Spotlight on Cutting to Cope: What Is Nonsuicidal Self-Injury?

Yolanda Evans, MD, Seattle Children’s

Today, nearly one in five children has a mental, emotional or behavioral disorder. While some seek relief from their distress using positive coping methods, others may choose methods that are harmful and potentially life-threatening.

Adolescent Medicine Specialist Dr. Yolanda Evans has seen a recent increase in teens coming to Seattle Children’s with self-injuries, such as cutting, burning, pinching and scratching, among others.

“It’s possible the increase may be partly due to the impact social media and technology has on the current generation,” Evans says. “Kids might see their peers online engaging in self-harming behavior as a way to cope with their emotions, influencing them to replicate that type of behavior.”

In the age of viral Internet challenges, such behaviors have become gamified — reaching an even broader group of young people. One, called the “blue whale challenge,” encouraged teens to complete 50 acts of self-harm over 50 days, ending in suicide by the final day.

However, Evans says people who injure themselves are not always suicidal. Read on to learn more about nonsuicidal self-injury, how you can identify it and how to address it.

What is nonsuicidal self-injury?

“It is a term used to describe a way of coping that involves inflicting damage to one’s self to manage distress without the intention of suicide,” Evans says. “Self-injury can come in different forms; a common form is cutting, which involves using a sharp object to superficially cut the skin on an area of the body, often the forearms, wrists, upper thighs and lower abdomen.”

Not meant as a suicide attempt, a person may self-injure as a way of punishment — to numb their negative feelings and/or to take their mind off emotional pain, anger or frustration.

In a study published in the American Journal of Public Health, researchers conducted an analysis of the Centers for Disease Control’s Youth Risk Behavior Surveillance System data to assess the prevalence of, and factors associated with, nonsuicidal self-injury.

Several health risks were associated with increased odds of nonsuicidal self-injury, including: feeling sad; suicidal thoughts, plans or attempts; being electronically bullied; trying to change weight; being gay, lesbian, bisexual or unsure; smoking cigarettes; hard drug use; and being forced to have sex.

“We most often see nonsuicidal self-injury in teens and young adults, and in females more than males,” Evans says. “This could be due to a variety of factors, such as societal pressures around body image.”

The role of providers and care team members

Providers and care team members are sometimes the first to learn about nonsuicidal self-injuring. Patients who are asked about such behaviors may feel more comfortable telling a healthcare professional, in confidence, than their parents.

To identify nonsuicidal self-injury, Evans recommends providers use the SOARS assessment model.

If a provider sees lesions on a patient that look suspicious (such as linear abrasions), Evans urges them to ask about it.

“Remain calm and ask if they’ve ever hurt themselves,” she says. “Use specific examples: ‘Have you ever cut, pinched, burned or scratched yourself?’ Ask about thoughts of suicide and talk about strategies to help them manage the emotions leading to the harmful behavior.”

How should caregivers respond?

While self-injury is not typically related to suicidal intent, Evans says intervention from parents or caregivers is still extremely important.

“I suggest parents put away any distractions, such as their phone, and calmly sit down with their child. They should voice their concerns and ask the child what their intent is or what issues they’re trying to solve by self-injuring.”

Evans also recommends attending to the injury (keeping it clean to prevent infection) and removing any items that have previously been used to self-injure or could be used impulsively, such as razors or other sharp objects.

While self-injury is not typically related to suicidal intent, Evans says it is still important for parents and caregivers to look for signs of suicidal intent if a child is self-injuring, including:

• Statements of despair, such as “Would anyone miss me or care if I was gone?”
• Giving away personal belongings
• Withdrawing from social situations
• Changes in eating or sleeping habits
• Written notes about ending their life
• A previous suicide attempt

“If you see these signs, you should immediately seek medical care for your child or teen by taking them to an urgent care clinic or emergency department,” Evans says.

Promoting positivity and resilience

Introducing positive coping mechanisms is key to helping kids manage their emotions.

“Make sure they have trusted people in their lives they can talk to, whether that be you, a friend or mental health therapist. It has to be someone they feel comfortable sharing their thoughts with, who won’t judge them,” Evans says.

Having a child or teen work directly with a mental health therapist can be effective because they are able to provide specific therapies to treat mental health issues.

Cognitive behavioral therapy and dialectical behavioral therapy are traditionally used for people managing depression and anxiety, Evans says. Dialectical behavioral therapy is associated with treating externalizing behaviors, such as self-injury, and involves learning how to be more aware of emotions and behavior patterns in order to make wise and thoughtful choices to cope with distress.

Resilience, which is an individual’s positive adaptation to the experience of adversity, is also an important concept that can help kids and teens manage their mental health.

“Building resilience can be done in various ways, like encouraging your child to engage in self-care, set goals, accept change, or simply take a break and focus on something else that can take their mind off their worries,” Evans says. “Activities could include going on a walk, reading a book, listening to music, meditating or creating art.”

Considering that current studies show nearly half of the 7.7 million children in the United States with mental health disorders are left untreated and there has been a significant increase in youth suicide in recent years, Evans believes it is more crucial than ever before that mental health is seen in the same way as physical health.

“It’s important to remember, having a mental health issue like depression and anxiety is not a choice,” Evans says. “Not only do we need to promote positive coping strategies to kids, we need to eliminate the stigma associated with mental health by discussing it openly.”