Changes in Clinical Functioning Among Adolescents Engaged in Deliberate Self-Harm

Purpose: This paper reports findings from a naturalistic study, which examined changes in clinical functioning over 16 weeks of Dialectical Behavior Therapy (DBT), implemented within the context of an intensive outpatient program among youth engaged in deliberate self-harm (DSH). DSH is a growing phenomenon, with lifetime estimates of 13-45% among community samples, and 40-80% among clinical samples. DSH has been described as difficult to treat, and as a correlate of many other psychiatric disorders and health-risking behaviors. While the relationship between self-harm and suicidality is complex, a history of self-harm is a primary indicator for suicide. DBT is one of the few promising treatments for DSH; however, little is known about changes in functioning while in treatment. This paper investigated within-person change as well as between-person differences in clinical functioning trajectories by baseline characteristics.

Methods: The sample consisted of 138 youth, ages 12-18, with present or recent episodes of DSH who had enrolled in a DBT program, specifically targeting DSH, over a 3-year period. Youth received Miller’s adaptation of DBT, which was delivered over 16 weeks with youth and families attending treatment 2x/week for 3 hours. Clinical functioning was measured weekly through the Youth Outcome Questionnaire Self-Report 2.0, a 64-item measure of clinical functioning for adolescents receiving treatment. Youth self-report on beliefs, attitudes, feelings, moods, and behaviors during the previous 7-day period using a 5-point Likert scale (0-4). The measure has six subscales and a Total Score. The clinical cutoff is 46, with higher scores indicating more distress. A Reliable Change Index of 18 connotes clinically significant change. Hierarchical Linear Modeling (HLM 7.0) was used to model linear growth and to examine variability in change by baseline characteristics.

Results: The sample was 85.5% female and 56.6% white with a mean age of 14.93 (SD=1.32). The mean intercept for the unconditional model was 83.41 (SE=3.05; p<.001), well above the clinical cutoff. Youth experienced improvement in clinical functioning at a rate of 2.02 points (SD=.24) per week (p<.001). Individual youth’s baseline score varied significantly from the group mean (p<.001), and their rate of improvement varied as well (p<.001). The ICC indicated that 60% of functioning differences was due to between-youth variability. Of the baseline characteristics (gender, race/ethnicity, sexual orientation, insurance type, prior psychiatric hospitalization, substance abuse history), two (insurance type, prior psychiatric hospitalization) significantly affected initial status, but not rate of improvement. The best model included both covariates and indicated that public insurance youth with no prior hospitalization showed the most distress at baseline; again, rate of improvement was not differentially affected across groups. We further determined that youth who stayed in treatment longer further improved with scores eventually falling below the clinical cutoff, suggesting benefit from longer treatment periods.

Conclusions: Youth with DSH experience complex problems that have been correlated to other serious concerns, including suicidality. To improve their and their families’ lives effective treatments are needed. This study demonstrated that even within a short treatment period clinical functioning can significantly improve. Implications for treatment and program implementation will be discussed.