Closing in on Crisis

Informing Clinical Practice Regarding Nonsuicidal Self-injury in Youth

Cara C. Young, PhD, RN, FNP-C; Amanda J. Simonton, BSN, RN; Stephanie Key, RN, MSN, CPNP-PC; Amanda N. Barczyk, PhD, MSW; Karla A. Lawson, PhD, MPH


J Pediatr Health Care. 2017;31(3):334-341. 

In This Article


Over the last decade, research on NSSI has begun to document the unique characteristics and functions of NSSI in both psychiatric in-patient and community-based samples of youth nationally and internationally (Jacobson & Gould, 2007; Lloyd-Richardson et al., 2007; Nock, 2010; Nock, Prinstein, & Sterba, 2009). The most commonly mentioned function of NSSI is affect regulation, with youth reporting NSSI as a way either to escape negative emotions or to feel something (Di Pierro, Sarno, Gallucci, & Madeddu, 2014; In-Albon, 2015; Klonsky, 2007; Nock & Prinstein, 2004). In addition, Klonsky & Muehlenkamp (2007) have identified two primary psychological characteristics of those who engage in NSSI: negative emotionality (represented by the emotions of depression, anxiety, stress) and self-derogation. These psychological characteristics combine with additional risk factors to increase the risk that youths may engage in NSSI. Childhood abuse and psychiatric diagnoses are common aggravating life circumstances that increase the likelihood of NSSI (Klonsky & Muehlenkamp, 2007). NSSI is also associated with issues of self-esteem, problems in interacting with peers and family members, and poor academic performance (In-Albon, 2015). Bullying has been found to have a mediating relationship with NSSI as well (Claes, Luyckx, Baetens, Van de Ven, & Witteman, 2015).

Although recent research has focused increasingly on NSSI in youth (Cloutier, Martin, Kennedy, Nixon, & Muehlenkamp, 2010; García-Nieto, Carballo, Díaz de Neira Hernando, De León-Martinez, & Baca-García, 2015; Giletta, Scholte, Engels, Ciairano, & Prinstein, 2012; Gulbas, Hausmann-Stabile, De Luca, Tyler, & Zayas, 2015),, studies have so far typically used patients' retrospective reports. This methodology introduces a risk for bias as the time span between the original act or ideation of NSSI and the later evaluation of precipitating factors widens. We are aware of only two studies that have examined youths who engage in NSSI at the point of crisis; Cloutier et al. (2010) investigated the incidence of NSSI and the distinct characteristics of those who engage only in NSSI and those who attempt suicide in an emergency department, and Nock et al. (2009) used an ecologic momentary assessment method to measure self-injurious thoughts and behaviors in real time. Nock et al.'s (2009) findings provided detailed reports about the context in which NSSI occurred; however, it is imperative to gain an accurate picture of the immediate reasons and contexts associated with engaging in NSSI and the additional circumstances that youth and their caregivers report as having contributed to the NSSI behavior. Such data can help inform the development of clinical training and practice protocols for pediatric health care providers in primary and acute care settings who must develop a comfort level with assessing their clients for NSSI and who need to establish procedures for coordinating care with mental health professionals once NSSI has been identified. This study was therefore undertaken to examine the self-reports of youths with NSSI who presented to the emergency department for treatment—to determine their reasons for engaging in NSSI and to evaluate additional contextual circumstances that may have contributed to their self-injurious behaviors.