Self-harm among adolescents: a growing public health concern

On World Mental Health Day, Francesca Sammut discusses why adolescents may engage in self-harming behaviour and gives parents advice on what to do in such situations.
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Adolescent self-harm is a growing public health concern that manifests with various self-injurious presentations for a range of psychosocial reasons.

Self-harm is the act of purposefully hurting oneself, usually without the intent to kill oneself. Clinicians routinely differentiate between non-suicidal self-injury (NSSI) and self-harm with suicidal intent.

Self-harming behaviours vary in severity and intensity, and may include self-inflicted scratches, cuts or burns; biting, choking or hitting oneself; pulling one’s own hair; picking at wounds or scabs to delay the healing process; and banging one’s head against the wall or hitting parts of the body against a hard surface.

Less obvious forms of self-harm include binge-drinking, substance misuse, engaging in unsafe sex and deliberate starvation. Self-harm may occasionally refer to self-poisoning through a medication overdose or through the ingestion of harmful substances.

The cycle of self-harm

Research shows that approximately half of adolescents who self-harm will do so more than once, with self-harming thoughts and behaviours persisting over a year. The act of self-harm follows a cycle involving precedent and antecedent events.

Prior to self-injury, a mild state of dissociation is likely invoked as individuals psychologically prepare themselves for self-harm. At a mundane level, this is known as “zoning out”. The very act of dissociation leads to decreased sensitivity to all kinds of pain; hence the individual is likely to experience little to no pain whilst physically injuring themselves.

Upon exposure to pain and stress, the body is physiologically hardwired to release a rush of endorphins, the body’s natural painkillers and feel-good chemicals. Self-harm is thus linked to a momentary increase in endorphin levels, which help numb both the emotional and physical pain. Consequentially, engagement in self-harm may be reinforced through this process’ addictive characteristic.

Why do adolescents engage in self-harming behaviour?

In addition to the cyclical process of self-harm, self-injury is described by many individuals as a means of emotional catharsis. Young people usually self-harm as a method of coping with strong and painful emotions.

Adolescents who self-harm may fail to perceive adequate means or outlets of self-expression and self-soothing, and thus resort to self-harming behaviour. Others explain self-harm as a way of “feeling something” when they are experiencing emotional numbness or emptiness.

Although less common, some adolescents self-harm as a form of self-reprimanding behaviour in response to a perceived misdeed.

Self-harm may be a vessel of control for instances in which adolescents feel helpless, opinionless or powerless. Generally, self-harm is a sign of distress.

Although self-harm may be used as an attention-seeking behaviour or as a cry for help, this is not the case for most instances of self-harm. Thus, it is vital for parents to avoid being judgmental by making sweeping statements such as ‘you are an attention-seeker’ or ‘you are being dramatic’.

Among others, adolescents who self-harm may fail to perceive adequate means or outlets of self-expression and self-soothing, and thus resort to self-harming behaviour.

Risk and protective factors

Although prevalence rates of self-harm vary across different community samples, it is estimated that around one in every 10 adolescents engage in self-harm, whereas approximately one in every five adolescents think about self-harming but do not actually self-harm.

Research has shown that adolescents are at greater risk for self-harm if they are female, have low self-esteem, are bullied, have a history of abuse, have separated or mentally distressed parents, have a low socioeconomic status, have poor family and peer relationships, or know a friend who self-harms. Other risk factors include sexual orientation/gender identity issues, mental health disorders (particularly depression), alcohol and substance misuse, truancy, and a history of running away from home.

There are far less research studies which focus on protective factors against self-harm. However, it appears that parental support, parents living in the same household, school connectedness, life satisfaction, and having a healthy diet are associated with lower risk for self-harm.

Signs to look out for

Adolescents who self-harm will often try to hide their self-injurious behaviour, often because they are ashamed of it. They may also worry about the impact of their behaviour on their loved ones; hence they wonder whether their self-injurious behaviour will cause anxiety, distress or anger to their family and friends. Ultimately, many adolescents fear being misunderstood or being rejected.

If you are worried that your child might be self-harming, these are some signs to look out for:

Physical: have injuries they cannot or will not explain; appear agitated; stop caring about their appearance hence look less put together; loss of sexual interest; or exhibit physical symptoms of depression, i.e., appear to be constantly tired, exhibit bed-seeking behaviour, sudden loss or gain in weight.

Behavioural: avoid activities that require undressing, such as swimming; wear long-sleeved tops and long trousers even in warm weather so that they avoid showing their skin; hide or act strange around objects that may be used for self-harm, such as blades, sharp knives, a mathematical compass, lighters and matches; increase the use of plasters, wound dressings, bandages or antiseptic spirits; engage in alcohol or substance misuse; exhibit behavioural symptoms of depression, i.e., changes in sleep and eating patterns, loss of interest in activities they usually enjoy, decreased motivation, reduced social interactions, avoid attending school or show a reduction in performance at school.

Emotional: exhibit frequent mood fluctuations, also known as ‘mood swings’; have ongoing temper outbursts; show hyper-sensitivity to rejection or failure and the need for excessive reassurance; express death wishes or suicidal ideations; or exhibit psychological symptoms of depression i.e., appear to be sad, emotionless, irritable or hopeless, cry more often, show signs of worthlessness or guilt, have trouble thinking, concentrating, making decisions, or remembering things.

Do not be afraid to ask your child about their self-harming experience or about their feelings in general.

How do I help an adolescent who is self-harming?

Open a channel of communication. Do not be afraid to ask your child about their self-harming experience or about their feelings in general. It is important to adopt a non-judgemental approach and to listen actively and empathically to what they have to say, without interrupting.

Be prepared for rejection or denial. It is normal for a self-harming adolescent to feel upset, refuse to talk about this subject, or outright deny self-harming. If the child pushes you away, provide them with reassurance by saying something like, ‘I can see that you are upset. Whenever you feel ready to talk about it, I will be here for you.’

Avoid strong reactions. Knowing that your child is self-harming or witnessing a self-harm episode can conjure up various negative, confusing, or even angry emotions. Reacting with anger, threats or panic will make it harder for your child to trust you and to feel safe around you.

Make the home environment safe. If you know that your child is self-harming, you can help by removing hazardous items that can be used to cause self-injury. Although it is unrealistic to remove all these items on a constant basis, this step is particularly important if your child informs you know that they are having urges to self-harm. These urges are more likely to be triggered during difficult and stressful periods. If your child lets you know that they are having suicidal thoughts, it is also imperative to keep medications locked away safely, to remove any accessible firearms and to seek professional assistance.

Find alternatives to invasive self-harming practices. Not all self-harming practices are invasive of the skin tissue or harmful to the body. Together with the self-harming adolescent, brainstorm self-harm methods that are less intense and perilous. A few examples include snapping a rubber band on the wrist, clenching ice or frozen items, and taking a very cold shower or bath.  

Set up a safety plan. Together with the self-harming adolescent, brainstorm different triggers and stressors that may lead to self-harm, and then think about activities that can provide alienation or soothing from thoughts of self-harm. This exercise will help you feel prepared for instances wherein thoughts and urges of self-harm arise. Examples of coping strategies and distraction techniques include going for a walk, engaging in vigorous exercise, talking to a trusted friend, punching or shouting into a pillow, tearing up a magazine, listening to music, or practising mindfulness-based exercises such as grounding techniques.

Seek assistance. If you notice deep or infected wounds on your child’s body, seek medical assistance immediately. If your child does not feel comfortable talking to you about their struggles, set up an appointment with the family GP or a mental health professional and encourage that they attend.

Screening for suicide risk

Most adolescents who self-harm seek momentary escapism, not death. However, recent studies suggest that adolescents who repeatedly engage in self-harm and have trouble quitting show higher rates of suicidal ideation, and thus have a higher risk for suicide than non-self-harming peers.

A common myth is that by asking someone directly about suicidal thoughts, one can drive them to become increasingly suicidal and push them to attempt suicide.

Another myth is that by divulging suicidal ideation, one ensures psychiatric hospitalisation. Both these statements are entirely false. It is vital that we verge away from mythical thinking as this may impede us from taking the necessary safeguarding actions that may ultimately save a life.

If you suspect that your child is experiencing suicidal thoughts, it is important to have a meaningful conversation with them so that you may address these thoughts together.

You can reach out for help by speaking to the family GP who can refer your child to the most appropriate mental health service, or by attending the Emergency Department at the general hospital where psychiatry specialist doctors are available 24/7. Alternatively, you may seek help from a counselling or psychology professional.  

Francesca Sammut is a registered mental health nurse, CRHT, Mental Health Services (Malta).

Also read this article about Understanding teenage angst. For more Child stories, follow this link.

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