children’s mental health ontario & ontario association for children’s aid societies 2008...

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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-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

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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 Do We Know About Self Harm?

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

Risk Factors for Self Harm

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

Learning About Self Harm: CAST 2004-2008

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)

Translating SOR Forms Into Data & Then Translating Them Into Information

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

Translating Standardized File Review Data Into Information

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

Translating Worker Knowledge Into Information

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

Translating Data Into Information Into Knowledge Into Evidence Based Practice Into Research

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.

THANK YOU!

Child Welfare Institute, CAS-Toronto

Developing evidence-based knowledge today...so we can be more effective tomorrow