Psychological Assessment 2012, Vol. 24, No.

1, 1120

2011 American Psychological Association 1040-3590/12/$12.00 DOI: 10.1037/a0025043

Adolescents With Suicidal and Nonsuicidal Self-Harm: Clinical Characteristics and Response to Therapeutic Assessment
Dennis Ougrin
Kings College London

Tobias Zundel
Tavistock Centre

Marinos Kyriakopoulos
Kings College London

Reetoo Banarsee
Imperial College London

Daniel Stahl and Eric Taylor

Kings College London
Self-harm is one of the best predictors of death by suicide, but few studies directly compare adolescents with suicidal versus nonsuicidal self-harm. Seventy adolescents presenting with self-harm (71% young women, ages 1218 years) who participated in a randomized controlled trial were divided into suicidal and nonsuicidal self-harm categories using the Columbia Classification Algorithm of Suicide Assessment. Adolescents with suicidal self-harm were more likely than those with nonsuicidal self-harm to be young women, 22/23 (96%) versus 34/47 (72%), odds ratio (OR) 8.33, 95% confidence interval (CI) [1.03, 50.0]; had a later age of onset of self-harm, 15.4 years vs. 13.8 years, mean difference 1.6, 95% CI [.8, 2.43]; and used self-poisoning more often, 18/23 (78%) versus 11/47 (23%), OR 3.43, 95% CI [2.00, 5.89]. Only those with nonsuicidal self-harm had an improvement on Childrens Global Assessment Scale score following a brief therapeutic intervention, mean difference 8.20, 95% CI [.97, 15.42]. However, there was no interaction between treatment and suicidality. There are important differences between adolescents presenting with suicidal and nonsuicidal self-harm. Suicidal self-harm in adolescence may be associated with a less favorable response to therapeutic assessment. Keywords: therapeutic assessment, self-harm, nonsuicidal self-injury, suicide attempt, adolescents

Self-harm in adolescence is a common problem (Evans, Hawton, Rodham, & Deeks, 2005) with lifetime prevalence of attempted suicide of 9.7%, whereas an additional 13.2% of adolescents engage in self-harm at some point during that period. Self-harm is one of the strongest predictors of eventual death by suicide in adolescence, increasing the risk up to 10-fold (Hawton & Harriss, 2007). Despite its high prevalence, there is no agreement about the definition of self-harm. Hawton et al. (2003) defined (deliberate)

This article was published Online First August 22, 2011. Dennis Ougrin and Eric Taylor, Department of Child and Adolescent Psychiatry, Kings College London, London, United Kingdom; Tobias Zundel, Adolescent Department, Tavistock Centre, London, United Kingdom; Marinos Kyriakopoulos, Department of Psychosis Studies, Kings College London; Reetoo Banarsee, Department of Public Health and Primary Care, Imperial College London, London, United Kingdom; Daniel Stahl, Department of Biostatistics, Kings College London. This research was supported by grants from Psychiatry Research Trust and West London Primary Care Research Consortium. We thank Gordana Milavic, Jo Fletcher, Paul Calaminus, Azeem Majeed, Robert Goodman, and Derek Bolton for their clinical, managerial, and research support. Correspondence concerning this article should be addressed to Dennis Ougrin, Department of Child and Adolescent Psychiatry, Kings College London, Institute of Psychiatry PO85, De Crespigny Park, London SE5 8AF, United Kingdom. E-mail: dennis.ougrin@kcl.ac.uk 11

self-harm as intentional self-injury or self-poisoning, irrespective of type of motivation or degree of suicidal intent. Many European investigators use this definition (Hawton et al., 2003; Schmidtke et al., 1996), which is also used in Australia (De Leo & Heller, 2004) and New Zealand (Carter, Reith, Whyte, & McPherson, 2005). Many American researchers subdivide self-harm into two main groups, suicidal acts with intent to die and instrumental suiciderelated behavior with no intent to die (Silverman, Berman, Sanddal, OCarroll, & Joiner, 2007), and have proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders disorders and criteria to include the new category Non-Suicidal Self Injury (American Psychiatric Association, 2010). Although there is much debate on this issue, few studies have investigated differences between patients with suicidal and nonsuicidal self-harm. If differences between the two groups exist, they could be related to one of these three domains: demographic characteristics, clinical characteristics, and self-harm-related variables (Walsh, 2006). Most of the proposed differences have not been demonstrated in large population-based studies directly comparing suicidal versus nonsuicidal groups.

Differences in Sociodemographic Characteristics, Prevalence, and Onset

Very few studies directly compare sociodemographic characteristics of suicide attempters versus nonsuicidal self-harmers

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(Muehlenkamp, 2005; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006; Sarkar, Sattar, Gode, & Basannar, 2006; Walsh, 2006). In the largest study investigating these differences, those with suicidal self-harm were more likely to be young women with less education from the Southern and Western United States (Nock & Kessler, 2006). A significant fact with respect to the design of this study was that the sample was drawn from young people who all initially classified their behavior as suicidal. However, nearly half of those were subsequently reclassified as having carried out a suicidal gesture, that is, self-harm without true suicidal intent. There are suggestions that nonsuicidal self-harm is equally prevalent among young men and young women (Gratz, 2001; Muehlenkamp & Gutierrez, 2007), although other studies found a female preponderance (Ross & Heath, 2002). Other possible sociodemographic differences may include a higher prevalence of nonsuicidal self-harm in Caucasians as compared with other racial groups (Muehlenkamp & Gutierrez, 2004, 2007).

have a higher prevalence of depression, drug abuse and drug dependence, conduct disorder and antisocial personality disorder, phobias, and multiple diagnoses. Limitations of the methodology of this study were discussed above; however, the results are important in the light of other studies that found differences between the two groups in depression scores, suicidal thinking, and attitude to life (Csorba et al., 2009; Jacobson, Muehlenkamp, Miller, & Turner, 2008; Muehlenkamp & Gutierrez, 2004), as well as the prevalence of anxiety disorders (Brausch & Gutierrez, 2010; Csorba et al., 2009; Jacobson et al., 2008; Muehlenkamp & Gutierrez, 2004). Regarding conduct problems, there have also been reports of a higher prevalence of externalizing disorders in nonsuicidal adolescents with self-harm (Grholg, Ekeberg, & Haldorsen, 2000).

Therapeutic Response
At present, most random allocation studies do not distinguish between adolescents with suicidal and nonsuicidal self-harm (Chanen et al., 2008; Cotgrove, Zirinsky, Black, & Weston, 1995; Harrington et al., 1998; Hazell et al., 2009; Wood, Trainor, Rothwell, Moore, & Harrington, 2001). In addition, despite psychosocial assessment having distinct therapeutic value (Poston & Hanson, 2010), no studies demonstrate a differential response of adolescents with different self-harm subtypes to a brief therapeutic intervention. There is good evidence of therapeutic response to a combination of medication and psychotherapy in young people with depression, including those with self-harm (Brent et al., 2008, 2009; TADS Team, 2007). The literature on subtypes of adolescents with self-harm is limited and developing. To investigate the possible differences between the adolescents with suicidal and nonsuicidal self-harm, we studied the participants of the Trial of Therapeutic Assessment in London (TOTAL; Ougrin et al., 2011). In the TOTAL, 26 clinicians were randomized to deliver either therapeutic assessment (TA), a 30-min manualized intervention in addition to assessment as usual (AAU), or AAU alone. There were 73 adolescents assessed; 70 (96%) of those agreed to participate in the study. Twenty (57%) adolescents in the TA and 18 (51%) in the AAU arm were assessed jointly with their parent or guardian. An average of five adolescents were assessed by each clinician in the TA arm (range 112) and an average of 4.4 (range 114) were assessed in the AAU group. The mean age of the participants was 15.6 years (SD 1.4). The majority of the participants in the sample were White (n 37, 53%). Fifty-six (80%) participants were young women, 28 (40%) self-harmed by self-poisoning alone, 37 (53%) self-harmed by self-injury alone, and 5 (7%) self-harmed by both self-poisoning and self-injury. Forty-one (59%) had self-harmed previously. There was no statistically significant difference between the TA and AAU arms in the proportion of the adolescents presenting with suicidal self-harm (31% vs. 34%, 2 .065, p .8). Overall, 53 (76%) participants met diagnostic criteria for at least one diagnosis, 42 (60%) had a primary diagnosis of an emotional disorder, nine (13%) had a primary diagnosis of a disruptive disorder, and two (3%) had other diagnoses. The adolescents in the TA arm were significantly more likely than those in the AAU arm to attend the first treatment appointment following the assessment, 29 (83%) versus 17 (49%), odds ratio (OR) 5.12, 95% confidence interval (CI) [1.49,

Differences in Self-Harm Behavior

Several studies propose that those who attempt suicide tend to favor high-lethality methods such as self-poisoning, whereas those who self-harm without suicidal intent are more likely to use low-lethality methods such as self-cutting (Csorba, Dinya, Plener, Nagy, & Pa li, 2009; Favazza & Conterio, 1989; Walsh & Rosen, 1988). However, no method of self-harm is exclusively related to suicidal intent, and adolescents may use different methods of self-harm at different times (Nock et al., 2006). Up to 70% of adolescents who self-harm without suicidal intent also attempt suicide (Nock et al., 2006). Guertin, Lloyd-Richardson, Spirito, Donaldson, and Boergers (2001) viewed nonsuicidal self-harm as a complicating factor in suicidal self-harm. Regarding chronicity, some studies indicate that adolescents who self-harm with no suicidal intent, compared with adolescents with suicidal intent, are more likely to engage in repetitive selfharming behavior (Csorba et al., 2009; Pattison & Kahan, 1983). However, an important minority of adolescents who repeatedly attempt suicide has also been described (Hawton & Harriss, 2008). Up to 55% of adolescents with nonsuicidal self-injury also repeatedly attempt suicide (Nock et al., 2006). There are no consistent findings differentiating suicidal and nonsuicidal self-harm in terms of time of onset. The frequency of both behaviors increases in adolescence and young adulthood and then diminishes over time. However, the peak onset for nonsuicidal self-harm could be between 12 and 14 years (Muehlenkamp & Gutierrez, 2004; Ross & Heath, 2002), whereas for suicidal self-harm, the peak onset is around the age of 16 (Nock et al., 2008).

Differences in Clinical Characteristics

Adolescents with both suicidal and nonsuicidal self-harm overwhelmingly (in about 90% of cases) satisfy diagnostic criteria for one or more psychiatric disorders (Jacobs, 1999; Nock et al., 2006), depression being the most common diagnosis in both groups. These results, however, only apply to the clinical samples, and it may be that in the nonreferred adolescents, the rate of psychiatric disorders is much lower. Nock and Kessler (2006) also found that adolescents with suicidal versus nonsuicidal self-harm

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17.55], and more likely to attend four or more treatment sessions, 14 (40%) versus 4 (11%), OR 5.19, 95% CI [2.22, 12.10]. Three months after the initial assessment, there were no statistically significant differences between the intervention and the control arms on the Strengths and Difficulties Questionnaire (SDQ) scores, 15.6 versus 16.0, mean difference 0.37, 95% CI [3.28, 2.53], or the Childrens Global Assessment Scale (CGAS) scores, 64.6 versus 60.1, mean difference 4.49, 95% CI [0.98, 9.96]. Only 34 (49%) of the parent-rated SDQs were available at follow-up; hence, only patient-rated versions were analyzed (available for 63 [90%] of the adolescents). The intervention and the control arms did not differ on repetition of self-harm: 9/35 (26%) in the TA group and 9/35 (26%) in the AAU group, 2 .0, p 1. Using the TOTAL sample, on the basis of the available literature, we hypothesized that adolescents with suicidal self-harm, compared with those in the nonsuicidal self-harm group, will be more likely to be young women and depressed. They also will be more likely to use self-poisoning as a method of self-harm and more likely to benefit from TA as measured by the CGAS and the SDQ scores. We also hypothesized that adolescents in the nonsuicidal self-harm group, compared with those in the suicidal selfharm group, will be more likely to have a diagnosis of conduct disorder, will have an earlier age of onset of self-harm, and will be more likely to have a history of previous self-harm. In summary, there are significant gaps in the knowledge of the possible differences between adolescents with suicidal and nonsuicidal self-harm, yet these differences may be important in the classification, phenomenology, and eventually differential interventions for the two groups. In this article, we investigate the clinical and sociodemographic differences between the adolescents presenting with suicidal and nonsuicidal self-harm.

than 16 years of age assented to participate. All participants and their guardians, if present, completed the SDQ and were assigned a CGAS score.

Interventions and Procedure

Control arm: Assessment as usual. AAU included a standard psychosocial history and risk assessment and followed the recommendations set out in the NICE (2004) guidelines. The assessment letter was sent to the relevant community team, and a copy was sent to the family in accordance with the trusts policies. A random sample of 10 (29%) of the clinical evaluations was selected to evaluate fidelity. Two independent psychiatrists rated adherence to 17 points that should be covered in a standard clinical self-harm evaluation (NICE, 2004). Adherence to these 17 points averaged 81.2%, with a minimum of 71% and a maximum of 100%. Interrater agreement was acceptable (overall Cohens .73, p .001, range: .431). Intervention arm: TA. The major components of TA are as follows. 1. Assessing risk and taking a standard psychosocial history (approximately 1 hr). Taking a 10-min break to review the information gathered and to prepare for the rest of the session, followed by a 30-min intervention covering the next four steps. Jointly constructing a diagram (based on the cognitive analytic therapy paradigm) that consists of three elements: reciprocal roles, core pain, and maladaptive procedures (Ryle, 2010). Identifying a target problem. Considering and enhancing motivation for change. Exploring potential exits (i.e., ways of breaking the vicious cycles identified). Describing the diagram and the exits in an understanding letter. In addition to the understanding letter, the family also receives the usual assessment letter.

2.

3.

Method Participants
Adolescents 12 to 18 years old not currently engaged with psychiatric services who had self-harmed and been referred for a psychosocial assessment met the inclusion criteria and were eligible for participation in the trial. Exclusion criteria were gross reality distortion (e.g., owing to psychotic illness or intoxication), known history of moderate or severe learning disability, lack of fluent English, immediate risk of violence or suicide, and the need for inpatient psychiatric admission. Self-harm was defined as self-injury or self-poisoning irrespective of the underlying intent (National Institute for Health and Clinical Excellence [NICE], 2004), in line with British national guidelines. The referral for psychosocial assessment was made either following a screening at the emergency departments of four inner London hospitals or following an urgent family doctors referral to the local outpatient child and adolescent mental health services. Both the referring practitioner and the emergency department staff were blind to the allocation of the adolescents to either TA or AAU. Eligible participants were approached with respect to participating in the trial after they had received medical clearance after an episode of self-harm. Parents (and 16- or 17-year-old participants) signed an informed consent document and adolescents younger

4. 5. 6.

7.

The assessment process was manualized, although assessing clinicians used clinical judgment when deciding on the best approach to exits. Family members were involved in all stages of TA whenever possible. Clinicians received training in TA over five half days accompanied by weekly homework and a video assessment before and after training with independent fidelity assessment. To ensure fidelity to TA, we selected a random sample of 10 (29%) of the clinicians audiotaped evaluations. Two independent clinicians rated adherence to the seven components of TA. Adherence to these seven points averaged 90.7%, with a minimum of 71.4% and a maximum of 100%. Interrater agreement was moderate (overall Cohens .64, p .001, range: .59 1). All 10 tapes showed that the clinicians had achieved the required level of competence in TA (33 points or more on the objective subscale of the Therapeutic Assessment Quality Assurance Tool, a 0 50 scale

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completed by an independent clinician rating the extent to which the five objectives of TA had been achieved). Three months after the initial assessment, three higher specialist trainees in psychiatry unaware of the patients allocation, conducted face-to-face interviews with the participants and their guardians, if available. If a face-to-face interview was not possible, a telephone follow-up interview was conducted. Participants and their guardians, whenever available, also completed the follow-up version of the SDQ. Randomization occurred at the level of clinician, and 26 clinicians were randomized. Twenty-two clinicians were from Center 1, and two each were from Centers 2 and 3. Randomization was conducted by a senior psychiatrist independent of the study clinicians. The randomization was stratified by center, and two blocks (block lengths 22 and 4) were created using a permuted block design to ensure that equal numbers of clinicians from each center were allocated to either intervention or control groups. The randomization scheme was generated using Web-based randomization software (http://www.randomization.com). The clinicians were informed of their allocation by e-mail. Once randomized, the clinicians administered either TA or AAU to all eligible adolescents presenting with self-harm for assessment as part of their routine work until a total of 70 adolescents were recruited. Randomization occurred irrespective of the type of self-harm in the adolescents. Power calculation for the TOTAL study (Ougrin et al., 2011) was based on the results of a pilot study (Ougrin, Ng, & Low, 2008). It was assumed that 75% of the participants in the intervention (TA) group and 40% of the participants in the control (AAU) group would attend the first community treatment session. The software nQuery Advisor 4.0 (Elashoff, 2000) was used to establish that 35 participants in each group (70 in total) were required. With the sample size of 70 and 80% power, differences between the two groups equal to or greater than an effect size of .48 for continuous variables and equal to or greater than an odds ratio of 2.79 for dichotomous variables at the two-sided 5% level were detectable. It was not possible to keep the clinicians unaware of the intervention they were delivering. Participants were unaware as to what type of assessment they were receiving. The study statistician and the researchers conducting follow-up assessments were unaware of the participants allocation.

Measures
Clinical diagnosis. Clinical diagnosis was recorded using the International Classification of Diseases 10th edition (ICD10) criteria (World Health Organization, 1992). To aid clinicians with the diagnostic process, the electronic Patient Journey System was used in 66 of the 70 assessments. The system provides examples of questions based on ICD10 criteria for a range of psychiatric disorders and requires that clinicians arrive at a primary diagnosis. Primary clinical diagnoses were collapsed to form the following four groups: (a) no diagnosis, (b) emotional disorders (including depressive and anxiety disorders), (c) disruptive disorders (including conduct and hyperkinetic disorders), and (d) other disorders. Sociodemographic data. Basic demographic data were collected using the standard self-report forms used for the assessment of all new patients at the participating National Health Service

hospital trusts. Ethnicity was recorded on the basis of a self-report question. The patients had to initially choose from 16 different categories. These were subsequently collapsed into two: White or non-White. The parental marital status question initially had eight response categories. These were collapsed into either intact (living with two biological parents) on nonintact. A rating of socioeconomic status was assigned by the assessing clinician on the basis of the occupation of the main breadwinner in the family (Office of Population Censuses and Surveys, 1991): Social Class I higher professional and managerial occupations; Social Class II intermediate managerial, administrative, or professional; Social Class III A supervisory or clerical and junior managerial, administrative, or professional; Social Class III B skilled manual workers; Social Class IV semiskilled and unskilled manual workers; and Social Class V casual or lowest grade workers, pensioners, and others who depend on the state for their income. This scale was also collapsed into two categories: manual and nonmanual workers. Suicidality. The Columbia Classification Algorithm of Suicide Assessment (Posner, Oquendo, Gould, Stanley, & Davies, 2007) was used to classify the young people on the basis of the index episode of self-harm. This is a classification algorithm in which the criteria for a suicide attempt include both self-injurious behavior and suicidal intent (at least some intention to commit suicide). The Columbia Classification Algorithm of Suicide Assessment has been shown to have good validity and reliability (interclass correlation coefficient .89). Because an episode of self-harm was an inclusion criterion for TOTAL, we used the following three categories to classify each index episode: (a) suicide attempt; (b) self-injurious behavior, no suicidal intent; and (c) self-injurious behavior, suicidal intent unknown. The clinical description of each index episode was independently rated by two senior psychiatrists. Disagreements were resolved by consensus. The three categories were then dichotomized into suicidal self-harm, which included Categories a and c, and nonsuicidal self-harm. Clinical guidelines suggest that the assessing clinicians should err on the side of caution when assessing adolescents with self-harm. The presence of suicidal intent in the adolescents with unknown intent should therefore be assumed (American Academy of Child & Adolescent Psychology, 2001; NICE, 2004). Measures of general psychopathology and function. Selfrated and parent-rated versions of the SDQ were used. The SDQ (Goodman, 2001) consists of 25 items that make up five 5-item subscales assessing conduct problems, hyperactivityinattention, emotional symptoms, peer problems, and prosocial behavior. Each item is rated on a 3-point scale: not true (a score of 0), somewhat true (a score of 1), or certainly true (a score of 2). The total difficulty score ranges from 0 to 40, and the Prosocial Behavior subscale score is not included in the total. A score of 20 or more indicates clinical abnormality. Only adolescent-reported SDQs were used, as only 39 (56%) of the adolescents had parental baseline scores. The CGAS was also used. The CGAS (Shaffer et al., 1983) is a clinician-rated scale assessing the functional status of a young person on a scale of 1100, with a score of at least 70 being indicative of adequate functioning.

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Statistical Analysis
Comparisons between the adolescents randomized to TA versus AAU are described in Ougrin et al., 2011. Here, all comparisons were conducted between the adolescents with suicidal and nonsuicidal self-harm. To evaluate the impact of TA, we used a random effects model with the intervention (TA vs. AAU), suicidality (suicidal vs. nonsuicidal self-harm), and the interaction between the intervention and suicidality as independent factors and CGAS and SDQ change scores as dependent variables. Patients were not sampled individually but as a group treated by a clinician. To adjust for possible clinicians effects, we included clinician as a random factor in the model that explicitly models the possible correlation between patients of the same clinician. We chose the CGAS and SDQ change score, from baseline to follow-up, as a dependent variable. We selected this design because the comparison groups used in this study (adolescents with and without suicidal intent) were different from the intervention and control arms created by the original randomization (adolescents allocated to TA vs. AAU irrespective of the intent; Ougrin et al., 2011), and we could not therefore use the analysis of covariance approach to analyzing clustered randomized controlled trials.

poisoning as the method of self-harm, and they were more likely to start self-harming at an older age (see Table 2). The following two factors were entered into logistic regression: age of onset and method of self-harm, adjusted for clustering around clinicians, age, and sex. Both method of self-harm and age of onset were significantly associated with type of self-harm. Adolescents with self-poisoning were more likely to belong to the suicidal self-harm group. Adolescents with suicidal self-harm were more likely to have a later age of onset of self-harm (see Table 3).

Impact of TA
In addition, we studied the impact of having TA versus AAU on two main clinically relevant findings: the SDQ and the CGAS scores. The SDQ and the CGAS score change from baseline to the 3-month follow-up assessment were used. A random effects model with the intervention as an independent factor and the clinician as a random factor showed that there was a significant difference in the intervention effect on the CGAS score change in the nonsuicidal group but not in the suicidal group. For the mean difference between TA and AAU in the suicidal group, M 0.22, 95% CI [10.66, 11.11], t(18) 0.043, p .966; for the mean difference between TA and AAU in the nonsuicidal group, M 6.39, 95% CI [0.67, 12.11], t(43) 2.25, p .03. However, this difference in change score between the suicidal and nonsuicidal groups was accompanied by a nonsignificant interaction between intervention and suicidality: F(1, 61) 1.27, p .26 (two factorial random effects model with intervention [TA vs. AAU] and type of self-harm [suicidal vs. nonsuicidal] as fixed factors). Suicidal and nonsuicidal adolescents did not differ on the SDQ score change at the 3-month follow up. Random effects models with the intervention as an independent factor and the clinician as a random factor showed no significant difference in the SDQ score change between TA and AAU in either the nonsuicidal group or

Results
There was a good level of agreement between the two raters in classifying suicidal and nonsuicidal cases ( .69, p .001). The disagreements were resolved by consensus. There were no significant differences between the two groups on most demographic characteristics studied. Suicidal adolescents were more likely to be young women (see Table 1). Of the clinical characteristics, the following two variables were found to be significantly different between the two groups. Young people with suicidal self-harm were more likely to use self-

Table 1 Demographic Characteristics of Adolescents With Suicidal and Nonsuicidal Self-Harm

Variable Sex Young men Young women Ethnicity White Non-White Socioeconomic status Nonmanual Manual Age in years M SD Family composition Intact Nonintact School or employment Yes No
a

Suicidal (n 23) 1 22 9 14 6 17 15.63 1.145 7 15 17 4

Nonsuicidal (n 47) 13 34

OR 0.12 0.44

95% CI [0.02, 0.97] [0.16, 1.21] [0.13, 1.20] [0.56, 0.71] [0.25, 2.13] [0.27, 3.73]

Significance (2-sided) .03a .13 .12 .20 .60 1

28 19 0.40 22 25 0.81b 15.56 1.404 0.73 18 28 1.01 38 9

Note. OR odds ratio; CI confidence interval. Fishers exact test. b Mean difference.

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Table 2 Clinical Characteristics of Adolescents With Suicidal and Nonsuicidal Self-Harm

Variable Method of self-harm Self-poisoning Self-injury Self-poisoning and self-injury Other Previous self-harm Yes No Age of onset in years M SD Any diagnosis Yes No Depression Yes No Conduct disorder Yes No SDQ score initial M SD CGAS score initial M SD Suicidal (n 23) 18 3 2 11 12 15.43 1.35 18 5 16 7 0 23 19.45 6.8 53.35 8.81 Nonsuicidal (n 47) 11 33 2 1 0.47 31 16 1.62b 13.8 1.78 1.23 35 12 2.39 23 24 6 41 1.02 18.43 6.23 54.83 9.68 1.48 .17 [2.35, 4.46] [6.14, 3.18] .54 .53 [0.75, 8.10] .13 [0.34, 5.17] 1 [0.80, 2.43] .001 [0.15, 1.47] .20 OR 3.43a 95% CI [2.00, 5.89] Significance (2-sided) .001

Note. OR odds ratio; CI confidence interval; SDQ Strengths and Difficulties Questionnaire; CGAS Children Global Assessment Scale. a The reference category is self-poisoning. b Mean difference.

the suicidal group. For the mean difference between AAU and TA in the suicidal group, M 3.12, 95% CI [1.49, 7.73], t(18) 1.42, p .172; for the mean difference between AAU and TA in the nonsuicidal group, M 0.42, 95% CI [3.56, 2.72], t(41) 0.27, p .79. A two-factorial random effects model did not reveal a significant interaction between type of intervention and suicidality, F(1, 59) 1.68, p .20, with the change of the SDQ score as the dependent variable and intervention (TA vs. AAU) and type of self-harm (suicidal vs. nonsuicidal) as independent variables. Furthermore, there was no significant main effect of type of intervention, F(1, 59) 0.98, p .33, and suicidality, F(1, 59) 0.46, p .50.

Nonsuicidal Self-Injury
We repeated all of the analyses with the nonsuicidal self-injury group (n 33) compared with other types of self-harm group (n 30) and separately compared with the suicide attempt group (n 23). The outcome of these analyses closely resembled the above results and no additional associations were found.

Discussion
We found three main differences between the adolescents presenting with suicidal and nonsuicidal self-harm in this study: (a)

Table 3 Summary of Hierarchical Regression Analysis for Variables Predicting Differences Between Adolescents With Suicidal and Nonsuicidal Self-Harm
Suicidalitya Method: Self-poisoning Age of onset Constant B 2.01 0.84 14.54 SE .70 .33 Wald 6.53 6.31 df (factor, error) 1, 70 1, 70 Significance .01 .01 Odds ratio 0.13 0.43 95% CI for odds ratio [0.03, 0.63] [0.23, 0.83]

Note. SE standard error; CI confidence interval; Method method of self-harm with self-poisoning as a reference category; Age of onset age at the first episode of self-harm. a The reference category is nonsuicidal self-harm. All results are adjusted for sex, age, and clustering around clinicians

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Adolescents with suicidal self-harm tend to have a later age of onset of this behavior, (b) they tend to use self-poisoning more often as the self-harm method, and (c) they are more likely to be young women. In addition, they may respond to TA less favorably than adolescents with nonsuicidal self-harm do. We did not find any differences in other demographic or clinical characteristics. To our knowledge, this is the first study in which the differential response of these two groups to a brief therapeutic intervention at the point of initial assessment was investigated. Many descriptive studies sought to compare adolescents with nonsuicidal self-harm and those with a combination of suicidal and nonsuicidal self-harm (Brausch & Gutierrez, 2010; Claes et al., 2010). Whereas it is certainly true that significant overlap may exist between these two behaviors, we chose to classify the adolescents in our study on the basis of the index episode of self-harm, in line with other researchers (Grholg et al., 2000). It is possible that some of the adolescents had a history of both suicidal and nonsuicidal self-harm, yet retrospective assessments of suicidality are unreliable and the index episode approach is the closest to clinical practice.

Differences in Clinical Characteristics

We did not find any differences in the likelihood of having a psychiatric diagnosis between the two groups, although well over 70% of the adolescents satisfied criteria for a psychiatric diagnosis in both groups. As other studies have reported a greater prevalence of psychiatric disorders (up to 90%), it may be that these were underestimated in this study, perhaps because we did not use a full semistructured interview to establish the diagnosis. We did not find an increased likelihood of the diagnosis of depression in the suicidal group, unlike previous studies (Brausch & Gutierrez, 2010; Csorba et al., 2009). However, depression was the most common diagnosis, and the absolute difference between the two groups was large, with 49% of nonsuicidal and 69% of suicidal adolescents satisfying criteria for a depressive condition. Previous studies have associated more externalizing problems with nonsuicidal self-harm (Grholg et al., 2000). All adolescents with conduct disorder were in the nonsuicidal group in this study sample. The difference between the two subgroups, however, did not reach a statistically significant level, possibly because of low statistical power. The absolute difference in the diagnosis of conduct disorder was substantial and possibly clinically significant.

Differences in Sociodemographic Characteristics

Many authors report self-harm in general to be more common in young women than in young men (Gratz, 2001; Muehlenkamp & Gutierrez, 2007), unlike completed suicide (Ougrin, Banarsee, Dunn-Toroosian, & Majeed, 2010), although this finding is not universal. Several studies also found a female preponderance in those with suicidal versus nonsuicidal self-harm (Muehlenkamp & Gutierrez, 2004; Nock & Kessler, 2006). This study supports the previous findings of a female preponderance in the risk of selfharm overall and in suicidal versus nonsuicidal self-harm in particular. It is possible that community samples with a lower severity of self-harm have a different sex ratio to clinical samples (Madge et al., 2008).

Differences in Response to TA
We found no difference in response as measured by the SDQ, but we found that adolescents with nonsuicidal self-harm were more likely to have a higher CGAS score 3 months after the initial TA. However, the differences found were no longer significant when the Intervention Suicidality interaction was considered, which may be explained by insufficient power. This finding was contrary to our hypothesis. We reasoned that the suicidal group would have a greater risk of having a diagnosis of depression and would therefore have a better response to community treatment on the basis of the combination of psychological treatment and pharmacological intervention (TADS Team, 2007). However, neither of these hypotheses was confirmed. It may be that the absence of clinical improvement in the suicidal group was partly mediated by nonsignificant differences in the prevalence of psychiatric disorders and partly reflected a more refractory nature of psychiatric disorders in this group. Other authors also noted that those with suicidal self-harm are likely to have worse posttreatment outcomes than nonsuicidal comparison groups (Dougherty et al., 2009) and that there is poor treatment engagement in the adolescents with suicidal and nonsuicidal self-harm (Ougrin & Latif, 2011). Both measures of clinical outcome used in this study are rather broad and may have therefore obscured important differences in specific clinical subdomains. Moreover, the 3-months follow-up period may have been too short to allow for the full benefit of the interventions to be realized.

Differences in Self-Harm Characteristics

Our findings are in line with other studies and suggest a strong link between cutting and nonsuicidal self-harm on one hand and self-poisoning and suicidal self-harm on the other (Csorba et al., 2009). However, we did not find an increased likelihood of repeat self-harm in the nonsuicidal group, which was contrary to the findings of other studies (Brausch & Gutierrez, 2010; Csorba et al., 2009). There is increasing evidence of self-harm being one part of a continuum of suicidal process ranging from thoughts of self-harm to completed suicide (Stanley, Winchel, Molcho, & Simeon, 1992). One longitudinal study demonstrated that nonsuicidal selfharm predicts future nonsuicidal self-harm rather than future suicidal attempts (Wichstrm, 2009), whereas another demonstrated nonsuicidal self-harm to be a strong predictor of suicide attempts (Wong, 2007). Our findings of nonsuicidal self-harm starting earlier in life than suicidal self-harm are of interest in the light of the theory proposing that suicide is often a result of the learned ability to hurt oneself (Joiner, 2005). Contrary to our expectations, we did not find a greater likelihood of having had a previous episode of self-harm in the nonsuicidal group as compared with the suicidal group.

Nonsuicidal Self-Injury
It would appear from the analysis that the nonsuicidal self-injury group closely resembles the nonsuicidal self-harm (which includes adolescents with both nonsuicidal self-poisoning and nonsuicidal self-injury) group. Using the term nonsuicidal self-harm may be preferable to nonsuicidal self-injury, as it encompasses those with nonsuicidal self-poisoning who would have otherwise fallen

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OUGRIN ET AL. American Psychiatric Association. (2010). DSM5: The future of psychiatric diagnosis. Retrieved August 12, 2010, from http://www.dsm5.org/ Pages/Default.aspx Boergers, J., Spirito, A., & Donaldson, D. (1998). Reasons for adolescent suicide attempts: Associations with psychological functioning. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 1287 1293. doi:10.1097/00004583-199812000-00012 Brausch, A. M., & Gutierrez, P. M. (2010). Differences in non-suicidal self-injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39, 233242. doi:10.1007/s10964-009-9482-0 Brent, D., Emslie, G., Clarke, G., Wagner, K. D., Asarnow, J. R., Keller, M., . . . Zelazny, J. (2008). Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRIresistant depression: The TORDIA randomized controlled trial. JAMA: The Journal of the American Medical Association, 299, 901913. doi: 10.1001/jama.299.8.901 Brent, D. A., Greenhill, L. L., Compton, S., Emslie, G., Wells, K., Walkup, J. T., . . . Turner, J. B. (2009). The Treatment of Adolescent Suicide Attempters Study (TASA): Predictors of suicidal events in an open treatment trial. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 987996. doi:10.1097/CHI.0b013e3181b5dbe4 Carter, G., Reith, D. M., Whyte, I. M., & McPherson, M. (2005). Repeated self-poisoning: Increasing severity of self-harm as a predictor of subsequent suicide. British Journal of Psychiatry, 186, 253257. doi:10.1192/ bjp.186.3.253 Chanen, A. M., Jackson, H. J., McCutcheon, L. K., Jovev, M., Dudgeon, P., Yuen, H. P., . . . McGorry, P. D. (2008). Early intervention for adolescents with borderline personality disorder using cognitive analytic therapy: Randomised controlled trial. The British Journal of Psychiatry, 193, 477 484. doi:10.1192/bjp.bp.107.048934 Claes, L., Muehlenkamp, J., Vandereycken, W., Hamelinck, L., Martens, H., & Claes, S. (2010). Comparison of non-suicidal self-injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit. Personality and Individual Differences, 48, 83 87. doi:10.1016/ j.paid.2009.09.001 Cotgrove, A. J., Zirinsky, L., Black, D., & Weston, D. (1995). Secondary prevention of attempted suicide in adolescence. Journal of Adolescence, 18, 569 577. doi:10.1006/jado.1995.1039 Csorba, J., Dinya, E., Plener, P., Nagy, E., & Pa li, E. (2009). Clinical diagnoses, characteristics of risk behaviour, differences between suicidal and non-suicidal subgroups of Hungarian adolescent outpatients practising self-injury. European Child & Adolescent Psychiatry, 18, 309 320. doi:10.1007/s00787-008-0733-5 De Leo, D., & Heller, T. S. (2004). Who are the kids who self-harm? An Australian self-report school survey. Medical Journal of Australia, 181, 140 144. Dougherty, D. M., Mathias, C. W., Marsh-Richard, D. M., Prevette, K. N., Dawes, M. A., Hatzis, E. S., . . . Nouvion, S. O. (2009). Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide. Psychiatry Research, 169, 2227. doi: 10.1016/j.psychres.2008.06.011 Elashoff, J. D. (2000). nQuery Advisor Version 4.0 users guide. Los Angeles, CA: Statistical Solutions. Evans, E., Hawton, K., Rodham, K., & Deeks, J. (2005). The prevalence of suicidal phenomena in adolescents: A systematic review of populationbased studies. Suicide and Life-Threatening Behavior, 35, 239 250. doi:10.1521/suli.2005.35.3.239 Favazza, A. R., & Conterio, K. (1989). Female habitual self-mutilators. Acta Psychiatrica Scandinavica, 79, 283289. doi:10.1111/j.16000447.1989.tb10259.x Goodman, R. (2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 13371345. doi:10.1097/00004583200111000-00015

through the dichotomized classification of nonsuicidal self-injury versus suicide attempts.

Limitations
We did not investigate other important differences that may exist between the adolescents with suicidal and nonsuicidal selfharm. In particular, we did not investigate possible differences in hopelessness, impulsiveness, disordered eating, problem-solving skills, and parental support, all of which have been shown to be potentially different between the two groups (Boergers, Spirito, & Donaldson, 1998; Grholg et al., 2000; Hargus, Hawton, & Rodham, 2009) and also potentially important for treatment choices. Hopelessness is especially important, as it appears to predict future suicide in those with self-harm, yet the reports from previous studies have not been consistent in establishing the differences between the two subgroups (Brausch & Gutierrez, 2010; Muehlenkamp & Gutierrez, 2007). In addition, our sample size was small, potentially contributing to a low power to detect differences between the two groups. We did not use a semistructured diagnostic schedule to establish the diagnosis, and this may have contributed to the underestimation of the prevalence of clinical diagnoses in this sample. However computerized prompting integrated with the electronic patients record system contributed to the standardization of the diagnoses. Although it is an important limitation of the study, using clinical diagnosis has the benefit of generalizing to clinicians routine practice. We considered adolescents with clear suicidal intent and those with unclear intent to belong to one group as opposed to combining the latter with the adolescents having clear nonsuicidal intent. This division is clearly arbitrary; however, we reasoned that the young people with mixed or unclear intent should probably be treated as suicidal in clinical practice. Suicidality rating was done by two independent raters. Neither was blind to the study hypotheses; however, the description of the index episode of self-harm was anonymized and the raters had no access to any other information about the adolescents at the time of the rating. Finally, as mentioned above, the short follow-up period may have prevented the discovery of further differences in treatment response between the two groups.

Clinical Implications
Adolescents with nonsuicidal and suicidal self-harm differ on several important clinical and sociodemographic characteristics and may respond to treatment differently. TA may be especially important in the nonsuicidal group. The nonsuicidal self-injury group seems to be similar to a broadly defined nonsuicidal selfharm group, which includes both nonsuicidal self-poisoning and nonsuicidal self-injury. Clinicians should consider suicidal intent carefully during their initial assessment.

References
American Academy of Child & Adolescent Psychology. (2001). Summary of the practice parameters for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 495 499. doi:10.1097/ 00004583-200104000-00024

ADOLESCENTS WITH SUICIDAL AND NONSUICIDAL SELF-HARM Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary data on the Deliberate Self-Harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23, 253263. doi:10.1023/A:1012779403943 Grholg, B., Ekeberg, O., & Haldorsen, T. (2000). Adolescents hospitalised with deliberate self-harm: The significance of an intention to die. European Child & Adolescent Psychiatry, 9, 244 254. doi:10.1007/ s007870070027 Guertin, T., Lloyd-Richardson, E., Spirito, A., Donaldson, D., & Boergers, J. (2001). Self-mutilative behavior in adolescents who attempt suicide by overdose. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 10621069. doi:10.1097/00004583-200109000-00015 Hargus, E., Hawton, K., & Rodham, K. (2009). Distinguishing between subgroups of adolescents who self-harm. Suicide and Life-Threatening Behavior, 39, 518 537. doi:10.1521/suli.2009.39.5.518 Harrington, R., Kerfoot, M., Dyer, E., McNiven, F., Gill, J., Harrington, V., . . . Byford, S. (1998). Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 512 518. Hawton, K., Hall, S., Simkin, S., Bale, L., Bond, A., Codd, S., & Stewart, A. (2003). Deliberate self-harm in adolescents: A study of characteristics and trends in Oxford, 1990 2000. Journal of Child Psychology and Psychiatry, 44, 11911198. doi:10.1111/1469-7610.00200 Hawton, K., & Harriss, L. (2007). Deliberate self-harm in young people: Characteristics and subsequent mortality in a 20-year cohort of patients presenting to hospital. Journal of Clinical Psychiatry, 68, 1574 1583. doi:10.4088/JCP.v68n1017 Hawton, K., & Harriss, L. (2008). Deliberate self-harm by under-15-yearolds: Characteristics, trends and outcome. Journal of Child Psychology and Psychiatry, 49, 441 448. doi:10.1111/j.1469-7610.2007.01852.x Hazell, P. L., Martin, G., McGill, K., Kay, T., Wood, A., Trainor, G., & Harrington, R. (2009). Group therapy for repeated deliberate self-harm in adolescents: Failure of replication of a randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 662 670. Jacobs, D. G. (Ed.). (1999). The Harvard Medical School guide to suicide assessment and intervention. San Francisco, CA: Jossey-Bass. Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, J. B. (2008). Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. Journal of Clinical Child and Adolescent Psychology, 37, 363375. doi:10.1080/15374410801955771 Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press. Madge, N., Hewitt, A., Hawton, K., de Wilde, E. J., Corcoran, P., Fekete, S., . . . Ystgaard, M. (2008). Deliberate self-harm within an international community sample of young people: Comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. Journal of Child Psychology and Psychiatry, 49, 667 677. doi:10.1111/j.14697610.2008.01879.x Muehlenkamp, J. J. (2005). Self-injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 324 333. doi: 10.1037/0002-9432.75.2.324 Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-Threatening Behavior, 34, 12 23. doi:10.1521/suli.34.1.12.27769 Muehlenkamp, J. J., & Gutierrez, P. M. (2007). Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Archives of Suicide Research, 11, 69 82. doi:10.1080/13811110600992902 National Institute for Health and Clinical Excellence. (2004). Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (Clinical Guideline 16). London, England: Author. Retrieved from http://www.nice. org.uk/nicemedia/pdf/CG016NICEguideline.pdf Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee,

19

S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133154. doi:10.1093/epirev/mxn002 Nock, M. K., Joiner, T. E., Jr., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144, 6572. doi:10.1016/j.psychres.2006.05.010 Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616 623. doi:10.1037/0021-843X.115.3.616 Office of Population Censuses and Surveys. (1991). Census user guide: 44. Social class based on occupation: Definitions in terms of standard occupational classification (SOC) unit groups and employment status. London, England: Author. Ougrin, D., Banarsee, R., Dunn-Toroosian, V., & Majeed, A. (2010). Suicide survey in a London borough: Primary care and public health perspectives. Journal of Public Health. Advance online publication. doi:10.1093/pubmed/fdq094 Ougrin, D., & Latif, S. (2011). Engagement with specific psychological treatment versus treatment as usual in adolescents with self-harm: Systematic review and meta-analysis. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 32, 74 80. doi:10.1027/0227-5910/ a000060 Ougrin, D., Ng, A. V., & Low, J. (2008). Therapeutic assessment based on cognitive-analytic therapy for young people presenting with self-harm: Pilot study. Psychiatric Bulletin, 32, 423 426. doi:10.1192/ pb.bp.107.018473 Ougrin, D., Zundel, T., Ng, A., Banarsee, R., Bottle, A., & Taylor, E. (2011). Trial of therapeutic assessment in London: Randomised controlled trial of therapeutic assessment versus standard psychosocial assessment in adolescents presenting with self-harm. Archives of Disease in Childhood, 96, 148 153. doi:10.1136/adc.2010.188755 Pattison, E. M., & Kahan, J. (1983). The deliberate self-harm syndrome. The American Journal of Psychiatry, 140, 867 872. Posner, K., Oquendo, M. A., Gould, M., Stanley, B., & Davies, M. (2007). Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDAs pediatric suicidal risk analysis of antidepressants. The American Journal of Psychiatry, 164, 10351043. doi:10.1176/appi.ajp.164.7.1035 Poston, J. M., & Hanson, W. E. (2010). Meta-analysis of psychological assessment as a therapeutic intervention. Psychological Assessment, 22, 203212. doi:10.1037/a0018679 Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31, 6777. doi:10.1023/A:1014089117419 Ryle, A. (2010). Cognitive analytic therapy. In N. Kazantzis, M. A. Reinecke, & A. Freeman (Eds.), Cognitive and behavioral theories in clinical practice (pp. 244 277). New York, NY: Guilford Press. Sarkar, P., Sattar, F. A., Gode, N., & Basannar, D. R. (2006). Failed suicide and deliberate self-harm: A need for specific nomenclature. Indian Journal of Psychiatry, 48, 78 83. doi:10.4103/0019-5545.31594 Schmidtke, A., Bille-Brahe, U., Deleo, D., Kerkhof, A., Bjerke, T., Crepet, P., . . . Sampaio-Faria, J. G. (1996). Attempted suicide in Europe: Rates, trends and sociodemographic characteristics of suicide attempters during the period 1989 1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 93, 327338. doi: 10.1111/j.1600-0447.1996.tb10656.x Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., & Aluwahlia, S. (1983). A childrens global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228 1231. Silverman, M. M., Berman, A. L., Sanddal, N. D., OCarroll, P. W., & Joiner, T. E. (2007). Rebuilding the tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 1: Back-

20

OUGRIN ET AL. Wong, P. S. J. (2007). Self-injurious behaviors in Hong Kong adolescents: Cross sectional and prospective studies. Hong Kong, Peoples Republic of China: University of Hong Kong. Wood, A., Trainor, G., Rothwell, J., Moore, A., & Harrington, R. (2001). Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1246 1253. doi:10.1097/00004583-200111000-00003 World Health Organization. (1992). The ICD10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines . Retrieved from http://www.who.int/classifications/icd/en/ bluebook.pdf

ground, rationale, and methodology. Suicide and Life-Threatening Behavior, 37, 248 263. doi:10.1521/suli.2007.37.3.248 Stanley, B., Winchel, R., Molcho, A., & Simeon, D. (1992). Suicide and the self-harm continuum: Phenomenological and biochemical evidence. International Review of Psychiatry, 4, 149 155. doi:10.3109/ 09540269209066312 TADS Team. (2007). The Treatment for Adolescents With Depression Study (TADS): Long-term effectiveness and safety outcomes. Archives of General Psychiatry, 64, 11321143. doi:10.1001/archpsyc.64.10.1132 Walsh, B. W. (2006). Treating self-injury: A practical guide. New York, NY: Guilford Press. Walsh, B. W., & Rosen, P. M. (1988). Self-mutilation: Theory, research, and treatment. New York, NY: Guilford Press. Wichstrm, L. (2009). Predictors of non-suicidal self-injury versus attempted suicide: Similar or different? Archives of Suicide Research, 13, 105122. doi:10.1080/13811110902834992

Received August 14, 2010 Revision received May 13, 2011 Accepted June 1, 2011