Identifying causal risk factors for self-harm among adolescents with U.S. child protective services contact

Objectives: To estimate effects of potentially modifiable risk factors for self-harm among adolescents in the Child Protective Services (CPS) system. Methods: Data came from the National Survey of Child and Adolescent Well-being, a nationally representative longitudinal survey. Candidate risk factors included child's feelings of worthlessness, the presence of supportive adults in the child's life, and parental psychological aggression. Propensity score weighting (PSW) was used to control for observed confounders, and the average effect of experiencing the risk factor among those who did was estimated using weighted logistic regression. Results: Odds ratios for self-harm comparing youth with low and high parental psychological aggression to none were 0.93 (0.35-2.45) and 1.25 (0.55-2.82), respectively. The OR for feelings of worthlessness was 1.73 (0.70-4.27), and for supportive adults 0.58 (0.28-1.19). The combination of survey and propensity score weights may have affected statistical power. Conclusions: Preventing self-harm in adolescents requires a multifaceted approach given the existing evidence base and lack of strong associations with individual risk factors. Fostering supportive relationships with adults merits future research given the observed, non-significant 42% reduction in odds of self-harm among CPS involved youth who had a supportive relationship with an adult, compared to those who did not.