Frequency of non-suicidal self-injury by adolescents have increased over the past 20 years. Given this prevalence and the associated health risks, it’s crucial for anyone treating adolescents to be aware of NSSI. ()
Medical staff who work with adolescents will likely meet patients who intentionally hurt themselves. Non-suicidal self-injury (NSSI) involves deliberate harm to one's own body without the intention to die. Girls are more likely to cut or pierce themselves, while boys are more likely to hit walls or themselves.
While estimates from the National Institutes of Health of NSSI by adolescents vary based on studies — from 1 in 6 to as high as 1 in 4 — rates have increased over the past 20 years. Given this prevalence and the associated health risks, it's crucial for anyone treating adolescents to be aware of NSSI, its risk factors, primary assessment considerations, and related resources.
Risk Factors
Adverse interpersonal experiences are the most common risk factors for NSSI.
In the past, professionals often believed traumatic childhood events like sexual abuse were associated with higher rates of NSSI. However, recent research shared by Current Psychiatry Reports has shown that emotional abuse is more common. Specifically, being bullied, parental critique or apathy, and indirect abuse (e.g., witnessing domestic violence), all strongly correlate with NSSI.
Military children may be at an elevated risk for trying NSSI. Bullying is likely a common risk factor for military kids as military-connected children report "higher rates of discrimination based on race/ethnicity, religion, gender, sexual orientation, and physical/mental disability than non-military connected children," according to a study published in Military Behavioral Health journal. Additionally, military families face unique emotional stressors due to deployments, relocations, and concern for the safety of deployed family members. For example, while a parent may not intend to be apathetic if they are deployed or worried about a deployed partner, the child may experience decreased emotional availability as apathy.
Assessment
Adolescents who self-injure frequently go to great lengths to hide their injuries. Many report a sense of shame or fear around adults discovering their behavior. Teenagers may self-injure for months or years before an adult knows.
As a result, NSSI may be discovered through indirect means.
"At times, parents have observed changes in behavior, such as declining school grades or difficulty regulating emotions, and are seeking services without being aware that their child is engaging in NSSI," explained Dr. Lisha Morris, a psychologist at Naval Medical Center Portsmouth's Child Mental Health Clinic in Virginia.
"Other families are informed by the parent of their child's friend, following viewing a text message or the child confiding in their friend."
Primary care providers can serve an essential role in helping adolescents get appropriate treatment.
"Children and adolescents engaging in NSSI are typically referred to mental health at our clinic through their PCM," continued Morris. "I would encourage PCMs to screen for NSSI, especially as children enter adolescence as we know that there is an increase in the prevalence of NSSI during adolescence."
Even if a patient is not currently self-injuring, it is still important to determine if they have a history of the behavior. Ceasing NSSI is associated with an increase in other risky behaviors, especially substance abuse.
Understand the Function
Adolescents primarily use NSSI as a form of emotional regulation. Studies have consistently shown that the experience of physical pain decreases negative affect. The act of self-harm can reduce negative feelings, thoughts, or internal experiences (e.g., anger, racing thoughts, or loneliness). It can also decrease the overall intensity of emotions, which helps if an adolescent feels overwhelmed.
Researchers, clinicians, and adolescent clients agree that a non-judgmental stance is an important first step in assessing NSSI, according to a report in the Journal of Marital and Family Therapy. Many adolescents who self-injure feel shame and do not want adults to discover the behavior. Approaching the assessment with a desire to understand how self-injury helps the patient can decrease the sense of being judged.
Questions that begin with "why" naturally evoke a defensive reaction, as they can be interpreted as accusatory. Instead of "why do you self-injure," providers should consider asking, "What does self-injury help you with?"
Assess for Risk
During the assessment, it is vital to explore the overall risk associated with the NSSI. Possible risks include:
The self-harm itself (e.g., method, frequency, intensity, location on body)
Potential medical complications (e.g., infection, required medical attention)
Other dangerous behaviors
NSSI can be associated with other high-risk behaviors like substance abuse, eating disorders, and unsafe sex.
It can be helpful to normalize the connection between NSSI and these other risky behaviors as a method of trying to feel better. For example, providers can ask, "Is there anything else you do to feel better, which others might consider risky?"
NSSI is also associated with an increased risk for suicide. A standard suicide assessment should be used by a provider according to their clinic's policy.
While the NSSI itself may not require urgent attention, these associated risks may increase the need for an urgent referral or close follow-up.
Identify Strengths
NSSI is often associated with feeling overwhelmed, so evaluating the patient's strengths is also key. It can help to ask the patient who they can go to for support, what comforts them, or what is going well for them.
Identifying these strengths can build rapport and highlight existing coping resources. If the patient cannot identify strengths, this can also inform the urgency of a provider's referral.
Accessing Resources
Therapy is frequently recommended as the most effective treatment for NSSI. A referral to a behavioral health specialist in a military medical treatment facility or a community provider will likely be necessary.
For military kids especially, it can be helpful to increase their overall social support.
"Friends play such an important role when one is struggling. It can be hard for military youth when they don't have a support network just after PCSing," said Dr. Kelly Blasko, program lead for the Defense Health Agency's Military Kids Connect program. "The Military Kids Connect website now has information to help military youth build healthy relationships that can be a support when difficulties arise."
Military OneSource also provides comprehensive services to increase family resilience and readiness through the Military Family Readiness System.
