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


In this study, we have examined reported reasons for engaging in NSSI and contextual factors associated with NSSI at the point of crisis. The interpersonal and intrapersonal themes associated with NSSI among youth are intensely emotional. Although maladaptive, NSSI serves as an emotional and functional coping mechanism for youths with a wide range of life circumstances. Emotions, trauma, relationship quality, sense of loss, and risky behaviors present a complex interplay of contextual and personal factors that contribute to risk for engaging in NSSI and suggest directions for clinical practice related to screening and early intervention.

Mental health care for youths in the primary care setting has developed significantly over the last two decades, and most mental health care is now offered by nonpsychiatric providers (Olfson, Blanco, Wang, Laje, & Correll, 2014). Current study findings that 63% of youths were instructed to follow up with their primary care provider underscores the reality that many complex psychiatric cases will present in primary care. The education of future primary care providers has therefore focused increasingly on the importance of mental health screening and management for children and adolescents. Nevertheless, addressing NSSI in the primary care setting remains a challenge for many pediatric health care providers. Openly discussing the incidence, prevalence, and factors associated with NSSI with youth and their families is an important first step in increasing awareness and decreasing stigma. NSSI is a significant public health concern, and acknowledging it with families will help parents become more aware of potential mental health concerns for their own children and may prompt individuals to seek mental health treatment earlier.

This study has provided an outline of risk factors that should be addressed with youth and their families. Discussion of youths' personal emotions and coping strategies should begin in childhood, well before adolescence. Because the context of stress is personal to each individual, early discussions about stress and ways to effectively manage it can encourage youths to develop healthy coping skills. Anticipatory guidance beginning during the early school years should include a discussion of what stress means and role playing about how to deal with it. Such education may serve to prevent NSSI as stressors increase with age.

Also important is the quality of youths' relationships. Relationships are the basis of support for all individuals, and assessing for poor relationships (e.g., bullying) is just as important as assessing for healthy relationships. Health care providers can stress to youths and parents the protective nature of healthy relationships, and they should review how to identify unhealthy relationships. Encouraging involvement in school and extracurricular activities can also provide a sense of belonging that promotes a support network and friendships with like-minded peers.

Health care providers must also be vigilant in assessing for evidence of past and present traumatic family events. Cohen, Kellner, and Mannarino (2008) suggest using a single screening question at each well-child visit: "Since the last time I saw you, has anything really scary or upsetting happened to you or your family?" (p. 448). Conversations elicited by such a question can be challenging for both families and providers. Certain traumatic situations are obvious, such as involvement with CPS, but it is difficult to intervene with families that experience high levels of stressors behind closed doors and fail to exhibit any outward warning signs. In such cases, observations of parent–child interactions at every visit and of physical and emotional reactions to questions about life at home or any struggles can provide important insights into potential underlying issues. Partnering with families on the most personal level can provide insight into daily life and stressors, so that providers can furnish resources well before NSSI becomes an option.

This study has certain limitations. The use of retrospective data from medical records led to missing data regarding individuals' medical, psychological, and social histories. For example, very little was documented regarding the history of youths' NSSI behaviors, which might have allowed for more complex analyses regarding the evolution of NSSI over time. In addition, this study was conducted in two medical centers within a single state. The sample did present a diverse population (e.g., 33.6% Hispanic, 63.8% with Medicaid or uninsured), but it might not be representative of youth engaging in NSSI in other geographic locations. Clinical practice could greatly benefit from large-scale epidemiologic examinations of NSSI to refine our knowledge related to prevalence, incidence, and associated factors, which would then provide an evidence base to inform the development of screening practices and treatment protocols.