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



The patients ranged in age from 6 to 18 years (mean [M] = 14.12, standard deviation [SD] = 2.206), and most were female (71.1%). The data for race/ethnicity showed that 71.5% reported themselves as White, followed by 13.1% Black; 33.6% reported themselves as having Hispanic ethnic heritage and 59.1% as non-Hispanic (missing data, n = 10). Medicaid or uninsured status was indicated by 63.8% of the patients.

Hospital Data

Most patients (n = 81, 60%) arrived in a privately operated vehicle; 14.1% (n = 19) were brought in by police or security officers. All patients were evaluated by a triage nurse, and the emergency department was the highest level of care for almost all of them (94.8%, n = 128). Substantial variability was identified for patients' lengths of stay, ranging from 48 minutes to 86 hours, 36 minutes (median = 6 hours, 3 min; 25th and 75th interquartile ranges = 3 hours, 42 minutes and 12 hours, 62 minutes, respectively), and this variability was primarily related to the unavailability of space within an in-patient psychiatric setting to which the patient was to be transferred. Discharge treatment varied on the basis of decision to transfer to an in-patient facility (n = 62, 45.9%) versus discharging to home (n = 73, 54.1%). Of patients who were not transferred to a psychiatric facility, 63% were discharged to home with instructions to follow up with an existing primary care provider, and 16% were referred to existing psychiatric services.

Mental Health History

Prior histories of mental health diagnoses and treatment were identified in 75.6% (n = 102) of the patients. The consistent theme among those who had prior histories of mental health dysfunction was a lack of adequate treatment. This was reported as an inconsistent use of prescribed medications for current disorders or a lack of effective counseling services. For example, one record stated that

Pt admits hx of counseling since age 4. Mother states after a long search for a therapist Pt had one appointment with a counselor … last May. Mother states Pt only saw this counselor once and is not currently receiving counseling services.

With regard to medication, another stated, "Patient reports he takes his medications on most days, however, 2 or 3 times a week he or his father will forget."

Intentional and unintentional forgetting, failure to refill medications as indicated, and financial burden associated with expensive medications appeared within such cases. System-level issues also affected individuals' ability to take medications as prescribed: one patient, for example, had not taken his psychiatric medications for 2 months before presenting at the emergency department because of an inability to reestablish Medicaid; another patient had aged out of treatment by his child psychiatrist when he turned 18 years old and had run out of his medications.

Characteristics of NSSI

Cutting was the most common form of self-harm (n = 83, 61.9%), followed by ingestion (n = 32, 23.9%). Seventy-eight patients (57.8%) had a previous history of NSSI, and a reason for engaging in NSSI was documented for most cases (n = 127, 94.1%). Content analysis of youths' reported reasons for engaging in NSSI showed three functional reasons and three emotional reasons. The functional reasons were (a) to escape emotions (e.g., "Patient reports that cutting helps her deflect her emotional pain. Patient states she is aware that this is not a good coping mechanism, but states that the relief it brings her is instantaneous and addictive."), (2) to feel something (e.g., "to feel like I'm still here … see if I could feel anything"), and (3) to punish oneself (e.g., "cuts when [he] feels he has not done the right thing or disobeyed mom"). The three primary emotions identified as reasons for engaging in NSSI were (a) anger (e.g., "Tonight she cut her wrist because 'sometimes she gets mad and loses it'"), (b) sadness (e.g., "He feels that no one cares about him and that he was feeling 'very depressed'"), and (c) stress (e.g., "I just feel stressed out.").

Contextual Influences on Youths Engaging in NSSI

Through content analysis for contextual circumstances, certain primary themes were generated from the personal narratives of the patients, patients' representatives (e.g., parent, guardian, extended family member, etc.), or hospital staff, typically those of social workers completing psychosocial assessments. These themes reflected the contexts in which patients' experiences occurred (i.e., family, peers/romantic relationship, school), which fell into five primary categories. Their order here does not imply order of importance; the meaning and impact of each theme was unique for each individual, and the quotations that follow present examples that capture the richness of patients' distinctive experiences.

Personal Emotions. Patients expressed a variety of strong emotions with which they struggled to cope effectively and/or to communicate to important people in their lives. "Stress" was highly prevalent in general. Intrapersonal stress was reported as "struggling to manage stress" and feeling "stressed because she would like to move forward with her life." Stress was frequently specific: "family stress" ("long-term stressor of not being able to see biological family as often as he would like to."), "stress at school" ("stressed about school … [School] puts a lot of emphasis on getting into college and patient feels like this is really stressful sometimes."), and "social stress" ("Patient denied any other stressors beside her relationship with her boyfriend."). Many patients reported multiple kinds of stress:

Patient's father died 1.5 ago … reports other family losses … peer pressure at school, patient is facing many transitions with new grade. Stress, friends, school, social pressure, self-critical thoughts.

Also found within the emotion of stress was a tendency toward self-criticism:

Patient reports being hard on herself if she is late on one assignment or messes up one time on an exam because she thinks about it ruining her chances of getting into the college of her choice.
Patient reports that she is a perfectionist. She worries about her grades, her self image, and her band performance.

"Emotional lability," documented frequently, ranged from recent irritability to extreme outbursts of anger with violence toward objects and/or others. Some youths were unable to pinpoint the source of their anger and admitted that there were positive factors within their lives.

[Patient] cannot figure out what makes her angry. [She] feels a lot of pressure from her parents. Patient knows she has parents who love her and do not abuse her. Parents are always telling her she needs to set the example for her younger brothers. Pt feels because she is the oldest, she expected to help take care of her younger brothers, help around the home, and set the example with behavior … wishes she could be the youngest sometimes and sometimes wishes she would wake up and be the youngest at home.

"Sadness," also highly prevalent, was expressed in various ways: "feeling depressed," "very hurt by dad's attitude towards her," "sadness in life." Sadness was mentioned as resulting from loneliness, disappointment, and mood instability. Other participants reported "numbness" and "boredom," which contributed either directly to engaging in NSSI as a way to escape those feelings or to use of substances to sustain the numbness: "Pt reports that he tries not to think about the sadness in his life and uses marijuana to stay high to help achieve numbness…".

Trauma. Trauma was found in a large number of patients. Often those with a history of abuse were further traumatized by events that unfolded after the abuse came to light.

History of sexual abuse by step-father…. Patient reported that she does not see mother, as "mother chose to stay with my abuser."
Maternal uncle had sexually abused patient from the age 5 until last [year], when patient told parents about the abuse. Uncle was arrested … and is still in jail waiting for trial. Maternal Grandmother treated the patient badly at first, blaming her for uncle's troubles and not believing her.

Foster care and the involvement of Child Protective Services (CPS) were traumatic events that greatly affected the patients. Of those with documentation (n = 71), 71.8% (n = 51) had a history of CPS involvement. Domestic violence, substance abuse, neglect/abandonment, and sexual/physical abuse were the most typical impetus for CPS involvement. Multiple traumas were the norm for patients who suffered abuse, with CPS removing them from their current residences and placing them within foster care or transitional housing. Closely related forms of trauma were unstable living environments, including transitional housing and frequent or routine residential moves. International, interstate, and intrastate moves deeply affected these youths as they moved away from their support systems, friends, and cultures. Moves were of course also associated with inconsistent mental health care. One family who had recently completed an intrastate move had been unable to reestablish Medicaid, which resulted in the youth's being off psychiatric medications for 2 months before presenting with NSSI. Another patient with a complex case history reported a

pending move out of the country … history of counseling since age 4. Mother states after a long search for a therapist [in current city] patient had one appointment with a counselor after family moved to [current city], from [another state] last May… Patient only saw this counselor once and is not currently receiving counseling services.

A final form of trauma was parental divorce or separation and associated custody issues. The stories related to these events were complex and convoluted, as can be seen in the following cases:

Mom reports that she and dad separated 4 months ago … she and dad had been married for 20 years and that she fought with the urge to divorce him for a long time until she became unable to tolerate his behavior any longer. Mom reports that dad will often … come by house after school to visit with him and sister … dad has attempted to stay with family on multiple occasions, stating that he has nowhere to go or that he will be able to visit with pt longer, but that mom is insistent that he leave the house as they are pursuing a divorce and she does not want pt to get mixed messages. Mom reports that dad's inconsistency with visitation and contact is difficult for everyone but especially pt.
Father reports that he and Pt's mother have had custody issues over Pt. Father reported that mother's family reported father to CPS for alleged drug use but that the case was closed as unfounded. Father reports that Pt was stressed during CPS investigation and worried that he would have to go live with his mother.

Relationship Quality. The quality of youths' relationships emerged as they described the members of their families and their peers. The quality of familial relationships included interpersonal conflict and dysfunctional parenting. Conflicts, arguments, and ineffective communication with family members were ubiquitous, and although parents were frequent participants in such conflicts, siblings and additional extended family members also contributed. Some reports of interpersonal conflict reflected the youth's witnessing domestic discord as opposed to participating in the conflict.

Family history of domestic violence perpetrated by bio father… Mom reports that she is remarried and that she doesn't speak about the family's history of domestic violence b/c she wants patient and her sister to become closer to step-dad despite the fact that both state having memories of the domestic violence between she and bio dad.

Dysfunctional parenting, distinct from reports of trauma, included lack of appropriate boundaries, discipline, or oversight as well as parental substance use and legal issues:

[Patient's] aunt reports that … mom died [several years ago] from an OD of illicit street drugs. [Patient] was the first to find mom deceased. Aunt reports that both mom and dad had [history] of substance abuse although dad had stopped using at the time of patient's birth … mom had an on-going substance abuse problem and provided very little discipline or guidance for pt. Per Aunt, mom often supplied patient with marijuana.

Peer relationship quality was characterized by significant interpersonal conflict and bullying. General "drama" with friends or romantic partners was played out within the school setting and through texts and social media. One youth was reported as having said that she "tried to message a boy from school on Facebook, but he has not messaged back," and another had stated that "[she] was upset over the last 24 hours because [her friend] texted her something that hurt her feelings … she knows it seems 'silly' to be so upset about something like a text but the text had hurt her feelings." Such instances overlapped with bullying, in which youths reported negative messaging and teasing through social media outlets such as Facebook:

Patient had posted at 1 am last night … to which a girl the patient liked stated, "Your parents were right. You were a mistake."

One patient specifically reported triggers to cutting behaviors as "parent relationship and being bullied at school." Also related to this theme were the few instances of youths reporting exposure to cutting behaviors by a friend or family member (i.e., cousin and sister).

Sense of Loss. Loss occurred within the family and in relation to peers. Within the family, loss emerged as youths reported feeling invisible and worthless (e.g., "Patient said she has thoughts of worthlessness since her real father has not been around since her birth."). Narratives differed according to the context in which the loss was experienced. Youths also reported wanting more attention from their parents (e.g., "She wants to leave her home and find a new family who cares for her. Feels parents would rather spend time with their friends than with her."), missing family members who were incarcerated or working long hours, and parents who were simply absent: "Patient has been in foster care for 5 months because patient's mom did not want to take care of her anymore.… Tonight she started to think about her mom." Loss manifested in relation to peers in terms of isolation and lack of social support. One patient was described as explaining that "her best friend and her are not as close as they were before and she feels like, she 'doesn't care about me' like 'she doesn't like me.' Pt stated that she has felt more distant with this friend in the last few months especially."

Reports of loss were also related to death and illness within the family or among peers. Traumatic deaths such as murder and suicide had significant impacts on youths, but death due to illness or advancing years of family members also contributed to engaging in NSSI. One particularly complex case involved a youth who had been placed with his cousin after being removed from his mother's care because of significant substance use and mental health issues. His cousin was then killed in a motor vehicle crash, and a friend and fellow gang member died in his arms after being shot. On top of these tragedies, his mother had recently been diagnosed with a rare and serious medical condition.

Risky Behaviors. Risky behaviors were reflected in legal issues, substance use, running away, and engagement in risky sex. Legal issues included physical fights, truancy, gang involvement, school expulsion, and arrests. Many of these reports described youth exhibiting a myriad of risky and deviant behaviors that culminated with presentation to the emergency department.

Mom feels patient's behaviors have escalated in the past year … grades have dropped. Patient steals anything she can from mom's room, money, cigarettes, prescription medications and mom's clothes. Mom tries to lock her bedroom door but the patient and her sister have broken the door too many times, mom does not keep anything in her bedroom now. Mom has to keep her prescription medications at one of her friend's home.

Moreover, many cases that contained risky behaviors included other primary themes as well:

[Patient has] history of drug abuse, recently released from jail, recently moved from [previous city] to [current city] away from gf. Biological mother abandoned patient and has issues with drugs and alcohol [herself]. anger issues.
Patient is currently 5 months pregnant. [Father of the baby] is boy on CPS custody & he is not around any longer. Pt was going to have an abortion, but recently decided to have the baby. Mother reported that CPS has been involved with the family. When pt was 10 yrs old, her father (mother's husband) hit patient & broke her jaw. He is currently in prison. Mother reports pt's behavior has become increasingly out of control since pt started high school. Pt is very "into boys" … has run away on several occasions, for as long as 4–5 days. Mother notified law on each occasion. Mother & patient's relationship seems very strained. There was no communication between patient & mother during interview … [hospital staff] states that pt reported to her that she wanted to go home but that she could only go home if mom allowed her to …. Patient reported that she always has to babysit for her siblings while mom goes out all night long and that she just wants more attention from mom.