Family Mental Wellness Newsletter

Be Informed: Self Harm In Children and Adolescents

What is Self-Harm?

By: Donald E. Greydanus, MD


Deliberate self-harm (DSH) is a behavior in which a person commits an act with the purpose of physically harming himself or herself with or without a real intent of suicide.
Deliberate self-harm (DSH) is a behavior in which a person commits an act with the purpose of physically harming himself or herself with or without a real intent of suicide. Youths use a number of DSH methods, most commonly cutting, poisoning, and overdosing. Children generally scratch or bite themselves.



Research reveals that nonsuicidal DSH in adolescents reflects underlying hopelessness and low self-esteem as well as other factors that precipitate attempts to deal with unacceptable inner feelings and/or affect the behaviors of others, such as peers or family members. As stress builds over time, the adolescent may resort to self-cutting when a personal threshold occurs after a gradual rise in tension (the “spring-path” mechanism) or because of a “switch-path” mechanism, in which an uncontrollable impulse for self-cutting is “switched” on. Switching on is the phenomenon of dissociation during the self-harm act and an uncontrollable need for more deliberate harm (as self-cutting). The self-harm action seeks to provide relief from a “terrible state of mind” and helps release unbearable as well as unremitting inner tension and pain.

Big picture

Causes of Self-harm

DSH, deliberate self-harm.


In interviews, youths who self-harm note intense, personal efforts to avoid overt suicidal thoughts, resistance to direct suicide action, extreme self-anger or self-disgust, intense distressing feelings, periods of dissociation, personal need to influence others, and attempts to seek aid from others. Persistent DSH may also be linked to a variety of mental health disorders, including major depression, substance abuse disorders, eating disorders, schizophrenia, and personality disorders.

Deliberate self-harm etiologicial factors

• Overt depression
• Low self-esteem and sense of persistent hopelessness
• Impulsivity
• School influence (such as bullying)
• Family dysfunction and conflict
• Poverty
• Abuse


The type of DSH behavior does not predict the degree, extent, or gravity of potential underlying psychopathology. In some children and adolescents who deliberately self-harm, there are severe family dysfunction and family communication problems. Such defects in communication can induce patterns of depersonalization that lead to states of dissociation. Other family pathology (including physical and/or sexual abuse, severe neglect, early separation from parents, a milieu of intense parental criticism, and rejection, and other patterns of chaos) can result in DSH and youths who run away from home and join the ranks of the homeless.12,13

What's not true?

Misleading information about DSH is common on the Internet. DSH is often described as rationale behavior that represents personal self-expression and reaction to what 21st century’s social networks label as life’s unchangeable and insurmountable challenges. Youth are taught by others on the Internet that DSH is harmless, even good for one’s mental health, and representative of an acceptable expression of personal distress that is simply part of being young.

Why do children an adolescents self harm?

Nonsuicidal deliberate self-harm (DSH) in adolescents reflects underlying hopelessness and low self-esteem as well as other factors that precipitate attempts to deal with unacceptable inner feelings and/or impact the behaviors of others, such as peers or family members.


Although the underlying causes of DSH vary widely, all youths with evidence of DSH must be carefully evaluated for risk of suicide. If the underlying factors are not eliminated (such as psychiatric problems or long-term conflicts with peers or parents), acts of DSH can become repetitive (even inveterate) and can involve severe self-mutilation. In addition, depression and suicidal ideation may increase. Suicide is usually the result of chronic problems in self-cutters; however, acute reactions can also lead to suicide in some situations, such as those marked by impulsivity or use of lethal methods.


Over time, the overall risk of suicide increases after a self-harm episode; this risk increases 1.7% after 5 years, 2.4% at 10 years, and 3.0% at 15 years. Approximately 5% of patients who present to an emergency department after self-harm commit suicide within 9 years of the self-harming incident. Males with bulimia and males who experience analgesia during self-cutting are especially vulnerable to overt suicide. Youths who cut their wrists are at higher risk for suicide than arm-cutters, although the latter is associated with more dissociation. Children who have been sexually abused are at increased risk for self-cutting behavior, eating disorders, and suicidal ideation.

Intervention

Early intervention may prevent or at least reduce chronic DSH behavior that if left untreated may become impervious to treatment.

The key to successful intervention is the development of positive coping mechanisms, the reduction or relief of underlying stress, and improvement in communication skills. Positive or auspicious outcomes are enhanced by having therapy during times of crises, a trusting relationship between patient and clinician, appropriate treatment of comorbid psychiatric illnesses, and if possible, support from family members and friends. With the encouragement of a trusted clinician, a youth may be able to reduce episodes of DSH.


Therapists can develop prevention programs that enhance the ability of those who self-harm to successfully manage stress in their lives and learn techniques of effective problem-solving. Although little is known about adolescents’ views on DSH prevention, some have suggested that social network systems can be added to telephone hotlines to help prevent or mitigate DSH behavior.21

Parents what you should know?

Early intervention may prevent or at least reduce chronic DSH behavior that if left untreated may become impervious to treatment. The risk of completed suicide increases over time with repeated DSH. Ignoring DSH may lead to suicide that might have been prevented.


Studies also note that most persons involved with DSH are secretive or hidden from psychiatric scrutiny.28 Only 50% of youths who self-harm seek professional help. Always be on the lookout for hidden DSH and ask questions if the evaluation reveals suspicious clues (eg, skin trauma consistent with self-cutting or other self-injury). Remember that youths engaged in DSH are at heightened risk for many high-risk behaviors, including unprotected sexual activity and illicit drug use.


Traditional intensive interventions include identification of DSH behavior; group therapy; school-based programs; hospitalization; art therapy; and psychopharmacological treatment for underlying disorders, such as depression, anxiety, ADHD, and psychosis. A meta-analysis of suicide data from 18 studies, unfortunately, concluded that there is no proven evidence that current management of DSH prevents eventual, or later, suicide.30 Thus, more research is needed to identify successful interventions for treating children and adolescents with DSH.

Is my child self-harming?

By: Parents guide to support


As a parent, you might suspect that your child is self-harming. If you are worried, keep an eye open for the following signs:

  • unexplained cuts, burns, bite-marks, bruises or bald patches
  • keeping themselves covered; avoiding swimming or changing clothes around others
  • bloody tissues in waste bins
  • being withdrawn or isolated from friends and family
  • low mood, lack of interest in life, depression or outbursts of anger
  • blaming themselves for problems or expressing feelings of failure, uselessness, or hopelessness


The feelings or experiences that might be connected to self-harm include anxiety, depression, low self-esteem, poor body image, gender identity, sexuality, abuse, school problems, bullying, social media pressure, family or friendship troubles and bereavement.

How can parents be supportive

It can be difficult to know what to do or how to react if you find out your child is self-harming. Here are some things that can really help:

  1. Avoid asking your child lots of questions all at once.
  2. Keep an eye on your child but avoid 'policing' them because this can increase their risk of self-harming.
  3. Consider whether your child is self-harming in areas that can’t be seen.
  4. Remember the self-harm is a coping mechanism. It is a symptom of an underlying problem.
  5. Keep open communication between you and your child and remember they may feel ashamed of their self-harm and find it very difficult to talk about. Here are some ways you could start the conversation.
  6. Talk to your child but try not to get into a hostile confrontation.
  7. Keep firm boundaries and don’t be afraid of disciplining your child. It is helpful to keep a sense of normality and this will help your child feel secure and emotionally stable.
  8. If you feel confident, you can ask whether removing whatever they are using to self-harm is likely to cause them use something less sanitary to self-harm with, or whether it reduces temptation. This can be a difficult question to ask and if you are not confident to ask this seek professional advice.
  9. Seek professional help. Your child may need a risk assessment from a qualified mental health professional. Talk to your GP and explore whether your child can be referred to your local Child and Adolescent Mental Health Service.
  10. Discovering and responding to self-harm can be a traumatic experience – it’s crucial that you seek support for yourself. It’s natural to feel guilt, shame, anger, sadness, frustration and despair – but it’s not your fault.

Need Help?

If your child is in crisis and needs immediate help, please call 911 for assistance.

National crisis hotline: 1-800-273-8255

Crisis line via online chat at https://suicidepreventionlifeline.org/chat or by text: Send the word HOME to 741741

Community Health Network: 317-621-5700

Provides immediate assessments by phone for persons experiencing a mental health crisis 24 hours daily and offers referrals ad scheduling for mental health and addiction treatment providers.

Sandra Eskenazi Mental Health Center:

317-880-8485

Provides 24-hour telephone crisis interventions for persons with mental health or addiction treatment emergencies.

Aspire Indiana Crisis Line: 1-800-560-4038

Provides 24-hour phone crisis interventions for persons experiencing a mental health or addictions crisis.

Adult & Child Mental Health Center:

1-877-882-5122

Provides a 24-hour crisis and referral phone line.

Families First: 317-251-7575

24-hour crisis and suicide intervention services by both phone and text messaging.

Indiana Coalition against Domestic Violence:

1-800-332-7385

Offers 24-hour crisis intervention, safety planning and shelter referrals for persons in domestic violence situations.

Contact info:

Email: gfields@staindy.org

Email: gfields@sjoa.org


work cell: 317-721-7164