Encountering a patient who intentionally self-injures can be quite perplexing and concerning as a pediatrician. Nonsuicidal self-injury (NSSI) involves intentionally damaging one's own body tissue without intent to die and in a way that is not consistent with expected norms of a culture.1 Common methods of NSSI in children and adolescents include cutting or skin carving, scratching/rubbing/pinching/picking at skin, hitting oneself, and skin burning.2,3 Many adolescents who self-injure report using multiple separate methods, on average three, based on method availability or desire for particular effect.4 Youth frequently self-injure on their arms, legs or abdomen, often in an attempt to conceal any injuries from others. Although pediatricians are often the first adults to learn of a youth's self-injury, many report feeling unprepared for how to appropriately address NSSI in their patients.5
A 15-year-old presents for her annual well visit. During your initial discussion, neither the patient nor her father indicates any concerns. However, during her private physical examination you notice superficial cuts on her mid-forearm and upper thigh. You ask how she got the cuts. She looks uncomfortable and attempts to minimize the cuts, insisting that they are scratches from her cat. When you gently suggest that the cuts do not look like cat scratches and express concern, she acknowledges that she has been cutting herself for the past 6 months due to stressors at school and conflict with a friend.
You gently ask the patient more about her self-injury, including what methods she uses, how often she self-injures, and her reasons for self-injuring. She shares that she cuts with razor blades and has been doing so about twice a month for the past 6 months. She reports that she started off scratching herself and progressed to cutting after her friend told her “cutting works better.” You ask if she ever thinks about dying while she cuts herself. She seems a bit taken aback by that question, denying any thoughts of suicide and states: “this might sound weird, but cutting actually makes me feel better. It's like a release for me.”
Epidemiology of NSSI in Youth
NSSI typically emerges in early adolescence (age 12–14 years), peaks in mid-adolescence (age 15–17 years) and then declines during young adulthood.6 Community sample estimates of the prevalence of NSSI among high school students vary widely, and suggest that between 13% and 50% of adolescents engage in at least one episode of NSSI.7–9 The occurrence of NSSI in children and younger adolescents is not well studied but is believed to be less common, with one survey of middle school students reporting rates of 8%.10 Findings regarding gender differences in prevalence have been inconsistent, with some studies reporting no gender differences (especially among younger children) and others reporting up to 3 times higher rates of NSSI in adolescent girls.2,3 Youth who identify as gender diverse or LGBTQ+ (lesbian, gay, bisexual, transgender, and queer/questioning) have been found to have higher rates of engagement in NSSI compared to their heterosexual and cisgender peers.11 Studies have also reported differences in rates of NSSI by race and ethnicity. For example, a study of the prevalence of NSSI among a representative sample of adolescents in the United States found that rates of NSSI were highest for Native American/Alaska Native (20%) adolescents, followed by Hispanic (19%), and White (17%) adolescents. Prevalence was lowest among adolescents who identified as Asian/Pacific Islander (14%) and Black (12%).12
Self-Injury, Mental Health, and Suicide Risk
NSSI is not a psychiatric diagnosis in itself and may occur in adolescents who do not meet formal diagnostic criteria for any mental health disorder.8 In more than 50% of cases, however, NSSI occurs alongside a diagnosable psychiatric condition(s), such as a mood disorder (ie, depression), anxiety disorder, trauma-related disorder (ie, posttraumatic stress disorder), and/or personality disorder.8,13 Screening for common psychiatric disorders should be part of the assessment when NSSI is discovered and may help guide treatment recommendations.
During an evaluation of NSSI in primary care, it is essential to understand the function that the self-injury is serving for the patient.8 Using of self-injury to reduce distress might seem nonsensical, but it is actually a goal shared by the many adolescents who engage in NSSI. The most common reasons adolescents cite for engaging in NSSI relate to emotion regulation. In particular, young people report using NSSI to reduce the intensity of negative emotions such as anger and sadness.7,8 Adolescents also commonly report using NSSI to provide a sense of security or control, to relieve tension, to distract oneself, to feel something, to punish oneself, to communicate distress, and to curb trauma-related symptoms such as flashbacks.7,8 In one study, adolescent boys were more likely to endorse using NSSI to communicate with or influence others, whereas girls were more likely to self-injure to punish themselves or relieve negative affect.7
Adolescents who self-injure typically report a reduction in the intensity of their negative affect (ie, depression, loneliness, frustration) and an increase in positive emotions (ie, relief) during and after acts of self-harm. The mechanism behind this relief is not fully understood but is believed to relate psychologically to the intense distraction NSSI offers from ruminating about negative stimuli, and biologically to the release of endogenous opioids.14,15 In this way, NSSI, although seemingly noxious, can become self-reinforcing.14
By definition, people who engage in NSSI do so without intent to die, and it is important that physicians do not assume the presence of suicidality based on an adolescent's engagement in self-injury.1 In fact, the relationship between NSSI and suicidality is complex. Although NSSI has been identified as a risk factor for future suicidality, the magnitude of this risk is uncertain, and research has definitively shown that NSSI is not solely predictive of future suicidal behavior.16 Automatically assuming a youth is suicidal based on their self-injury without further exploration with the youth may lead to treatment decisions (such as forced psychiatric hospitalization) that may not be necessary in the moment and could risk alienating the patient. Thus, it is critical to specifically assess for suicidal ideation, plan, intent and attempt in any encounter where NSSI is discussed.
Suicidal behavior and NSSI do share many risk factors including low self-esteem, loneliness, poor problem-solving skills, and low distress tolerance.17 Although many adolescents who self-injure do not exhibit suicidal behavior, community studies have found that between 19% and 63% of people with a history of NSSI do report some experience of suicidal thoughts and/or behaviors.18 Rates of suicidal ideation among adolescents who engage in NSSI have been estimated to be at least double that of those who do not self-injure.19 At the same time, more than two-thirds of suicide deaths in youth occur in the absence of prior NSSI and parasuicidal behavior.20
Certain characteristics of NSSI and the person doing the self-harm have been shown to elevate risk for co-occurrence of suicidal behaviors, including ideation and attempts. Regarding characteristics of NSSI itself, some research has demonstrated a dose-dependent relationship between frequency of engagement in NSSI and risk for suicidal behaviors (ideation and attempt), such that risk for suicidal behaviors increases up to between 20 and 50 incidents of NSSI and then plateaus or declines.17,18 This has been interpreted to suggest that repetitive NSSI may increase one's tolerance for pain and lower their fear of death until the point of plateau, at which point NSSI may be adopted as an effective strategy for coping with distress.21 A positive correlation has been found between risk for suicidal behaviors and the number of methods used to self-injure, as well as duration of engagement in NSSI.13 There is particular reason to be concerned about the possibility of co-occurring suicidality if a patient who self-injures reports an increase in the frequency of their NSSI, escalating severity of their NSSI (such as adoption of more methods of injury to achieve that same effect), worsening depressive symptoms, or a feeling that NSSI is no longer a useful coping strategy.4 Additionally, recent research has supported the existence of a positive correlation between social media exposure to NSSI and future self-harm and suicidality-related outcomes among adolescents.22 High-risk characteristics in the person doing the self-harm include severe depressive symptoms, especially anhedonia and low self-esteem, hopelessness, engagement in risky behaviors including substance use and aggression, and feelings of being isolated, especially from parents.19,23
Assessment of NSSI Behavior in Primary Care
Although the patient in the above illustrative case had visible signs of her cutting that raised suspicion, physical signs of NSSI may not always be present to offer an entry point for discussion. Given its prevalence in the general adolescent population, screening for NSSI should be part of standard psychosocial assessments in primary care, whether by patient report or by clinician interview, and can often be asked about at the same time as questions about suicidal ideation. For instance, a patient who answers affirmatively to question 9 of the Patient Health Questionnaire-9, which asks about thoughts of death and hurting oneself, should prompt further evaluation of both suicidal ideation and NSSI. Although suicidal ideation and NSSI are separate entities with separate treatment approaches, they can easily be screened for together.
When screening for NSSI and when exploring an occurrence of NSSI with a patient, it is imperative that pediatricians do so with an empathic, non-judgmental, and curious tone. Young people who engage in NSSI often do not bring it to the attention of medical providers or other adults for fear of being labeled as “attention seeking” or “dramatic,” and there is research showing that health care professionals often possess negative feelings about these patients, especially those who have repeat presentations.24 Adolescents are perceptive and their picking up on this negative feeling could result in their choosing not to discuss their NSSI or, even more importantly, their possible feelings of suicide. It is important for pediatricians to think about and work through their own biases regarding NSSI to ensure a genuinely supportive approach.1
The SOARS assessment tool, developed by Westers et al.,1 offers one way to ask about factors that are important to assess when someone reveals NSSI. Each letter in the mnemonic corresponds to an aspect of assessment: S for suicidal ideation (does the patient ever think about suicide while self-injuring?); O for onset, frequency, and methods (how long has the patient being doing this? how often, and with what?); A for aftercare (how do they care for any wounds and have they ever hurt themselves to the point where they should have received medical attention?); R for reasons (what does the NSSI do for them? in what ways is it helpful?); and S for stage of change (how open are they to stopping?).1 Evaluation of these factors can help the pediatrician assess level of risk and necessary intervention.
Interventions for NSSI in Youth
Adolescents often hide evidence of their NSSI from the adults in their lives, including their parents. When learning about NSSI in a minor, a pediatrician may understandably struggle with whether to break confidentiality and disclose the behavior to parents/guardians. This decision must be made with the clinician's judgment regarding the relative risks of that disclosure (potential loss of trust from the youth) versus the risk of imminent and future serious harm.25
One consideration for letting parents know about their child's NSSI is that many successful interventions for addressing NSSI in adolescents often include family interventions as part of the treatment. Studies have shown that parental response, especially when they first learn of the occurrence of NSSI in their child, can affect the likelihood of whether youth will seek help for their NSSI.26 Qualitative studies of family responses to NSSI have shown that youth feel most supported when parents are able to respond calmly, validate their feelings of distress, and maintain open and nonjudgmental communication and inquiries of how they can help.27 Learning of a child's NSSI is typically a distressing event for a parent that evokes feelings of guilt, concerns about their parenting abilities, and shame that may keep them from seeking help for themselves or their child. Parents often feel lacking in strategies to best support their child and may reflexively respond with increased discipline, intrusive monitoring, and efforts to control the behaviors that can backfire by increasing their child's distress and reliance on cutting as a coping strategy.27
Although it is important to respect privacy and place disclosure in the context of a thoughtful assessment of risk, pediatricians can play a role in educating parents on NSSI and in dispelling some common misconceptions about its function, so that parents can best support their child. Helping parents place the NSSI within the context of their child's developmental phase and other mental health concerns can help parents develop empathy for their child and use more supportive parenting strategies.28 Offering practical and often written information to parents may help them feel more adept at helping their child who self-harms, and several organizations, such as the Cornell Research Program on Self-Injury and Recovery, have created helpful handouts and online webinars for parents and caregivers to learn more.29
Validating the feelings of distress that lead to the NSSI is different from condoning or supporting the behavior. Accepting that the NSSI is serving a purpose for the patient and is helping in some way can help the patient feel heard and not judged. Pediatricians can use motivational interviewing strategies to assess how interested the patient is in stopping their self-injury and in finding alternative and safer means of meeting their needs.1 If patients are open to stopping the behavior, a referral to a therapist is an appropriate next step for addressing the NSSI as well as any comorbid psychiatric issues that are likely to be present. General therapies that have been found to be helpful for treating NSSI include cognitive-behavioral therapy (CBT), dialectic-behavioral therapy (DBT), and mentalization based-therapy. In recent years, randomized controlled trials of protocols more specifically tailored toward addressing NSSI are also offering promising options. The Cutting Down Programme is one such program that is focused on NSSI and integrates principles of CBT and DBT.30
Unfortunately, NSSI is a relatively common occurrence in youth, and pediatricians must be prepared to address this behavior in their patients in an open and nonjudgmental way. Screening for NSSI should be accompanied by screening for suicidal ideation and comorbid psychiatric disorders to ensure the patient's current risk is properly assessed and that they are connected with the right resources and treatments.
- Westers NJ, Muehlenkamp JJ, Lau M. SOARS model: risk assessment of nonsuicidal self-injury. Contemp Pediatr. 2016;33(7):25–31.
- Sornberger MJ, Heath NL, Toste JR, McLouth R. Nonsuicidal self-injury and gender: patterns of prevalence, methods, and locations among adolescents. Suicide Life Threat Behav. 2012;42(3):266–278. doi:10.1111/j.1943-278X.2012.0088.x [CrossRef] PMID:22435988
- Barrocas AL, Hankin BL, Young JF, Abela JRZ. Rates of nonsuicidal self-injury in youth: age, sex, and behavioral methods in a community sample. Pediatrics. 2012;130(1):39–45. doi:10.1542/peds.2011-2094 [CrossRef] PMID:22689875
- Jennifer J, Kerr PLM. Untangling a complex web: how non-suicidal self-injury and suicide attempts differ. Prev Res. 2010;17(1):8–11.
- Taliaferro LA, Muehlenkamp JJ, Hetler J, et al. Nonsuicidal self-injury among adolescents: a training priority for primary care providers. Suicide Life-Threatening Behav. 2013;43(3June):250–261. doi:10.1111/sltb.12001 [CrossRef]
- Adrian M, Zeman J, Erdley C, Whitlock K, Sim L. Trajectories of non-suicidal self-injury in adolescent girls following inpatient hospitalization. Clin Child Psychol Psychiatry. 2019;24(4):831–846. doi:10.1177/1359104519839732 [CrossRef] PMID:30947520
- Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. Psychol Med. 2007;37(8):1183–1192. doi:10.1017/S003329170700027X [CrossRef] PMID:17349105
- Peterson J, Freedenthal S, Sheldon C, Andersen R. Nonsuicidal self injury in adolescents. Psychiatry (Edgmont). 2008;5(11):20–26. PMID:19724714
- Yates TM, Tracy AJ, Luthar SS. Non-suicidal self-injury among “privileged” youths: longitudinal and cross-sectional approaches to developmental process. J Consult Clin Psychol. 2008;76(1):52–62. doi:10.1037/0022-006X.76.1.52 [CrossRef] PMID:18229983
- Hilt LM, Nock MK, Lloyd-Richardson EE, Prinstein MJ. Longitudinal study of nonsuicidal self-injury among young adolescents: rates, correlates, and preliminary test of an interpersonal model. J Early Adolesc. 2008;28(3):455–469. doi:10.1177/0272431608316604 [CrossRef]
- Jackman K, Honig J, Bockting W. Nonsuicidal self-injury among lesbian, gay, bisexual and transgender populations: an integrative review. J Clin Nurs. 2016;25(23–24):3438–3453. doi:10.1111/jocn.13236 [CrossRef] PMID:27272643
- Monto MA, Mcree N, Deryck FS. Non-suicidal self-injury among a representative sample of US adolescents, 2015. Am J Public Health. 2018;108(8):1042–1048. doi:10.2105/AJPH.2018.304470 [CrossRef]
- Nock MK, Joiner TE Jr, Gordon KH, Lloyd-Richardson E, Prinstein MJ. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65–72. doi:10.1016/j.psychres.2006.05.010 [CrossRef] PMID:16887199
- Bresin K, Gordon KH. Endogenous opioids and nonsuicidal self-injury: a mechanism of affect regulation. Neurosci Biobehav Rev. 2013;37(3):374–383. doi:10.1016/j.neubiorev.2013.01.020 [CrossRef] PMID:23339875
- Hasking PA, Di Simplicio M, McEvoy PM, Rees CS. Emotional cascade theory and non-suicidal self-injury: the importance of imagery and positive affect. Cogn Emotion. 2018;32(5):941–952. doi:10.1080/02699931.2017.1368456 [CrossRef] PMID:28838289
- Ribeiro JD, Franklin JC, Fox KR, et al. Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med. 2016;46(2):225–236. doi:10.1017/S0033291715001804 [CrossRef] PMID:26370729
- Whitlock J, Knox KL. The relationship between self-injurious behavior and suicide in a young adult population. Arch Pediatr Adolesc Med. 2007;161(7):634–640. doi:10.1001/archpedi.161.7.634 [CrossRef] PMID:17606825
- Whitlock J, Muehlenkamp J, Eckenrode J, et al. Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health. 2013;52(4):486–492. doi:10.1016/j.jadohealth.2012.09.010 [CrossRef] PMID:23298982
- Stewart JG, Esposito EC, Glenn CR, et al. Adolescent self-injurers: comparing non-ideators, suicide ideators, and suicide attempters. J Psychiatr Res. 2017;84:105–112. doi:10.1016/j.jpsychires.2016.09.031 [CrossRef] PMID:27716512
- Castellví P, Lucas-Romero E, Miranda-Mendizábal A, et al. Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: a systematic review with meta-analysis. J Affect Disord. 2017;215:37–48. doi:10.1016/j.jad.2017.03.035 [CrossRef] PMID:28315579
- Turner BJ, Layden BK, Butler SM, Chapman AL. How often, or how many ways: clarifying the relationship between non-suicidal self-injury and suicidality. Arch Suicide Res. 2013;17(4):397–415. doi:10.1080/13811118.2013.802660 [CrossRef] PMID:24224673
- Memon AM, Sharma SG, Mohite SS, Jain S. The role of online social networking on deliberate self-harm and suicidality in adolescents: a systematized review of literature. Indian J Psychiatry. 2018;60(4):384–392. PMID:30581202
- Brausch AM, Gutierrez PM. Differences in non-suicidal self-injury and suicide attempts in adolescents. J Youth Adolesc. 2010;39(3):233–242. doi:10.1007/s10964-009-9482-0 [CrossRef] PMID:19941045
- Saunders KEA, Hawton K, Fortune S, Farrell S. Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review. J Affect Disord. 2012;139(3):205–216. doi:10.1016/j.jad.2011.08.024 [CrossRef] PMID:21925740
- Vallance AK. ‘Shhh! Please don't tell…’ Confidentiality in child and adolescent mental health. BJPsych Adv. 2016;22(1):25–35. doi:10.1192/apt.bp.114.013854 [CrossRef]
- Klineberg E, Kelly MJ, Stansfeld SA, Bhui KS. How do adolescents talk about self-harm: a qualitative study of disclosure in an ethnically diverse urban population in England. BMC Public Health. 2013;13(1):572. doi:10.1186/1471-2458-13-572 [CrossRef] PMID:23758739
- Curtis S, Thorn P, McRoberts A, Hetrick S, Rice S, Robinson J. Caring for young people who self-harm: a review of perspectives from families and young people. Int J Environ Res Public Health. 2018;15(5):950. doi:10.3390/ijerph15050950 [CrossRef] PMID:29747476
- Ferrey AE, Hughes ND, Simkin S, et al. The impact of self-harm by young people on parents and families: a qualitative study. BMJ Open. 2016;6(1):e009631. doi:10.1136/bmjopen-2015-009631 [CrossRef] PMID:26739734
- Sweet M, Whitlock JL. Information for parents: what you need to know about self-injury. Accessed January 25, 2021. http://www.selfin-jury.bctr.cornell.edu/perch/resources/info-for-parents-english.pdf
- Kaess M, Edinger A, Fischer-Waldschmidt G, Parzer P, Brunner R, Resch F. Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre, randomised controlled trial. Eur Child Adolesc Psychiatry. 2020;29(6):881–891. doi:10.1007/s00787-019-01399-1 [CrossRef] PMID:31512050