Self-Injury and Suicide

Description of the Strategy

Self-injurious thoughts and behaviors in children and adolescents represent an enormous public health concern around the world. In the United States, for example, completed suicide is currently the sixth leading cause of death among children (5–14 years) and the third leading cause of death among adolescents and young adults (15–24 years). Nonfatal self-injurious behaviors are even more common. Approximately 20% of high school students report seriously considering suicide, and 9% report making an actual suicide attempt in the previous 12 months. Moreover, up to 40% of adolescents in the community and 60% of adolescent psychiatric inpatients report engaging in self-mutilative behavior. Despite the high prevalence and serious physical and psychological damage associated with these behaviors, information about effective evaluation and treatment practices is limited.

The evaluation and treatment of self-injurious behaviors is often hindered by a failure to carefully distinguish among and assess the different self-injurious constructs of interest. For instance, what does it mean to say a child or adolescent is suicidal? The following nomenclature has been recommended by researchers to clarify such issues. Suicide refers to death from a self-inflicted injury in which the individual intended to die. Suicide attempt refers to potentially selfinjurious, but currently nonfatal, behavior in which the individual intended to die. Suicidal ideation refers to self-reported thoughts of making a suicide attempt. Self-mutilative behavior refers to intentional destruction of one's own body tissue in which there is no intent to die. Evaluation of self-injurious thoughts and behaviors should include the collection of data related to each of these constructs.

Evaluation should also focus on factors known to be associated with self-injurious thoughts and behaviors. Self-injurious thoughts and behaviors are multidetermined events, and etiological factors will vary somewhat from case to case; however, research has identified several variables associated with increased risk. These include the presence of a mood disorder, particularly with hopelessness and anhedonia; a substance use disorder; a psychotic disorder; anxiety and agitation; difficulties with problem solving and cognitive flexibility; and a previous history of self-injurious behaviors, particularly previous suicide attempts. The evaluation should also include an examination of the degree of planning of and preparation for self-injurious behavior. In addition, the individual's ability to implement any identified plan should be taken into consideration (e.g., does the individual have access to a firearm, pills, sharp object, or other means of self-injury?).

Cognitive-behavioral treatment strategies for modifying self-injurious thoughts and behaviors center on reducing the frequency of these thoughts and behaviors, as well as on modifying correlates or risk factors that are present that might play a role in the generation or maintenance of self-injurious thoughts and behaviors. Perhaps the most common component in cognitivebehavioral treatments for self-injurious thoughts and behaviors is a focus on improving interpersonal problem-solving skills. This typically involves teaching the individual several steps for identifying problems, generating potential solutions, evaluating the probable consequences associated with each solution, choosing and implementing a solution, and engaging in self-evaluation.

Cognitive-behavioral treatments for self-injurious thoughts and behaviors also typically emphasize improving emotion regulation and distress tolerance skills. It is believed that those who resort to self-injury often do so to relieve distress due to an inability to inhibit impulsive responding to provocative events. Thus, alternative, more adaptive skills for relieving or tolerating distress and for inhibiting impulsive responding are taught and practiced. Emotion regulation skills taught in such treatments include identifying and labeling emotions (both positive and negative), expressing emotions (both verbally and nonverbally), and engaging in pleasurable activities. Distress tolerance skills include engaging in distraction and relaxation exercises. Consistent with the cognitivebehavioral approach, throughout each of these components there is also an emphasis on self-monitoring of the individual's thoughts, behaviors, and emotions and special attention to the antecedents and consequences of the self-injurious thoughts and behaviors.

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