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Appreciating Complexity in Adolescent Self-Harm Risk Factors: Psychological Profiling in a Longitudinal Community Sample

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Past research identifies a number of risk factors for adolescent self-harm, but often fails to account for overlap between these factors. This study investigated the underlying, broader concepts by identifying different psychological profiles among adolescents. We then compared new self-harm rates over a six-month period across different psychological profiles. Australian high school students (n = 326, 68.1% female) completed a questionnaire including a broad range of psychological and socioenvironmental risk and protective factors. Non-hierarchical cluster analysis produced six groups with different psychological profiles at baseline and rate of new self-harm at follow-up. The lowest rate was 1.4% in a group that appeared psychologically healthy; the highest rate was 37.5% in a group that displayed numerous psychological difficulties. Four groups with average self-harm had varied psychological profiles including low impulsivity, anxiety, impulsivity, and poor use of positive coping strategies. Identifying multiple profiles with distinct psychological characteristics can improve detection, guide prevention, and tailor treatment.
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J Youth Adolescence
DOI 10.1007/s10964-017-0721-5
EMPIRICAL RESEARCH
Appreciating Complexity in Adolescent Self-Harm Risk Factors:
Psychological Proling in a Longitudinal Community Sample
Sarah Stanford
1
Michael P. Jones
1
Jennifer L. Hudson
1
Received: 16 March 2017 / Accepted: 11 July 2017
© Springer Science+Business Media, LLC 2017
Abstract Past research identies a number of risk factors
for adolescent self-harm, but often fails to account for
overlap between these factors. This study investigated the
underlying, broader concepts by identifying different psy-
chological proles among adolescents. We then compared
new self-harm rates over a six-month period across different
psychological proles. Australian high school students (n=
326, 68.1% female) completed a questionnaire including a
broad range of psychological and socioenvironmental risk
and protective factors. Non-hierarchical cluster analysis
produced six groups with different psychological proles at
baseline and rate of new self-harm at follow-up. The lowest
rate was 1.4% in a group that appeared psychologically
healthy; the highest rate was 37.5% in a group that dis-
played numerous psychological difculties. Four groups
with average self-harm had varied psychological proles
including low impulsivity, anxiety, impulsivity, and poor
use of positive coping strategies. Identifying multiple pro-
les with distinct psychological characteristics can improve
detection, guide prevention, and tailor treatment.
Keywords Self-harm Risk factors Adolescence
Psychological proles
Introduction
Self-harm is common among teens, with community pre-
valence estimated at 515% and even higher (Brunner et al.
2014; Madge et al. 2008; Moran et al. 2012; Stallard et al.
2013). Self-harm rates are thought to peak in mid-adoles-
cence, with an average onset of self-harm around age 1214
(Jacobson and Gould 2007). Rates gradually decrease
throughout older adolescence and the emerging adult years
(Moran et al. 2012). Adolescent self-harm is a considerable
source of stress for those supporting a teen through self-
harm, including family and friends (McVey-Noble et al.
2006), and those who work with teens in schools and in
other community settings (Best 2006). Two reasons for
stress are: concern for the teens physical safety, and the
potential for contagion among peers. First, while self-harm
often occurs without suicidal intent, self-harm is a strong
risk factor for suicide attempt (Taliaferro and Muehlenkamp
2014) and completed suicide (Yoshimasu et al. 2008).
Second, there is evidence that self-harm by friends is
associated with increased risk of self-harm (OConnor et al.
2009), leading to concern that social contagion may occur
following self-harm. In light of these concerns, research is
required in order to better understand, prevent, and treat
self-harm (Robinson et al. 2016). This study contributes to
this knowledge gap by developing our understanding of
psychological risk factors for self-harm in adolescence
using a prole analysis.
This study adopts a broad denition of the term self-
harmas any behavior that is intentionally self-inicted with
immediate physical consequences (Morgan 1979), includ-
ing self-harm with and without suicidal intent. It is difcult
to draw distinct categories between suicidal and non-
suicidal self-harm since suicidal intent is complex and can
be ambiguous and transient (Brunner et al. 2014; Hawton
*Sarah Stanford
Sarah.stanford@mq.edu.au
1
Macquarie University, Balaclava Rd, North Ryde, NSW 2109,
Australia
et al. 2010; Kapur et al. 2013; Lofthouse and Yager-
Schweller 2009). Indeed, Joiners interpersonal theory of
suicide (2005) proposes that self-harm desensitizes people
towards self-destructive behavior, which may increase the
likelihood of people acting on suicidal thoughts.
There is a growing understanding of the factors asso-
ciated with self-harm, although much is yet to be under-
stood regarding the mechanisms and interactions at play
(Hawton et al. 2012). In selecting factors to focus on in this
study, we prioritized factors that were included in large
community adolescent samples (for more detail see Stan-
ford and Jones 2015). Notable large international studies
include the Saving and Empowering Young Lives in Eur-
ope (SEYLE) project with 12,068 adolescents (Brunner
et al. 2014) and the Child & Adolescent Self-harm in
Europe (CASE) study consisting of 30,477 adolescents
(Madge et al. 2011). These larger studies sit within a
growing literature base that includes a number of smaller
but nonetheless substantial studies. For example, Heerde
and colleagues (2015) report on a longitudinal study of
3876 adolescents in Australia and the US participating in
the International Youth Development Study; Mars and
colleagues (2014) present ndings from 4799 adolescents in
the UK participating in the Avon Longitudinal Study of
Parents and Children. Findings from this research body
identify psychological risk factors that are consistently
associated with increased self-harm; from these we selected
depressive and anxiety symptoms, self-esteem, impulsivity,
and attention and conduct difculties. Prior work has
focused more on risk factors rather than protective factors
(Fortune and Hawton 2005) but protective factors are an
important area for future research (Fliege et al. 2009).
Psychological protective factors include coping strategies
(Guerreiro et al. 2015), meaning in life (Kleiman and
Beaver 2016) and life satisfaction (Heisel and Flett 2004).
While the focus is on psychological factors, this study
includes a number of social and environmental factors that
are frequently included in risk factor research. Factors
commonly measured in association with self-harm include
age, gender, ethnicity, parental divorce/separation, bullying,
and self-harm modeling (Brunner et al. 2014; Hawton et al.
2012). Protective factors include supportive relationships
and spirituality (Brunner et al. 2014).
There are several limitations that are commonly
acknowledged in past self-harm risk factor research. For
example, using clinical samples limits generalizability to
community settings, cross-sectional designs limit our
understanding of the causal pathway, and using a narrow set
of factors limits comparability between variables and fails to
account for the effect of unmeasured variables (Wilcox et al.
2012). However, there is an important conceptual limitation
that is less often discussed. Research typically approaches
risk factors as distinct components. That is, depression,
anxiety, and self-esteem, for example, are considered
unique factors. Yet we know that there is considerable
overlap between these factors. A potential problem with
assigning risk factor status to a specic construct is that it
might just be a proxy for the realrisk factor. Therefore
researchers are beginning to develop another way of
approaching the risk factor problem to consider multiple
overlapping variables simultaneously.
In recent years, a small contingent of research has begun
to take a prole approach to investigate self-harm in more
complex ways. Somer and colleagues (2015) explain that
prole or latent class analyses identify comparatively
homogeneous subpopulations from within the hetero-
geneous population of people who report self-harm. An
improved understanding of these groups could assist in
understanding people who self-harm, developing interven-
tions, informing treatment decisions, and developing mod-
els to explain self-harm (Klonsky and Olino 2008; Somer
et al. 2015). However, past prole research has primarily
focused on the characteristics of self-harm behavior rather
than on the psychological prole of those who self-harm.
For example, research has identied subtypes within those
who report self-harm based on severity and method of self-
harm in adolescents (Somer et al. 2015) and in adults
(Hamza and Willoughby 2013; Bracken-Minor et al. 2012;
Klonsky and Olino 2008; Whitlock et al. 2008). A con-
sistent nding across these studies is that increased self-
harm severity and frequency was associated with increased
psychological pathology and more severe suicidal behavior.
Research using adolescent samples has also focused on
combined psychological, suicidal and sociodemographic
factors (Jiang et al. 2010), or a range of risk taking beha-
viors including self-harm (Thullen et al. 2015). In each of
these studies, aspects of self-harm and/or suicidal behavior
were included in the variables used to create the proles
along with other risk factors. Researchers have used the
prole approach to identify variability in relationships with
parents and peers in adolescent (Lundh et al. 2009) and
university samples (Martin et al. 2016).
In contrast to prior work, this study focuses on psycho-
logical risk factors for self-harm. It will assign individuals
to groups based entirely on psychological proles and
explore how these proles relate to self-harm behavior at
follow-up. Since this is a study of risk factors, self-harm
behavior is not included in the prole creation. Instead, the
analysis focuses on the variables thought to be earlier in the
causal pathway (Kraemer et al. 2001). Research focused on
psychological proles is extremely limited. In our previous
Australian community sample, adolescents grouped natu-
rally into six distinct proles of individuals based on a range
of factors including depression, anxiety, low self-esteem,
coping strategies, and impulsivity (Stanford and Jones
2012). Two proles were characterized by having an
J Youth Adolescence
undesirable psychological prole that could be loosely
described as psychopathology. The six proles of indivi-
duals could be divided into three with comparatively low
rates of self-harm (516% lifetime prevalence) and three
with comparatively high rates (2558% lifetime pre-
valence). Not surprisingly, the three groups that could be
broadly described as having a normalpsychological pro-
le had low self-harm rates. Of the three high self-harm rate
proles, one was characterized only by high scores on
impulsivity but was otherwise unremarkable (lifetime self-
harm prevalence 33%). The two remaining high self-harm
rate proles were both characterised by psychological
pathology, but distinguishable by their use of coping stra-
tegies. One pathological group demonstrated positive cop-
ing strategies, and lifetime self-harm prevalence was 25%.
The other group with psychological pathology had poor
coping and low social support; lifetime self-harm in this
group was 58%. However its cross-sectional design and
combining high school and university students in the sam-
ple limited this study.
Current Study
The current study reports on 326 Australian high school
students who completed a baseline survey and a six-month
follow-up. Since the mechanisms and interactions under-
lying self-harm are not yet well understood (Hawton et al.
2012), this study aims to deepen the current understanding
of the psychological risk factors for self-harm. The aim is to
compare the rate of new self-harm at six-month follow-up
in groups with different psychological proles. We hypo-
thesize that proles with poorer psychological function at
baseline will be associated with higher rate of new self-
harm at six-month follow-up, as found in past cross-
sectional research (Somer et al. 2015; Stanford and
Jones 2012). To further understand these groups, we
will describe a range of social and environmental
factors. The study extends prior work by using a long-
itudinal design in an adolescent sample. These results will
assist teachers, counselors, and others who work with
adolescents in community settings to identify adolescents
who may be at risk of future self-harm. Applications of
these ndings are pertinent for both prevention and inter-
vention strategies.
Methods
Participants
Data were collected as part of the Youth Coping Project to
investigate youth coping and welfare. This article reports on
the subset who completed the baseline survey and a six-
month follow-up (n=326), which is part of a larger base-
line sample (n=1521). Participants were in year 711 at
baseline in 2014, and year 812 at follow-up 6 months later
in 2015. The sample was 68.1% female (n=222) and mean
age was 14.1 (SD =1.4). These students were drawn from
four mainstream co-educational schools and one girls
school. The majority of students were born in Australia
(90.8%) and their biological parents were married (81.3%).
All participating schools were private, fee-charging schools
(Independent or Catholic), however the nancial prole of
the participating schools varied. Median weekly income
(based on Census 2011) for the suburbs of the schools
ranged from $711 to $2513 and annual school fees for a
Year 7 student ranged from $5000 to $13,655. There was a
small degree of variability in mental health and socio-
demographic factors between the schools, as expected given
the geographical area covered. Inclusion required a satis-
factory level of competence in reading and comprehending
English. Participants and their parents provided informed
consent. The study had ethical approval from Macquarie
University. Participation rate varied by school, depending
the schools success in collecting parental consent and
availability for students to participate during class time.
Participating students received a small token of appreciation
(i.e., chocolate or novelty gift) and participating schools
received a welfare report summarising data for their school.
The overall response rate for the rst survey (Survey 1) was
30.2%; of these, 58.7% completed the follow-up survey
(Survey 2).
Measures
Students completed the online questionnaire during class
time and most students completed the survey in 1525
minutes. Measures were selected to prioritize factors with
strong prior association with self-harm and to include a
number of protective factors. We selected brief, validated
scales where possible. Scales were not diagnostic.
Self-harm
Self-harm behavior was assessed in two parts. The rst
question asked broadly about lifetime self-harm: Have you
tried to hurt yourself? You should answer Yesif you have
TRIED to hurt yourself, whether or not you were success-
ful. You should NOT include hurting yourself by accident
(response options No/Yes). The second part asked more
specically about six-month self-harm frequency, with
response options None, I have not self-harmed in the last
6 months; 1; 25; 610; 11+(Lloyd-Richardson et al.
2007). This approach is similar to brief measures of self-
harm used in prior research (Haavisto et al. 2005; Hay and
J Youth Adolescence
Meldrum 2010; Kaminski et al. 2010; Tolmunen et al.
2008) and past research indicates that adolescents are able
to accurately self-code behavior (Stanford and Jones 2010).
Self-harm frequency was dichotomized into Occasional (5
occurrences) and Repetitive self-harm (6+occurrences).
Self-harm modeling was measured by asking how many
friends and how many family members have hurt them-
selves on purpose in the last six months.
Depression and anxiety
Depressive and anxiety symptoms were measured using the
14-item Hospital and Anxiety Depression Scale (HADS),
originally developed by Zigmond and Snaith (1983). Par-
ticipants responded on a four-point likert scale from Most
of the timeto Not at allto items such as I feel tense or
wound up(anxiety symptoms) and I still enjoy the things I
used to enjoy(depressive symptoms). The HADS has been
used in previous adolescent self-harm research (e.g., Madge
et al. 2008) and has been shown to have adequate test-retest
reliability and good discriminant validity in adolescent
samples (White et al. 1999). Internal consistency in our
sample was good for depressive and anxiety symptoms
(Cronbachs alpha .72 and .83, respectively).
Self-esteem
Self-esteem was measured with the ten-item Rosenberg
Self-Esteem Scale (RSES). It measures self-acceptance,
self-respect, and positive self-evaluation on a 4-point scale
from strongly agreeto strongly disagree. The RSES has
shown strong internal consistency, test-retest reliability, and
convergent validity (Swenson 2003), and high self-esteem
was negatively correlated with emotional and behavioral
disorders for most age/gender combinations (r=.42 to
.65) (Bagley and Mallick 2001). Internal consistency in
our sample was good (Cronbachs alpha .90).
Conduct and attention difculties
Difculties with conduct and attention were measured using
the Externalizing (conduct) and Attention subscales of the
17-item version of the Pediatric Symptom Checklist (PSC).
The youth-report PSC-17 has been used previously in
adolescent samples (Duke et al. 2005; Roffman et al. 2001).
Higher total score correlated negatively with higher self-
esteem (r=.37, p<0.001) and with getting into trouble
(r=.37) (Roffman et al. 2001). In our sample, Cronbachs
alphas were adequate (attention subscale: .78; externalising
(conduct) subscale: .70).
Impulsivity
Impulsivity was measured using six items from Plutchicks
Impulsivity scale, as used in prior self-harm research (e.g.,
Madge et al. 2008). An example item is I plan ahead,with
four likert response options from Almost neverto Very
often.As expected, impulsivity correlated with attention
difculties (r=.42, p<.001) and conduct difculties
(r =.35, p<.001). Internal consistency was lower than
ideal in our sample (Cronbachs alpha: .58).
Coping strategies
Coping was measured using a 14 item shortened version of
the Ways of Coping Questionnaire adapted by Piko (2001);
see also Folkman et al. 1986. Students were asked to think
about a difcult or negative experience you have been
through in the last year. How much did you use these ways
of coping?with ve response options (Noneto Very
much). An example item is I made a plan of action and
followed it.Exploratory factor analysis in two-thirds of the
sample produced three factors according to Kaisers criter-
ion, which appeared to be positive coping, negative coping,
and wishful thinking. For simplicity, we trialed a two-factor
solution and wishful thinking sat well with the negative
factors, offering a comparable t to the three-factor solution
(see Table 3). Each one of our factors aligned with two of
Pikos factors. For example, Pikos support-seeking and
problem-analyzing factors were represented by positive
coping. There were two exceptions. Tried to look on the
bright sidesat with positive coping in our sample, whereas
in Pikos sample this item was on the negative coping sub-
scale. Prayer t with the negative coping strategies in Pikos
sample, but sat with the positive strategies in our sample, in
which 70% identied as Christian. This may reect cultural
differences in optimism in the Australian culture and the
Christian faith in the participating schools. Cronbachs alpha
was adequate for positive (.78) and negative (.69) scales.
Conrmatory factor analysis in the remaining one-third of
the sample broadly supported the two-factor solution. The t
measures were lower than ideal, although broadly supportive
of the two-factor solution. The likelihood ratio test suggests
that the original and conrmatory models are different (χ
2
=
298.7, df =71, p<.001). The root mean square error of
approximation and comparative t index were slightly
higher than ideal (.78 and .87, respectively). Further research
is needed to explore the validity of this measure and
applicability across different cultures and subcultures.
Meaning in life
Meaning in life was measured using the three-item (short-
form) Meaning in Life scale, with a ve-point scale for
J Youth Adolescence
responses (Not at all trueto Completely true; Kobau
et al. 2010). Participants were asked to take a moment to
think about what makes your life feel important to them. An
example item is My life has a clear sense of purpose.
Kobau reports acceptable internal consistency and relia-
bility (α=.89) and correlations with autonomy, compe-
tency, and relatedness show reasonable convergent validity
(r.63). In our sample Cronbachs alpha was high at .91.
Life satisfaction
The ve-item Satisfaction With Life Scale (SWLS) mea-
sures global life satisfaction with good internal consistency,
test-retest reliability, and correlations with other measures
of subjective wellbeing and personality characteristics
(Diener et al. 1985). The SWLS has been used in adolescent
samples (Neto 1993). In our sample Cronbachs alpha was
high at .89.
Sociodemographic variables
Participants reported age, gender, country of birth, parents
marital status and number of older and younger siblings.
Supportive relationships
The Vaux Social Support Record measured connectedness
to family, peers, and adults at school (Vaux 1988). Three
items for each domain measure practical and emotional
support, rated on a three-point scale of Not at all,toA
lot. This version has been used in previous self-harm
research with Cronbachs alpha indicating good internal
consistency (.85 for adults at school; .91 for family mem-
bers; .90 for peers; Kaminski et al. 2010), which was similar
to our sample (friends.82; family .80; school .82).
Bullying
Being a victim of bullying and bullying others were mea-
sured through selected items from Rigbys Bullying Pre-
valence Questionnaire (Rigby and Slee 1993). They report
Cronbachs alpha showing adequate internal reliability for
the victim (.75.78) and bully (.78.86) scales, and low
correlation between the two scales (r<.20). Our sample
showed similar patterns for Cronbachs alpha (victim .84;
bully .67) and correlation between scales (r =.27).
Religious beliefs and practices
Students were instructed to mark strongly disagreeor not
at allif the statements were not relevant, and to substitute
words that t with your religious beliefs and practices.
Importance of faith was measured using the ve-item short
version of the Santa Clara Strength of Religious Faith
Questionnaire (SCSRFQ) (Plante et al. 2002). This measure
is designed for use with multiple religious traditions and has
demonstrated good reliability and validity in a range of
settings (Plante et al. 2002). Religious coping was measured
using a shortened, adapted version of the brief measure of
religious coping (Brief RCOPE), which measures positive
and negative patterns of religious coping methods (Parga-
ment et al. 1998). Positive patterns include religious for-
giveness and seeking spiritual support; negative patterns
surveys spiritual discontent and viewing God as punishing.
The scale was shortened from 14 items to eight by taking
the top four items on each scale (positive and negative); two
items were similar in the top four for negative coping, so
one was excluded and the next highest loading item was
chosen. The items were reworded to adapt to adolescents
e.g., changed Sought help from God in letting go of my
angerto Asked God to help me let go of my anger.
Responses on likert scale Not at allto A lot. Cronbachs
alphas were .93 for the positive scale and .90 for the
negative scale. As expected, the two scales showed minimal
correlation (r =.13). Positive religious coping was corre-
lated with Strength of Faith (r=.41, p<.001) but negative
religious coping was not (r=.13, p<.001).
Procedure
We developed this project in collaboration with schools,
with ethical approval from Macquarie University. Pre-testing
from adolescents and adults provided positive feedback. We
presented the survey as the Youth Coping Research Project,
and invited students to participate to help us understand what
life is like for young people and how they cope with chal-
lenges. The survey was broad and the self-harm measure-
ment was brief, therefore it was not considered advantageous
to draw attention to self-harm beyond listing it in the study
description. The project had a dual-purpose in that partici-
pating schools received a welfare feedback report that
overviewed mental health and wellbeing.
Students and parents provided informed consent after
receiving the information and consent forms through printed
and electronic communication. The information described
the aim and procedures, and included a list of domains
included in the survey. We reminded the school community
about the survey using all forms of school communication
available, including assembly announcements, roll call
reminders, and paper and email newsletters. This commu-
nication emphasized that the survey was both voluntary and
anonymous. Students completed the questionnaire online to
reduce the risk of socially desirable responses and to enable
efcient data collection (Booth-Kewley et al. 2007; LaBrie
et al. 2006). After completing the survey, students were
informed of support available within and outside the school
J Youth Adolescence
(verbally and through printed materials), and researchers
were available to discuss any questions that arose. Students
lled in a support request form, and members of the
schools welfare team followed students who responded
positively. To enable data matching with the second survey,
students created an ID code. This included the last two
letters of their rst name, last two letters of their last name,
rst letter of their rst name, their date of birth, and number
of older siblings.
Analytic Approach
Step 1: we sought to create parsimonious measures of
psychological traits by creating composite components
that combine multiple individual variables. This helps to
avoid any single construct from dominating the next step of
forming proles. This was achieved using principal com-
ponents analysis followed by orthogonal (varimax) rotation
with the following variables: depressive and anxiety
symptoms, self-esteem, attention and conduct difculties,
impulsivity, positive and negative coping, meaning in life,
and life satisfaction. Step 2: we used a non-hierarchical
cluster analysis to allocate students to mutually exclusive
groups (proles) based on the latent components created in
Step 1. The aim was to form independent groups that are
internally homogenous but different from the other proles.
The non-hierarchical approach does not pre-determine how
many proles to form. Therefore we considered a number of
prole solutions from one to ten proles and identied the
point of inection where the within-prole homogeneity
started to plateau using the Euclidean distance (Fig. 1). The
prole of psychological variables was interpreted to char-
acterize the distinguishing features of each prole. Step 3:
we compared rates of new self-harm at six-month follow-up
across proles, which represent distinct psychological pro-
les. We compared the percentage within each prole who
report new six-month self-harm among students who did
not report recent self-harm at baseline. Step 4: we described
the psychological prole and self-harm rates at baseline for
each prole, followed by other social and environmental
factors. Given the non-normal distribution present in many
psychological and demographic variables, we compared
traits across proles using the Pearson Chi-Square tests for
categorical variables and Kruskal-Wallis tests for numeric
variables. Pairwise comparisons between groups similarly
used Pearson Chi-Square tests and Mann-Whitney tests.
Results
Six-month self-harm prevalence at baseline was 12.3%
occasional (n=40) and 5.2% repetitive (n=17). In Step 1
described above, we found three components that
represented the individual psychological variables (Table
1). Poor copingincluded below average use of positive
coping strategies, depressive symptoms, low self-esteem,
and low life satisfaction and meaning in life. Anxiety
symptomsfeatured high anxiety; it also included low self-
esteem and above average use of negative coping strategies.
Impulsivitywas marked by high impulsivity and dif-
culties with attention and conduct behaviors. Factor load-
ings are available in Table 4. As expected, the correlation
between the three components was weak (highest correla-
tion r=.17, p<.001). In Step 2 described above, it
appeared that the benets of increasing complexity dimin-
ished after the six-prole solution (Fig. 1). The six-prole
solution, therefore, was chosen to balance complexity and
efciency. The mean component score for each prole gave
an overview of the psychological characteristics of each
prole (Fig. 2).
In Step 3 described above, we compared the percentage
within each prole who reported new six-month self-harm
among students who did not report recent self-harm at
baseline (Table 1). As expected, new self-harm varied
between the proles, and rates appeared to vary in line with
degree of psychological pathology (1.4% (n=1) to 37.5%
(n=3)). The following section describes the psychological
prole in more detail and briey describes the social and
environmental features of the groups, as described in Steps
3 and 4 above (Tables 1and 2).
Prole 1: Psychologically Healthy1.4% New
Self-Harm
As evident in the psychological component scores in Table
1, this group (n=72) had less anxiety and better than
average use of coping strategies (higher on positive and
lower on negative strategies). The individual psychological
variables in Table 1also showed an overall healthy score
for this prole; low anxiety and high self-esteem were
standout scores. This was accompanied by the lowest rate of
Fig. 1 Euclidean distance for prole solutions 1 to 10: the benets of
increasing complexity diminished after the six-prole solution
J Youth Adolescence
Table 1 Psychological prole of six proles formed at baseline for the longitudinal sample (n=326) and new self-harm at follow-up among those who did not self-harm at baseline (n=269).
Statistics are mean (SD) or % (n)
1 Psychologically
healthy(n=72)
2 Low impulsivity
(n=58)
3 Poor coping
(n=59)
4 Anxiety
(n=58)
5 Impulsive
(n=42)
6 Pathological
(n=37)
K-W or χ
2
pAverage
Psychological components
Anxious symptoms 0.80 (0.38)
2,3,4,5,6
0.27 (0.53)
1,3,4,6
0.55 (0.47)
1,2,4,5,6
0.52 (0.48)
1,2,3,5,6
0.10 (0.56)
1,3,4,6
1.26 (0.51)
1,2,3,4,5
122.388 <.001 0.02 (0.82)
Poor coping 0.70 (0.41)
2,3,5,6
0.26 (0.50)
1,3,4,5,6
0.59 (0.44)
1,2,4,5,6
0.69 (0.45)
2,3,5,6
0.26 (0.62)
1,2,3,4,6
1.23 (0.66)
1,2,3,4,5,6
122.116 <.001 0.03 (0.85)
Impulsivity 0.26 (0.51)
2,4,5,6
1.00 (0.40)
1,3,4,5,6
0.28 (0.47)
2,4,5,6
0.21 (0.44)
1,2,3,5
1.26 (0.50)
1,2,3,4,6
0.14 (0.73)
1,2,3,5
106.735 <.001 0.07 (0.82)
Individual variables
Depression 5.1 (1.9)
2,3,4,5,6
6.4 (2.0)
1,6
7.1(2.4)
1,6
6.5 (2.3)
1,6
7.3 (2.5)
1,6
10.1 (2.9)
1,2,3,4,5
76.447 <.001 6.8 (2.7)
Anxiety 4.8 (2.1)
2,3,4,5,6
9.1 (3.7)
1,3,4,5,6
6.3 (2.7)
1,2,4,5,6
11.0 (3.3)
1,2,3,6
10.2 (3.1)
1,2,3,6
14.8 (2.6)
1,2,3,4,5
179.88 <.001 8.8 (4.3)
Self-esteem 24.2 (3.5)
2,3,4,5,6
16.4 (4.0)
1,6
17.4 (3.4)
1,6
17.1 (3.7)
1,6
15.8 (3.5)
1,6
7.4 (3.7)
1,2,3,4,5
186.781 <.001 17.3 (5.9)
Attention difculties 3.8 (1.8)
3,4,5,6
3.5 (1.9)
3,4,5,6
4.7 (2.1)
1,2,4,5,6
6.6 (2.0)
1,2,3,5
7.8 (1.5)
1,2,3,4,6
6.7 (2.0)
1,2,3,5
136.901 <.001 5.3 (2.5)
Conduct difculties 2.0 (1.9)
4,5,6
1.3 (1.4)
3,4,5,6
2.4 (1.7)
2,4,5,6
3.2 (1.9)
1,2,3,5
6.0 (2.1)
1,2,3,4,6
3.7 (2.3)
1,2,3,5
104.457 <.001 2.9 (2.3)
Impulsivity 2.1 (0.4)
2,5,6
1.6 (0.3)
1,3,4,5,6
2.1 (0.4)
2,4,5,6
2.2 (0.4)
2,3,5
2.9 (0.4)
1,2,3,4,6
2.3 (0.6)
1,2,3,5
141.398 <.001 2.2 (0.5)
Positive coping 3.6 (0.4)
2,3,5,6
3.4 (0.5)
1,3,4,5,6
2.4 (0.5)
1,2,4,5
3.6 (0.4)
2,3,5,6
2.7 (0.6)
1,2,3,6
2.1 (0.7)
1,2,3,4,5
184.505 <.001 3.1 (0.8)
Negative coping 2.0 (0.5)
2,4,5,6
2.4 (0.5)
1,3,4,5,6
2.1 (0.5)
2,4,5,6
2.9 (0.6)
1,2,3,6
3.0 (0.7)
1,2,3,6
3.4 (0.7)
1,2,3,4,5
144.237 <.001 2.5 (0.7)
Meaning in life 4.5 (0.5)
2,3,4,5,6
4.1 (0.7)
1,3,5,6
3.3 (0.9)
1,2,4,6
4.1 (0.7)
1,3,5,6
3.0 (1.0)
1,2,4,6
2.1 (0.9)
1,2,3,4,5
140.843 <.001 3.7 (1.1)
Life satisfaction 4.9 (0.9)
2,3,4,5,6
4.0 (1.0)
1,3,5,6
3.5 (1.2)
1,2,4,6
4.0 (1.1)
1,3,5,6
3.0 (1.2)
1,2,4,6
1.6 (1.0)
1,2,3,4,5
151.053 <.001 3.7 (1.4)
Six-month self-harm at baseline (n=326)
Baseline: None 98.6% (71)
3,6
91.4% (53)
6
84.7% (50)
1,6
87.9% (51)
6
85.7% (36)
6
21.6% (8)
1,2,3,4,5
139.013 <.001 82.5% (269)
Occasional 1.4% (1)
3,6
8.6% (5)
6
15.3% (9)
1,6
10.3% (6)
6
9.5% (4)
6
40.5% (15)
1,2,4,5
12.3% (40)
Repetitive O
6
O
6
O
6
1.7% (1)
6
4.8% (2) 37.8% (14)
1,2,3,4,5
5.2% (17)
Six-month new self-harm at follow-up among those who did not self-harm at baseline (n=269)
New self-harm at follow-up 1.4% (1)
4,5,6
7.5% (4)
6
8.0% (4) 9.8% (5)
1,6
13.9% (5)
1
37.5% (3)
1,2,4
15.265 0.009 8.2% (22)
J Youth Adolescence
six-month occasional self-harm and no adolescents in this
group reported repetitive self-harm. The social and envir-
onmental description of this group was similarly unre-
markable (Table 2). As a group, these adolescents reported
good support from family, friends, and adults at school. It is
worth noting that this group reported the lowest level of
self-harm modeling from friends: 16.7% reported having a
friend who self-harmed compared with the group average of
30.1%. This was the largest prole. At six-month follow-up,
there was only one case of new self-harm.
Prole 2: Low Impulsivity7.5% New Self-Harm
This prole (n=58) appears psychologically healthy, with
scores for most psychological variables similar to the
average. The only dening feature of this prole was a low
score on the psychological component Impulsivity, and
corresponding low impulsivity on the individual variables.
This prole was signicantly lower on the impulsivity
component scores than the other ve proles, as evidenced
by the pairwise comparisons. The social and environmental
features largely reected the averages for the whole sample,
with notably high support from family and friends. Within
the 53 without self-harm at baseline, four reported self-harm
at follow-up.
Prole 3: Poor Coping and Low Anxiety8.0% New
Self-Harm
Component scores for this prole (n=59) indicated below
average use of positive coping strategies and lower than
average anxiety. On the impulsivity component this prole
was mid-range: higher than the low impulsivity prole
(Prole 2) but lower than Proles 4, 5 and 6. The social and
environmental features on the whole reected the averages
for the sample, although support from family and friends
was lower than that reported by Proles 1 and 2. Among the
50 without self-harm at baseline, four reported self-harm at
follow-up.
Prole 4: High Anxiety9.8% New Self-Harm
Anxiety was slightly high in Prole 4 (n=58); higher than
in all proles except the comparatively pathological Prole
6. The scores for positive and negative coping strategies
were slightly above average. Social and environmental
features of this prole were largely mid-range, apart from
self-harm modeling from friends: it was much higher in this
prole, on par with the highest level among all proles
(43.1%). Of 51 who did not report self-harm at baseline,
ve reported self-harm at follow-up.
Prole 5: Impulsive13.9% New Self-Harm
Prole 5 (n=42) was marked by high impulsivity on the
psychological component scores. This was reected in the
individual variable scores: high impulsivity, and difculties
with attention and conduct. The standout social feature of
this prole was high scores on both bullying others and
being a victim of bullying. This prole had the highest
percentage of males. Of 36 who did not report self-harm at
baseline, ve reported self-harm at follow-up.
Prole 6: Psychological Pathology37.5% New Self-
Harm
Prole 6 (n=37) was the smallest group, and the psycho-
logical component scores revealed high levels of anxiety
and difculty coping. This was corroborated in the indivi-
dual psychological variables, where we saw high depressive
and anxiety symptoms, low self-esteem, low levels of
positive coping strategies, high use of negative coping
strategies, and low meaning in life and life satisfaction. The
social and environmental prole in Table 2added to the
picture with the lowest levels of support from family,
Fig. 2 Component mean scores
for adolescents: average of the
whole sample (far left) and the
six proles. The shaded area
indicates +/0.5 SD, the
expected variation of normal
scores. The vertical lines at each
mean indicate standard error
J Youth Adolescence
friends, and adults at school, and the highest score on victim
of bullying experiences. This prole was female dominated
and had a lower percentage of biological parents married.
This prole reported the highest levels of occasional
(40.5%) and repetitive (37.8%) self-harm at baseline, along
with the highest level of new self-harm at follow-up (37.5%
of the eight without self-harm at baseline).
Five- and seven-cluster solutions were also considered,
and while the proles must necessarily differ in detail, they
were not fundamentally different from those reported in the
six-cluster solution in this article. For example, the ve-
cluster solution yields similar proles, however the six-
cluster solution offers greater clarity regarding scores for
impulsivity.
Discussion
Adolescent self-harm is common, but poses concerns for the
teens physical safety, general mental health, and the
potential for contagion among peers (OConnor et al. 2009;
Taliaferro and Muehlenkamp 2014). Past research identies
a number of risk factors for adolescent self-harm, but much
is yet to be understood regarding the mechanisms and
interactions at play (Hawton et al. 2012). An important
limitation in past research is that research typically
approaches risk factors as distinct components. Yet we
know that there is considerable overlap between many risk
factors (e.g., depression and anxiety). Therefore in recent
years, a small contingent of self-harm research has adopted
a prole approach to consider multiple overlapping factors
simultaneously and identify distinct groups within those
who report self-harm (Somer et al. 2015). This study
focused on psychological risk factors for self-harm and
assigned individuals to groups based entirely on psycholo-
gical proles, as in limited prior cross-sectional research
(Stanford and Jones 2012). This study extended prior
research by exploring how these proles related to self-
harm behavior at follow-up. We hypothesized that proles
with poorer psychological function at baseline would be
associated with higher rate of new self-harm at six-month
follow-up, as found in past cross-sectional research (Somer
et al. 2015; Stanford and Jones 2012).
Australian high school students (n=326, 68.1% female)
completed a questionnaire including a broad range of psy-
chological and socioenvironmental risk and protective fac-
tors. Non-hierarchical cluster analysis produced six groups
with different psychological proles at baseline and rate of
new self-harm at follow-up. Overall six-month self-harm
prevalence was 12.3% for occasional self-harm and 5.2%
for repetitive self-harm. This is broadly in line with rates in
other community samples (Stallard et al. 2013). The lowest
rate of new self-harm was 1.4% in the psychologically
Table 2 Social and environmental scores for the six proles. Statistics are mean (SD) or %(n)
1 Psychologically
healthy(n=72)
2 Low impulsivity
(n=58)
3 Poor coping
(n=59)
4 Anxiety
(n=58)
5 Impulsive
(n=42)
6 Pathological
(n=37)
K-W or χ
2
pAverage
Age mean (SD) 14.1 (1.3) 14.2 (1.4) 13.8 (1.4) 14.1 (1.5) 14.0 (1.6) 14.2 (1.4) .919 .469 14.1 (1.4)
Female % (n) 62.5% (45) 77.6% (45) 59.3% (35) 77.6% (45) 50.0% (21)
6
83.8% (31)
5
18.460 .002 68.1% (222)
Parents married % (n) 80.6% (58) 86.2% (50) 84.7% (50) 82.8% (48) 78.6% (33) 70.3% (26) 4.651 .460 81.3% (265)
Born overseas % (n) 4.2% (3) 8.6% (5) 13.6% (8) 5.2% (3) 9.5% (4) 18.9% (7) 8.862 .115 9.2% (30)
Supportive family 5.6 (0.9)
2,3,4,5,6
5.2 (1.2)
1,3,4,5,6
4.5 (1.5)
1,2
4.7 (1.4)
1,2,5,6
4.1 (1.4)
1,2,4
3.5 (1.8)
1,2,4
15.511 <.001 4.7 (1.5)
Supportive friends 4.9 (1.2)
3,4,5,6
4.6 (1.3)
3,4,5,6
3.7 (1.5)
1,2
4.0 (1.5)
1,2,6
3.7 (1.3)
1,2,4,6
2.8 (1.9)
1,2,4,5
13.515 <.001 4.1 (1.5)
Supportive adult at school 4.6 (1.5)
2,3,4,5,6
4.1 (1.5)
1,5,6
3.8 (1.5)
1
3.7 (1.7)
1,2,5,6
3.0 (1.6)
1,2,4
2.8 (1.7)
1,2,4
9.337 <.001 3.8 (1.7)
Self-harm modeling: friends 16.7% (12)
4,6
32.8% (19) 22.0% (13) 43.1% (25)
1
31.0% (13) 43.2% (16)
1
15.920 .007 30.1% (98)
Self-harm modeling: family 1.4% (1) 10.3% (6) 10.2% (6) 13.8% (8) 4.8% (2) 10.8% (4) 8.421 .135 8.3% (27)
Victim of bullying 1.7 (1.4)
2,4,5,6
2.5 (1.7)
1,6
2.4 (2.0) 2.8 (2.4)
1,6
3.2 (2.4)
1
3.9 (2.6)
1,2,4
6.777 <.001 2.6 (2.1)
Bully others 0.21 (0.6)
5,6
0.3 (0.8)
5,6
0.3 (0.6) 0.4 (1.0)
5,6
1.4 (1.4)
1,2,4,6
0.9 (1.4)
1,2,4,5
11.178 <.001 0.5 (1.0)
Importance of faith 3.2 (0.8)
2,3,5,6
2.9 (0.8)
1,3,5,6
2.5 (0.7)
1,2,4
3.0 (0.9)
3,5,6
2.5 (0.8)
1,2,4
2.3 (1.0)
1,2,4
10.577 <.001 2.8 (0.9)
Positive religious coping 3.2 (0.8)
3,5,6
3.0 (0.8)
3,5,6
2.4 (0.9)
1,2
3.0 (0.9)
5,6
2.5 (1.0)
1,2,4
2.2 (0.9)
1,2,4
10.772 <.001 2.8 (0.9)
Negative religious coping 1.6 (0.7)
3,4,5,6
1.8 (0.8)
4,5,6
1.9 (0.8)
1
2.1 (0.9)
1,2,6
2.2 (0.9)
1,2,6
2.7 (1.1)
1,2,4,5
9.619 <.001 2.0 (0.9)
J Youth Adolescence
healthyprole; total self-harm across both time points for
this group was 2.8%. This group appeared psychologically
healthy, with good use of coping strategies and low anxiety.
At the other end of the spectrum, the highest rate of new
self-harm was 37.5% in the pathologicalprole; 86.5% of
the pathological prole reported self-harm at either time
point. This group appeared to have multiple difculties,
with scores indicating high anxiety and poor use of coping
strategies. This concurs with prior work identifying greater
psychological pathology in groups with higher self-harm
rates, a common nding across studies creating proles
based on psychological (Stanford and Jones 2012) and self-
harm (Somer et al. 2015) characteristics. An understanding
of the highest risk prole for self-harm may assist teachers
and counsellors in detecting those who are the highest
priority for treatment (Somer et al. 2015) and at greatest risk
for future self-harm.
In between these two endpoints, new self-harm was
around average for the remaining four proles (7.5% to
13.9%). The psychological scores for these four proles
were varied, and suggest a group with low impulsivity, a
group with low anxiety but below average use of positive
coping strategies, a group with mild anxiety but good use of
positive coping strategies, and an impulsive group. This
concurs with past research suggesting that there is no single
prole to describe adolescents who self-harm (Stanford and
Jones 2012), and therefore we require a more complex
approach to understanding risk factors. Each group of
adolescents may have different prevention and intervention
needs. For example, while some adolescents may need
assistance with coping strategies, others need help with
anxiety, and still others need to bolster their ability to
manage impulsive tendencies when faced with the desire
to self-harm. Thus there is no one size ts allapproach to
preventing and reducing self-harm in community
adolescents.
The results of this study concur with and extend prior
research into psychological risk factors for self-harm. For
example, past research has identied combined bully-victim
status as a stronger risk factor for self-harm compared with
either bully or victim status independently (Barker et al.
2008). In our sample, this combination was primarily evi-
dent in the impulsive prolethe group with the highest
score on bullying others. The pathologicalprole also
displayed this combination more subtly. Where previous
research has identied bully-victim status as a strong risk
factor for self-harm in general, our study gives insight into
one subgroup in which this this risk factor is prominent. As
another example, past research has identied that coping
strategies are associated with self-harm (De Leo and Heller
2004; Hall and Place 2010; Lewinsohn et al. 1994). How-
ever, non-signicant ndings also exist (ODonnell et al.
2004). In our results, below average use of positive coping
strategies was evident in two out of the six proles. These
two proles had different rates of new self-harm, with
higher self-harm in the pathologicalprole in which poor
coping was accompanied by elevated depressive and anxi-
ety symptoms, and lower self-esteem. It would be difcult
to capture these nuances in a typical predictive or cumula-
tive risk model. Therefore there is a need for more complex
models such as a prole approach.
A key nding in our work is identifying a group of
adolescents who were average on all psychological mea-
sures (apart from low impulsivity) who reported new self-
harm (7.5%) at a rate on par with the average for the whole
sample (8.2%). These adolescents did not appear to
experience above average difculties in psychological
domains, coping strategies, or relationships. Around one-
third of this group reported awareness of self-harm among
friends, which is in line with the average for the sample. It is
beyond the scope of this study to investigate the role of
social contagion in each group, but this ags an important
area for future research (Jarvi et al. 2013). The absence of
typical psychological self-harm risk factors in this group
conrms the need to move beyond a single list of self-harm
risk factors. In community settings, these adolescents may
not be identiable through any known risk factors. This is
concerning, given that 2565% of those who self-harm do
not disclose the behavior to anybody (Armiento et al. 2014;
Madge et al. 2008; Rubenstein et al. 1998). Therefore
policies to respond to and reduce self-harm need to be
designed with hidden behavior in mind.
Reecting on the heterogeneity of adolescents who self-
harm, we suggest three strategies for self-harm prevention
and intervention in schools: screening, gatekeeper training,
and mental health programs. These programs are designed
to operate in addition to the existing student support sys-
tems (Juhnke et al. 2011).
Given the variability in, and indeed, absence of risk
factors identied, we recommend universal screening for
self-harm in schools. Initial research suggests that screening
is largely well received and does not cause undue distress;
however, further research is needed to ascertain sensitivity/
specicity and nancial viability (Robinson et al. 2011).
Further research is also needed to better understand whether
distress occurs for any participants and develop strategies to
reduce potential distress (Hasking et al. 2015). However,
even if screening is effective, low-risk, and nancially
viable in a cost-benet analysis, schools may lack the
resources to undertake universal screening for all adoles-
cents. Where universal screening is not possible, we
recommend targeted screening. Bearing in mind the varia-
bility of self-harm risk factors, we recommend that school
counsellors use a brief mental health screening tool with all
clients or students, regardless of the reason for referral.
Screening should include a brief questionnaire, either
J Youth Adolescence
pencil-and-paper or, preferably, using an online platform to
maximize detection (Ougrin and Boege 2013).
Gatekeeper training aims to equip staff or student peer
leaders with skills to respond to students disclosing
self-harm and/or suicidal thoughts. While much of the
gatekeeper research centers on suicide prevention (e.g.,
Wasserman et al. 2015), evaluations of gatekeeper training
for self-harm appear promising. For example, training for
school welfare staff delivered by the Orygen Youth Health
service reported increased knowledge of, and condence
and perceived skill in working with self-harm (Robinson
et al. 2008). Improvements were greater among those with
lower knowledge, condence and skill at baseline. How-
ever, participants did not report reduced anxiety surround-
ing working with adolescents who self-harm. Future
research should include randomized controlled trials and a
broader range of outcomes including rates of self-harm,
staff anxiety, and improvements in practice. Research into
suicide prevention suggests that gatekeeper training is an
important component of the solution, although improve-
ments in skills, knowledge, and condence may not trans-
late directly to reductions in suicide attempts or self-harm
(Wasserman et al. 2015; Wyman et al. 2008).
Mental health literacy and self-harm/suicide prevention
programs are designed to increase awareness of mental
health challenges and self-harm, reduce stigma, and
encourage help-seeking. Programs should be universal
where possible: prevention programs that target at-risk
adolescents are likely to miss a proportion of adolescents
with current or future self-harm, particularly those without
discernible psychological pathology. General mental health
literacy programs aim to reduce stigma and encourage help-
seeking. For example, preliminary evidence using a ran-
domized controlled trial suggested that the HeadStrong
program reduced stigma, but failed to increase help-seeking
behavior (Perry et al. 2014). Perry and colleagues suggest
that sustained education is needed to change help-seeking
behavior and maintain these effects. Mental health literacy
programs can also include contact, that is an interactive
session with a young person with lived experience of mental
illness. While potentially valuable, contact is yet to prove
efcacious in adolescent samples and further research is
needed (Chisholm et al. 2016). School-based self-harm
programs appear to be a promising strategy for universal
self-harm prevention (Robinson et al. 2016). However,
schools are often concerned regarding the potential for
iatrogenic effects when discussing self-harm. To address
these concerns, we need large randomized controlled trials
to review the positive and negative effects of programs on a
range of outcomes (Robinson et al. 2013). One such pro-
gram is the Signs of Self-Injuryprogram. It is the only
universal self-harm program currently evaluated (Robinson
et al. 2016). Initial evidence for the program appears
promising, with no increase in self-harm thoughts, behavior,
or frequency (Muehlenkamp et al. 2010). To avoid iatro-
genic effects, discussions about self-harm should be framed
within broader mental health programs, with a large focus
on protective behaviors and strengthening resilience
(Juhnke et al. 2012; Knightsmith 2015; Robinson et al.
2016). Schools should also make students aware of avenues
for support online, as there is emerging evidence to suggest
that this may be less intimidating for adolescents and may
lead to seeking in-person professional support (Frost et al.
2015).
Finally, efforts should be made to build supportive
environments in which people are willing to disclose self-
harm, and where people know how to respond in safe and
supportive ways (Juhnke et al. 2012). It can be very difcult
to disclose self-harm. Barriers to disclosure include fearing
a negative response, concern that the disclosure would be
spread in the community, and not viewing self-harm as
problematic (Klineberg et al. 2013; Wadman et al. 2016).
When adolescents do disclose, they do not necessarily open
up to the school counsellor or a trained mental health pro-
fessional. In an adolescent community sample, students
were twice as likely to disclose to a peer rather than an adult
(Hasking et al. 2015). When disclosing to an adult, the most
common person was a parent rather than a mental health
worker or teacher. Disclosure to peers can cause concern
regarding the potential for contagionin schools (Jarvi
et al. 2013). Indeed, one-third of participants in this study
reported awareness of self-harm among peers. Therefore,
we need multifaceted mental health programs that reduce
stigma and empower all levels of the community.
This study has several strengths. For the rst time, we
explored psychological proles longitudinally in a com-
munity sample. There are two key advantages to the psy-
chological proling approach. Firstly, we can consider
multiple overlapping variables simultaneously rather than
treating each variable as statistically independent. Secondly,
we can identify multiple groups with varying proles.
Traditional risk factor models that create a single prole of
risk factors cannot account for this variability. By using a
longitudinal sample we were able to explore whether psy-
chological proles identied at Time 1 were associated with
new self-harm at Time 2. Another strength of this study was
the inclusion of a broad range of risk and protective factors.
There were, however, several limitations. It was not
possible to cover all risk factors. The broad nature of the
project necessitated utilizing brief, self-report measures
which indicated symptomology; it would be good to clarify
these ndings using diagnostic scales. Despite considerable
efforts to engage students in the research, using opt-in
parental consent contributed to a lower than ideal partici-
pation rate and may have reduced the samples representa-
tiveness. Although response rate varied depending on the
J Youth Adolescence
schools effort in collecting parental consent, all participat-
ing schools communicated that opt-in parental consent was
very challenging to administer. Indeed, schools expressed
that they have difculty obtaining parental consent for
activities with high desirability such as excursions. Further,
timetabling challenges in two schools impacted upon the
retention rate, as very few students in those schools were
able to participate. The constraints of this project only
enabled a six-month follow-up; therefore it was not possible
to investigate psychological proles over the course of
adolescence. This study reports on data from fee-paying
Independent schools. While a comparison of each schools
fees and location indicates considerable variability in
sociodemographic composition, future research should
include a broader sample range including public schools.
Future research in larger samples should explore proles
for male and female adolescents separately, since the pro-
portion of males varied between groups. Randomized con-
trolled trials could explore the efcacy of universal and
targeted prevention programs focused on one or more of the
psychological risk factors identied, such as anxiety,
impulsivity, and coping strategies. Programs could also
target bullying, and strategies to improve supportive rela-
tionships. Program evaluation could consider whether
adolescents in different proles respond differently to the
prevention or intervention strategy. It may be necessary to
support tailored program strategies with brief mental health
screening tools to enable efcacious program selection.
Future research can build on the current study by recruiting
larger samples and conducting longer follow-ups. This
study focused on new self-harm rates; larger scale studies
can explore trajectories and consider whether adolescent
proles remain stable over time (Klonsky and Olino 2008).
This is an important question for prole research, given that
self-harm severity, method, and function changes over time
(Owens et al. 2015; Townsend et al. 2016; Wadman et al.
2016).
Conclusion
Past research identies a number of risk factors for ado-
lescent self-harm, but often fails to account for overlap
between these factors. Thus the current understanding of the
complex interactions between risk factors is limited. This
study contributes to this knowledge gap by developing our
understanding of psychological risk factors for self-harm in
adolescence using a prole analysis. This article used psy-
chological proling to explore complexity in self-harm risk
factors in a longitudinal adolescent community sample. We
identied six groups with distinct psychological proles. As
expected, increased psychological pathology at baseline
was associated with higher rates of new self-harm at follow-
up. Notably, this study highlighted diversity in risk factors
for adolescent self-harm. We identied a number of groups
with similar self-harm rate that display disparate psycho-
logical proles, including difculties with anxiety, impul-
sivity, and coping strategies. Therefore adolescents who
self-harm cannot be accurately described using a single list
of risk and protective factors. A more complex under-
standing of the psychological risk factors for adolescent
self-harm may assist in detecting those who are at greatest
risk for future self-harm, and ultimately moving toward
prevention.
Author Contributions S.S. participated in writing, design, and
analysis, and carried out the data collection. M.J. contributed to
writing, design, and analysis. J.H. provided clinical guidance and
feedback on the manuscript. All authors read and approved the nal
manuscript.
Compliance with Ethical Standards
Conict of Interest The authors declare that they have no compet-
ing interests.
Ethical Approval The study was reviewed and approved by the
Macquarie University Human Research Ethics Committee, reference
number 5201400575.
Informed Consent The project was approved by the School Prin-
cipal, Executive and school counsellors in each school. Parents and
students provided opt-in informed consent at the rst time point; this
consent covered the baseline and follow-up survey. At the follow-up,
parents were provided the full study information and the opportunity to
opt-out on behalf of their teen, and students again provided opt-in
informed consent.
Appendix
Table 3, Table 4
J Youth Adolescence
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Sarah Stanford recently completed her PhD Psychology at Macquarie
University. Her PhD focused on risk factors for and outcomes of self-
harm in adolescence and early-mid adulthood.
Professor Mike Jones is Associate Dean (Research) in the Faculty of
Human Sciences and Deputy Head of the Psychology Department at
Macquarie University. His primary research interests are in braingut
interactions. Together with Australian and international collaborators
he seeks to understand the mechanisms by which functional
gastrointestinal disorders are so strongly associated with a number of
psychological disorders and negative personality traits.
Professor Jennie Hudson is an Australian Research Council, Future
Fellow within the Centre for Emotional Health, Department of
Psychology. Jennies research focuses on understanding factors that
contribute to the development of anxiety disorders in children and
adolescents. Her work also involves the development and evaluation of
evidence based treatments for anxiety and depression in young people.
J Youth Adolescence
... The heterogeneity of the NSSI population was highlighted In a study by Stanford et al. [47] in 2018. The authors employed cluster analysis in a community sample of high school students with a history of NSSI and identified six psychological profiles: psychologically healthy, low impulsivity, poor coping, anxiety, impulsive, and pathological. ...
... As is evident from the studies presented above, there is in the research field a growing interest in identification of subgroups among individuals engaging in NSSI. Several authors point out that knowledge of risk factors and predictors associated with different NSSI subgroups and trajectories is crucial to the planning of treatment and prevention strategies [46][47][48]. ...
... Our intention in the present study is to follow up on some of the questions formulated by Robinson and Wilson [38], and thus adding to the body of knowledge regarding the characteristics of which groups can be identified in adolescents using different methods. Further, we intend to add to the few studies that have used exploratory, datadriven stratification in a sample of participants with NSSI [34,47,48]. ...
Article
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Abstract Background Nonsuicidal self-injury (NSSI) is highly prevalent in adolescents. In survey and interview studies assessing NSSI, methods of assessment have been shown to influence prevalence estimates. However, knowledge of which groups of adolescents that are identified with different measurement methods is lacking, and the characteristics of identified groups are yet to be investigated. Further, only a handful of studies have been carried out using exploratory methods to identify subgroups among adolescents with NSSI. Methods The performance of two prevalence measures (single-item vs. behavioral checklist) in the same cross-sectional community sample (n = 266, age M = 14.21, 58.3% female) of adolescents was compared regarding prevalence estimates and also characterization of the identified groups with lifetime NSSI prevalence. A cluster analysis was carried out in the same sample. Identified clusters were compared to the two groups defined using the prevalence measures. Results A total of 118 (44.4%) participants acknowledged having engaged in NSSI at least once. Of these, a group of 55 (20.7%) adolescents confirmed NSSI on a single item and 63 (23.7%) adolescents confirmed NSSI only on a behavioral checklist, while denying NSSI on the single item. Groups differed significantly, with the single-item group being more severely affected and having higher mean scores on difficulties in emotion regulation, self-criticism, number of methods, higher frequency of NSSI, higher rates of suicidal ideation and suicidal behavior and lower mean score on health-related quality of life. All cases with higher severity were not identified by the single-item question. Cluster analysis identified three clusters, two of which fit well with the groups identified by single-item and behavioral checklist measures. Conclusions When investigating NSSI prevalence in adolescents, findings are influenced by the researchers’ choice of measures. The present study provides some directions toward what kind of influence to expect given the type of measure used, both with regards to the size of the identified group and its composition. Implications for future research as well as clinical and preventive work are discussed.
... Although individuals with additional risk factors or low resources may be especially vulnerable to NSSI, many adolescents who self-injure report no other existing psychological disorders or risk factors, indicating that positive social reinforcement-such as fostering closeness, gaining social support, or achieving group affiliation or status-is a powerful motivator to engage in NSSI behaviour (Brooks, 2015;Jarvi et al., 2013;Stanford et al., 2018;. Moreover, Curtis (2017) reported that for some adolescents, NSSI is part of the group culture, the "thing to do," a game, or even a form of competition within the group. ...
... According to the NCCDH (2017), whole school or universal approaches are most effective for promoting mental health and influencing healthy development, especially when they are offered at critical times in students' development and are designed to address relevant and appropriate protective factors (Dray et al., 2017). Stanford et al. (2018) agreed, stating that universal programs were preferable to targeted programs, since the latter may overlook unidentified at-risk adolescents. Mantoura (2017) stated that targeted programs would not improve the overall mental health of the population and advocated for the implementation of culturally relevant universal programs that incorporated gender perspectives. ...
... Of the eligible girls in Grades 5 and 6, only 72 girls registered and only 40 of those registrants completed the program. In-school comprehensive mental health programs would satisfy components of the Alberta Health and Life Skills curriculum (Alberta Education, 2020) and provide valuable support to all young girls-those already experiencing mental health concerns, those who may be identified as at risk, and those who would not otherwise be identified but who may be vulnerable nonetheless (Stanford et al., 2018). According to Shinaberry (2016), this kind of program does not yet exist. ...
Article
Current mental health disorder rates for preadolescent and adolescent girls demonstrate a disturbing trend, most notably a drastic increase in reports of non-suicidal self-injury (NSSI), especially in the age category of 10- to 14-year-olds. NSSI has become normalized in the adolescent population, and social contagion—the spreading of NSSI through peer and media influence—has become a significant concern. This article defines and discusses NSSI and social contagion and explores why preadolescent and adolescent girls may be particularly vulnerable to it. Further, current Canadian approaches to mental health promotion and primary prevention are reviewed, and an argument is made for the development and implementation of elementary school–based, gender-specific, comprehensive mental health programs. Incorporating interconnected evidence-based protective factors such as self-worth, self-compassion, emotion regulation, healthy relationships, communication, and family and school systems will provide young girls with valuable skills and knowledge to mitigate their engagement with NSSI and to resist social contagion.
... Na atualidade, a autolesão tem sido praticada por uma parcela significativa de adolescentes, sendo considerado pela Organização Mundial da Saúde (OMS) um problema de saúde pública (Cronemberger & Silva, 2023;Gámez Guadi et al., 2022;Stanford et al., 2018). Esse fenômeno tem sido cada vez mais identificado em populações clínicas e não clínicas, e ocorrendo cada vez mais cedo. ...
Article
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The paper is the result of research on self-injury in the transition from childhood to adolescence. The objective is to present and discuss the research results of a survey on the characteristics of self-injurious behavior among adolescents in the city of Volta Redonda/RJ. A Cross-sectional study with 61 pre-adolescents and adolescents assisted by the Specialized Reference Center for Social Assistance of both sexes, aged between 10 and 16 years old, with self-harm practice, seeking to collect data on the characterization of this behavior, sociodemographic profile and referrals made. Data analysis was conducted through the categorization of interviews, descriptive analysis of simple and relative frequency survey, and standard deviation. As a result, most participants are female (80.3%), between 13 and 14 years old (50.9%), who predominantly used sharp objects (88.5%), mainly affecting arms, hands, or wrists (94.1%). Family conflicts stand out (83.6%) as a motivation and the majority (50.8%) were not referred for treatment. With these results, the study had concluded that knowledge about the characterization of self-injurious behavior in adolescents is fundamental for the design of public policies for prevention and psychosocial assistance for adolescents.
... The conclusions drawn by Stanford, Jones and Hudson (2018) that there is a wide variety of factors that motivate NSSI, and that they interact, contribute to the understanding that the self-injurious behavior of the participants in this research is complex and is not related to one or the other cause alone. As shown by Hawton, Saunders and O'connor (2012), NSSI in young women results from a combination of genetic, biological, psychiatric, psychological, social and cultural factors. ...
Article
Full-text available
Self-injury among young women is a public health problem that is still little known and understood by parents, educators and health professionals. We sought to understand selfinjurious behavior in young women from a perspective of the meaning, actions and interpretation of the experienced situation. This qualitative research used semi-structured interview for data collection from January to March 2020. The data were organized by the MAXQDA software and analyzed based on Symbolic Interactionism. The five interviewees are young people educated by their mothers, with little or no contact with their fathers. They narrated stories of sexual abuse, parental rejection, bullying and low acceptance in the school environment. They established a pessimistic perception of themselves arising from their own interpretations and their social interactions. They saw self-injury as a refuge. They practiced self-injury when they were under unbearable negative feelings. They lived in a cycle of substituting psychological suffering for physical suffering. All admitted having anxious temperaments, low self-esteem and socioemotional disabilities. Self-injury is directly linked to the meanings these young women give to themselves. At schools, the incorporation of knowledge about well-being should be encouraged to train people who are more effective in solving problems.
... En un estudio realizado en Australia por Stanford et al. (2018) en el que participaron 326 estudiantes con edades en la primera muestra de 7 a 11 años y cuyo objetivo fue analizar los factores de riesgo en las conductas autolesivas, se agruparon una serie de variables para crear perfiles psicológicos; el perfil con más casos de reincidencia en autolesiones fue el perfil patología psicológica con un 37,5% de casos, el que engloba factores cómo sintomatología depresiva y ansiosa, bajos niveles de afrontamiento y autoestima, poco sentido de vida y escaso apoyo familiar. ...
Article
Full-text available
The objective is to determine the relationship between parental divorce and the development of Cutting in adolescence, it has a mixed approach of non-experimental transversal design of descriptive scope and phenomenological design. It was determined that there is a relationship between the development of Cutting and parental divorce in 10 secondary students that participated in the research, due to the change of various factors in the family environment and the behavior of the parents, which cause alterations in mental health.
... The most prominent individual-related risk factors included emotional dysregulation, problematic coping mechanisms, certain cognitive schemas, low selfesteem, and personality traits, including low agreeableness, neuroticism, impulsivity, and psychopathic traits. [23][24][25][26][27][28][29][30][31][32][33][34][35] With respect to the factors within the family system, the parent-child relationship (PCR) emerged as the strongest predictor of mental health problems among adolescents, especially in authoritarian and controlling par-enting. [36][37][38][39][40][41] Peer-related loneliness and bullying emerged as strong risk factors. ...
Article
Full-text available
Background The prevalence of mental health problems in adolescents has been identified as a global concern. Early screening and identification can offer benefits in terms of primary prevention and reduced healthcare costs. This study aimed to develop a tool to assess the risk of developing mental health problems in adolescents. Methods The study followed an exploratory sequential design and was divided into five phases. The Multidimensional Psychosocial Risk Screen (MPRS) is a newly developed self-report measure. The various steps in its development and validation have been elaborated. The MPRS was evaluated with a sample of 934 adolescents aged 12-18, spread across the 8th-12th grade. Results Exploratory and confirmatory factor analyses revealed a robust factor structure. The extracted five factors were named as Parent–Child Relationship (PCR), Self-Concept (SC), Teacher–Student Dynamics (TSD), Social Media Use (SMU), and Peer Interaction (PI). The reliability of the subscales ranged from 0.60 to 0.80. The overall reliability of the scale was good (a = 0.87). Convergent validity of the scale was established using standard measures of risk factors and emotional and behavioural problems. Conclusions The MPRS can be considered an effective tool with an adequate factor structure and good psychometric properties. It can be beneficial in the early detection of vulnerabilities to mental health problems in adolescents and, therefore, seen as a key element in primary prevention and fostering individualized interventions.
... Like many selfreport measures, there is likely to be a degree of social desirability bias in the reporting of self-injury. Nevertheless, Stanford and Jones (2010) found that adolescents are able to accurately self-code selfinjurious behaviour, using this single item method in previous research (Stanford et al., 2018). Bias may also impact upon the report of EMS. ...
Article
Objective There is emerging research demonstrating relationships between specific Early Maladaptive Schemas and self-injurious behaviour (SIB) in young people. Evidence also highlights the importance of conceptualising SIB in terms of its motivating function, differentiating between intrapersonal and interpersonal functions of the behaviour. Despite this, there is a relative absence of evidence linking schemas and functions of SIB. The current study sought to explore the relationship between schemas and motivations for self-injury in a community sample of young people with a history of self-injury. Method 125 Australian secondary and university students aged between 16 and 25 years who reported SIB history completed the Young Schema Questionnaire and the Inventory of Statements about Self-Injury. Results Multiple regression analyses found that the schemas of Abandonment/Instability and Entitlement significantly predicted intrapersonal functions of self-injury. In contrast, Insufficient Self-Control significantly predicted interpersonal functions. Defectiveness/Shame and Entitlement predicted self-injury with suicidal intent. Conclusions We discuss the findings regarding distinct patterns in the associations between schemas and the functions of self-injurious behaviour among youth with self-injury history. The present study also highlights how schemas may help to understand the motivations behind self-injury and assist clinicians in the assessment of risk for self-injury and suicide among youth, as well as to formulate plans for treatment and early intervention. KEY POINTS What is already known about this topic: • Young people are motivated to self-injure for a variety of reasons, including to manage internal distress (intrapersonal) and influence their external environment (interpersonal). • Alongside these motivating functions, vulnerability factors, such as childhood maltreatment and intense negative emotions, predispose a young person to self-injury when confronted with stress. • Early maladaptive schemas are also increasingly being identified as vulnerability factors for self-injury, particularly Defectiveness/Shame and Abandonment/Instability. What this topic adds: • Young people’s motivations to self-injure are influenced by their early maladaptive schemas. • Young people who self-injure for intrapersonal motivations report schemas of Abandonment/Instability, those who self-injure for interpersonal motivations report an Insufficient self-control schema, and those who self-injure with some suicidal intent report schemas of Defectiveness/Shame. • This highlights that the importance of understanding both the function and the schema when working with young people who self-injure. Youth whose self-injurious behaviour is interpersonally motivated may require interpersonal skill-building. For youth who self-injure for intrapersonal or suicidal motivations, a treatment such as schema therapy may be warranted.
Technical Report
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Background and aim: Suicide continues to be a major public health challenge in Australia with significant individual, community, and societal impacts. Targeted and timely research efforts are essential to effectively address this challenge in a rapidly changing world. Building on our earlier research priority setting exercise conducted in 2017, the present project aimed to inform future priorities in Australian suicide prevention research and identify shifts in research emphasis over time. Method: We examined current research priorities in Australian suicide prevention research by reviewing grants and fellowships funded and peer-reviewed journal articles published during 2017-2022, which were categorised according to an existing classification framework. We also surveyed key stakeholders with a known interest in suicide prevention research as to where future research emphasis should be placed and categorised their responses according to the same framework. Replicating the methodology from our earlier exercise, enabled us to contrast current and future research priorities and identify any shifts in research emphasis over time. Key findings: Overall research investment and publication output in Australian suicide prevention research has increased significantly in 2017-2022, with 393 journal articles published and 110 grants and fellowships funded to the tune of $45.1m. This represents more than a quadrupling of total research funding over a 5-year period and a 50% increase in annual publication output compared to our earlier exercise conducted over a 7.5-year period in 2010-2017. Recent research funding efforts are starting to manifest key changes in the types of research called for by stakeholders, while the associated evidence base is yet to fully materialise in publications. Notably, intervention studies (43%) emerged as the most frequently funded study type, while epidemiological research continued to dominate in published articles (59%). Mirroring stakeholder identified priorities, recent grants and publications reflected a relative shift in emphasis away from suicide and a greater focus on suicide attempts. Young people continued to be the most commonly researched target group. While digital and online settings featured strongly in research funding, stakeholders prioritised research in community settings. Four percent of articles and one quarter of grants noted the inclusion of people with lived experience or co-design. Conclusions: The recent boost in national research funding for suicide prevention is encouraging and commensurate with the significant scale of the task ahead to develop the evidence base and more effective solutions to address the persistent public health challenge of suicide in Australia. Research funding efforts are driving key changes in research emphasis called for by stakeholders, including a stronger emphasis on intervention research. While publications are also showing some positive signs, the required evidence base on effective interventions, protective factors, and social determinants is yet to fully materialise in this literature to support practice. To effectively address suicide in Australia in the future, it will therefore be important to maintain the overall thrust and direction of national research investment, coupled with a stronger emphasis on research translation. The present findings suggest that key priority areas for future suicide prevention research should address suicide attempts, protective factors, social determinants, community settings, and interventions, and focus on strengthening effective research translation into practice.
Article
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Resumo A autolesão entre mulheres jovens é problema de saúde pública ainda pouco conhecido e compreendido por pais, educadores e profissionais de saúde. Procurou-se compreender o comportamento autolesivo em mulheres jovens numa perspectiva do significado, ações e interpretação da situação vivenciada. Trata-se de pesquisa com abordagem qualitativa que utilizou entrevista semiestruturada para coleta de dados, no período de janeiro a março de 2020. Os dados foram organizados pelo programa MAXQDA e analisados com base no Interacionismo Simbólico. As cinco entrevistadas são jovens educadas pelas mães, possuem pouco ou nenhum contato com os pais. Narraram histórias de abuso sexual, rejeição paterna, bullying e baixo acolhimento no ambiente escolar. Estabeleceram uma percepção pessimista de si, oriunda de interpretações próprias e de suas interações sociais. Enxergaram a autolesão como refúgio. Praticaram a autolesão quando estavam sob sentimentos negativos insuportáveis. Viviam num ciclo de substituição do sofrer psicológico pelo padecimento físico. Todas admitiram possuir temperamentos ansiosos, baixa autoestima e inabilidades socioemocionais. A autolesão tem vínculo direto com os significados que essas jovens se atribuem. Nas escolas, a incorporação de conhecimento sobre bem-estar deve ser estimulada para a formação de pessoas mais eficazes na resolução de problemas.
Article
Purpose: This study builds upon and extends previous longitudinal research on deliberate self-harm (DSH) among youth by investigating which risk and protective factors during adolescence predict DSH thoughts and behavior in young adulthood. Methods: Self-report data came from 1,945 participants recruited as state-representative cohorts from Washington State and Victoria, Australia. Participants completed surveys in seventh grade (average age 13 years), as they transitioned through eighth and ninth grades and online at age 25 years. Retention of the original sample at age 25 years was 88%. A range of risk and protective factors in adolescence for DSH thoughts and behavior in young adulthood were examined using multivariable analyses. Results: Across the sample, 9.55% (n = 162) and 2.83% (n = 48) of young adult participants reported DSH thoughts and behaviors, respectively. In the combined risk-protective factor multivariable model for young adulthood DSH thoughts, depressive symptoms in adolescence (adjusted odds ratio [AOR] = 1.05; confidence interval [CI] = 1.00-1.09) increased risk, while higher levels of adolescent adaptive coping strategies (AOR = 0.46; CI = 0.28-0.74), higher levels of adolescent community rewards for prosocial behavior (AOR = 0.73; CI = 0.57-0.93), and living in Washington State decreased risk. In the final multivariable model for DSH behavior in young adulthood, less positive family management strategies during adolescence remained the only significant predictor (AOR = 1.90; CI = 1.01-3.60). Discussion: DSH prevention and intervention programs should not only focus on managing depression and building/enhancing family connections and support but also promote resilience through efforts to promote adaptive coping and connections to adults within one's community who recognize and reward prosocial behavior.
Article
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Objectives To investigate whether intergroup contact in addition to education is more effective than education alone in reducing stigma of mental illness in adolescents. Design A pragmatic cluster randomised controlled trial compared education alone with education plus contact. Blocking was used to randomly stratify classes within schools to condition. Random allocation was concealed, generated by a computer algorithm, and undertaken after pretest. Data was collected at pretest and 2-week follow-up. Analyses use an intention-to-treat basis. Setting Secondary schools in Birmingham, UK. Participants The parents and guardians of all students in year 8 (age 12–13 years) were approached to take part. Interventions A 1-day educational programme in each school led by mental health professional staff. Students in the ‘contact’ condition received an interactive session with a young person with lived experience of mental illness. Outcomes The primary outcome was students’ attitudinal stigma of mental illness. Secondary outcomes included knowledge-based stigma, mental health literacy, emotional well-being and resilience, and help-seeking attitudes. Results Participants were recruited between 1 May 2011 and 30 April 2012. 769 participants completed the pretest and were randomised to condition. 657 (85%) provided follow-up data. At 2-week follow-up, attitudinal stigma improved in both conditions with no significant effect of condition (95% CI −0.40 to 0.22, p=0.5, d=0.01). Significant improvements were found in the education-alone condition compared with the contact and education condition for the secondary outcomes of knowledge-based stigma, mental health literacy, emotional well-being and resilience, and help-seeking attitudes. Conclusions Contact was found to reduce the impact of the intervention for a number of outcomes. Caution is advised before employing intergroup contact with younger student age groups. The education intervention appeared to be successful in reducing stigma, promoting mental health knowledge, and increasing mental health literacy, as well as improving emotional well-being and resilience. A larger trial is needed to confirm these results. Trial registration number ISRCTN07406026; Results.
Article
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Background: Although increasing numbers of young people are seeking help online for self-injury, relatively little is known about their online help-seeking preferences. Aims: To investigate the perspectives of young people who self-injure regarding online services, with the aim of informing online service delivery. Method: A mixed-methods exploratory analysis regarding the perspectives of a subsample of young people who reported a history of self-injury and responded to questions regarding preferences for future online help-seeking (N = 457). The sample was identified as part of a larger study (N = 1,463) exploring self-injury and help-seeking. Results: Seven themes emerged in relation to preferences for future online help-seeking: information, guidance, reduced isolation, online culture, facilitation of help-seeking, access, and privacy. Direct contact with a professional via instant messaging was the most highly endorsed form of online support. Conclusion: Young people expressed clear preferences regarding online services for self-injury, supporting the importance of consumer consultation in development of online services.
Article
For decades, suicide rates among minority African American and Latino young people have been stable and, when compared with Whites, relatively low. This is no longer the case, underscoring the need for documenting and understanding the problem of suicidality in this population. We report on the prevalence and predictors of suicidality among 879 urban adolescents in the Reach for Health study. All youth resided in economically disadvantaged neighborhoods; 69% were African American, 16% Latino, and 15% reported mixed or other ethnicity. In the past year, 15% had seriously considered suicide; 13% had made a suicide plan, 11% had attempted suicide at least once, and 4% reported multiple attempts. Risk factors significantly related to suicidal ideation are being female, having basic needs unmet, engaging in same‐gender sex, and depression. Resiliency factors include family closeness and, marginally, religiosity. Risk factors related to reports of suicide attempts are being female, being Hispanic, and depression; family closeness is strong resiliency factor. Family composition, ethnic identity, coping style, peer support, and school attachment are not significant correlates of suicidal ideation or attempts.
Chapter
Background: Self-harm is a concerning problem amongst young people, yet the current understanding of the psychological basis to self-harm is limited, particularly that which relates to adolescents in the general community. Aim: The aim of this study was to 1) expand on past research by including a measure of coping strategies and 2) identify distinct psychological profiles and explore the association of these profiles with self-harm rates. Methods: 944 school students from 4 secondary schools aged 11 to 19 and 166 first year psychology students in Sydney, Australia completed a self-report questionnaire. Each participant completed measures of depression, anxiety, and stress, impulsivity, coping strategies, and risk of developing an eating disorder. Clusters of students based on only on psychological profile were formed using non-hierarchical cluster analysis. Differentiation across clusters was then sought based on self-harm rate. Finally, other characteristics of the individual were compared across clusters, including communication with family and friends, bullying, and sexual orientation. Results: Community participants grouped naturally into six distinct clusters of individuals of which four could be described as "normal" in having a desirable psychological profile while the other two clusters were characterized by having an undesirable psychological profile that could be loosely described as psychopathology. The six clusters of individuals could also be divided into three with comparatively low rates of self-harm (5-16% lifetime prevalence) and those with comparatively high rates (25-58% lifetime prevalence). Not surprisingly the three low self-harm rate clusters were also among those characterized by a "normal" psychological profile. Of the three high self-harm rate clusters one was characterized only by high scores on impulsivity but was otherwise unremarkable (lifetime self-harm prevalence 33%). The two remaining high self-harm rate clusters were characterized by complex but quite different psychological profiles. One of these clusters scored high on psychological pathology, high on problem solving skills and high on positive outlook (lifetime self-harm prevalence 25%) while the other scored high on psychological pathology, average on problem solving, low on social support, low on positive outlook and also high on withdrawing as a coping strategy (lifetime self-harm rate 58%). Conclusions: The results presented here carry four key messages. First, adverse psychological factors are clearly associated with elevated rates of both recent and lifetime self-harm. Second, finding three clusters of individuals with high self-harm rates but quite distinct adverse psychological profiles suggests that there maybe multiple paths to self-harm and attempting to find a single model incorporating all risk factors may therefore be unproductive. This has important implications for future research in this area and for clinicians working with adolescents, ie there is no single profile to look out for. These results stand in contrast to previous literature that focuses primarily on identifying a single risk profile for adolescent self-harm. Third, the presence of self-harm in the three psychologically "normal" groups suggests that a subset of adolescents who self-harm may not be identifiable through any known risk factors. This makes it difficult for clinicians, school personnel, and parents to identify adolescents who engage in self-harm. Fourth, although some aspects of psychopathology are not amenable to remedy, their effects on self-harm rates may be ameliorated by teaching adolescents good coping skills and ensuring adequate social support since this differentiates clusters that both have adverse psychological profiles but quite different self-harm rates.
Article
Background: Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm. Methods: Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams). Results: A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode. Limitations: Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care. Conclusions: The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.
Article
Six young adults (aged 19-21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.
Article
The first book of its kind to address suicide, self-injury, and violence in school settings The frequency of suicide, students' self-injury, and violence in school settings requires preventative and response policies and procedures for the safety and protection of faculty and students. Suicide, Self-Injury, and Violence in the Schools: Assessment, Prevention, and Intervention Strategies is the first book to provide first responders-specifically, school counselors, psychologists, social workers, teachers, and administrators-with information on assessing risk. In addition, guidelines are included on how to respond to these crises in a practical and proactive manner that minimizes risk and/or impact on the school community. The authors, nationally renowned experts on suicide, self-injury, and violence among children and adolescents, present: Critical information on suicide and suicidal behaviors specific to children and adolescents Pertinent issues related to nonsuicidal self-injury behaviors Guidance on conducting effective face-to-face clinical interviews with violent and potentially violent students and their families Important prevention and screening topics for middle and high school counselors Discussion on psychological first aid in response to school violence survivors and their parents Filled with mini-case vignettes, as well as checklists for school personnel to use, this timely reference supports school professionals in devising the very best prevention, intervention, and post?crisis strategies. It is a much-needed resource for establishing a collaborative, nonsuicidal, nonviolent environment both within and outside the school setting.
Article
Purpose: There have been few longitudinal studies of deliberate self-harm (DSH) in adolescents. This cross-national longitudinal study outlines risk and protective factors for DSH incidence and persistence. Methods: Seventh and ninth grade students (average ages 13 and 15 years) were recruited as state-representative cohorts, surveyed, and then followed up 12 months later (N = 3,876), using the same methods in Washington State and Victoria, Australia. The retention rate was 99% in both states at follow-up. A range of risk and protective factors for DSH were examined using multivariate analyses. Results: The prevalence of DSH in the past year was 1.53% in Grade 7 and .91% in Grade 9 for males and 4.12% and 1.34% for Grade 7 and Grade 9 females, respectively, with similar rates across states. In multivariate analyses, incident DSH was lower in Washington State (odds ratio [OR] = .67; 95% confidence interval [CI] = .45-1.00) relative to Victoria 12 months later. Risk factors for incident DSH included being female (OR = 1.93; CI = 1.35-2.76), high depressive symptoms (OR = 3.52; CI = 2.37-5.21), antisocial behavior (OR = 2.42; CI = 1.46-4.00), and lifetime (OR = 1.85; CI = 1.11-3.08) and past month (OR = 2.70; CI = 1.57-4.64) alcohol use relative to never using alcohol. Conclusions: Much self-harm in adolescents resolves over the course of 12 months. Young people who self-harm have high rates of other health risk behaviors associated with family and peer risks that may all be targets for preventive intervention.