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Indian Pediatr 2011;48:
367-371 |
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Deliberate Self Harm in Children |
P Krishnakumar, MG Geeta and A Riyaz
From the Department of Pediatrics, Medical College,
Calicut, Kerala, India.
Correspondence to: Dr P Krishnakumar, Aswathi, Behind
Nellikode Vishnu Temple, Thondayad, Post
Chevarambalam, Calicut, Kerala 673 017, India.
Email: [email protected]
Received: January 25, 2010;
Initial review: March 8, 2010;
Accepted: May 7, 2010.
Published online. 2010 August
10.
PII: S097475590900085-1
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Objective: To study the nature of deliberate self-harm (DSH) in
children and to identify the associated factors.
Setting: Child Guidance Clinic attached to the
Department of Pediatrics of a teaching hospital in South India.
Subjects: Children with history of deliberate self
harm who were referred to the CGC for psychological evaluation during a 10
year period.
Methods: Children and parents were interviewed
together and separately and details regarding age, sex, family and school
environment, stresses and nature of self harm were documented. Psychiatric
diagnosis was made based on DSM IV diagnostic criteria.
Results: Among the 30 children included in the
study, 21 were boys and 9 were girls. Majority of children were between
the ages of 11 and 13 years, the youngest being 6 years old. 76% of
children had history of acute stressful life events and 62% of them had
chronic ongoing stress. 62 % of children had stress in the family and 41%
had stress at school. Stress in the family included death of a parent,
conflicts with parents or siblings, mental illness in the family, parental
alcoholism and parental disharmony. Stress at school included conflicts
with classmates, punishment or negative comments by teachers and learning
problems. Psychiatric disorders were present in 52% of children, the
commonest being depressive disorder. The commonest mode of DSH was self
poisoning, and rat poison (zinc phosphide) was the commonest substance
used.
Conclusions: Deliberate self harm occurs in young
children and the risk factors are comparable to those in adolescents.
Key words: Attempted suicide, Children, Deliberate self harm,
India.
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Deliberate self harm (DSH) is defined as an
act with a non-fatal outcome in which an individual deliberately initiates
behaviour which causes bodily injury or ingests a substance in excess of
the therapeutic dose or ingests a non-ingestible substance [1]. Even
though deliberate self harm is common among adolescents, it is very rare
in children [2,3]. Most of the studies on DSH among children and
adolescents focus on adolescents and there is scant data on DSH in
children. It has been shown that deliberate self harm in childhood is
often a forerunner of DSH in adolescence [4].Deliberate self harm is an
indicator of underlying psychosocial problems and there is an increased
risk of suicidal behavior in later life [5-7]. The present
study was conducted to analyze the nature of deliberate self harm in
children as well as to identify the factors associated with it.
Methods
All children admitted to the Department of Pediatrics
with suspected deliberate self harm are referred to the Child Guidance
Clinic (CGC), for child psychiatry evaluation, prior to discharge. The
admission policy of the department restricts admission to children below
13 years. Hence the present analysis includes only children aged 12 years
and below. The final analysis includes only those cases in which both
parents and child agreed that the child consumed the poisonous substance
or attempted self harm intentionally. Children with accidental injuries,
accidental or homicidal poisoning, and mental retardation were excluded.
Verbal informed consent from both parents was taken prior to inclusion in
the study.
In the CGC, children and their parents were interviewed
together and separately and details regarding age, sex, family and school
environment, stresses and nature of self harm were documented. Psychiatric
diagnosis was made based on DSM IV diagnostic criteria [9]. For the
study purpose, acute stress was arbitrarily defined as stress that
occurred during the previous one-month period (examination failures, death
or separation of loved ones, conflicts with parents, teachers or siblings)
and chronic stress as long-term ongoing stresses (learning problems and
adjustment problems at school, financial problems in the family, ongoing
conflicts with parents or siblings, parental disharmony etc). Depending on
the source, stress factors were further classified as family stress (death
of a parent, mental illness in the family, financial problems, conflicts
among parents, parental alcoholism, divorce and separation), parent stress
(punitive parent, conflict with parents), school stress (examination
failures, poor academic achievement, change of school, general adjustment
problems at school), peer stress (bullying by classmates, being ignored by
friends, conflicts with class mates) and teacher stress (punishment,
adverse comments, being ignored) [10].
In the proforma, questions to elicit the actual intent
to commit suicide were framed using the concerned part of the National
Institute of Mental Health Diagnostic Interview Schedule for Children -
Child informant (Interview about self) [11]. Children who attempted
suicide were identified in accordance with the definition of attempted
suicide by the National Institute of Mental Health Task Force [12].
According to this definition, self-injurious behavior is considered as a
suicide attempt if it is associated with the psychological intent to end
one’s own life. Factors associated with attempted suicide in children were
analyzed separately.
Data collection on DSH was started in January 1999 and
the present analysis includes data for the 10 year period up to December
2008. The result of a preliminary analysis of data from January 1999 to
December 2003 was published previously [8]. Statistical analysis was done
using the Epi info version 3.4; 2007 statistical package.
Results
Thirty children (9, 30% girls) were referred to the CGC
during the study period with history of DSH. Of these, 23 children were
above 11 years of age and 6 children were between 9 and 11 years. The
youngest was a 6 year old girl. A twelve year old boy who attempted
hanging died and was not included in the final analysis. Hence the final
analysis included 29 children. Stress leading to DSH was present in 26
(90%) of children (Table I).
TABLE I
Stress Factors in Children with Deliberate Self-harm (N=29)
Stress |
No |
(%) |
Arguments or conflicts prior to DSH |
16 |
55 |
Chronic stress |
18 |
62 |
Acute stress |
22 |
76 |
Acute stress on chronic stress |
14 |
48 |
Some type of stress (acute or chronic) |
26 |
90 |
Family stress |
18 |
62 |
Conflict with parents |
12 |
41 |
Conflict with siblings |
8 |
27 |
Parental disharmony |
4 |
14 |
Family history of mental illness |
4 |
14 |
One parent expired |
4 |
14 |
Father expired |
3 |
10 |
Mother expired |
2 |
7 |
Both parents expired |
1 |
3 |
Parental alcoholism |
1 |
3 |
School stress |
12 |
41 |
Learning problems |
8 |
28 |
Conflict with teachers (teacher stress) |
5 |
17 |
Conflicts with peers (peer stress) |
4 |
14 |
A real life model was present in 5 (17%) children. The
mother of a 12 year old girl, who attempted hanging, had committed suicide
a year ago by the same method. In other cases, children had come to know
about suicide when someone in the locality had attempted the same. Two
children read about suicide in the newspapers of whom one child had read
about a student who committed suicide. Seven (24%) children came to know
about suicide by watching television. The 6 year old girl had been told by
a relative that she would die if she ate face cream.
Though 14 (48%) children had harbored suicidal thoughts
in the preceding one month, the act of DSH was preplanned in only 7 (26%)
of them. The act was the first attempt in 27 children, the second in one
child and the third in another child. The second attempt was by a 11 year
old boy who consumed antipsychotic tablets and benzodiazepines. Both
attempts were attention seeking behaviors and there was no actual
intention to die. The third attempt was by a 12 year old girl who had lost
her father when she was a year old and whose mother committed suicide by
hanging a year ago. The first two attempts were when the mother was alive-
the first by cutting a vein and the second by drinking kerosene. The
present one was by attempted hanging. She had the intention to die, was
depressed and refused to promise that she would not repeat the same act.
15 (52%) children had some type of psychiatric
disorder. Among them 11 (38%) children had depressive disorder, 6 (21%)
had conduct disorder and 2 (6%) had ADHD. One child had features of OCD.
The commonest mode of DSH was self poisoning by
ingestion of a pesticide. The pesticides used included rat poison (zinc
phosphide-10; 34%), organophosphorous pesticides (3; 10%) and pyrethrin
(2; 7%). One child each had consumed kero-sene and face cream. Eight (27%)
children attempted self poisoning with drugs. The drugs implicated were
alprazolam, paracetamol, carbamazepine, erythromycin, clonazepam,
haloperidol and nitrazepam. Five (17%) children attempted hanging.
The act of DSH was attempted suicide in 15 (52%)
children (5,33% girls) as per the definition, since they had the intention
to die. These children were analyzed separately. All of them except the 6
year old girl were between 11 and 13 years of age. Nine (60%) children had
depressive disorder and 4 (27%) had conduct disorder. One child had ADHD.
Some type of psychiatric disorder was present in 11 (73%) children. 12
(80%) children had suicidal ideation in the past one month. 12 of them
said they would not repeat the act but three were not sure. It was the
first attempt in 14 children and the third attempt in one child.
Psychiatric disorders and depressive disorders were seen significantly
more frequently in children who attempted suicide than in those who did
not (P=0.04). There was no statistically significant difference in
the stress experienced by these two groups of children. Although 12 (80%)
children had harboured suicidal thoughts in the previous one month period,
DSH was an impulsive act in 10 (67%) children and was pre-planned in only
5 (33%) children.
Discussion
The present sample consisted of 30 children aged 12
years and below who attended the CGC with deliberate self harm during a
period of 10 years. The lifetime prevalence of DSH among adolescents was
reported to be 18% in a school based study from Delhi [13]. It is
well documented that only a small percentage of children and adolescents
with DSH seek professional help [1,5,13]. Hence it is probable that
our data indicate only the tip of the iceberg.
When the data on childhood poisoning from eight
regional hospitals in India were reviewed in 1998, it was found that
suicidal poisoning occurred only in children above the age of 12 years
[14,15]. In the present sample all children who attempted suicide were
above the age of 11 years, except for one child. The male/female ratio in
the present sample was 2.3:1. Studies on DSH in children and adolescents
have reported a higher incidence in females [1,3,16]. Other Indian studies
have reported equal prevalence of DSH among adolescent boys and girls
[13,17,18].
The association between stress and DSH in adolescents
is well documented [1,3,13,17,19]. Both acute and chronic stress have been
found to be associated with suicidal behavior in adolescents [10].
In the present sample 90 % of children had experienced either acute or
chronic stress and nearly half of them had acute stressful experiences in
addition to ongoing stress.
The family was the source of stress in the majority of
children in our sample, similar to previous studies [1,3,13,17,19]. In our
sample, 14% of children had lost one or both parents and another 14 %
experienced parental disharmony. Studies have reported that living with
both parents is protective and that DSH is more common with history of
parental demise [1,20]. Repetition of DSH is more common in children
coming from dysfunctional families [21]. It could be assumed that
supportive family environment helps children to cope with life stresses
better and prevents deliberate self harm.
Studies have noted that academic stress is an important
cause for DSH [5,13,18,19,22]. The finding that 41% of children in the
present sample had school related stress supports this observation. High
parental expectations and resultant parental behaviors were found to
contribute to school-related stress in the present sample.
The finding that more than half of the children with
DSH had psychiatric disorders is comparable with the results of previous
studies among children and adolescents [1,5,21]. One important finding is
that none of the children received any professional help although they had
symptoms several months prior to the act of self harm. The parents did not
identify their symptoms nor did they recognize their gravity. Early
recognition and treatment of mental illnesses is important for the
prevention of suicide because untreated and under-treated psychiatric
disorders were found to contribute to attempted suicide [23].
In our sample, psychiatric disorders were significantly
higher among children who attempted suicide compared to those in whom the
DSH was not attempted suicide. Studies on attempted suicide among
adolescents have reported that mood disorder, conduct disorder, ADHD and
substance abuse are risk factors for suicidal behavior [5,2,24].
Hospital based studies report self poisoning as the
commonest method of DSH in adolescents [3, 13]. In the present
sample of children, the mode of DSH was self poisoning in the majority of
cases followed by attempted hanging. The substances used for self
poisoning were common household pesticides and drugs. A study of completed
suicides in children and adolescents from Delhi noted that suicide
prevention strategies based on risk factors could be more effective rather
than limiting access to methods since methods used to commit suicide were
widely available [25].
The influence of modeling on suicidal behavior of
children and adolescents is well documented. Children can get the idea of
DSH from real life models or from the media [1,13]. In our sample a
real life model was present in 17% children while 24% children learned
about suicidal behavior by watching TV or cinema. The influence of visual
media on the behavior of children needs in-depth evaluation and it is
necessary to plan and implement appropriate guidelines for portrayal of
suicide and deliberate self harm in the visual media.
This is a hospital based study and the findings could
not be generalized. The prevalence and correlates of DSH in children and
adolescents vary in different regions [13,18]. The findings of the present
study may not be applicable to other regions. The regional characteristics
should be considered while planning preventive strategies.
Contributors: PK designed the study, collected
data, conducted the psychological evaluation of the children, and wrote
the initial draft of the paper. MGG helped in study design and prepared
the final draft of the paper. AR supervised the study and helped in
writing the paper.
Funding: None.
Competing interests: None stated.
What is Already Known?
• Deliberate self harm is common among
adolescents and the risk factors include psychiatric disorders and
stress in the family and school.
What This Study Adds?
• Deliberate self harm also occurs in children
and the risk factors are comparable to those in adolescents.
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