key: cord-0870224-7rwqd3i6
authors: Burton, E Thomaseo
title: Equitable assessment and treatment of self-harm
date: 2021-09-21
journal: Lancet Child Adolesc Health
DOI: 10.1016/s2352-4642(21)00303-5
sha: 4848e154efacf64bd9e5fa6cecd82992231e462b
doc_id: 870224
cord_uid: 7rwqd3i6

nan

The past 18 months have taxed the coping reserves of children and adolescents worldwide. The COVID-19 pandemic has disrupted even the most basic routines, and it is not clear when or if things will return to how they once were. Very early in the pandemic, it became clear that minoritised ethnic communities would be disproportionately affected. 1 In efforts to limit transmission of SARS-CoV-2, schools around the world shut down and students sheltered in place at home. Although home is often considered to be a safe space, the pandemic highlighted the vastly disparate home environments in which children and adolescents live. In the USA, the effects of racism and racial discrimination on the mental health of Black and Latinx youth were evident long before the pandemic, but in the absence of the support and structure offered by the school environment, mental health challenges have become even more apparent.

The imbalance of power and privilege among and between ethnic groups contributes to differences in access to resources and opportunities, 2 and pandemicrelated school closures disproportionately limited access to resources for Black and Latinx children and adolescents in the USA. The academic deficits will most likely plague a generation, and school closures have engendered social isolation, food insecurity, and increased susceptibility to neglect and abuse, with no clear outlet for reporting. 3 Moreover, young people whose mental health needs were addressed through school-based resources did not have access to these services. Taken together in a context of increased stress due to economic hardship, fear of contracting or spreading a deadly virus, and threats of racially motivated violence, increased rates and intensity of mental health presentations are to be expected. 4 Self-harm, more formally termed non-suicidal self-injury, is fairly common among children and adolescents, with lifetime prevalence rates ranging from 17% to 60%. 5 Self-harm is a concerning psychiatric phenomenon both as a predictor of increased suicide risk and in its own right. Evidence suggests that the main function of self-harm behaviour is to regulate intense negative emotions, heightened stress, and feelings of numbness or emptiness; 6 all of which are events a child or adolescent may experience and attribute to the COVID-19 pandemic. 7 In The Lancet Child and Adolescent Health, Bushra Farooq and colleagues 8 of 10 211 White children and adolescents; p<0·0001). Despite these seemingly discriminatory assessment practices, the model suggested an annual increase of 2% in the rates of self-harm in White groups, 7% in Black groups, 5% in South Asian groups, and 11% in other non-White groups. This increase might be attributable to more accurate reporting in recent years, but another plausible explanation is that rates of self-harm among these ethnic groups are increasing.

Other studies 9 have also shown that lower rates of formally diagnosed mental health concerns can misrepresent actual mental health burden among minoritised ethnic groups. The danger is that undiagnosed mental health conditions go untreated, and untreated conditions could become more intractable over time. Moreover, young people who do not feel safe or heard by providers are not likely to seek mental health services; youth from minoritised ethnic backgrounds, in particular, are less likely to feel safe or heard by their care providers. 2 Considering what we know about risk factors for selfharm behaviours among young people in minoritised ethnic groups, it is crucial that we act. A key first step suggested by Farooq and colleagues 8 is to identify and address conscious and unconscious bias among staff who will encounter these children and adolescents. Training in diversity, cultural humility, and anti-racism often aid in the introspection needed to identify such bias in oneself. Next is development, implementation, and evaluation of culturally appropriate methods of prevention, assessment, and treatment. For example, the authors 8 identified difficult family dynamics as a precipitant for self-harm among Black and South Asian children and adolescents. Inquiring about and addressing familial issues might garner greater buyinto treatment from these young people. Equitable assessment and treatment also require a more nuanced examination of intersecting identities such as race, ethnicity, gender, social class, disability status, and religious beliefs. Understanding these aspects of identity can also aid in identifying protective factors.

It is very likely that children and adolescents in minoritised ethnic groups will continue to present with self-harm behaviours. As schools reopen, stressors will shift to reacclimatising to schedules and routines, social and academic pressures, and concerns about staying safe and healthy. Some relief might come from social reintegration and some semblance of normalcy. However, the COVID-19 pandemic is still very much active, and the long-term effects are yet unknown. We will be untangling the effects on child and adolescent mental health for years to come. I declare no competing interests. E Thomaseo Burton eburto10@uthsc.edu

Children's Foundation Research Institute, Le Bonheur Children's Hospital

Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities

The impact of racism on child and adolescent health

Mental health effects of school closures during COVID-19

Rapid systematic review: the impact of social isolation and loneliness on the mental health of children

Non-suicidal self-injury in adolescence

The functions of nonsuicidal self-injury: converging evidence for a two-factor structure

COVID-19 and nonsuicidal self-injury: the pandemic's influence on an adolescent epidemic

Self-harm in children and adolescents by ethnic group: an observational cohort study from the Multicentre Study of Self-Harm in England

Nonsuicidal self-injury among African American and Hispanic adolescents and young adults: a Systematic Review