SCOPING REVIEW

Practices applied in schools in situations of self-mutilation among adolescents: scope review protocol

Verônica de Medeiros Alves1, Ana Paula Nogueira de Magalhães1, Cristiane Cardoso de Paula2, Maria Cicera dos Santos Albuquerque1, Priscilla Souza dos Santos1, Lucas Gabriel de Melo Pedrosa1

1Universidade Federal de Alagoas, Maceió, AL, Brazil

2Universidade Federal de Santa Maria, Santa Maria, RS, Brazil

ABSTRACT

Objective: Identify practices applied in schools in situations of non-suicidal self-injury in adolescents. Method: The search strategy will be applied in Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed), Excerpta Medica Database (EMBASE/Elsevier); Cumulated Index in Nursing and Allied Health Literature (CINAHL/Ebsco); Scopus/Elsevier, Cochrane Library; Latin America and the Caribbean Health Sciences Literature (LILACS) by Virtual Health Library (VHL), Nursing Database (BDENF); PsycINFO; Education Resources Information Center (ERIC); Web of Science Core Collection, Scientific Electronic Library Online (SCIELO), and gray literature. Primary, quantitative and/or qualitative research articles will be considered without restriction regarding publication date and language. Results will be entered into EndNote X9, and duplicates will be removed. The Rayyan QCRI20 will be used in the selection of studies. This will be done by two independent reviewers blindly. Disagreements will be resolved by consensus or a third reviewer. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flowchart will be used. Data will be extracted using the extraction tool in the JBI scoping review approach.

Descriptors: Self-Injurious Behavior; Adolescent; Schools.

INTRODUCTION

Non-suicidal self-injury is the individual's repeated behavior of inflicting superficial, yet painful, injuries to the surface of his or her body. The purpose is to reduce negative emotions, such as tension, anxiety, and self-reproach, and/or resolve an interpersonal difficulty(¹).

Non-suicidal self-injury is present in adolescents, with a lifetime prevalence between 17% and 60%. It is influenced by multiple factors, including social contagion, interpersonal stressors, neurobiological background, emotional dysregulation, and adverse childhood experiences(²). A systematic review of longitudinal studies showed that its prevalence peaks around 15-16 years and declines in late adolescence (around 18 years)(3). Worldwide, the prevalence varies between 17% and 60% of adolescents(2).

The main risk factors include bullying, mental disorders, and neglect in childhood. Neurobiological studies have shown abnormal stress processing in people with non-suicidal self-injury and an elevated pain threshold in people with repetitive non-suicidal self-injury(4). A systematic review identified psychological (psychiatric morbidity, presence of previous non-suicidal self-injury, psychic suffering), psychosocial (alcohol misuse, family relationships, and poor families), and sociodemographic (age, gender, and ethnicity) risk factors for repeat non-suicidal self-injury. suicidal in adolescents(5).

A study in Brazil, with 517 students (10 to 14 years old), identified a frequency of 9.48% of adolescents with non-suicidal self-injury. The main reasons were to alleviate feelings of emptiness or indifference and cease bad feelings or sensations. The predominance was in females(6). Meta-analysis of cross-sectional studies showed that school absenteeism was associated with an increased risk of non-suicidal self-harm [aOR: 1.37, 95% confidence interval, 1.20-1.57, p= 0.01](7).

Thus, the school becomes a place where it is possible to identify some warning signs: intense anxiety and sadness; apathy; indifference and difficulties in interpersonal relationships; social isolation; sudden changes in behavior; loss of interest in activities you used to enjoy; cold clothes used in hot weather; irritation and aggression for no apparent reason; frequent boredom; worsening in school performance(8).

In Brazil, through Law No. 13,819, of April 26, 2019, the National Policy for the Prevention of Self-Mutilation and Suicide was instituted. From then on, health establishments and schools were obliged to register cases of suicide attempts and non-suicidal self-injury(9). In this scenario, teachers were responsible for dealing with an issue that involved knowing mental illness related to non-suicidal self-injury. This approximation must happen free of prejudice and in a welcoming way. Thus, the need arose to carry out a scoping review to identify the practices applied in schools in situations of non-suicidal self-injury in adolescents. A scoping review is a Joanna Briggs Institute (JBI) method that maps available evidence, identifies knowledge gaps, and guides potential research studies(10-11).

A preliminary search of JBI Evidence Synthesis, Open Science Framework (OSF), the Cochrane Library and Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) was performed in October 2022, and no completed or ongoing systematic or scoping reviews were found. At The International Prospective Register of Systematic Reviews (PROSPERO), a systematic review protocol registered on September 20, 2020, under number CRD42020203378, was identified to evaluate the impact of school intervention on non-suicidal self-injury and the study participants are school-level people or adolescent students aged between 13 and 18 years(12). The current scoping review differs in purpose and study participants.

METHOD

This scoping review will follow the methodological recommendations of the JBI(13). A review protocol was registered in the OSF, under the DOI: 10.17605/OSF.IO/GQAE8 to provide transparency to the process. For the quality and transparency of the writing of this article, the guidelines contained in the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist will be followed(13).

Research question

The review question will be structured by the Participants, Concept, and Context (PCC) acronym. Participants: adolescents, Concept: practices applied in situations of non-suicidal self-injury, and Context: formal education school.

The review question is: What are the practices applied in schools in situations of non-suicidal self-injury in adolescents?

Eligibility criteria

Participants

Documents addressing adolescents will be included, considering the age between 10 and 19 years(14). This will include studies in which data were collected from school professionals, including teachers, administrators, curriculum specialists, researchers, school guidance counselors, vice principals, student counselors, school nurses, educational psychologists, social workers, providers of youth health clinics, policy or education decision-makers, community mental health professionals and other health service professionals(15,16) that carry out activities in schools or partnership with them.

Concept

This review will include documents reporting practices applied in non-suicidal self-injury situation. Practices are those aimed at care, promoting, preventing mental health, and treating non-suicidal self-injury behavior(17).

Non-suicidal self-injury is characterized by the individual's repeated behavior of inflicting superficial injuries, although painful, to the surface of his body. The purpose is to reduce negative emotions, such as tension, anxiety, and self-reproach, and/or to resolve an interpersonal difficulty. The individual will often report an immediate sense of relief that occurs during non-suicidal self-injury(¹). Documents with approaches aimed exclusively at self-injury with suicidal intent will be excluded.

Context

Studies that address formal education schools will be considered, including elementary school (Middle school) and high school(18).

Types of sources

The review will consider primary research articles with quantitative designs, including experimental, descriptive, and observational studies, reporting any quantitative data that may be included in the review and/or qualitative, including phenomenology, grounded theory, ethnography, participatory and qualitative description.

There will be no limitations on publication date and language.

Search Strategy

The search strategy was carried out as follows: an initial search in the MEDLINE/PubMed and Virtual Health Library (VHL) databases was used to establish the relevant search terms identified in the controlled vocabularies: Health Sciences Descriptors (DECS) and Medical Subject Heading (MESH). Keywords identified from the synonyms indicated by the vocabularies, authors' keyword suggestions, team feedback, and terms identified from the preliminary search in the titles, abstracts, and keywords of the articles will be considered. The search strategy applied in MEDLINE/PubMed will be adapted in other sources (Figure 1): Excerpta (EMBASE/Elsevier); Cumulative Index to Nursing and Allied Health Literature (CINAHL/EBSCO); Academic Search Premier (EBSCO), Scopus/Elsevier, Cochrane Library; Scientific and Technical Literature of Latin America and the Caribbean (LILACS), Nursing Database (BDENF), Index Psychology - Periodicals among others from the Regional Portal of the VHL and also the Virtual Library in Adolescent Health (ADOLEC); PsycINFO from the American Psychological Association (APA), Education Resources Information Center (ERIC) and Web of Science Core Collection (Clarivate Analytics), Scientific Electronic Library Online (SCIELO). A search will be made for additional studies in the reference lists of all publications included in the review.

Figure 1 – Search strategy in the MEDLINE/PubMed database. Maceio, AL, Brazil, 2023

Sources of information

A search for gray literature will be carried out in the Bank of Theses and Dissertations of Capes (Coordination for the Improvement of Higher Education Personnel), DART-E, Open Access Thesis and Dissertations (OATD), and the Brazilian Institute of Information in Science and Technology (IBICT), on the World Health Organization (WHO) website and academic search engines: Google Scholar and Bielefeld Academic Search Engine (BASE).

Study selection

Retrieved results will be entered into EndNote v.X9 (Clarivate Analytics, PA, USA), and duplicates will be removed.

The selection of studies will be performed using the Rayyan QCRI2024 online platform. Rayyan is designed to streamline the initial screening of abstracts and titles using a semi-automation process(19). The selection of studies will be based on titles and abstracts according to the eligibility criteria described above. The selection will be made by two independent reviewers blindly, and possible disagreements will be resolved by consensus or by a third reviewer. In cases of doubt, the material will be kept for reading the full text, which will provide more elements for the decision on the relevance of the material to the review.

When accessing the abstracts in the Rayyan QCRI20, based on the inclusion and exclusion criteria, the documents selected and included for full-text reading will be copied to a second screening, where the full-text reading will occur. The reasons for exclusion will be described in an appendix to the review. The results of the search and inclusion process of studies will be reported in the final review of the scoping review and presented in a flowchart PRISMA Extension for Scoping Reviews(11).

Data extraction

Data will be extracted using the standard extraction tool in the JBI scoping review approach(10) for characterizing the studies (Title, Year, Author, Country, Objectives/purpose, Type of study and Data collection method). Specific items will be inserted in this extraction tool to meet the objectives of this review (Figure 2): Participants (Category of education professionals, Type of care, promotion and prevention practice, or school health service - for example, age/gender, sample - Responsible, Instruments used, Instruction used to evaluate the practice), Concept (self-mutilation or non-suicidal self-injury, age group), Context. A pilot will be conducted on the first 10 articles included. The extraction tool can be adapted during the data extraction phase, and the revisions will be documented in the final scope review. The extraction step will be double independent or in a panel to guarantee quality and avoid bias. Any disagreements will be resolved through consensus or by a third reviewer. The review team will contact the authors if an article cannot be retrieved or clarification is needed.

 General characteristics

Characterization of the studies: Title, year, author, country, objectives/purpose, type of study, collection method.

Participants (Education professionals category, Type of care, promotion and prevention practice, or school health service - for example, age/sex, sample - Responsible, Instruments used, Instruction used to evaluate the practice)

Concept: (non-suicidal self-mutilation or self-injury, age group)

Context: formal education school

Figure 2 - Instrument for extracting data for scoping review. Maceio, AL, Brazil, 2023

Data analysis and presentation

The data extracted from the included studies will be presented in a narrative summary and tables according to the categories listed in the extraction tool: characterization of the studies, participants, concept, context, applied practice, person in charge, evaluation, and time intervals for monitoring the practices.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

FUNDING

This paper was carried out with the support of the National Council for Scientific and Technological Development (CNPq). Process No. 406326/2021-5.

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Submission: 03/03/2023

Approved: 07/10/2023