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Eur Child Adolesc Psychiatry (2012) 21:369377

DOI 10.1007/s00787-012-0269-6

ORIGINAL CONTRIBUTION

Epidemiology and nature of self-harm in children


and adolescents: findings from the multicentre study
of self-harm in England
Keith Hawton Helen Bergen Keith Waters
Jennifer Ness Jayne Cooper Sarah Steeg
Navneet Kapur

Received: 23 November 2011 / Accepted: 13 March 2012 / Published online: 25 March 2012
Springer-Verlag 2012

Abstract We examined epidemiology and characteristics


of self-harm in adolescents and impact of national guidance
on management. Data were collected in six hospitals in
three centres between 2000 and 2007 in the Multicentre
Study of Self-harm in England. Of 5,205 individuals (7,150
episodes of self-harm), three-quarters were female. The
female:male ratio in 1014 year-olds was 5.0 and 2.7 in
1518 year-olds. Rates of self-harm varied somewhat
between the centres. In females they averaged 302 per
100,000 (95 % CI 269335) in 1014 year-olds and 1,423
(95 % CI 1,3461,501) in 1518 year-olds, and were 67
(95 % CI 5282) and 466 (95 % CI 422510), respectively,
in males. Self-poisoning was the most common method,
involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night.
Repetition of self-harm was frequent (53.3 % had a history
of prior self-harm and 17.7 % repeated within a year).
Relationship problems were the predominant difficulties
associated with self-harm. Specialist assessment occurred
in 57 % of episodes. Self-harm in children and adolescents
in England is common, especially in older adolescents, and
paracetamol overdose is the predominant method. National

K. Hawton (&)  H. Bergen


Department of Psychiatry, Centre for Suicide Research,
Warneford Hospital, University of Oxford,
Headington, Oxford OX3 7JX, UK
e-mail: keith.hawton@psych.ox.ac.uk
K. Waters  J. Ness
Derbyshire Healthcare NHS Foundation Trust, Derby, England
J. Cooper  S. Steeg  N. Kapur
Centre for Suicide Prevention, University of Manchester,
Manchester, UK

guidance on provision of psychosocial assessment in all


cases of self-harm requires further implementation.
Keywords Children  Adolescents  Self-harm 
Epidemiology  Alcohol  Paracetamol

Introduction
Self-harm (intentional self-poisoning or self-injury, with or
without suicidal intent) in children and adolescents has
been identified as a major problem in several countries
[1, 2]. Much recent information on self-harm in young
people has been based on surveys, usually in schools [3, 4].
This has highlighted the extent of the problem at the
community level. Most individuals who gain access to
clinical care, however, have presented to hospital following
self-harm [5]. However, only a minority of individuals who
self-harm in the community present to hospital [3] or any
health facility [5]. Studies of children and adolescents
presenting to hospital have usually been based on single
hospitals [6, 7]. There is a need for data from multiple
centres to give a more representative picture of the extent
and nature of clinical demand.
In official clinical guidance on management of self-harm
there has been an understandable focus on children and
adolescents who self-harm. This includes, for example, the
National Institute for Clinical Excellence guides on selfharm published in the UK in 2004 [8] and 2011 [9] and
guidance from the Australian and New Zealand Colleges of
Psychiatrists and Emergency Medicine [10]. In addition,
national strategies on prevention of suicide include a focus
on self-harm patients [1113]. This is because of the risk of
suicide following self-harm [14], including in young people [6, 15].

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Eur Child Adolesc Psychiatry (2012) 21:369377

National guidance on management of self-harm in the


UK recommends that all self-harm patients, regardless of
risk and need, should receive a psychosocial assessment,
and that all patients under 16 years of age presenting to
general hospital should be admitted to a hospital bed [8]. It
is important to see whether this guidance is being followed.
We have conducted a study of self-harm in children
and adolescents based on the Multicentre Study of Selfharm in England, through which data are systematically
collected in hospitals in three centres (Oxford, Manchester
and Derby) on all presentations for self-harm [16, 17]. We
have investigated population-based rates of self-harm in
children and adolescents by gender and age groups, trends
in rates over time, methods used for self-harm, diurnal
and annual temporal patterns, clinical characteristics,
aftercare and repetition of self-harm. We have also
examined whether national guidance on psychosocial
assessment and admission of under-16 year-olds is being
followed.

[20]. Demographic, clinical and hospital management data


on each episode were collected by clinicians using forms in
Oxford and Manchester and by direct computer data entry
in Derby. Patients not receiving an assessment were identified through scrutiny of emergency department and
medical records, from which more limited data were
extracted by research clerks. The reliability of this method
of case ascertainment has previously been demonstrated
[21].
Data for this study included sex, age, date of self-harm,
method of self-harm (including drugs used in self-poisoning and details of self-injury), alcohol involvement, time of
presentation to hospital, psychiatric history (including of
self-harm), hospital admissions, psychosocial assessment,
problems and aftercare. Problems were recorded on a
standard list and were defined as difficulties facing the
individuals at the time of self-harm. Unique personal
information allowed us to identify repetition of self-harm
where this resulted in re-presentation of an individual to a
hospital within the same centre.

Method

Rates of self-harm

Setting and sample

Rates of self-harm were calculated for defined population


areas within the three centre catchments from which virtually all hospitals presenting self-harm episodes would
have gone to a study hospital. This applied to Oxford City,
the South Manchester area and the Derby Unitary Area.
Mid-year population estimates were obtained from the
Office for National Statistics (ONS) [22]. Rates were calculated (with 95 % confidence intervals) for each centre.

The study was undertaken in three centres currently


involved in the Multicentre Study of Self-harm (see
Hawton et al. [16] and Bergen et al. [17]). Data were
collected on all patients who presented with self-harm to
general hospital emergency departments in Oxford (one
emergency department), Manchester (three) and Derby
(two) for the 8-year period 1st January 2000 to 31st
December 2007.
Definition of self-harm
Self-harm was defined as intentional self-poisoning or selfinjury, irrespective of type of motivation including degree
of suicidal intent. This definition is in keeping with usual
policy in the UK [9, 18] and Europe [19]. It included, for
example, acts such as intentional overdoses of medication,
self-cutting, attempted hanging, but did not include acts
such as hair pulling, risk-taking behaviour, or purging.
Self-harm was confirmed either during psychosocial
assessment of patients or through scrutiny of clinical
records (see below).
Data collection
Following self-harm, the majority of patients received an
assessment by specialist psychiatric clinicians (and in
Manchester some also by emergency department staff)

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Ethical approval
The monitoring systems in Oxford and Derby have
approval from local Health/Psychiatric Research Ethics
Committees to collect data on self-harm. Self-harm monitoring in Manchester is part of a clinical audit system and
has been ratified by the local Research Ethics Committee.
All three monitoring systems are fully compliant with the
Data Protection Act of 1998. All centres have approval
under Sect. 251 of the NHS Act 2006 to collect patient
identifiable information without patient consent.
Statistical analyses
Rates of self-harm and trends in rates were calculated
separately for each centre. The v2 test for trend (linear by
linear association, two-sided) was used to test the significance of changes over the period 2000 and 2007. Analyses
and calculations were performed with Microsoft Office
Excel 2003, SPSS v15.0 [23], and Stata v10.0. [24].

Eur Child Adolesc Psychiatry (2012) 21:369377

371

centre were unreliable). The majority of individuals aged


under 16 years were admitted (84.1 %), significantly more
than those aged 1618 years (64.8 %; v2 = 57.9,
p \ 0.001).

Results
Study population
A total of 5,205 individuals were included in the study,
three-quarters (74.6 %) of whom were female. During the
study period these individuals were involved in 7,150 selfharm episodes which resulted in presentation to the study
hospitals (Table 1).
Only four (0.1 %) of the individuals were under
10 years of age, 929 (17.8 %) were aged 1014 years, and
4,272 (82.1 %) 1518 years. The female to male ratio in
the 1014 years age group was 5.0, and in the 1518 years
age group, 2.7.
Nearly two-thirds of the individuals (2,847, 64.8 %)
were known to be students (either attending school or
higher education), with information on student/employment status missing for 15.6 % (814). Most were White
(88.5 %, N = 2,905), 3.5 % (115) Black, 2.6 % (134)
South Asian, and 2.5 % (130) from other ethnic groups
(information missing in 36.9 % (1,921) cases).

Rates of self-harm
In females, the annual person-based rates averaged over
the study period in 1518 year-olds were 4.7 times greater
than those in 1014 year-olds; in males they were 3.1
times greater (Table 2). There were no significant trends
in overall rates by gender during the 8-year study period.
However, there were changes in females aged
1518 years (v2 = 4.16, p = 0.04), with rates peaking in
2003 and subsequently declining. The overall female:male
rate ratio in age group 1014 years was 4.5 and varied
across the centres between 4.0 (Derby) and 5.8 (Oxford).
In age group 1518 years the overall female: male rate
ratio was 3.1 and varied between 2.5 (South Manchester)
and 3.4 (Oxford).
Rates rose in females with each year of age until age
1517 years (Fig. 1). Rates were significantly higher in
1518-year-old females in South Manchester than in the
other two centres. In males, rates rose more slowly with
age, and, except in Oxford (where rates appeared to peak at
age 16 years), were still rising at age 18 years (Fig. 2).
Rates in males aged 1518 years were significantly higher
in South Manchester than in the other two centres. Rates
were also significantly higher in females aged 1014 years
in South Manchester than in Derby.

Psychosocial assessment and admission


During the latter part of the study period (20052007)
following the introduction of the national guidance [8],
specialist psychosocial assessment occurred in 57.0 %
(N = 1,500) of episodes (4 not known). Admission to a
hospital bed for self-harm presentations occurred in 70.7 %
(N = 1,063) in Oxford and Manchester (data for the third
Table 1 Numbers of episodes
of self-harm and persons
involved, by gender, 20002007

Centres
Oxford N (%)

Manchester N (%)

Derby N (%)

N (%)

1,952

3,073

2,125a

7,150a

Males

397 (20.3)

812 (26.4)

532 (25.1)

1,741 (24.4)

Females

1,555 (79.7)

2,261 (73.6)

1,590 (74.9)

5,406 (75.6)

1,342

2,339

1,524a

5,205a

Males

311 (23.2)

630 (26.9)

383 (25.2)

1,322 (25.4)

Females

1,031 (76.8)

1,709 (73.1)

1,138 (74.8)

3,880 (74.6)

Episodes

Persons
a

n = 3 episodes where gender


was not known

Total

Table 2 Person-based annual rates of self-harm per 100,000 in the three centres, by gender and age group: average of years 20002007
Oxford
Rate

95 % CI

South Manchester

Derby

Rate

Rate

95 % CI

Combined
95 % CI

Rate

95 % CI

Males
1014 years

64

3592

95

52138

59

4078

67

5282

1518 years

410

334486

687

556817

428

371486

466

422510

Females
1014 years

369

1518 years

1,377

296442
1,2401,514

410
1,737

318502
1,5291,945

240
1,352

200279
1,2481,456

302
1,423

269335
1,3461,501

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Fig. 1 Average rate of self-harm 20002007 for males, by single


year of age, and centre

Fig. 2 Average rate of self-harm 20002007 for females, by single


year of age, and centre

Methods used for self-harm


There were differences between the two genders in the
broad categories of methods used for self-harm
(v2 = 49.17, df = 2, p \ 0.001), with more than threequarters (79.5 %, N = 4,297) of the females using selfpoisoning compared with less than three-quarters (72.9 %,
N = 1,270) of the males. Self-injury was more frequent in
the males (22.7 %, N = 393) than the females (15.3 %,
N = 828). In 5 % (N = 359) cases episodes of self-harm
involved both self-poisoning and self-injury. There were no
major changes in the broad categories of methods used by
either males or females during the study period. Also these
methods did not differ between age groups 1014 and
1518 years.
Self-poisoning Multiple drugs were used in many episodes of self-poisoning and hence the percentages given

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below total over 100 %. Paracetamol (including compounds) was by far the most frequent drug used for selfpoisoning (58.2 %, N = 3,343), followed by antidepressants (13.1 %, N = 752). Drugs used relatively infrequently included salicylate (including compounds; 6.9 %,
N = 399), benzodiazepines (2.5 %, N = 150), major
tranquillisers (2.1 %, N = 122) and co-proxamol (1.9 %,
N = 105). Other drugs (e.g., NSAIDs, opiates, antibiotics)
were used in 43.0 % (N = 2,474) episodes. During the
study period there was a significant decrease in self-poisoning with salicylate and compounds (v2 = 9.44,
p = 0.002) and co-proxamol (v2 = 30.45, p \ 0.001). The
use of other drugs for self-poisoning significantly
increased during this period (v2 = 28.02, p \ 0.001).
Self-injury By far the most common method of selfinjury was self-cutting or stabbing (87.7 %, N = 1,364),
followed in frequency by hanging (3.4 %, N = 53),
jumping (2.7 %, N = 42), traffic-related acts (1.0 %,
N = 16), carbon monoxide poisoning (0.6 %, N = 10) and
drowning (0.3 %, N = 4). Self-injury involving other
methods occurred in 4.2 % (N = 66). There were gender
differences in methods of self-injury (v2 = 31.65, df = 6,
p \ 0.01), with cutting/stabbing occurring in a greater
proportion of episodes by females (90.5 vs. 81.3 %) and
hanging/asphyxiation in more episodes by males (6.0 vs.
3.2 %). There were no significant differences, however, in
the methods of self-injury by age groups (1014 years vs.
1518 years).
Alcohol Whether or not alcohol was involved in episodes of self-harm was known in 3,451 (84.8 %) assessed
episodes. Alcohol was more often involved in episodes by
males (38.5 %, N = 327) than females (32.7 %, N = 851;
v2 = 9.98, p = 0.002). Involvement of alcohol did not
change significantly during the study period in either
gender. Alcohol was more often involved in episodes by
adolescents aged 1518 years (37.3 %, N = 1,118) than
1014 year-olds (13.2 %, N = 60; v2 = 101.1, p \ 0.001).
Time of day
The time of presentation for self-harm showed marked
diurnal variation with lowest numbers between 6.00 a.m.
and 9.00 a.m. and then increasing numbers until a peak was
reached between 10.00 p.m. and 1.00 a.m. (Figure 3).
Involvement of alcohol showed a similar pattern, except
that increasing proportions of episodes involving alcohol
occurred between 1.00 am and 5.00 a.m. (Fig. 3).
Previous psychiatric history
Of the 3,077 individuals who had a psychosocial assessment at their first episode in the study period, 28.0 %
(N = 689) had received previous psychiatric treatment

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p \ 0.001), bereavement (6.5 %, N = 155 vs. 3.6 %,


N = 19; v2 = 6.54, p = 0.011), finances (6.2 %, N = 149
vs. 1.5 %, N = 8; v2 = 19.0, p \ 0.001) and housing
(9.1 %, N = 219 vs. 1.7 %, N = 9; v2 = 33.5, p \ 0.001).
More 1014 year-olds had problems with friends (20.9 %,
N = 112 vs. 14.7 %, N = 354; v2 = 12.6, p \ 0.001).
Similar proportions in the two age groups had problems
with family members and with studying (or work).
Clinical aftercare

Fig. 3 Distribution of number of assessed episodes by time of


presentation and alcohol involvement

(614 not known) and 12.9 % (N = 321) were in treatment


at the time of self-harm (598 not known). Over half
(53.3 %, N = 1,092) had a history of previous self-harm
(738 not known).
Current problems
Problems were identified in assessed individuals, aged
1018 years (N = 3,077). Data were missing in approximately 4.5 % (N = 140) cases, except for drug and alcohol
problems where data were missing for 23.6 % (N = 725).
Many of the children and adolescents were facing multiple
problems at their first presentation in the study period. The
most frequent problems were in relationships with families
(44.5 %, N = 1,309) and with partners (28.6 %, N = 840)
followed by study/employment problems (23.0 %,
N = 676) and difficulties in relationships with friends
(15.9 %, N = 466). Problems which were significantly
more common in females than males were with families
(46.2 %, N = 1,027 vs. 39.1 %, N = 281, v2 = 10.9,
p \ 0.001) and friends (17.0 %, N = 378 vs. 12.3 %,
N = 88, v2 = 9.3, p = 0.002). Problems which were significantly more common in males than females were with
alcohol (16.0 %, N = 88 vs. 8.0 %, N = 144 v2 = 30.4,
p \ 0.001), drugs (11.3 %, N = 62 vs. 4.2 %, N = 76,
v2 = 37.8, p \ 0.001), housing (10.7 %, N = 77 vs.
6.8 %, N = 151, v2 = 11.5, p = 0.001) and legal issues
(4.6 %, N = 33 vs. 1.4 %, N = 30, v2 = 27.1, p \ 0.001).
The main differences between younger and older adolescents were that more 1518 year-olds than 1014 yearolds had problems in relationships with boyfriends or
girlfriends (33.6 %, N = 808 vs. 6.0 %, N = 32;
v2 = 161, p \ 0.001), and problems with alcohol (11.7 %,
N = 219 vs. 2.7 %, N = 13; v2 = 35.5, p \ 0.001), drugs
(6.9 %, N = 129 vs. 2.1 %, N = 10; v2 = 16.3,

Following their first episodes of self-harm during the study


period, nearly a third (32.5 %; N = 1,690) of individuals
were referred (or re-referred) for outpatient, day patient or
community mental health team (CMHT) care and 2.6 %
(N = 133) were admitted as psychiatric inpatients. A far
greater proportion of 1014 year-olds than 1518 year-olds
were referred for outpatient/day patient or CMHT care
(506/929, 54.5 % vs. 1,180/4,272, 27.6 %, v2 = 251,
p \ 0.001). Referral back to GP care (only) occurred in
43.1 % (N = 2,245) and was more common in 1518 yearolds than 1014 year-olds (2,035/4,272, 47.6 % vs.
210/929, 22.6 %; v2 = 195, p \ 0.001). Referral to other
agencies (e.g., social services, voluntary agencies) occurred in 10.4 % (N = 542). Self-discharge before psychosocial assessment occurred in 4.7 % and was more
common in 1518 year-olds than 1014 year-olds (226/
4,272, 5.3 % vs. 19/929, 2.0 %, v2 = 17.9, p \ 0.001) and
in males than females (83/1,321, 6.3 % vs. 162/3,877,
4.2 %, v2 = 9.7, p = 0.002).
Repetition of self-harm
Of children and adolescents who presented to the hospitals
in the three centres with self-harm each year between 2000
and 2006 (N = 5,096), an average of 17.7 % represented to
hospital following a further self-harm episode within
12 months. The annual percentage did not change significantly during the study period (v2 for trend = 0.15,
p = 0.70). It also did not differ between males (average
18.0 %) and females (17.4 %; v2 = 0.23, p = 0.6), nor
between those aged 1014 years (average 17.7 %) and
those aged 1518 years (average 17.7 %; v2 = 0.002,
p = 1.0).

Discussion
We have used data from the Multicentre Study of Selfharm in England to provide information on the epidemiology, characteristics and aftercare of a large sample of
children and adolescents who presented to hospital over an
8-year period following self-harm. While some individuals

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374

were under 10 years of age, numbers and rates of self-harm


increased rapidly in all three centres from the age of
12 years, especially in females. This pattern appears to be
related to completion of puberty and also mood disorder,
alcohol use and onset of sexual activity [25]. In our study,
consistent with previous findings [26], there was earlier
onset of self-harm in females than males, as reflected in the
much higher female:male ratio in 1014 year-olds (5.0)
than 1518 year-olds (2.7).
The variation in rates of self-harm between geographical
areas illustrates the importance of obtaining data from
multiple centres to provide more representative information on self-harm in children and adolescents at a national
level. It is not possible to obtain such data without specialised monitoring since national data are only available for
admissions, and, as we have shown, these would not
identify a large proportion of cases and would be subject to
considerable variation between hospitals. The differences
in rates of self-harm between centres probably partly reflect
variation in socio-economic deprivation [17].
The average rates of self-harm in 1518-year-old
females of 1,423 (95 % CI 1,3461,501) per 100,000
equates to 1 in 70 in this age group presenting to hospital
following self-harm each year; in males the average rate of
466 equates to 1 in every 215. Rates did not change
markedly during the study period, unlike in people of all
ages, in whom rates decreased during 20002007, in
keeping with trends in national rates of suicide [17].
Together with the fact that repetition of self-harm also did
not change during the study period, this suggests that recent
guidelines [8, 27] may not have had an impact on self-harm
in this age group.
Self-poisoning was the most frequent method of selfharm, especially in females. Paracetamol remains the drug
most frequently used for self-poisoning in young people in
England [6], with 58.2 % of overdoses involving this drug.
Paracetamol overdose continues to cause substantial numbers of deaths in the UK due to hepatotoxicity. While
hospital management of paracetamol poisoning has
improved and decreased pack sizes have contributed to
reduced mortality and morbidity [28], there is a continuing
need to reduce the number of deaths from this cause.
Reduction in the use of co-proxamol during the study
period was largely related to partial withdrawal of this drug
during 20052007 (followed by full withdrawal) due to its
poor benefit to risk ratio, especially its high toxicity in
overdose [29].
While self-cutting was the most frequent method of selfinjury, especially in females, it represented a minority of
all self-harm episodes. This contrasts markedly with selfharm at the community level in adolescents in England, in
which the majority of self-harm episodes in females and
half of those in males involve self-cutting [3]. This

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difference relates to the greater likelihood that self-poisoning in adolescents will result in presentation to hospital
(and to any clinical service) compared with self-cutting [5,
30].
Alcohol use and problems appeared to be related to selfharm in many cases, including in some of the younger
adolescents. Strategies to tackle youth drinking patterns,
including under-age drinking [31] may have beneficial
effects on self-harm.
The diurnal variation in self-harm hospital presentations
found in this study, including alcohol-related self-harm,
with a peak at night, are relevant to availability of clinical
services for young self-harm patients. Admission of all
children and adolescents who present with self-harm at
night to allow opportunity for full recovery and psychosocial assessment, as is recommended for all those aged
16 years and under [8], would seem sensible.
Over half of the children and adolescents in this study
were repeaters of self-harm, yet only just over a quarter had
a history of psychiatric treatment, highlighting the fact that
much self-harm in the community does not result in clinical
care [5]. Also, repetition of self-harm resulting in hospital
presentation within 1 year following a first episode in the
study period was common, occurring in 17.7 %.
As found in other studies [3234], relationship problems
predominated among the difficulties the children and adolescents were facing at the time of self-harm, with problems with families and friends being especially common in
females. Problems with alcohol, drugs and legal issues
were more common in the males. There were differences in
the nature of problems individuals faced at the time of selfharm, with problems with boyfriends/girlfriends, alcohol,
drugs, bereavement, finances and housing being more
common in 1518 year-olds, and more 1014 year-olds
facing problems with friends. We did not have systematic
information on psychiatric disorders in the children and
adolescents in this study, but other studies have shown that
the majority of those presenting with self-harm are likely to
have disorders, especially depression [35, 36]. Effective
therapeutic interventions are therefore likely to include a
combined focus on life problems and mental health [1]. At
present, unfortunately, evidence of effective interventions
for children and adolescents based on randomised controlled trials is lacking [3739].
The fact that psychosocial assessment occurred in only
57 % of presentations in this study, even though the three
centres involved have well-established specialised selfharm services, demonstrates the extent to which hospitals
fall short of implementing the national guideline recommendation that all self-harm patients should receive a
specialist assessment. As non-assessment may have several
causes (e.g., self-discharge, patient refusal, unavailability
of staff, emergency department policy), this requires

Eur Child Adolesc Psychiatry (2012) 21:369377

further investigation, especially given the accumulating


evidence that psychosocial assessment is associated with
reduction in risk of repetition of self-harm [20, 40] and the
fact that provision of appropriate psychiatric and social
care is unlikely in the absence of an assessment. Nearly
three-quarter of individuals were admitted to a hospital bed
following self-harm. The fact that 84 % of under-16 yearolds were admitted suggests that the 2004 national guideline recommendation of admission in this age group [8] is
being followed.
The proportion of patients, especially older adolescents,
who were referred back to their general practitioners
without specialist aftercare is somewhat surprising, especially given the emphasis in national guidance on provision
of care regardless of risk or need [8]. A somewhat lower
rate of psychiatric aftercare following general hospital
presentation for self-harm has previously been found in
adolescents in England compared to other countries in
Europe [41]. The low rate of psychiatric hospital admission
is particularly notable, but in accord with previous findings
from the UK [6]. This appears to reflect differences in
mental healthcare policy between countries. It also means
that our findings on aftercare cannot necessarily be generalised to other countries.
Strengths and limitations
This study was conducted in multiple centres and included
a large sample of patients. Thus it is likely to have provided
more representative findings than studies based on single
centres, although the fact that the centre populations
include large numbers of students may have introduced
some bias in findings relating to older adolescents.
The study was limited to hospital presentations. These
represent a minority of self-harm episodes in adolescents at
the community level [3, 4], with profound differences in
methods of self-harm between those who do and do not
present to hospital [5, 30]. Nevertheless, since hospital
presentation is the main route by which adolescents are
seen by clinical services [5], our findings are relevant to
those children and adolescents for whom aftercare interventions can be provided. Reliable admission data were
only available for two of the centres and rates in Manchester could only be calculated for South Manchester.
While we had information on drugs used for self-poisoning, we had none on prescribing or other measures of
availability of drugs. We have, however, previously demonstrated that changes in prescribing of antidepressants for
under-18 year-olds following national guidance resulted in
substantial changes in use of antidepressants for self-poisoning [42].

375

Finally, our information on aftercare was restricted to


that which was proposed and agreed at the time of hospital
discharge. It does not necessarily indicate the care that
actually occurred.

Conclusions
Using data collected systematically in multiple hospitals
in England on self-harm presentations by children and
adolescents, we have shown that self-harm becomes more
common with age, especially after the age of 12 years and
in females, and that rates of self-harm remain high,
especially in older adolescents. We have highlighted a
continuing problem of use of paracetamol for self-poisoning and the important role that alcohol has in selfharm. There is a clear diurnal pattern in numbers of
hospital presentations, with a preponderance at night,
especially for alcohol-related self-harm. Problems facing
children and adolescents who self-harm often include
relationship difficulties, especially for females. Repetition
of self-harm is common. Implementation of the national
guidance that psychosocial assessment should be conducted with all patients presenting to hospital with selfharm clearly presents a challenge.
This study demonstrates the value of multicentre collection of information on self-harm in children and adolescents. The findings also emphasise the need for large
scale longitudinal studies and for development of effective
aftercare interventions.
Acknowledgments For assistance with data collection we thank
Deborah Casey, Elizabeth Bale and Anna Shepherd in Oxford, Elizabeth Murphy, Iain Donaldson, Maria Healey and Stella Dickson in
Manchester, and Carol Stalker in Derby, and members of the general
hospital psychiatric and other clinical services, and hospital administration staff in all three centres. KH is a National Institute for Health
Research Senior Investigator. NK is also supported by the Manchester
Mental Health and Social Care Trust. We acknowledge financial
support from the Department of Health under the NHS R&D Programme (DH/DSH2008). The Department of Health had no role in
study design, the collection, analysis and interpretation of data, the
writing of the report, and the decision to submit the paper for publication. The views and opinions expressed herein do not necessarily
reflect those of the Department of Health.
Conflict of interest
of interest.

The authors declare that they have no conflict

Appendix
See appendix Table 3.

123

376
Table 3 Problems identified in
assessed individuals, aged
1018 years (N = 3077), by
gender

Missing data in approximately


n = 140 (4.5 %) cases, with
valid N ranging from
29322941 except for drug and
alcohol problems with 725
(23.6 %) missing, valid
N = 2352
Bold p values indicate results
which were significant after
Bonferroni correction (p \
0.004) due to multiple
comparisons

Eur Child Adolesc Psychiatry (2012) 21:369377

Males N (%)

Females N (%)

v2

Relationship with family

281 (39.1)

1027 (46.2)

10.9

Relationship with partner

216 (29.9)

623 (28.1)

0.86

0.368

Study/employment

169 (23.5)

507 (22.8)

0.15

0.703

Relationship with other friends

88 (12.3)

378 (17.0)

Alcohol

88 (16.0)

144 (8.0)

30.4

<0.001

11.5

0.001

0.001

0.002

Housing

77 (10.7)

151 (6.8)

Mental health

73 (10.1)

163 (7.3)

Drugs

62 (11.3)

76 (4.2)

Financial

53 (7.4)

104 (4.7)

7.68

0.006

Bereavement

42 (5.9)

132 (6.0)

0.01

0.925

Consequences of abuse

38 (5.3)

177 (8.0)

5.76

0.016

Physical health

31 (4.3)

82 (3.7)

0.57

Legal

33 (4.6)

30 (1.4)

Other problems

96 (13.4)

343 (15.5)

References
1. Hawton K, Rodham K (2006) By their own young hand: deliberate self-harm and suicidal ideas in adolescents. Jessica Kingsley
Publishers, London
2. Hulten A, Jiang GX, Wasserman D, Hawton K, Hjelmeland H,
De Leo D, Ostamo A, Salander-Renberg E, Schmidtke A (2001)
Repetition of attempted suicide among teenagers in Europe:
frequency, timing and risk factors. Eur Child Adolesc Psychiatry
10:161169
3. Hawton K, Rodham K, Evans E, Weatherall R (2002) Deliberate
self-harm in adolescents: self report survey in schools in England.
BMJ 325:12071211
4. Madge N, Hewitt A, Hawton K, de Wilde EJ, Corcoran P, Fekete S,
Van Heeringen K, De Leo D, Ystgaard M (2008) Deliberate selfharm within an international community sample of young people:
comparative findings from the Child and Adolescent Self-harm in
Europe (CASE) Study. J Child Psychol Psychiatry 49:667677
5. Ystgaard M, Arensman E, Hawton K, Madge N, Van Heeringen
K, Hewitt A, de Wilde EJ, De Leo D, Fekete S (2009) Deliberate
self harm in adolescents: comparison between those who receive
help following self harm and those who do not. J Adolesc
32:875891. doi:10.1016/j.adolescence.2008.10.010
6. Hawton K, Hall S, Simkin S, Bale E, Bond A, Codd S, Stewart A
(2003) Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 19902000. J Child Psychol Psychiatry 44:11911198
7. Cassidy C, McNicholas F, Lennon R, Tobin B, Doherty M, Adamson N (2009) Deliberate self-harm (DSH): A follow-up study
of Irish children. Ir Med J 102(4)
8. National Collaborating Centre for Mental Health (2004) Selfharm: the short-term physical and psychological management and
secondary prevention of self-harm in primary and secondary care
(full guideline) Clinical Guideline 16. National Institute for
Clinical Excellence, London
9. National Collaborating Centre for Mental Health (2011)
Self-harm (longer term management) (Clinical Guideline 133).
National Institute for Clinical Excellence, London
10. Australian College for Emergency Medicine (ACEM) and The
Royal Australian and New Zealand College of Psychiatrists
(RANZCP) (2000) Guidelines for the management of deliberate
self harm in young people. Australasian College for Emergency

123

9.31

11.
12.

13.

14.

15.

16.

17.

18.

19.

20.

5.73
37.8

27.1
1.82

0.017
<0.001

0.452
<0.001
0.177

Medicine (ACEM) and The Royal Australian and New Zealand


College of Psychiatrists (RANZCP), Melbourne
Department of Health (2002) National suicide prevention strategy
for England. Department of Health, London
Health Service Executive the National Suicide Review Group and
Department of Health and Children (2005) Reach Out: National
Strategy for Action on Suicide Prevention 20052014. Health
Service Executive Dublin
U. S. Department of Health and Human Services (2001) National
Strategy for Suicide Prevention: Goals and Objectives for Action.
U.S. Department of Health and Human Services, Public Health
Service, Rockville
Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry
181:193199
Hawton K, Harriss L (2007) Deliberate self-harm in young
people: characteristics and subsequent mortality in a 20-year
cohort of patients presenting to hospital. J Clin Psychiatry
68:15741583
Hawton K, Bergen H, Casey D, Simkin S, Palmer B, Cooper J,
Kapur N, Horrocks J, House A, Lilley R, Noble R, Owens D
(2007) Self-harm in England: a tale of three cities. Multicentre
study of self-harm. Soc Psychiatry Psychiatr Epidemiol
42:513521. doi:10.1007/s00127-007-0199-7
Bergen H, Hawton K, Waters K, Cooper J, Kapur N (2010)
Epidemiology and trends in non-fatal self-harm in three centres in
England, 2000 to 2007. Br J Psychiatry 197:493498. doi:
10.1192/bjp.bp.110.077651
Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A (2003)
Deliberate self-harm in Oxford, 19902000: a time of change in
patient characteristics. Psychol Med 33:987996
Schmidtke A, Bille Brahe U, De Leo D, Kerkhof A, Bjerke T,
Crepet P, Haring C, Hawton K, Lonnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander Renberg E, Temesvary B, Wasserman D, Fricke S, Weinacker B, Sampaio Faria JG
(1996) Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period
19891992. Results of the WHO/EURO Multicentre Study on
Parasuicide. Acta Psychiatr Scand 93:327338
Kapur N, Murphy E, Cooper J, Bergen H, Hawton K, Simkin S,
Casey D, Horrocks J, Lilley R, Noble R, Owens D (2008) Psychosocial assessment following self-harm: results from the multi-

Eur Child Adolesc Psychiatry (2012) 21:369377

21.

22.

23.
24.
25.

26.

27.

28.

29.

30.

31.

32.

33.

centre monitoring of self-harm project. J Affect Disord


106:285293. doi:10.1016/j.jad.2007.07.010
Sellar C, Goldacre MJ, Hawton K (1990) Reliability of routine
hospital data on poisoning as measures of deliberate self poisoning in adolescents. J Epidemiol Community Health
44:313315
Population estimates for UK, England and Wales, Scotland and
Northern Irelandcurrent datasets (2008) http://www.statistics.
gov.uk/statbase/Product.asp?vlnk=15106. Accessed 19/05/2011
SPSS Inc (2007) SPSS for Windows Release 15.0.1.1
Stata Corporation (2007) Stata Statistical Software: Release 10.
Stata Corporation, College Station, TX
Patton GC, Hemphill SA, Beyers JM, Bond L, Toumbourou JW,
McMorris BJ, Catalano RF (2007) Pubertal stage and deliberate
self-harm in adolescents. J Am Acad Child Adolesc Psychiatry
46:508514
Hawton K, Harriss L (2008) The changing gender ratio in
occurrence of deliberate self-harm across the life-cycle. Crisis
29:410
Royal College of Psychiatrists (2004) Assessment following selfharm in adults. Council Report CR122. Royal College of Psychiatrists, London
Hawton K, Simkin S, Deeks J, Cooper J, Johnston A, Waters K,
Arundel M, Bernal W, Gunson B, Hudson M, Suri D, Simpson K
(2004) UK legislation on analgesic packs: before and after study
of long term effect on poisonings. BMJ 329:10761079
Hawton K, Bergen H, Simkin S, Brock A, Griffiths C, Romeri E,
Smith KL, Kapur N, Gunnell D (2009) Effect of withdrawal of
co-proxamol on prescribing and deaths from drug poisoning in
England and Wales: time series analysis. BMJ 338:b2270
Hawton K, Rodham K, Evans E, Harriss L (2009) Adolescents
who self harm: a comparison of those go to general hospital and
those who do not. Child Adolesc Mental Health 14:2430
World Health Organisation (2010) mhGAP Intervention Guide
for mental, neurological and substance use disorders in nonspecialized health settings. http://whqlibdoc.who.int/publications/
2010/9789241548069_eng.pdf
Hawton K, Fagg J, Simkin S, Bale E, Bond A (2000) Deliberate
self-harm in adolescents in Oxford, 19851995. J Adolesc
23:4755
Dieserud G, Gerhardsen RM, Van den Weghe H, Corbett K
(2010) Adolescent suicide attempts in Brum, Norway,

377

34.

35.

36.

37.

38.

39.

40.

41.

42.

19842006: trends, triggers, and underlying reasons. Crisis


31:255264
Webb L (2002) Deliberate self-harm in adolescence: a systematic
review of psychological and psychosocial factors. J Adv Nurs
38:235244
Burgess S, Hawton K, Loveday G (1998) Adolescents who take
overdoses: outcome in terms of changes in psychopathology and
the adolescents attitudes to their care and to their overdoses.
J Adolesc 21:209218
Carter GL, Issakidis C, Clover K (2003) Correlates of youth
suicide attempters in Australian community and clinical samples.
Aust N Z J Psychiatry 37:286293
Harrington R, Kerfoot M, Dyer E, McNiven F, Gill J, Harrington
V, Woodham A, Byford S (1998) Randomized trial of a homebased family intervention for children who have deliberately
poisoned themselves. J Am Acad Child Adolesc Psychiatry
37:512518
Green JM, Wood AJ, Kerfoot MJ, Trainor G, Roberts C, Rothwell J, Woodham A, Ayodeji E, Barrett B, Byford S, Harrington
R (2011) Group therapy for adolescents with repeated self harm:
randomised controlled trial with economic evaluation. BMJ
342:d682
Hazell PL, Martin G, McGill K, Wood TK, Trainor G, Harrington
R (2009) Group therapy for repeated deliberate self-harm in
adolescents: failure of replication of a randomized trial. J Am
Acad Child Adolesc Psychiatry 48:662670
Bergen H, Hawton K, Waters K, Cooper J, Kapur N (2010)
Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses. J Affect
Disord 123:95101. doi:10.1016/j.jad.2010.05.001
Hulten A, Wasserman D, Hawton K, Jiang GX, Salander-Renberg
E, Schmidtke A, Bille-Brahe U, Bjerke T, Kerkhof A, Michel K,
Querejeta I (2000) Recommended care for young people
(1519 years) after suicide attempts in certain European countries. Eur Child Adolesc Psychiatry 9:100108
Bergen H, Hawton K, Murphy E, Cooper J, Kapur N, Stalker C,
Waters K (2009) Trends in prescribing and self-poisoning in
relation to UK regulatory authority warnings against use of SSRI
antidepressants in under-18 year-olds. Br J Clin Pharmacol
68:618629. doi:10.1111/j.1365-2125.2009.03481.x

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