Self-induced harm is common among adolescents and is a significant, albeit infrequent, risk factor for suicide (Gromatsky et al., 2020). While most youth suicides do not occur in the context of a youth with self-harm behavior, a modest percentage may progress to being at higher risk. This said, both for relieve of their underlying distress and as a barrier to progression to higher risk behaviors, primary care providers can play a significant role as interveners. Once a PCP learns of a youth’s positive self-harm profile, their role in managing the youth’s care will have multiple facets of which monitoring for suicidal risk is but one element.
Youth with self-harm profiles typically are struggling with at least one if not a number of social adjustment problems and/or associated mental health conditions. Ideally, appropriate intervention will include assessing for these underlying concerns and developing a treatment plan that includes behavioral health professionals, the parents/family, and the youth. Ongoing monitoring of the youth’s self-harm profile, along with monitoring for suicide risk should be incorporated in the treatment plan with all parties attending to these issues.
For the majority of affected youth, self –harm behaviors are hidden from others but once identified as a concern, the primary care pediatrician is often the most capable of conducting periodic physical examinations in a neutral and supportive setting by reassessing the severity of the behavior and they can also contribute by screening for suicidal tendencies at office contacts.
Because suicidal responses are not routinely seen with individuals exhibiting self-harm behaviors, the syndrome is typically identified as “non-suicidal self-injury” (NSSI). NSSI may arise as either impulsive or more routine reactions to unpleasant feelings or situations. The rates of NSSI during adolescence are not insignificant, and have been estimated as 17-18% (Brown and Plener, 2017).
In a study of 462 adolescent girls, Gromatsky and colleagues found a correlation between emergence of self-harm and behavioral disorders, parental substance abuse, adolescent disinhibition, younger age, and lower income. Interestingly, they did not find a correlation with anxiety or depressive states per se, but this does not mean that depression and anxiety are not risk factors for self-harm, but rather that paying attention to the aforementioned variables may help us catch the behavior earlier as they may be more closely associated with first onset.
While more research is needed, this is helpful information for primary care providers on the front lines. Here are some steps to consider
- Youth who present with behavioral disorders, such as Oppositional Defiant Disorder, Conduct disorder, ADHD, or sub-threshold disruptive behaviors, should be asked about self-harm behaviors and/or ideation.
- Those with irritability and mood symptoms should be screened for depression and anxiety and inquiry about self-harm tendencies should again be made.
- In families with evidence of parent-child relationship problems or those with other significant stressors impacting trust and communication, the issues of self-harm should be explored with both parents and the adolescent.
- For any case where the presence of self-harm behaviors or impulses are documented, referrals to mental health treatment should be discussed and initiated with parents and children, with follow through planned at a subsequent visit scheduled in a timely manner.
- SMARTCare is available for families and providers to discuss self-injury and help with further referrals.
Rates of suicide in the youth population in San Diego (2016 data):
Ages 5-14– rates are low with a flat trend line (3 cases)
Ages 15-19– rates are variable year to year with 17 cases reported
Ages 20-24—there has been a modest rise in rates with 32 incidents documented
Brown, R. C., & Plener, P. L. (2017). Non-suicidal Self-Injury in Adolescence. Current Psychiatry Reports, 19(3), 1–8. https://doi.org/10.1007/s11920-017-0767-9
Gromatsky, M. A., He, S., Perlman, G., Klein, D. N., Kotov, R., & Waszczuk, M. A. (2020). Prospective Prediction of First Onset of Nonsuicidal Self-Injury in Adolescent Girls. Journal of the American Academy of Child and Adolescent Psychiatry, 59(9), 1049–1057. https://doi.org/10.1016/j.jaac.2019.08.006
San Diego County Health and Human Services Agency (2018). San Diego County Suicide Prevention Council Annual Report to the Community Youth Suicide Prevention : New School Policies and Beyond, 47, 1–8.