Factors associated with deliberate self-harm among
E. M. McMahon1,2, U. Reulbach1,2, P. Corcoran1, H. S. Keeley3, I. J. Perry2and E. Arensman1*
1National Suicide Research Foundation, Cork, Republic of Ireland
2Department of Epidemiology and Public Health, University College Cork, Republic of Ireland
3Child and Adolescent Mental Health Services, Mallow, Co. Cork, Republic of Ireland
Background. Deliberate self-harm (DSH) is a major public health problem, with young people most at risk. Lifetime
prevalence of DSH in Irish adolescents is between 8% and 12%, and it is three times more prevalent among girls
than boys. The aim of the study was to identify the psychological, life-style and life event factors associated with
self-harm in Irish adolescents.
Method. A cross-sectional study was conducted, with 3881 adolescents in 39 schools completing an anonymous
questionnaire as part of the Child and Adolescent Self-harm in Europe (CASE) study. There was an equal gender
balance and 53.1% of students were 16 years old. Information was obtained on history of self-harm life events, and
demographic, psychological and life-style factors.
Results. Based on multivariate analyses, important factors associated with DSH among both genders were drug use
and knowing a friend who had engaged in self-harm. Among girls, poor self-esteem, forced sexual activity, self-harm
of a family member, fights with parents and problems with friendships also remained in the final model. For boys,
experiencing bullying, problems with schoolwork, impulsivity and anxiety remained.
Conclusions. Distinct profiles of boys and girls who engage in self-harm were identified. Associations between DSH
and some life-style and life event factors suggest that mental health factors are not the sole indicators of risk of self-
harm. The importance of school-related risk factors underlines the need to develop gender-specific initiatives in
schools to reduce the prevalence of self-harm.
Received 18 June 2009; Revised 8 November 2009; Accepted 16 November 2009; First published online 8 January 2010
Key words: Adolescence, deliberate self harm, gender differences, school-based survey.
Deliberate self-harm (DSH) is recognized worldwide
as a major public health problem, with a severe impact
on the individual, their family, and the health services
(World Health Organization, 1999). In the Republic of
Ireland, the highest rates of hospital-treated DSH are
among 15- to 19-year-old girls (639 per 100000) and
20- to 24-year-old men (433/100000) (National Suicide
Research Foundation, 2009). Young Irish men are also
over-represented among those who die by suicide,
with peak rates among those aged 20–24 years, unlike
most European countries where suicide rates increase
with age (National Suicide Research Foundation,
2009). DSH includes a range of behaviours associated
with different levels of medical severity and varying
levels of suicidal intent.
Population-based studies reveal the prevalence of
DSH to be much higher than indicated by hospital
presentations. The school-based Child and Adolescent
Self-harm in Europe (CASE) study, on which this
study is based, reported that 9.1% of Irish adolescents
surveyed had harmed themselves at some point, of
whom 45.9% reported repeated episodes (Morey et al.
2008). This was a higher prevalence than previously
(O’Sullivan & Fitzgerald, 1998; Lynch et al. 2006). Self-
harm was much more common among girls than boys.
Self-cutting and overdose were the most common
DSH methods (Morey et al. 2008).
International comparisons of the prevalence of
DSH have been aided by the development of rigorous
methodologies including clear definitions of DSH,
such as that used by seven international centres in-
volved in the CASE study, including the present study
based on the data of the Irish CASE centre. Lifetime
* Address for correspondence: E. Arensman, Ph.D., National
Suicide Research Foundation, 1 Perrott Avenue, College Road, Cork,
Republic of Ireland.
Psychological Medicine (2010), 40, 1811–1819.
f Cambridge University Press 2010
prevalence of DSH in adolescents ranges from 5.7%
(The Netherlands) to 17% (Australia) among girls and
2.4% (The Netherlands) to 6.5% (Belgium) among
boys (Madge et al. 2008).
Less than one-fifth of adolescent self-harm comes to
the attention of the health services, with approxi-
mately one-third seeking help from their social circle
only, and around half not seeking help at all (Ystgaard
et al. 2009). However, a history of self-harm is a major
risk factor for repeated self-harm and subsequent
suicide (Gunnell et al. 2008; Tidemalm et al. 2008).
A retrospective study of young people who died by
suicide found that almost half had a known history of
DSH (Hawton et al. 1999). Suicide is the leading cause
of death in men aged 15–34 years in the Republic
of Ireland, and suicide rates among young people
aged 15–19 years in the Republic of Ireland are the
third highest in the European Union (Eurostat,
2009). Enhanced knowledge of the factors associated
with self-harm is essential in developing appropriate
education, prevention and screening programmes,
which have been identified as important compo-
nents of suicide prevention policies (Garland & Zigler,
1993; Evans et al. 2004; Scott et al. 2009). A growing
number of population-based studies have examined
various factors potentially associated
harm among young people (Evans et al. 2004). Our
school-based study aimed to examine a broad range of
factors potentially associated with DSH in boys and
girls from psychological, life-style and life event do-
mains, using the novel and rigorous CASE method-
Design and participants
The study was conducted using a cross-sectional de-
sign. Data were gathered in schools in the counties of
Cork and Kerry in the Republic of Ireland during late
2003 and early 2004. Power calculations indicated that
a minimum of 3000 students was required to return
a 95% confidence interval (CI) of 9.0–11.0% for a pos-
tulated prevalence of DSH of 10%. A list of all schools
within Cork and Kerry was obtained and each school
was categorized by region as well as by type of school:
co-educational, all boys or all girls. Using a random
selection, 54 schools were invited to take part and 39
schools participated in the survey.
Principals and teaching staff were informed about
the study procedure in advance. An information sheet
and opt-out form were sent to parents. Students were
also given the opportunity to opt out on the day of
the survey. Ethical approval for the study was granted
by the Clinical Research Ethics Committee of the
Cork Teaching Hospitals. The questionnaire was
administered with a member of the research team
present and completed by students in a class setting.
After participants had completed the survey there was
a general discussion about the help and support
available for young people in their local communities
and each participant received a resource kit. Students
who wished to ask further questions could approach
the facilitators after the session.
The survey in the Republic of Ireland was part of the
CASE study (Madge et al. 2008). A standardized, in-
ternationally validated, anonymous questionnaire was
designed by CASE collaborators and used for data
collection by each of the seven centres involved in the
study (six centres in Europe and one in Australia). The
questionnaire comprised a wide range of variables,
including demographics, life-style factors and ques-
tions about DSH and self-harm thoughts. The ques-
tionnaire also included three validated psychological
scales. Depressivesymptoms and anxiety
measured using the Hospital Anxiety and Depression
Scale (HADS), which has been validated for use
with an adolescent population (White et al. 1999).
Cronbach’s a for our sample was 0.71 and 0.79 for
the depression and anxiety subscales, respectively.
Impulsivity was measured using six items from the
Plutchik impulsivity scale (Plutchik et al. 1989). This
scale assesses impulsivity that is independent of
aggressive behaviour and has shown good internal
consistency and concurrent validity in adolescents
(Plutchik & Van Praag, 1989; Grosz et al. 1994). Self-
esteem was measured using an eight-item version of
the self-concept scale (Robson, 1989). Strong conver-
gent and discriminant validation of the scale has been
reported (Addeo et al. 1994). Cronbach’s a for our
sample was 0.71 for the impulsivity scale and 0.91 for
the self-esteem scale. The selection of variables in-
cluded in the questionnaire was based on empirical
findings of smaller-scale studies conducted previously
which showed potential associations between DSH
and various factors, as well as the theoretical literature
concerning the self-harm process.
A distinctive aspect of this study was that partici-
pants who reported self-harm were asked to describe,
in their own words, the method(s) they had used to
harm themselves. This description was later coded
according to a standardized definition of deliberate
self-harm: ‘An act with non-fatal outcome in which an
individual deliberately did one or more of the follow-
ing: initiated behaviour (for example, self cutting,
jumping from a height), which they intended to cause
self-harm; ingested a substance in excess of the
1812 E. M. McMahon et al.
prescribed or generally recognizable therapeutic dose;
ingested a recreational or illicit drug that was an
act that the person regarded as self-harm; or ingested
a non-ingestible substance or object’ (Madge et al.
2008). Episodes of DSH were classified as a ‘yes’, ‘no’
or ‘no information given’ by three independent raters
using the standardized definition above (Cohen’s
k=0.77). When participants reported that they had
harmed themselves in the past but did not describe
the act, they were classified ‘no information given’
and were not included as a DSH case. The definition
used allowed for a wide range of motives and levels
of suicidal intent. Self-harm thoughts were defined as
having thoughts of harming oneself without acting on
them on that occasion.
Most questions relating to history of various nega-
tive life events were answered by ‘yes’ or ‘no’, and
included the timing of the event (more than 1 year
ago or within the previous year). Additional questions
relating to alcohol consumption included number of
drinks consumed in a typical week and number of
times drunk. For the purposes of this analysis, re-
spondents were classified into four categories based
on alcohol consumption and drunkenness pattern.
Heavy drinking was defined as four or more episodes
of drunkenness in the past year (Rossow et al. 2007),
and heavy drinkers were compared with all other
patterns of alcohol consumption (abstainers, light and
Smoking behaviour was categorized to include all
current smokers in one category while non-smokers
and ex-smokers formed the second category. Use of
illegal drugs was assessed by questions relating to five
different categories of illegal drug. Respondents with
and without illegal drug use in the past year were in-
cluded in two separate categories. Information ob-
tained on living arrangements was recoded into either
living with both parents or any other family structure
for the purpose of this analysis.
Of the 54 schools invited to participate, 39 schools took
part in the study. Of the 4583 students invited to
complete the questionnaire, 3881 participated in the
survey (85% response rate). Of the surveys, eighty
were then disregarded as these did not fit the age cri-
terion of 15, 16 or 17 years, were not filled in seriously,
or gender was missing. Surveys were judged to have
not been completed seriously if responses were in-
consistent or if they included statements indicating
that the questionnaire was not taken seriously. A total
of 52% of the participants were girls and the majority
(53.1%) of students were aged 16 years.
Proportions of boys and girls reporting self-harm and
self-harm thoughts were compared by calculating 95%
CIs assuming a t approximation. To investigate the
associations between DSH and potential associated
factors, x2tests were performed. Because there was
clear evidence that associations were modified by
gender (i.e. interaction) all analyses were carried out
separately for boys and girls. For each potential associ-
ated factor, we computed crude age-adjusted odds
ratios (ORs) for lifetime DSH. A multivariate logistic
regression model was constructed. The method used
was backward with the usage of likelihood ratios. The
probability for stepwise removal was set at 0.01. A low
threshold for removal was set due to the large sample
size giving adequate power and the fact that a wide
range of variables was included with many statisti-
cally significant crude associations. All categorical
variables entered in this model were dichotomous.
To check the consistency of the model a forward ap-
proach with a probability of stepwise entry of 0.005
was also used. The data were analysed using the stat-
istical software package SPSS 16.0.2 (SPSS Inc., USA).
Prevalence of DSH
More detailed findings on the prevalence of self-harm
in our population have been reported elsewhere
(Morey et al. 2008). Marked gender differences were
evident in the prevalence of DSH, with more than
three girls for every one boy reporting a lifetime his-
tory of DSH, DSH in the previous year and self-harm
thoughts (Table 1).
Univariate analyses: association between lifetime
history of DSH and risk factors
Lifetime history of DSH was associated with a range
of mental health, psychological, life-style and life
event factors (Table 2). All four psychological scales/
subscales were strongly associated with DSH for both
genders. ORs for anxiety, self-esteem and impulsivity
and DSH were higher for boys than for girls, with
higher ORs for increased levels of depressive symp-
toms among girls than among boys.
Among girls, the factor most strongly associated
with self-harm was serious physical abuse (OR 12.03,
95% CI 7.53–19.21). Among boys, knowing a friend
who engaged in DSH was the factor most strongly
associated with DSH (OR 10.90, 95% CI 6.78–17.54).
Both boys and girls who knew of a family member
who engaged in DSH were more likely to report DSH
themselves. For both genders, all negative life events
Deliberate self-harm among Irish adolescents1813
examined were associated with DSH at the 0.0005
level, with the exception of death of a family member
among both girls and boys and death of someone else
close among girls. ORs for problems with a boyfriend
or girlfriend were higher among boys (OR 5.31,
95% CI 3.34–8.42) than among girls (OR 2.82, 95% CI
2.12–3.74), as were worries about sexual orientation.
Having experienced bullying at school was also
more strongly associated with self-harm among boys
Table 2. Factors associated with lifetime history of self-harm
Girls only Boys only
odds ratio95% CIp
odds ratio95% CIp
Serious physical abuse
DSH of family member
Forced sexual activity
Fights with parents
DSH of friend
Drug taking in past year
Worries about sexual orientation
Trouble with the police
Problems with schoolwork
Other distressing event
Fights with friends
Difficulty making/keeping friends
Arguments between parents
Bullied at school
Friend/family member suicide
Self/family member serious illness
Serious illness of close friend
Not living with both parents
Death of family member
Death of someone else close
CI, Confidence interval; DSH, deliberate self-harm.
aOdds ratio for one point increase in score.
Table 1. Prevalence of self-harm and self-harm thoughts (adapted from Morey et al. 2008)
pNo. (%)No. (%)99% CI No. (%)99% CI
Lifetime history of self-harm
Self-harm in past year
Self-harm thoughts in past year
CI, Confidence interval.
1814E. M. McMahon et al.
Potential associations between DSH and several
life-style factors were examined. Those adolescents
who had used illegal drugs in the past year reported
more DSH than those with no drug use. The associ-
ation between drug use and DSH was the strongest of
all factors examined for both genders. Smoking and
heavy drinking (defined by at least four episodes of
drunkenness in the past year) were also significantly
associated with DSH.
Multivariate analyses: association between lifetime
history of DSH and risk factors
Based on multivariate analysis, six factors remained
associated with DSH among boys and seven factors
among girls (Table 3). The only common factors that
remained in the final model among both boys and
girls were knowing a friend who had engaged in DSH
and drug use in the past year. Of the four psycho-
logical scales/subscales included in the analysis, only
self-esteem remained in the final model for girls. For
boys, both anxiety and impulsivity remained. For
boys, two school-related factors were in the model:
problems with keeping up with schoolwork and
having experienced bullying at school. For girls, there
were two factors in the domain of relationships:
problems in making or keeping friends and serious
fights with parents. Having been forced to engage in
sexual activity against their will remained for girls
only, as did knowledge of a family member who had
engaged in DSH.
In terms of broad domains of risk factors, psycho-
logical and school-related factors featured strongly
in the final model for boys, while interpersonal and
relationship factors had greater importance for girls.
The knowledge of self-harm by friends as well as drug
use were common to both genders.
This school-based study sought to identify the factors
associated with DSH among Irish adolescents. In our
large representative sample we found that the factors
strongly associated with the reporting of a lifetime
history of DSH differed by gender, with each set
of factors suggesting a profile of at-risk youth. The
specificfemale profileisoneinvolving low self-esteem,
relationship problems (difficulties with parents and
friends) and forced sexual activity. The male profile
involves anxiety, impulsivity and school problems
(bullying and schoolwork difficulties). Additionally,
the factors shared by girls and boys relate to drug
taking and knowing others who engage in DSH.
Our finding that knowledge of self-harm by a friend
was strongly associated with DSH for both genders
lends support to previous studies pointing to the con-
tagion of suicidal behaviour (Borowsky et al. 2001;
Marusic et al. 2004). The strong association that we
found between DSH and knowledge of DSH in a
friend was also reported by other CASE study centres
in Australia (De Leo & Heller, 2004) and the UK
(Hawton et al. 2002). The clustering of suicidal behav-
iour has been found to be a particularly distinctive
feature among adolescents only (Gould et al. 1994).
Therefore, the school setting may be appropriate
for interventions to limit possible ‘copycat’ effects
of self-harming behaviour. However, due to the
Table 3. Multivariate logistic regression for lifetime history of DSH
Girls only Boys only
odds ratio95% CIp
odds ratio 95% CIp
DSH of friend
Any drugs in past year
DSH of family member
Forced sexual activity
Difficulty making/keeping friends
Fights with parents
Problems with schoolwork
Bullied at school
DSH, Deliberate self-harm; CI, confidence interval.
Deliberate self-harm among Irish adolescents1815
cross-sectional design, investigation of pathways to
self-harm was not possible.
Drug use in the past year was associated with DSH
for both genders. It is worth noting that the majority of
adolescents in this sample reported drug use, making
this a relatively commonplace event among those who
had not harmed themselves as well as those who had.
However, unlike heavy drinking and smoking, use of
illegal drugs remained in the multivariate analysis for
both genders. It may be that motives for drug taking
and for DSH are similar. The mostly commonly re-
ported motive for self-harm in this group of young
people was ‘to get relief from a terrible state of mind’
(Morey et al. 2008). Self-medication for psychological
distress has also been reported to be a central motive
in adolescent drug use (Sattar et al. 2007). Therefore,
it may be that young people experiencing distress
attempt to relieve these negative feelings through
drug use and, in some cases, self-harm.
Consistent associations between depression and
suicidal behaviour in adolescents have been reported
elsewhere (Evans et al. 2005). Although significantly
associated with DSH in our univariate analyses, de-
pressive symptoms did not remain in the multivariate
analysis for either gender. This echoes the findings of
Harrington et al. (2006), who reported that the inde-
pendent contribution of major depression to risk of
self-harm among adolescents was not significant
(Harrington et al. 2006). Hawton et al. (2002) reported
that, for the English CASE centre, psychological fac-
tors were more strongly associated with DSH among
girls than boys and that depression, anxiety, im-
pulsivity and self-esteem all remained in the final
model for girls. In contrast, we found that mental
health/psychological factors were more important for
boys, with the exception of depression. Anxiety and
impulsivity remained in the final model for boys, in-
dicating a profile of young male self-harm in the
Republic of Ireland which is distinct in its psycho-
logical correlates. The finding that self-esteem re-
mained in the final model for girls is in keeping with
other studies (Beautrais et al. 1999).
Adolescents who had self-harmed had significantly
higher levels of anxiety, depression and impulsivity
and lower self-esteem than those who had not, sup-
porting the view that adolescent self-harmers of both
genders form a subgroup with more severe psycho-
pathology (Voros et al. 2005). However, our findings
that certain life events, exposure to DSH in others, and
drug use have stronger associations with DSH than
some mental health factors offer alternative indicators
for the identification of at-risk youth.
This study was carried out using a cross-sectional
design, which makes it difficult to draw conclusions
on causal or temporal relationships between risk
factors and DSH. The study examined self-harm epi-
sodes reported to have happened at any time in
the past, and therefore reported self-harm did not
necessarily occur after the various associated factors
and events, making it difficult to draw conclusions on
causality. The psychological scales and life-style items
measured current state and life-style at one time point
only, which may have been up to several years after
any reported DSH. Controlled longitudinal studies are
recommended in order to examine the direction of the
effect and specificity of the risk factors associated with
This study does not examine the severity of self-
harming behaviour. Further research should focus on
the subgroup of adolescents who report repeated
DSH, as these may constitute a group at high risk of
further self-harm and suicide. A continuum of severity
could be postulated which ranges from no self-harm
thoughts or behaviour, through self-harm thoughts
only, single-episode DSH and repeated DSH. A pro-
spective study has reported that the factors associated
with a first act of DSH in adolescence differ from those
associated with a repeat act (O’Connor et al. 2009a),
underlining the importance of examining different
stages of the self-harm process. This study focused
on identifying factors associated with risk of self-
harm in adolescents. There may also be positive con-
figurations of life-style and psychological factors
which confer resilience to suicidal behaviour, and
which should be the focus of further research due to
their relevance to promotion of positive mental health
strengths of our study include the use of multivariate
analysis to describe a range of factors associated with
DSH for each gender. The wide range of risk factors
identified by the survey supports a life-course model
of the aetiology of DSH, in which risk of develop-
ing suicidal behaviour depends on accumulation of
psychological and social factors and a broad variety of
negative life events across the lifespan from childhood
into adolescence (Fergusson et al. 2000). The associ-
ations we have identified between lifetime history of
certain life events and DSH may reflect the importance
of childhood experiences as well as more age-specific
stressors associated with adolescence.
Research examining whether national trends and
cross-national differences in prevalence of DSH are
mirrored in suicide rates has revealed contradictory
findings (Portzky et al. 2008; O’Connor et al. 2009b).
However, it is worth noting that a remarkable charac-
teristic of Irish suicide rates in recent years is the sharp
increase in suicide among young men since the 1990s
(Department of Public Health, 2001). Prospective
studies of those treated for DSH have found strong
1816 E. M. McMahon et al.
links between DSH and subsequent suicide (Hawton
et al. 1993; Tidemalm et al. 2008). The relatively low
prevalence of DSH among boys, combined with the
high rates of suicide in males in this age group, may
indicate that the subgroup of boys who report DSH is
a particularly high-risk group. It is also a possibility
that some boys were reluctant to disclose details of
their self-harm, resulting in artificially low prevalence
(Keeley, 2008). The profile of the male adolescent self-
harmer described here as involved in drug use, with
high levels of impulsivity and anxiety and with
peers who have also self-harmed bears a close resem-
blance to the profile of young men who die by suicide
(Walinder & Rutzt, 2001). Interestingly, such a profile
does not mirror that reported by the English CASE
centre, which found anxiety and impulsivity to be
most associated with DSH among girls (Hawton et al.
As well as striking similarities in terms of the
importance of factors such as knowledge of DSH in
others and drug use, there are some important differ-
ences between our findings and those of the English
and Scottish CASE studies, nearest geographically to
the Republic of Ireland. Forced sexual activity was
associated with DSH among girls in our multivariate
analysis but this was not the case in the English or
Scottish studies. This association warrants further
examination in terms of prevalence and correlates
among the Irish sample. Among boys, the strength
of the associationbetween
factors – school bullying and, in particular, problems
with schoolwork – was unique among CASE centres.
Problems with schoolwork were the most frequently
reported of all negative life events for both genders
among our sample (Sullivan et al. 2004). The associ-
ations between DSH and schoolwork problems and
school bullying may reflect the particular social and
educational pressures of second-level education in the
Republic of Ireland.
Given the fact that DSH is common among adoles-
cents, schools have an important role to play in its
prevention. Our findings also underline the import-
ance of school-based risk factors among boys, bringing
the focus onto the school as central in preventing self-
harm and suicide in boys. This in keeping with the
recommendations of the Irish ‘Reach Out’ strategy
for suicide prevention (Health Service Executive,
2005). Primary prevention strategies should aim to
modify factors associated with self-harm through pro-
motion of positive mental health among all students,
and through equipping students with the skills to
positively manage stress, and interpersonal conflict
(Sullivan et al. 2004). Our findings also point to the
importance of anti-bullying initiatives and drugs
education. Secondary prevention strategies could be
aimed at individuals who have been identified as at
risk of suicidal behaviour. School-based screening
has been found to identify suicidal and emotionally
troubled adolescents who had not been identified as at
risk by school staff (Scott et al. 2009). Early support and
help for young people who have harmed themselves
are crucial to prevent further episodes, as environ-
mental influences on suicidal behaviour have been
shown to be most pronounced early in the suicidal
process, but less so following repeated episodes
(Neeleman et al. 2004). School welfare staff are ideally
placed to provide this support, and specific training in
managing self-harm has been found to increase their
confidence and skills (Robinson et al. 2008). The school
environment is also a critical arena in which the
stigma surrounding mental health problems must be
tackled (Health Service Executive, 2005). Knowledge
of the gender- and country-specific profile of young
people who engage in self-harm can inform preven-
tion strategies and aid identification of those at risk.
We thank the National Suicide Review Group, the
Ireland Funds and the Pobal-Dormant Accounts Fund
who provided funding for this study. We also thank
Carolyn Morey for her leading role in the data collec-
tion and for her input in the data entry and data
analysis, Rachel Farrow and Eric Kelleher who were
involved in the data collection, Eileen Williamson for
her programme support, the school staff who helped
us with the study, the students who participated and
Dr Nicola Madge and Dr Erik Jan de Wilde for co-
ordinating the study at the international level. The re-
search was conducted in collaboration with the Child
and Adolescent Self-harm in Europe (CASE) study.
The work was done by the National Suicide Research
Foundation, Cork, Republic of Ireland.
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