Predicting, Assessing, and Treating Self-Harm in Adolescents

Causes of nonfatal injuries per 100,000 youths aged 11 to 19 in the US

Kids, I don’t know what’s wrong with these kids todayKids, who can understand anything they say?Kids, they are disobedient, disrespectful oafsNoisy, crazy, sloppy, lazy, loafers . . . Why can’t they be like we were- perfect in every way?What’s the matter with kids today?”
-Lee Adams “Kids,” Bye Bye Birdie (1960)

Self-injurious behavior (SIB)/deliberate self-harm (DSH) refers to behavior in which a person deliberately and directly harms himself or herself by intentionally damaging or destroying his or her body tissue; that behavior may or may not signify deliberate or overt intent to commit suicide, but DSH/SIB may result in a completed suicide. (DSH is used in this article to include SIB.) A history and repeated instances of DSH are strongly linked to and are risk factors for completed suicides.^1,2

Methods of DSH/nonsuicidal self-injury (NSSI) can range from superficial scratches or abrasions to severe tissue damage (ie, barely injuring the skin but no bleeding, to deep cuts, abrasions, broken bones) to extreme damage (destruction/ removal of body parts). Descriptions of DSH include multiple vague and inconsistent terms: NSSI, SIB, DSH, self-mutilation, self-harm, self- poisoning, self-injury, self-inflicted injury, body modification, self-immolation, and suicide.

Here we differentiate between 3 types of DSH: NSSI, culturally sanctioned body modifications (tattooing or body piercing), and unintentional or accidental injury. We exclude suicide, since suicidal youths harm themselves because they intend to die, but youths who engage in DSH typically do not have suicide as the main goal. We do not view DSH as an inevitable or immutable harbinger of suicide in youths.

Etiology

Developmentally, adolescents often respond impulsively and capriciously to the stresses of growth and development (ie, biological, cognitive, emotional, hormonal, physical, and psychosocial). Most adolescents who self-harm do so in response to interpersonal crises and use DSH as a means of affect regulation and communication.³

Part of the complexity of being an adolescent is the evolution-controlled failure of maturation of the prefrontal cortex until well after finalization of pubertal development.⁴ Many youths become involved in a variety of negative, often enigmatic and furtive behaviors years before they actually realize the serious nature of these activities. Parents, physicians, clinicians, and society have been frustrated for millennia by the seemingly frivolous and illogical behavior of adolescents. Witness this lament of the brilliant Greek philosopher Plato⁵ (427-347 bc):

The son feels equal to his father, he has no respect for his parents anymore . . . all he wants is to be free . . . students insult their teachers . . . and on top of this situation, in the name of liberty and equality, sex is everywhere.

Since the etiology of DSH is not actually known, its causes and associations are at best “probable.” Scientific literature notes that risks for engaging in DSH are highest for youths who live in poverty; have chronic medical problems, physical pain, or psychological pain; or suffer from psychiatric distress or severe mental illness (including psychosis). Some of these youths report that they experience a brief psychotic episode or symptoms of dissociation while they self-harm.⁴ Some youths reported that they feel relief/satisfaction, and they did not feel any pain when they engaged in DSH. They also said that the sight of their own blood allowed them to “feel alive” or “real.”⁶

Youths who engage in DSH were found to suffer from psychiatric illnesses (eg, anxiety, depression, borderline personality disorders, PTSD, schizophrenia).⁷ They also may have multiple comorbid disorders and may engage in substance use and/or have characteristics of impulsivity and low self-esteem. Youths with a family history of psychiatric disorders (ie, first-degree relatives) are also at risk, especially if they experience family dysfunction and conflict, if they were victims of child maltreatment (emotional, mental, or physical abuse), or if they were exposed to violence, trauma, or bullying.⁸

Alternatively and contrary to most of the previous research literature on NSSI, DSH may not be a symptom of a mental disorder but can occur in the absence of psychopathology. This theory posits that DSH functions as a means of affect regulation, help-seeking behavior, or social attention–acquiring behavior.⁹

Prevalence of self-harm in adolescents

Self-injury typically begins in early adolescence and is most prevalent among adolescents and young adults.⁷ Worldwide the prevalence of DSH among adolescents ranges between 6.2% and 46.5% and appears equally prevalent across sexes, ethnicities, and socioeconomic statuses. In addition, DSH typically has a consistent presentation cross-nationally and across settings (mental health treatment centers, psychiatric hospitals, and community populations).¹

A community sample showed that one-third of surveyed adolescents reported a history of DSH and 16% said they engaged in repeated self-harm.¹

A recent survey of high school students in the US found that nationwide 8% of students (grades 9 and 10) attempted suicide 1 or more times during the 12 months before the survey.¹⁰ In a study of 77 adolescents who engaged in DSH, 70% said they had attempted suicide, 55% said they had made multiple attempts, over half endorsed psychiatric symptoms that met criteria for a diagnosable psychiatric illness, and 59.6% admitted to substance use.⁹

DSH rates have increased over the past 20 years for adolescents and young adults, especially among females aged 15 to 19 years.⁶ The rising prevalence of DSH may have occurred because of increased media exposure. Today’s youths have more access to visual and auditory stimuli that glorify SIB: lyrics, texts, and paradigms of DSH (in vivo; in songs, print media, movies; and on the Internet) abound.⁷ Such exposure provides social support to an otherwise isolated adolescent, normalizes DSH as a form of release, and may expand an adolescent’s repertoire of methods for self-harm. Youths are at increased risk for self-harm and for making poor choices at this stage of development.

Data on and methods of self-harm are listed in the Table.

Clinical characteristics

DSH most often begins in early adolescence; it often involves self-cutting (wrists, arms, or body), a drug overdose (self-poisoning), biting, or scratching. Head-banging or self-biting most often occurs in pre-pubertal individuals. DSH in which body parts are destroyed or removed (such as eye gouging or removal of parts of lips, ears, and fingertips) most often occurs in individuals with intellectual disabilities, neurodevelopmental disorders, or psychosis. The least common methods of DSH involve using bleach, acid, or other abrasive chemicals or breaking one’s bones.

Concepts of evaluation

Many adolescents with a history of DSH have seen their primary care physician during their time of self-harming, although adolescents and parents/caregivers may not report DSH to the physician. If DSH is reported, adolescents or parents/caregivers may minimize such behavior; this is often complicated by the failure of the involved primary care clinician not to investigate these actions further.

If the clinician does detect an abrasion, bruise, or other injury, he or she may make an assumption about causation. The physician may assume that when an adolescent engages in SIB, he or she was not actually trying to commit suicide but was merely seeking attention; or, the behavior may be seen as a “weak, harmless attempt” and therefore serious assessment or management is not deemed warranted. Parents, the adolescent, and associated clinicians may all agree with that assessment.

Each adolescent who presents with behavioral or mental health problems that disrupt daily adaptive function should be screened for the following:

• Current/history of suicidal behavior (ideation, intent, attempts, plans)

• Any tissue damage; comorbid anxiety, borderline personality disorder, depression, eating disorders, or depression; history of maltreatment (emotional, physical, or sexual abuse)

• A history of DSH

• The presence or history of psychosis

When self-injury is detected, information regarding the type, location, severity, intensity, and frequency is important for providing clues about appropriate therapy.

Be suspicious of unexplained skin injuries and scars on school-aged children and adolescents. All instances of SIB warrant further assessment and management. As part of the usual differential diagnosis, factors that are associated with DSH need to be evaluated (eg, psychiatric disorders, child maltreatment, sleep problems/disorders, substance use/abuse).

Sleep dysfunction in youths is a common cause of many problems, and a thorough sleep evaluation along with correction of any sleep problem that is found is critical. The human brain needs normal sleep to function properly. The improvement of comorbid mental health problems can be dramatic in youths who have their acute or chronic sleep debt corrected.

Experienced and highly skilled professionals are needed when working with youths who exhibit DSH behavior and their parents/caregivers. The team of professionals should include the referring physician (as the team leader), the treating psychiatrist, psychiatric nurses or physician assistants, other clinicians (eg, counselors, psychologists, social workers), other specialists (eg, dermatologist), and occupational therapists (for youths with tactile issues and neurodevelopmental disorders). The psychiatrist should coordinate care with the referring primary care physician.

Management

Principles of evaluation for youths with DSH follow those of classic medicine and psychiatry. The assessors spend sufficient time with the adolescent in an initial evaluation and subsequent visits to determine the underlying issues and develop a management strategy. All forms of injury presented or discovered during examination should be differentiated from injury inflicted by others, such as from child abuse, or medical causes (eg, allergic reactions, dermatoses). Important data about the self-injury include its occurrences, intensity, types of SIB, repeated instances, and a history of depression as well as suicide attempts.

All acts of DSH should be taken seriously. Psychiatrists can be very helpful in communicating to primary care clinicians how to assess youths and how to determine referral for maximum benefit. A detailed mental status examination (MSE) should be conducted whenever the assessing clinician’s index of suspicion is raised or when the youth has injuries.¹¹ Information from the comprehensive MSE is combined with clinical observations of the adolescent, information from the adolescent’s medical history located in the clinical record, and evaluations from other treating clinicians to make a detailed differential diagnosis and create a subsequent management plan.

Treatment interventions

Data on effective treatment of adolescents with DSH are limited. Most adolescents who participated in research protocols were from a clinical population and had a history of psychiatric treatment (ie, hospitalization, previous suicide attempts, current suicide ideation). Randomized controlled trials (RCTs) that identify evidence-based, specific, and effective treatments for adolescents with DSH/NSSI are lacking. Moreover, many clinicians do not have the specialized training needed to treat the developmental and complex psychiatric/psychosocial problems that plague adolescents.

Treatments for DSH in adolescents reflect modifications of effective empirical interventions for culturally and ethnically diverse adults. These adults received care in several settings (inpatient psychiatric, outpatient community) and were managed using multimodal interventions (ie, individual, group, family therapy, telephone calls for follow-up). The duration of most therapy for adults was 1 year. Other management plans are “well established” for children and adolescents who suffer from such disorders or conditions as trauma, maltreatment (abuse), insomnia, eating disorders, anxiety, depression, schizophrenia, and suicide attempts.

Few systematic reviews of treatment interventions for DSH with adolescents are available. Only trauma-focused cognitive-behavioral therapy met research criteria of the National Registry of Evidence-based Programs and Practices.

Reviews of research on adolescents who self-injure also support the value of dialectical behavior therapy and acceptance and commitment therapy. Both of these therapies are effective for adults. They are also shown to be empirically ‘‘well established’’ for the management of the sequelae of problems seen in children and adolescents with psychiatric disorders (eg, anxiety, depression, eating disorders, PTSD, schizophrenia, suicidal ideation), and they can be effective for insomnia and trauma. Results with children who primarily engage in DSH are limited.

Although the empirically supported treatments for self-injury among adolescents are effective, further research is needed with larger, culturally, ethnically, and socioeconomically diverse groups. There are no published RCTs of pharmacological agents that specifically target self-harm in adolescents. In addi-tion, there are currently no evidence-based psychological or pharmacological treatments for self-injury.

Conclusions

The principles of multidisciplinary management considered in this discussion are clinical conjectures limited by the lack of research in adolescents with DSH. Despite such dearth of research, some basic principles of care are recommended. For example, addressing potential comorbid sleep problems (eg, insomnia) and substance use disorders is vital for the overall health of youths with DSH. To understand the negative behaviors, clinicians should spend sufficient time and provide a clear, explicit message that the adolescent will not be abandoned in a time of great emotional need.

Psychiatrists can provide therapy, coordinate the efforts of a multidisciplinary treatment team, and proffer guidance to primary care clinicians in the management of these adolescents-as part of an overall multidisciplinary management approach. Didactic psychiatrists can share the principles of behavioral science with primary care clinicians, which may be better accepted by the youths than more extensive formal treatments. These problem-focused, solution-oriented interventions can be brief (20 to 30 minutes) and limited to 2 to 4 sessions. Co-locating mental health services with those for primary care may mollify the concerns of young patients. More research is needed to assess this approach, which has gained increasing popularity in the past decade.

Disclosures:

Dr Greydanus is Professor and Founding Chair and Dr Pratt is Professor in the department of pediatric and adolescent medicine at Western Michigan University Homer Stryker MD School of Medicine in Kalamazoo, Mich. The authors report no conflicts of interest concerning the subject matter of this article.

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