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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 24-31

Self-injury behavior: manifestations and risk factors in school-aged children in Assuit Governorate


Department of Pediatrics, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission03-Sep-2019
Date of Decision12-Dec-2019
Date of Acceptance09-Dec-2019
Date of Web Publication26-Mar-2020

Correspondence Address:
Nashwa H Hassan
Department of Pediatrics, Faculty of Medicine, Al-Azhar University, Assiut, Sohag, 25825
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_117_19

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  Abstract 


Background Nonsuicidal self-injury is any self-directed behavior that causes immediate destruction of body tissues. This behavior is manifested in a variety of forms, such as cutting, skin carving, burning, severe abrading, scratching and punching, hitting of head or any part of the body, pica, vomits, hair pulling, inserting objects in orifices, pulling fingers or toes or nails, inserting fingers in orifices, extreme eating or drinking, and grinding. The aim of this study was to detect self-injury and risk factors that lead to this behavior among children from 5 to 16 years in the Al-Azhar University Hospital Clinic.
Patients and methods This study included 50 cases aged 5–16 years. Another 50 of the matched children regarding age (5–16 years) and sex were included in the study as a control group.
Results The most common forms of self-injury in our study were pica (40%), vomiting (12%), burning (4%), loud sounds and shouting (8%), nail eating (26%), head hitting and body hitting (20%), interfering with wound healing and playing with electricity (8%), and some of them had multiple forms of self-injury. Self-injury is related to family history (56%), common in low-educated parents, and fewer incidences of intellectual jobs among parents of the studied group.
Conclusion Self-injuries among the pediatric population are underestimated and should be focused especially among children with social, developmental, or intellectual problems. Self-injuries are common among children with attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, conduct disorders, and intellectual disabilities. Low social class and low education of parents are risk factors of self-injury and must be studied to decrease self-injury and suicide. Child abuse is one of the risk factors of self-injury, which should be limited.

Keywords: self-harm, self-injury, self-induced trauma (SIT)


How to cite this article:
Mohammed AM, Mohammed IS, Hassan NH. Self-injury behavior: manifestations and risk factors in school-aged children in Assuit Governorate. Al-Azhar Assiut Med J 2020;18:24-31

How to cite this URL:
Mohammed AM, Mohammed IS, Hassan NH. Self-injury behavior: manifestations and risk factors in school-aged children in Assuit Governorate. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Aug 4];18:24-31. Available from: http://www.azmj.eg.net/text.asp?2020/18/1/24/281345




  Introduction Top


Nonsuicidal self-injury is any self-directed behavior that causes immediate destruction of body tissues. This behavior is manifested in a variety of forms, such as cutting, skin carving, burning, severe abrading, scratching and punching, hitting of head or any part of the body, pica, vomits, hair pulling, inserting objects in orifices, pulling fingers or toes or nails, inserting fingers in the orifices, extreme eating or drinking, and grinding [1].

Self-harm is an intentional act of self-poisoning or self-injury irrespective of the type of motivation or degree of suicidal intent [2].

Risk factors associated with adolescent self-harm were hyperkinetic disorder, conduct disorder, tic disorder, depressive disorder, anxiety disorders, eating disorders, developmental disorder, schizophrenia/schizoaffective disorder, attention-deficit hyperactivity disorder, obsessive-compulsive disorder, autistic disorder, conversion disorder, adjustment disorder, intellectual disability, drug-related disorder, and others [3].

The most common diagnosed ailment with self-harm was depression, followed by adjustment disorder and post-traumatic stress disorder and child abuse. In the group without self-harm, psychosis was the most common diagnosis, followed by attention-deficit hyperactivity disorder or anxiety disorder [4].

The occurrence of adolescent self-harm was closely related to their mental health status and stressful life events [5].

Episodes of self-injury or mutilation are often followed by feelings of disappointment or abandonment [5].


  Aim Top


The aim of this study was detecting self-injury and risk factors of self-injury among children from 5 to 16 years in the Al-Azhar University Hospital Clinic. The study was approved by Al-Azhar-Assiut Faculty of Medicine ethical committee.


  Patients and methods Top


Patients

A total of 50 cases aged 5–16 years were included in the study. Another 50 normal children matched regarding age (5–16 years) and sex were included in the study as a control group. The study was approved by Al-Azhar-Assiut Faculty of Medicine ethical committee.

Inclusion criteria

The following were the inclusion criteria:
  1. Children with self-injury in the first visit to the clinic.
  2. Any child with a history of self-injury.
  3. Children with self-injury from 5 to 16 years old.
  4. Any history of self-induced trauma and previous mental health care.


Exclusion criteria

  1. Children below 5 years old and above 16 years old.
  2. Children with chronic diseases, for example, liver disease.
  3. Patient with insufficient data.
  4. A child who refuses or caregiver refuses to participate in this research.



  Results Top


This cross-sectional study included 50 children (28 males and 22 females), with a mean of age of 9.19±3.33 years, attending Pediatric Psychiatry Clinic, Al-Azhar University Hospital, from October 2017 to March 2018. Fifty normal children matched regarding age and sex were included as a control group.

[Table 1] shows the descriptive data of the study group, and their age ranged between 5 and 16 years, with a mean of 9.19±3.33 years. Age of control group ranged between 5 and 16 years, with a mean of 8.90±2.98 years.
Table 1 Descriptive data of the study groups

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There was a nonstatistically significant difference between study and control groups regarding age and sex.

Twenty-five (50%) patients and seven (14%) controls had positive consanguinity lineage, and this was a statistically significant difference (P=0.0002) ([Figure 1]).
Figure 1 Consanguinity of parent distribution in the study group.

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As seen in [Table 2], regarding family history, 28 (56%) patients had a positive family history and 15 (30%) controls had positive FH, and this difference was statistically significant (P=0.008) ([Figure 2]).
Table 2 Family history of a similar condition of self-injury in the studied group

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Figure 2 Family history of similar condition in the studied group.

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As seen in [Table 3], regarding mother education, there was a statistically significant lower education level in the case group compared with the control group (P=0.004).
Table 3 Parental education in the studied group

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Regarding father education, there was a statistically significant lower education level in the case group compared with the control group (P=0.006) ([Figure 3] and [Figure 4]).
Figure 3 Mother education in the studied group.

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Figure 4 Father education in the studied group.

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[Table 4] shows that maternal and paternal work was significantly associated with self-injury, with fewer incidences of parents who had intellectual jobs compared with controls ([Figure 5] and [Figure 6]).
Table 4 Parental job in the studied group

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Figure 5 Maternal job in the studied group.

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Figure 6 Paternal job in the studied group.

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As seen in [Table 5], regarding disease characteristics, only two (4%) of patients experienced pain. Four (8%) patients enacted the behavior alone, 44 (88%) enacted the behavior in front of others, and two (4%) enacted it both alone and in front of others.
Table 5 Disease characteristics in the study group

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[Table 6] shows a statistically significantly lower number of self-injury/month in mothers working in intellectual jobs compared with housewives ([Figure 7]).
Table 6 Relation between mother job and number of self-injury per month

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Figure 7 Relation between mother job and numbers of self-injury.

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[Table 7] shows there is a statistically significant higher verbal abuse in the study group compared with the control group (P=0.001).
Table 7 Verbal abuse between the two groups

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[Table 8] and [Table 9] show the commonest forms of self-injury according to our study and manifestations.
Table 8 The commonest forms of self-injury according to our study

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Table 9 Risk factors of self −injury behavior according to our study

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  Discussion Top


There was a nonstatistically significant difference between the case and control groups regarding age and sex.

On the contrary, another study disagrees with our study [6], which reported that among vocational school students, 25.64% of boys and 35.41% of girls reported a lifetime history of some forms of direct self-injury. Another study found that females reported higher prevalence rates than their male counterparts [7].

The difference in prevalence between boys and girls was not significant in another study which found associations with suicidality and direct self-injurious behavior among high-risk youth [8], as well as results on possible functions (e.g. emotion-regulation, self-punishment, and antisuicidal functions of direct self-injurious behavior) [9].

The most common forms of self-injury in our study were pica (40%), vomiting (12%), burning (4%), loud sounds and shouting (8%), nail eating (26%), head hitting and body hitting (20%), interfering with wound healing and playing with electricity (8%), and some of them had multiple forms of self-injury. Another study stated that common forms of NSSI include cutting, skin carving, biting, scratching, hitting, head banging, and interfering with wound healing [10].

In this study, 25 (50%) patients and seven (14%) controls have positive consanguinity, and this was a statistically significant difference (P=0.0002). Regarding family history, 28 (56%) patients had positive family history and 15 (30%) controls had positive FH, and this difference was statistically significant (P=0.008). Other studies stated that genetic risk factors and early stressors increase the likelihood of vulnerability factors (e.g. high emotion reactivity and poor social skills), which in turn increase the odds of mental disorders and maladaptive coping skills including self-injury [11]. Families of self-injurers show higher levels of hostility and criticism than those of matched controls [12].

Regarding mother education, there was a statistically significant lower education level in the studied group compared with the control group (P=0.004), as a less educated mother is not aware of what is wrong with her child and how to deal with it.

Regarding father education, there was a statistically significant lower education level in the studied group compared with the control group (P=0.006). Illiteracy makes this family not able to deal with and understand their problems and exact cause.

Maternal and paternal work was significantly associated with self-injury, with fewer incidences of intellectual jobs among cases compared with controls, and also work based on education was statistically significantly related, as there was a lower number of self-injury among children with mothers working in intellectual jobs compared with housewives. There is a statistically significant higher age in patients with many times of self-injury per month of occurrence (P=0.001).

Only two (4%) of patients experienced pain. However, this decreased pain sensitivity has been confirmed in multiple behavioral studies, in which relative to nonjuring controls, those with a history of self-injury showed less pain sensitivity and higher thresholds to various types of pain (e.g. pressure and thermal) [13],[14],[15].

Potential explanations for this decreased pain sensitivity are that it results from habituation to physical pain, the release of endorphins during self-injury, or the belief that one deserves to be injured [16],[17],[18]; however, the actual mechanism is not known. Regardless of why it occurs, the absence of painful consequences for engaging in self-injury makes treating this behavior even more difficult.Four (8%) patients enacted the behavior alone, 44 (88%) enacted the behavior in front of others, and two (4%) enacted it both alone and in front of others. Another study stated that thoughts of engaging in self-injury typically occur when the person is alone and experiencing negative thoughts or feelings (e.g. having a bad memory, feeling anger, self-hatred, and numbness) in response to a stressful event [19].

There is a statistically significant higher verbal abuse in the case group compared with the control group (P=0.001); as child abuse is one of the risk factors, another study stated child abuse in 26% [4].


  Conclusion Top


Self-injuries among the pediatric population are underestimated and should be focused especially among children with social, developmental, or intellectual problems. Self-injuries are common among children with attention-deficit/hyperactivity disorder (ADHD), depression, anxiety, conduct disorders, and intellectual disabilities. Low social class and low education of parents are risk factors of self-injury and must be studied to decrease self-injury and suicide. Child abuse is one of the risk factors of self-injury that should be limited.

Recommendation

From the results of this study, we can recommend the following:
  1. Give more care for children who had a family history of self-injury or suicide.
  2. Improve education and social level of society to decrease the incidence of self-injuries.
  3. Advice parents to take care of their children and prevent child abuse.
  4. Assessment of self-injurious thoughts and behaviors should be done followed by the assessment of less sensitive constructs such as the presence of depressive and anxious symptoms to gradually work up to prevent and decrease self-injury.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Matsumoto T. Understanding and treating self-injury. Seishin Shinkeigaku Zasshi 2012; 114:983–989.  Back to cited text no. 1
    
2.
Kerr PL, Muehlenkamp JJ, Turner JM. Nonsuicidal self-injury: a review of current research for family medicine and primary care physicians. J Am Board Fam M 2010; 23:240–259.  Back to cited text no. 2
    
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Peterson C, Xu L, Leemis RW, Stone DM, Ballesteros MF. Non-fatal self-inflicted versus undetermined intent injuries: patient characteristics and incidence of subsequent self-inflicted injuries. Injury Prev 2018; 25:521–528.  Back to cited text no. 3
    
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Patel B, AM C, RM C. Intentional self-inflicted and peer-inflicted aerosol skin injuries called ‘frosties’: cohort series and systematic literature review. Aust J Gen Pract 2018; 47:477–482.  Back to cited text no. 5
    
6.
Horváth LO, Balint M, Ferenczi-Dallos G, Farkas L, Gadoros J, Gyori D et al. Direct self-injurious behavior (D-SIB) and life events among vocational school and high school students. Int J Environ Res Public Health 2018; 15:1068.  Back to cited text no. 6
    
7.
Nixon MK, Cloutier P, Jansson SM. Nonsuicidal self-harm in youth: a population-based survey. Canadian Med Assoc J 2008; 178:306–312.  Back to cited text no. 7
    
8.
Swahn MH, Ali B, Bossarte RM, van Dulmen M, Crosby A, Jones AC et al. Self-harm and suicide attempts among high-risk, urban youth in the US: shared and unique risk and protective factors. Int J Environ Res Public Health 2012; 9:178–191  Back to cited text no. 8
    
9.
Klonsky ED, Muehlenkamp JJ. Self-injury: a research review for the practitioner. J Clin Psychol 2007; 63:1045–1056.  Back to cited text no. 9
    
10.
Rodav O, Levy S, Hamdan S. Clinical characteristics and functions of non-suicide self-injury in youth. Eur Psychiatr 2014; 29:503–508.  Back to cited text no. 10
    
11.
Nock MK. Actions speak louder than words: an elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Appl Prev Psychol 2008; 12:159–168.  Back to cited text no. 11
    
12.
Wedig MM, Nock MK. Parental expressed emotion and adolescent self-injury. J Am Acad Child Adolesc Psychiatry 2007; 46:1171–1178.  Back to cited text no. 12
    
13.
Bohus M, Limberger M, Ebner U, Glocker FX, Schwarz B et al. Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior. Psychiatr Res 2000; 95:251–260.  Back to cited text no. 13
    
14.
Kemperman I, Russ MJ, Clark WC, Kakuma T, Zanine E, Harrison K. Pain assessment in self-injurious patients with borderline personality disorder using signal detection theory. Psychiatr Res 1997; 70:175–183.  Back to cited text no. 14
    
15.
Russ MJ, Campbell SS, Kakuma T, Harrison K, Zanine E. EEG theta activity and pain insensitivity in self-injurious borderline patients. Psychiatr Res 1999; 89:201–214.  Back to cited text no. 15
    
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Comer R, Laird JD. Choosing to suffer as a consequence of expecting to suffer: Why do people do it?. J Personal Soc Psychol 1975; 32:92–101.  Back to cited text no. 16
    
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Goldberg J, Sakinofsky I. Intropunitiveness and parasuicide: prediction of interview response. Br J Psychiatr 1988; 153:801–804.  Back to cited text no. 17
    
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Nock MK, Kessler RC. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J Abnorm Psychol 2006; 115:616–623.  Back to cited text no. 18
    
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Nock MK, Favazza A. Non-suicidal self-injury: definition and classification. In: Nock MK, editor. Understanding nonsuicidal self-injury: Origins, assessment, and treatment. American Psychological Association; 2009. 9–18.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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