Psychosocial and Life Factors

Six of the eight papers reviewed sought to identify different factors or associates which correlated with self-harming thoughts and behaviors. McMahon, Reulbach, Corcoran, Keeley, Perry & Arensman (2010) conducted a cross-sectional study, the aim of which was to examine a broad range of factors associated with self-harm. Participants completed a standardised, internationally validated questionnaire anonymously, as part of the Child and Adolescent Self-harm in Europe (CASE) study. Researchers found that a lifetime history of self-harm was significantly

associated with a range of psychological, lifestyle, interpersonal and life event factors illustrated in Table 5 below:-

Table 5 - Factors associated with lifetime history of self-harm Psychological Factors Life style Factors Interpersonal Factors Depression Anxiety Self esteem Impulsivity Worries about sexual orientation Drug use (past year) Smoking Heavy drinking Fights with friends Difficulty making/keeping friends Boy/girlfriend problems Serious physical abuse Self- harm in family member Forced sexual activity Trouble with police Schoolwork problems Other distressing event Arguments between parents DHS of friend Bullied at school Friend/family member suicide Self/family serious illness Fights with friends Parents separation/divorce Not living with both parents Death of family member Death of someone close Life Events

Some factors were pertinent to both males & females, whilst some were specific according to gender. For males, two general areas of risk were identified -

experiencing psychological issues and negative experiences related to school. More specifically anxiety, impulsivity, problems keeping up with schoolwork, and being a victim of bullying were all factors which significantly correlated with adolescent male self-harm. For both males and females, drug use and having a friend or relative, especially a close one for males, who engaged in self-harm was a significant factor. The broad areas of risk for females were in interpersonal interactions and

relationships. More specifically of significance for them was low self-esteem,

problems making or keeping friends, serious relationship problems (with both parents and peers), and being forced into sexual activity. The study has been useful in

identifying not only general broad areas of risk, but also a number of specific factors that may be associated with self-harm based on gender. The main limitation is the relatively limited age cohort to which the data can be generalised.

Bakken & Gunter (2012) also looked for correlates of self-harm, using a random sample of ethnically diverse high school students, who anonymously completed the Delaware Youth Risk Behaviour Survey. Bullying victimisation, being involved in fights, sexual assault, substance use, use of hardcore drugs, sad/hopelessness, dieting behaviours, being the member of a sexual minority and sexual behaviour were all investigated to ascertain whether they were associated with self-harm and suicidal thoughts. A separate analysis was conducted to investigate any difference made by gender. Supporting research findings by McMahon et al (2010) they found strong associations between self-harm and being a victim of bullying, with those

experiencing high levels of bullying more likely to engage in self-harm than those experiencing low levels. They also found that substance abuse (excluding hardcore drugs such as cocaine and inhalants) correlated significantly with both variables, but especially self-harm. For males, more common substance use e.g., alcohol, cigarettes, soft drugs, were predictive of both self-harm and suicidal thoughts. This was

supported by research conducted by Madge et al (2008) who also found an association between self-harm and the use of substances. In their study they found that alcohol was implicated in one in five episodes of self-harm and the use of illegal drugs was implicated in one in nine cases. The use of drugs and alcohol was more likely to be associated with male self-harming behaviour than female. Again supporting the finding of McMahon et al (2010), Bakken & Gunter (2012) found negative emotional states such as sadness and hopelessness to be significantly associated with self-harm and suicidal thoughts - especially for males. Being a member of a sexual minority for males was linked to suicidal thoughts but not self-harm - whilst an association was found with both variables for females.

In line with the study aims, the research identified a number of factors associated with self-harm and in doing so have supported some of the findings of previous literature, as well as highlighting new factors using a large random sample and standardised method of assessment, allowing confidence in the research findings. Importantly for the current study, the above studies validate the importance of conducting analysis along gender lines when studying self-harm. Bakken & Gunter (2012) found that when their data was analysed along gender lines, this accounted for between a quarter and a fifth of the variance found in the dependent variables, demonstrating the skewing effect that can occur when gender is not taken into account. The result of this is an

underestimation of the importance of gender specificity in researching and understanding self-harm.

Again looking for correlates of self-harm, a longitudinal study was conducted by Haavisto, Sourander, Multimaki, Parkkola, Santalahti, Helenius, Nikolakaros,

Moilanen, Kumpulainen, Piha, Aronen, Puura,Linna, Almqvist (2005), who followed boys over a ten year period from the age of 8 to 18 years, when they were about to begin national service in Finland. Parents and teachers completed a number of published, standardised assessments e.g., Rutter Parents Scale and Rutter Teacher Scale for the boys when they were 8 years old, assessing their antisocial behaviours, hyperkinetic and neurotic symptoms and gave estimations about whether they thought the child needed psychiatric help. The boys rated themselves for depression,

psychosomatic symptoms and bullying. Details about parents were collected, including their level of education. At age 18, follow up measures were taken just prior to military call up, assessing psychopathy during the previous 6 months, as well as other standardised measures of adaptive functioning and substance use, together with demographic and life events information. Deliberate self-harm was measured using three response variables; ‘no suicidality’ ‘ideation of self-harm only’ and ‘acts of self-harm’. Assessing the significance of the relationship between the explanatory variables e.g., depression, somatic complaints and the three response variables, Haavisto et al (2005) found that anxiety and depression were strongly associated with both thoughts and acts of self-harm. In addition they found that aggressive behaviour displayed externally or not, was associated with self-harm. Externalised aggression was associated with acts of self-harm, whilst internalisation e.g., withdrawal, rumination, were strongly associated with both thoughts and acts of self-harm.

These researchers also found the same lifestyle choices, highlighted as significant in later studies (McMahon, 2010; Baaken & Gunter, 2012), correlated with self-harm behaviours. Smoking, heavy alcohol use and the use of illicit drugs were all

associated with both thoughts and acts of self-harm. In addition they highlighted poor relationships in general to be significant, including disruptive family dynamics e.g., divorce, parental ill health.

Although dated, a strength of this research is its longitudinal nature, allowing hypotheses to be explored over time. Researchers found that boys who reported feeling depressed at age 8 showed an increased risk of displaying thoughts and acts of self-harm at age 18. The same was found in relation to somatic health problems - parental reports of somatic health problems at age 8, correlated with later thoughts of harm, but not actual self-harm. The reports made by the boys themselves however, were associated not only with later thoughts of self-harm, but also acts. This showed that there was a link between certain detrimental factors experienced during the primary years and self-harm in adolescence. It also showed the importance of the child’s voice in assessing their inner state.

The importance of relationships in general was highlighted by this research, not only for girls as found by McMahon et al (2010), but also for boys. The absence of parental involvement was established as an important associate of self-harm. Parental level of education also turned out to be influential. Researchers found that boys who had at least one parents with a higher level of basic education (had graduated from upper secondary school) at the age of 8, were less likely later on to display acts of self-harm, although the risk of self-harm thoughts were elevated. By contrast boys of parents with

lower educational attainment were found to be more likely to show externalising behaviours and acts of self-harm. This could suggest that higher levels of parental attainment promoted patterns of interaction between parents and children which discouraged acts of self-harm, though not necessarily thoughts of it. Poor school achievement, as assessed by teachers, was another factor associated with later acts of self-harm.

The study was conducted in Finland as part of a nationwide study at the time when all 18 year olds faced compulsory military service. The follow up self- assessment data was collected when the young men were about to begin their service. It is possible that these very particular set of circumstances, not faced by the majority of young people in the UK who self-harm, may have an effect on how the young men behaved and

subsequently assessed themselves. This confounding factor potentially reduces the generalisability of the study.