Deliberate self-harm in Children and Adolescents

This article contains some graphic details and possible triggers.

Donald E. Greydanus, MeD has an article in Psychiatric Times(free registration required) titled Treating Self-Harm in Children and Adolescents A Complex Conundrum for the Clinician. It’s also a difficult and important subject for family members.

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.

Here is where understanding DSH it gets to be so important.

Research suggests that persons at high risk for suicide include those who use clandestine means to avoid detection of DSH; those who use highly lethal methods to hurt themselves, such as shooting; those who express a strong or unremitting death wish; and those who have comorbid psychiatric disorders.

Some of the factors that precipitate DSH are:

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

Education is one of the most important factors in dealing with DSH, as early intervention is critical in mitigating the effects

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.

The risk of suicide increases over time

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 espe-cially vulnerable for 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.

Only about 50% of young people who self-harm receive treatment, they are also at high risk for impulsive behaviours such as unprotected sex and the use of drugs.

There  are interventions that have shown success.

The key to successful intervention is the development of positive coping mechanisms, the reduction or relief of underlying stress, and improvement in communication skills.5,31 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, which will allow time for CNS maturation and an eventual end to such abstruse, capricious, or arbitrary behavior.

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.

Suicide is considered to be under reported as many deaths are not unequivocally due to deliberate self harm, but according to Statscan, approximately 500 people under the age of 24 commit suicide in Canada each year. At least some of these could be prevented by appropriate intervention.

Some resources:

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