Age of first self-harm act in childhood and adolescence: A scoping review protocol

Daisy Wiggin; Elaine McMahon; Fiona McNicholas; Almas Khan; Eve Griffin

doi:10.12688/hrbopenres.13764.1

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Study Protocol

Age of first self-harm act in childhood and adolescence: A scoping review protocol

[version 1; peer review: 2 approved with reservations]

Daisy Wiggin ¹, Elaine McMahon^1,2, Fiona McNicholas^3-5, Almas Khan^1,2, Eve Griffin^1,2

Daisy Wiggin ¹, Elaine McMahon^1,2, [...] Fiona McNicholas^3-5, Almas Khan^1,2, Eve Griffin^1,2

PUBLISHED 26 Jul 2023

Author details Author details

¹ School of Public Health, University College Cork, Cork, Ireland
² National Suicide Research Foundation, Cork, Ireland
³ Department of Psychiatry, School of Medicine, University College Dublin, Dublin, Ireland
⁴ Department of Child and Adolescent Liaison Psychiatry, Our Lady’s Children’s Hospital Crumlin, Dublin, Ireland
⁵ Lucena Child and Adolescent Mental Health Services, St John of God, Dublin, Ireland

Daisy Wiggin
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation

Elaine McMahon
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Fiona McNicholas
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Almas Khan
Roles: Validation, Writing – Review & Editing

Eve Griffin
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Self-harm in young people is associated with adverse outcomes for many. The age of first self-harm is not often reported in the literature and there is considerable heterogeneity in how it is reported and in the methods used to estimate it. The objective of this study will be to examine the age of first self-harm act in childhood and adolescence and to identify the methods used to assess this.
Methods: This scoping review will follow JBI guidance. Five electronic databases, Medline, PsycInfo, CINAHL Plus, Embase, and Web of Science will be searched from inception. Grey literature will be searched via Google Scholar. Studies reporting the age of first act of self-harm in young people aged 17 years and younger are of interest. Any study design and methodology will be eligible for inclusion. Included studies may use any self-harm definition, any measures used to assess self-harm and the age of the first act. The focus can be in any context, including health services presenting or community samples. Title and abstract screening and full text screening will be carried out by two reviewers independently. The data extraction tool will be piloted by two reviewers independently, included studies will undergo data extraction by one reviewer and this will be checked by a second, independent reviewer.
Results: The resulting data will be presented using descriptive statistics, in tabular format, and accompanied with a narrative presentation of results. The results of this study will be distributed by publication in an academic journal.

Keywords

Youth self-harm, onset of self-harm, child and adolescent mental health, suicidal behaviour

Corresponding author: Daisy Wiggin

Competing interests: No competing interests were disclosed.

Grant information: Health Research Board (CDA-2021-008) to DW; and Health Research Board (EIA-2019-005) to EG.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2023 Wiggin D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Wiggin D, McMahon E, McNicholas F et al. Age of first self-harm act in childhood and adolescence: A scoping review protocol [version 1; peer review: 2 approved with reservations]. HRB Open Res 2023, 6:36 (https://doi.org/10.12688/hrbopenres.13764.1) First published: 26 Jul 2023, 6:36 (https://doi.org/10.12688/hrbopenres.13764.1) Latest published: 22 Nov 2023, 6:36 (https://doi.org/10.12688/hrbopenres.13764.2)

Introduction

Self-harm in childhood and adolescence is a concerning public health phenomenon associated with an increased risk of mental health problems, future self-harm (Mars et al., 2014) and dying by suicide (Hawton et al., 2020; Ross et al., 2023). Self-harm is defined in this review as ‘an act with non-fatal outcome in which an individual deliberately initiates a non-habitual behaviour, that without intervention from others will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realising changes that the person desires via the actual or expected physical consequences’ (Schmidtke et al., 1996). This definition does not differentiate based on the motive(s) of or suicidal intent associated with the behaviour. It is argued that suicidal intent is a dimensional phenomenon (Hawton et al., 2012) and therefore, it is inclusive of both non-suicidal self-injury (NSSI) and attempted suicide, a dichotomy used mostly in the United States and Canada (Muehlenkamp et al., 2012). Moreover, an international study of self-harm in the community found that ‘non-suicidal’ reasons (e.g., relief from terrible state of mind, self-punishment) often co-occurred with a wish to die (Scoliers et al., 2009).

The lifetime prevalence of self-harm in adolescence has been estimated to be 16.1%, however there are inconsistencies in estimates which are thought to arise from differences in nomenclature, geographical area, and whether a single or multiple item measure is used (Muehlenkamp et al., 2012). In Ireland, rates of hospital-presenting self-harm have increased by 22% in adolescents and young people under 25 years of age, with the most pronounced increase among females aged 10–14 years (Griffin et al., 2018), suggesting that the age of engaging in self-harm for the first time may be decreasing.

Defining and measuring age of onset of psychopathology in general is difficult (Jones, 2013), the knock-on effect being that the operationalisation of age of onset in the literature is highly inconsistent. In a large meta-analysis estimating the age of onset of a range of disorders, first symptom, first diagnosis, first hospitalisation and first contact with treatment service were reported definitions (Solmi et al., 2022). Similarly, in schizophrenia, age at onset has been defined as age at first admission to hospital, age at first psychotic symptoms, and age at first contact with healthcare professionals (Immonen et al., 2017). It is difficult to know if early symptoms are in fact signalling a mental disorder, it is only in retrospect when a decision can be made regarding the relevance of early symptoms to an eventual disorder (Jones, 2013). Self-harm may be different, as it is a behaviour rather than a disorder, however it is often associated with borderline personality disorder for example (American Psychiatric Association, 2022), although its close relationship with this diagnosis has been challenged (Long et al., 2013). Self-harm will be considered as a standalone behaviour in this review. A prior systematic review found that age at first NSSI act averaged between 12–14 years; variations in the estimate suggest that there may be different developmental trajectories in NSSI (Cipriano et al., 2017). Further, a meta-analysis estimates the first self-harm act to be at an average age of 12.8 years (95% CI 11.78-13.84; Gillies et al., 2018). However, the operationalisation of age of first act and the methods used to determine first act are not reported in these reviews.

The study of age of first act of self-harm is relatively new, and an informal literature search suggests studies in the area are rather heterogeneous in their definitions, operationalisations, and methods of assessment. Therefore, a scoping review is an appropriate design to provide an overview of the literature with respect to the age of first act of self-harm in childhood and adolescence (Munn et al., 2018). This review aims to report as well as map the available evidence with a view to improving understanding of how age of first self-harm act is measured and defined, and to identify gaps in how this can be accurately achieved. This review aims to answer the following research question and sub question: What is the age of first act of self-harm in young people aged 17 years and younger and what definitions and methods are used to determine age of first act?

Methods

This protocol was prepared following JBI guidance for the preparation of scoping review protocols (Peters et al., 2022) and has been registered on the Open Science Framework (Wiggin et al., 2023). The review will be conducted in accordance with JBI guidance for the conduct of scoping reviews (Peters et al., 2020) and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review extension (PRISMA-ScR; Tricco et al., 2018).

Eligibility criteria

All primary studies which report the age of first self-harm act will be eligible for inclusion. No language or time restrictions will be applied. Table 1 contains a list of the full inclusion and exclusion criteria. An exclusion criterion of note is stereotypic self-harm behaviours associated with intellectual disabilities and neurodivergence. These behaviours are argued to be biologically driven and serve a purpose of self-stimulation and a need for increased sensory input (e.g., intense, repetitive, rhythmic behaviours such as eyeball pressing and head banging; (Ryan et al., 2008). This category of behaviour is outside the conceptual scope of this review.

Table 1. Inclusion and exclusion criteria.

Inclusion Criteria

Exclusion Criteria

▪   Sample first self-harmed at 17 years or
younger
▪   Age of first self-harm act reported
▪   Any self-harm definition used by authors
▪   Any measures used to assess age of first
self-harm act
▪   Any context (e.g., health-service
presenting, community)

▪   Age of first self-harm act not reported
▪   Age of first self-harm act was reported to be in adulthood (18 years and above)
▪   Study examines stereotypic self-harm behaviours more common in intellectual
disabilities and autism (e.g., intense, repetitive, rhythmic behaviours such as
eyeball pressing and head banging)
▪   Study reports on thoughts of self-harm and/or thoughts of suicide only

Population

The population of interest is anyone who first self-harmed during childhood and adolescence. Adolescence as the time between childhood and adulthood has varied timespans and beginning and ending ages. With evolving economic and social contexts, it has recently been argued that the ages of 10–24 years better fit the current development of adolescents (Sawyer et al., 2018). That being said, health services are provided to children and adolescents until the age of 18 years in many countries, after which they are treated as adults. Therefore, the term adolescence in this review refers to those aged 10–17, with children being aged 10 years and under (Sawyer et al., 2018).

Concepts

The concepts of interest are self-harm, as defined above, and the age at which self-harm was first engaged in during childhood and adolescence. Self-harm is defined differently across the literature, with some drawing a dichotomy between suicide attempts and NSSI and others who do not use this dichotomy. Additionally, NSSI Disorder and Suicidal Behavior Disorder have been proposed in the DSM-5 (American Psychiatric Association, 2022). Studies operating from any definition of self-harm or these proposed disorders will be eligible for inclusion in this review. Age of first act is also differentially applied in the literature; as previously mentioned it can be defined as the first self-harm presentation to health services or when first self-harmed in a private setting. Studies will be eligible regardless of the operationalisation of age of first act; details of the operationalisation will be collected as part of this review. However, this can be impacted by the availability of data and methodological constraints which are discussed next.

Context

Self-harm can occur in the context of community and in health service-presenting samples, including primary and secondary care. The iceberg model of self-harm estimates that adolescents who present to hospital represent 6% of those who self-harm in the community in Ireland (McMahon et al., 2014); this estimate is higher in England (Geulayov et al., 2018). This provides evidence that hospital presentations represent a small proportion of adolescents who self-harm. In the interest of capturing a broad view of the literature, all settings are of interest in this current review. In a community sample, the start of self-harm can mean when the person initiates the behaviour in a private setting, presents to a general practitioner or other healthcare practitioner, or it is confirmed by a parent/guardian. This information is often captured using retrospective recall via self-report survey data or interviews. In self-harm that presents to hospital, the start of self-harm would often be captured by surveillance registries (e.g., National Self-Harm Registry Ireland (Joyce et al., 2022), Multicentre Study of Self-Harm in England (Hawton et al., 2007)) as the first presentation to hospital. All determinations of engaging in self-harm for the first time will be included in this review and reported.

Evidence sources

Electronic searches for relevant studies have been conducted in Medline (EBSCO), PsycInfo (EBSCO), Embase (Elsevier), CINAHL Plus (EBSCO), and Web of Science (Clarivate) from inception to 26^th June 2023. Grey literature will be included by screening the first 50 results of a Google Scholar search. Any study methodology will be eligible for inclusion. In the instance where sources are encountered in duplicate – primary sources and evidence syntheses that have included the primary source – primary sources will be excluded if already incorporated into an included evidence synthesis unless the data they contain are not otherwise reported in the evidence synthesis.

Search strategy

Search terms related to the concepts of age at first act (e.g., ‘age of onset’), self-harm (e.g., ‘deliberate self-harm’) and the population of interest (e.g., ‘child’) were developed in consultation with prior systematic reviews and primary studies in this area. The full search strategy for Medline is available from the Open Science Framework registration (Wiggin et al., 2023). The search strategy was developed with and validated by a librarian in University College Cork.

Study records

Data management. The search results will be exported to Zotero for deduplication and then to Rayyan (https://www.rayyan.ai/) for managing citations, performing title and abstract screening, and data extraction.

Selection process. Titles and abstracts of eligible studies will be assessed according to the eligibility criteria in Table 1. The screening process will be piloted with five potentially relevant articles to assess for consistent application. Articles deemed relevant at this stage will undergo full-text screening according to the eligibility criteria. During the pilot and both screening stages, two reviewers will work independently, disagreements will be resolved by discussion or a third reviewer if necessary. Given the broad nature of a scoping review, new relevant terms and locations of evidence may be discovered during the selection process. Therefore, the search strategy may be modified during the review process to account for new discoveries. Studies excluded after full-text screening will be reported, alongside reasons for exclusion, in the final report. Included studies will be subject to forward and backward citation searching.

Data extraction. Data extraction will be performed on all studies included after full-text screening. This will be completed by one reviewer and checked by an independent second reviewer. Disagreements will be resolved by discussion or a third reviewer if necessary. The data extraction form below will be piloted by two reviewers independently on a small subset of studies to ensure all relevant results are extracted, with any proposed discrepancies and amendments being discussed and decided by the wider research team. Study authors will be contacted for additional information if necessary. The final version of the data extraction form used will be included in the final report with any amendments explained. The proposed data extraction items are outlined in Table 2.

Table 2. Data extraction items.

Items
1. Primary author
2. Year of publication
3. Geographic setting(s) of the study
4. Funding source(s)
5. Study design
6. Study period
7. Self-harm definition used
8. First self-harm act definition used
9. Method used to determine age of first act
10. Method used to assess self-harm behaviour
11. First act is a primary study aim
12. Sample size
13. Sample characteristics:
• Age (mean and standard deviation or equivalent)
• Gender (proportions)
• Age of first act (mean and standard deviation or equivalent)
• Method of self-harm used for first act (proportions)
• Contact with primary and/or secondary mental health services (proportions)

Data analysis and presentation

Findings will be descriptively, narratively, and graphically presented. Evidence related to age of first self-harm act will be reported using descriptive statistics and tables. Definitions of first self-harm act, methods used to assess age at first act, definitions of self-harm, and the relevant contexts will be presented in tabular format, narratively, and using descriptive statistics if appropriate.

Deviations from the protocol

Amendments to the protocol prior to and during the conduct of the review will be documented by tabulating version history and important changes in the protocol. Any such deviations will be described in the final report.

Study status

The search strategy has been implemented and records are awaiting screening at the time of publication of this protocol.

Data availability

Underlying data

Open Science Framework: Age of first self-harm act in childhood and adolescence: A scoping review protocol. https://doi.org/10.17605/OSF.IO/FEHTD. (Wiggin et al., 2023).

This project contains the following underlying data:

Medline-Search-Strategy_Age-of-Onset_ScR.docx. (Full search strategy for Medline).

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgements

Thank you to Virginia Conrick for contributing to the development and validation of the search strategy.

Faculty Opinions recommended

References

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Geulayov G, Casey D, McDonald KC, et al.: Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): A retrospective study. Lancet Psychiatry. 2018; 5(2): 167–174. PubMed Abstract | Publisher Full Text
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Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 26 Jul 2023

Author details Author details

Daisy Wiggin
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation

Elaine McMahon
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Fiona McNicholas
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Almas Khan
Roles: Validation, Writing – Review & Editing

Eve Griffin
Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

Health Research Board (CDA-2021-008) to DW; and Health Research Board (EIA-2019-005) to EG.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

version 2

Revised

Published: 22 Nov 2023, 6:36

https://doi.org/10.12688/hrbopenres.13764.2

version 1

Published: 26 Jul 2023, 6:36

https://doi.org/10.12688/hrbopenres.13764.1

© 2023 Wiggin D et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Wiggin D, McMahon E, McNicholas F et al. Age of first self-harm act in childhood and adolescence: A scoping review protocol [version 1; peer review: 2 approved with reservations]. HRB Open Res 2023, 6:36 (https://doi.org/10.12688/hrbopenres.13764.1)

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VERSION 1

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Reviewer Report 05 Oct 2023

Faraz Mughal, School of Medicine, Keele University, Keele, England, UK

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15056.r36098

This is a clear, concise, and well written protocol.

I only have a few comments to make as it is written very well, is coherent, and should add useful new findings to this topic area.

... Continue reading

This is a clear, concise, and well written protocol.

I only have a few comments to make as it is written very well, is coherent, and should add useful new findings to this topic area.

It is good the authors will report this scoping review in line the relevant PRISMA checklist.

I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature. Could also run searches on Microsoft Edge.

It is not clear how the data extraction will be checked by a second member of the team - what is this process?

A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Primary care, suicide prevention, self-harm.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Report a concern

Author Response 24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

24 Nov 2023

Author Response

Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first ... Continue reading Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature.”
Response: This is a valid point. We will expand the search of Google Scholar to include the first 100 results. In addition, as per the suggestion of Reviewer 1, we’ve included searching EThOS to improve our coverage of grey literature , including publications from charity organisations, NGOs, governmental agencies, and dissertations. The two abovementioned changes have been reflected and detailed in the ‘Evidence sources’ subsection of the Methods section.

Comment: “It is not clear how the data extraction will be checked by a second member of the team - what is this process?”
Response: The text in the ‘Data extraction’ part of the ‘Study records’ subsection of the Methods section has been updated to include that extracted data will be checked against the originating record.

Comment: “A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.”
Response: We apologise that you weren’t able to access the Medline search strategy, we hope you can access it directly via the following link: https://osf.io/uqmkf.
Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature.”
Response: This is a valid point. We will expand the search of Google Scholar to include the first 100 results. In addition, as per the suggestion of Reviewer 1, we’ve included searching EThOS to improve our coverage of grey literature , including publications from charity organisations, NGOs, governmental agencies, and dissertations. The two abovementioned changes have been reflected and detailed in the ‘Evidence sources’ subsection of the Methods section.

Comment: “It is not clear how the data extraction will be checked by a second member of the team - what is this process?”
Response: The text in the ‘Data extraction’ part of the ‘Study records’ subsection of the Methods section has been updated to include that extracted data will be checked against the originating record.

Comment: “A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.”
Response: We apologise that you weren’t able to access the Medline search strategy, we hope you can access it directly via the following link: https://osf.io/uqmkf.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

24 Nov 2023

Author Response

Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first ... Continue reading Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature.”
Response: This is a valid point. We will expand the search of Google Scholar to include the first 100 results. In addition, as per the suggestion of Reviewer 1, we’ve included searching EThOS to improve our coverage of grey literature , including publications from charity organisations, NGOs, governmental agencies, and dissertations. The two abovementioned changes have been reflected and detailed in the ‘Evidence sources’ subsection of the Methods section.

Comment: “It is not clear how the data extraction will be checked by a second member of the team - what is this process?”
Response: The text in the ‘Data extraction’ part of the ‘Study records’ subsection of the Methods section has been updated to include that extracted data will be checked against the originating record.

Comment: “A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.”
Response: We apologise that you weren’t able to access the Medline search strategy, we hope you can access it directly via the following link: https://osf.io/uqmkf.
Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature.”
Response: This is a valid point. We will expand the search of Google Scholar to include the first 100 results. In addition, as per the suggestion of Reviewer 1, we’ve included searching EThOS to improve our coverage of grey literature , including publications from charity organisations, NGOs, governmental agencies, and dissertations. The two abovementioned changes have been reflected and detailed in the ‘Evidence sources’ subsection of the Methods section.

Comment: “It is not clear how the data extraction will be checked by a second member of the team - what is this process?”
Response: The text in the ‘Data extraction’ part of the ‘Study records’ subsection of the Methods section has been updated to include that extracted data will be checked against the originating record.

Comment: “A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.”
Response: We apologise that you weren’t able to access the Medline search strategy, we hope you can access it directly via the following link: https://osf.io/uqmkf.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 05 Oct 2023

Daniel Romeu, Leeds Institute of Health Sciences, University of Leeds, Leeds, England, UK

Approved with Reservations

https://doi.org/10.21956/hrbopenres.15056.r36097

Thank you for the opportunity to review this scoping review protocol. It is clearly and comprehensively written and addresses an important gap in the literature. I support its acceptance for indexing with a few minor suggested amendments.

Introduction

The background to the proposed review is clearly outlined and its rationale is evident. Although this is only the protocol, it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?

The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.

Methods
The authors have transparently described the proposed methods which are robust and in keeping with JBI guidance. The process of study selection and data extraction is strong and its iterative nature has been acknowledged. The authors plan to pilot the tools they will use for these processes.

Eligibility criteria

The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in "many countries". Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.

The authors refer to settings as either being community- or health service-based, then explain that "all settings" are of interest. I suspect that this refers to "all healthcare settings" but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.

Evidence sources

The empirical evidence sources look appropriate and the search strategies appear broad but robust. The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?

The authors have specified Google Scholar as their only grey literature source, and they will stop screening after 50 results. Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a 'stop rule' for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors' consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Mental health, self-harm, health services, unexplained symptoms

CITE

Report a concern

Author Response 24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

24 Nov 2023

Author Response

Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be ... Continue reading Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?”
Response: Thank you for this suggestion, we have added a section after the methods entitled ‘Implications for research and practice’ in which we describe the anticipated impact of this research.

Comment: “The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.”
Response: Thank you for this helpful comment. This is a very valid point, and we agree that self-harm is associated with a wider breadth of emotional distress than originally mentioned. We have revised the Introduction section accordingly. In paragraph three of the Introduction section, we mention that a substantial proportion of young people who self-harm have been given psychiatric diagnoses, but a majority self-harm in the absence of receiving a diagnosis. We outline that this is the basis on which we decide to treat self-harm as a standalone behaviour.

Comment: “The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in “many countries”. Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.”
Response: In the ‘Population’ subsection of the Methods section, we list countries who use 18 years of age as the transition age from child and adolescent to adult mental health services according to the MILESTONE study.

Comment: “The authors refer to settings as either being community- or health service-based, then explain that “all settings” are of interest. I suspect that this refers to “all healthcare settings” but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.”
Response: Thank you for highlighting this. We intend to include all settings including healthcare and community settings like schools and third sector organisations and have clarified this in the ‘Context’ subsection and in ‘Table 1. Inclusion and exclusion criteria’ located in the Methods section.

Comment: “The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?”
Response: The search strategy as detailed in this protocol retrieved approximately 3,000 original records on 26^th June 2023. We deem this a feasible number of records to screen over the course of a few months. If the screening and extraction process becomes lengthy we will invite a third reviewer to join the reviewing team. We have included text to this effect in the ‘Data management’ part of the ‘Study records’ subsection in the Methods section.

Comment: “Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a ‘stop rule’ for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors’ consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?”
Response: Thank you for highlighting the importance of grey literature. We did not use a ‘stop rule’ for the Google Scholar search. SCIE is part of the Web of Science’s Core Collection, a database we included in our evidence sources. We will include EThOS in our grey literature search, expand our Google Scholar search to the first 100 results as per the suggestion of Reviewer 2, and have detailed how we will further expand our search to include the suggested sources of information in the ‘Evidence sources’ subsection of the Methods section.
Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?”
Response: Thank you for this suggestion, we have added a section after the methods entitled ‘Implications for research and practice’ in which we describe the anticipated impact of this research.

Comment: “The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.”
Response: Thank you for this helpful comment. This is a very valid point, and we agree that self-harm is associated with a wider breadth of emotional distress than originally mentioned. We have revised the Introduction section accordingly. In paragraph three of the Introduction section, we mention that a substantial proportion of young people who self-harm have been given psychiatric diagnoses, but a majority self-harm in the absence of receiving a diagnosis. We outline that this is the basis on which we decide to treat self-harm as a standalone behaviour.

Comment: “The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in “many countries”. Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.”
Response: In the ‘Population’ subsection of the Methods section, we list countries who use 18 years of age as the transition age from child and adolescent to adult mental health services according to the MILESTONE study.

Comment: “The authors refer to settings as either being community- or health service-based, then explain that “all settings” are of interest. I suspect that this refers to “all healthcare settings” but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.”
Response: Thank you for highlighting this. We intend to include all settings including healthcare and community settings like schools and third sector organisations and have clarified this in the ‘Context’ subsection and in ‘Table 1. Inclusion and exclusion criteria’ located in the Methods section.

Comment: “The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?”
Response: The search strategy as detailed in this protocol retrieved approximately 3,000 original records on 26^th June 2023. We deem this a feasible number of records to screen over the course of a few months. If the screening and extraction process becomes lengthy we will invite a third reviewer to join the reviewing team. We have included text to this effect in the ‘Data management’ part of the ‘Study records’ subsection in the Methods section.

Comment: “Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a ‘stop rule’ for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors’ consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?”
Response: Thank you for highlighting the importance of grey literature. We did not use a ‘stop rule’ for the Google Scholar search. SCIE is part of the Web of Science’s Core Collection, a database we included in our evidence sources. We will include EThOS in our grey literature search, expand our Google Scholar search to the first 100 results as per the suggestion of Reviewer 2, and have detailed how we will further expand our search to include the suggested sources of information in the ‘Evidence sources’ subsection of the Methods section.
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

24 Nov 2023

Author Response

Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be ... Continue reading Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?”
Response: Thank you for this suggestion, we have added a section after the methods entitled ‘Implications for research and practice’ in which we describe the anticipated impact of this research.

Comment: “The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.”
Response: Thank you for this helpful comment. This is a very valid point, and we agree that self-harm is associated with a wider breadth of emotional distress than originally mentioned. We have revised the Introduction section accordingly. In paragraph three of the Introduction section, we mention that a substantial proportion of young people who self-harm have been given psychiatric diagnoses, but a majority self-harm in the absence of receiving a diagnosis. We outline that this is the basis on which we decide to treat self-harm as a standalone behaviour.

Comment: “The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in “many countries”. Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.”
Response: In the ‘Population’ subsection of the Methods section, we list countries who use 18 years of age as the transition age from child and adolescent to adult mental health services according to the MILESTONE study.

Comment: “The authors refer to settings as either being community- or health service-based, then explain that “all settings” are of interest. I suspect that this refers to “all healthcare settings” but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.”
Response: Thank you for highlighting this. We intend to include all settings including healthcare and community settings like schools and third sector organisations and have clarified this in the ‘Context’ subsection and in ‘Table 1. Inclusion and exclusion criteria’ located in the Methods section.

Comment: “The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?”
Response: The search strategy as detailed in this protocol retrieved approximately 3,000 original records on 26^th June 2023. We deem this a feasible number of records to screen over the course of a few months. If the screening and extraction process becomes lengthy we will invite a third reviewer to join the reviewing team. We have included text to this effect in the ‘Data management’ part of the ‘Study records’ subsection in the Methods section.

Comment: “Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a ‘stop rule’ for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors’ consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?”
Response: Thank you for highlighting the importance of grey literature. We did not use a ‘stop rule’ for the Google Scholar search. SCIE is part of the Web of Science’s Core Collection, a database we included in our evidence sources. We will include EThOS in our grey literature search, expand our Google Scholar search to the first 100 results as per the suggestion of Reviewer 2, and have detailed how we will further expand our search to include the suggested sources of information in the ‘Evidence sources’ subsection of the Methods section.
Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?”
Response: Thank you for this suggestion, we have added a section after the methods entitled ‘Implications for research and practice’ in which we describe the anticipated impact of this research.

Comment: “The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.”
Response: Thank you for this helpful comment. This is a very valid point, and we agree that self-harm is associated with a wider breadth of emotional distress than originally mentioned. We have revised the Introduction section accordingly. In paragraph three of the Introduction section, we mention that a substantial proportion of young people who self-harm have been given psychiatric diagnoses, but a majority self-harm in the absence of receiving a diagnosis. We outline that this is the basis on which we decide to treat self-harm as a standalone behaviour.

Comment: “The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in “many countries”. Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.”
Response: In the ‘Population’ subsection of the Methods section, we list countries who use 18 years of age as the transition age from child and adolescent to adult mental health services according to the MILESTONE study.

Comment: “The authors refer to settings as either being community- or health service-based, then explain that “all settings” are of interest. I suspect that this refers to “all healthcare settings” but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.”
Response: Thank you for highlighting this. We intend to include all settings including healthcare and community settings like schools and third sector organisations and have clarified this in the ‘Context’ subsection and in ‘Table 1. Inclusion and exclusion criteria’ located in the Methods section.

Comment: “The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?”
Response: The search strategy as detailed in this protocol retrieved approximately 3,000 original records on 26^th June 2023. We deem this a feasible number of records to screen over the course of a few months. If the screening and extraction process becomes lengthy we will invite a third reviewer to join the reviewing team. We have included text to this effect in the ‘Data management’ part of the ‘Study records’ subsection in the Methods section.

Comment: “Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a ‘stop rule’ for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors’ consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?”
Response: Thank you for highlighting the importance of grey literature. We did not use a ‘stop rule’ for the Google Scholar search. SCIE is part of the Web of Science’s Core Collection, a database we included in our evidence sources. We will include EThOS in our grey literature search, expand our Google Scholar search to the first 100 results as per the suggestion of Reviewer 2, and have detailed how we will further expand our search to include the suggested sources of information in the ‘Evidence sources’ subsection of the Methods section.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 26 Jul 2023

Open Peer Review

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Reviewer Reports

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	1	2
Version 2 (revision) 22 Nov 23	read	read
Version 1 26 Jul 23	read	read

Daniel Romeu, University of Leeds, Leeds, UK
Faraz Mughal, Keele University, Keele, UK

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Reviewer Report

22 Views

11 Dec 2023 | for Version 2

Faraz Mughal, School of Medicine, Keele University, Keele, England, UK

22 Views Cite this report Responses(0)

Approved

I am happy with these revisions. Please proceed to full approval from my part.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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30 Views

23 Nov 2023 | for Version 2

Daniel Romeu, Leeds Institute of Health Sciences, University of Leeds, Leeds, England, UK

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Approved

I have reviewed the revised article and I can confirm that the authors have considered my comments and made appropriate improvements to their manuscript. I am happy for the article to be accepted for indexing in its current form.

Competing Interests

No competing interests were disclosed.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Reviewer Report

52 Views

05 Oct 2023 | for Version 1

Faraz Mughal, School of Medicine, Keele University, Keele, England, UK

52 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Primary care, suicide prevention, self-harm.

Respond to this report

Responses (1)

Author Response

24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

Thank you for reviewing our protocol and offering valid points for improvement. We respond to your comments below.

Comment: “I would expand the google scholar search to the first 100 or even more hits to screen and consider using incognito to get an accurate picture of what it is on the internet in terms of grey literature.”
Response: This is a valid point. We will expand the search of Google Scholar to include the first 100 results. In addition, as per the suggestion of Reviewer 1, we’ve included searching EThOS to improve our coverage of grey literature , including publications from charity organisations, NGOs, governmental agencies, and dissertations. The two abovementioned changes have been reflected and detailed in the ‘Evidence sources’ subsection of the Methods section.

Comment: “It is not clear how the data extraction will be checked by a second member of the team - what is this process?”
Response: The text in the ‘Data extraction’ part of the ‘Study records’ subsection of the Methods section has been updated to include that extracted data will be checked against the originating record.

Comment: “A minor point but I couldn't find the MEDLINE search strategy in the OSF registration.”
Response: We apologise that you weren’t able to access the Medline search strategy, we hope you can access it directly via the following link: https://osf.io/uqmkf.

View more View less

Competing Interests

No competing interests were disclosed.

Back to all reports

Reviewer Report

64 Views

05 Oct 2023 | for Version 1

Daniel Romeu, Leeds Institute of Health Sciences, University of Leeds, Leeds, England, UK

64 Views Cite this report Responses(1)

Approved With Reservations

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Mental health, self-harm, health services, unexplained symptoms

Respond to this report

Responses (1)

Author Response

24 Nov 2023

Daisy Wiggin, School of Public Health, University College Cork, Cork, Ireland

Thank you for your thoughtful review of our protocol and proposing important opportunities for clarification and improvement. We have provided responses to your comments below.

Comment: “it would be useful for the authors to outline the expected implications of this review and its results. What impact will this knowledge have on future research and clinical practice?”
Response: Thank you for this suggestion, we have added a section after the methods entitled ‘Implications for research and practice’ in which we describe the anticipated impact of this research.

Comment: “The authors mention the association of self-harm with borderline personality disorder and allude to its controversy without offering opinion. The concept of borderline personality disorder is in itself controversial. Self-harm is associated with a breadth of mental health conditions (mood disorders, psychotic disorders, neurodevelopmental conditions, substance misuse, personality disorders etc). I wonder whether the authors should comment on this (rather than the association with BPD specifically) and use that as justification for the consideration of self-harm as a standalone behaviour in this review.”
Response: Thank you for this helpful comment. This is a very valid point, and we agree that self-harm is associated with a wider breadth of emotional distress than originally mentioned. We have revised the Introduction section accordingly. In paragraph three of the Introduction section, we mention that a substantial proportion of young people who self-harm have been given psychiatric diagnoses, but a majority self-harm in the absence of receiving a diagnosis. We outline that this is the basis on which we decide to treat self-harm as a standalone behaviour.

Comment: “The justification of excluding young people aged 18 and over is unclear beyond explanation that this is the cut-off for adult services in “many countries”. Specifying which countries have this cut-off will improve the generalisability and impact of this review and its findings.”
Response: In the ‘Population’ subsection of the Methods section, we list countries who use 18 years of age as the transition age from child and adolescent to adult mental health services according to the MILESTONE study.

Comment: “The authors refer to settings as either being community- or health service-based, then explain that “all settings” are of interest. I suspect that this refers to “all healthcare settings” but this is not explicit. There is no mention of other important settings such as schools and third-sector organisations which should be considered.”
Response: Thank you for highlighting this. We intend to include all settings including healthcare and community settings like schools and third sector organisations and have clarified this in the ‘Context’ subsection and in ‘Table 1. Inclusion and exclusion criteria’ located in the Methods section.

Comment: “The protocol would benefit from commentary on the feasibility of managing the results given the minimal exclusion criteria (have pilot searches been conducted)?”
Response: The search strategy as detailed in this protocol retrieved approximately 3,000 original records on 26^th June 2023. We deem this a feasible number of records to screen over the course of a few months. If the screening and extraction process becomes lengthy we will invite a third reviewer to join the reviewing team. We have included text to this effect in the ‘Data management’ part of the ‘Study records’ subsection in the Methods section.

Comment: “Reviewing the grey literature is essential to the achieving the research aims and the breadth of this topic area warrants a more extensive approach. Have the authors considered a ‘stop rule’ for their Google search (stopping when X number of irrelevant consecutive results have been found)? Charities, third-sector organisations and dissertations may yield important results, and this review would be strengthened by the authors’ consideration of these sources of information. Have they considered grey literature databases e.g. SCIE, EThOS?”
Response: Thank you for highlighting the importance of grey literature. We did not use a ‘stop rule’ for the Google Scholar search. SCIE is part of the Web of Science’s Core Collection, a database we included in our evidence sources. We will include EThOS in our grey literature search, expand our Google Scholar search to the first 100 results as per the suggestion of Reviewer 2, and have detailed how we will further expand our search to include the suggested sources of information in the ‘Evidence sources’ subsection of the Methods section.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Age of first self-harm act in childhood and adolescence: A scoping review protocol

Abstract

Keywords

Introduction

Methods

Eligibility criteria

Table 1. Inclusion and exclusion criteria.

Population

Concepts

Context

Evidence sources

Search strategy

Study records

Table 2. Data extraction items.

Data analysis and presentation

Deviations from the protocol

Study status

Data availability

Underlying data

Acknowledgements

References

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Age of first self-harm act in childhood and adolescence: A scoping review protocol

Abstract

Keywords

Introduction

Methods

Eligibility criteria

Table 1. Inclusion and exclusion criteria.

Population

Concepts

Context

Evidence sources

Search strategy

Study records

Table 2. Data extraction items.

Data analysis and presentation

Deviations from the protocol

Study status

Data availability

Underlying data

Acknowledgements

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

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