Evidence-Based Reviews

Adolescents who self-harm: How to protect them from themselves

Current Psychiatry. 2010 August;9(8):15-A

References

1. O’Carroll PW, Berman AL, Maris RW, et al. Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav. 1996;26:237-252.

2. Nock MK, Joiner TE, Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65-72.

3. Centers for Disease Control and Prevention. Injury prevention and control: data and statistics (WISQARS). Available at: http://www.cdc.gov/injury/wisqars. Accessed June 22, 2010.

4. National Center for Health Statistics. Health, United States, 2006. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf#062. Accessed May 28, 2010.

5. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res. 2007;11(2):129-147.

6. Muehlenkamp JJ, Gutierrez PM. An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav. 2004;34:12-23.

7. Nixon MK, Cloutier PF, Aggarwal S. Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry. 2002;41:1333-1341.

8. Whitlock J, Knox KL. The relationship between self-injurious behavior and suicide in a young adult population. Arch Pediatr Adolesc Med. 2007;161:634-640.

9. Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47:372-394.

10. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40(suppl 7):24S-51S.

11. Laye-Gindhu A, Schonert-Reichl KA. Nonsuicidal self-harm among community adolescents: understanding the “whats” and “whys” of self-harm. J Youth Adolesc. 2005;34:447-457.

12. Muehlenkamp JJ, Gutierrez PM. Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res. 2007;11:69-82.

13. Gould MS, Greenberg T, Velting DM, et al. Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2003;42:386-405.

14. Beck AT, Kovacs M, Weissmann A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;46:343-352.

15. Holi MM, Pelkonen M, Karlsson L, et al. Psychometric properties and clinical utility of the Scale for Suicidal Ideation (SSI) in adolescents. BMC Psychiatry. 2005;5:8.-

16. Shea SC. The practical art of suicide assessment: a guide for mental health professionals and substance abuse counselors. New York, NY: John Wiley; 1999.

17. Gould MS, Marrocco FA, Kleinman M, et al. Evaluating iatrogenic risk of youth suicide screening programs. JAMA. 2005;293:1635-1643.

18. Horowitz LM, Wang PS, Koocher GP, et al. Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics. 2001;107:1133-1137.

19. Kennedy SP, Baraff LJ, Suddath RL, et al. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004;43:452-460.

20. Lewis LM. No-harm contracts: a review of what we know. Suicide Life Threat Behav. 2007;37:50-57.

21. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behavior. Am J Psychiatry. 2003;160(suppl 11):1-60.

22. Speckens AE, Hawton K. Social problem solving in adolescents with suicidal behavior: a systematic review. Suicide Life Threat Behav. 2005;35:365-387.

23. Henriques G, Beck AT, Brown GK. Cognitive therapy for adolescent and young adult suicide attempters. American Behavioral Scientist. 2003;46:1258-1268.

24. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002;32:146-157.

25. Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behav Modif. 2008;32:77-108.

26. Jick H, Kaye JA, Jick SS. Antidepressants and the risk of suicidal behaviors. JAMA. 2004;292:338-343.

27. Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA. 2007;297(15):1683-1696.

28. Simon GE. The antidepressant quandary—considering suicide risk when treating adolescent depression. N Engl J Med. 2006;355:2722-2723.

Acknowledgements

The authors wish to thank students Scott Schubert from Regis University, Denver, CO, and Emily Peterson from Beloit College, Beloit, WI, for their help in preparing the manuscript.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Table

Hospitalization or home? Acute crisis planning for self-harming youth

Hospitalization is more appropriate when ≥1 of the following is present with suicidal or self-injurious thoughts: Current suicidal thoughts or plans Previous serious suicide attempts A need for a more lengthy evaluation in a safe setting Significant psychiatric symptoms (especially a mood disorder and/or psychosis) Significant impulsive and unpredictable behaviors Continued substance abuse problems or intoxication Conflicts with parents, family members, or a significant other Inability to form a therapeutic alliance with the clinician Inability to honestly participate in a safety evaluation
Home is more appropriate when: The youth has no active suicidal thoughts or plans, history of suicide attempts, medical problems requiring hospital care, significant substance abuse problems, or psychiatric disorders (especially a mood disorder) needing acute stabilization Precipitating conflicts or situations have been adequately diminished or resolved A supportive adult in the home will monitor the youth’s safety and the relationship is positive and stable enough to allow a safe return The adolescent has a strategy for communicating unsafe or overwhelmed feelings to the parent, guardian, or supportive adult, such as the use of “check-in” times and a rating scale for upset or unsafe feelings The youth will begin or continue outpatient psychotherapy Family has been cautioned about how alcohol and drugs can cause disinhibition and increase impulsivity, and will prevent access to substances Parent or guardian agrees to remove or secure lethal means of suicide such as firearms The youth and parent or guardian agree on a safety plan and follow-up services and an appointment is scheduled The youth and parent or guardian have an identified contact person or a safe place to go, such as a hospital emergency department, if a situation deteriorates and becomes unsafe

Hospitalization is more appropriate when ≥1 of the following is present with suicidal or self-injurious thoughts:

Current suicidal thoughts or plans
Previous serious suicide attempts
A need for a more lengthy evaluation in a safe setting
Significant psychiatric symptoms (especially a mood disorder and/or psychosis)
Significant impulsive and unpredictable behaviors
Continued substance abuse problems or intoxication
Conflicts with parents, family members, or a significant other
Inability to form a therapeutic alliance with the clinician
Inability to honestly participate in a safety evaluation

Home is more appropriate when:

The youth has no active suicidal thoughts or plans, history of suicide attempts, medical problems requiring hospital care, significant substance abuse problems, or psychiatric disorders (especially a mood disorder) needing acute stabilization
Precipitating conflicts or situations have been adequately diminished or resolved
A supportive adult in the home will monitor the youth’s safety and the relationship is positive and stable enough to allow a safe return
The adolescent has a strategy for communicating unsafe or overwhelmed feelings to the parent, guardian, or supportive adult, such as the use of “check-in” times and a rating scale for upset or unsafe feelings
The youth will begin or continue outpatient psychotherapy
Family has been cautioned about how alcohol and drugs can cause disinhibition and increase impulsivity, and will prevent access to substances
Parent or guardian agrees to remove or secure lethal means of suicide such as firearms
The youth and parent or guardian agree on a safety plan and follow-up services and an appointment is scheduled
The youth and parent or guardian have an identified contact person or a safe place to go, such as a hospital emergency department, if a situation deteriorates and becomes unsafe