Interventions for self‐harm in children and adolescents

TY - JOUR

T1 - Interventions for self‐harm in children and adolescents

AU - Witt, Katrina G

AU - Hetrick, Sarah E.

AU - Rajaram, Gowri

AU - Hazell, Philip

AU - Taylor Salisbury, Tatiana

AU - Townsend, Ellen

AU - Hawton, Keith

N1 - Funding Information: Primary outcome(s): i) repetition of SH according to self-and parent-report; however, only data from self-report were used; ii) suicide (unclear how ascertained); iii) compliance, as measured by the proportion of participants who completed treatment Source(s) of funding: "This investigation was supported by NIMH grant MH52411 and by a grant from the van Amerigen Foundation" (Spirito 2002, p. 435). Funding Information: KGW: is an editor for the Cochrane Common Mental Disorders Group, and senior editor for the Self-Harm and Suicide Satellite of the group. SEH: is the joint co-ordinating editor of the Cochrane Common Mental Disorders Group. She is funded by an Auckland Medical Research Foundation Douglas Goodfellow Repatriation Fellowship to develop and test a digital intervention for young people who engage in self-harm. She is the Principal Clinical Advisor of the Suicide Prevention Office of the Ministry of Health for the New Zealand Government. GR: no declarations of interest to report in relation to this review PH: no declarations of interest to report in relation to this review TLTS: no declarations of interest to report in relation to this review ET: no declarations of interest to report in relation to this review KH: no declarations of interest to report in relation to this review Funding Information: Secondary outcome(s): i) suicide, according to collateral informant (parent) report; iii) suicidal ideation, as measured by the SIQ; iii) depression, as measured by the CES-D; iv) problem-solving, as measured by the Social Problem Solving Inventory-Revised (SPSI-R; Maydeu-Olivares 1996) and the Means-Ends Problem-Solving Procedure (MEPS; Platt 1971); v) treatment adherence, as measured by the number of sessions attended; vi) anger, as measured by the State-Trait Anger Expression Inventory (STAXI; Spiel-berger 1988) Source(s) of funding: "This project was supported by NIMH (MH05749), the American Foundation for Suicide Prevention, and the Harvard Pilgrim Research Foundation” (Donaldson 2005, p. 113). Funding Information: Secondary outcome(s): i) SH, as determined from hospital admissions and ED presentations; ii) hopelessness, as measured by the BHS; iii) depression, as measured by the MADRS; iv) BPD symptom severity, as measured by Borderline Symptom List (BSL; Bohus 2007) Source(s) of funding: "The study was funded by grants from the Norwegian Directorate of Health, the South Eastern Health Authority, the Extra-Foundation for Health and Rehabilitation, and the University of Oslo" (Mehlum 2014, p. 1090). Funding Information: Conflict(s) of interest: "Dr. Asarnow has received grant or research support from the National Institute of Mental Health, the American Foundation for Suicide Prevention, the American Psychological Association (APA) Committee on Division/APA Relations, and the Society of Clinical Child and Adolescent Psychology (Division 53 of the APA). She has served as a consultant on quality improvement interventions for depression and suicidal/self-harm behavior. Dr. Hughes has received grant or research support from the American Foundation for Suicide Prevention. She has served as a consultant on quality improvement interventions for depression and suicidal/self-harm behavior in youth. Dr. Sugar has received research support from the National Institutes of Health (NIH) through multiple divisions including the National Institute of Mental Health (NIMH), the National Institute of General Medical Sciences (NIGMS), the National Institute of Child Health and Human Development (NICHD), the National Institute of Allergy and Infectious Diseases (NIAID), and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); the Health Resources and Services Administration (HRSA); the US Department of Veterans Affairs; and the John Templeton Foundation. She has served on technical expert panels for the Centers for Medicare and Medicaid Services and Data Safety and Monitoring Boards for both academic institutions and Kaiser Permanente. Dr. Babeva reports no biomedical financial interests or potential conflicts of interest" (Asarnow 2017, p.513). Funding Information: Source(s) of funding: “This research was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project number 07/03)” (p. 215). Funding Information: Secondary outcome(s): i) repetition of SH, as measured by the C-SSRS; ii) depression, as measured by the MADRS and the BDI; iii) global impairment, as measured by the Columbia Impairment Scale (CIS; Bird 1993); iv) symptom severity, as measured by the Clinical Global Impression Severity (CGI-S) and Improvement (CGI-I) subscales (Guy 1976) Source(s) of funding: "This work was supported by a grant from the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario. The work was also supported in part by Academic Scholars Awards and the Departments of Psychiatry at the University of Toronto and Sunnybrook Health Sciences Centre" (Sinyor 2020, p. 693). Funding Information: Conflict(s) of interest: "Dr. Fonagy is the Chief Executive of the Anna Freud Centre, London, which regularly offers training courses in mentalization based treatment (MBT) and National Clinical Lead for the Department of Health’s Improved Access to Psychological Therapies for Children and Young People Programme. He has received grant income from the National Institute of Clinical Excellence, the UK Mental Health Research Network, the British Academy, the Wellcome Trust, the National Institute of Health Research (Senior Investigator Award and Research for Patient Benefit Pro-gramme), the Pulitzer Foundation, the Department for Children, Schools, and Families, the Central and East London Comprehensive Local Research Network (CLRN) Programme, the NHS Health Technology Assessment (HTA) programme, the Department of Health’s IAPT Programme, and the Hope for Depression Foundation. Dr. Rossouw reports no biomedical, financial interests, or potential conflicts of interest" (Rossouw 2012, p. 1312). Funding Information: Source(s) of funding: "This research was supported by the Department of Health, London" (Harrington 1998, p. 517). Funding Information: Secondary outcomes: i) ED visits, hospitalisation, and other service use according to self-report using a modified version of the Service Assessment for Children and Adolescents (SACA; Stiffman 2000); ii) depression, as measured by the CES-D Source of funding: "…this publication was supported by grants from the National Institute of Mental Health [R34 MH078082] and the American Foundation for Suicide Prevention (AFSP)" (p.513). Funding Information: Conflict(s) of interest: "All authors report no financial relationships with commercial interests of relevance to this study. Dr Sinyor reports that he has received grant support from the Innovation Fund of the Alternative Funding Plan from the Academic Health Sciences Centres of Ontario, the American Foundation for Suicide Prevention, the Ontario Ministry of Research and Innovation, and the University of Toronto, Department of Psychiatry Excellence Fund. Dr Bryan reports that he has received grant support from the Department of Defense, Department of the Air Force, National Institute of Mental Health, Bob Woodruff Foundation, and the Boeing company; and consulting fees from Oui Therapeutics and Neurostat Analytical Solutions" (Sinyor 2020, p. 693). Funding Information: The authors thank the following trial authors for providing us with unpublished data: Molly Adrian, Joan Asarnow, Emily Cooney, Andrew Cotgrove, Jonathon Green, Helen Griffiths, Philip Hazell, Elizabeth McCauley, Lars Mehlum, Dennis Ougrin, Trudie Rossouw, Erica V. Rozmid, Pilar Santamarina-P?rez, Mark Sinyor, Anthony Spirito, and Rabia Zaheer. The authors and the CCMD Editorial Team are also grateful to the following peer reviewers for their time and comments: Sarah Knowles, Nuala Livingstone, Jean Sellar-Edmunds, and Peter Szatmari. They would also like to thank Cochrane Copy Edit Support for the team's help and Phil Roberts from the University of York for graphic design support in the production of Figure 2. This project has previously been supported by the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). KH is funded by Oxford Health NHS Foundation Trust. He is a National Institute for Health Research (NIHR) Senior Investigator and personal funding from NIHR helped support this update. The NIHR is the largest single funder of the CCMD Group. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Funding Information: This project has previously been supported by the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO). KH is funded by Oxford Health NHS Foundation Trust. He is a National Institute for Health Research (NIHR) Senior Investigator and personal funding from NIHR helped support this update. Funding Information: Primary outcome(s): i) repetition of SH according to self-report; ii) depression, as measured by the MFQ; iii) suicidal ideation, as measured by the SIQ; iv) general health, as measured by the HoNOSCA Source(s) of funding: "This research was supported by a project grant from the Mental Health Foundation and by a Training Fellowship to Miss Trainor from the National Health Service Executive North West” (Wood 2001a, p. 1246). Funding Information: KW is supported by an Emerging Leadership 1 Fellowship awarded by the NHMRC (APP1177787). National Institute for Health Research (NIHR), UK Funding Information: Conflict(s) of interest: “Drs McCauley Berk, Adrian, Cohen, Korslund, Hughes, and Avina reported receiving grant support from the National Institute of Mental Health (NIMH), National Institutes of Health. Dr Asarnow reported receiving grant support from the American Psychological Association and the Society of Clinical Child and Adolescent Psychology and serving as a consultant on quality improvement interventions for depression and suicidal/self-harm behaviour. Dr Harned reported receiving grant support and personal fees from the Behavioral Tech LLC outside the work represented in this article. Dr Linehan reported receiving royalties from Guilford Press for books she has written on dialectical behaviour therapy, royalties for training materials from Behavioral Tech LLC, and compensation for dialectical behaviour therapy workshops, online programs, and books. No other disclosures reported" (McCauley 2018, p. 8). Funding Information: Secondary outcome(s): i) suicide, according to medical and/or health service records; iii) suicidal ideation as measured by the SIQ; iv) depression as measured by the Mood and Feelings Questionnaire (MFQ; Angold 1995); v) general functioning as measured by the Health of the Nation Outcome Scale for Children and Adolescents (HoNOSCA; Gowers 1999); vi) health economics information Source(s) of funding: "This study was funded by the Health Foundation and sponsored by the University of Manchester" (Green 2011, p. 11). Funding Information: Secondary outcome(s): i) treatment completion, as measured by attendance at four or more treatment sessions during the three-month follow-up period; ii) number of treatment sessions attended; iii) psychopathology, as measured by the SDQ; iv) general functioning, as measured by the C-GAS Source(s) of funding: "The study was funded from the following three sources: Psychiatry Research Fund (Institute of Psychiatry, King’s College London), Maudsley Charitable Funds (South London and Mauds-ley NHS Trust) and West London Research Consortium" (Ougrin 2011, p. 153). Publisher Copyright: Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

PY - 2021/3/7

Y1 - 2021/3/7

N2 - BackgroundSelf‐harm (SH; intentional self‐poisoning or self‐injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.ObjectivesTo assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment‐as‐usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.Search methodsWe searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).Selection criteriaWe included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment‐as‐usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow‐up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.Data collection and analysisWe independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post‐intervention) was appraised for each intervention using the GRADE approach.Main resultsWe included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT‐A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post‐intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high‐certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)‐based psychotherapy and TAU for repetition of SH at post‐intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low‐certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT‐A) reduces repetition of SH at post‐intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low‐certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post‐intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate‐certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six‐month follow‐up assessment, for group‐based psychotherapy at the six‐ or 12‐month follow‐up assessments, for a remote contact intervention (emergency cards) at the 12‐month assessment, or for therapeutic assessment at the 12‐ or 24‐month follow‐up assessments.Authors' conclusionsGiven the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT‐A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT‐based psychotherapy should also be further developed and evaluated in children and adolescents.

AB - BackgroundSelf‐harm (SH; intentional self‐poisoning or self‐injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents.ObjectivesTo assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment‐as‐usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH.Search methodsWe searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020).Selection criteriaWe included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment‐as‐usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow‐up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide.Data collection and analysisWe independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post‐intervention) was appraised for each intervention using the GRADE approach.Main resultsWe included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT‐A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post‐intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high‐certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)‐based psychotherapy and TAU for repetition of SH at post‐intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low‐certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT‐A) reduces repetition of SH at post‐intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low‐certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post‐intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate‐certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six‐month follow‐up assessment, for group‐based psychotherapy at the six‐ or 12‐month follow‐up assessments, for a remote contact intervention (emergency cards) at the 12‐month assessment, or for therapeutic assessment at the 12‐ or 24‐month follow‐up assessments.Authors' conclusionsGiven the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT‐A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT‐based psychotherapy should also be further developed and evaluated in children and adolescents.

UR - http://www.scopus.com/inward/record.url?scp=85102712966&partnerID=8YFLogxK

U2 - 10.1002/14651858.CD013667.pub2

DO - 10.1002/14651858.CD013667.pub2

M3 - Article

SN - 1469-493X

VL - 2021

JO - Cochrane Database of Systematic Reviews

JF - Cochrane Database of Systematic Reviews

IS - 3

M1 - CD013667

ER -