Adolescent Self-Harm Assessment and Treatment

Due to a wide variety of factors and stressors, you may care for patients who engage in self-harm or non-suicidal self-injury (NSSI). Children and adolescents might choose self-harm for a number of reasons and they often make this choice because they lack healthy coping strategies for difficult emotions. 

What is self-harm or non-suicidal self-injury in children and adolescents? 

Self-harm or self-injury is the purposeful act of inflicting harm to one’s own body without the intent to end one’s life. Most commonly, adolescents engage in cutting or scratching, but NSSI can take many forms, including head-banging, pinching, biting and burning. Self-harm in children is unique from suicidal behavior, as the function of the behavior is different. The purpose of suicidal behavior is to end one’s life, while the function of NSSI is typically to reduce overwhelming or intolerable emotions. Youth may engage in self-harm to regulate or distract from uncomfortable emotions, to relieve stress, to punish oneself or to seek connection with others. It can be helpful to think of NSSI as a maladaptive coping strategy to manage uncomfortable emotional experiences. 

How common is self-harm in youth? 

Rates of NSSI have increased over the last 15 years, with approximately 17% of adolescents reporting they have engaged in self-harm at least once. The average age of onset is about 13 years old, with behaviors peaking at around 16 years old. While most adolescents report engaging in only one to two instances of self-harm, higher frequency of NSSI is associated with poorer long-term outcomes, including increased risk of suicidal ideation and suicide attempts. Early intervention is critical in preventing NSSI from becoming chronic, as these behaviors are often highly reinforcing.

Self-harm warning signs and risk factors for children 

While the method and purpose of NSSI varies widely among adolescents, there are several common warning signs and risk factors to be aware of. Caregivers and pediatricians should look out for the following: 

• Visible marks such as scratches, cuts or burns that are not clearly explained by typical activities 
• Sharp objects or other “tools,” such as razors or lighters, found in a child’s room 
• Covering up with weather-inappropriate clothing, such as long sleeves in the summer, or refusing to participate in activities that involve fewer clothes, such has swimming 
• Worsening symptoms of depression or anxiety 
• Regularly isolating for long periods of time 
• Knowledge of a friend who engages in self-injurious behaviors 

Self-harm assessment for children and adolescents 

Set the stage for an open and honest conversation by building rapport with your patient and providing space to talk without a caregiver in the room. When you have built some trust, transition the conversation to mental health and self-harm. Start gathering information by asking about the following: 

• General mood and current stressors: “How has your mood been recently?” or “What are some stressful things happening in your life right now?” 
• Validate how your patient has been feeling: “I think any kid would feel upset about that!” or “That sounds like a really difficult experience!” 
• Simply ask about self-injurious behaviors: “Sometimes when teens feel overwhelmed or are experiencing a lot of stress, they engage in self-harm. Is this something you’ve ever struggled with?” Avoid asking in a way that may decrease the likelihood of your patient answering truthfully, such as “You don’t self-harm, do you?” 
• Determine the purpose of the behavior. NSSI is a complex behavior, and the function may be related to stress reduction, self-punishment, rebellion or a plea for connection and help. Ask: “What does self-harm do for you? How does it make you feel?” 
• Ask about the method and frequency of the behavior: “What do you do to hurt yourself? How often do you hurt yourself?” 
• Assess for any potential medical complications: “Have you ever been seen by a doctor for your self-harm, such as getting stitches?” 
• Ask about thoughts of suicide or if your patient has engaged in suicidal behaviors: “Have things ever gotten so bad that you’ve thought about wanting to kill yourself? Have you ever started to do anything to kill yourself?” 

Other important pieces of information to gather include other risky behaviors your patient may be engaging in, current or past abuse or trauma, and systems of support your patient can count on.  

NSSI treatment and management 

If a patient reports thoughts of suicide or engaging in suicidal behaviors (e.g., writing suicide notes, gathering items for a plan, giving away possessions, etc.), they need an immediate psychiatric evaluation and should be taken to a crisis center or emergency department.  

Self-harm treatment centers on finding kids the immediate help they need to reduce harm and setting families up for long-term success. 

Determine the level of risk and connect to supports 

Even if your patient denies suicidality, if they’ve been engaging in NSSI, it’s critical to connect them to a mental health provider as soon as possible. Chronic self-harm is associated with poorer long-term treatment outcomes and increased risk of suicidal ideation and suicide attempts; immediate intervention can lower suicidal risk and improve overall functioning.  

Mental health providers will assess the presence of underlying psychiatric conditions like depression and anxiety, and provide evidence-based treatments, such as cognitive-behavioral therapy, dialectical behavior therapy or family therapy. Therapy often focuses on enhancing emotion regulation and distress tolerance, developing problem-solving skills and improving communication deficits to help teens more effectively manage intense and uncomfortable emotional experiences. 

Helping caregivers manage their child’s NSSI 

Caregivers are often unaware of their child’s self-harm behavior. Given that there is a safety concern, caregivers should be alerted to the NSSI. Give your patient choices in how you’ll tell their caregivers. Does your patient want to start the conversation, or do they want you to take the lead?  

When discussing NSSI with caregivers, it’s important to highlight the following: 

• Many teens avoid discussing self-harm with caregivers out of fear that caregivers will be mad or disappointed. Encourage caregivers to embrace their curiosity and temporarily suspend judgment and consequences. 
• Open communication between caregivers and children is one of the most effective self-harm management strategies. Encourage caregivers to schedule regular and frequent times to check in with their child. 
• Reduce access to means. Encourage caregivers to remove or lock up items that their child is self-harming with or could. 
• Seeking help from a mental health provider is critical to help identify and treat the underlying causes of NSSI.  

For many caregivers, discovering that their child is engaging in NSSI can be overwhelming. It’s important to let caregivers know that there are effective treatments available, and the risk of NSSI can be minimized through open and frequent communication and reducing access to tools frequently used to self-harm.  

Professional resources for NSSI 

• Cornell University College of Human Ecology: Self-Injury & Recovery Resources. A comprehensive resource with informational handouts for a variety of audiences
• American Academy of Pediatrics: HealthyChildren.org - When Children and Teens Self-Harm
• Pediatric Mental Health Institute at Children’s Hospital Colorado