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Some people just don’t stand a chance’. Does significant childhood adversity lead to more depression, deliberate self-harm and suicide attempts within NZs younger generation?

Sinead O’Brien

Introduction

When I first heard the phrase ‘some people just don’t stand a chance’ I was on my mental health placement in a psychiatric ward. Being a student nurse I was aware of the statistics surrounding the prevalence of mental health problems, but this was my first eye-opener to the reality of these statistics. There were people my age, people who went to polytechnic and university just as I did, people who you wouldn’t give a second look at on the street; and one patient that really got to me was a young girl. This girl had come in due to an overdose and had written a suicide note to her parents and what really broke my heart was that she was only 16. My own younger brother is 16. I thought to myself; why am I seeing so many young people come through this institution? How could a person so young and inexperienced in life feel like they were ready to leave it already? When talking to one of the ward nurses on the subject she referred mainly to their upbringings, stating that a lot of them “simply never stood a chance”.

For New Zealand being such a beautiful first world country, its suicide rate is alarmingly high when in parallel with other countries. According to the Ministry of Health New Zealand is currently ranked with the 14^th highest overall suicide rate, putting us in the upper half of some of the highest rates in the world. Furthermore out of the 35 countries listed we are ranked with the third highest rate of suicide in youth aged 15-24 (Ministry of Health, 2016). If we zone in on the actual numbers its confronting to see that in one year 508 New Zealanders died by suicide, 7267 were hospitalized due to intentional self-harm, and the majority of these people were between the ages of 15-24 years old (Ministry of Health, 2016). It’s hard to ignore this problem when the statistics speak so loudly, so that poses the issue of why it is being said that these people seemingly ‘don’t stand a chance’ when it comes to developing depression and suicidal ideation. Although it’s known that depression has a possible familial component I wanted to look deeper into the environmental influences that these young New Zealanders face, particularly to see if their childhood histories and experiences are something that inevitably shape their paths.

Background

To articulate this issue in more depth we have to think about some of the aspects related to suicide, and a well-known one is depression. Depression is something that can be built up over many years and a common trigger for it is experiencing difficult or stressful situations (Ministry of Health, 2017). Depression is generally diagnosed in the mid-20’s age group however can develop at any age, including childhood. Recent statistics show that in New Zealand more than half a million people have been diagnosed with depression at some point in their lives, and we have more than 200,000 people living with anxiety disorders (Mental Health Foundation, 2017). When I read through patient histories within the acute psychiatric ward a high prevalence of self-harming behaviour was noted – generally cutting – within the patients who had presented with suicidal tendencies, and this observation correlates with the recent NZ Suicide Facts stating that higher rates of intentional self harm were found in the youth age group (15-24 years), as well as those living in neighborhoods of high deprivation (Ministry of Health, 2016).

An important age-old debate is the one of nature versus nurture, and this comes into play heavily when discussing depression and suicide. Does it happen because the person is genetically inclined to? Familial and twin studies would suggest there is linkage between the genetics of a person and developing a Major Depressive Disorder (MDD), however is not an imperative sign that they will develop this condition – and this is where environmental factors become important to consider (Lohoff, 2010). From a broad search there is strong suggestion that family distress can be a risk factor towards suicidality in young people, one research paper stating that ‘family factors, particularly living with a step parent, significantly adds to the risk’ (de Kloet, Starling, Hainsworth, Berntsen, Chapman, & Hancock, 2011). Related environmental aspects include having a family member who has committed suicide, alcohol and substance abuse, and family history of child maltreatment (Centers for Disease Control and Prevention, 2016). I stated previously that high levels of deprivation is a large factor and can relate to all of the above factors – ultimately leading to suicidality. As the younger generation is the most prevalent age group for suicide I decided to zone in on childhood adversity as the main focus, because according to statistics this area is most relevant.

The first years of a child’s life are when the brain undergoes rapid development and is shaped by early experiences, determining whether the brains architecture will be fragile or sturdy (Center on the Developing Child, 2007). Therefore significant adversity in early childhood such as neglect, poverty, abuse, parental substance abuse, or exposure to violence can have a huge toll on the brain as well as a child’s physical health as they develop and age (Center on the Developing Child, 2007). To investigate and develop a research question for this topic I used the PECOT model, which stands for Population, Exposure, Comparison, Outcome, and Time (Toouli, 2007).

PECOT

For my research I have chosen to exclude people who have a mental impairment (i.e. intellectual disability), as well as those who have developed psychosis as they may create outlier evidence when trying to make conclusions about the information I have found.

So with this knowledge, and worrying suicide prevalence, the question I pose to guide my research is: Does significant childhood adversity lead to more depression, deliberate self-harm, and suicide attempts within NZs younger generation?

Literature Review

One of the main adversities experienced in childhood is abuse – and this is defined in the Children Young Persons and their Families Act as either physical, emotional or sexual abuse or neglect where the child can be (or is likely to be) harmed, ill treated, abused, or seriously deprived (New Zealand Government, 2017). One of the most preventable consequences of child abuse is the development of suicidal tendencies in adolescence or adulthood, but often the abuse is not reported as the abuser is nearly always a family member, and at a young age the children simply don’t know any better than to suffer through the abuse (Saha, Paul, Das, Dinda, Mukherjee, & Basu, 2013).   

Saha et al. (2013) states that there are several social factors that predispose children to abuse, such as: parental substance dependence, poor parental education status, poor socio-economic status, and domestic violence. In New Zealand we use deprivation quintiles to help represent the level of deprivation of an area of residence, and this takes into account factors such as income, home ownership, support, employment, qualifications, living space, communication and transport of the residence – ultimately showing which areas are most deprived. In the Ministry of Health Suicide Facts document the information gathered correlates with the information provided by Saha et al. (2013) as the greater the deprivation in an area, the higher the suicide rates were, and this correlation was most prominent in the youth population (Ministry of Health, 2016). But from these findings it should mean that all children who live in low socio-economic areas are destined to be abused and eventually commit suicide – so why isn’t this the case for all of them?

Young children who experience recurring abuse are particularly vulnerable to toxic stress, which is something that can affect the developing brain, and can generally lead to mental health problems (Center on the Developing Child, 2007) – but what determines the varying outcomes is how the child handles the stress. When the mind is presented with stress we can choose to either externalise it, or internalise it, and this is where suicidal tendencies can present within the child. With the toxic stress created from child abuse the person can channel their feelings into externalised behaviours, which can lead to the development of problems such as delinquency, teen pregnancy, low academic achievement and drug use (Saha et al., 2013). Or they can internalise their feelings and will then exhibit behaviours such as loneliness, withdrawal, depression, and anxiety, which can ultimately lead to suicidal ideation (Smith & Tyler, 2010) – therefore the way a person processes stress from their childhood adversities has a great impact on their future mental wellbeing, and can be an explanation as to why some youth develop suicidal tendencies, whereas others under the same conditions don’t.

With my research I wanted to investigate self-harm as part of the depression and suicidal umbrella, and found within my literature review that a leading cause of self-harm (in terms of abuse) was sexual abuse, as victims felt a sense of self blame (Murray, MacDonald, & Fox, 2008). In a sexual-abuse study conducted by Wherry et al. (2013) they showed a comparison to non-abused adolescents stating that there was a conclusively larger proportion of suicidality and self-harm in those who were abused, both sexually and in other forms. As for children, there was double the likeliness of experiencing suicidal ideation in those who were maltreated or exposed to domestic violence, proving to us that significant childhood adversity is a leading risk factor when it comes to suicidality/self-harm. Murray et al. (2008) states that although a large portion of self-harmers experience sexual abuse, there are many that do not. And reasons for self-harm in these cases are generally in relation to the lack of emotional support – where the person is incapable of understanding or managing their painful feelings in ways other than self-harming. This compliments the earlier literature I found about processing stress in either externalising or internalising behaviours.

Many of the articles I read had the same pattern in their discussion, which was that a lot of adolescent/young adult suicidality could be avoided if intervention was implemented early on. The Center on the Developing Child (2007) summarised the situation quite simply by stating ‘Most potential health problems will not become mental health problems if we respond to them early’. This factor has important clinical implications because a lot of the time child and adolescent problems will go unnoticed until they’re very forgone, or in some cases it has become too late. Those who are in the prime position of recognizing the signs of a child experiencing mental health difficulties are the individuals themselves, friends, or family members (Burton, 2014). Often if the child is young they may be unaware of who they can report problems to, and on the other end of the scale; if the family members are the abusers they may not want to disclose that there are any problems to begin with. But when looking at our demographic group, it’s the 15-24 year olds who have the highest suicide rates in New Zealand, and by this age ‘right and wrong’ is generally known – therefore this is when internalising and self-blaming behaviours can set in and lead to suicide if the right help has not been implemented earlier on in life. 

To conclude what my literature review has taught me – when young children aren’t taught how to correctly handle stress, it can often lead to either externalised or internalised behaviours, and these behaviours dictate how they handle adversity and other situations in their later life. Incorrect teaching on how to cope with stress generally happens in early childhood when the brain is developing, and is usually the result of abuse or neglect towards the child. When a child is abused, especially for a prolonged amount of time, they are a lot more likely to develop suicidal tendencies in their adolescent years, and this is one of the main reasons that intervention in these younger years is integral, but not always practical when mental health problems stemming from abuse don’t generally develop or become noticed until later years.

So do some people just not stand a chance? Yes. But with early intervention, or even any intervention at all, we can change the pathway of these suicidal youth and stop the cycle before it carries on to further generations of children.

Recommendations

From reviewing the literature it has become apparent that there are worldwide gaps in the education of both parents and children when it comes to mental health. Therefore my recommendation is implementation of early intervention for both children and parents, because if we can put resources into education around the problems before they start – we can save a lot of money and resources down the track trying to fix them once they’ve become too far gone.  Also if we were able to intervene at an early age there is a high chance that the adolescent suicide rate in NZ would eventually drop.

We can liken this situation to any other health problem we come across – for example type 2 diabetes. From early on we try educate people to exercise, eat well, and recognise the onset of signs of diabetes. This firstly creates awareness in people, which is very important for prevention, and secondly it enables people to know what to do if the situation arises. This is the same with mental health. If a parent were to be aware of the mental health consequences their actions could potentially inflict on their child, there is a chance they would try prevent it. If the parent knew how to recognise the signs of depression and suicidality, then perhaps they would be able to get their child the help they needed before it was too late. In New Zealand we unfortunately have a ‘sweep it under the rug’ mentality when it comes to mental illness and although its improving there is still a lot of stigmatisation surrounding the topic – making it hard for families to be open when the subject arises, Saha et al. (2013) suggests family therapy as a way around this as it helps families to better express their feelings in a constructive manner. They also state inability to control emotional outbursts is an important risk factor in parents with a history of physically abusing their children, therefore family therapy can help teach them techniques for anger management, parenting skills, and non-physical means of discipline. In terms of the child, if they have been abused in some way they may need social skill training to teach them how to have positive interactions with others, as well as learn how to come up with ways of handling negative social situations.

It’s logically evident that early intervention is of great importance when the end goal is to lower the suicide rates in our youth. But to say that a person doesn’t stand a chance, however true it may seem, is putting the sole blame onto them, and this shouldn’t be the case for them – they do stand a chance, they just need help along the way.

Think of a rose flower. If they’re grown in the right soil and nourished with care the chances are that they will blossom and live out their life as a beautiful flower. But if they’re being trodden on, neglected to be watered and aren’t getting enough sunshine, there is a slim chance they will grow to be a beautiful rose; the more likely option is that they will wilt and die. But the earlier someone tries to fix the rose, the better chance it will have of survival.

References

Burton, M. (2014). Self-harm: working with vulnerable adolescents. Practice Nursing, 25(5), 245-251.

Centers for Disease Control and Prevention. (2016). Suicide: Risk and Protective Factors. Retrieved from: http://www.cdc.gov/

Center on the Developing Child. (2007). The Impact of Early Adversity on Child Development (InBrief). Retrieved from: http://www.developingchild.harvard.edu/

de Kloet, L., Starling, J., Hainsworth, C., Berntsen, E., Chapman, L., & Hancock, K. (2011). Risk factors for self-harm in children and adolescents admitted to a mental health inpatient unit. Australian & New Zealand Journal of Psychiatry, 45(9), 749-755. doi:10.3109/00048674.2011.595682

Lohoff, F. W. (2010). Overview of the Genetics of Major Depressive Disorder. Current Psychiatry Reports, 12(6), 539–546. doi:10.1007/s11920-010-0150-6

Mental Health Foundation. (2017). Mental Health Foundation: Quick Facts and Stats 2014. Retrieved from: http://www.mentalhealth.org.nz/

Ministry of Health. (2016). Suicide Facts: Deaths and intentional self-harm hospitalisations: 2013. Wellington: Ministry of Health

Ministry of Health. (2017). Depression. Retrieved from: http://www.health.govt.nz/

Murray, C., MacDonald, S., & Fox, J. (2008). Body satisfaction, eating disorders and suicide ideation in an Internet sample of self-harmers reporting and not reporting childhood sexual abuse. Psychology, Health & Medicine, 13(1), 29-42.

New Zealand Government. (2017). Children, Young Persons, and their Families Act 1989: Amended 2016. Retrieved from: http://www.legislation.govt.nz/

Saha, I., Paul, B., Das, D. K., Dinda, J., Mukherjee, A., & Basu, S. (2013). Repeated Abuse during Childhood and Adolescence Leading to Suicidal Behaviour in an Adolescent: A Case Report. Journal Of Family Violence, 28(2), 213-217. doi:10.1007/s10896-012-9481-x

Smith, D. D., & Tyler, N. C. (2010). Introduction to special education: Making a difference. Upper Saddle River, N.J: Merrill.

Toouli, J. (2007). Editorial. HPB: The Official Journal of the International Hepato Pancreato Billary Association, 9(4), 249-250. doi:10.1080/13651820701546794

Wherry, J. N., Baldwin, S., Junco, K., & Floyd, B. (2013). Suicidal Thoughts/Behaviours in Sexually Abused Children. Journal of Child Sexual Abuse, 22(5), 534-551. doi:10.1080/10538712.2013.800938