Suicide and Deliberate Self-harm 119teachers and peers.Being bullied and bullying others are both more likely.
Unemployment is common among older teenagers.
6 Family members, friends, or media reports may have provided models for
imitation. Contagion within adolescent units is well described. There is
concern, but little hard evidence, on the role of the internet and social
networking sites.
7 Roughly 10–20% have made a previous attempt.
8 Since most DSH is on the spur of the moment,impulsesare more likely
to be acted on when there is immediate access to prescribed or over-the-
counter medication.
Precipitating factors
A clear precipitant in the two days before DSH can be identified in about
two-thirds of cases; psychiatric disorder is more likely when there is no
identifiable precipitant. In many cases, a relatively minor additional stress
seems to be the ‘last straw’ for an individual who has been rendered
vulnerable by a multiplicity of prior and concurrent adversities. Acute pre-
cipitants sometimes trigger DSH in young people who are otherwise well
adjusted. The commonest precipitants are rows with family, friends, or
boy/girlfriend. An episode of physical or sexual abuse may also precipitate
DSH.
Motivation
At the time they harm themselves, young people commonly feel angry
with someone, or feel lonely and unwanted. Worry about the future
is more prominent in older teenagers. Hopelessness is prominent only
in the severely depressed minority. DSH typically reflects a desire for
temporary respite from distressing circumstances (functioning rather like
getting drunk), or a wish to influence family and friends. It is rarely a ‘cry
for help’ directed at professionals (which is one reason why offers of help
from professionals are commonly rejected). The circumstances of the DSH
do not usually suggest a serious intent to die or advanced planning. DSH is
usually impulsive: roughly half of the young people have contemplated it
for less than 15 minutes before carrying it out. At the other extreme, only
10–15% have thought about self-harm for more than a day.
Assessment
It is widely held that all children and adolescents who harm themselves
should have a mental health and psychosocial assessment – a view that
owes more to commonsense and prudence than to hard evidence that
universal rather than selective assessment reduces subsequent recurrence
rates or fatality. Assessment may involve a child and adolescent psychi-
atrist, but can equally involve a suitably trained social worker, nurse or
other mental health professional. Informants can be interviewed at once,
but assessment of the child or adolescent may need to wait until toxic