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uh, what I wanted to speak to and thank you for finding the time. Oh, they have. Catarina is what it looks like. Anyway, uh, So, uh, what I wanted to speak to you about, um, is self harm and suicide in young people? Uh, you can probably see it, right? Uh, my my slide. Is that right? Yes, we can see it. Great. All right, so, um, Look, um, I really have very few, um, uh, things to the clan, except for a couple of books that I wrote and self help, Uh, and we'll look quickly at self harm. Why? It's important what it looks like around the world and how to assess it a little bit. And then what works for self harm in young people? Um, that's, uh, the world before covid what it looked like in terms of suicide. Um, if you have, like, dark brown sort of yellowish number colors, it means that suicide was going up before covid. And then, um, if it's like dark blue, uh, aquamarine sort of color means it was going down. Um, can anyone predict what's happening with suicide in Ukraine at the moment, people think it's going up down or remains the same like this year. We haven't got official data, of course, but what would people predict? Maybe if people could say in the chat something that they think or you wouldn't say What usually happens to suicide during the war? I think it's increases. Uh, any other thoughts? Thank you. Grace, for contributing. Uh, well, it's, uh it's interestingly, really always goes down during the times of war. Um, but what happens to it, uh, after the war is usually a very substantial increase. So we could be fairly certain that at the moment this year, Ukraine will have a very low suicide rate. Um, there's something about cohesion, and, uh um, galvanizing everybody. That seems to be a protective factor. Um, suicide looks very similar across the ages in different countries. So usually you have a fairly low rate of suicide in Children, young people, and then the older you are the greater risk of suicide. There are two exceptions to this one. Interestingly, is, um, southeast Asia. Uh, India. Uh, I think there's a couple. At least a couple of people here from from there There, you can see this sort of top top left hand side is interesting by model distribution, where you have a lot of suicides in young women, then a reduction and then another increase towards the end of life. The other exception is Eastern Europe. In males, you have a very steep increase early in life, then a plateau and a slight increase at the end of of life. Uh, so, uh, who would you? Who would you say in in this call is at the highest risk of suicide. Any thoughts just from the demographic points of you? No, it's actually myself. So I'm male, which gives me three or four times higher. The risk, uh, from Eastern Europe, which you can see is A is a high risk. Um, and I'm the oldest. I think here. So demographically, I'm by far at the greatest risk of suicide. Anyway, um, in Europe, you can see in young people there is a, uh, north south divide. Um, a lot more suicides in young people in, um in northern Europe and eastern Europe. Um, as I mentioned to you before, in most Western countries, there's about three or four suicides in males to one female. Uh, and that is true throughout the Western world In many, uh, eastern countries in southern countries, it's not the case. Um uh, in India, the link The ratio is very different in China. In some areas, actually more females than males. A child suicide is relatively rare, but it is, uh, in most Western countries, the second leading cause of death in young people and Children, Um, which is something that people often get surprised by. Uh, does anybody know what is the top cause of death in young people and Children in the western world? But the kids die off no hypothesis. All right, I'll tell you, it's, uh, somebody knows who's that? Someone has put depression in the chat. Emotional, emotional. Not far. Not far. Not far, Not far. Oh, yeah. Yeah, you're right. Uh, people are just not far. It's actually the accident. So Children die of accidents. Uh, primarily road traffic accidents, but also all kinds of accidents. That's number one cause of death number two. Cause of this is suicide in most western countries. Um, some years in America it could be homicide, but mostly in the last few years. It also was has always been suicide. Um So when you think about, um, different age groups you can see in females it's the middle aged females who I had at the highest risk. Um, increasingly so in males as well. It's the middle middle age, uh, males that are at the highest risk. Uh, we used to have this very depressing picture of, uh, old males in the UK, which were the highest risk. But now, unfortunately, it has changed in terms of days of the week. Then it's actually, um, Mondays that have the highest risk of suicide of any day of the week. Um, not the weekend, Like we used to think when people get drunk, uh, typically high on drugs, it's actually the day after that. Uh, interestingly in countries were the working week begins on Sundays. Then, um, we often see the greatest number of suicides on Sundays, Not not during the weekend. Um, there are some special groups of young people and people in general who have particularly high risk of suicide worth. Knowing about one of these groups is people with ASD with autism. They have about eight times the risk of, um uh of suicide and people with normal IQ and autism have a particularly high risk of suicide about 10 times the people without a S D terms of methods can. It's a very culture specific. In in most Western countries it's hanging. That's the top, uh, method of suicide. You can see in males on the left. Um, that's by far the greatest, uh, the most common method in females. Interestingly, traditionally, it was self poisoning around 20 years ago, there was an interesting crossover that started. And now, every year we have more and more hanging as, um as a method of suicide in females to, um, in some countries, for example, in the Indian subcontinent. Um, poisoning, as especially with the organophosphates, uh, could be a significantly, uh, more prevalent method of of suicide. Um, in some countries, it may be jumping from heights, For example, um, in terms of boys and young males, um, they observed the very interesting and, um, and concerning peak of this, um, in sort of young boys in the late eighties, early nineties in girls. Um, they're even more concerned now. We've never seen as much, um, as many suicides in girls and young females as we're seeing now. So um since the 18 sixties now is the highest risk. Girls and young females are at the highest risk, uh, of suicides that they have ever been. Uh, it's a long it's a topic of it of a separate conversation. Why, this may be the case now, self harm. Now, um, the reason why we are so interested in self harm is because self harm is, um, as far as we could say, the the the strongest predictor of of suicide that you know. So when I say self harm, I mean self injury, like by cutting or self poisoning, for example, by taking an overdose or, um, other types of self harm, for example, attempted hanging, jumping from heights, attempted drowning. So all of that in the UK at least it's called self hum. And when you think about those behaviors intentional self harm, irrespective of whether the child wanted to kill themselves or not, you know that group of the head is seems to be the strongest known risk factor for for completed suicide. Um, a child who comes with significant self harm to an emergency department in the in the hospital, Um uh, carriers about 20 times the risk of dying. Um, in fact, about 1% of Children will die over 10 years. Of the ones who come to the emergency department, half of that 1% will be definitely be suicides. The others probably accidents or, uh, undetermined causes. Um, self harm, uh, increases has increased dramatically in the last few years. Um, we used to say it's about 10% of kids who self harm. Now it's probably closer to 20% a good sort of range in most Western countries between 15 to 20% of a lifetime self harm prevalence. There are major differences between countries. Uh, some countries have very low self harm rate, such as Holland. Uh, some other countries have very high self harm rates. Self harm is exceptionally common in kids with ASD. At least half of them have a lifetime prevalence of self harm. Um, it would be fair to say that, um, the drivers or the precipitants of self harm in kids with AIDS, they are quite different from, um, kids who have no asd. Very often, it's secondary to abnormal sensory processing. Um, disturbance of sameness and other ASD typical behaviors perhaps seen an increase in self harm in the primary care as well. I'm sure Sharon, if she's listening, will recognize that we have a lot a lot more kids coming with self harm, especially girls and safeguarding connected to safeguarding issues as well. So we've seen safeguarding shoot up safeguarding issues along with mental health issues. Indeed. And that was even before before covid. Um, globally. So I was saying that sell Tom is the second leading cause of death in, um in kids in the West. Um, globally seldom. Also is, uh, well, suicide is is a common cause of death. Um, uh, interestingly, in girls in all the girl's teenaged girls, the top cause of death worldwide is actually maternal conditions of giving birth. Um, now, is there anything that you could do about self harm? Um, up until about 2015, Um, I was saying no, um, there was really no evidence that anything to do really makes a difference. In 2015, I published a matter analysis for the first time, which shows that actually, we're not fully, uh, totally wasting our time here. Now, I will just orient you quickly to meta analysis how they work. So what you have on the left are all studies. They're called randomized controlled trials, where you have kids in two groups randomly allocated. One of them is getting psychological therapy of some sort, and the other one is getting a control. Could be non specific conversations or waiting list or some other controlled condition, but like you might be familiar with the sort of placebo controlled trials. But you give a medication to one group of kids and placebo to the other. It's a similar idea. In psychological therapies. One group gets psychological therapy, the other one doesn't, and you can see these little blue dots. That's the overall effect of psychological therapy. If it's on the left of this vertical line, it means that on average, kids were self harming less. If you begin psychological therapy, then if you did nothing, if the Dot is to the right, it means that, um, kids were actually self harming more in psychological therapy than if you did nothing. And this little, um uh, sort of horizontal line around the blue dots is called, uh, 95% confidence interval. It means statistically how confident we are in this finding and the wider this range, the less confident we are. If if that horizontal line crosses the vertical line, it means that statistically it cannot be certain whether it did any harm or any good or made no difference. So you can see. And then, if you were to squeeze all of these studies into one, you will get this black diamond here at the very bottom. And that is the overall effect of all psychological therapies on self harm in kids. And you can see that that black diamond doesn't quite cross the line of nonsignificance. So it means that overall psychological therapies in 2015, we're doing a little bit more good than bad. Now let me see if you can gas some psychological therapies. So let's look at Esposito. Smythe is This is the first one here, which seems to be significant. Uh, can anybody guess what psychological therapy that might be? Let's see if people know any psychological therapies what psychological therapies might reduce. So prom people think self medication. Interesting? Uh, no, that's there's personal counts to the interesting, uh, any specific psychological therapies. And anybody has heard about specific psychological therapies that might work people had about uh, CBT support groups. Interesting. Yeah. Um, does anybody know what CBT stands for? Cognitive behavior therapy Indeed. Yes, Crazy that that's the case. So, um, in fact, you know that as believe. Exactly. Right. Thank you. So that is CBT. You can see it has a positive study in kids. Uh, now melim here, which seems to have a very large effect size. That's, um DBT. I don't expect many people would know what that stands for, but if anybody does that, they are remarkable. Does anybody come across DPT? Oh, yes. That's not uh, that's, uh wow, I I'm I'm surprised you know this, but this is Ruso infan again. That's a very specific to north London MBT. Yes, but melim is not that mail, um is DBT Does anybody know what DBT stands for? Uh, yes. Uh, wonder. Wow. I'm surprised people notice stuff anyway, uh, so that is true. So, in fact, of all of these three therapies that seems to be effective, it's the DBT that now has by far the largest effect, the largest evidence base beyond this very, um, strong effect you can see in mail them. Um, there are now two other independent DBT studies. Uh, that stands for the actual behavior therapy for the lessons, and they all seem to indicate that it leads to significant reduction in the, um, in south home. Uh, in fact, we've just published, um, the new nice guidelines. Um, if people, um I'm not familiar with this. Have a look. It's nice dot org. It's a very useful resource. Has, um, treatment guidelines for most disorders, including self harm. Uh, the latest version for self harm was published in on the seventh of November this year, and it actually for the first time recommends DVT as the treatment of choice for psychological therapy for self harm in kids. Now, um, what happened since then? Um, we continued this work. This is with my, um, colleagues in Austria and Germany. Um, we think that the conclusion still stands. And, um, overall, psychological therapists probably make more more good than harm. DBT uh, in 2020 had two studies so stronger evidence base. Um, one additional thing that we have found was that family assented therapy. Um, although it doesn't reduce self harm in kids almost certainly reduces thinking about suicide. And that's something that is worth noting, um, so we now talk about to psychological therapies. One is deputy to reduce self home and one family therapy to to reduce thinking about suicide. Now, um, you might be familiar with risk factors for self harm. Um, so I will not. It will not be a surprising list for you. I just wanted to highlight two or three points here. Uh, one of them is, um uh, really childhood abuse. It's something that is often not inquired about. So when you see a child with self harm or young person, um, typical people ask about depression, anxiety, all of these well known risk factors for self harm. Very rarely do they ask about childhood abuse, which is a very common, um, problem. And as Sharon was saying, actually, um, in her practice, she sees a lot of that. Um, the other thing to focus your attention is, um, on the history of self harm in the family, also your side in the family and also in the environment. Children are very Braun to influences, especially in their teenage years, from their friends and other people around them, especially including self harm, um, presented to them by social media. And so, um, enquiring about friends and relatives with self harm is important and could have significant implications for for treatment. So what determines a child who moves from thinking about suicide to actually attempting suicide? Are these factors of those? I really wanted to focus your attention on hopelessness. I mean, that's something that is a key psychological concept in your assessment of of a child with self harm. You want to find out whether the child can see the future has any hope for the future. And the childhood doesn't who is truly hopeless, which is quite rare in kids. A lot more common in adults. Uh, you know, they will be at at a at a high risk. Um, and you may want to think whether, um, they're okay. You know whether they're safe to go home or not. Um, the other relatively new factor which is important is body dissatisfaction again, Uh, I know that my junior doctors very rarely ask about, um but it's a small fear. It seems to be a very common problem in kids. Uh, we have, uh, at the moment that we have, uh uh, we have a whole service just put it this morning here and the person in charge, Bruce Clark tells me that basically 95% of of the kids who come, uh, to the B D D service actually have attempted suicide at least once. So we're asking about It's all about noses in boys and hips and girls, basically the most common problem they have. Yeah, and for completed suicide, as we mentioned, it's the male sex that seems to determine, uh, confer 3 to 4 times the risk of of completing suicide, um, again, really wanted to highlight the family history of suicidal behavior, something that we rarely asked about. And, uh, drug and alcohol misuse Remember that a child who uses alcohol and drugs often will be at risk purely because it's a dis inhibiting substance. And in order to overcome the fear of death, which is one of the most fundamental fears that the human being has the child must have some. Some mechanism have to overcome this. And unfortunately, the availability of alcohol and drugs is something that could could reduce that barrier. So to go. And I'm going to ask you just a question about the family history of suicidal behavior. Are there statistics for how common it is or what the risk is for Children of of parents or carers who have committed suicide? Or I guess they are committed suicide or displayed suicidal behavior than what is the risk? Uh, for Children. It's, uh okay, So, um so? So if if you have parents who died by suicide, um, then your risk is very much higher. Um, I can't remember the specific, um, odds ratios, but they will be pretty high. They will not be as high as 20 because I know that odd ratios or 20 is something that is, as far as we know, the highest risk factor for serious, and that's a serious attempt and self harm. But it it is an important factor. And, um, as I said, you know, has significant implications with treatment as well. You don't want to just talk to the child when when there is a lot of self harm. And, um uh, and so it's Seidel thinking in the family as well. It's a very important point. Thanks, Sean. So what happens to kids when they come to A and E A and E is the equivalent of E R emergency room in the UK Um, about a third of them will come back with another cell time episode. Um, and, uh, 1% that will will die, Um, over 10 years and again, of the of all of the kids who come to emergency rooms in the UK it's the kids with violent self harm, such as attempted, attempted hanging, attempted jumping, attempted drowning that have the highest risk of, uh, completing suicide, you know, eight times the so basically 8% of them will die over 10 years. Now, note that still, the vast majority of kids who come with self harm will not die the vast, vast majority, which is why public health measures are so important. So if you prevent a child from dying in the moment of distress, uh, for example, if there is a barrier, um, on the bridge or in the underground or, um, if you can buy more than 16, uh, paracetamol tablets take in the UK know these public health measures, you know, they have a very important role because if a child doesn't die in the moment of significant distress, then they will almost certainly live like the vast majority of them, even with very severe attempts, Um, they will. They will still live. And that's a really important message here. Um, then just to say that social support is probably one of the most important protective factor you can see that kids who are these red dots? They tend to congregate, uh, separate from other kids in schools, and they often could be interconnected with each other. Um, but you can see school, um, at the top and school at the bottom. Uh, some schools are a lot better at integrating kids with them suicide than others. And, uh, in the school at the bottom, where you can see the relationships of these kids away from other kids and interconnected with each other. You know, then that is a recipe for a cluster of suicides which, unfortunately once in a while, um, happens around the world. But schools have a very important role to play, and social cohesion is probably the most important protective factor for for suicide. So, um, we're nowhere near good enough at predicting suicide. Um, and self harming kids. Uh, even though we know loads of risk, I have a huge review international Review that I lead, uh, well, we identified 410 different risk factors for self, for self harm and suicide and kids, believe it or not, we're still not very far down the line in predicting if anybody's interested, have a look at these, um uh, links. They're really interesting stuff that happens. This is Matthew Nock in Harvard, a colleague of mine who developed implicit association tasks. They sort of measure associations between concepts of me self I and, on one hand, life, future hope and, on the other hand, death, dying hopelessness. And if you measure in milliseconds the associations between these two concepts, you can determine which Children are more at risk of suicide. It's really interesting. You can test yourself on all kinds of implicit associations, including, like whether you like Donald Trump or whoever the other guy is De Santis and whether or Biden Um uh, so that's really fun to have a look amazing, very promising way forward, Doctor Green. We we unfortunately have to. This is my last. This is my last slide. Anyway, we could listen to you for a long time. It's absolutely fascinating and important. Thank you Yeah. So just to say that my last slide here is that I think that about the current pandemic and, you know, we see a lot of self and a lot of suicide, especially in goals in the UK and something that we need to be really aware of, that there are loads of stresses in that were present during the pandemic, which determined self harm. So just to summarize, um, suicide is the second leading cause of death in most kids in the West, Self harm is the strongest known predictor of of suicide. Uh, DBT, which stands for dialectical behavior Therapy is probably, uh Well, it is definitely the leading psychological therapy, uh, for, um, uh, for self harm. And remember that a lot of risk factors that are known have been exaggerated by the pandemic. That's all from me. Thank you for your attention. Huge. Thank you to doctor Professor. You grin. I should say who has once again delivered a fantastic, informative lecture. Um, and stepped in very last minute, uh, to travel for a lecture who was unable to, uh, to continue to do their lecture today because of, uh, clinical commitments. Um, and, uh Thank you. So so much to everyone who's joined. And please do fill in the feedback form because we must have your feedback to continue with starting the next lecture right away on pediatrics with Dr Caroline Delahunt. A. So, uh, we'll close this meeting now. Huge, Huge. Thanks. Thanks.