Deliberate self harm in adolescents: self report survey in schools in EnglandBMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7374.1207 (Published 23 November 2002) Cite this as: BMJ 2002;325:1207
All rapid responses
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. 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. 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
It has been argued that psychiatrists must have a central role in the
assessment of all who self harm. 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. 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
1 Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in
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Competing interests: No competing interests