children’s mental health ontario & ontario association for children’s aid societies 2008...
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Children’s Mental Health Ontario & Ontario Association for Children’s 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-TorontoSTUDENTS:
Connie Cheung, M.A., Ph.D. (candidate), OISE/University of TorontoSarah Beatty, MSW, York UniversityRESEARCH ASSISTANTS
April Mazzuca, MSW, CWI, CAS-TorontoTeju Pathare, MA, Clinical Psych, CAS-TorontoCAS-TORONTO STAFF
Natasha Budzarov & Sarah Singer, MSW, CAS -Toronto
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 Children’s Bureau
What terms refer to self-harm?
Self-harm
Self-injury
Serious occurrence
Deliberate self-harm
Para-suicide
Attempted suicide
Suicidal behaviour
What is self harm?
‘The deliberate destruction or alternation of
body tissue without conscious suicidal
intent, resulting in injury severe enough for
tissue damage’
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
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….
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
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
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
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
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
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
Why do youth self-harm?
Way of dealing with strong emotions
Way to communicate distress
Way to cope
Biological addiction (e.g. cutter’s high)
Social attachment to sub-group
Poor impulsivity control
Children’s 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…
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)
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 Children’s 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 SOR’s into SPSS = longitudinal data
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
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%)
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
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 SOR’s 6% to 10% of in care population with 1 or more SOR’s 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
CAS-Toronto 2004 SOR data
Single SOR Repeat SOR TOTAL
Male 43 x=13.9yrs
14 x=10.3yrs
57 males [56%]
Female 33 x=14.5yrs
11 x=15.2yrs
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
“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 youthSelf- 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
Types of self harming behaviours Single SOR (76) Repeat SOR
(25) M F M FHarm- 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
CAS-Toronto 2005 SOR data
MalesM age = 14.7 years
42 10 52 males
(58%)
FemaleM age = 15. 2 years
30 8 38 females
(42%)
TotalM age = 14.9 years
72
(80%)
18
(20%)
90 Youth
Single SOR Repeat SOR TOTALSingle SOR Repeat SOR TOTAL
What we learned about youth in care who self harm…myths & 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; <1% 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
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
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)
Reliability of coding with coders
Reliability established between coders30% 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
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)
*2 =5.9, p <.04
0
2
4
6
8
10
12
14
16
Physical Sexual Emotional Neglect
Type of Abuse
Nu
mb
er
of
Ch
ild
ren
wh
o h
av
e E
xp
eri
en
ced Control SOR Group*
*2 =5.9, p<.04
0
2
4
6
8
10
12
14
16
Physical Sexual Emotional Neglect
Type of Abuse
Nu
mb
er
of
Ch
ild
ren
wh
o h
av
e E
xp
eri
en
ced Control SOR Group*
*2 =4.28, p<.08
0
2
4
6
8
10
12
14
16
Physical Sexual Emotional Neglect
Type of Abuse
Nu
mb
er
of
Ch
ild
ren
wh
o h
av
e E
xp
eri
en
ced Control SOR Group
*
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)
0
0.5
1
1.5
2
2.5
DevelopmentalIssues
Difficulties withSchool
Mental HealthDiagnosis
Amount of Total Risk
Risk Factor
Mea
n A
mo
un
t
Control
SOR
*
* p <.05
0
0.5
1
1.5
2
2.5
DevelopmentalIssues
Difficulties withSchool
Mental HealthDiagnosis
Amount of Total Risk
Risk Factor
Mea
n A
mo
un
t
Control
SOR
*
* p<.05
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
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Maternal Risk Risky Behaviour Abuse History
Maternal Risk Factor
Mea
n S
co
reControl
SOR Group
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
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 children’s likelihood of developing self-harming behaviours
Controlled for the effects of physical abuse
Series of ordinal regressions
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
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
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”
Worker interviews: question format Interviews
The interviews divided into 4 different sections:
(a) Worker – client relationship
(b) Client’s interpersonal relationship with significant
others
(c) Precursors to self-harming behaviours
(d) Treatment outcomes
Worker interviews: precursors to self harm
Precursors to Self Harm
Trauma Stressful Events
SELF-HARMING EPISODE
Not Being Heard
Worker interviews: effect of change vs. no change in incidentsChildren 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 theirself harming behaviours:
Changed their method of self harm Younger: running into traffic, more threats to self
harm
Older: AWOL’s, engaging in very risky behaviours
Worker interviews: individual factors
Individual Factors
Good Temperament
Athleticism
Resourcefulness
Advanced Social and Cognitive Skills
RESILIENCE
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
Worker interviews: environmental factors
Environmental Factors
Supportive Role ModelSupportive Environment RESILIENCE
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
Worker interviews: providing protection, developing resilience
Environmental + Individual Factors
Individual AttributesSupports from Environment RESILIENCE
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
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 children’s vulnerability to self harmThe experience of physical abuseAn accumulation of risk
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 children’s lives
That treatment appears to be most effective when it utilizes both the child’s own strengths and supports within the child’s environment Self harm should be addressed specifically Treatment plans should be individualized
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 child’s life may reduce the likelihood of self harm
Treatment appears to be most effective when treatment plans are individualized (i.e., drawing on the child’s own strengths and making necessary changes to the environment) and we can specifically addresses self harm
Questions for future research… How does the pattern of self harm develop over
time? Start age Method selected Gender differences
Does the child’s 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
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?
Disseminate learning, evolve knowledge, develop EBP = partner,
collaborate & share, share, share… PublicationsCheung, 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 ReportReport on the Self Harm Network’s Survey on Children/ Youth Who Self
Harm (Dec. 2006)
PresentationsCheung, 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 women’s 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 don’t know . Paper presented at the Ontario Association of Children’s Aid Societies Conference & Children’s 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
Recent ConferencesJune 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 ResearchCIHR Net Grant, PI, Dr. Christine Wekerle, UWO.