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European Child & Adolescent Psychiatry

, Volume 28, Issue 10, pp 1281–1282 | Cite as

Differential pathways from childhood maltreatment to self-harm and suicidal ideation

  • Michael KaessEmail author
Editorial
  • 512 Downloads

Self-harm and suicidal behavior range among the most prominent public health concerns in children and adolescents. The term “self-harm” commonly includes both direct and indirect self-damage with and without suicidal intent; whereas, the term “self-injury” refers to direct self-damage only but again regardless of its intent. Self-harm has a mean prevalence of 18% worldwide [1], and a study investigating the life-time prevalence of self-injury among European adolescents found rates up to 39% [2]. Suicidal ideation and suicide attempts have been reported in about 12% and 4% of adolescents, respectively [3]. The particular importance of adolescent self-harm is underlined by the fact that it is often associated with suicidal ideation and behavior, and that it is one of the strongest risk factors predicting suicidal behavior [4] and death by suicide later in life [5].

Research trying to better understand the developmental pathways into self-harm and suicidal behavior is highly warranted. One of the risk factors that has often been reported for adolescent self-harm and suicidal behavior is childhood maltreatment [6, 7]. However, the evidence of the overall strong association between childhood adversity and these outcomes is limited by the following factors:
  1. 1.

    Very few prospective studies have been conducted and most data are derived from retrospective assessment of childhood maltreatment, which may be prone to substantial recall bias, particularly since individuals engaging in self-harm and suicidal behavior commonly suffer from mental health problems that may have an impact on their current perception of childhood experiences.

     
  2. 2.

    Most data are derived from adult samples and to a substantially lesser extent from adolescent samples with a mean age commonly > 14 years. However, given that self-harm (and also suicidal ideation and behavior) often occurs in early adolescence [8], the period of mid-to-late childhood and early adolescence is certainly understudied.

     
  3. 3.

    The pathways from early adversity to self-harm and suicidal behavior are relatively unclear, and directionality or even causality has yet to be established unequivocally.

     

The original article of Paul and Ortin (2019) in this issue has overcome some of the serious limitations. The authors investigated self-harm behavior and suicidal ideation in children at the age of 9 years; childhood abuse and neglect had already been investigated at the children’s age of 3 years within this longitudinal cohort, which adhered to a strictly prospective design. Most interestingly, they investigated potential pathways from early maltreatment to self-harm via different types of psychopathology. While neglect predicted both suicidal ideation and self-harm via internalizing psychopathology, physical and psychological abuse only predicted self-harm via more externalizing mental health problems [9]. Thus, the authors found evidence for specific pathways linking particular types of maltreatment with self-harm and suicidal ideation later in childhood.

The respective results may not only be relevant for the development of particular internalizing versus externalizing disorders, but they also fit those subjects commonly suffering from complex childhood adversity including various types of maltreatment. These individuals, who we often see as subjects suffering from borderline personality disorder [10] or complex posttraumatic stress disorder [11], usually show a characteristic combination of both internalizing and externalizing psychopathology.

There are also some limitations to the study of Paul and Ortin (2019), e.g., the assessment of self-harm, which was not divided into non-suicidal self-injury and suicidal behavior (as nowadays suggested within the DSM-5), was limited; in addition, all assessments were based on self-report only. However, the CBCL has recently been shown to have good validity in the assessment of self-harm and suicidal behavior [12]. Overall, this study represents an important step in the right direction.

The results of the article add to the ongoing discussion of different types and differential effects of childhood maltreatment. Negative childhood experiences can be quite heterogeneous; thus, it is quite plausible that the short- and long-lasting effects may differ substantially. There is some evidence that this is true for both biological and psychopathological consequences [13]. However, research on the differential effects of different types of childhood adversity has also been limited due to the substantial overlap of these different types. This overlap may require larger samples to finally disentangle particular subgroups of maltreatment, e.g., those with pure neglect and those with abuse only. Of course, future research will also need to address the role of genes and of parents’ personality or psychopathology in large-scale and longitudinal studies. One might argue that different parents might be prone to different types of maltreatment based on their genetic predisposition, their upbringing, and/or their own personality and psychopathological profiles. For example, depressed parents may rather neglect than abuse their offspring. It seems plausible that we see more internalizing symptoms among their children, but is this caused by the type of maltreatment or rather by the shared genetic risk or the parental psychopathology itself? In turn, parents with externalizing psychopathology may tend to abuse rather than neglect their children; but again, having children with externalizing psychopathology might not only be a consequence of the type of maltreatment. There are still more questions than answers on this topic, but this is certainly a very important and interesting area of research for the future.

Overall, the article from Paul and Ortin in this issue suggests that childhood maltreatment is an important risk factor for self-harm and suicidal behavior in later life, and that different psychopathological pathways may mediate this association depending on the type of maltreatment experienced. More research on such differential pathways may facilitate a more tailored prevention and early intervention for children and adolescents who are at-risk of self-harm and suicidal behavior in the future.

References

  1. 1.
    Muehlenkamp JJ, Claes L, Havertape L, Plener PL (2012) International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child Adolesc Psychiatry Ment Health 6:10CrossRefGoogle Scholar
  2. 2.
    Brunner R, Kaess M, Parzer P, Fischer G, Carli V, Hoven CW, Wasserman C, Sarchiapone M, Resch F, Apter A, Balazs J, Barzilay S, Bobes J, Corcoran P, Cosmanm D, Haring C, Iosuec M, Kahn JP, Keeley H, Meszaros G, Nemes B, Podlogar T, Postuvan V, Saiz PA, Sisask M, Tubiana A, Varnik A, Wasserman D (2014) Life-time prevalence and psychosocial correlates of adolescent direct self-injurious behavior: a comparative study of findings in 11 European countries. J Child Psychol Psychiatry 55:337–348CrossRefGoogle Scholar
  3. 3.
    Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, Kessler RC (2013) Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the national comorbidity survey replication adolescent supplement. JAMA Psychiatry 70(3):300–310CrossRefGoogle Scholar
  4. 4.
    Koenig J, Brunner R, Fischer-Waldschmidt G, Parzer P, Plener PL, Park J, Wasserman C, Carli V, Hoven CW, Sarchiapone M, Wasserman D, Resch F, Kaess M (2017) Prospective risk for suicidal thoughts and behaviour in adolescents with onset, maintenance or cessation of direct self-injurious behaviour. Eur Child Adolesc Psychiatry 26(3):345–354CrossRefGoogle Scholar
  5. 5.
    Hawton K, Bergen H, Cooper J, Turnbull P, Waters K, Ness J, Kapur N (2015) Suicide following self-harm: findings from the multicentre study of self-harm in England, 2000–2012. J Affect Disord 175:147–151CrossRefGoogle Scholar
  6. 6.
    Liu RT, Scopelliti KM, Pittman SK, Zamora AS (2018) Childhood maltreatment and non-suicidal self-injury: a systematic review and meta-analysis. Lancet Psychiatry 5(1):51–64CrossRefGoogle Scholar
  7. 7.
    Liu J, Fang Y, Gong J, Cui X, Meng T, Xiao B, He Y, Shen Y, Luo X (2017) Associations between suicidal behavior and childhood abuse and neglect: a meta-analysis. J Affect Disord 220:147–155CrossRefGoogle Scholar
  8. 8.
    Jacobson CM, Gould M (2017) The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res 11:129–147CrossRefGoogle Scholar
  9. 9.
    Paul E, Ortin A (2019) Psychopathological mechanisms of early neglect and abuse on suicidal ideation and self-harm in middle childhood. Eur Child Adolesc Psychiatry.  https://doi.org/10.1007/s00787-019-01287-8 CrossRefPubMedGoogle Scholar
  10. 10.
    Fonagy P, Speranza M, Luyten P, Kaess M, Hessels C, Bohus M (2015) ESCAP expert article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice. Eur Child Adolesc Psychiatry 24(11):1307–1320CrossRefGoogle Scholar
  11. 11.
    Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, Humayun A, Jones LM, Kagee A, Rousseau C, Somasundaram D, Suzuki Y, Wessely S, van Ommeren M, Reed GM (2017) A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clin Psychol Rev 58:1–15CrossRefGoogle Scholar
  12. 12.
    Van Meter AR, Algorta GP, Youngstrom EA, Lechtman Y, Youngstrom JK, Feeny NC, Findling RL (2018) Assessing for suicidal behavior in youth using the achenbach system of empirically based assessment. Eur Child Adolesc Psychiatry 27(2):159–169CrossRefGoogle Scholar
  13. 13.
    Teicher MH, Samson JA (2018) Annual research review: enduring neurobiological effects of childhood abuse and neglect. J Child Psychol Psychiatry 57(3):241–266CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of BernBernSwitzerland
  2. 2.Section for Translational Psychobiology in Child and Adolescent Psychiatry, Department of Child and Adolescent Psychiatry, Center for Psychosocial MedicineUniversity Hospital HeidelbergHeidelbergGermany

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