Connecting Knowledge and Research

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Deliberate self-harm (DSH) is a widespreadproblem among young people. In a commu-nity sample report, at least 1 episode of non- suicidal self-injury (NSSI) was found among one third to one half of all United States adolescents.1 In a random sample of undergraduate and graduate students identified via an internet survey, “The lifetime prevalence rate of � 1 self-injurious behavior incident was 17.0%. Seventy-five percent of those students engaged in self-injurious behav- iors more than once.”2

A wide range in prevalence data is attributed to the fact that many who self-injure do not seek medical assistance. The gender difference in DSH prevalence is slightly higher in younger females but evens out in adulthood.

Self-injury is defined in various ways in the literature, but for this article, the term deliberate self-harm is used to describe “intentional destruction of body tissue without suicidal intent and for purposes not socially sanctioned.”3

It is important to recognize that a percentage of persons who self-harm eventually do attempt suicide. Hawton

and Harriss4 found that, in a sample of 4,843 young peo- ple followed in a 20-year cohort, 1.7% had committed suicide. It is crucial to note that 90% of these individuals had used overdosing to self-harm.

Various terms are used to label DSH, including self- injurious behavior, intentional self-injury, nonsuicidal self-injury, and self-mutilation. DSH occurs in various forms, with the most common including cutting, brand- ing or burning, picking at skin or reopening wounds (dermatillomania), pulling hair (trichotillomania), hitting or punching, and head banging.5

DSH is often regarded as a chronic condition associated with such sequelae as physical injury, scarring, cosmetics impairment, and unintended death.6 DSH assessment and identification in young people in the primary care setting poses particular challenges to primary care providers (PCPs).

BACKGROUND AND SIGNIFICANCE There is little information on PCP involvement in DSH assessment and identification. This lack is a result of both

ABSTRACT Deliberate self-harm is a major public health concern among young people age 12-24 years old. Health care providers lack basic knowledge regarding the assess- ment and identification of deliberate self-harm, thus delaying recognition. Given the time restrictions and knowledge deficit of health care providers, a detailed physical, psychological, and psychosocial assessment is often excluded during well and acute visits. Using the evidence, this article outlines some guidelines to fur- ther providers’ understanding of the essential components of assessment, which can enhance the identification of deliberate self-harm in the primary care setting.

Keywords: adolescent, assessment, deliberate self-harm, risk, young adult © 2012 American College of Nurse Practitioners

Assessment and Identification of Deliberate Self-Harm in Adolescents

and Young Adults Courtney Brooks Catledge, FNP-BC,

Kathleen Scharer, PMHCSN-BC, and Sara Fuller, PNP

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the acceptability of self-harm behavior throughout time7

and such practice barriers as inadequate training, screen- ing tools, reimbursement, and mental health resources for referrals.8 Recent literature reflects an advancement in understanding that DSH behaviors serve as affect regula- tion, self-punishment, interpersonal influence and boundaries, antidissociation, or sensation seeking.1

Literature on treatment has been limited to suicidal risk and treating injuries in emergency departments.9 Despite the availability of suicide risk assessments and emergency treatment guidelines for acute care settings, there continues to be inconsistent assessment and management of young adult patients in the primary care setting. Many PCPs are excluding both the physical and psychosocial assessment needed to identify and prevent DSH.8

ONSET IN ADOLESCENT AND YOUNG ADULTS DSH occurs across the lifespan, yet young people are seen as participating in the behavior at disproportion- ately higher rates.10 The Center for Suicide Preven - tion11 found that the behaviors usually start in early adolescence, then increase between ages 16 to 25. DSH has been rare in those under 12.12 Thus the focus of this article is the young adult population ranging in age from 12 to 24.

Skegg identified various risk factors that contribute to young people’s risk of participating in DSH.12 The demographic factors include age, gender, and socioeco- nomic status. Psychosocial factors that affect DHS partic- ipation incorporate childhood experiences such as child abuse and other forms of family dysfunction.

Lastly, the presence of or a family history of psychi- atric illness, especially anxiety, depression, and personality disorders, is a strong precursor to young adult participa- tion in DSH. More females than males tend to self-harm. Skegg12 found low socioeconomic status, education level, and income and living in poverty to be associated with increased risk of DSH, yet the literature overall lacks consistency on this topic.

FUNCTIONS OF PARTICIPATING IN DSH BEHAVIOR The literature clearly supports DSH as a behavior without the intentional desire to die.13 The terminology itself is rec- ognized as the intent to harm without having fatal out- comes.12 DSH serves as a mechanism to regulate effect in stressful situations; communicate distress to others; coerce or compete with other self-injurers; resolve conflicts; release

anger, tension, or emotional pain; provide a sense of secu- rity or control; punish oneself; generate intimacy; and serve as suicide alternative.13,14 Harris’ study reported that 1 par- ticipant said, “The purpose of some acts of self-harm is to preserve life… professionals sometimes find this a difficult concept to understand.”15 This quotation reinforces the idea that DSH is used as a coping mechanism that may seem to be the only option. Harris recognizes that those who repeatedly self-harm may demonstrate variations in methods, as well as differing intention and motive.15

FACTORS ASSOCIATED WITH DSH Factors associated with DSH include sexual abuse, family dysfunction, psychosocial factors, and psychological fac- tors.3,10,12 In addition, childhood sexual abuse is thought to contribute to early initiation of DSH as a method to remedy psychological issues such as the depression and anxiety typically associated with both abuse and DHS.16

Fliege and colleagues10 correlated stressful, traumatic experiences in childhood to DSH.

Evidence supports a strong correlation between psychological factors and DSH. Anxiety, depression, hopelessness, anger, and impulsivity were the most prevalent in the literature.10,17 Problems with friends, boy/girlfriends, schoolwork, alcohol and drug use, and bullying were some additional psychosocial factors in the literature that were shown to have an impact on both behavior and risk for DSH.18

PRACTICE AND KNOWLEDGE ASSESSMENT OF DSH IN PRIMARY CARE Morey et al’s study found that only 49.8% of those engaging in DSH sought help after the event and the assistance included mainly friends or family members, with only 11.3% presenting to the hospital.16 Ozer and colleagues19 found that approximately one third of ado- lescents seen in primary care said they were asked about their emotional health. Multiple reasons for underutiliza- tion of screening opportunities in the primary care set- ting were noted, including physician lack of confidence to treat such illness as depression and lack of integrated systems for both screening and management.19 Of those patients seeking services for DSH, many acknowledged negative experiences, with a perceived lack of patient involvement in management decisions, hostile staff behavior, lack of staff knowledge, and the need for better after-care arrangements.20,21

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RECOMMENDATIONS PCPs of young people should assess for evidence of and risk for DSH. Providers need to be educated to enhance their ability to identify, assess, and manage DSH in pri- mary care using current evidence. Assessing young people for DSH can impact the prevention and reoccurrence of those behaviors. Ozer and colleagues19 found that PCPs should include a screening for emotional distress as a standard part of young adult care. A timely assessment is important, especially during the early teen years, which have been found to be an important life phase in the prevention and early identification for self-harm.9,22,23

THERAPEUTIC RELATIONSHIP PCPs of young adults need to create a trusting, private environment without family or caregivers present initially to ensure patient safety and accurate assessment data. Establishing a therapeutic relationship with young people in the primary care setting is essential to demonstrate trust, respect, and rapport.3,13 A matter-of-fact approach that is neither critical nor overly sympathetic works best. It is critical to establish a working relationship to promote joint clinical decision making based on the foundational elements of understanding and compassion.

Skegg noted the impor- tance of providers guarding against a reaction of horror, while recognizing that assess- ment should work towards identifying the functions of the behavior in a non-judgmental way.12 Walsh noted that self- injury can produce extreme reactions in caregivers including shock, disgust, recoil, judgment, anxiety, fear, anger, and confusion; therefore, PCPs should examine their behaviors and reactions so as not to compromise the therapeutic relationship.13

Confidentiality and privacy should be emphasized with the caveat that certain types of behaviors such as child abuse or current suicidal intention must be reported. Purcell et al24 identified that a large portion of HCPs do not interview their patients in private. Given the correlation that DSH has with family dysfunction and abuse, the initial interview should be in private to reduce the risk of rebound abuse by a perpetrator.

Strong communication skills on the part of the PCP are important to both establish a relationship and collect the information needed for a comprehensive assessment.

PHYSICAL ASSESSMENT Behavioral clues to participating in DSH include dress- ing in long sleeves and pants even in warm weather, wearing wrist bands or bulky bracelets, avoidance of activity where the person has to change clothes or expose skin such as physical education class. These behaviors may indicate the need for a comprehensive skin examination even if the presenting problems might not require it. A comprehensive skin assessment should included normally clothed areas such as breasts, entire arms, legs, upper and inner thighs, and abdomen. Considering the number of young adults who deliber- ately self-harm, a skin assessment should be conducted annually. Evidence of scratches, burns, lacerations, objects felt under the skin by palpation, or multiple scars with- out reasonable explanations may be signs of self-harm. Scars will vary greatly in appearance, depending upon

their age and depth of cutting and what is used to cut. Razor blades are quite commonly used but other objects such as nail clippers or scissors may be used. Sometimes the skin is gouged, perhaps with a flat blade screw driver. Many who cut choose to cut over and over again in the same spot so that there may only be a single line. But cross-hatched wounds or even words may be carved into the skin. The number of cuts

also will vary widely from 1 or 2 to more than 100.25

Objects can be embedded under the skin, such as nee- dles or glass pieces. Burns are often from cigarettes but candle flames, lighters or matches may also be used. Walsh noted that most individuals who self-harm cut the extremities and abdomen, not the neck.13 Proper assess- ment of wounds can provide objective information about the frequency and level of physical damage. Additional clues may consist of signs of anger, sadness, and anxiety expressed through acts of defiance or with- drawal, and low self-esteem. 25 Documentation should include location of the evidence of self-harm, type of

It is critical to establish a working relationship to promote joint clinical

decision making based on the foundational elements

of understanding and compassion.

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injury, size, and stage of healing for later comparison since it is common for the same sites to be reused.

Self-Injury Risk Assessment Health care providers, when providing either acute or preventative care services, should include a self-injury risk assessment. Assessment should be specific to the patient presentation at the time of the encounter and take into account gender variations, previous behavior, and any comorbidity. Functions and characteristics of self-harm vary greatly between patients and DSH episodes so it is important to assess each episode sepa- rately.26 Young adults who self-harm should be taken seriously by PCPs.27 A comprehensive self-injury risk assessment guides the PCP on appropriate care and fol- low-up.3,9,17,25 According to Peterson and colleagues,1

Walsh,13 and Spender,28 the self-injury risk assessment should include the items listed in Table 1.

Psychosocial and Psychological Risk Assessment PCPs should complete a psychosocial and a psychological risk assessment, including suicide risk assessment based on individual circumstances. Consideration should be given to interviewing family and other key people while main- taining patient confidentiality and with patient consent. A preliminary psychosocial assessment should be completed at initial presentation to determine the individual’s men- tal capacity, level of distress, and presence of mental ill- ness.26 All who have self-harmed should be assessed for clinical and demographic characteristics known to be associated with risk of further self-harm or suicide.

PCPs must identify the key psychological characteristics associated with risk, such as depression, hopelessness, and suicidal intent.26 Assessment of suicide risk, history of physi- cal and sexual abuse, substance abuse history, evaluation of family functioning, and identification of comorbid psychi- atric illness should all be included in the assessment.1,29

Unless the person is suicidal, a self-harm contract is gener- ally not effective. However, if the individual reports some suicidal ideation, check for a plan and then determine if fur- ther intervention is needed immediately.

The vast majority of DSH is through cutting, which by itself rarely causes death. However, the use of alcohol can increase the risk of suicide in patients who self- harm.4 Whitlock and Knox,30 in a random sample of col- lege students, looked at the relationship between DSH and suicidality, with the results showing that as DSH episodes increase, so does suicide attempt. Some self- injurers will move from a low lethality method to higher lethality, thereby increasing suicide risk. Clinicians work- ing with persons with DSH need to monitor over time whether their clients are also experiencing suicidal ideation, planning, and behaviour, with the priority to respond to the suicidal crisis first.13

PCPs need to monitor patient motivation for self- injury and specifics of the act. In response to a DSH act, the PCP needs to address the patient’s psychosocial needs, poor problem solving, and impulsivity to prevent further acts. This may require a referral to a mental health professional.23

While various instruments to measure self-harm have been developed for research, 2 measures have been devel- oped for clinicians. The Self-Harm Inventory31 is a 22- item self-report questionnaire that includes questions about high-risk behaviors of overdosing or attempted suicides, self-harm, and 3 items that deal with eating-dis- order behaviors. This free paper measure is easy to use and has reasonable validity and reliability. It is available in the cited paper.

Diamond and colleagues8 have been developing a computer-based behavioral health assessment tool that takes about 13 minutes to complete. The assessment is scored by the computer so that results are immediately available to the provider. This screen includes important issues relating to DSH, including self-harm questions, and has good psychometric data.

PCPs should remember the correlation DSH has with abuse, family tension/stressors, and other underlying

Table 1. Self-Injury Risk Assessment Criteria

• History (age at onset, type of self-injury, functions, wounds per episode, duration per episode, duration of the problem, body area[s], extent of physical damage, other forms of self-harm)

• Details of recent self-injury (types, functions, number of wounds, temporal dimensions, extent of physical damage, body areas, patterns, use of a tool, physical location, social context)

• Antecedents (historical, environmental, biological, cognitive, affective, and behavioral triggers)

• Consequences/aftermath (emotional relief, attention from others, and environmental, biological, cognitive, affective, behavioral results)

• Other details2,14,29

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mental disorders.10,25,27 Compared with those who do not self-harm, those who do experience more frequent negative and unstable emotions, including anxiety, depression, aggressiveness, and impulsivity in their daily lives.10 When working with the family, it is important to know if problems within the household have led to the patient’s DSH,10 since the approach to the family would have to be modified if it would likely increase the risk of further DSH or suicide. The duty to share information with parents is limited to generalities, and providers must be cautious about what is shared, protecting the patient’s confidences while ensuring safety.

EVIDENCE-BASED MANAGEMENT AND FOLLOW-UP PCPs should provide evidence-based management and follow-up. Treatment for the patient exhibiting DSH or risk should include a management plan3 developed in conjunction with the patient. Initial treatment for the patient who participates in DSH should include treat- ment for physical consequences of self-harm.26 Skegg12

identified general principles of care after self-harm (Table 2). Youth who engage in DSH do grow into adults who may continue to self-harm, or they may cease the behav- iour, only to have it restart in adulthood under severe stress. Alternately, some individuals who engage in DSH may gradually escalate the type or intensity of their DSH behaviors and eventually attempt suicide if their coping attempts are unsuccessful in regulating their affect or dis- tress increases significantly.30 Therefore, the individual plan should identify coping skills and deficits with a plan to increase those skills.

Psychoeducation for the patient and family, cognitive problem-solving skills, family therapy, and dialectical behavior therapy (DBT) are often appropriate, depending on patient needs.1 Spender found that treatment may include alternative forms of communication, including writing in a diary or blog, composing poetry or music, drawing or painting, chatting on a messaging network, or talking more to friends or family members.28

PCP EDUCATION PCPs of young adults with DSH should be educated on the characteristics, signs and symptoms, incidence and etiology, and sequelae. They also should know commu- nity referral resources and practice recommendations, including comprehensive target physical assessment and psychosocial assessment. Ozer and colleagues19 reported

that when clinicians have the training and tools needed to provide primary care, the result is improved clinician self-efficacy, thus increased rates of screening and coun- seling of adolescents for risky health behaviors.

PRACTICE IMPLICATIONS Deliberate self-harm has existed for centuries and has taken on a variety of forms, yet there are few practice guidelines available specific to the best practice stan- dards of assessment and identification of young adults in the primary care setting. The above assessment recom- mendation was created to assist primary PCPs in offer- ing best practice care to young adults with DSH. This recommendation is quite important, given both the increasing numbers of young adults participating in DSH and the lack of PCPs with knowledge, skill, and resources to provide care. Using a targeted assessment in this population will lead to an improved likelihood of identifying DSH. As a result, improvement can be made to provide best practice treatment that reduces repeat episodes and long-term sequelae.

The guideline recognizes the importance of establish- ing a therapeutic relationship with the realization that PCPs are stretched to their limits when it comes to time and resources. As a result, the guideline should be imple- mented over several visits. Within the context of the ini- tial visit, priority should be given to creating a safe and therapeutic environment for assessment, so that with

Table 2. Evidence-Based Management and Follow-Up13

• Monitor patient for further suicidal or self-harm thoughts

• Identify support available in a crisis

• Come to a shared understanding of the meaning of the behavior and the patient’s needs

• Treat psychiatric illness vigorously

• Attend to substance abuse

• Help patient to identify and work toward solving problems and improve coping skills

• Enlist support of family and friends where possible

• Encourage adaptive expression of emotion

• Avoid prescribing quantities of medicine that could be lethal in overdose

• Assertive follow-up in an empathic relationship

• Affirm the values of hope and of caring for oneself

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additional encounters, more detailed assessment findings can be gathered. This assessment can be effectively car- ried out only in an environment perceived to be safe by the patient.

The initial assessment must include a physical, suicide risk, and psychosocial and psychological risk assessments to ensure young people are not a serious threat to them- selves or others, as well as ensure there is no imminent danger in the home, work, or other personal environ- ment. This also identifies their mental competence and the need for treatment of physical injury and any identi- fied psychological disorders.

During follow-up encounters, PCPs can complete the assessments to improve understanding of the DSH behav- ior and collaborate with patients to establish a comprehen- sive treatment plan. Subsequent encounters may also provide insight into the need for additional referral and follow-up. It is important to find ways to reduce and elim- inate the health care barriers encountered by young adults. Understanding and addressing the barriers that prevent them from seeking help must be dealt with, rather than waiting for young adults to seek out PCPs.32

NURSING EDUCATION IMPLICATIONS A major problem in the care of adolescents who self-harm or are suicidal is that PCPs may have difficulty dealing with these intentional acts.33-35 The intentional nature of the behavior can be difficult for providers to understand and to accept when they are dealing with potentially life-threaten- ing problems of other clients or when their own anxieties about the behavior interfere with providing compassionate care. The education of all health professionals needs to include opportunities to examine feelings about DSH behaviors, gain some understanding about the factors that influence these behaviors, and receive education about appropriate responses for the level of care they will be pro- viding. Assessment, identification, and treatment of DSH in the adolescent and adult population need to be included.

Student nurses and NPs need to understand the issue of DSH and should be taught how DSH presents, the underlying risk factors, and the evidence-based manage- ment strategies. Student nurses should also be taught spe- cific red flags for to look for when assessing the young adult that would better equip them to identify and coun- sel patients exhibiting the risk or behaviors of DSH. Finally, they need to be taught how and when to refer DSH patients for further care.

At the graduate level, advanced practice nurses need detailed information on the assessment, psychosocial fac- tors, psychological factors, peer association, and evi- dence-based management strategies to properly provide comprehensive primary care. A good understanding of child abuse, anxiety and depressive disorders, stress-related illness, and peer association cues should be part of the advanced practice curriculum.

Neville and Poustie6 recognized the need for greater training and support for all members of the primary health care team as part of continuing education. Taylor et al20

noted that PCPs need improved knowledge, communica- tion, and follow-up, thus compounding the need for further assessment of the educational and health care system to identify where knowledge and experience could be attained.

CONCLUSION Every young adult who engages in DSH should be taken seriously by the health care team. Providers need to take an active role in improving outcomes for those who are at risk for or participating in DSH. It must start with a thorough and comprehensive assessment.

References

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Courtney B. Catledge, DNP, MPH, MSN, APRN, FNP-BC, is an instructor at the University of South Carolina in Lancaster and can be reached at [email protected]. Kathleen M. Scharer, PhD, RN, PMHCNS-BC, FAAN, is a professor, and Sara Fuller, PhD, APRN, BC, PNP, FAAN, is a professor (retired), both at the University of South Carolina, Columbia. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

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