title: Uncovering key patterns in self-harm in adolescents: Sequence analysis using the Card Sort Task for Self-harm (CaTS).
abstract: Self-harm is a significant clinical issue in adolescence. There is little research on the interplay of key factors in the months, weeks, days and hours leading to self-harm. We developed the Card Sort Task for Self-harm (CaTS) to investigate the pattern of thoughts, feelings, events and behaviours leading to self-harm.
  
  
  
  Forty-five young people (aged 13-21 years) with recent repeated self-harm completed the CaTS to describe their first ever/most recent self-harm episode. Lag sequential analysis determined significant transitions in factors leading to self-harm (presented in state transition diagrams).
  
  
  
  A significant sequential structure to the card sequences produced was observed demonstrating similarities and important differences in antecedents to first and most recent self-harm. Life-events were distal in the self-harm pathway and more heterogeneous. Of significant clinical concern was that the wish to die and hopelessness emerged as important antecedents in the most recent episode. First ever self-harm was associated with feeling better afterward, but this disappeared for the most recent episode.
  
  
  
  Larger sample sizes are necessary to examine longer chains of sequences and differences in genders, age and type of self-harm. The sample was self-selected with 53% having experience of living in care.
  
  
  
  The CaTs offers a systematic approach to understanding the dynamic interplay of factors that lead to self-harm in young people. It offers a method to target key points for intervention in the self-harm pathway. Crucially the factors most proximal to self-harm (negative emotions, impulsivity and access to means) are modifiable with existing clinical interventions.
authors.affiliation: Self-Harm Research Group, School of Psychology, University Park, The University of Nottingham, Nottingham NG7 2RD, UK. Electronic address: ellen.townsend@nottingham.ac.uk.
authors.forename: E
authors.initials: E
authors.lastname: Townsend
authors.affiliation: Self-Harm Research Group, School of Psychology, University Park, The University of Nottingham, Nottingham NG7 2RD, UK.
authors.forename: R
authors.initials: R
authors.lastname: Wadman
authors.affiliation: Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK.
authors.forename: K
authors.initials: K
authors.lastname: Sayal
authors.affiliation: Child and Adolescent Mental Health Service, Nottinghamshire Healthcare NHS Foundation Trust, Thorneywood CAMHS, Porchester Rd, Nottingham NG3 6LF, UK.
authors.forename: M
authors.initials: M
authors.lastname: Armstrong
authors.affiliation: Harmless, 7 Mansfield Road, Nottingham NG1 3FB, UK.
authors.forename: C
authors.initials: C
authors.lastname: Harroe
authors.affiliation: Child and Adolescent Mental Health Service, Nottinghamshire Healthcare NHS Foundation Trust, Thorneywood CAMHS, Porchester Rd, Nottingham NG3 6LF, UK.
authors.forename: P
authors.initials: P
authors.lastname: Majumder
authors.affiliation: School of Neurosciences, Psychology and Behaviour, University of Leicester, Westcotes Drive, Leicester LE3 0QU, UK.
authors.forename: P
authors.initials: P
authors.lastname: Vostanis
authors.affiliation: Self-Harm Research Group, School of Psychology, University Park, The University of Nottingham, Nottingham NG7 2RD, UK.
authors.forename: D
authors.initials: D
authors.lastname: Clarke
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior / Q000523:psychology*; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D016728:Self-Injurious Behavior / Q000523:psychology*; D055815:Young Adult
keywords: Adolescence; Card sort; Impulsivity; Negative emotions; Self-harm; Sequence analysis