Pattison and Kahan first described ‘deliberate
self-harm’ as a syndrome in 1983 [1]. The typical pattern described was
that of onset in late adolescence, multiple recurrent episodes, low
lethality and harm deliberately inflicted upon body. Most authors
distinguish between deliberate self-harm and suicide, based on the absence
or presence of the apparent intent to kill oneself. While others use it as
an all encompassing term that includes a wide range of behaviors ranging
from attempted hanging to superficial cutting [2]. Regardless of the
definition, it is known that a prior attempt of deliberate self-harm is
one of the strongest predictors of future completed suicide [3]. While
much has been talked about suicide attempts and acts of deliberate
self-harm among adolescents, there is a relative paucity of research
evidence regarding acts of deliberate self-harm amongst children under the
age of 13 [4]. A study by Sourander, et al. [5] suggested that
deliberate self-harm among children is a herald for self-harm behavior in
adolescents.
In the current issue of Indian Pediatrics,
Krishnakumar, et al.[6], report a study where 30 children, aged 6
to 13 years were followed up in the Child Guidance Clinic after being
admitted to the inpatient pediatric unit for attempted self-harm. This is
one of the first studies that focuses specifically on children less than
13 and does not target children and adolescents as a mixed group.
Consenting parents and children were interviewed using the concerned part
of NIMH DISC and child informant interview. Stressors were categorized as
acute, chronic and acute on chronic, as well as on the basis of source of
stress as parent, family, school, peer and teacher related. Children whose
act of self-harm was considered to be an act of suicide attempt were
further subcategorized and were analyzed separately. 73% of this subgroup
had some kind of a psychiatric disorder (depressive disorder, ADHD and
conduct disorder). The male to female ratio was 2.3:1. The most common
method used was self-poisoning. 24% of the children had learnt about
suicide by watching television. The authors concluded that the self-harm
behaviors and the associated risk factors in this young population were
similar to those in adolescents.
In several ways the results of this study are
consistent with those in existing literature. The authors cite certain
regional and cultural factors possibly contributing to some of the
results. Some differences from western studies are noted, including a male
preponderance, and absence of substance use and sexual abuse as possible
associated risk factors [7]. Taboo of mental illness and deliberate
self-harm, neglect of the girl child all leading to underreporting and
overall lower prevalence of substance use and sexual trauma in rural South
India could explain some of these differences.
As the authors note, their data possibly represent only
the tip of the iceberg; deliberate self-harm is slowly becoming a public
health problem. There is an increasing need to educate not only
pediatricians but also parents and school teachers to identify early signs
of depression and anxiety in young children. Since routine annual physical
examinations are not a norm in India, the responsibility of teachers and
parents is even greater. Moodiness, sadness, academic decline and social
withdrawal may be early signs of an underlying mood disorder in children
[8]. Early identification of symptoms and timely intervention is one of
the best preventive measures on self-harm and suicidal behaviors. It is a
myth that talking about suicide increases risk of suicide. Curtailing the
access to media and better parental supervision and guidance during media
viewing can also minimize self-harm in young children.
Funding: None.
Competing interests: None stated.
References
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syndrome. Am J Psychiatr. 1983;140:867-72.
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