Responding to non-suicidal self injury & suicidality in the school setting May 2013

1. Responding to non-suicidal self injury & suicidality in the school settingMay 2013 Lydia Senediak (Senior Clinical Psychologist: CAMHS Hornsby Ku-ring-gai)

2. NSSI: definition The direct, deliberate destruction of body tissue without lethal intention (Nock, 2009)

3. Non-suicidal self-injury (NSSI) Usually in the context of: • Mental health problems especially depression • Situational stress ______________________ • To numb/ anaesthetize [disconnect] • To feel/ control [connect]

4. Patterns • Gender: - females generally 2 – 4 x higher (depending on method) • Methods: • Cutting (incl. scratching)/ picking skin • Self-hitting/ biting/ burning • Inserting objects • Transmission: - Peer contagion - Electronic communication/ social media • Comorbidity: • Depressive symptoms (80%)

5. Moran et al (Lancet, 2012) N = 1802 (community sample) [15y - 29y] 7 waves of FU from middle teens to late 20s One in 12 adolescents self harm (8%) but only a tenth continue to late 20s Of the 14 yp who continued self harming, 13 = female Adolescent symptoms of depression and anxiety are associated with on-going self harm in 20s (6x more likely)

6. Teen depression : the facts • Up to two-fifths of adolescents suffer from depressed mood in any 6 month period • Five percent of young people suffer from a clinical depression • About 48% of young people with a diagnosis of depression will have another episode within 2 years • About 75% will have another episode within 5 years

7. Epidemiology NSSI (community studies) • Approx. 3 - 12% in past 12 months • Life-time prevalence: 8 - 15% often cited

8. “It works. I get to feel something real, and when everything else seems so crazy and out of control, it’s the only thing I can control.. Without it I may not be here” Andrew

9. What we see… Struggle to regulate emotions & responses Reactive Maladaptive coping strategies Unhelpful view of world & self ________________________ History of loss/ traumatic experiences Unhealthy view/ engagement in relationships Often reluctant to involve parents ++

10. Age of onset…. • Majority begin between 12 and 15 years of age • Occurs in approx. 5 – 8% of Primary School children (Barrocas et al, 2012) • Approx. 20 -25% of the self-harmers say they started in the 6th Grade or earlier (Ross and Heath, 2002)

11. “I don’t feel the pain until the next day. I’m not sure what I feel when I cut, but afterwards it’s like a relief” Heather

13. Signs to look for……NSSI • Overly secretive behaviour (e.g. when changing clothes; excessive time in bathroom). Isolation ++ • Refusal to participate in activities revealing DSH (e.g. swimming) • Inappropriate clothing for the weather (e.g. constantly wearing long sleeves, etc.) • Blood stained clothing • Unexplained scars, bruising, cuts (or bandages/ covers) • Possession (hoarding) of implements (e.g. razors, lighters, knives, etc.)

14. Cessation factors • Developing a sense of self and finding ‘your own voice’ – feeling validated • individuation • Safe, predictable environment • Ability to identify and express feelings more appropriately • Impulse control/ maturity

15. NNSI and Suicide risk • Vast majority child and adolescent self-harmers have little suicidal intent • However, self harm (with or without suicidal intent) is a strong predictor of later suicide (present in histories of some 40 – 60% of suicides) (e.g. Cavanagh et al, 2003) Rate of suicide attempt increases as frequency of NSSI increases

16. Self-injury as an ‘adaptive’ mechanism DSH serves a function in their lives

17. Helpful responses from staff Viewing the self-harm as one way of trying to cope/ express meaning Repeatedly, people who self-injure list compassionate, non-shaming listening and calm interest as most helpful” (Alderman, 1977; Wise, 1999; Hyman, 1999)

18. Youth Suicide: Frequency (Australia) • Each year approx. 400 young people (aged 15-24 years) die from suicide • Rates for 15 – 24 year olds fell by 56% between 1997 & 2006 • Most common method is hanging • In 15-19 year olds, for every suicide by a female there are approx. 3 – 4 suicides by a male [femalesmake many more suicide attempts]

19. Indicators of greater suicide risk:Be more concerned if: • Marked problems with sleep/appetite and social withdrawal • Increased risk-taking behaviour • Giving away possessions/ rituals around goodbyes • Increased alcohol/ substance use • Direct/Indirect comments containing hopelessness/ suicidal thoughts ________________________ • Hallucinations or delusions (extra concern)

20. Preventative interventions:plan AHEAD for WELL-BEING

21. School management response • Clear management protocols (separate NSSI and suicidal behaviour). Develop re-entry plans • Defined staff roles • Open about your limitations (incl. boundaries re: confidentiality) • Inform/ guide parents • Seek mental health assessment and treatment • Limit possible contagion to others

22. Contacting parents When (? clinical threshold): clarify with student Who contacts….Who to contact? Cultural sensitivity Possible contra-indications

23. Take home messages • Most get better with maturity • Seek mental health assessment: • Assess comorbidity • Review suicidal intent • Explore relevant Hx and triggers • Involve parents in collaborative planning whenever possible • Enhance well-being & help-seeking across the school community. TEAM APPROACH

24. “ Our greatest glory is not in never falling, but in rising every time we fall” Confucius Thank you. Best wishes for the future!