Summary / Abstract

Title: Ethnicity and adolescent deliberate self-harm

Synopsis: The characteristics of all adolescents referred to the psychiatric service of a tertiary hospitalfollowing an episode of deliberate self-harm (DSH) were studied. Of 100 adolescents selected over a 3-year period, 64 White and 28Black adolescents were compared to identify factors associated with DSH in Black adolescents. The main findings were: (1) thereferral rate for Black adolescents was in proportion to the community composition; (2) the characteristics of Black and Whiteadolescents referred following DSH were similar for background socio-demographic variables, psychiatric symptoms, circumstances ofthe attempt and outcome. However, more social stress was reported in the Black group. adolescents, DSH, psychiatry, self, referrals, ethnicity, self harm, deliberate self, social stress, Goddard, ethnic groups, community, findings, episode, Fombonne, Subotsky, proportion, West Indian, Child Psychology, background sociodemographic variables, composition, afro caribbean, self poisoning, depression, comparison, Professionals, representatives, ethnic groupings, local population, abnormal psychosocial situations,

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Additional keywords for: Ethnicity and adolescent deliberate self-harm

journal adolescence 1996 19 513 521 ethnicity adolescent deliberate self harm nick goddard fiona subotsky eric fombonne characteristics adolescents referred psychiatric service tertiary hospital episode deliberate self harm dsh studied 100 adolescents selected 3 year period 64 white 28 black adolescents compared identify factors associated dsh black adolescents main findings 1 referral rate black adolescents proportion community composition 2 characteristics black white adolescents referred dsh background sociodemographic variables psychiatric symptoms circumstances attempt outcome social stress reported black group 1996 association professionals services adolescents introduction groups people special consideration provision services view acknowledged higher risk suicide groups deliberately self harmed elderly people adolescents recent nhs health advisory service thematic review suicide prevention 1994 draws particular attention problem suicidal behaviour children adolescents suicidal behaviour covers broad spectrum behaviours expression despair wish die term deliberate self harm dsh refer deliberate non habitual act causes self harm potential non habitual excludes overdose drugs alcohol habitual user quantification degree problem proven difficult country collects official statistics dsh studies attempting overcome deficiency vary age groupings consequence diekstra 1993 reviewing studies based adolescent samples found rates 2 2 10 5 wide range reflecting differences age groups studied definition dsh hawton fagg 1992 estimated 19 000 20 000 adolescents 19 years old take overdose year england wales account 4 7 general hospital admissions 12 20 year olds goldacre hawton 1985 dsh young people represents area major public health concern attempt understand nature problem psychosocial correlates dsh children adolescents examined reviewed kosky 1983 brooksbank 1985 kingsbury 1993 third adolescents present overdose live single parent family tenth parent seven presently case social services hawton et al 1982 kienhorst et al 1990 report findings plus increased drugs alcohol reprint requests correspondence addressed dr n goddard belgrave department child psychiatry king college hospital denmark hill london se5 9rs u k 0140 1971 96 06051309 25 00 0 1996 association professionals services adolescents 514 n goddard f subotsky e fombonne attempters substance misuse associated suicide parasuicide young people hawton et al 1993 issue ethnicity factor dsh received attention adolescent population age 12 15 years old referrals deliberate self poisoning 1982 1990 asians caucasians coventry n 340 examined mcgibben et al 1992 significant difference found rates dsh asian caucasian females 4 06 1000 3 47 1000 respectively kingsbury 1994 looked psychological social characteristics asian adolescent overdose sample 50 adolescents age 12 18 13 asians 37 caucasians seen february 1987 april 1988 main findings asians socially isolated caucasian peers higher rates depression hopelessness longer premeditation times previous overdose attempts black population characteristics dsh adolescents described united states national school based representative survey 11 631 students grades 9 12 found hispanic white students reported higher levels suicidal thoughts behaviours black students differences statistically significant cdc 1991 great britain research mainly adult populations burke 1976 found rates self poisoning west indian immigrants birmingham exceeded rates west indies self poisoning prevalent native birmingham population merril owens 1987 compared rates self poisoning referrals birmingham hospital five groups asian west indian irish scottish english study focused adult population rates 16 year olds rates west indian males 98 100 000 females 229 100 000 english comparison group males 236 100 000 females 341 100 000 study small samples non english populations 16 west indian males 37 west indian females ages breakdown age literature suggests lower rate dsh black population little consideration psychological social characteristics black adolescent dsh black ethnic grouping clearly defined american cdc report ethnic groupings examined white hispanic black explanation basis divisions adult studies dsh mainly refer west indian study black refer black afro caribbean black african black full programme intervention ultimately prevention provided important examine characteristics dsh black adolescents aim study compare referral rates dsh ethnicity examine characteristics black white adolescents referred self harm particular questions answered i referral rates black adolescents dsh representative local population ii characteristics black white adolescent dsh method case notes referrals department child adolescent psychiatry south london hospital january 1990 december 1992 reviewed criteria 515 ethnicity adolescent self harm inclusion i age 10 years ii first referral department episode dsh first referrals selected avoid bias sample severe cases counted times sample hundred four cases identified case excluded misclassification actually referred overdose family three cases two female male due insufficient information case notes found leaving sample size 100 measures data collected structured collection sheet designed cover background demographic variables factors previously shown important dsh e g personal characteristics family factors method substance abuse outcome maudsley children department item sheet obtained case item sheets routinely filled patients referred maudsley children department aim provide multi axial summary symptomatology diagnosis psychosocial medical factors aspects treatment item sheet validity reliability reported previous studies thorley 1982 1987 goodman simonoff 1990 item sheet previously studies look child adolescent psychiatric problems e g depression pearce 1978 harrington et al 1990 hallucinations garralda 1984 firesetting jacobsen 1985 purposes study 14 items systematically describing emotional symptoms examined 10 item depression scale created cut depression taken score six twelve items look antisocial behaviour cut point five taken indicate conduct disorder addition item sheets contain section abnormal psychosocial situations draft version axis v icd 10 reliability validity reported previous studies van goor lambo 1987 van goor lambo et al 1994 individual items scored 0 present 1 minimal 2 definitely present scales indicate depression conduct disorders created sub sets items depression comprised 10 items looking depressed mood suicidal ideas guilt loss appetite sleep disturbance abnormal sensitivity school refusal ruminations anxiety irritability cut score six designated indicative depression conduct disorder 12 items defiance stealing destructiveness truancy running away home sexual misbehaviour fighting violent assault drug taking substance abuse cruelty animals antisocial behaviour score five threshold conduct disorder race classified basis groupings 1991 census black caribbean black african black indian pakistani bangladeshi chinese asian white classification made basis recorded notes casualty card insufficient information found clarification sought gp 22 cases 14 white 7 black 1 population data taken lambeth southwark lewisham breakdown 1991 census data measure inadequacy notes lacking 40 information rated inadequate items 20 missing data father employment 516 n goddard f subotsky e fombonne status 61 missing mother employment status 43 missing presence step parents home 25 missing number siblings 24 omitted analysis analysis data analysed conventional descriptive statistics analysis performed spss package chi square tests student t tests performed look group differences results ethnic composition sixty four cases classified white 20 black caribbean 2 black african 6 black remainder two asian six individual representatives ethnic groups groups collapsed three broad groups white black asian ethnic groups compared percentage proportions local population age 10 17 table 1 ethnic groupings cases reflected rates local community c 2 0 91 df 2 p 0 64 significant difference found sexes white c 2 18 55 df 1 p 0 0 001 black group c 2 8 18 df 1 p 0 005 gender effect examined stratified analysis revealing gender effect independent race odds ratio 0 14 95 ci 0 06 0 32 males significantly represented cases dsh socio demographic factors females predominated groups 55 64 84 white group 25 28 89 black group significant group differences mean ages white black groups 14 65 14 5 respectively t 0 49 df 90 p 0 63 difference two groups rates absence school white 13 64 black 6 28 c 2 0 01 df 1 p 0 92 involvement social services white 17 64 black 7 28 c 2 0 01 df 1 p 0 92 dsh characteristics information collected methods factors precipitating episode dsh personal family psychiatric history table 2 groups showed high rates family break 50 biological parents home previous table 1 comparison ethnicity sex referrals dsh local population sex ethnic group referrals dsh ethnic group local n 100 population 10 17 year olds white black total white black total female 55 25 6 86 30 13 6 49 male 9 3 2 14 32 13 6 51 total 64 28 8 100 62 26 12 100 517 ethnicity adolescent self harm family psychiatric history dsh family rates white group twice black group trend fell short significance p 0 10 p 0 13 respectively possibly due lack power study method dsh self poisoning predominantly paracetamol aspirin combination tablets precipitants family arguments boy girlfriend problems school related problems two groups differ background characteristics effect gender item sheets item sheets initially analysed symptomatology emotional disorders disorders conduct abnormal psychosocial situations table 2 characteristics dsh ethnic group white black p personal history mother home 48 62 77 19 28 68 0 48 father home 26 60 43 11 26 42 0 88 previously seen child psychiatrist psychologist 13 57 22 4 24 17 0 75 family history psychiatric history family 20 54 37 3 21 14 0 10 previous episode dsh family 18 55 33 3 23 13 0 13 method medication paracetamol 29 63 46 13 28 46 0 85 aspirin 18 63 29 7 28 25 0 92 non steroidal anti inflammatory drug 6 63 10 1 28 4 0 43 psychotropics 8 63 13 4 28 14 1 00 non prescribed 4 63 6 1 28 4 1 00 precipitants school problems 24 58 41 5 26 19 0 08 family stressors 15 58 26 6 26 23 1 00 family relationships 43 58 74 20 26 77 1 00 non family relationships 21 58 36 5 26 19 0 19 comparisons white black groups significant 0 05 level c 2 tests fisher exact tests table 3 outcome dsh white black p n 64 n 28 admitted 31 48 16 57 0 59 seen child psychiatrist 48 75 19 68 0 65 seen social worker 42 66 14 50 0 24 appointments refused self discharge taken 23 36 14 50 0 30 518 n goddard f subotsky e fombonne emotional symptoms information available 80 subjects comparing individual items revealed total emotional score ranging 2 12 m 2 75 d 1 72 seventy eight percent scored 2 16 3 5 6 5 differences ethnic groups c 2 2 3 df 2 p 0 31 10 item depression scale subjects score cut differences ethnicity white 2 55 black 0 disorders conduct information available 78 subjects range scores 0 14 m 2 4 d 3 05 forty four percent scored 0 22 1 3 25 3 seventeen percent scored cut point five taken indicate conduct disorder ethnic group differences white 9 55 black 4 23 p n psychosocial three areas examined intrafamilial stress looked stress affecting family white 30 51 black 12 23 p n intrafamilial discord measure stress resulting difficult family relationships white 44 53 black 20 24 p n social stressors condensation two item sheet questions persecution discrimination migration social transplantation significantly increased black group white 5 54 black 7 25 p 0 04 difference appeared accounted males p 0 048 difference females significant p 0 25 outcome race table 3 shows outcome young people dsh race found affect likelihood admitted type assessment received refusal follow discussion data referral rates dsh suggest proportion cases referred representative local population methodological considerations relevant criticisms limitations ethnicity research variable focusing varied definitions ethnic groups people placed groups sheldon parker 1992 mckenzie crowcroft 1994 similarly condensing groupings whilst allowing comparison result loss specific information ethnic groups study based referrals department four cases dsh lead contact medical services diekstra et al 1989 cases presenting casualty department necessarily referred referral biases operating levels time study ethnicity routinely recorded casualty referral bias level excluded research looking access psychiatric services indicated differential exists black white people britain disadvantage black community moodley perkins 1990 ethnic minority adolescents low utilisation services noted despite evident need help barker adelman 1994 referral rates study proportion underlying community making bias community studies addressing issues examine potential areas bias service utilisation 519 ethnicity adolescent self harm examining time trends rates dsh white black adolescents study study geographical area 1984 found 7 50 subjects 14 west indian descent taylor stansfeld 1984 compared 28 100 subjects study ethnicity based mother place birth west indian implying caribbean compared two fold increase dsh product socio demographic change population current figures found 1981 census 1986 ilea figures ethnic composition difference reflect true increase rates dsh true increase referrals dsh reflect wider ethnic groupings current study possible draw firm conclusions rates dsh two studies two groups showed differences matched closely characteristics previously described samples e g goldacre hawton 1985 kienhorst et al 1990 selection criteria dsh form self poisoning detected reflects clinical experience child psychiatrists kingsbury 1993 non referral self injury suggest source referral bias trend reaching significance white adolescents report previous episode dsh family black clear difference due underreporting black adolescents represents true difference pathways dsh group black adolescent group differed significantly social stress males social stress comprised two factors migration adverse discrimination detailed account taken form discrimination suggests social stressors significant factor dsh black male adolescents specifically enquired assessment outcome different two groups adequacy notes measure adequacy information study necessarily reflection clinical practice clinicians recording information routine assessment necessarily record previous studies looking psychiatric presentations afro caribbean children found lower ratio emotional conduct disorders white children graham meadows 1967 rutter et al 1974 recently goodman richards 1995 replicated finding second generation afro caribbean children britain whilst afro caribbean girls age 13 displayed emotional disorders non afro caribbean comparison group difference abolished age 13 looking suicidal ideas attempts threats component emotional symptoms group differences found afro caribbean comparison group supporting findings current study considering race purely grounds colour criticised racist simplistic hutchinson mckenzie 1995 considering investigated sub group adolescent population black group provide starting point study provides evidence dsh problem black adolescents magnitude nature white adolescents suggestion social stressors play larger dsh black male adolescents role nature social stress particular consideration clinical assessment dsh group future research required components social stressors pedersen et al 1973 study white non white suicide attempters united states concluded future research suicide attempts 520 n goddard f subotsky e fombonne imperative consider race separate factor studies need look detail race dsh mediated race colour race mixture biological variables social variables self identity acknowledgements dr goddard funded south thames 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