KIDS
June 14, 2010

Teens Who Hurt Themselves

The medical community calls it "non-suicidal self-injury" (NSSI); the kids call it "cutting."

The medical community calls it "non-suicidal self-injury" (NSSI); the kids call it "cutting." By either label, it is the act of deliberately causing injury to one's body and while it is not performed with conscious suicide intent, it can have a more serious outcome than anticipated.

Some self-harmers, usually girls, expressed a need to hurt themselves because of shame, or disgust. When this was the motivation, their negative emotions were worsened by the self-harming episode. Boys were also motivated by boredom perceiving the self-harm activity as fun, or desiring to win membership in a peer group.

A recent article shed some light on this surprisingly common behavior and underscored the need for parents, physicians, and those who work with teens and young adults to know how to respond when they see it.

Who Does It?

Self-harm behaviors usually begin in adolescence and these teens. It is more common in girls than boys. The Prevalence of NSSI is 12-37.2 % in US high school students and 12-20% of late adolescent/young adults. NSSI is seen from ages 10-25, although more typically starts between 11-15 year olds. Cutting may be a single episode or a chronic pattern, but self-harmers think of themselves as "one who self-injures." About a quarter of the adolescents and young adults who report NSSI have only done it once. Among those who repeat the injury, 40% stop within a year and almost 80% start within five years of starting. Self-harmers may have psychiatric diagnoses including depression or anxiety, but may also occur independently of other mental health conditions.

Self-injury tends to spread within teenage populations. The Internet and media can act to facilitate this. As with other risky adolescent behaviors, media attention can show NSSI in a falsely normalized and romanticized light, which tends to reinforce such actions.

What Do They Do?

The authors of the recent study in the Public Library of Science Medicine describe "common" NSSI as self-injury that is performed compulsively, episodically, and repetitively. Injuries include scratching, cutting, punching, banging oneself with an object capable of causing injury, biting, ripping, burning or tearing skin, and falling, jumping and bone breaking. Girls are more likely to cut themselves, while boys are more likely to hit bite or punch themselves. Girls are more likely to self-harm as a solitary activity, while boys may perform acts alone, or in groups.

Boys may engage in self-harm in the context of a peer challenge, a test of will, strength, endurance, or "masculinity."

Why Do They Do It?

There are many possible reasons why teens may engage in cutting or NSSI and explanations have ranged from psychological to social to biological. NSSI may be an attempt to decrease psychological pain and distress by using self-injury to distract oneself. Self-harmers are more likely to have thought about or performed suicidal acts. Unlike a suicide attempt, self-injury is most commonly used to temporarily diminish distress, rather than escape stress by ending one's life.

Some researchers believe that acts of NSSI should be seen as signals that an individual is feeling considerable stress and that these feelings may in fact lead to consideration of suicide if they don't obtain some relief. When self- injurious acts are performed frequently and the methods of self-injury are of the type to cause severe tissue damage, the risk of severe mental health problems and future behaviors related to suicide are increased.

A study that explored the motivations of self-harmers found they showed more emotional distress, more antisocial behavior, difficulty with anger, and poorer self-esteem than non-self harming peers. Study participants endorsed a desire to externalize their inner pain; they wanted to send a message about inner pain, or to move the pain from their heart. After the episode they felt relief.

Some self-harmers, usually girls, expressed a need to hurt themselves because of shame, or disgust. When this was the motivation, their negative emotions were worsened by the self-harming episode. Boys were also motivated by boredom perceiving the self-harm activity as fun, or desiring to win membership in a peer group.

Studies have shown that while a significant proportion of adolescents harm themselves intentionally, an even larger proportion think about hurting themselves and have self-destructive thoughts. The authors concluded, based on their view of self-harm as a maladaptive effort to relieve stress, that adolescents need both recognition of their emotional distress and attention to safer, and more effective coping skills.

Treatment

Treating teens who injure themselves is multi-faceted. Treatment can include drugs, teaching problem solving and cognitive behavioral therapy designed to help the adolescent think about his or her concerns more productively and less emotionally. Other underlying mental health problems must identified and be treated appropriately. There may be a role for medications. One of the first steps in treating NSSI is to figure out what the painful stressors in a teen/ young adult's life are and to identify more effective coping skills. Self-harmers should also be assessed for suicide risk.

Parents should try to talk with their teens and consult with their families' medical care providers if they have concerns. There are websites and resources for both teens and parents.

The wounds and bruises themselves must be examined to determine severity and infection. The teen/young adult must be educated about proper wound care, and helped to more clearly understand the risks that they are taking with their body. The underlying emotional/social stressors and the role of peer pressure must be addressed.

What Can Parents Do?

Parents should pay attention to unexplained changes in their teens' emotional and physical health. In addition to changes in the usual activities, peer interactions, and academic performance, there are some specific signs of self–harm that a parent may notice.

Teens who practice NSSI may have unexplained wounds, scars or bandages. They may be unwilling to expose their injuries and scars. They may try to avoid gym class or swimming outings to avoid exposing their bodies. They may possess implements that can be used for self-harm such as razor blades.

Parents should try to talk with their teens and consult with their families' medical care providers if they have concerns. There are websites and resources for both teens and parents.

The following websites are resources about self-injury:
http://kidshealth.org/teen/your_mind/mental_health/cutting.html
http://www.selfinjury.com/

From the American Academy of Child and Adolescent Psychiatry:
http://www.aacap.org/cs/root/facts_for_families/selfinjury_in_adolescents

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