INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Deliberate self-harm in adolescence: a systematic review

of psychological and psychosocial factors
Lucy Webb BSc MSc RMN
Department of Psychology, Staffordshire University, Stoke-on-Trent Staffordshire, UK

Submitted for publication 13 June 2001

Accepted for publication 1 February 2002

Correspondence: WEBB L. (2002) Journal of Advanced Nursing 38(3), 235–244

Lucy Webb, Deliberate self-harm in adolescence: a systematic review of psychological and
Department of Addictive Behaviour psychosocial factors
and Psychological Medicine,
Aims. This paper is a systematic review of the research literature that identifies
St George’s Hospital Medical School,
psychological and psychosocial factors associated with adolescent deliberate self-
Cranmer Terrace,
London SW17 0RE, harm (DSH). The aims of this review were to identify the key psychological and
UK. psychosocial factors that aid the identification of individuals at risk of DSH, and
E-mail: lwebb@sghms.ac.uk suggest specific strategies for intervention.
Background. Research has highlighted a parallel rise in rates of DSH referrals to
general hospitals and rates of successful suicides in the younger age groups and
gender groups. It is also highlighted that pressure on services in responding to these
increases may be resulting in an inadequate response to both first-episode DSH and
repetition of self-harm. One cause for concern is the lack of adequate psychosocial
assessment for adolescents presenting at hospital following a DSH incident.
Research of the literature suggests that there may be a paucity of research into
after-care strategies in self-harm to prevent repetition and escalation of self-
destructive behaviour.
Methods. A systematic review of the literature was conducted to identify the
psychological and psychosocial factors relating to DSH.
Results. The results found typical psychological and psychosocial factors associated
with DSH in adolescents, although psychosocial factors were less consistently
measured because of the breadth of tools and methods used.
Conclusions. It is discussed whether associated factors are causative of DSH or the
accompanying symptoms in DSH. It is suggested that positive psychosocial factors
may have a part to play in providing protection against DSH behaviour. Therapeutic
responses to DSH are suggested as preventative measures against repeat episodes.

Keywords: deliberate self-harm, adolescents, psychological, psychosocial,

treatment, family dysfunction, depression, hopelessness, impulsivity

differ in epidemiology, compelling evidence points to a

Introduction
Government policy in the United Kingdom (UK) has focused
on the need to reduce suicide rates in the UK [Department of
Health (DOH) 1992, 1998]. Evidence suggests that the
prevalence of suicide and suicidal behaviour is rising for
young males, and deliberate self-harm (DSH) is increasing in
young females (Kerkhof 2000). van Heeringen et al. (2000)
argue that, while suicide and nonfatal self-harm appear to
shared continuum of self-harm behaviour. They propose a
suicidal pathway of increasing hopelessness, anger and
suicidal ideation, and a decreasing escape potential, which
results in a serious suicidal act for those unable to escape.
Evidence from Hawton and Fagg (1988) and Hawton et al.
(1993) suggests that self-poisoning in particular is associated
with suicidal behaviour in the UK. Hawton et al. (1997)
report that rates of repeat self-harm episodes have increased

Ó 2002 Blackwell Science Ltd 235

L. Webb
since 1985, and rates of first-episode DSH have not reduced.
They suggest that pressure on services from increased DSH
rates results in a poorer response to DSH patients, especially
in psychosocial assessment. Their findings suggest there still
remains a lack of effective primary prevention for first-
episode DSH, and that repeat DSH patients have not received
sufficient intervention to prevent repetition. In the same
study, they find correlation between increases in DSH and
national suicide rates, especially in the 15–24 age group.
There is a particularly marked parallel between trends for
male DSH and male suicides.
The implication from this research is that first-episode
DSH patients may be engaging in repeat episodes because of a
lack of effective intervention. It may be that a proportion of
first-episode DSH patients is embarking on a particular
course of behaviour that results in suicide.
However, as many studies of DSH feature a high percent-
age of self-poisoners, patients self-harming by other means
may be masked by inclusion with self-poisoning patients.
Indeed, case evidence suggests that self-mutilation can be a
coping strategy in anxiety and is a protective element against
suicide (Babiker & Arnold 1997).
General DSH research has, nevertheless, highlighted the
need to examine after-care strategies in self-harm to prevent
repetition and escalation of self-destructive behaviour, but
there has been less focus on the prevention and understanding
of the seeds of self-harming behaviour. An understanding of
the psychological and psychosocial background of DSH is
necessary to appreciate the kinds of pressures being faced by
young people and what helps them cope with those pressures.
Erikson’s (1950) theory of adolescent crisis indicates the
need for identity development in the context of the wider social
world from a basis of supportive family life and good self-
esteem. Therefore, the purpose of this systematic review was to
examine the relevant psychological and psychosocial factors
associated with adolescent DSH and examine what features are
involved with adaptive coping. It was intended that a psycho-
logical and psychosocial understanding could be found to aid
professionals working with families and young people.
The questions posed for this systematic review were:
1. What factors are associated with adolescent DSH?
2. What factors are associated with non-DSH?
3. What indicators exist for effective identification and
intervention of vulnerable DSH individuals?
Method
Identification of relevant studies
A literature search from 1990 to 2000 was carried out using
the following electronic databases: Medline, Cinahl, Bids ISI
236 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
Service, Social Sciences Citation Index and PsycLit 1994–
1997 and 1998–1999. Relevant available journals were also
hand searched and appropriate citations followed up either by
hand or through electronic databases. Search keywords were
for self-harm, self-injury, DSH, self-destructive behaviour
(behavior), self-mutilation, self-poisoning and self-inflicted
injury. Searches were reduced using Boolean operators of
AND with families, family therapy, family dynamics, adoles-
cence, adolescents, young people, teenagers and children.
From this initial selection of studies it became clear that the
broad terms of self-harm and DSH are interpreted differently
between disciplines and cultures, there often being little
differentiation between nonsuicidal self-injury and actual
suicide attempts. Some researchers purposely exclude self-
laceration/self-cutting. Many researchers restrict their partic-
ipants to self-poisoners with no discrimination between ‘cry
for help’ episodes and suicidal attempts, while others include
all self-harm episodes regardless of intent. Many of the
studies reviewed relied on hospital diagnosis of DSH, which
may exclude many self-destructive behaviours.
In focusing on primary factors provoking general DSH, this
review accepted research that included either nonsuicidal
behaviour, or self-harm behaviour that is possibly closer to
suicidality. Within these definitions, this review attempted to
include a broad definition of self-harm that included poison-
ing, cutting/mutilation and other reckless behaviour that was
intentionally self-destructive or harming. The literature
review revealed an over-representation of DSH by poisoning,
the implications for which are discussed later in this paper.
Inclusion criteria
Clinical studies were included where participants had
engaged in DSH (broad definition) as adolescents and were
representative of a general population. Research needed to be
based on original data collection. Outcome measures had to
include psychological or psychosocial elements and discrim-
inate between DSH and non-DSH behaviour. Otherwise,
outcome measures could be specific or broad and explorat-
ory. It was accepted that elements in DSH may be researched
quantitatively or qualitatively, with selection based on the
strength and quality of the evidence produced. However,
studies analysing comparison data were considered to pro-
vide the strongest evidence, with noncomparison studies
providing supporting evidence. Surveys needed to focus on
DSH as one element of the measures taken, and epidemio-
logical studies were considered where they provided relevant
demographic data. All studies were required to be relevant to
the general culture in the UK, but not necessarily UK based
(that is, of western culture with general population samples
rather than specific ethnic groups) and produced within the
Integrative literature reviews and meta-analyses
last 10 years for cultural relevance. Alcohol-only studies were
not included.
Grouping of studies
Studies were grouped according to their contribution to the
aims of the review in terms of social, family dysfunction and
psychological factors, as listed in Table 1. Studies with
findings relevant to more than one group were categorized
according to their main findings.
Psychosocial factors
Although psychosocial factors were considered to include both
family and social aspects of an adolescent’s life, these elements
were treated separately to differentiate between pressures from
within the home and from the young persons’ social world.
Family dysfunction
Studies were placed in this group if they looked at family
dysfunction as a main outcome measure or if it was the main
finding relevant to this review.
Psychological factors
Studies in this group had findings relating to psychological
and psychiatric factors associated with DSH such as indica-
tors of mood, cognitive functioning or psychiatric illness.
Repetition of DSH
Several studies concentrated on repetition of self-harm, with
only one featuring adolescents specifically. This study com-
pared repeaters with nonrepeaters and used the same cohort
as the study by Kingsbury et al. (1999).
Results
Eleven studies were identified as eligible for inclusion in the
review. Thirty-one studies were identified in the initial
searches, of which 13 did not meet the inclusion criteria.
Of the remaining 18, six were excluded on the grounds of
poor reporting or poor discrimination of details, nonrelevant
outcome measures or having data which were not original.
Two selected studies used the same subject cohort but
focused on different research questions. Two other selected
studies used medical records that covered the same patients
but, again, pursued different research questions.
Social factors
Five studies reported social factors associated with DSH
particularly, while one included social factors among issues
Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
Deliberate self-harm in adolescence
of family functioning. McLaughlin et al. (1996) reported
DSH adolescents overall measuring significantly higher prob-
lems with family, friends, boy/girlfriends and school than
controls. When only severe problems were measured, the
DSH group showed significantly more problems in family and
school. This study also shows DSH adolescents perceiving
their parents understanding them significantly less than a
community control group, although not perceiving any
greater parental criticism than other groups. Qualitative data
suggests that the nature of the school problems concerned
bullying more than studies.
Rubenstein et al.’s (1998) survey of high school students
found risk factors for DSH to be depression and stress, with
the major stressors (P < 0Æ001) being worries about sexual-
ity, feelings of past violation, family suicidality and illness,
personal loss and, to a lesser extent (P < 0Æ01), achievement
pressure, achievement failure, family conflict and friend
suicidality. Protective factors of DSH were measured as
family intactness and cohesion. Family cohesion was all the
more important where a family was no longer intact.
From the epidemiological survey by Hawton et al. (1996),
an opportunity section of DSH patients showed significant
outcome measures for problems with family relationships,
friends and schoolwork. Problems with drugs or alcohol were
uncommon. This study did not look at interaction between
these factors, although relationship problems featured highly
in 91Æ5% of the group. There is no indication if this would
not be true, however, for the general population of adoles-
cents. From a more recent population, Hawton et al. (1997)
note significant differences (P < 0Æ001) in the reported
problems by gender with girls having problems with family
members, while problems for boys included employment/
studies, alcohol, drugs and finances, with some significant
concerns re sexual partner (P < 0Æ05).
Kerfoot et al. (1996) compared problems of overdose
adolescents with psychiatric and community controls, finding
significant reporting of bullying, coming from a broken home
and family being on benefits, differentiating the overdose
group from the psychiatric group. Both these groups were
significantly differentiated from the community controls by
social isolation, poor school attendance, poor relationship
with mother, family event in past year, criminal conviction
and knowing someone who had taken an overdose.
Family dysfunction
Tulloch et al. (1997) compared DSH Accident and Emerg-
ency (A & E) admissions with accidental injury patients for
parent–child communication, family adaptability and cohe-
sion, child depression, family life events and locus of control.
237
 Table 1 Studies from final selection included in systematic review
238
Study Participant details
Repetition of self-harm
Hawton et al. Consecutive patients
(UK, 1999) (13–18 years) admitted to
hospital having taken
overdoses
Psychosocial factors associated with DSH
McLaughlin et al. Deliberate self-harming
(UK, 1996) adolescents (12–17 years)
consecutively admitted to
casualty depts for
deliberate self-harm
(excluding laceration)
Rubenstein et al. Children in grades 10
(USA, 1998) and 11 in one high school
Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
Hawton et al. A total of 755 patients
(UK, 1996) <16 years referred to
general hospital in Oxford
for self-poisoning or
self-injury. 133 boys,
642 girls, and total of
854 episodes
Hawton et al. A total of 7437 consecutive
(UK, 1997) patients referred over
11-year period to general
hospital (Oxford) for
self-poisoning or self-injury.
About 738 patients
psychiatrically assessed
over 1 year
Methodologies
Repeaters vs. non-repeaters
on scales of depression,
hopelessness, suicidal intent,
impulsivity, anger, self-esteem,
problem-solving
DSH vs. matched psychiatric
outpatients and non-clinical
group
Survey of school students
Chi-square analysis of
measure on suicidality,
depression, stress and
relationships
Total population survey
including methods of
self-harm and demographic
characteristics, over a
period of 17 years.
Measures taken of previous
and current psychiatric
treatment, changes over time,
and problems identified
(between 85 and 93) including
relationships with family,
friends, schoolwork, social
isolation
Epidemiological population
survey measured for
demographic variables, method
of harm and repetition. Also,
data collected on problems
preceding self-harm episode
L. Webb
Subjects included
and excluded Findings Definition of DSH
n ¼ 45, No difference in groups Self-poisoning admissions
repeaters ¼ 18 when depression controlled. to general hospital and
girls ¼ 38, boys ¼ 7 Depression levels self-poisoning and
characteristic of repetition? injury on repetition
DSH ¼ 51, (ex. ¼ 9), Sign: Family school and Deliberate overdoses
psychiatric ¼ 32, boy/girlfriend problems for
non-clinical ¼ 37, DSH group. Sign: hopelessness
girls ¼ 80% ¼ DSH group. Correlations
between hopelessness and poor
problem-solving solutions.
n ¼ 272 DSH ¼ sexuality, stress and Suicidality – intent of
refusers ¼ 134 (32%), depression, violation and hurting or killing
girls ¼ 20%, family suicidality oneself
DSH boys ¼ 4%
755 referrals, and Current problems ¼ Self-poisoning
99 repeat episodes. relationships, lack of (any substance)
Self-poisoning ¼ 824, family support, social and self-injury
self-injury ¼ 53 incl. school, non-aggression,
23 dual method non-violence victims.
episodes. Current No difference between
problem measures ¼ 212 problems by gender except
(girls ¼ 180, boys ¼ 32) for girls ¼ CSA rates
All self-harm admissions Increase in males DSH Self-poisoning and
(n ¼ 7437), correlates with suicide rate self-injury. No alcohol-
assessed patients ¼ 738. and repetition rate only poisoning
No explanation of
selection of assessed
patients.
Girls ¼ 422, boys ¼ 316
Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244

Integrative literature reviews and meta-analyses

Table 1 (Continued)

Subjects included
Study Participant details Methodologies and excluded Findings Definition of DSH

Family dysfunction and DSH

Garber et al. Children and their mothers. One-year longitudinal study. n ¼ 240 children, Family functioning mediates As rated by suicidality
(USA, 1998) About 77% of mothers with Depressive mothers vs. non- Excluded/dropouts ¼ 19 suicidality and mothers’ rating scales
history of mood disorder depressive mothers on measures depression
of child’s suicidal symptoms
and family functioning
Rubenstein et al.
(USA, 1998)
(reported above)

Martin et al. High school students Correlational analysis n ¼ 352, FAD scale sensitive to Discrete definitions of
(AUS, 1995) (mean age 15Æ2 years) between depression items, Incomplete/distorted dysfunction and suicidal suicide attempters,
suicide behaviours, life events responses ¼ 64, behaviour. DSH ¼ poor thinkers, planners
and family assessment DSH girls ¼ 14 (8%), affective involvement. and DSH
DSH boys ¼ 17 (9%) Depression in all
suicidal groups

Kerfoot et al. Forty consecutive self-
(UK, 1996) poisoning admissions to
casualty departments
(11–16 years) Excludes
alcohol-only cases. Also
excludes care-for children
Overdose vs. matched
non-suicidal psychiatric
group vs. matched
non-suicidal random group,
on measures of hopelessness,
suicidal ideation, problem-
solving, substance use and
family assessment
Overdoses n ¼ 40, Evidence of impulsivity, Intentional self-
refusers n ¼ 17. depression, suicidal ideation, administration of more
Family functioning, hopelessness, and oppositional than prescribed dose
overdoses n ¼ 39, disorder – sign. Higher than substance. Excludes
psychiatric n ¼ 38, psychiatric controls. Family alcohol only poisoning.
controls n ¼ 40. dysfunction correlation
Girls ¼ 34, boys ¼ 6 with DSH

Deliberate self-harm in adolescence

Tulloch et al. 104 adolescents Comparison study 52 DSH vs. DSH ¼ 36 girls, 16 boys Impairment of Overdose and
(AUS 1997) 14–19 years 52 non-patients Non-patients ¼ matched family self-injury
controls communication in
DSH group
239
240

L. Webb
Table 1 (Continued)

Subjects included
Study Participant details Methodologies and excluded Findings Definition of DSH

Harrington 162 consecutive patients,
et al. (UK, 17 years, referred to child
1998) mental health following
deliberate self-poisoning,
and with consenting
parents/guardian
Psychological factors associated with DSH
Kingsbury et al. A total of 33 consecutive
(UK, 1999) overdose patient admitted
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Randomized trial of routine Routine care No significant Hawton definition
care vs. family intervention n ¼ 77 Family differences excluding
for DSH children. Outcome intervention n ¼ 85, between self-cutting and
measures ¼ suicidal ideation, no reported dropouts, treatment groups hanging
hopelessness and family exclusions or on outcome measures.
functioning. Secondary refusers. Subgroups: lower
measures ¼ alternative solutions Girls ¼ 76, boys ¼ 9 suicidal ideation
scale, social problem solving for family intervention
inventory, general health only for non-depressed
questionnaire patients
Overdose vs. matched Overdose n ¼ 33, Depression does not characterize Self-poisoning
community control vs. matched, refusers n ¼ 12. DSH solely. Impulsivity is

to casualty department. non-overdose/psychosis Community n ¼ 30, discriminant of DSH when

Age ¼ 12–18 years psychiatric control on measures psychiatric n ¼ 30. depression controlled. Problem-
of depression, hopelessness, Girls ¼ 28, boys ¼ 5 solving may be mediated by
anger, impulsivity, self-concept, impulsivity
problem-solving

Patton et al. A total of 1699 secondary Cohort study, cluster sampling
(AUS, 1997) school students (15–16 years) survey. Measured for suicide
intent inc. self-laceration,
self-poisoning, recklessness
and self-battery. Multivariate
analyses against psychiatric
morbidity, antisocial behaviours,
alcohol and marijuana use and
sexual activity
n ¼ 1699 from 2066 0Æ5% prevalence of DSH in
selected. Dropouts/ population. Self-laceration and
refusers/ absentees recklessness most common.
n ¼ 367 Laceration and poisoning higher
(82Æ2% response rate) in females. High psychiatric
morbidity ¼ sexually active,
antisocial (girls)
Derived from Beck
Suicide Intent Scale.
Includes laceration,
poisoning, recklessness,
self-battery. Excluded
self-ecoration, alcohol/
marijuana use alone and
restriction of eating.

Harrington et al. 9
(UK, 1998). =
As reported above
Hawton et al.
;
(UK, 1997).
Integrative literature reviews and meta-analyses
An absence of a family confidant was strongly associated
with adolescent DSH, particularly in children with an
internal locus of control. Family cohesiveness and intactness
was also shown to play an important role in protection
against DSH by Rubenstein et al. (1998). Garber et al.
(1998) looked at the relationship between adolescent suicidal
symptoms and depression in their mothers and found that,
where mother/child ratings of family functioning were poor,
adolescent suicide symptoms were likely to be high
(P < 0Æ001). Maternal depression itself was insignificant in
contributing to adolescent suicide symptoms.
Martin et al. (1995) surveyed Australian teenagers for
associations between their perceptions of family dynamics
and depression and suicidality. Multiple regression of Family
Assessment Device (FAD) (Epstein et al. 1983) subscales
showed all family features contributing to suicidality and
depression, notably poor quality of boundaries and relating
(roles, affective responsiveness) contributed to attempters and
harmers particularly. Family structure was also important,
with attempters only correlated significantly to divorced
families (P < 0Æ01), while depression was higher (ns) for
adolescents in separated/divorced families and even higher
for adolescents (ns) who had lost a parent.
Kerfoot et al. (1996) compared overdoses with psychiatric
and community controls and found no significant differences
between the overdose and psychiatric groups in mental
disorders, suicidal ideation and hopelessness, although both
groups were markedly different than the control group.
However, the overdose group was distinct from the psychi-
atric group in family functioning as measured by the FAD.
They had higher scores on subscales for communication,
roles, affective responsiveness and general functioning
(P < 0Æ005), with nonsignificant differences also in affective
involvement and behaviour control.
Harrington et al. (1998) trialed home-based family inter-
vention vs. routine outpatient care with overdose children
and found no difference between groups on outcome meas-
ures of suicidal ideation, hopelessness or family assessment
(FAD) overall. However, analysis of subgroups showed
reduction of suicidal ideation in the family intervention
group for those children who were not depressed. Children
who were depressed remained depressed and suicidal, but
those without major depression were able to benefit from
family intervention.
Psychological factors
Only three studies focused on psychological states, but all
highlighted depression and hopelessness as major features of
DSH. Harrington et al. (1998) showed depression to be a
Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
Deliberate self-harm in adolescence
crucial factor in treatment. Kingsbury et al. (1999) compared
overdose adolescents with psychiatric and community con-
trols on measures of mental states and problem-solving.
Depression featured significantly for both overdose and
psychiatric groups, as did low self-esteem and poor prob-
lem-solving. Overdose adolescents, however, were more
depressed, hopeless, angry and impulsive than the other two
groups. When depression was controlled for, the remaining
significant difference between the overdose group and the
psychiatric controls was impulsivity (P < 0Æ05). Although the
overdose group scored most highly on all measures, in this
study, the psychological state that separates self-harmers from
other distressed adolescents appears to be impulsivity.
Patton et al. (1997) also looked at suicidal behaviours and
psychological states in an Australian high school population.
Psychiatric morbidity (anxiety and depression) was found to
have the strongest association with DSH, particularly self-
poisoning and self-laceration, and was more strongly associ-
ated with girls. Antisocial behaviour was associated with
DSH in girls only, and being sexually active was associated
with DSH in both boys and girls. In the categorization of self-
harm, Patton et al. (1997) included self-battery and deliber-
ate recklessness, self-laceration and self-poisoning. Girls were
significantly more likely to engage in self-laceration and self-
poisoning, and boys more likely to engage in deliberate
recklessness and self-battery.
Repetition of DSH
Hawton et al. (1999) used participants from the cohort
studied by Kingsbury et al. (1999) comparing repeaters with
first time self-harmers. Significant differences were found in
higher levels of depression (P < 0Æ001), hopelessness (P <
0Æ01), state anger (P < 0Æ07), self concept and poor problem-
solving (P < 0Æ05) in repeaters. No significant differences
were found for suicidal intent, impulsivity or trait anger, and
no significant differences were found when depression scores
were controlled for.
Discussion
The results indicate a cluster of common psychological
symptoms associated with acts of DSH, but psychosocial
factors tend to be more varied and difficult to categorize. It is
interesting that psychological factors such as depression and
hopelessness have emerged as strongly associated with DSH,
despite the range of definitions of DSH, and in comparison
with psychosocial factors. This finding may well reflect the
global nature of depression and hopelessness as symptoms of
mental distress, but may also have been operationalized in
241
L. Webb
comparison with family dysfunction and other psychosocial
factors by the greater uniformity of measurement tools and
items used to detect these symptoms.
The presence of depression and hopelessness is hardly
surprising, and these may be accompanying factors, and not
pre-existing factors, of DSH in adolescents. The common
psychosocial factors emerging from this review are poor
family communication and relating, and social worries such
as relationships, sexuality and career/examination pressures.
As these factors could be pre-existent of depression, depres-
sion may be a secondary or interactive factor of DSH. It
certainly appears that depression, family dysfunction and
social pressure are likely to exist together in adolescent DSH.
Strengths and weaknesses of the studies
The various definitions of DSH among the studies has made
if difficult to tease out possible differences between methods
of DSH, but has enabled examination of DSH as a group of
associated behaviours. Studies of self-poisoners predomin-
ate, and no study fully attempts to separate and compare
poisoning with other self-destructive behaviour. The findings
of this review are likely to apply largely to adolescents who
overdose and have suicidal thoughts. By taking a broad
definition of DSH, however, this review has highlighted
different expressions of DSH, especially between males and
females.
One bias revealed by this review may be that most of the
studies recruited participants following referral to A & E
departments and receiving a diagnosis of DSH. No study
provides an explanation of how that diagnosis was made. Also,
while some studies are restricted to self-poisoning, others
include self-injury, self-battery and deliberate recklessness.
Most of the studies treat self-harm and attempted suicide as
interchangeable and undifferentiated. Studies based on DSH
patients rely on medical diagnosis of DSH, whereas surveys
rely on self-report of DSH or suicidal intentions. Thus,
undisclosed DSH attempts are omitted in patient samples,
while surveys may include ideators who may never perform an
act of DSH. It has been demonstrated that DSH repetition is a
risk factor in suicide (Hawton et al. 1997), however, there is
little evidence showing suicide and DSH acts are provoked by
the same factors. This review can only confirm that depression
and poor problem-solving tend to be implicated in both acts.
It is interesting that the surveys and patient studies record
different proportions of poisoners and injurers, which sug-
gests a bias in medical categories of DSH towards female
overdose patients. The surveys reveal the possibility of a
richer expression of DSH that goes undetected in patient
groups and also suggests a gender bias in the medical
242 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
recording of DSH in the UK. The Australian survey by Patton
et al. (1997) suggests male expression of DSH involves
recklessness and self-battery, which is perhaps unrecognized
medically as DSH. It is possible therefore that studies based
on self-poisoning are looking at a female expression and
causation of adolescent distress. Hawton et al. (1999) have
shown females to be more worried by family problems, while
males worry about social events. It may be therefore that
research based on self-poisoners overestimates the import-
ance of family dysfunction in general DSH.
Measurement tools vary widely between studies, although
tools measuring psychological states have common origins
and so share many features. Psychosocial measures vary more
widely, with the exception of the McMaster FAD. Collection
of data about social problems has been more arbitrary,
depending either on the researchers’ own categories of poss-
ible problems or self-report from semi-structured interviews.
Inclusion of survey data has been useful in detecting the
scope of DSH in a general population of adolescents, and
informative about possible DSH in the preact stage. Data from
a range of methods has also helped to triangulate findings.
Psychological factors associated with DSH
Many of the studies support the view that depression and
hopelessness are associated with DSH. However, these states
do not feature exclusively in DSH, but depression needs to be
present in both initial DSH episodes and repetitions. With
depression controlled for, studies in this review have shown
that impulsivity, poor problem-solving and family dysfunc-
tion are features that distinguish DSH from controls. Again,
these are findings based largely on self-poisoners. Whereas an
adolescent would appear to need to be depressed to take an
overdose, depression may not be the primary cause of the
adolescent’s self-harming behaviour. Kingsbury et al. (1999)
found impulsivity to be an important factor, independent of
depression, but apparently linked to poor problem-solving.
They suggest an interaction between the two, with impulsiv-
ity interfering with the process of problem-solving. Tulloch
et al.’s (1997) study implicated an internal locus of control,
suggesting a tendency to self-blame as a marker for vulner-
ability. In their study, self-blame is distinct from a general
measure of depression, suggesting it could be an important
feature of depression in DSH.
There were no significant differences in psychological factors
between boys and girls in type of DSH. In studies of overdoses,
the vast majority of patients were female but, in the surveys, the
numbers of DSH students were more evenly spread between
genders. Patton et al. (1997) reported boys adopting more
violent means of DSH and girls more likely to engage in
Integrative literature reviews and meta-analyses
antisocial behaviour. This may reflect more of a judgement on
the kinds of activity perceived as normative for boys and girls
rather than objective levels of activities in these categories.
This evidence suggests that a particular set of psychological
states is associated with DSH, particularly overdose, where
features such as poor problem-solving and impulsivity may
distinguish the DSH adolescent from another distressed
adolescent. There is no evidence to suggest that these
psychological states are directly causative of DSH. However,
psychosocial factors may give an indication of what makes
adolescents depressed, hopeless and impulsive.
Psychosocial and family dysfunction factors associated
with DSH
One of the problems noted in this review has been identifying
factors specific to DSH adolescents. The evidence from
studies examining psychosocial problems shows a combina-
tion of internal family conflicts and external pressures.
Tulloch et al. (1997) make a strong association between
DSH and poor family communication, while McLaughlin
et al. (1996) identify both family and school problems to be
the most severe difficulties faced distinctly by DSH adoles-
cents. Rubenstein et al. (1998) reveal that the major stressors
for this group are personal identity difficulties (sexuality,
personal violation), family problems (illness and conflict) and
external problems (achievement pressure and failure). There
are also problems that are both internal and external
(bullying, poor family communication, broken home) (Ker-
foot et al. 1996), and differentiating DSH adolescents from
other distressed youngsters are family boundary and com-
munication problems (Martin et al. 1995).
Whereas distressed adolescents have a wide range of
difficulties to cope with, it may be that a particular comb-
ination of external and internal problems, in association with
resulting or pre-existing psychological states, may lead
adolescents to resort to DSH.
Many of the social and family problems identified are likely
to impinge on the adolescent’s self esteem and sense of
identity. It appears feasible that, in the many cases included in
these studies, the depression and sense of hopelessness
recorded could be because of, at least in part, these personal
stressors. Few studies have focused on protective factors, but
those identified lie within the family. Family cohesiveness and
intactness have been identified by Rubenstein et al. (1998) to
offset the effects of other stressors. Garber et al. (1998) note
that poor family functioning is associated with significantly
higher suicidal symptoms in adolescents with depressed
mothers. Rather than family problems contributing to the
overall stress on the adolescent, it appears that the absence of
Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(3), 235–244
Deliberate self-harm in adolescence
protective factors within the family may distinguish the DSH
adolescent from an otherwise distressed adolescent.
Conclusion
This review has illuminated several areas in the adolescent
DSH research where further and more specific research
would be informative. The issue of definition appears partic-
ularly important in light of the confusion about the nature of
nonsuicidal DSH and suicide attempts. There is also a need to
differentiate the causative factors in self-poisoning and self-
mutilation. There also appears to be a gender bias in the
research into DSH in the UK as the participant groups are
dominated by female overdose hospital admissions. Surveys
have revealed that there may also be a substantial number of
potential and actual DSH that goes undisclosed in the general
population.
The main findings of this review, however, have been the
possible family and social factors that may be primary con-
tributors to first episode overdose DSH, and research into this
aspect of adolescent life appears under investigated. Research
has focused on psychological factors associated with DSH and
repetition of DSH while little investigation has been made into
the factors which may create or interact with those psycholog-
ical states. Family life is difficult to investigate and the social
and personal problems of adolescents are naturally many and
varied. Some of the studies reviewed here, however, have
teased out psychosocial and family factors associated with
DSH in adolescence, but these findings warrant replication and
more detailed investigation to gain a clearer picture of the
psychosocial contributors to adolescent DSH.
This review has also revealed a dearth of research
concerning treatment approaches and outcomes while under-
lining the importance of family communication in protecting
against DSH. Professionals working where family interven-
tion is part of a treatment package are well placed to provide
further evidence of the importance or otherwise of family
functioning. A demonstration of the effectiveness of
family intervention in DSH would support the view that
family dysfunction is a key element in DSH.
Implications for practice
These findings suggest a profile by which professionals
working with this client group may identify individuals at
the preact stage. A vulnerable adolescent appears to be
depressed, with feelings of hopelessness and with a tendency
toward self-blame and impulsivity. He/she is likely to be
experiencing personal worries with pressure from school or
relationships. Most specifically, a vulnerable individual is
243
L. Webb
likely to experience poor family communication channels
with no parental confidant. Findings from this review suggest
that key preventative intervention strategies lie in improving
family communication. This may be as important as tackling
the depressive symptoms in preventing first-episode DSH.
These findings also suggest that a response to a DSH act
needs to include addressing the adolescent’s psychosocial
needs, poor problem-solving and impulsivity, to prevent
further acts of DSH. Planned action strategies such as ‘green
card’ rapid admission systems for A & E departments, crisis
telephone help lines or an identified ‘parental confidant’
within the family or the school/college system would go some
way to addressing the adolescent’s immediate needs.
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