PRINCIPAL NET INVESTIGATOR:

1. Children’s Mental Health Ontario & Ontario Association for Children’s Aid Societies 2008 JOINT CONFERENCE Risk & Resilience Factors in Youth In Care Who Self Harm: Mining Data, Guiding Knowledge, Improving Outcomes PRINCIPAL NET INVESTIGATOR: Deborah Goodman, MSW, Ph.D., Child Welfare Institute (CWI), CAS-Toronto STUDENTS: Connie Cheung, M.A., Ph.D. (candidate), OISE/University of Toronto Sarah Beatty, MSW, York University RESEARCH ASSISTANTS April Mazzuca, MSW, CWI, CAS-Toronto Teju Pathare, MA, Clinical Psych, CAS-Toronto CAS-TORONTO STAFF Natasha Budzarov & Sarah Singer, MSW, CAS -Toronto

2. What Do We Know About Self Harm?

3. What is self-harm? “a range of things that people do to themselves in a deliberate and usually hidden way, which are damaging” National Inquiry Panel into Self Harm, 2005 UK “refers to a wide-range of behaviours with motives ranging from coping and survival to attempts to seriously injure or even kill oneself” National Children’s Bureau

4. Self-harm Self-injury Serious occurrence Deliberate self-harm Para-suicide Attempted suicide Suicidal behaviour What terms refer to self-harm?

5. What is self harm? ‘The deliberate destruction or alternation of body tissue without conscious suicidal intent, resulting in injury severe enough for tissue damage’

6. Literature: Examples of self-harming behaviours (generally agreed) • Self-cutting/wound picking • Burning/scalding • Self-battery • Swallowing/insert objects into body • Self-poisoning • Overdose • Self-hanging/suffocating • Head-banging • Placing self in danger • Hair/eyelash pulling

7. Literature: Examples of self-harming behaviours (to be determined) • Excessive drinking /substance abuse • Unsafe sex / teen pregnancy • Dangerous driving • Multiple Tattooing / Piercing • Bulimia / Anorexia • Risky lifestyles • Others….

8. Literature: Overview on self-harming behaviours in children and youth • Relatively very little is known about self-harming behaviours in children and youth • Main limitations in literature: • Conceptualizations and classification systems of self harm have varied from one study to another • Research has primarily focused on the prevalence and nature of self harm • Much of the literature is based on retrospective studies • Relatively little research examining self-harming behaviours in non-clinical populations • Little examination of the frequency of self harm as a factor

9. What do we know about self-harm? • Self-injury behaviours are common (10% admissions to medical wards, UK; 7-11% 13-16 yrs old UK; 7-10% CIC in Ontario CASs) • There is no common definition • Etiology not well understood • Self-harm often is not an isolated event (high % repeat) • Strong association between attempted suicide, self-harm and suicide • Not clear what treatment is most effective • Negative stigma attached to the event • Scarcity of resources & support • Strategies for suicide prevention; few for self-harm • Many knowledge gaps

10. What do we know about self-harming youth? • Self-injury behaviours are common • Self-injury is a deliberate action • Incidence in adolescents seems to be rising • Earliest signs may appear in childhood but recognized in adolescence • Severity of self-harm not dependent on seriousness of underlying problems (e.g. tolerance effect) • Most people who self-abuse describe their childhoods as: hurtful, rejected, abandoned, invalidating

11. Risk Factors for Self Harm

12. Social, environmental & educational, risk factors associated with self harm • Child-specific experiences or factors associated with self-harming behaviours: • Childhood sexual abuse • Childhood physical abuse • Neglect • Childhood separation and loss • Quality and security of childhood attachment relationships • Emotion dysregulation (e.g., impulsivity) • Poor academic achievement • Poor school attendance • School misconduct • Not communicating with others about problems

13. Genetic risk factors associated with self harm • Genetic disorders that are associated with youth who self-harm • Cornelia de Lange Syndrome • Prader Willi Syndrome • Fragile X Syndrome • Cri du Chat Syndrome

14. Family risk factors associated with self harm • Family-specific characteristics associated with youth who self-harm • Living apart from both parents • Conflicts and arguments within the home • Too much/too little parental supervision • Poor family functioning • Family member with history of self harm

15. Why do youth self-harm? • Way of dealing with strong emotions • Way to communicate distress • Way to cope • Biological addiction (e.g. cutter’s high) • Social attachment to sub-group • Poor impulsivity control

16. Learning About Self Harm: CAST 2004-2008

17. Children’s Aid Society of Toronto (CAST) & self harming youth: 2004 • What did we know for sure? • All communities, all cultures have youth who self harm • All Children Aid Societies have children and youth in care who self harm • Self-harming behaviours are associated with specific risk factors • Did not know a lot • What did we need to know? • Needed an in depth understanding of: • Who self harms (e.g. risk factors, gender effects, age effects) • Why children/youth choose to self harm • The nature of self harm (e.g., method (s), single vs. multiple episodes, threat vs. actual) • Needed to identify the risk and protective factors associated with self harm so earlier identification, support to caregivers… • Needed insights into what treatments works, for who, for which self-harming types and magnitude of treatment effect…

18. Methodology: Down the rabbit hole of learning… • Systematic collection of all self harm events and threats from SOR forms inputted into SPSS = 298 youth & 609 events to date (2004-07) • Survey of GTA professionals on Self Harm (2006) • Standardized file review: population of 20 boys age 10 and under who self harm (2005) • Standardized file review: random sample of 18 youth who self harm vs. 18 matched youth who do not self harm (2006-08) • Standardized interviews with 6 workers of youth: 2 with youth with single SOR vs. 4 with youth with multiple SORs (2007-08) • Standardized file review: 24 pregnant teens in care vs.12 non-pregnant teens in care (2007-08). • Standardized interviews with pregnant teens in care: 8 teens interviewed to date (2007-08)

19. Translating SOR Forms Into Data & Then Translating Them Into Information

20. Ministry of Youth and Child Services: Serious Occurrence Report (SOR) • SOR Report is a mandatory “event” report completed by all Ontario child welfare workers • Documents serious incidents that happen to children who are in the care of Children’s Aid Society of Toronto (CAST) • Each event submitted to the Ministry of Child and Youth Services • Documents instances of self harm • + Attempts - Narrative based • + Threats - Activity analysis only • CAS-Toronto has SOR data starting from 2000 • 2004 -2007 inputted all SOR’s into SPSS = longitudinal data

21. What do we know about youth in CAS care in Ontario? • More than any other childhood disorder, child maltreatment is associated with adverse physical and mental health consequences for children and families • In 2005/06 the 53 Ontario: • CASs have over 18,000 children in care • 9,272 Crown wards on Dec 31, 2006 • 58% male vs. 42% female • 82% are ‘special needs’ • 9%-10% are ‘high risk’ (e.g. suicidal/self harm) • 35% have a history of abuse

22. What do we know about youth in CAS-Toronto care? In 2005/06 CAS-Toronto served nearly 31,000 children/youth; over 12,500 families; 2,200 children in care; about 3,300 in care in one year period; over 1,100 are Crown Wards • 2000/01= under 12 (49%): over 13 (51%) • 2004/05= under 12 (43%): over 13 (57%) • 2005/06= under 12 (40%): over 13 (60%)

23. What do we know about the child in care population in CAS-Toronto? • Over 50% youth in care are Crown Wards (means CAS is the permanent parent) • 54% male • 46% female • 83% are special needs • 42% are on medication • Primary Diagnosis (Crown Wards) • 20% ADHD • 18% emotional difficulties • 13% developmental delays • 10% psychiatric diagnosis

24. How many children in care of Children Aid Societies self harm? • Analyses of 2004 SOR data from 6 CASs (about 8,000 of 16,000 children in care) • Range across 6 CASs of SOR’s • 6% to 10% of in care population with 1 or more SOR’s • Approximately 7.4% of child welfare youth self-harm • Death by suicide very rare event • Of the youth with an SOR • 60% SOR youth have self-harmed • 40% threat of harm

25. CAS-Toronto 2004 SOR data Single SOR Repeat SOR TOTAL

26. “Harm” vs. “threat of harm” vs. “restraint” 2004 SOR data Single SOR Repeat SOR TOTAL

27. Types of self harming behaviours Single SOR (76) Repeat SOR (25) M F M F

28. CAS-Toronto 2005 SOR data Single SOR Repeat SOR TOTAL

29. Myths Hi rate of suicide of youth in care Self-harm is a high frequency event for in-care youth Prevalence of youth in care who self harm is much higher than the general population Self-harm is a homogeneous event Nothing works Realities Youth suicide for in-care is a very rare event 6%-10% self-harm; of those 2%-3% do repeat self-harm; <1% are responsible for most SORs Seems to be similar; again with small number of youth responsible for most SORs Boys do more self harm events than threats; Repeat self harm youth differ by gender & type from Single self harm youth Individual treatment plans, supportive environment, seeing self harm as primary, close monitoring make positive impact on reducing self harming behaviour overtime What we learned about youth in care who self harm…myths & realities

30. Translating Standardized File Review Data Into Information

31. Purpose & methodology of standardized file review (SFR) • Purpose • To examine different predictors of self harm • Examine whether the effects of risk can be modified by certain protective factors • Methodology • 36 files where randomly selected to be reviewed • 18 children with a history of 1 or 2 self-harming episodes • 18 children without a history of self harm • Roughly matched in age, gender, ethnicity and length in care

32. Focus of file review examination Standardized file reviews examined two different areas: • Child-specific variables: individual pre-dispositions that are unique to the child • Exposure to risk (e.g., mental health diagnosis) • Protective factors (e.g., high cognitive functioning, supportive relationships) • Mother-specific variables: maternal pre-dispositions • Exposure to risk (e.g., risky behaviours, drug abuse) • Past experience (e.g., experience of abuse)

33. Reliability of coding with coders • Reliability established between coders • 30% of all transcripts • Kappa value of .86 (when taking into account responses by chance, agreement between raters was 86%) • Disagreements resolved through discussion and consulting the original file • Remaining files independently coded between raters

34. Exploring risk factors associated with self harm: maltreatment experiences • Q1 - Are children/ youth experiences with abuse similar in those with and without self-harming behaviours? • Examined group differences in the type of abuse experienced by children • Chi-square analysis (categorical data)

35. * *2 =5.9, p <.04

36. * *2 =5.9, p<.04

37. * *2 =4.28, p<.08

38. Exploring risk factors associated with self harm: predictors of self harm • Q2 - What are some predictors of self harm? • Examined whether an accumulation of child-specific risk significantly predicted self-harming behaviours • Developmental Issues (e.g., developmental delay) • Difficulties with school (e.g., special needs classes) • Mental health diagnosis (e.g., ADHD) • Controlled for the effects of physical abuse • Ordinal regression analysis (number of SORs is an ordinal variable)

39. * * p <.05

40. * * p<.05

41. Exploring risk factors associated with self harm: maternal predictors • Q3 - What are some maternal predictors of self harm? • Examined whether maternal factors (e.g., exposure to risk, experience of abuse) can predict self harm in their children • Controlled for the effects of child-specific factors (i.e., experience with physical abuse and exposure to risk) • Ordinal regression analysis

43. Exploring risk factors associated with self harm: factors for greater risk • Q4 – Do certain factors place children at more risk for developing self-harming behaviours? • Children with self-harming behaviours are also more likely to have experienced physical abuse • Children who are exposed to more risk are also more vulnerable to self-harming behaviours

44. Exploring resilience factors associated with self harm: modify risk Q5 - Can the presence of positive, supportive relationships with others moderate the effects of individual risk on self-harming behaviours? • Examined whether the amount of positive, supportive relationships reduced children’s likelihood of developing self-harming behaviours • Controlled for the effects of physical abuse • Series of ordinal regressions

45. Exploring resilience factors associated with self harm: moderation effect • Q6 - How do we detect a moderation effect? • Individual risk and social relationship variables are first entered into the model to examine whether they significantly predict the likelihood of self harm • Individual risk factor is required to be a significant predictor of self harm in the first model • In the second model, an interaction term (individual risk X social relationship) is entered • The individual risk factor is expected to lose its significance once this interaction term is entered in which the interaction term becomes a significant predictor

46. Exploring resilience factors associated with self harm: models • Model 1: Individual risk significantly predicted the likelihood of children displaying self-harming behaviours • Controlling for the effects of physical abuse • Amount of social relationships did not significantly predict the likelihood of self harm • Model 2: The interaction between individual risk and amount of social supports predicted the likelihood of self harm • Individual risk is no longer a significant predictor

47. Translating Worker Knowledge Into Information

48. Worker interviews: purpose & methodology • Purpose: • To begin exploring different treatment and intervention strategies that have been effective in reducing self-harming incidents • Child-welfare worker interviews were used to examine worker perceptions of: • Children who were able to reduce their self-harming behaviours • Children whose self-harming episodes did not change • Methodology: • Six, semi-structured, qualitative interviews with child welfare workers • All interviews were audio-taped and researcher notes taken • Participants were gathered through “purposive sampling”

49. Worker interviews: question format • Interviews • The interviews divided into 4 different sections: (a) Worker – client relationship (b) Client’s interpersonal relationship with significant others (c) Precursors to self-harming behaviours (d) Treatment outcomes

50. Worker interviews: precursors to self harm Precursors to Self Harm SELF-HARMING EPISODE Stressful Events Trauma Not Being Heard