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

2. NSSI: definition The direct, deliberate destruction of body tissue without lethal intention (Nock, 2009) (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) - females generally 2 – 4 x higher (depending on method)  Methods: – Cutting (incl. scratching)/ picking skin – Self-hitting/ biting/ burning – Inserting objects  Transmission: - Peer contagion - Peer contagion - Electronic communication/ social media - 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 - 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…. Age of onset…. Majority begin between 12 and 15 years of age Majority begin between 12 and 15 years of age Occurs in approx. 5 – 8% of Primary School children (Barrocas et al, 2012) 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 6 th Grade or earlier (Ross and Heath, 2002) Approx. 20 -25% of the self-harmers say they started in the 6 th 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” “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 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 Self-injury as an ‘adaptive’ mechanism DSH serves a function in their lives DSH serves a function in their lives

17. Helpful responses from staff 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 [females make 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 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! Thank you. Best wishes for the future!