A Pediatrician’s Guide to Non-Suicidal Self-Harm in Teenagers

When treating children and adolescents, it’s not uncommon to see patients who have engaged in self-harm. Laura Judd-Glossy, PhD, discusses how primary care providers can recognize self-injury, work with families and help teens. Self-injury often takes the form of cutting, but also includes scratching, burning, self-hitting, putting items under the skin or interfering with the healing of wounds. This kind of non-suicidal self-injury is most common among adolescents and young adults, with approximately 10% of teens reporting that they have engaged in self-harm.

The age of onset is commonly 12 to 15 years of age, and more common in females than males. However, it does occur in childhood in an estimated 1.3% of 5- to 10-year-olds.

This kind of self-harm is unique from suicidal behavior, as the function of the behaviors is different. Youth may engage in self-harm for a variety of reasons: to regulate their emotions, punish themselves, relieve stress or seek acceptance from others. Youth typically engage in suicidal behavior to end one’s life.

While self-injury is traditionally associated with borderline personality disorder, eating disorders or childhood trauma, it can also be associated with depression, anxiety, PTSD, conduct or oppositional defiant disorders or substance abuse disorders.

It can be helpful to think of it as a maladaptive coping strategy to a problem, rather than solely a problem itself. In other words, it’s not simply about how to help a teen stop engaging in self-harm, but rather considering and developing better coping strategies for the larger problems the patient is trying to use self-harm to solve.

Warning signs for teen self-injury

Parents and pediatricians alike should look for warning signs of self-injurious behavior. These could include:

• Visible marks such as scratches, cuts or burns that are not clearly explained by typical activities
• Covering up with weather-inappropriate clothing such as long sleeves in the summer or refusing to participate in activities that involve fewer clothes, such as swimming
• Sharp objects found in a child’s room
• Worsening symptoms of depression or anxiety
• Knowledge of a friend who is self-harming

Assessment for self-harm in teenagers

It’s helpful to build rapport with the patient by discussing their interests and activities, ideally without their parent or guardian in the room in order to facilitate an open and honest conversation. When you have built some trust and it’s time to ask about self-injury, look for information on:

• Function of the behavior: “What does your self-injury do for you? How does it make you feel?”
• Method of self-injury: “What did you do to hurt yourself?”
• Potential for medical complications: “Have you ever needed to be seen by a doctor for your self-injury, such as for stitches or other medical treatment?”
• General mood and current stressors: “How have you been feeling recently? What has been stressful for you?”
• Other risky behavior: “What other risky behavior have you engaged in?”
• Abuse or trauma: “Have any scary things ever happened to you? Has anyone ever hurt you physically or sexually?”
• Risk of suicide: “Have things ever gotten so bad that you’ve had thoughts about wanting to kill yourself?”
• Areas of strength and resilience: “What keeps you going? Who can you count on?”

Managing self-harm in teenagers

After gathering this information, consider the patient’s level of risk. If a patient is suicidal at the time of the assessment, then they need an immediate psychiatric evaluation. Even if the patient denies current suicidality, if they’ve been engaging in self-harm, they need the right support.

Parents and guardians are often unaware of the behavior. Offer information about self-injury and be sure to give the teen options on how this information will be communicated. The teen might initiate the conversation on their own or have the pediatrician take the lead.

Ideal resources for parents and families should discuss evidence-based treatment, such as cognitive-behavioral therapy, dialectical behavior therapy or family therapy, as well as discussion about means restriction. You’ll find some excellent options below.

Resources for non-suicidal self-injury

Pediatric Mental Health Institute at Children’s Hospital Colorado.

Self-Injury: Why Teens Do It, How to Help: An in-depth article from Contemporary Pediatrics with clinical scenarios, assessment charts and more

Cornell University College of Human Ecology: Self-Injury & Recovery Resources: A comprehensive resource for clinicians dealing with self-harm, including information briefs on dozens of self-harm related topics

S.A.F.E. Alternatives: A leading outpatient facility for teens and adults who self-harm with tons of info on self-harm treatment and interventions