Children's Hospital Colorado
Pediatric Mental Health Institute
Pediatric Mental Health Institute

Managing Self-Harm

College-level courses are starting in high school, phones are pinging throughout the night with social media and text alerts and achievement is often seen as being of ultimate importance. It's become increasingly clear that the pressures of our fast-paced society are having an impact on our developing teenagers who, despite their best efforts, are often struggling to cope. Self-harm (also known as self-injury and self-mutilation) is one such effort. Once believed to indicate severe psychopathology, it is now clear that self-harming behavior is associated with a wide variety of stressors. Typically an impulsive behavior, most adolescents report engaging in self-harm after less than an hour of planning.

A 2015 American Psychological Association study on the prevalence of self-harm found that approximately 17% of adolescents have engaged in self-injury at least once and about 1.3% of children age 5 to 10 have, as well. Findings of gender differences vary, with some suggesting that females engage in self-harm more frequently, while other studies find the prevalence to be about equal between males and females. Of note: self-harming behaviors can be associated with intellectual and developmental disabilities, such as autism spectrum disorders. However, as the function and treatment of these specific self-harming behaviors can look quite different, this will not be specifically addressed here.

What is self-harm?

Self-harm is the purposeful act of inflicting pain to one's own body, often in an effort to reduce or eliminate emotional distress. Self-harming behavior can take many forms. Most commonly, adolescents engage in cutting, scratching and burning, though children and teens use other methods, such as banging, picking, punching walls and biting.

Deliberate self-harm can be both suicidal (i.e. an act of self-inflicted pain or injury while experiencing suicidal ideation: may be working up to an attempt or distracting from the urge) or non-suicidal (i.e. an act of self-inflicted pain or injury independent from thoughts or urges toward suicide). Research suggests that the majority of adolescents who self-harm are doing so to seek quick relief from distress and are not actively suicidal. This is known as non-suicidal self-injury, or NSSI.

Warning signs and risk factors of self-harm

As with many other mental health conditions and symptoms, no two adolescents will be the same. However, the following are some common predictors of self-harm that warrant further exploration:

  • Visible marks that are disproportionate to typical activities or activity level
  • Finding sharp objects or other 'tools,' such as razors and lighters, hidden in the child's room or belongings
  • Regularly isolating for long periods of time, especially following a bad day, negative consequences or conflicts with peers or family
  • Knowledge of a friend or peer who is self-harming
  • Concerns from a sibling or close friend about finding hidden objects, observed marks or behaviors

Starting the conversation about self-harm

Acknowledge that this is a complex behavior

The choice to engage in self-harming behavior is rarely related to only one underlying cause or concern. It may be related to self-punishment, rebellion, rejection of parental value, stress reduction, seeking acceptance, to transfer pain from emotional to physical or a cry for help (among many others). It is important to try to understand why this behavior has become a pattern for this child. What are they getting from it? What is the reinforcement? What does it do for them?

Understand and acknowledge that there is a purpose to this behavior

At its core, self-harming behaviors serve a purpose for the person. Typically, they represent a maladaptive effort to reduce or control emotional pain or distress, especially when current distress feels as though it overwhelms available or typical coping patterns. Additionally, when children or teens feel pain, even when it is self-inflicted, it releases endorphins. Often, the euphoria or numbing response associated with an endorphin dump is experienced by sensation-seeking adolescents as a fix for their high-intensity emotions. Acknowledging with adolescents that this behavior does have a purpose and that they experience it as helpful in some way will reduce their feelings of being judged. It also increases the likelihood that they will be more forthcoming in conversation.

Stop thinking of attention-seeking behaviors as pathological

Attention is one of the fundamental needs of a typically developing, relational human being. Seeking attention is a normal behavior that often indicates a teenager feels they need more interpersonally than they are currently receiving. Not long ago, attention-seeking behaviors, specifically self-harming, were seen as negative behaviors that adults should ignore so adolescents wouldn't use them to meet their needs. However, this understanding is often incomplete and can result in overly punitive responses, versus supportive and solution-focused ones.

Pay attention to your attitudes about this topic when managing self-harm with adolescents. Thinking of deliberate self-harm as a pathological attention-seeking behavior that needs to be ignored sets you up to overlook or under-react to a potentially serious and dangerous behavior.

Helping parents whose child self-harms

Encourage open communication

One of the most effective self-harm management strategies is to promote open communication between teens and parents. This requires parents to embrace their curiosity and temporarily suspend judgment and consequences. Thinking that parents will be mad, disappointed or upset often drives teens to keep secrets even when they know they need help.

Parents should start the conversation in a calm way when they have ample time to talk. Encourage parents to use pop culture, news articles or other sources of information to initiate the conversation if they feel stuck. Start with "I read an interesting article on self-harm today. Is this something you or your friends have ever struggled with?" Using this approach for a broad variety of topics (i.e. suicide, bullying, substance use, etc.) helps to send a clear message to children and teens that parents are interested and available to talk about uncomfortable topics.

Parents should be acutely aware of their reactions. Teens are often hypersensitive to reactions they perceive as angry, a perception that may impact their willingness to be open in the future.

Model the healthy management of emotions

One of the most effective strategies for teaching children new skills is for parents to show their kids the skills. Emotion regulation is no different. Parents should demonstrate healthy and effective stress management and distress tolerance skills from the time children are young.

Children who observe healthy coping strategies are more likely to develop their own coping styles and to utilize these to effectively manage intense emotions. Modeling is useful as children age and become acutely aware of their expectations in comparison to those of others.

In conflict with teenagers, parents must focus on remaining calm, taking space if they're about to lose their cool and making an effort to engage their child in collaborative problem-solving to address the issue. A good rule of thumb is to not ask anything of an adolescent that parents are not willing to do themselves.

Encourage and engage in help-seeking behaviors

Adolescents who are self-harming should have a thorough psychiatric evaluation as soon as possible to assess the presence of underlying psychiatric conditions such as depression, anxiety, suicidal ideation and other high-risk behaviors. If an adolescent displays suicidal ideation and self-harming behaviors, order an urgent professional evaluation. Early evaluation is critical, as self-harming behaviors can be highly reinforcing and early intervention is most effective at keeping the behavior from becoming chronic.

Family therapy is one of the most effective self-harm management strategies for adolescents who are self-harming. Through family therapy, a clinician can help the family improve communication, enhance conflict-resolution and problem-solving skills and improve parent-child and sibling relationships. Additionally, individual or group therapy is beneficial, as it focuses on enhancing mood regulation, distress tolerance and coping skills. This helps adolescents more effectively manage stress and intense emotional experiences.

Self-harm resources

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