 615 will self harm annually for each suicide victim. In view of the high rate of repetition of self harm, the ratio of such events to suicide will be substantially higher. A good marker of suicide risk would be three times more common in males and would rise between the ages of 15 and 25 years. Deliberate self harm displays the opposite characteristics. The difference between self harm and suicide may be more qualitative than quantitative in adolescents. There may be important gender differences in the significance of self harming behaviour[3]. It has been argued that psychiatrists must have a central role in the assessment of all who self harm[4]. The findings by Hawton et al suggest that this view is both excessively rigid and unfeasible. Young people who commit murder are more likely to have histories of aggression[5]. In simple behavioural terms, fighting is a lesser variant of murder. Nevertheless, nobody would propose that all children who start a fight should undergo a forensic risk assessment by a psychiatrist. Suicide is an extremely tragic event and this is particularly the case when the victim is a teenager. Consequently, prevention efforts must be sensibly targeted. Using deliberate self harm as a marker of suicidal risk will lead to a misdirection of limited suicide prevention resources towards less appropriate populations. Recently, there has been a welcome growth in psychological services for adolescents, delivered by education, social services and charities. The overstatement of the association between self harm and suicide has a negative impact on the ability of such agencies to work effectively with vulnerable adolescents. In clinical practice, I have frequently witnessed services responding with disproportionate panic when an adolescent discloses self harm or suicidal ideation. This is unlikely to be experienced by the adolescent as containing and may be counter- therapeutic. A better understanding of the epidemiology of deliberate self harm will facilitate a more appropriate and measured response in the future. 1 Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002; 325: 1207 -11. 2 McClure GMG. Suicide in children and adolescents in England and Wales 1970-1998. Br J Psych 2001; 178: 469-74. 3 Farbstein I, Dycian A, Gothelf D, King RA, Cohen DJ, Kron S et al. A Follow-up Study of Adolescent Attempted Suicide in Israel. J Am Acad Child Adolesc Psychiatry 2002; 41: 1342-9. 4 Isacson G, Rich CL. Management of patients who deliberately harm themselves. BMJ 2001; 322: 213-5. 5 Sheldrick C. The assessment and management of risk in adolescents. J Child Psychol Psychiat 1999; 40: 507-18. Competing interests:   None declared