Evidence-Based Reviews

Adolescents who self-harm: How to protect them from themselves

Current Psychiatry. 2010 August;9(8):15-A

References

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2. Nock MK, Joiner TE, Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65-72.

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Consider using standardized measures of suicidal intentions such as the Scale for Suicidal Ideation (SSI).¹⁴ Although the SSI was developed for adults, a large case-control study validated the scale’s use in adolescent psychiatric outpatients and students.¹⁵ In addition to assessing subjective reports of suicidal intent, the SSI also takes into account objective indicators of increased risk, such as planning an attempt, hiding details from others, and making preparations for death.

Questions to ask. After a self-harm incident, it may be helpful to begin the psychiatric interview with a general question such as, “What happened that led you to hurt yourself?” This does not categorize the act as suicidal and allows the adolescent to describe it in his or her own words. Shea¹⁶ suggests normalizing the act by assuming that self-harm occurred, rather than making the patient admit to it. For example, an interviewer might say “Many people I know who are hurting inside also try to hurt their body; how often do you do that?”

Inquire about suicidal intent in a few ways. For example, first ask, “Do you ever wish you were dead?” and follow up with, “Would you ever do anything to try to make yourself dead?” Asking about suicidal thoughts does not increase suicidal thoughts or behavior.^10,17

Clinical Point

Reviewing thoughts and feelings leading up to self-harm can help identify triggers, coping difficulties, and issues to address in treatment

Reviewing thoughts and feelings leading up to a self-harm act can help identify triggers, coping difficulties, and issues to address in treatment. This behavioral analysis can be completed using the mnemonic ABC:

Antecedents (situations or stressors leading to self-harming thoughts or actions)
Behavior characteristics (frequency, intensity, and duration of self-harming)
Consequences (eg, emotional relief, care and attention from others).

The results of this analysis could suggest treatment strategies, such as cognitive restructuring or techniques for decreasing feelings of distress.

The Risk of Suicide Questionnaire, which is designed for adolescents, asks:¹⁸

Are you here because you tried to hurt yourself?
In the past week, have you been having thoughts about killing yourself?
Have you ever tried to hurt yourself in the past?
Has something very stressful happened to you in the past few weeks?

Research has yet to determine whether this simple, rapid screen accurately identifies the need for psychiatric hospitalization or risk for suicidal outcomes. Although clinician- and self-administered suicide questionnaires may be useful for screening large populations, they are not a substitute for a thorough clinical assessment.

Inpatient or outpatient? When evaluating self-harming adolescents, first determine if they are in imminent danger of suicide and if more intensive services, such as hospitalization, are needed to maintain safety. Inpatient psychiatric services are appropriate for adolescents with suicidal thoughts or self-harm behaviors in addition to acute psychiatric disorders, significant substance abuse, serious medical issues, poor social supports, or inability to be managed safely as an outpatient.¹⁹ See the Table for a list of additional factors to consider.

Clinical Point

First determine if self-harming adolescents are in imminent danger of suicide and if more intensive services are needed to maintain safety

Consent for treatment may be required because many self-harming adolescents do not present with life-threatening symptoms. Laws regarding consent vary among states. In some jurisdictions, patients age ≥15 can consent to mental health treatment without parents’ knowledge or consent. If an adolescent is in imminent danger and cannot voluntarily consent to treatment, physicians can initiate mental health “holds.” Some states allow registered nurses, psychologists, licensed social workers, and others to initiate mental health holds.

Table 2

Strategies for assessing adolescent self-harm

Complete a thorough psychiatric evaluation
Interview the adolescent separately from parents
Obtain collateral information from parents and family, teachers, caseworkers, and others as needed
Use an empathic, nonjudgmental manner
Note appearance and presence of scarring and bruises, and patient’s clothing style
Ask about current and past self-harming thoughts and behavior: suicidal thoughts: frequency, duration, plans, and any triggers suicide intent: extent of desire to carry out suicidal thoughts and die past suicide attempts: number of attempts, methods, intentions, and consequences nonsuicidal self-injury: total episodes, duration, frequency, and triggers for self-harm
Ask about acute stressors (eg, break-up, loss or rejection, conflict with parents)
Inquire about thoughts, feelings, and events leading up to the self-harm episode
Assess for psychosis and ask about homicidal thoughts. If yes, assess whether there is a duty to warn others
Ask about drug/alcohol use and consider a urine toxicology screen to help clarify whether substance abuse problems may be contributing to self-harm
Assess family interaction and communication style, noting conflicts that might impact safety
Consider using a standardized measure, such as the Scale for Suicidal Ideation^14,15