Deliberate Self-harm In Adolescents Research Articles

Investigating the Effective Factors in the Formation of Deliberate Self-harm in Adolescence: Mental Health Professionals’ Viewpoints

Objective: This study aims to investigate the issues related to the formation and persistence of deliberate self-harm behavior in adolescents from Iranian mental health professionals’ viewpoints. Methods: The present qualitative study used semi-structured interviews to record the experiences of 9 mental health professionals with work experience in deliberate self-harm behavior in adolescence. The participants were selected via the purposive sampling method. The Sterling content analysis method was used to analyze the transcription of the interviews. Results: The semantic units of the interview were classified into 32 initial codes. The extracted sub-themes were as follows: A rejection of new identities, repression, the disintegration of social identity, materialism, economic poverty, unresolved parental conflicts, the lack of authority, the ambivalency between boundaries and freedom, shame, and guilt, blame, fear of harm, liberation, self-care, escape mechanism, and replacement, affect regulation, coping with self-disintegration and self-esteem, relationship conflicts with adults and peers, identity creation, identity disorder, boundless mental structure, lack of self-confidence, and distorted self-perception. The following four themes were categorized as subcategories of transformational injuries: Traumatic society, vulnerable family, interpersonal impact, and interpersonal effectiveness. Conclusion: Mental health specialists considered deliberate self-harm traumatic; however, they deem it for eliminating negative emotions and controlling the internal and external world of adolescents. Furthermore, they consider this behavior a reaction to cultural conflicts, cultural materialism, and the disintegration of identity and role during adolescence in families not being capable to facilitate low-risk transformation for adolescents because of economic and psychological factors.

Deliberate self-harm in adolescents: A review of literature.

Deliberate self-harm is a rising epidemic in the youth. This review examined the different self-harm behavior, approach to treatment, and the implication of such behaviors in the adolescent population in the academic literature. Using the PubMed database, we searched for specific terms related to different self-harm behaviors in Adolescents. The bibliography of the articles found relevant for the review was also screened. Each study's findings were taken with reference to our topic and findings were summarized. After reviewing the literature, we found that the prevalence of suicidal attempts was as high as 18% in the past year While the nonsuicidal attempts were as high as 31%. Risk factors associated with higher levels of suicide were bullying, loneliness and anxiety, tobacco and alcohol use, and weak family and social relationships. While the factors playing a protective role are being connected to school, having good social support, and attending school. There are very few studies focused on interventions related to suicide prevention in Adolescent and postvention programs. Out of the evidence available, the interventions are not focused on the target individuals and lack replicability. Self-harm is a major public health concern which needs to be understood holistically. The interventions aimed at preventing and managing self-harm behavior still need to be more targeted and precise. Other targets may include interventions suited to different phases of development, stopping the progression of the behavior to adulthood, including the varied population in such intervention, etc.

Adolescent Peer Victimization and Deliberate Self-Harm: A Three-Wave Moderated Mediation Model.

Background: Identifying deliberate self-harm (DSH) and peer victimization in adolescents is a public health issue. The present study evaluates a three-wave longitudinal model to examine the effect of peer victimization on DSH and the roles of internalizing problems (depression and anxiety) and perceived peer and teacher support climate in this relationship. Methods: The participants were 2381 adolescents (51.2% boys, Mage = 13.38, SD = .59) from Chinese middle schools. Self-report measures were used to collect data every 6 months in three waves. Results: (1) Peer victimization at T1 positively predicted DSH at T3. (2) Depression at T2, rather than anxiety, mediated the relationship between peer victimization at T1 and DSH at T3. (3) Perceived peer support climate at T1 played a moderating role between peer victimization at T1 and depression and anxiety at T2, but perceived teacher support climate did not. Peer victimization had a stronger predictive effect on depression and anxiety for students with high level of perceived peer support climate. Limitations: Study limitations include the short interval (6months) of the longitudinal design, the reliance on self-report questionnaires, the inclusion of only one aspect of student-student and teacher-student relationships, and the age limitation. Conclusions: The results demonstrated the importance of prevention for improving social and emotional skills to reduce peer victimization and of interventions to promote a peer support climate in the classroom. The findings highlight the need to consider different types of internalizing problems and perceived support in studies of DSH in adolescents.

Emotion dysregulation and deliberate self-harm in adolescents

Adolescents belong to the high-risk group for deliberate self-harm. Data shows that about 20 percent of teenagers in the world engage in self-injurious behavior in forms of scratching, razor blading, hitting, biting, hair-grabbing, and head-banging against walls just to relieve pain. This study aims to determine the correlation between emotion dysregulation and deliberate self-harm in adolescents. This study applied two instruments to measure each variable: (1) Difficulties in Emotion Regulation Scale (DERS), developed by Victor and Klonsky (2016), to measure emotion dysregulation; and (2) Deliberate Self-Harm Inventory, developed by Gratz (2001), to measure deliberate self-harm. Researchers implemented a quantitative approach with a correlational design to answer the research questions. Participants were 174 adolescents recruited from the distribution of online questionnaires with purposive sampling technique. Findings from the study indicate that emotion dysregulation is positively correlated with deliberate self-harm in adolescents with a sig p value < 0.005. This research concludes that the higher the emotion dysregulation, the higher the deliberate self-harm in adolescents.

Deliberate self-harm in adolescents during COVID-19: The roles of pandemic-related stress, emotion regulation difficulties, and social distancing

The objective of this study was to conduct an ecologically valid test of etiological models of deliberate self-harm (DSH) during the COVID-19 pandemic. Using a sample of Canadian adolescents, we investigated: (1) the association between COVID-19-related stress and DSH; (2) whether emotion regulation (ER) difficulties mediated/moderated this association, including whether these effects differed by age; and (3) whether the mediating/moderating effects of ER difficulties were stronger among socially distanced youth. Canadian adolescents (N = 809) aged 12-18 were recruited on social media and completed an online survey. COVID-19-related stress was associated with recent DSH. Nonacceptance of emotional responses and limited access to ER strategies fully mediated this association. The indirect effect through nonacceptance of emotional responses was stronger among more socially distanced youth, whereas the indirect effect through limited access to ER strategies was stronger among older and more socially distanced youth. COVID-19-related stress and ER difficulties did not interact to predict DSH, nor did age or social distancing moderate these interactions. These results align with etiological models proposing central roles for stress and ER difficulties in DSH. Furthermore, this study underscores a need to support adolescents, particularly older teens with reduced in-person interactions, in adaptively coping with pandemic-related stress.

Developing a Text Messaging Intervention to Reduce Deliberate Self-Harm in Chinese Adolescents: Qualitative Study

BackgroundDeliberate self-harm is common during adolescence and can have detrimental consequences for the well-being of adolescents. Although it is sometimes difficult to engage adolescents in traditional psychotherapies for deliberate self-harm, SMS text messaging has been shown to be promising for cost-effective and low-intensity interventions.ObjectiveThis study aimed to investigate the views of Chinese adolescents with deliberate self-harm about SMS text messaging interventions in order to develop an acceptable and culturally competent intervention for adolescents with deliberate self-harm.MethodsSemistructured interviews were conducted with 23 adolescents who had experience with deliberate self-harm. The transcripts of the interviews were analyzed using thematic analysis.ResultsFour themes were identified: beneficial perception of receiving messages, short frequency and duration of messages, caring content in messages, and specific times for sending messages. Most of the participants perceived SMS text messaging interventions to be beneficial. The key factors that emerged for the content of the intervention included encouragement and company, feeling like a virtual friend, providing coping strategies, and individualized messages. In addition, the preferred frequency and duration of the SMS text messaging intervention were identified.ConclusionsOur study will help in the development of a culturally appropriate SMS text messaging intervention for adolescents with deliberate self-harm. It has the potential to decrease deliberate self-harm instances by providing acceptable support for adolescents with deliberate self-harm who may be reluctant to seek face-to-face psychotherapies.

Before the damage is done: Early childhood hyperactivity difficulties in adolescents with deliberate self-harm - findings from the DALSC cohort.

Background:Deliberate self-harm (DSH) is a growing issue among Danish adolescents, and a dramatic increase in the incidence of DSH has been observed since the turn of the millennium. The importance of early childhood factors on later development has been established, but research on the trajectories of DSH is still scarce, and longitudinal studies are much needed.Method:Participants were 3,291 children and their mothers from The Danish Longitudinal Survey of Children (DALSC), a Danish population-based birth cohort from 1995. Logistic regression and mediation analyses were used to examine significant early childhood determinants of self-harming behavior in adolescence.Results:The study found that 17.9% of the children had a history with DSH at the age of 18 years. A significant relationship was found between the likelihood of DSH at the age of 18 years and hyperactivity difficulties assessed through the Strengths and Difficulties Questionnaire (SDQ) at 3 and 7 years of age. Using a mediation model, it is documented that difficulties in peer relationships at the age of 11 years is a partial mediator explaining 19% of the variation.Limitations:i) a vague definition of self-harm in the questionnaires; ii) lack of sample representation as children of lower socio-economic groups have lower participation rates, and only Danish-ethnicity children have been sampled; iii) possibility of omitted variable bias.Conclusion:The adolescents engaging in DSH are experiencing a more complex range of psychosocial problems than those who do not have experience with DSH. The main finding of the study is that hyperactivity as a risk factor for the development of DSH in adolescence can be identified as early as 3–7 years of age. This relationship between the very early occurring hyperactivity and later DSH, to the best of our knowledge, has not previously been described.

Adolescent deliberate self-harm: long-term effect on healthcare use

Adolescent deliberate self-harm: long-term effect on healthcare use

The pervasive effects of timing of parental mental health disorders on adolescent deliberate self-harm risk.

Children whose parents have mental health disorders are at increased risk for deliberate self-harm (DSH). However, the effect of timing of parental mental health disorders on adolescent DSH risk remains under-researched. The aim of this study was to investigate how parental hospital admissions for mental health disorders and/or DSH in different developmental periods impact on the child’s DSH risk in adolescence. A nested case-control sample was compiled from a total population cohort sample drawn from administrative health records in Western Australia. The sample comprised 7,151 adolescents who had a DSH-related hospital admission (cases), and 143,020 matched controls who hadn’t had a DSH-related hospital admission. The occurrence of parental hospital admissions related to mental health disorders and/or DSH behaviours was then analysed for the cases and controls. The timing of the parental hospital admissions was partitioned into four stages in the child’s life course: (1) pre-pregnancy, (2) pregnancy and infancy, (3) childhood, and (4) adolescence. We found that adolescents of a parent with mental health and/or DSH-related hospital admissions in all developmental periods except pregnancy and infancy were significantly more likely than controls to have a DSH-related hospital admission. Compared to parental hospital admissions that occurred during childhood and adolescence, those that occurred before pregnancy conferred a higher risk for adolescent DSH: adjusted odds ratio (aOR) = 1.25 for having only one parent hospitalised and 1.66 for having both parents hospitalised for mental health disorders; aOR = 1.97 for having any parent hospitalised for DSH, all being significant at the level of p < .001. This study shows that timing is important for understanding intergenerational transmission of DSH risk. The pre-pregnancy period is as critical as period after childbirth for effective intervention targeting adult mental health disorders and DSH, highlighting the important role of adult mental health services in preventing DSH risk in future generations.

The role of dissociation and abuse among adolescents who self-harm.

Retrospective recall of dissociative symptoms has been found to mediate the association between childhood abuse and deliberate self-harm (DSH) in later life. To disentangle the effect of recall bias, we tested whether dissociation symptoms ascertained during an acute DSH presentation mediates this link. All participants with DSH were recruited during emergency presentation. Seventy-one individuals aged 11-17 years with overdose (OD) and/or self-injury (SI) participated in semi-structured interviews and psychiatric assessment to measure abuse and dissociation. An age- and gender-matched comparison group of 42 non-psychiatric patients admitted to the same service were also assessed. The DSH groups reported significantly higher levels of abuse and dissociation compared to comparison group. Dissociation significantly mediated the association between abuse and DSH. Of the four dissociation subtypes, 'depersonalisation' was the primary mediator. Adolescents with chronic patterns of DSH and the 'OD + SI' self-harm type reported more severe dissociation. Exposure to abuse significantly increased the risk of DSH in adolescence. This association was mediated by dissociation. Our findings suggest a possible dose-response relationship between dissociation with DSH chronicity and the 'OD + SI' self-harm type, implicating the importance of evaluating dissociation and depersonalisation symptoms as well as abuse exposure in DSH management.

What is the relationship between dissociation and self-harming behaviour in adolescents?

Deliberate self-harm in adolescents is an increasing clinical problem, but there is a limited understanding of the mechanisms causing or maintaining this behaviour. One proposed mechanism is that of dissociation. However, the role this mechanism may play is unclear: although some suggest that adolescents engage in self-harm to end the aversive experience of dissociation, others propose that self-harm is used to purposefully trigger a dissociative state to avoid emotional pain. This systematic review is the first to evaluate the available evidence regarding the relationship between dissociation and deliberate self-harm in adolescents (aged 18 or younger). Nineteen relevant studies were identified. These studies were limited by cross-sectional design and poor methods of measurement, but some important conclusions could be drawn. The majority of studies found a positive correlation between the severity of dissociation and the severity and frequency of deliberate self-harm in adolescents, and a small number of results suggest that dissociation mediates the relationship between childhood trauma and adolescent self-harm.

Deliberate self-harm in adolescents in Southern Sri Lanka; a hospital based Study

Introduction: Little is known about adolescents who engage in deliberate self-harm (DSH). Therefore, using data from medical and police records of the Teaching Hospital Karapitiya, we examined patterns of DSH among young people. Methods: We examined records of episodes of DSH for 2001 and for the 5 year period from 2006 through 2010. Data on 1720 individuals between 10 and 18 years old were gathered. Results: There was a striking increase from 2001 to 2010 in admissions of young people with DSH. In 2001, there were 137 cases; in 2010, the number had nearly tripled (N=391). Case fatality rates were low; in 2001, it was 8%; in 2010, it was 0.25%. Comparing 2001 to 2010, cases involving poisons decreased from 58% to 46%; cases involving medicinal overdoses increased from 41% to 54%. Adolescents rarely used other methods. In 2001 and in each year from 2006 to 2010, adolescents aged 15-18 years accounted for at least 85% of the sample, and there were three times more girls than boys. Conclusion: Decreases in suicides have been substantial; nonetheless, rates of non-fatal DSH have climbed. We call for research on antecedents and correlates of DSH in groups at high risk, such as older adolescent girls.

Suicide After Deliberate Self-Harm in Adolescents and Young Adults.

Among adolescents and young adults with nonfatal self-harm, our objective is to identify risk factors for repeated nonfatal self-harm and suicide death over the following year. A national cohort of patients in the Medicaid program, aged 12 to 24 years (n = 32 395), was followed for up to 1 year after self-harm. Cause of death information was obtained from the National Death Index. Repeat self-harm per 1000 person-years and suicide deaths per 100 000 person-years were determined. Hazard ratios (HRs) of repeat self-harm and suicide were estimated by Cox proportional hazard models. Suicide standardized mortality rate ratios were derived by comparison with demographically matched general population controls. The 12-month suicide standardized mortality rate ratio after self-harm was significantly higher for adolescents (46.0, 95% confidence interval [CI]: 29.9-67.9) than young adults (19.2, 95% CI: 12.7-28.0). Hazards of suicide after self-harm were significantly higher for American Indians and Alaskan natives than non-Hispanic white patients (HR: 4.69, 95% CI: 2.41-9.13) and for self-harm patients who initially used violent methods (HR: 18.04, 95% CI: 9.92-32.80), especially firearms (HR: 35.73, 95% CI: 15.42-82.79), compared with nonviolent self-harm methods (1.00, reference). The hazards of repeat self-harm were higher for female subjects than male subjects (HR: 1.25, 95% CI: 1.18-1.33); patients with personality disorders (HR: 1.55, 95% CI: 1.42-1.69); and patients whose initial self-harm was treated in an inpatient setting (HR: 1.65, 95% CI: 1.49-1.83) compared with an emergency department (HR: 0.62, 95% CI: 0.55-0.69) or outpatient (1.00, reference) setting. After nonfatal self-harm, adolescents and young adults were at markedly elevated risk of suicide. Among these high-risk patients, those who used violent self-harm methods, particularly firearms, were at especially high risk underscoring the importance of follow-up care to help ensure their safety.

Prevalence, Causes and Most Common Method of Deliberate Self-Harm Used by Adolescent of Pakistan

This study was conducted in Lahore, Pakistan to explore the overall and gender-wise prevalence of Deliberate Self-Harm in adolescents. Identification of most common reason and method practiced for DSH by adolescents were also the objective of study. The sample size for the study was calculated with G-power factor formula and as per the results generated from the software, a sample of (N=200) hundred males and hundred females was analyzed. ISAS inventory was used as research tool in this study. Cross-sectional survey was conducted and it was found that 62% adolescents indulged into the practice of DSH. Furthermore biting was the most common method and affect regulation was identified as most common reason due to which adolescents practiced DSH. It was also exhibited by data analysis that females were twice more active participant of DSH as compared to males.

The impact of child maltreatment on the risk of deliberate self-harm among adolescents: A population-wide cohort study using linked administrative records

Adolescents exposed to maltreatment have an elevated risk of deliberate self-harm (DSH). The aim of this study was to investigate longitudinally the effects of the number, timing, and type of maltreatment allegations on adolescent risk of having a DSH-related hospital admission, using linked data in Western Australia. A total of 351,372 children born between 1986 and 2000 were followed from birth up to the year 2010. Cox regression models were utilized, while controlling for a range of psychosocial covariates. Compared to children without allegations of maltreatment, children with unsubstantiated allegations only (aHR=1.04, 95%CI: 1.00–1.08, p<.01) and children with a substantiated allegation (aHR=1.10, 95%CI: 1.06–1.15, p<.001) all had significantly increased risk of DSH in adolescence. Among children with a substantiated allegation of maltreatment, the greater the number of allegations, the longer the exposure to maltreatment, and the more types of maltreatment experienced by a child, the higher the child's risk of DSH. However, this dose–response pattern was not found among children with unsubstantiated allegations only. This study calls for the early identification of children who are vulnerable to maltreatment, the better identification of the duration and severity of maltreatment experiences, and the provision of continued care and support, to reduce the child's DSH risk in adolescence.

Influence of exposure to perinatal risk factors and parental mental health related hospital admission on adolescent deliberate self-harm risk.

Adolescent deliberate self-harm (DSH) has been found to be associated with a range of bio-psycho-social factors. Simultaneous investigations of these factors enable more robust estimation of the independent effect of a specific risk factor by adjusting for a more complete set of covariates. However, few studies have had the ability to examine all of these factors together. This study used the linkage of population-level de-identified data collections from government agencies to investigate a range of biological, psychological, and social risk factors and their effects on adolescent risk of DSH (with or without suicidal intent). The investigation was undertaken by progressively adjusting for plausible covariates, including fetal growth status and birth order, early familial social factors, parental hospital admissions due to psychiatric disorders or DSH, and parental all-cause death. Conditional logistic regression was used for data analysis. Children's psychiatric history was analysed to examine the extent to which it may account for the link between the risk factors and adolescent DSH risk. This study identified significant biological and perinatal social risk factorsfor adolescent DSH risk, including overdue birth, high birth order (≥2), single or teen/young motherhood, high neighbourhood socioeconomic disadvantage, and parental psychiatric and/or DSH-related hospital admissions. Further, parental psychiatric and/or DSH-related admissions, and children's psychiatric admissions in particular, largely attenuated the effects of the perinatal social risk factors but not the biological factors on adolescent DSH risk. These results highlight the importance of taking joint actions involving both health and social services in the prevention of adolescent DSH.

Concurrent adversities and deliberate self-harm among indigenous Sami and majority Norwegian adolescents: the Norwegian Arctic Adolescent Health Study

Abstract Background: Few studies have investigated proximal relationships between deliberate self-harm (DSH) and concurrent adversities. Objective: We aimed to investigate these relationships in a community population of 4881 indigenous Sami and majority Norwegian adolescents, 15 to 16 years old, and related to ethnicity and gender. Methods: Youth with and without self-reports of DSH last year were compared on 12 concurrent adversities, on scales measuring family and peer functioning, and on sociodemographic conditions. Results: DSH last year was reported by 22.3% of the adolescents, and by more girls (28.8%) than boys (15.9%). All 12 concurrent adversities were related strongly to DSH last year. Deliberate self-harmers reported twice as many concurrent adversities as non-DSHs, and a large effect size (Cohen’s d = 0.80) indicated a strong multiple additive relationship, but among DSHs no ethnic or gender differences were found. Multivariately, among Sami youth sexual abuse [odds ratio (OR), 8.4] was strongly related to DSH, whereas among majority Norwegians sexual abuse (OR, 3.9) and violence (OR, 4.5) were identified as the strongest predictors. Similarly, among boys violence from adults (OR, 8.8) was associated most strongly with DSH, whereas among girls sexual abuse (OR, 4.3) was the most robust predictor. DSHs reported more conflicts with parents, less family support and involvement, and more peer problems than non-DSHs, and DHS girls had more difficulties in these relationships than DHS boys. Only small ethnic differences were found. Conclusion: Adolescent DSHs reported twice as many concurrent adversities as non-DSHs, sexual abuse and violence were strongly related to DSH. Ethnic and gender differences in risk factors were found. Clinicians should inquire about traumatic experiences such as sexual and physical abuses, and should have a family, peer, and gender perspective in their work.

The Indirect Effect of Early Experiences on Deliberate Self-Harm in Adolescence: Mediation by Negative Emotional States and Moderation by Daily Peer Hassles

The present study examines whether early experiences of threat, subordination and devaluation with family influence adolescents’ negative emotional states and subsequently deliberate self-harm; and if this effect is conditioned by daily peer hassles. The sample consisted of 441 adolescents (57.6 % female) with ages between 13 and 18 years old from middle and high schools. Participants completed self-report instruments measuring early memories of threat, subordination and devaluation, daily peer hassles, negative affect and deliberate self-harm behaviors. Results from conditional process analysis showed that adolescents who feel devalued and experience threat and submission within family tend to endorse high levels of negative affect, which in turn accounts for increased endorsements on deliberate self-harm. Moreover, the impact of negative affect on deliberate self-harm is amplified by the presence of moderate and high levels of daily peer hassles. This study suggests the relevance of assessing and intervening on type of emotional memories (i.e., threat, subordination and devaluation), daily disruptions with peers and negative emotional states with adolescents who self-injure. These findings may be useful in the development of preventive and intervention programs for reducing deliberate self-harm in adolescence.

Incidence and Course of Adolescent Deliberate Self-Harm in Victoria, Australia, and Washington State

PurposeThere have been few longitudinal studies of deliberate self-harm (DSH) in adolescents. This cross-national longitudinal study outlines risk and protective factors for DSH incidence and persistence. MethodsSeventh and ninth grade students (average ages 13 and 15 years) were recruited as state-representative cohorts, surveyed, and then followed up 12 months later (N = 3,876), using the same methods in Washington State and Victoria, Australia. The retention rate was 99% in both states at follow-up. A range of risk and protective factors for DSH were examined using multivariate analyses. ResultsThe prevalence of DSH in the past year was 1.53% in Grade 7 and .91% in Grade 9 for males and 4.12% and 1.34% for Grade 7 and Grade 9 females, respectively, with similar rates across states. In multivariate analyses, incident DSH was lower in Washington State (odds ratio [OR] = .67; 95% confidence interval [CI] = .45–1.00) relative to Victoria 12 months later. Risk factors for incident DSH included being female (OR = 1.93; CI = 1.35–2.76), high depressive symptoms (OR = 3.52; CI = 2.37–5.21), antisocial behavior (OR = 2.42; CI = 1.46–4.00), and lifetime (OR = 1.85; CI = 1.11–3.08) and past month (OR = 2.70; CI = 1.57–4.64) alcohol use relative to never using alcohol. ConclusionsMuch self-harm in adolescents resolves over the course of 12 months. Young people who self-harm have high rates of other health risk behaviors associated with family and peer risks that may all be targets for preventive intervention.

Comment on: Deliberate self-harm in adolescents

Dear Sir, I am writing to add to the pertinent points raised by the article ‘Deliberate self-harm in adolescents’.(1) Beyond the role of primary care physicians and specialist care, parents and school counsellors can access a community-based mental health programme called REACH (Response, Early intervention and Assessment in Community mental Health)(2,3) to help children and adolescents cope with self-harm behaviours. This programme is available to all students from mainstream and special schools in Singapore. The REACH team comprises different allied health professionals such as psychologists, occupational therapists, registered nurses and medical social workers in each of the four teams (in accordance with the Ministry of Education’s school zoning). After obtaining important information on the students from the school counsellor and a detailed triaging process, REACH’s multidisciplinary team responds in a timely manner based on the severity of the mental health condition. With its strategic location in the community and away from hospitals, REACH epitomises the term ‘right-siting’ of healthcare. In cases where the self-harm behaviour is due to a serious mental illness, REACH is able to quickly refer the student to a child psychiatrist clinic for further evaluation and management. With this approach, patients do not face the stigma of having to visit psychiatric clinics and there is less strain on the tertiary psychiatric clinics. REACH was first developed in 2007 under the National Mental Health Blueprint and is now operated by three hospitals – the North and South teams are under the Institute of Mental Health, while the West and East teams are under the National University Health System and KK Women’s and Children’s Hospital, respectively. With the parents’ consent, staff from the REACH team visit the students’ school or home to conduct an assessment or intervention. As the first assessment is free of charge (subsequent interventions are chargeable) and interventions are conducted in school or at home, REACH’s service is attractive to both parents and students. A case conference with the school and the student’s parents is also conducted at the end of the assessment and before any interventions are started. REACH’s service is meant to be time-limited with clear continuity-of-care guidelines and discharge policies. REACH aims to administer secondary intervention while bringing mental health care closer to students.(4) With general practitioners and voluntary welfare organisation staff trained in basic child mental health joining REACH as community partners, we hope that a growing mental health network will eventually be set up in Singapore to provide more seamless and effective mental health care for our child and adolescent populations. Yours sincerely,