This is an abridged version of Prevention of self-harm and suicide in children and young people who have been in foster, kinship, or residential care: Learning from South Korea and the USA by Dr Rhiannon Evans, reader in social science and public health at Cardiff University.
Rhiannon works at the Centre for Development, Evaluation, Complexity, and Implementation in Public Health Improvement. The research centre aims to generate evidence-based interventions to improve the health and wellbeing of children and young people and Rhiannon's area of expertise is focused on interventions targeting mental health, self-harm, and suicide.
Her fellowship intended to understand international practice in self-harm and suicide interventions for care-experienced children and young people. It considered Fostering Healthy Futures from the USA, which is a likely candidate for transfer to the UK.
It further explored innovative practice in South Korea, in order to move beyond the traditional evidence-base sometimes drawn upon to inform intervention work. This article focuses on that aspect of Rhiannon's fellowship.
UK CONTEXT
Self-harm and suicide is a major international concern. In the UK, there is a higher risk of suicide-related outcomes among children and young people who have been in care. This can encompass individuals who have lived in formal kinship care, foster care, or residential care.
In my previous research, I have found a lack of approaches in the UK with most programmes originating from the USA. There are other countries, notably South Korea, that have high suicide rates and are progressing with innovation, but evaluation research is rarely accessed internationally.
FELLOWSHIP APPROACH
I spent 10 weeks in the two internationally contrasting countries of South Korea and the USA. During this time, I aimed to:
- Understand the international context of self-harm and suicide in children and young people, particularly in care-experienced individuals
- Develop my expertise in intervention adaptation, in the event I identified an approach that could potentially be brought to the UK
- Identify an innovative programme that could be adapted to the UK
- Build international collaboration around self-harm and suicide to strengthen the research community.
I did not have a specific intervention that I wanted to study in South Korea, and so this objective was more exploratory.
My research has always focused on the identification of evidence-based interventions that effectively target mental health and wellbeing, along with suicide-related outcomes, among care-experienced children and young people.
While the review was comprehensive, one of the challenges was that most evidence-based approaches originated from the USA. This was also true of mentoring programmes, specifically the Fostering Healthy Futures programme. This intervention provides social and emotional curricula for young people in foster care, in addition to mentoring by a trainee graduate social worker or psychologist.
AT-RISK GROUPS
There are children and young people that may be at higher risk of suicide-related outcomes. Many have been in care. There is extensive international variation in definitions, but care-experienced often includes those who have been in formal kinship care, foster care, and residential care. In some countries, like the UK, there can be other mechanisms through which young people enter statutory care, such as special guardianship orders.
Care-experienced individuals are reported to be at an increased risk of suicide attempts when compared with non-care-experienced groups (Evans et al., 2017). Equally, some of the most recent evidence from the UK found that people with a history of foster care are more likely to die early, with self-harm and poor mental health being among the key explanations (Murray et al., 2020). More broadly, this population is found to have lower levels of wellbeing and higher rates of diagnosable psychiatric diagnoses (Long et al., 2017, Ford et al., 2018).
SOUTH KOREA CONTEXT
Throughout my four weeks in South Korea, I travelled to Seoul and Busan to explore the culture and its role in children and young people's self-harm and suicide. While I sought to understand this in specific reference to individuals with experience in care, ultimately the focus ended up being more general.
Professor Sungyoup Hong and colleagues from the Catholic University of Korea, Seoul, were particularly supportive in my learning. Tracing the history of South Korea, I came to understand the role of the Joseon Dynasty (1392-1897) and Confucianism in structuring cultural values (or cultural stress as Professor Hong termed it). This included deference to authority, notably parents, and the privileging of patience, which meant young people felt they could not “complain”.
I was also fortunate to visit the Demilitarized Zone at the North Korean border, which provided insight into the historical impacts of war and separation. Meanwhile, throughout my meetings, colleagues emphasised the role rapid economic development had on the population's wellbeing, notably the increase in inequality.
There were also a range of contemporary issues that helped explain self-harm and suicide among younger generations. South Korea is a technologically advanced society, ranking first in the world for high-speed internet penetration. While this has contributed to economic growth, it has arguably facilitated cyberbulling and digital exclusion.
Education experiences can be challenging, with students expected to spend long periods at school and after-school facilities. I visited Dr Hyun Ju Hong, a child psychiatrist at Hallym University Sacred Heart Hospital in Seoul. Dr Hong is currently advising the South Korean government on how schools support mental health, with the aim of starting to introduce wellbeing policies and programmes.
Of particular interest to me was the role of K-pop idols in children and young people's lives. I was fortunate to see a K-pop concert in Seoul and witnessed trainee idol groups performing in the streets of Seoul's central Hongdae area.
In my meetings with Dr Sejung Park at Pukyoung National University, Busan, I learned about her work on the influence of suicide among K-pop idols and their memorialisation. This was an interesting phenomenon, given the evidence-base showing that the reporting of suicide methods and the romanticising of death in the media, can impact others to engage in similar behaviours.
RESULTS & RECOMMENDATIONS
Throughout my fellowship visit in South Korea and the USA, I prioritised exploring and understanding self-harm and suicide prevention interventions for children and young people, and for care-experienced individuals in particular. I asked colleagues about their awareness of evidence-based approaches where available, and the uniqueness of their delivery in their respective countries.
While I made initial connections in Seoul to explore interventions for care-experienced children and young people, in practice this didn't progress, and I ended up pursuing different learning opportunities. Therefore, while I spent time considering mental health and suicide prevention provision in educational and clinical settings, I did not become aware of specific programmes in social care contexts.
While my fellowship did support my previous research finding that most interventions targeting suicide-related outcomes among care-experienced individuals are in the USA, there were examples of broader suicide prevention innovation in South Korea.
It remains important that when identifying interventions for adaptation to the UK, or any country, we take a global perspective and are vigilant in the knowledge that relevant innovation can be generated in diverse contexts.
There is significant benefit to be derived from developing an international research network to support understanding of self-harm and suicide across a range of countries and cultures. While networks do exist, these are often centralised in European or globally north countries. At the very least they tend not to be proactively inclusive of a range of countries, notably South Korea. Sharing knowledge and expertise internationally will enrich the self-harm and suicide community.
POST-FELLOWSHIP
I am a co-applicant for a recently funded GW4 academic community generator application Young people's self-harm and suicidal behaviour: Developing qualitative research to understand the influence of context and culture.
GW4 offers collaborator-generating funding for researchers across the universities of Cardiff, Bath, Bristol and Exeter. The successful grant will link these universities with research, policy and practice partners in Brazil, Rwanda, and South Korea to develop capacity in qualitative research methodologies in self-harm and suicide to further strengthen our understanding of the socio-cultural context.
Our South Korean partnership, primarily with Professor Sungyoup Hong, has been facilitated through my time as a Churchill Fellow. I also continue to work with Professor Hyun Ju Hong in South Korea, sharing ongoing policy and research on the Whole School Approach to wellbeing in Wales. This will support the South Korea government in developing a national school approach to mental health.
ABOUT THE CHURCHILL FELLOWSHIP
The Churchill Fellowship is a national network of 3,800 inspiring individuals whose mission is to find the world's best solutions for the UK's current challenges.
Up to 150 Churchill Fellows are funded each year to visit the world's leading practitioners and projects on a topic of their choice – from social policy to healthcare to education and more – and bring back new ideas for their communities and sectors across the UK.
Any UK adult citizen can apply, regardless of qualifications, background or age. Fellows are chosen for their potential as change-makers, not their past track record or status.
Find out about fellows and their ideas at www.churchillfellowship.org
