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Three Part Question

In [children] is [deliberate self-harm a predictor] for being subject to a [child protection plan]?

Clinical Scenario

A 13 year old female presents with self-inflicted lacerations on her wrists. It is revealed she has a history of physical and emotional abuse, and a child protection plan is in place. You wonder if deliberate self-harm is a predictor for being subject to a child protection plan?

Search Strategy

Medline using OVID interface

Medline: ({[self-harm or self-injury or deliberate self-harm or self-injurious behaviour] OR self-poisoning OR [drug and alcohol abuse]} AND {[adolescents or teenagers or young adults] OR [children or adolescents or youth or child or teenager]} AND [child abuse or child neglect or child maltreatment] AND [social services OR [child welfare system or child protection or children’s services] AND [emergency department or emergency room])

PubMed: ([self-harm or self-injury] OR [self-mutilation] OR [cutting] OR [self-poisoning] OR [alcohol misuse] OR [drug misuse]) AND ([adolescents or young adults] OR [children] OR [teenagers]) AND ([child abuse] OR [child neglect] OR [child maltreatment]) AND ([social services] OR [child protection plan] OR [child welfare] AND emergency department)

Search Outcome

114 full-texts articles were obtained and screened. 99 of these were irrelevant and excluded leaving 11 papers included in the review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Anne E. Rhodes et al. 2012 Canada	4,683 12–17-year-olds who had been removed from their parental home because of maltreatment and 1,034,546 of their population-based peers.	Cohort study	Rates of a first presentation to the ED for suicide-related behaviour.	Adjusted odds ratio for first ED presentation for suicide related behaviour in those who suffered maltreatment, compared to their peers was 5.13 for boys and 5.36 for girls.	Coding in hospital records did not differentiate suicidal related behaviours- included both suicidal intent and non-suicidal self-injury. The study also lacks information on the type of abuse/maltreatment. Some sociodemographic factors such as ethnicity and postcode were missing from the records.
Tara Santens et al. 2018 Belgium	217 subjects aged 10-21 who had been involved in Flemish Child Welfare Services.	Online survey	Non-suicidal self-injury	32.7% of the sample engaged in non-suicidal self-injury.	Cross-sectional data so can’t draw causal conclusions. Self-reporting bias.
Christina M. Sellers et al. 2019 U.S.	1050 adolescents aged 11-17.5 who were subjects of child abuse or neglect investigations.	Secondary analysis of a national survey (data was obtained from the National Survey of Child and Adolescent Wellbeing II).	Substance and alcohol misuse	43.24% reported lifetime alcohol use and 23.01% marijuana use at baseline. This increased to 55.77% and 38.69% respectively by the third wave at 36 months.	Data is 10 years old so not representative of the current population. Self-reporting bias. Did not explore other forms of substance abuse e.g., inhalants or cocaine use. All forms of self-harm were not explored only suicidal ideation.
Masako Tanaka et al. 2011 Canada	117 adolescents aged 13-19 who were receiving services from Child Protection Services (CPS).	Cohort Study	Substance and alcohol abuse	In the youth involved with CPS 14.5% had exceeded the clinical cut off for The Alcohol Use Disorders Identification Test, compared to 20.8% of the comparison group. 24.8% met the cut for CRAFT, while only 15.8% did for the comparison.	Self-reporting bias Study sample was too small to generalise to the broad population of child welfare. Does not measure self-injury in terms of cutaneous damage or self-poisoning.

Comment(s)

Overall the study design of the papers included was inconsistent and could be improved. The papers examined were heterogenous as different settings, forms of self-harm and outcomes were measured. While deliberate self-harm was not found to be a predictor for being subject to child protection plan, it is still an important and prevalent issue in children suffering from child abuse.

Clinical Bottom Line

In children, deliberate self-harm is not a strong predictor for being subject to a child protection plan.

References

1. Anne E. Rhodes, Michael H. Boyle, Jennifer Bethell, Christine Wekerle, Deborah Goodman, Lil Tonmyr, Bruce Leslie, Kelvin Lam, Ian Manion Child maltreatment and onset of emergency department presentations for suicide-related behaviors Child Abuse and Neglect 2012; 542-551
2. Tara Santens, Laurence Claes, Guy S Diamond, Guy Bosmans Depressive symptoms and self-harm among youngsters referred to child welfare: The role of trust in caregiver support and communication Child Abuse and Neglect 2018; 155-167
3. Christina M Sellers, Ruth G McRoy, Kimberly H McManama O'Brien Substance use and suicidal ideation among child welfare involved adolescents: A longitudinal examination Addictive Behaviours 2019; 39-45
4. Masako Tanaka, Christine Wekerle, Mary Lou Schmuck, Angela Paglia-Boak, MAP Research Team The linkages among childhood maltreatment, adolescent mental health, and self-compassion in child welfare adolescents Child Abuse and Neglect 2011; 887-898