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Abstract This study investigates knowledge, attitudes and training needs concerning deliberate self-harm (DSH) in adolescents, amongst a variety of professionals involved in the assessment and management of adolescence who self-harm. A questionnaire survey was completed by 126 health professionals working with adolescents who harm themselves. The main outcome measures were a knowledge measure and three attitude measures (generated using factor analysis). The mean percentage of correctly answered knowledge questions, across all professional groups, was 60%. With regard to knowlege, over three-quarters of participants were unaware that homosexual young men and those who had been sexually abused are at greater risk of DSH, whilst one third of staff were unaware that adolescents who self-harm are at increased risk of suicide. Staff who felt more effective felt less negative towards this group of patients (B=−0.21, p=0.03). Forty-two per cent of the participants wanted further training in DSH amongst adolescents.

1. Introduction Deliberate self-harm (DSH) is a serious and growing problem amongst adolescents (Fergusson, Woodward, & Horwood, 2000). DSH is a deliberate, self-initiated, and non-fatal act, carried out in the knowledge that it is potentially harmful. This includes self-poisoning or self-injury, irrespective of the apparent level of suicidal intention. The most common form of DSH is self-poisoning. (Hawton, Fagg, & Simkin, 1997). James and Hawton (1985) found that only 41% of self-poisoners expressed intent to die. Lifetime prevalence estimates of DSH range from 1.5% to 10.1% among females and 1.3% to 3.8% among males (Brent, 1997). One per cent will commit suicide in the year following a suicidal attempt, whilst 10% are likely to repeat the attempt within 3 months (Spirito, Plummer, & Gispcrt, 1992) and 20% are likely to repeat with in a 15-year period. These adolescents are more likely to have psychiatric, academic, social and behavioural problems (Taylor & Stansfield, 1989; Flisher, 1999) but are notoriously difficult to engage in follow-up (Trautman, Stewart & Morishma, 1993; Nasr, Vostanis, & Winkley, 1997). House, Owens and Storer (1992) noted a general perception amongst hospital staff that treatment of adult patients who self-harm was ineffective leading to ambivalence towards assessment and referral for psychiatric follow-up. Negative attitude amongst staff working with self-harming adult patients has been found in other studies (Barber et al., 1975; Patel, 1975; Ghodse, 1978). However to date there has been surprisingly little research about attitudes of clinicians to deliberate self-harm in adolescents. The purpose of this study is to investigate: (a) level of knowledge concerning DSH in adolescents; (b) attitudes towards adolescents who harm themselves; (c) training needs; amongst of a variety of professionals involved in the assessment and management of children and adolescence who self-harm.

3. Results Response rate and demographic characteristics of the participants are presented in Table 2. Participants included psychiatrists (working or training in child and adolescent psychiatry), non-psychiatric doctors, psychiatric nurses, non-psychiatric nurses and 39 other professionals (including social workers, psychologists, psychotherapists and teachers). Table 2. Participation rates and demographic characteristics of participants Borough All A B C Total no. of participants 126 40 35 51 Participation rate (%) 66 56 81 66 % male 33 27 40 31 Age <25 yrs 11 4 2 5 25–34 yrs 55 14 17 24 35–44 yrs 37 8 13 16 >45 yrs 20 12 2 6 Mean years experience 9.3 11.7 7.1 9.0 No. of psychiatrists 20 7 8 5 No. of non-psychiatric doctors 19 10 0 9 No. of psychiatric nurses 20 2 13 5 No. of non-psychiatric nurses 48 9 13 26 Table options There were no significant differences between male and female participants in knowledge or the three attitude factors. Doctors were more likely to be male and nurses female (χ2=7.27, df=1, p<0.01). Age was correlated with number of years experience working with children and adolescents (r=0.71, p<0.01). In subsequent analyses experience rather than age was selected as a predictor variable since it was considered that experience has greater conceptual validity. Experience was not related to knowledge (B=−0.13, p=0.14), effectiveness (B=0.09, p=0.37), negativity (B=−0.02, p=0.81) or worry (B=−0.04, p=0.71) using regression analysis. Borough was not related to gender (χ2=1.43, df=2, p=0.49), knowledge (F(2, 123)=0.23, p=0.79), effectiveness (F(2, 113)=0.98, p=0.38), negativity (F(2, 109)=0.44, p=0.65) or worry (F(2, 116)=0.87, p=0.42). However borough was related to experience (F(2,122)=3.28, p<0.05) with borough B (containing the inpatient unit) having professionals with less experience than borough A (p<0.05) but not being significantly different from borough C. 3.1. Knowledge about self-harm in children and adolescence For eight of the 11 knowledge questions, more than 50% of the respondents answered correctly (Table 3). Comparisons of proportions of correct responses among psychiatrists, non-psychiatric doctors, psychiatric nurses and non-psychiatric nurses (the four groups of sufficient size for comparison) revealed significant group differences for 7 of the 11 questions. Table 3. Professional groups and knowledge about deliberate self-harm Correct answers (%) Statement on self-harm (T=true/F=false) All proof groupsa Psychiatrists Non-psychiatric doctors Psychiatric nurses Non-psychiatric nurses pb Self-harm is more common in girls than boys (T) 77 90 95 65 75 NS People who self-harm have an increased likelihood of committing suicide in the future (T) 66 100 90 55 54 < 0.001 Children and adolescents who have been sexually abused are no more likely to self-harm than the general population (F) 67 75 90 65 46 <0.05 There is no evidence that intervention by a mental health professional reduces further episodes of self-harm in severity and frequency (F) 58 75 63 45 46 NS Behaviour modification programmes are not successful in the short term for young people who self-harm (F) 40 65 42 45 18 <0.05 People who self-harm often have poor communication skills and low self esteem (T) 75 90 79 60 68 NS Self-harm is more likely to occur among young people who are socio-economically deprived (T) 33 75 42 20 25 <0.01 Gay young men are no more likely to self-harm than the general population (F) 18 10 11 10 29 NS Girls are more likely than boys to kill themselves (F) 80 100 90 85 71 <0.05 The majority of young people who self-harm present to health services (F) 62 85 53 80 43 <0.01 Young people who self-harm are usually mentally ill (F) 83 100 84 85 64 <0.05 a Includes all participants. b Using Chi-squared tests. Table options 3.2. Attitudes to adolescents who harm themselves Maximum possible scores, mean scores and standard deviations on the three attitude measures are shown in Table 4. In general participants felt they were reasonably effective in managing DSH. For instance 71% of participants agreed or strongly agreed with the statement “I think that the amount of effort I make when dealing with a self-harming child makes a difference to the outcome.” Interestingly, there were generally low scores on negativity across all groups. For example, in response to the statement “children and adolescents who self-harm waste NHS time and resources,” 98% of participants disagreed or strongly disagreed. A substantial number of participants reported worry about these patients. Twenty per cent of participants agreed or strongly agreed with the attitude statement “I am worried that I am going to be blamed for what might happen to these children.” Table 4. Mean scores (s.d.) of knowledge and attitude items by professional groups Item (max possible score) All 1. Psychiatrists 2. Non-psychiatric doctors 3. Psychiatric nurses 4. Non-psychiatric nurses R test Post hoc group comparisons Knowledge (11) 6.75 (2.24) 8.65 (1.66) 7.37 (2.17) 6.15 (1.79) 5.39(1.89) F(3,83)=13.0, p<0.001 1>3***, 1>4*** Effectiveness (15) 10.60 (1.93) 10.37 (1.07) 9.50 (2.46) 11.35 (1.90) 10.92 (1.76) F(3, 79)=3.59, p<0.05 2>4** Negativity (15) 4.32 (1.55) 4.74 (0.93) 4.00 (1.85) 4.60 (1.85) 4.00 (1.44) F(3,77)=1.29, NS 3>2*, 1>2* Worry (9) 3.17 (1.60) 4.58 (1.50) 3.16 (1.39) 2.75 (1.41) 2.52 (1.37) F(3,81)=8.80, p<0.01 1>3**, 1>4** *p<0.05; **p<0.01; ***p<0.001. Table options 3.3. Knowledge and attitudes within professional groups A single measure of knowledge was obtained by summing the total number of correct responses, with a possible maximum score of 11. Table 4 shows the mean scores on the knowledge and attitude measures for all participants and for each professional group, along with results of one-way ANOVA between the four professional groups. There were significant group differences in total knowledge. Post hoc Tukey's test revealed no significant differences between psychiatric doctors and non-psychiatric doctors whilst psychiatric doctors had greater knowledge than both nurse groups and non-psychiatric doctors had greater knowledge than non-psychiatric nurses. Scores on the personal effectiveness item were higher in psychiatric nurses than non-psychiatric doctors. Psychiatrists reported more worry than the other groups. There were no group differences for negativity. 3.4. The relationship between knowledge and attitudes The relationship between knowledge and the three attitude factors was explored with linear regression. Knowledge was not related to effectiveness or negativity, whilst there was a non-significant trend for participants with more knowledge to be more worried (B=0.16, p=0.09). Participants who felt more effective experienced less worry (B=−0.23, p=0.01). This result was analysed in further detail and identified that only non-psychiatric nurses who felt more effective experienced less worry (B=−0.52, p=0.01) whilst there was no significant relationship for the other professional groups. Participants who felt more effective felt less negativity (B=−0.21, p=0.03). There were no significant relationships between knowledge and negativity or between worry and negativity. 3.5. Training Forty-two per cent of the participants wanted further training in deliberate self-harm amongst adolescents. Many noted that they had none or very little training about deliberate self-harm in young people. However the specific areas in which they felt they needed further training varied across the professional groups. CAMHS staff identified deficits of training in evidence-based treatment practices, multidisciplinary assessment and supervision. Inpatient unit and non-psychiatric staff identified training needs in acute management, handling volatile situations, and communicating with these patients. A few non-psychiatric staff felt that this was a specialist area and that they personally did not need training. However, in common with many of the non-psychiatric staff, they felt it was very important to be trained in the appropriate pathways of referral to psychiatric services particularly out of normal working hours.