Self-Harm in Adolescence

If you’re like most parents, the idea of your teen intentionally harming himself or herself is a tough one to wrap your mind around.  However, an increasing number of adolescents today are secretly harming or mutilating themselves while their parents are completely oblivious.

Self-harm behavior is usually not done with the intent to die.  In other words, it’s usually not a suicide attempt.  This type of self-harm is often referred to as “non-suicidal self-injury” (NSSI for short).  However, there are occasions when death – or at least the thrill or ambivalence of flirting with death – is involved.  Regardless, self-harm in adolescents isn’t normal or healthy and should be taken very seriously.

This brief guide is designed to help you know what to look for and what to do if you suspect your teen is engaging in any type of self-harm.

Self-Harm in Adolescents – Statistics and Facts

Since the vast majority of individuals who engage in self-harm go out of their way to hide it, accurate statistics are limited.

• In the U.S., nearly 2 million cases of self-harm are reported each year
• One in 7 males and 1 in 5 females engage in self-harm behaviors every year
• Self-harm behavior is often learned from friends or websites that promote self-harm
• Nearly 70% of youth admitted to the hospital for self-harm report prior self-harm behavior that was never reported
• Nearly 14 % of high school students reported engaging in self-harm behavior in a 2002 Canadian study

For individuals who engage in self-harm:

• 60% are females
• Approximately 1 out of 2 have a history of sexual abuse
• 9 out of 10 start in their pre-teen or teen years
• The behavior starts about age 14 and continues into early adulthood in 50%

Types of Self-Harm

Adolescents who engage in self-harm or self-mutilation do so in a variety of ways, including:

• Cutting or scratching
• Burning
• Inserting objects into their body or under their skin
• Overdosing on medications or drugs
• Injesting poison in various forms
• Hanging
• Jumping in front of vehicles or from high places
• Hitting oneself
• Picking scabs to keep wounds from healing
• Carving or branding the skin
• Pulling hair out
• Head banging
• Biting oneself
• Getting excessive body piercings

Why Teens Harm Themselves

There are many different reasons an individual may engage in self-harm or self-mutilation, including to:

• Cope with stress
• Punish themselves, usually out of self-hatred
• Alleviate anxiety or feelings of nervousness
• Feel alive when they’re feeling emotionally numb or dead inside
• Reduce negative emotions, such as anger, loneliness, or sadness
• Take their minds off their problems
• Induce a temporary “high” (from the endorphins released into their bloodstream)
• Fit in with their peers or respond to a dare
• Experiment
• Cope with parents who are demanding or who invalidate them
• Release pent-up emotions that they believe are bad or wrong for them to have

Teens may also engage in self-harm as a sort of ritual or ceremony.  Also, the behavior can become habitual or even addictive, often making it even more difficult to stop.  On rare occasions, self-harm or self-mutilation is the result of an unsuccessful suicide attempt.  But even when it’s not, some types of self-harm are very dangerous and can result in accidental death even though that wasn’t the intent.

Mental Health Issues Related to Self-Harm in Teens

Self-harm behavior doesn’t always occur as the result of an underlying mental health disorder.  However, there are several psychiatric disorders often associated with self-harm, including:

• Borderline Personality Disorder (self-harm is very common in this disorder)
• Depression
• Anxiety disorders
• PTSD (posttraumatic stress disorder)
• Eating disorders, such as bulimia or anorexia
• Substance use disorders
• Conduct disorder
• Oppositional defiant disorder

Risk Factors for Self-Harm in Teens

There are several factors that increase the risk of self-harm in teens, including:

• Severe stress
• Lack of healthy coping skills
• Bullying
• Being extremely self-critical
• Current or past abuse or neglect
• One of more major losses (major in the eyes of your teen), such as a break-up or death
• Previous self-harm
• Mental health issues
• Being around friends or family members who engage in self-harm behavior

Looking for and Recognizing the Signs of Self-Harm

Adolescents are often very clever, and will go to great lengths to hide the scars and wounds of self-harm from parents, teachers, and anyone else who might attempt to intervene or ask questions.  Sadly, many parents are completely unaware of their child’s self-harm. Fortunately, there are often tell-tale signs if you know what to look for.

Following are several warning signs that your teen may be engaging in self-harm:

• Insisting on wearing long sleeves or pants even in the heat of summer
• Cuts, scratches, bruises, carvings, or burns anywhere on their body – most commonly on arms, legs, or abdomen
• Spending time with friends or acquaintances who harm themselves
• Missing patches of hair, including from the eyelashes or eyebrows
• Sharp objects hidden in your teen’s bedroom, backpack, clothes pockets, or car
• Isolating in his or her bedroom with the door locked, especially after a stressful event (e.g. a fight or break-up with a friend or significant other, conflicts at home, a major loss or disappointment, or a difficult day at school)
• Wounds or scars are noticed by a teacher, coach, or family doctor
• Someone (often a close friend or sibling) reports seeing your teen engage in self-harm
• Finding sharp objects (e.g. a box cutter, knife, or razor blade) in your teen’s room with blood on them

Knowing the First Steps to Take  

If you have discovered or have reason to believe your teen is engaging in self-harm behaviors, take action.  Don’t ignore it or brush it off as some adolescent “phase”.  Self-harm in teens is dangerous and unhealthy, and the scars can last a lifetime.  The sooner you intervene and get help for your child, the better.  Following are the first steps to take:

1 – Talk to your teen.  Share your concerns without panicking or being dramatic.  Let him or her know you want to help in any way you can.  Be patient and calm, and let your teen know you’re available to talk and willing to listen.  Don’t pressure, nag, or scold – doing so will just add more stress to your teen’s life which could trigger more self-harm behavior in response.

Don’t be surprised if your teen gives you the “everything’s fine” or “you’re just over-reacting” brush off.  He or she may do this out of embarrassment, shame, or fear of consequences.

2 – Set up an appointment for an evaluation.  When it comes to self-harm, have your teen evaluated by a mental health professional.  A psychologist or psychiatrist who specializes in working with children and adolescents is ideal.  He or she can determine if your child has an underlying mental health issue that’s fueling the self-destructive behavior, or, if not, identify and address the root issue (e.g. family conflict, peer pressure or bulling, etc.) with the appropriate treatment.

3 – Get your teen into treatment.  The third step to help your teen is to get him or her into treatment.  Treatment recommendations will be made once your teen is evaluated.  With self-harm, the treatment approach and methods will depend at least partly on whether there’s an underlying mental health issue, such as depression, borderline personality disorder, or anxiety.

Treatment for teens who engage in self–harm usually involves some form of psychotherapy or “talk therapy”, and may also include medication (usually to treat symptoms of depression, anxiety, or another psychiatric disorder).   Hospitalization may be necessary if the self-harm behavior is frequent or severe.

Psychotherapy – There are several types of psychotherapy that can benefit your teen.  These include:

• Cognitive behavioral therapy (CBT) – CBT is a relatively short term type of talk therapy. It focuses on helping your teen identify and change negative thought patterns, behaviors, self-talk, and beliefs that are contributing to and reinforcing self-harm.  CBT is also very beneficial in the treatment of depression, anxiety, and many other disorders.
• Dialectical behavior therapy (DBT) – Based on the tenets of CBT, DBT was originally designed to treat borderline personality disorder, a disorder that frequently includes self-mutilation and other forms of self-harm. DBT can reduce self-harm by helping teens learn to manage their stress, have healthier relationships, and manage intense negative emotions. 
• Mindfulness-based therapy – There are several different therapies based on mindfulness. They help increase self-awareness and the ability to stay in the present moment, and use mindfulness techniques to alleviate negative emotions. 
• Psychodynamic psychotherapy – This type of therapy helps individuals explore issues lurking at the subconscious or unconscious level that often stem from negative childhood experiences and other painful memories.
• Family therapy – Family therapy focuses on addressing and changing unhealthy family dynamics, resolving conflicts, and helping family members interact in healthier and more positive, appropriate ways.

Medication – Although medication is not used to treat self-harm per se, it can be very beneficial in alleviating symptoms of depression or other disorders that may be present.  When these troubling symptoms start to improve, your teen will likely feel less inclined to engage in self-harm as a coping mechanism.

Hospitalization – Psychiatric hospitalization may be necessary if your teen’s self-harm is frequent, repetitive, extreme, or potentially life-threatening (more on this below). 

Supporting and Encouraging Your Child  

Many parents initially feel at a loss when it comes to supporting and encouraging a child who’s engaging in self-destructive behavior such as self-harm or self-mutilation.  However, there are several things you can do to help your teen as he or she learns healthier ways to cope with painful emotions, a mental health issue, and other life challenges.

Two of the most important things to remember about self-harm are:

• It’s not a sign of weakness in your child
• In most cases, it’s not something your child can simply stop doing or overcome with willpower or determination

Following are several ways you can support and encourage your teen:

• Make yourself available (and willing) to listen and let your teen know you’re there for him or her
• Educate yourself about self-harm in teens; if your teen has a mental health disorder, educate yourself about that as well
• Take an active role in your teen’s treatment
• Validate your child’s feelings and listen with compassion
• Accept and love your teen unconditionally
• Take any type of self-harm very seriously, but don’t assume it’s a suicide attempt
• Don’t assume your child is trying to get attention; teens who engage in this behavior often feel very ashamed and don’t want anyone to know they’re harming themselves
• Strive to stay calm and don’t over-react, even though you may feel scared, frustrated, angry, or confused by your child’s behavior
• Make time for and plan quality family time and 1:1 time with your teen
• Don’t resort to threats or punishment in an attempt to stop your teen’s behavior
• Respect your child’s privacy; don’t tell friends, neighbors, and others who have no need to know about your child’s self-harm. Doing so can exacerbate the feelings of shame and embarrassment our child is likely already feeling
• Be a good role model for handling stress and negative emotions
• Remember that learning to overcome self-harm is a process that takes time; be patient with your teen as he or she learns healthy, new coping skills
• Be willing to address and work on your own challenges as a parent, e.g. if you’re frequently critical, demanding, or over-bearing, work with a therapist individually or participate in family therapy to address these and other issues that may be negatively impacting your teen
• Strive to create and maintain a peaceful, happy, and low-stress home environment
• Respect your teen’s experience even if you don’t understand it
• If your teen wants to talk about an incident of self-harm, don’t encourage it or allow him or her to get into detail as it may lead to another incident
• Encourage your teen to practice new coping skills at home

What to Do When Things Escalate

When it comes to self-harm behaviors in teens, the pattern and course can vary significantly.  It can also escalate to a crisis point during times of significant stress.  Some teens will respond well to treatment, while others may get worse as time goes on, especially if underlying issues haven’t been identified.

If things do escalate – for example, your teen’s behavior becomes increasingly frequent, dangerous, or severe – reach out for help immediately.  You can:

• Contact your child’s treatment provider
• Enlist the help of a close family member or friend
• Take your child to the nearest hospital emergency room (if you can do so safely)
• Call 911

When Individual Therapy isn’t Enough

While individual therapy can be very effective in treating adolescent self-harm, it’s not always enough.  If your teen doesn’t have a good support system, is battling a serious mental health disorder, or experiences a crisis that escalates the self-harm behaviors or triggers suicidal thoughts, more intensive treatment will be necessary.

More intensive types of treatment include:

• Intensive outpatient treatment (IOP) / Psychiatric day treatment
• Residential treatment
• Inpatient psychiatric treatment

Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how often (e.g. twice a week, 5 days a week) your child is required to go.  These programs are the next step up from regular outpatient treatment (i.e. an hour of therapy once or twice a week).

Residential treatment involves having your child stay at a non-hospital treatment facility that specializes in treating adolescents with mental health disorders.  Residential treatment typically lasts between 30 to 180 days, depending on the disorder and its severity.

Inpatient psychiatric treatment is the highest and most intensive level of treatment for self-harming adolescents.  It involves admitting your child to an adolescent psychiatric hospital unit where patients are monitored by medical personnel 24/7. This level of treatment may last for a few days to a few weeks, and is particularly beneficial for adolescents who are actively suicidal or an imminent danger to themselves or others, usually due to severe depression, psychosis, or mania.

Each of these intensive levels of treatment typically provides daily or bi-weekly visits with a psychiatrist and daily therapy (often both group and individual, and a combination of different types, such as psychotherapy, art therapy, music therapy, etc.).

Taking Care of Yourself

Dealing with a teen engaging in self-harm can be very stressful.  You’ll need to be on top of your game in order to effectively help him or her overcome the self-destructive behavior and learn new coping skills.  It’s imperative you take good care of yourself as well.  Some things you can do include:

• Surrounding yourself with as much support as possible (e.g. through therapy, church, family and friends, or support groups)
• Get plenty of sleep so you feel refreshed and energized
• Find healthy ways to manage your own stress, such as yoga, meditation, and regular exercise
• Make time for yourself

Your teen will be looking to you for guidance, emotional support, encouragement, and hope.  Taking good care of yourself will enable you to be the loving, patient, supportive parent he or she needs to succeed.