• By Dartington SRU
  • Posted on Tuesday 28th August, 2012

Only sound evidence can guide prevention

Before preventive services can be fashioned, there has to be sound evidence about the cause and development of the problem to be tackled. This indicates when and where it is best to intervene if the causal chains that lead to the situation causing concern are to be broken.There are few validated explanations of problems like delinquency, drug misuse and suicide. Moreover, those that exist usually comprise an eclectic mixture of genetic, psychological and social variables.One area of considerable concern in present-day Britain is self-harm by adolescents. Why, asks the rational observer, do teenagers choose to do such horrible things to themselves and what can be done to stop it? Several explanatory models and treatments are available but a review of the evidence on their benefits shows that they have limited predictive and therapeutic value.This dearth of knowledge is surprising given the extent of the problem; 10 per cent of adolescents in the UK will have self-harmed by the time they leave school and 10 per cent of them will do so again within a year. There is an additional problem for practitioners in that adolescents are notoriously difficult to treat as they often withdraw from help or defy advice. So what is known and is it robust enough to justify a preventive program?The factors that need to be considered by clinicians trying to understand self harm are fairly clear and include details of the behavior, such as the intent, motivation, lethality and method, any triggers emanating from stress, substance misuse, mental and physical illness and abuse, along with longer-term sociodemographic, psychiatric and psychological variables.But if assessment is difficult, it is nothing like as challenging as deciding on the best treatment, as the review shows the evidence base for all therapeutic options is sparse and weak. A scrutiny of randomised controlled trials testing the efficacy of pharmacological, social and psychological therapeutic interventions to reduce self-harm found some encouraging results but was unable to come up with definitive recommendations. Indeed, so hazy were the results that the authors expressed the need for clearer definitions and measurements before cross-national comparisons of evaluations could be entertained. There was, however, some evidence of effectiveness in some areas, for example the programs Family Intervention for Suicide Prevention and Therapeutic Assessment improved engagement with after care, and Multisystemic Therapy reduced self-harm repetition when compared with hospitalization. Dialectical Behavior Therapy and Cognitive Behavior Therapy showed the best results for adult self-harm but have not been adequately evaluated to show for certain whether this benefit applies to adolescents. Similarly, the Signs Of Suicide and Multisystemic Therapy approaches, along with the use of pharmacological agents, need more rigorous testing to assess their value for teenagers. The arresting conclusion is, therefore, that while some promising approaches have been identified with regard to engagement and outcomes, “at present there are no independently replicated findings of any intervention being effective in reducing or preventing self-harm in adolescents.” It is to be hoped that the pressing nature of the self-harm problem across all countries will stimulate the development of common definitions and measures and encourage the testing of different treatments. Once underway, this process should soon establish the stronger knowledge base needed to inform effective prevention.*********Reference:Ougrin D, Tranah T, Leigh E, Taylor L and Asarnow J. (2012). Practitioner Review: Self-harm in adolescents. Journal of Child Psychology and Psychiatry, 53(4), 337-350.

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