Donald E. Greydanus, MD

Kids, I don’t know what’s wrong with these kids today

Kids, who can understand anything they say?

Kids, they are disobedient, disrespectful oafs

Noisy, crazy, sloppy, lazy, loafers . . . 

Why can’t they be like we were- perfect in every way?

Self-injurious behavior (SIB)/deliberate self-harm (DSH) refers to behavior in which a person deliberately and directly harms himself or herself by intentionally damaging or destroying his or her body tissue; that behavior may or may not signify deliberate or overt intent to commit suicide, but DSH/SIB may result in a completed suicide. (DSH is used in this article to include SIB.) A history and repeated instances of DSH are strongly linked to and are risk factors for completed suicides.

Methods of DSH/nonsuicidal self-injury (NSSI) can range from superficial scratches or abrasions to severe tissue damage (ie, barely injuring the skin but no bleeding, to deep cuts, abrasions, broken bones) to extreme damage (destruction/ removal of body parts). Descriptions of DSH include multiple vague and inconsistent terms: NSSI, SIB, DSH, self-mutilation, self-harm, self- poisoning, self-injury, self-inflicted injury, body modification, self-immolation, and suicide.

Here we differentiate between 3 types of DSH: NSSI, culturally sanctioned body modifications (tattooing or body piercing), and unintentional or accidental injury. We exclude suicide, since suicidal youths harm themselves because they intend to die, but youths who engage in DSH typically do not have suicide as the main goal. We do not view DSH as an inevitable or immutable harbinger of suicide in youths.

Developmentally, adolescents often respond impulsively and capriciously to the stresses of growth and development (ie, biological, cognitive, emotional, hormonal, physical, and psychosocial). Most adolescents who self-harm do so in response to interpersonal crises and use DSH as a means of affect regulation and communication.

Part of the complexity of being an adolescent is the evolution-controlled failure of maturation of the prefrontal cortex until well after finalization of pubertal development.

 Many youths become involved in a variety of negative, often enigmatic and furtive behaviors years before they actually realize the serious nature of these activities. Parents, physicians, clinicians, and society have been frustrated for millennia by the seemingly frivolous and illogical behavior of adolescents. Witness this lament of the brilliant Greek philosopher Plato

The son feels equal to his father, he has no respect for his parents anymore . . . all he wants is to be free . . . students insult their teachers . . . and on top of this situation, in the name of liberty and equality, sex is everywhere.

Since the etiology of DSH is not actually known, its causes and associations are at best “probable.” Scientific literature notes that risks for engaging in DSH are highest for youths who live in poverty; have chronic medical problems, physical pain, or psychological pain; or suffer from psychiatric distress or severe mental illness (including psychosis). Some of these youths report that they experience a brief psychotic episode or symptoms of dissociation while they self-harm.

 Some youths reported that they feel relief/satisfaction, and they did not feel any pain when they engaged in DSH. They also said that the sight of their own blood allowed them to “feel alive” or “real.”

Youths who engage in DSH were found to suffer from psychiatric illnesses (eg, anxiety, depression, borderline personality disorders, PTSD, schizophrenia).

 They also may have multiple comorbid disorders and may engage in substance use and/or have characteristics of impulsivity and low self-esteem. Youths with a family history of psychiatric disorders (ie, first-degree relatives) are also at risk, especially if they experience family dysfunction and conflict, if they were victims of child maltreatment (emotional, mental, or physical abuse), or if they were exposed to violence, trauma, or bullying.

Alternatively and contrary to most of the previous research literature on NSSI, DSH may not be a symptom of a mental disorder but can occur in the absence of psychopathology. This theory posits that DSH functions as a means of affect regulation, help-seeking behavior, or social attention–acquiring behavior.

Self-injury typically begins in early adolescence and is most prevalent among adolescents and young adults.

 Worldwide the prevalence of DSH among adolescents ranges between 6.2% and 46.5% and appears equally prevalent across sexes, ethnicities, and socioeconomic statuses. In addition, DSH typically has a consistent presentation cross-nationally and across settings (mental health treatment centers, psychiatric hospitals, and community populations).

A community sample showed that one-third of surveyed adolescents reported a history of DSH and 16% said they engaged in repeated self-harm.

A recent survey of high school students in the US found that nationwide 8% of students (grades 9 and 10) attempted suicide 1 or more times during the 12 months before the survey.

 In a study of 77 adolescents who engaged in DSH, 70% said they had attempted suicide, 55% said they had made multiple attempts, over half endorsed psychiatric symptoms that met criteria for a diagnosable psychiatric illness, and 59.6% admitted to substance use.

DSH rates have increased over the past 20 years for adolescents and young adults, especially among females aged 15 to 19 years.

 The rising prevalence of DSH may have occurred because of increased media exposure. Today’s youths have more access to visual and auditory stimuli that glorify SIB: lyrics, texts, and paradigms of DSH (in vivo; in songs, print media, movies; and on the Internet) abound.

 Such exposure provides social support to an otherwise isolated adolescent, normalizes DSH as a form of release, and may expand an adolescent’s repertoire of methods for self-harm. Youths are at increased risk for self-harm and for making poor choices at this stage of development.

Data on and methods of self-harm are listed in the 

DSH most often begins in early adolescence; it often involves self-cutting (wrists, arms, or body), a drug overdose (self-poisoning), biting, or scratching. Head-banging or self-biting most often occurs in pre-pubertal individuals. DSH in which body parts are destroyed or removed (such as eye gouging or removal of parts of lips, ears, and fingertips) most often occurs in individuals with intellectual disabilities, neurodevelopmental disorders, or psychosis. The least common methods of DSH involve using bleach, acid, or other abrasive chemicals or breaking one’s bones.

Many adolescents with a history of DSH have seen their primary care physician during their time of self-harming, although adolescents and parents/caregivers may not report DSH to the physician. If DSH is reported, adolescents or parents/caregivers may minimize such behavior; this is often complicated by the failure of the involved primary care clinician not to investigate these actions further.

If the clinician does detect an abrasion, bruise, or other injury, he or she may make an assumption about causation. The physician may assume that when an adolescent engages in SIB, he or she was not actually trying to commit suicide but was merely seeking attention; or, the behavior may be seen as a “weak, harmless attempt” and therefore serious assessment or management is not deemed warranted. Parents, the adolescent, and associated clinicians may all agree with that assessment.

Each adolescent who presents with behavioral or mental health problems that disrupt daily adaptive function should be screened for the following:

• Current/history of suicidal behavior (ideation, intent, attempts, plans)

• Any tissue damage; comorbid anxiety, borderline personality disorder, depression, eating disorders, or depression; history of maltreatment (emotional, physical, or sexual abuse)

When self-injury is detected, information regarding the type, location, severity, intensity, and frequency is important for providing clues about appropriate therapy.

Be suspicious of unexplained skin injuries and scars on school-aged children and adolescents. All instances of SIB warrant further assessment and management. As part of the usual differential diagnosis, factors that are associated with DSH need to be evaluated (eg, psychiatric disorders, child maltreatment, sleep problems/disorders, substance use/abuse).

Sleep dysfunction in youths is a common cause of many problems, and a thorough sleep evaluation along with correction of any sleep problem that is found is critical. The human brain needs normal sleep to function properly. The improvement of comorbid mental health problems can be dramatic in youths who have their acute or chronic sleep debt corrected.

Experienced and highly skilled professionals are needed when working with youths who exhibit DSH behavior and their parents/caregivers. The team of professionals should include the referring physician (as the team leader), the treating psychiatrist, psychiatric nurses or physician assistants, other clinicians (eg, counselors, psychologists, social workers), other specialists (eg, dermatologist), and occupational therapists (for youths with tactile issues and neurodevelopmental disorders). The psychiatrist should coordinate care with the referring primary care physician.

Principles of evaluation for youths with DSH follow those of classic medicine and psychiatry. The assessors spend sufficient time with the adolescent in an initial evaluation and subsequent visits to determine the underlying issues and develop a management strategy. All forms of injury presented or discovered during examination should be differentiated from injury inflicted by others, such as from child abuse, or medical causes (eg, allergic reactions, dermatoses). Important data about the self-injury include its occurrences, intensity, types of SIB, repeated instances, and a history of depression as well as suicide attempts.

All acts of DSH should be taken seriously. Psychiatrists can be very helpful in communicating to primary care clinicians how to assess youths and how to determine referral for maximum benefit. A detailed mental status examination (MSE) should be conducted whenever the assessing clinician’s index of suspicion is raised or when the youth has injuries.

 Information from the comprehensive MSE is combined with clinical observations of the adolescent, information from the adolescent’s medical history located in the clinical record, and evaluations from other treating clinicians to make a detailed differential diagnosis and create a subsequent management plan.

Data on effective treatment of adolescents with DSH are limited. Most adolescents who participated in research protocols were from a clinical population and had a history of psychiatric treatment (ie, hospitalization, previous suicide attempts, current suicide ideation). Randomized controlled trials (RCTs) that identify evidence-based, specific, and effective treatments for adolescents with DSH/NSSI are lacking. Moreover, many clinicians do not have the specialized training needed to treat the developmental and complex psychiatric/psychosocial problems that plague adolescents.

Treatments for DSH in adolescents reflect modifications of effective empirical interventions for culturally and ethnically diverse adults. These adults received care in several settings (inpatient psychiatric, outpatient community) and were managed using multimodal interventions (ie, individual, group, family therapy, telephone calls for follow-up). The duration of most therapy for adults was 1 year. Other management plans are “well established” for children and adolescents who suffer from such disorders or conditions as trauma, maltreatment (abuse), insomnia, eating disorders, anxiety, depression, schizophrenia, and suicide attempts.

Few systematic reviews of treatment interventions for DSH with adolescents are available. Only trauma-focused cognitive-behavioral therapy met research criteria of the National Registry of Evidence-based Programs and Practices.

Reviews of research on adolescents who self-injure also support the value of dialectical behavior therapy and acceptance and commitment therapy. Both of these therapies are effective for adults. They are also shown to be empirically ‘‘well established’’ for the management of the sequelae of problems seen in children and adolescents with psychiatric disorders (eg, anxiety, depression, eating disorders, PTSD, schizophrenia, suicidal ideation), and they can be effective for insomnia and trauma. Results with children who primarily engage in DSH are limited.

Although the empirically supported treatments for self-injury among adolescents are effective, further research is needed with larger, culturally, ethnically, and socioeconomically diverse groups. There are no published RCTs of pharmacological agents that specifically target self-harm in adolescents. In addi-tion, there are currently no evidence-based psychological or pharmacological treatments for self-injury.

The principles of multidisciplinary management considered in this discussion are clinical conjectures limited by the lack of research in adolescents with DSH. Despite such dearth of research, some basic principles of care are recommended. For example, addressing potential comorbid sleep problems (eg, insomnia) and substance use disorders is vital for the overall health of youths with DSH. To understand the negative behaviors, clinicians should spend sufficient time and provide a clear, explicit message that the adolescent will not be abandoned in a time of great emotional need.

Psychiatrists can provide therapy, coordinate the efforts of a multidisciplinary treatment team, and proffer guidance to primary care clinicians in the management of these adolescents-as part of an overall multidisciplinary management approach. Didactic psychiatrists can share the principles of behavioral science with primary care clinicians, which may be better accepted by the youths than more extensive formal treatments. These problem-focused, solution-oriented interventions can be brief (20 to 30 minutes) and limited to 2 to 4 sessions. Co-locating mental health services with those for primary care may mollify the concerns of young patients. More research is needed to assess this approach, which has gained increasing popularity in the past decade.

Dr Greydanus is Professor and Founding Chair and Dr Pratt is Professor in the department of pediatric and adolescent medicine at Western Michigan University Homer Stryker MD School of Medicine in Kalamazoo, Mich. The authors report no conflicts of interest concerning the subject matter of this article.

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 Mehlum L, TÃ¸rmoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. 

 Mitrou F, Gaudie J, Lawrence D, et al. Antecedents of hospital admission for deliberate self-harm from a 14-year follow-up study using data-linkage. 

 Greydanus DE. Treating self-harm in children and adolescents: a complex conundrum for the clinician. 

. http://classics.mit.edu/Plato/republic.html. Accessed December 15, 2014.

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 Lang CM, Sharma-Patel K. The relation between childhood maltreatment and self-injury: a review of the literature on conceptualization and intervention. 

 Nock MK, Joiner TE Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. 

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 Perepletchikova F, Axelrod SR, Kaufman J, et al. Adapting dialectical behaviour therapy for children: towards a new research agenda for paediatric suicidal and non-suicidal self-injurious behaviours. 

Articles

The authors differentiate between 3 types of deliberate self-harm: nonsuicidal self-injury, culturally sanctioned body modifications (tattooing or body piercing), and unintentional or accidental injury. 

Predicting, Assessing, and Treating Self-Harm in Adolescents

Psychopharmacology has become a cardinal feature of psychiatric treatment for adolescents in the 21st century.

 Successful transition of youth with psychiatric disorders from the initial treatment to long-term management is fraught with pitfalls that can sabotage success. A major conundrum is lack of adherence to recommended psychopharmacological regimens. Limited adherence (nonadherence, nonconcordance) can be a major sticking point in the management of chronic illnesses-both psychiatric and medical.

This discussion focuses on approaches to improve medication adherence, particularly in reference to helping adolescents remain on recommended psychopharmacological regimens when transitioning from acute to long-term maintenance.

For physicians, improving patient adherence to medication recommendations has proved to be a complex task. Even patients who have been court-ordered to treatment show limited follow-through.

 There is no established evidence-based strategy that improves medication adherence in all cases.

 Poor treatment response is a warning sign of nonadherence. When clinical progress is not seen, counseling an adolescent patient about the need for the medication, getting the patient to “buy-in” to the recommended medication(s), and working on the therapeutic alliance will usually result in better adherence than simply switching to another medication, increasing the dosage, or adding another medication.

While the adult literature on nonadherence is considerable, there is a dearth of publications regarding this dilemma in children and adolescents. Two recent articles have proposed theoretical models to help us understand the origins of nonadherence in this population, with suggestions on strategies to improve it.

 Most authors propose similar strategies to improve medication adherence, which generally include discussing with patients the importance of medication, setting up rewards, providing handouts, increasing education of both patient and parents/caregivers, sending reminders about appointments, and using supplementary health care workers in the education process (eg, nurses, social workers, primary care clinicians).

 In addition to specific techniques, the regular day-to-day clinical encounters psychiatrists and patients have can do much to augment adherence.

Limited communication may contribute to nonadherence; therefore, efforts to build a mutually beneficial rapport should begin during the initial evaluation. Allow enough time to establish an effective communication pattern with the patient. Minimal time spent may lead to the patient’s lack of respect for the clinician and to problems with treatment recommendations. If the initial clinician is not overseeing the long-term maintenance management, the new clinician who becomes involved will need to start building rapport from the beginning.

What is already known about transitioning psychopharmacology in children and adolescents? 
? Psychopharmacology is important for adolescents with psychiatric disorders, but many youths become treatment-nonadherent. Getting them to take their medications regularly is very challenging, and research in this area of child and adolescent psychiatry is limited.

What new information does this article provide? 
? Try a variety of techniques to improve compliance based on knowledge of the specific patient as well as the patient’s disorder. Good rapport with the patient is crucial. You and the office staff must be accepting of the often difficult adolescent patient. The patient’s consent on treatment choice is vital to improve compliance with medications. Personalize strategies to ensure treatment adherence (eg, texting reminders regarding medication, using e-mail for any questions that arise outside of office visits).

What are the implications for psychiatric practice? 
? Adjust the schedule so more time can be spent developing a healthy and mutually beneficial therapeutic alliance. Keep good notes that provide information about what makes this patient “tick.” Do not rely on the patient’s diagnosis alone; treat comorbidities as well. Avoid coercion-you cannot “force” the patient to take medications. If you do not get the adolescent’s “buy-in,” expect limited compli-ance. You will be working with this patient over a long period, and you have time on your side.

Successful treatment requires engaging the young patient in the health care process according to his or her cognitive level and psychiatric diagnosis. The 6 A’s of basic outpatient care are availability, accessibility, approachability, acceptability, appropriateness, and affordability.

 Competent caring for an adolescent with a chronic condition will not occur if the clinician is not readily accessible. Evening hours often work well for saturnine youths who may not be appreciative of an early morning visit, when circadian rhythms are not well aligned. If the clinician is not-or does not appear to be-approachable, he or she will not be successful in dealing with a youth’s intimate and complicated mental health issues over the long term. It is difficult to establish a beneficial alliance if the youth finds it difficult to see the clinician or is forced to see one that he does not trust.

The patient should feel that he is liked. Adolescents need a warm and accepting milieu. Malignant attitude problems may come from the young patient or his parents, but they should never arise from the office personnel. Because cost is an increasingly common barrier, the care should be affordable to the patient and family.

Trust of the clinician and the profession in general is a major component for acceptance (and adherence) of psychotropics by children and adolescents.

 The patient’s parents may also resist use of psychotropics for their child.

 As trust builds, the clinician can more clearly and succinctly explain the need for medications and can overcome the family’s intrinsic distrust of them.

 Failing to engage patients in treatment decisions will often result in treatment nonadherence and, thus, negative outcomes. A power struggle might ensue and result in patients who sabotage treatment efforts.

As with adult patients, shared decision making is an important component in effectively managing symptoms in young patients.

 Although this may be more complex in psychiatry than in general medicine, shared decision making is necessary for optimal results.

 More research is clearly needed to understand an adolescent’s experience with and perceptions of recommended psychotropic medications.

Western medicine comes out of the Hippocratic tradition, which granted rights to the treating physician on the basis of the long-held belief that the physician would unselfishly and professionally act in the best interests of the patient.

 Twentieth century medicine, based on earlier historical developments in the United States, emphasized the rights of patients. This concept was strongly stimulated by the Nuremberg trials in 1946. The term “informed consent” was first used in a medical malpractice trial in 1957.

 Even if minors cannot legally provide consent to solidify trust and openness, clinicians should make sure that their patient understands the treatment options and agrees to the choices.

It is vital that the patient consents to the treatment or he may sabotage the treatment, refuse to take the recommended medication(s), and weaken the critical therapeutic alliance. Principles of confidentiality must be clearly established and continuously followed for the benefit of all involved-the pediatric patient, his parents/caregivers, and the psychiatrist.

 HIPAA (Health Insurance Portability and Accountability Act) rules must be followed

; however, confidentiality is not absolute, and the clinician’s judgment is important.

Intermittent evaluation of the clinician-patient conversation (ie, the nature of the conversation versus specific therapy) is important and will improve adherence.

 Antagonistic actions, such as coercion and compulsion, can have long-lasting, disastrous results on the therapeutic alliance.

 Understanding the patient and his motivations for using or not using a medication is important in devising strategies to ameliorate fragile medication adherence.

 Patient education is a key factor in motivating depressed adults to feel better about themselves; the same strat-egy can be used for adolescents.

New technology (eg, answering questions via e-mail), embraced by most youths, is a powerful communication tool.

 Young patients are often forgetful; thus, strategies such as texting reminders can improve medication adherence.

The presence of comorbid conditions such as ADHD (

presents suggestions for management of ADHD), severe family dysfunction, and chronic medical problems complicate medication adherence.

 Comorbidities need to be addressed simultaneously with the presenting disorder.

Inevitably, conflicts arise between the adolescent and the treating clinician-conflicts between adolescents and society have been noted for thousands of years and are not necessarily pathological.

 Plato (427 bc to 347 bc), the great classical philosopher and mathematician, said, “The son feels equal to his father, he has no respect for his parents anymore . . . all he wants to be is free . . . students insult their teachers . . . and on top of this situation, in the name of liberty and equality, sex is everywhere!”

 This master philosopher was simply articulating a classic, yet dour, description of normal, yet inevitable, aspects of adolescence.

John, an 11-year-old with ADHD, is readmitted to the psychiatric inpatient unit because of impulsive behaviors that “do not respond to treatment.” His family reports that medications work well in the beginning but soon after they “lose power,” which leads to relapse. On the unit, John is uncooperative, angry, and agitated; does not follow directions; and gets into fights with other patients. He is given a stimulant he had not tried before, and he shows a spectacular improvement. He becomes helpful to staff and his fellow patients to the point that he gets the title of “honorary mental health worker.” Discharge plans involve returning home in 48 hours. On the day before discharge, John begins to exhibit the same type of behaviors that brought him to the unit. These behaviors are initially interpreted as decreased medication effectiveness, and the dose is increased. On the day of discharge, the behaviors become so impulsive that John needs quiet time.

How could it be that such initially spectacular improvement faded away so quickly?

Angela, a 12-year-old with ADHD, is on a regimen of a long-acting stimulant in the morning and a short-acting stimulant in the afternoon to help her complete her homework. This regimen has worked well for many months. The child of divorced parents, Angela spends part of the week with her father and part with her mother. She feels very good about taking her medication. However, for the past several weeks, Angela’s performance at school has declined because she has not handed in some of her homework. This has led to an increase in the dose of the short-acting stimulant in the afternoon, which consequently has caused insomnia. Psychotherapeutic work was started to help Angela overcome some oppositional behavior toward certain teachers.

What made a long-stable situation suddenly worsen?

Treatment failures in both cases are related to nonadherence. In John’s case, even when confined to the psychiatric unit, he still managed to avoid taking medication. He had become close to his “fellow” mental health workers, so when they confronted him with the possibility that he may not have been taking his medication, he opened up and shared that he felt “stupid and ashamed” to have to take medicine. This was supportively addressed in the inpatient setting for 2 days and followed up by the outpatient psychiatrist, with good results and improved outcome.

Angela, as it turns out, was cared for by a maternal grandmother on certain days who “did not believe” in medication and would not administer the short-acting stimulant on days that coincided with math and history homework-the two subjects Angela was failing. Once the grandmother was involved in the treatment effort and offered education as well as support, she resolved her opposition to medications and Angela returned to her usual good level of functioning.

Pediatric Psychopharmacology in the 21st Century.

 Greydanus DE, Calles JL Jr, Patel DR, et al, eds. 

Clinical Aspects of Psychopharmacology in Childhood and Adolescence. 

New York: Nova Science Publishers Inc; 2011.


 World Health Organization. Adherence to long-term therapies: evidence for action; 2003. 

http://www.who.int/hiv/pub/prev_care/lttherapies/en

 Kaplan G, Pannullo D, Brodzinsky D, Hitt JC. Noncompliance with family court mandated evaluations in a juvenile justice clinic. 

 Haynes RB, Yao X, Degani A, et al. Interventions to enhance medication adherence. 

 Gearing RE, Mian IA. An approach to maximizing treatment adherence of children and adolescents with psychotic disorders and major mood disorders. 

 Charach A, Volpe T, Boydell KM, Gearing RE. A theoretical approach to medication adherence for children and youth with psychiatric disorders. 

 Eisenmann CM. Revising a medication education program on an inpatient child and adolescent psychiatric unit. 

 This discussion focuses on approaches to improve medication adherence, particularly in reference to helping adolescents remain on recommended psychopharmacological regimens when transitioning from acute to long-term maintenance.

Strategies to Improve Medication Adherence in Youths

Deliberate self-harm (DSH) behaviors should be taken seriously by the psychiatrist. Comprehensive evaluation and treatment must be individualized for each patient, but here are important points to keep in mind when assessing and treating these difficult conditions.



• Cutting
• Poisoning
• Drug overdose
• Battery (hitting)
• Biting
• Shooting
• Burning
• Hanging
• Pinching
• Scratching
• Well jumping
• Jumping from bridges, buildings, or other high places



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



• Nonsuicidal deliberate self-harm 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.

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

• The key to successful interventions is the development of positive coping mechanisms, the reduction of relief underlying stress, and improvement in communication skills.

Note: Adapted from an article published in 

Treating Self-Harm in Children and Adolescents

Here we list important points to keep in mind when assessing and treating patients who self harm.

Self-Harm Prevention Tips: Things to Look For

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.

Children and adolescents with intellectual and developmental disabilities are also at risk for various self-injurious behaviors, although they are typically not cognizant of the behavior. 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.

 provides some prevalence figures from recent studies around the world. These data illustrate that DSH is a ubiquitous phenomenon in which research and clinical mental health professionals as well as primary care clinicians have a role.

As our understanding of the mechanisms that underlie DSH improves, better management methods can be implemented. Clinicians are often flummoxed by the seemingly paradoxical self-injurious behavior of children and adolescents. Etiological models are traditionally construed in an attempt to understand suicidality, while the self-harming behavior of a child or adolescent is often viewed as the result of diverse socioeconomic influences (

Research has identified various conducive factors (eg, peers, school, family, religious milieu) that affect suicidal ideation and self-derogation in adolescents.

 Recent research links the aggravated effects of bullying (including cyberbullying) to DSH and suicidal ideation.

• Cutting
• Poisoning
• Drug overdose
• Battery (hitting)
• Biting
• Shooting
• Burning
• Hanging
• Pinching
• Scratching
• Well jumping
• Jumping from bridges, buildings, or other high places

It is not currently helpful to separate DSH into major and minor types, because evaluation and treatment must be individualized for each patient. Predicting the suicidal potential of any patient with DSH is complex; classifying DSH as minor could be tragically misleading. Clearly, more systematic research is needed.

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.

TABLE 2: Prevalence studies in deliberate self-harm behavior
   

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.

TABLE 3: Deliberate self-harm etiological factors 

• Overt depression
• Low self-esteem and sense of persistent hopelessness
• Impulsivity
• School influence of intimation (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 dis-sociation. 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.

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.

CHECKPOINTS 
? 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.

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

? The key to successful interventions is the development of positive coping mechanisms, the reduction of relief underlying stress, and improvement in communication skills.

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.

Self-harming behavior in patients with intellectual disability is a common and difficult behavior for clinicians to understand and effectively address. It can be part of overall aggressive behavior that is directed toward others or inward.

 One study found that DSH behaviors eventually develop in 10% of children and adolescents with intellectual disability.

 Other studies have shown a prevalence of 1.7% to 41%.

 In this population, self-injurious behavior often includes skin-picking, head banging, eye gouging, and similar mutilation behaviors.

Remember that patients with intellectual disability have suicidal thoughts and can complete suicide; indeed, those at risk for suicide share similar neurogenetic factors whether they have an intellectual disability or normal intelligence.

 A careful evaluation is necessary to identify underlying factors that can be a complex combination of neurobiological and psychosocial/environmental phenomena (ie, DSH may be an adverse effect of psychopharmacology).

 A change in routine, presentation of difficult tasks, or an inability to perform tasks can precipitate self-mutilation in all patients who have an intellectual disability.

Other factors related to DSH in adults with intellectual disability include low functional ability level, not living with a family caregiver, visual disability, and comorbid attention-deficit/hyperactivity disorder (ADHD).

It is critical for clinicians to try to understand what the patient with DSH is trying to communicate and to provide early treatment. Ongoing studies are looking at the development of specific aggression profiles to direct specific treatment for patients with aggressive behavior, including DSH.

 Remission of DSH can occur in adults with intellectual disability, and current research is seeking underlying factors that can encourage remission in self-injurious behavior.

 Studies are also looking at a management model of early intervention and prevention.

All patients who exhibit recent or chronic self-harming behaviors need a careful and meticulous evaluation to determine the best individualized management strategies. In many, a recurrent motif develops; statistical analysis using hurdle models may help identify these malignant patterns.

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.

 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.

Thus, more research is needed to identify successful interventions for treating children and adolescents with DSH.

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, 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.

Management of self-injurious behavior in youths with intellectual disability

Management approaches for youths with intellectual disability and self-injurious behavior are rooted in psychological measures, including behavior modification (as differential reinforcement, extinction, punishment, response interruption, and redirection); giving the patient comforting or preferred items; placing the patient in protective helmets and/or gloves; and judicious use of psychopharmacological agents (eg, anticonvulsants, antipsychotics, antidepressants).

 Primary treatment with an antipsychotic is not recommended unless the underlying cause of the self-injurious behavior is the result of a psychotic disorder.

 Punishment-based therapies are not recommended. Research on optimal management is under way.

The role of restraint or other aggressive interventions (eg, hitting, confining the patient to a room, refusing to allow play time) in the management of patients who self-harm remains questionable. Some current research focuses on the ethics of restraint versus the need to develop optimal practice standards for restraint with minimal harm to the patient with intellectual disability.

DSH is a relatively common and pervasive, yet often surreptitious, phenomenon that may start in childhood and escalate in adolescence and young adulthood. Repeated DSH is linked to eventual suicide.

 Adolescent girls seem more vulnerable to this behavior than adolescent boys. Key components of DSH behavior are negative emotion and saturnine self-derogation. Etiological factors behind DSH include attempts to resist suicidal thoughts, expression of disgust or self-anger, attempts to seek help from others, a desperate desire to remove periods of dissociation, and audacious wishes to influence others.

Study findings indicate an association between DSH and drug and alcohol abuse and eating disorders. Research is seeking to categorize various subgroups, such as major versus minor, types 1 through 4, those with serious versus minimal injury, as well as others. Fortunately, most are not at high risk for completed suicide.

 All DSH behavior should be taken seriously by the psychiatrist, and comprehensive evaluation as well as individualized management should be provided.

Research should look at ways to improve primary, secondary, and tertiary prevention as well as methods of intervention.

 Effective interventions will prevent DSH from becoming a repetitive pattern that can result in suicide.

 Greydanus DE, Shek D. Deliberate self-harm and suicide in adolescents. 

 Vajani M, Annest JL, Crosby AE, et al. Nonfatal and fatal self-harm injuries among children aged 10-14 years-United States and Oregon, 2001-2003. 

 Hay C, Meldrum R. Bullying victimization and adolescent self-harm: testing hypotheses from general strain theory. 

 Lloyd-Richardson EE, Perrine N, Dierker L, Kelley ML. Characteristics and functions of non-suicidal self-injury in a community sample of adolescents. 

 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. 

Attention-deficit/hyperactivity disorder is a fascinating condition that has perplexed clinicians, researchers, parents and patients for a long time. Research indicated that management of ADHD in children and adolescents should emphasize a multimodal approach, with attention to proper school placement, appropriate psychological therapy and, in many situations, psychopharmacology. This review focuses on the medications that have been noted to provide benefit to adolescents with ADHD.

Methylphenidate (Ritalin, Concerta, Metadate, Methylin) is the most commonly prescribed stimulant with hundreds of randomized, controlled studies noting that it may provide benefit to patients with ADHD in various ways: enhance concentration, reduce hyperarousal as well as impulsivity, improve tasks (i.e., homework completion, school and/or work performance), and/or lessen antisocial and aggressive behavior. Research reveals that the methylphenidate mechanism of action involves increasing extracellular dopamine levels by selective binding of the presynaptic dopamine transporter in the central nervous system (prefrontal and striatal areas) in addition to norepinephrine transporter blockage (Solanto et al., 2001).

(due to copyright concerns, this table cannot be reproduced online. Please see p48 of the print edition--Ed.)

 outlines the well-known daily dosage schedule and some of the adverse reactions for methylphenidate. This chemical crosses the blood-brain barrier after gastrointestinal absorption, with stimulant effects that begin in 30 to 45 minutes, peak in one to two hours and then wane after three to five hours.

With all the various types of medications as well as different formulations that can be used to treat ADHD in adolescents, choosing the right one can be a difficult task. This analysis of the options will help make that choice easier.

Author | Donald E. Greydanus, MD

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