A significant proportion of Child and Adolescent Mental Health Service (CAMHS) work involves supporting children and young people (CYP) experiencing self-harm (SH) (Hay, Majumder, Fosker, Karim, & O'Reilly, 2015). The high priority accorded the prevention and treatment of SH is justified because of its link with subsequent suicide (Chan et al., 2016). Child and Adolescent Mental Health (CAMH) regularly publishes articles on SH in line with its aim of publishing work of clinical relevance to CAMHS professionals. The practice continues in this issue which has three articles on the subject of SH (Marraccini et al., 2021; Ward & Curran, 2021; Ramsey et al., 2021).

The first article by Marraccini et al. characterised preadolescent children (6–12 years) admitted to a large teaching hospital in south-eastern United States with suicidal behaviour and compared them with adolescents (13–18 years). The authors found that compared with adolescents, preadolescent children were twice more likely to be male, and to be from a Black ethnic background. The preadolescent children were also three times more likely to have a neurodevelopmental disorder such as autism spectrum condition (ASC) or attention deficit hyperactivity disorder (ADHD). The most common stressors were school related. The latter finding emphasises the importance of academic, social and environmental adjustments in schools to accommodate the needs of children with ASC and ADHD. In relation to ethnicity, the overrepresentation of Black children in the preadolescent group study is consistent with the finding in the United States that although suicides decreased among White children aged 5 to 11 years from 2008 to 2012, the rates increased among Black children of same age range (Bridge et al., 2018). This racial disparity in suicide rates may partly be linked to difficulties with help seeking among children of Black ethnicity (Opara et al., 2020). These findings add to a recent call for CAMHS to recognise CYP of Black ethnicity as a particularly vulnerable group (Ayodeji et al., 2021).

CYP with both ADHD and SH are a particularly concerning group because the two conditions can potentially reinforce each other (Allely, 2014). The demographic profile for these conditions show reversed gender proportions whereby more males are affected by ADHD, whereas more females experience SH. One hypothesis for the lower prevalence of ADHD in females is under-recognition (Sayal, Prasad, Daley, Ford, & Coghill, 2018). The article by Ward and Curran 2021 suggests that screening for ADHD symptoms among CYP who present with SH may improve the identification of CYP affected by ADHD – especially females who are more likely to present with SH. The authors analysed the ADHD subscale of the Strengths and Difficulties Questionnaire (SDQ) which were routinely completed by CYP seen in Accident and Emergency Departments in South West London following SH. They found that compared with UK reference population, the CYP presenting with SH were 10 times more likely to score above the cut-off on the ADHD subscale of the SDQ. Seventy-eight percent of the subjects in the study were females, which is consistent with the established epidemiology of CYP experiencing SH. Thus, this study is a call for clinicians to broaden their clinical antennae to improve identification of CYP with ADHD such as in the course of assessment of episodes of SH, more so among females. The availability of free and easy-to-use screening questionnaires such as the SDQ makes this a potentially readily implementable programme in CAMHS.

Dialectical behavioural therapy (DBT) is an evidence-based intervention for SH among adolescents (Kothgassner et al., 2021). Based on emerging evidence of a role for self-criticism in the onset and maintenance of SH, Kothgassner et al. 2021 examined the added benefit of coupling DBT with extra intervention to specifically target self-criticism compared with standard DBT. Their clinical trial in the mid-south region of the United States involved adolescents with self-harming behaviour of which one group received the extra intervention aimed at identifying and internalising positive aspects of themselves. The study found that posttreatment, the extra intervention aimed at reducing self-criticism was associated with fewer episodes of SH compared with standard DBT. The added benefit was more obvious in participants with lower or average levels of pretreatment self-criticism. The authors suggested that the limited benefit for participants with high baseline self-criticism may be due to either a possible mood-improving effect of SH in that group or their need for more intensive intervention. However, although the additional self-criticism–targeted therapy seemed beneficial in terms of reducing frequency of SH, the mechanism of benefit was unclear because there was no direct treatment effect on self-criticism. Given the serious short- and long-term consequences of self-harming behaviours, identification of additional therapeutic strategies to reduce SH remains important. In this regard, targeting self-criticism looks promising but requires further investigation.

An additional aim of this editorial is to introduce myself as a new Associate Editor of CAMH. I will be responsible for a new “Letters to the Editor” section of the Journal. CAMH is an international Journal with a fast growing readership. The fantastic growth of the Journal is reflected in recent metrics, including the increase in the Impact Factor from 1.77 in 2019 to 2.17 in 2020. The editorial board is looking at opportunities to engage more actively with CAMH readers. The new letter section provides one such opportunity. The new section will start with this issue of CAMH. Details of the new section are now available online https://acamh.onlinelibrary.wiley.com/hub/journal/14753588/forauthors.html, but I will highlight a few crucial points. Letters have to be in response to articles already published in the Journal. This is intended to keep letters relevant to discourses that are current in the Journal. Letters may add context, clarify, correct, offer a different interpretation or extend the findings of the target article. To keep letters topical, they need to be submitted within 2 weeks of publication of the print version of the issue containing the target article. It is worth remembering that some articles in an issue are available online as Early View for several weeks ahead of the print version. This gives adequate time for letters to be submitted even ahead of the print version of the target article. A word limit of 500-700 applies, so letters need to be succinct and focused. Submissions will be via https://mc.manuscriptcentral.com/camh_journal. Accepted letters will be assigned a doi; a selection will be published in the print version of the Journal, whereas the rest will appear online. I am very much looking forward to receiving and reviewing your letters.

In addition to managing the letters section, my other remit in the editorial board relates to the theme of inequality. The disproportionate impact of the COVID-19 pandemic on already disadvantaged and marginalised groups and the continuing evidence of racial inequality in mental health make the theme of inequality topical and a matter that CAMH needs to remain alert to. Five concerned colleagues and I have recently published an Editorial Perspective in CAMH on this subject (Ayodeji et al., 2021). The article was published in the September 2021 issue of CAMH, both online and in print. We focused the article on CYP of Black ethnicity while acknowledging that other racialised minority CYP also experience racial inequality. We contrasted the low community prevalence of mental disorder among Black CYP in the United Kingdom with their overrepresentation in more restrictive in-patient psychiatric settings and wondered whether this partly reflects difficulties with early access to CAMHS. We argued that CAMHS needs to be more welcoming for Black CYP and make more efforts to improve their experience of mental health services. I commend this article to our readers and suggest that they share it with colleagues in their Services.

Acknowledgements

The author is an Associate Editor for Child and Adolescent Mental Health. The author has declared that they have no competing or potential conflicts of interest.

Ethical information

No ethical information was required for this editorial.