It’s hard to imagine wanting to intentionally cut or burn yourself, given the severe pain such injuries can cause. But intentional self-harm is actually surprisingly common among American teens: About one in five adolescents say they’ve harmed themselves to ease emotional distress, according to a 2014 review of studies on self-harm.
While self-harm used to be thought of as a cry for attention, it’s now considered a potential precursor to an eventual suicide attempt. And suicide is on the rise in the U.S. among people of all ages, even kids as young as 10 years old, according to a recent report by the Centers for Disease Control and Prevention.
“NPs and PAs play an important role in protecting children at risk of self-harm. A nurse is the first eyes and ears of the [physician],” says Cora Breuner, MD, MPH, FAAP, past chair of American Academy of Pediatrics’ Committee on Adolescence, professor of pediatrics in the Adolescent Medicine Division at Seattle Children’s Hospital.
As potentially the only healthcare practitioner to see some parts of an adolescent’s body, she adds, nurses and APPs have a unique opportunity to note cuts or scars that might otherwise get overlooked.
What is self-harm?
Self-harm is any action that deliberately harms the body without the intent of suicide. It includes more than 16 behaviors, such as cutting, scratching, burning, embedding objects under the skin, or punching objects with the intention of hurting yourself. Most people self-harm their hands, arms, abdomen and thighs.
Why do people self-harm?
While we don’t entirely understand why teens and young adults self-harm, common explanations from those who practice it include stress relief, to feel more in control of the body or mind, to cope with anxiety or past trauma, or to express feelings. Some people self-harm simply because it feels good or distracts them while others can’t pinpoint any particular motive.
In theory, self-harm can light up the reward center of the brain, explains Dr. Breuner, which could be why frequent cutting can become addictive.
“To many, it’s a way of feeling like they’re alive, which is to feel anything,” she says. “Sometimes it’s to help themselves heal. It’s super metaphoric, but you have something broken in yourself. If you can heal a wound, there’s something in yourself you can fix.”
Although self-harm itself isn’t a suicide attempt, teens who regularly harm themselves over time are at greater risk of a future suicide attempt.
“We used to think it didn’t mean much and hoped that if you ignored it, kids would stop doing it,” Dr. Breuner recalls. “But some people who continue to cut are suicidal. We now teach healthcare practitioners not to ignore this behavior.”
Why are certain groups more at risk for self-harm than others?
Self-harm tends to start around age 15, and the majority of people stop within five years. Girls are more likely to engage in self-harm behavior at younger ages and to attempt more serious forms, like cutting. Boys, meanwhile, are more likely to hurt themselves intentionally while drunk or high in social settings.
Dr. Breuner attributes self-harm in teens to less parental involvement and structure along with hormonal shifts around puberty, which causes mood changes. She also points to excessive social media use.
“A lot of copycat stuff happens. They think it’s an acceptable way of self-expression. Glorified images of self-harm are constantly being posted,” she says.
Recognizing patients who practice self-harm
Aside from visible cuts or scars on the hands, wrists, arms, thighs, and belly, kids who have a history of sexual, physical or substance abuse may be more likely to self-harm.
The most common mental health diagnoses linked to self-harm include:
- Borderline personality disorder (up to 80 percent of people with the condition engage in self-harm)
- Anxiety disorders
- Eating disorders
Dr. Breuner recommends screening for self-harm at every visit beginning in the adolescent years. Here’s how:
- Have a one-on-one. Starting sometime between the ages of 12 to 15, spend at least five minutes alone with a child at the beginning of each visit. Have a confidential conversation and assess for signs of self-harm and physical or sexual abuse.
- Don’t forget a confidential statement. Begin each confidential conversation by telling the child that everything he or she says is between the two of you — but that a caregiver will be notified if the child is being hurt or wants to hurt him or herself.
- Offer medical care. If a child has self-inflicted injuries, first treat potential infections and send him or her to the ER if a cut requires stitches. Be prepared to refer the patient to a dermatologist or plastic surgeon for scar revision procedures, if necessary.
- Tell the parent. Dr. Breuner advises talking to the parent in the presence of the patient if the child is under 18 if you’re concerned about self-harm. “You want to honor the kid’s ability to have confidential communication, but … we need to get child the attention they deserve,” she says.
- Suggest removing all sharp objects from the home. Ask the child to give the parents all of his or her sharp objects. Tell the parent to sweep the child’s room and lock up all sharp objects in the house, including cooking knives and razors. “That’s when it really hits home. They have to buy a lockbox and use it until they have the child firmly established with someone who can take care of them,” says Dr. Breuner.
- Make a referral. “Get the child help they need from a social worker or a mental health provider in community as soon as possible,” Dr. Breuner adds.
Tips for talking with parents
It may seem daunting, but Dr. Breuner says most self-harm conversations go surprisingly well.
“Parents are almost always relieved,” she says. “They had a suspicion because there was blood on the towel or knives went missing. [Now,] there’s no more secrets.”
When having the actual conversation, don’t make a fuss, Dr. Breuner emphasizes. Why? The child may interpret it as positive attention that could encourage another self-harm episode.
If you become emotional, walk out of the room, then come back for a to-the-point discussion with the family. Tell the parent something like, “Let’s get your child into therapy immediately. This behavior can reflect an untreated mental health condition like anxiety or depression, which can lead to more serious self-harm.”
Use a gentle and nurturing tone — without pointing fingers.
Research suggests the following are effective treatments for self-harm:
- Dialectical behavioral therapy (DBT). This specialized form of talk therapy was originally invented for people diagnosed with borderline personality disorder; a recent study suggests it reduces rates of self-harm and hospital stays in adolescents.
- Cognitive behavioral therapy (CBT). A type of talk therapy, CBT involves learning to identify negative thinking patterns and gives patients tools to more effectively manage stressful situations.
- Exposure therapy. This psychological therapy helps people confront their fears in a safe environment. It’s particularly helpful for panic disorder, obsessive-compulsive disorder and anxiety disorders.
- Medications. Antidepressants and other prescriptions can help in conjunction with therapy, but they won’t make self-harm thoughts go away, Dr. Breuner explains: “It might lift the depression so they can talk to a therapist, but you have to do the work.”
Other therapies may include acceptance and commitment therapy or trauma-informed therapy, says Breuner.
Ultimately, communication is key to preventing and treating self-harm, she adds. Advise parents to explain to their kids that self-harm isn’t self-expression, and it can lead to permanent scars. Parents should also encourage their kids to open up to an adult if they’re struggling so they can get the professional help they need.
Prevalence of Nonsuicidal Self-Injury in Nonclinical Samples: Systematic Review, Meta-Analysis and Meta-Regression, Suicide and Life-Threatening Behavior.
Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017, Centers for Disease Control and Prevention.
Self-Injury, Cornell Research Program on Self-Injury and Recovery.
Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents, Journal of the American Academy of Child and Adolescent Psychiatry.
The relationship between non-suicidal self-injury and borderline personality disorder symptoms in a college sample, Borderline Personality Disorder and Emotion Dysregulation.
Cognitive Behavioral Therapy, Mayo Clinic.
What is Exposure Therapy?, American Psychological Association.