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Title: Self-harming Behaviours in Children and Youth in Care: Understanding Those at Risk Author: Connie Cheung Last modified by: CAST Created Date – PowerPoint PPT presentation

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Title: Children


1
Childrens Mental Health Ontario Ontario
Association for Childrens 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 Childrens Bureau

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

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. cutters high)
  • Social attachment to sub-group
  • Poor impulsivity control

16
Learning About Self Harm CAST 2004-2008
17
Childrens 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
  1. Systematic collection of all self harm events and
    threats from SOR forms inputted into SPSS 298
    youth 609 events to date (2004-07)
  2. Survey of GTA professionals on Self Harm (2006)
  3. Standardized file review population of 20 boys
    age 10 and under who self harm (2005)
  4. Standardized file review random sample of 18
    youth who self harm vs. 18 matched youth who do
    not self harm (2006-08)
  5. Standardized interviews with 6 workers of youth
    2 with youth with single SOR vs. 4 with youth
    with multiple SORs (2007-08)
  6. Standardized file review 24 pregnant teens in
    care vs.12 non-pregnant teens in care (2007-08).
  7. 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 Childrens 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 SORs 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 SORs
  • 6 to 10 of in care population with 1 or more
    SORs
  • 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

Male 43 x13.9yrs 14 x10.3yrs 57 males 56
Female 33 x14.5yrs 11 x15.2yrs 44 females 44
Total 76 25 101 Youth
75 are single 25 are repeat
Total SOR 76 32 159 68 235 SOR
Repeat 2-3 14 33 SOR 14 all SORs
Repeat 4-6 5 23 SOR 10 all SORs
Repeat 7 6 103 SOR 44 all SORs
26
Harm vs. threat of harm vs. restraint 2004
SOR data
  • Single SOR Repeat SOR TOTAL

M F M F
Youth 43 33 14 11 101 youth
Self- Harm injury 26 16 9 46 97 SORs
Self Harm Threat 15 15 5 42 77 SORs
Self Harm Restraint 2 2 47 10 61 SORs
Sub Total 43 33 61 98 235 SORs
Total 76 159 235
27
Types of self harming behaviours
  • Single SOR (76) Repeat SOR (25)
  • M
    F M F

Harm- cut, scratch, stab 13 10 3 33
Harm head bang 10 7 40 16
Harm choking, hanging 4 0 4 3
Harm overdose, meds, poisons 4 10 0 10
Harm jump into traffic, out windows 1 0 0 1
Harm other (insert /swallow objects) 2 0 5 10
Threat - cut,scratch, stab 0 2 1 8
Threat head bang 1 0 0 0
Threat choking, hanging 0 0 1 0
Threat overdose, meds, poisons 1 0 0 1
Threat jump into traffic, out windows 3 1 0 6
Threat other (insert /swallow objects) 4 3 7 10
28
CAS-Toronto 2005 SOR data
Single SOR Repeat SOR TOTAL
Males M age 14.7 years 42 10 52 males (58)
Female M age 15. 2 years 30 8 38 females (42)
Total M age 14.9 years 72 (80) 18 (20) 90 Youth
29
What we learned about youth in care who self
harmmyths realities
  • 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 lt1 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

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 lt.04
36

?2 5.9, plt.04
37

?2 4.28, plt.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 lt.05
40

plt.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

42
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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 childrens
    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) Clients 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

Stressful Events
SELF-HARMING EPISODE
Trauma
Not Being Heard
51
Worker interviews effect of change vs. no change
in incidents
  • Children who were able to reduce the amount
  • of self-harming behaviours
  • Self-harming behaviours decreased in frequency
    and intensity over time
  • Children who did not show a reduction in their
  • self harming behaviours
  • Changed their method of self harm
  • Younger running into traffic, more threats to
    self harm
  • Older AWOLs, engaging in very risky behaviours

52
Worker interviews individual factors
  • Individual Factors

Advanced Social and Cognitive Skills
Good Temperament
Resourcefulness
RESILIENCE
Athleticism
53
Worker interviews individual factors
  • Advanced Social and Cognitive Skills
  • Able to get along with others
  • Ability to reason out problems/issues that arise
  • Good Temperament
  • Easy going
  • Sense of humour
  • Athleticism
  • Good at sports
  • Resourcefulness
  • Ability to recognize when help is needed
  • Knowing where to get appropriate services

54
Worker interviews environmental factors
  • Environmental Factors

Supportive Role Model
Supportive Environment
RESILIENCE
55
Worker interviews external factors
  • Characteristics of a Supportive Role Model
  • Empathetic
  • Understand needs
  • Consistency
  • Advocates for the child
  • Characteristic of a Supportive Environment
  • Provided structure
  • Setting expectations

56
Worker interviews providing protection,
developing resilience
  • Environmental Individual Factors

Individual Attributes
Supports from Environment
RESILIENCE
57
Treatment intervention strategies for
self-harming behaviours
Step ONE Address self-harming behaviours EARLY
with a SPECIALIZED treatment plan that is
FLEXIBLE
Step TWO Ensure that treatment plan builds on
INDIVIDUAL and ENVIRONMENTAL protective factors
Step THREE GOODNESS-OF-FIT
58
Translating Data Into Information Into Knowledge
Into Evidence Based Practice Into Research
59
What do we know about self harm youth in care
NOW in 2008?
  • That the patterns of self harm amongst children
    and youth in care are similar to that of
    community samples
  • That there are certain risk factors that increase
    childrens vulnerability to self harm
  • The experience of physical abuse
  • An accumulation of risk

60
What do we know about self harm youth in care
NOW in 2008?
  • That the effects of these risk factors can be
    modified by increasing the amount of positive,
    supportive relationships in the childrens lives
  • That treatment appears to be most effective when
    it utilizes both the childs own strengths and
    supports within the childs environment
  • Self harm should be addressed specifically
  • Treatment plans should be individualized

61
What are the implications for practice?
  • We can do something to help children/ youth
    reduce or manage their self-harming behaviours
  • Although some children may be more vulnerable to
    self harm, by making necessary changes to the
    environment we can reduce the chances of self
    harm
  • Our results suggest that increasing the amount of
    positive, protective relationships in the childs
    life may reduce the likelihood of self harm
  • Treatment appears to be most effective when
    treatment plans are individualized (i.e., drawing
    on the childs own strengths and making necessary
    changes to the environment) and we can
    specifically addresses self harm

62
Questions for future research
  • How does the pattern of self harm develop over
    time?
  • Start age
  • Method selected
  • Gender differences
  • Does the childs personality impact self harm
    occurrence? If so, does it influence what method
    of self harm is selected?
  • Depressive personality
  • Impulsive personality
  • Anxiety-prone personality
  • Attention seeking personality
  • Does poor parent-child interactions facilitate
    the likelihood of self harm?
  • Maternal negativity
  • Insecure attachment

63
  • Are there maternal characteristics that place
    children at greater risk for self harm?
  • Community sample
  • How does the family environment affect
    self-harming behaviours in children?
  • Amount of risk the family is exposed to
  • Neighbourhood effects
  • Mediation effects
  • What are some other factors that can protect
    against self-harming behaviours?

64
Disseminate learning, evolve knowledge, develop
EBP partner, collaborate share, share, share
  • Publications
  • Cheung, C., Goodman, D. (2007) Youth in Care
    and Deliberate Self Harm Furthering Our
    Understanding About Risk. OACAS Journal, 51(3),
    2-9
  •  
  • Cheung, C., Goodman, D. (2007) The Effects
    of Self Harming Behaviours of Youth in Child
    Welfare Care. First Peoples Child and Family
    Review 3(2), 37-41.
  •  
  • Goodman, D. (2005) Youth in Child Welfare Care
    Self-Harming Behaviours Preliminary Findings,
    OACAS Journal, 49 (1). 5-8.
  • Technical Report
  • Report on the Self Harm Networks Survey on
    Children/ Youth Who Self Harm (Dec. 2006)

65
  • Presentations
  • Cheung, C., Beatty, S., Goodman, D. (Nov 2007)
    Self Harming Behaviours of Youth In Care
    Understanding Those at Risk AND Taking a Closer
    Look Exploring Single verses Multiple
    Self-Harming Episodes of Children-in-Care. Joint
    research studies presented at Canadian Injury
    Prevention Safety Promotion Conference
    Toronto, ON
  • Mazzuca, A. (Oct 2007) Voices of Young Mothers
    In Care An exploration of young womens
    experience of pregnancy and mothering. Maternal
    Health and Well Being Conference, York
    University, ON
  • Goodman, D, Cheung, C., Beatty, S. (May 2007)
    Self-harming behaviours of youth in care
    Understanding those at risk and what we can do to
    help. Research presented to 2007 Child
    Psychotherapies Development Conference, Sick
    Kids, Toronto, ON.
  • Goodman, D. (Oct 2005) Youth in Care Who
    Self-Harm Invited presentation, Lamarsh
    Centre,York University, ON.
  • Goodman, D. Cheung, C. (June 2006). Children
    Who Self Harm- what we know, what we need to know
    and what we dont know . Paper presented at the
    Ontario Association of Childrens Aid Societies
    Conference Childrens Mental Health Ontario,
    Toronto, ON
  • Goodman, D. (March 2005). Imploding Myths,
    Confirming Realities about the Youth in CAS Care
    who Self Harm Presentation to the 2005 Annual
    Day in Psychotherapies, Hospital for Sick
    Children, Toronto, ON

66
  • Recent Conferences
  • June 2008 - OACAS CMHO, Goodman, Cheung
    Beatty, Risk and Resilience Factors in Youth in
    Care Who Self Harm Mining Data, Building
    Knowledge, Improving Outcomes
  • June 2008 -OACAS CMHO, Jellinek-Siegel, Markle,
    Mazzuca, Young Mothers in Care.
  • Recent Field Presentations
  • NET Conference (Nov. 14, 2007)
  • Foster Parent Association (Nov. 15, 2007)
  • CAS-Toronto Team meetings, Branch Conferences,
    Senior Management Committee
  • Significant Thanks to the Funder of This Research
  • CIHR Net Grant,
  • PI, Dr. Christine Wekerle, UWO.

67

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