Health, Social Care and Sport Committee Inquiry into Suicide Prevention:
Oral evidence by Dr Rhiannon Evans
1. Overview
I welcome the opportunity to provide oral evidence to the Committee. I present this evidence on behalf of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer) at Cardiff University, which has a specific focus on improving the health and wellbeing of children and young people. The following evidence considers previous and current research undertaken by the Centre, in addition to referencing the wider research evidence.
The following evidence primarily focuses on self-harm prevention and intervention, which is the substantive expertise of the Centre. Self-harm is defined as any act with a non-fatal outcome, where an individual engages in behaviour or ingests a substance with the intention of causing harm to themselves. Self-harm is employed as a broader category than self-injury, as it includes both the infliction of damage to the external surface of the body and self-poisoning. Self-harm with or without an associated suicidal intent are not differentiated here, as they are arguably located along the same continuum. Self-harm is a risk factor for suicide, hence the importance of prevention and intervention. Young people who present to an emergency department for self-harm are more than sixteen times as likely to die by suicide.
2. Self-harm Prevention and Intervention in Educational Settings
Despite a proliferation in the number and range of interventions intended to address adolescent self-harm, there is a limited evidence-base for effective approaches particularly within educational settings. To date the evidence base is much stronger for suicidal ideation, suicide attempt and suicide than for self-harm (Wasserman et al., 2015). Some support tools for adolescent self-harm are available, such as Signs of Self-injury (SoSI), which is informed by the Sign of Suicide Prevention Programme, but only preliminary evaluation of these programmes have been reported.
Cardiff University, University of Bristol, University of Bath and University of Exeter were funded by the GW4 collaboration to undertake a mapping of schools’ existing provision around student self-harm, with the aim to develop effective intervention (Evans et al., 2015). The study comprised a survey of 153 secondary schools across Wales and South West England. In Wales, the School Health Research Network (SHRN) supported the survey. SHRN collects bi-annual data on student health and wellbeing, in addition to data on the school environment, to support health planning. All secondary schools in Wales are now part of the network.
Findings from the study indicate that emotional health and wellbeing are the priority for secondary schools, and for many, further investment in anxiety management and resilience may mitigate student self-harm. On site counselling and CAMHS are the most frequently provided services for student self-harm. Counselling was ranked as the most useful approach by 25% of schools. Key to the data were that only 54% of staff have received training on student self-harm, with only 22% of schools stating the adequacy of the training to be high or very high. This is despite the fact that 86% of senior managers and 74% of teachers have been involved in intervening with cases of student self-harm. The study also explored barriers to addressing student self-harm. Inadequate staff training was cited as a major barrier in 48% of cases. Additionally 80% of schools stated that fear of encouraging students to engage in self-harm was a major or minor barrier.
3. Self-harm and Suicide Prevention and Intervention in Social Care Settings
Care-experienced children and young people are at an elevated risk of suicide related outcomes. A recent systematic review undertaken by DECIPHer found that individuals who reside in care are more than three times as likely to attempt suicide than non-care experienced individuals (Evans et al., 2017).
NICE guidance on supporting the mental health and wellbeing of individuals in care has focused on multi-agency team working that is inclusive of different professions. However, these structures are not considered to be working effectively (House of Commons Education Committee, 2016). Explanations of these failings have tended to focus on lack of time and resources.
A recent DECIPHer study explored the lived experiences of foster and residential carers who manage self-harm within the care setting (Evans, 2018). Almost all carers had direct experience of self-harm amongst the children and young people they care for. Carers reported that support for this professional role was lacking, with training in identifying risk factors and providing intervention often only occurring following a young person’s suicide. As such provision is reactionary rather than proactive, and more significant investment is required to adequately equip carers.
Carers also indicated tensions in inter-professional working, and the feeling of being seen as ‘glorified babysitters’, with their expertise being routinely discounted. These tensions were particularly evident within contacts with clinical professionals. Carers suggested the need to enhance the professional standing of their professional group. There have been recommendations from the foster care sector, including the introduction of accredited and standardised pre- and post-approval training (Lawson & Cann, 2016). There is further focus on incorporating learning about their role into social work (and other professionals) training to improve understanding and collaboration, and ensuring that carers’ views are always invited and taken into consideration by those involved with the team around the child. However, there needs to be a more concerted and sustained effort to improve inter-professional working.
4. Experiences of Children and Young People Presenting to Emergency Departments for Self-harm or Suicide-related Outcomes
Presentations by children and young people to emergency departments for self-harm is a major concern. Data report that 18,788 individuals aged <18 years in England and Wales were admitted to hospital or treated at an emergency department (ED) in 2015-2016, which is a 14% increase on 2013-2014 (NSPCC, 2016).
NICE guidance on the short-term management and prevention of recurrent self-harm prescribe the care pathway that individuals should receive within the first 48 hours of presentation for self-harm. This includes treatment for medical injury and a psychosocial assessment to ascertain need and risk. Receipt of appropriate services remains limited, with only 60% of individuals (aged ≥11 years) obtaining a psychosocial assessment (Kapur et al., 2008), despite it being associated with a 51% decreased risk in repeat episodes by persons with no psychiatric treatment history and a 26% decreased risk in those with a treatment history (Bergen et al., 2010). Health care professionals have stated the need for more prompt assessment, with this issue being especially pertinent in the UK. In Wales NICE guidance implementation remains under-examined. Public Health Wales (2014) have recommended that Welsh Government develop mechanisms to ensure appropriate service delivery in accordance with this guidance. However to date there is no systematic mechanism for understanding service users’ experience of short-term management and prevention care pathways.
A further issue around short-term management and prevention services is the quality of care provided. Positive experiences of care are vital as negative treatment by health care professionals can inhibit future help-seeking and exacerbate recurrent behaviours. Evidence reports largely negative attitudes amongst clinical staff. A systematic review indicates that individuals who self-harm are viewed less positively than other patients, with repeated self-harmers being particularly vulnerable to negative perceptions (Saunders et al., 2012). There is limited evidence about the impact of service-user age upon professionals’ attitudes, although one study does report that 98% of staff disagree with the statement that children and adolescents who self-harm waste NHS resources (Crawford et al., 2003). Negative professional attitudes are reflected in service users’ accounts of clinical provision, where staff are reported to foster poor communication strategies with patients and to possess a limited knowledge of self-harm (Taylor et al., 2009).
DECIPHer is currently undertaking a Health and Care Research Wales funded study to explore the experiences of short-term provision for children and young people who present at the University Hospital of Wales. The Self-HARm provision in Emergency Services (SHARES) study will aim to improve service provision for this population, in addition to the service for accompanying carers.
5. References
Bergen H., Hawton, K., Waters, K., Cooper, J. and Kapur, N. (2010) Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses. Journal of Affective Disorders, 127(1-3), 257-265.
Crawford, T., Geraghty, W., Street, K. and Simonoff, E. (2003) Staff knowledge and attitudes towards deliberate self-harm in adolescents. Journal of Adolescence, 26(5), 619-629.
Evans, R. (2018) Survival, Signaling, and Security: Foster Carers’ and Residential Carers’ Accounts of Self-Harming Practices Among Children and Young People in Care. Qualitative Health Research, 28(6), 939-949.
Evans, R., Russell, A., Mathews, F., Parker, R., the Self-harm and Suicide in Schools GW4 Research Collaboration & Janssens, A. (2015) GW4 Children and Young People’s Suicide and Self-harm Research Collaboration Report. Available at: https://www.cardiff.ac.uk/__data/assets/pdf_file/0011/535673/GW4-Self-harm-and-Suicide-Prevention-Collaboration-Report.pdf
Evans, R., White, J., Turley, R., Morgan, H., Slater, T. Strange, H. & Scourfield, J. (2017) Comparison of suicidal ideation, suicide attempt and suicide in children and young people in care and non-care populations: Systematic review and meta-analysis of prevalence. Children and Youth Services Review 82, 122-129.
House of Commons Education Committee (2016) Mental health and well-being of looked-after children. Fourth report of Session 2015-2016. Available at: https://publications.parliament.uk/pa/cm201516/cmselect/cmeduc/481/481.pdf (Accessed 3rd August 2017).
Kapur, N., Murphy, E., Cooper, J., Bergen, H., Simlkin, S….Owens, D. (2008) Research report: Psychosocial assessment following self-harm: Results from the Multi-Centre Monitoring of Self-Harm Project. Journal of Affective Disorders, 106, 285-293.
Lawson, K. & Cann, R. (2016). State of the Nation's Foster Care 2016. London, The Fostering Network.
NSPCC (2016) Rise in children hospitalised for self-harm as thousands contact Childline. Available at: https://www.nspcc.org.uk/fighting-for-childhood/news-opinion/rise-children-hospitalised-self-harm-thousands-contact-childline/
Public Health Wales (2014) Thematic review of deaths of children and adolescents through probably suicide, 2006-2012. Available at: http://www2.nphs.wales.nhs.uk:8080/ChildDeathReviewDocs.nsf/5633c1d141208e8880256f2a004937d1/ce6956a584dd1f6b80257c9f003c3fa1/$FILE/PHW%20probable%20suicide%20web.pdf
Saunders, K., Hawton, K., Fortune, S. and Farrell, S. (2012) Attitudes and knowledge of clinical staff regarding people who self-harm: A systematic review. Journal of Affective Disorders, 139(3), 205-216.
Taylor, T.L., Hawton, K., Fortune, S. and Kapur, N. (2009) Attitudes towards clinical services among people who self-harm; systematic review. BJ Psych, 194(2), 104-110.
Wasserman, D., Hoven, C. W., Wasserman, C., Wall, M., Eisenberg, R., Hadlaczky, G., . . . Carli, V. (2015). School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet, 385(9977), 1536-1544. doi:10.1016/s0140-6736(14)61213-7