Overview
Definition:
Self-harm in pediatrics refers to any act of intentionally causing injury to oneself
This can range from superficial cuts and burns to more severe behaviors with the intent to die, though the primary goal is often self-punishment, self-soothing, or communicating distress
It is crucial to distinguish between non-suicidal self-injury (NSSI) and suicidal behavior, although NSSI is a significant risk factor for future suicide attempts.
Epidemiology:
The prevalence of self-harm among adolescents is significant, with estimates varying widely but generally reported between 10-20% in general adolescent populations and higher in clinical settings
Peak incidence is typically in mid-adolescence (14-16 years)
Boys and girls engage in self-harm, though methods may differ
girls more often report cutting, while boys may report more violent methods like hitting or burning
Early onset of self-harm predicts poorer long-term outcomes.
Clinical Significance:
Self-harm in children and adolescents is a critical public health concern and a marker of significant underlying psychological distress
It indicates a failure to cope with overwhelming emotions and can lead to severe physical injury, infection, and long-term psychological morbidity
Identifying and managing self-harm effectively is paramount for preventing future suicidal behavior and improving mental well-being in this vulnerable population
It requires a compassionate, non-judgmental approach and thorough assessment.
Clinical Presentation
Symptoms:
Unexplained injuries such as cuts, bruises, burns, or abrasions
Frequent "accidents" or injuries that are inconsistent with the reported mechanism
Wearing long sleeves or pants even in warm weather to conceal injuries
Social withdrawal or isolation
Changes in mood, such as increased irritability, sadness, or hopelessness
Sleep disturbances, including insomnia or hypersomnia
Decreased interest in previously enjoyed activities
Suicidal ideation or talk of death.
Signs:
Presence of fresh or healing self-inflicted wounds
Evidence of bleeding that is not readily explained
Defensive or evasive behavior when asked about injuries
Signs of malnutrition or poor hygiene if self-care has deteriorated
Poor eye contact or withdrawn affect during interviews
History of previous self-harm episodes or suicidal behavior.
Diagnostic Criteria:
There are no formal diagnostic criteria for self-harm itself
it is a behavior
Diagnosis relies on a comprehensive clinical assessment of the behavior and underlying mental health conditions
ICD-11 codes for self-harm behaviors and specific mental disorders (e.g., depressive disorders, adjustment disorders, conduct disorders, personality disorders) are used
The assessment focuses on identifying the intent (self-injury vs
suicide), triggers, function of the behavior, and associated psychiatric comorbidities.
Diagnostic Approach
History Taking:
Directly ask about self-harm
Inquire about any thoughts of hurting oneself, even if not suicidal
Ask about the method, frequency, and intent of self-harm
Explore triggers and underlying emotional states (e.g., anger, sadness, emptiness, numbness)
Assess for suicidal ideation, intent, and plan
Screen for co-occurring mental health conditions like depression, anxiety, trauma, eating disorders, and substance use
Inquire about family history of mental illness and suicide
Assess for history of abuse or neglect
Ask about social support systems and coping mechanisms
Inquire about recent stressors.
Physical Examination:
A thorough head-to-toe physical examination to document and assess the extent of any self-inflicted injuries
Document the type, location, size, and depth of wounds
Assess for signs of infection, such as redness, swelling, pus, or fever
Evaluate vital signs for any instability
Assess for injuries that may indicate an attempt to end one's life
Document any signs suggestive of underlying medical conditions or trauma.
Investigations:
For acute self-harm: Wound cultures if infection is suspected
Complete blood count (CBC) and basic metabolic panel (BMP) if significant bleeding or dehydration
Toxicology screen if substance intoxication is suspected
Imaging (X-rays, CT scans) may be necessary for trauma assessment or to rule out internal injuries
Psychiatric evaluation is paramount
Standardized questionnaires for depression (e.g., PHQ-9), anxiety (e.g., GAD-7), and suicidality are useful
Assessment for trauma using appropriate validated tools (e.g., CAPS-5 for PTSD).
Differential Diagnosis:
Accidental self-injury
Munchausen syndrome
factitious disorder imposed on self
somatization disorder
malingering
other psychiatric disorders with impulse control deficits (e.g., conduct disorder, oppositional defiant disorder)
emerging personality disorders
psychosis with command hallucinations
substance intoxication or withdrawal
The key distinction is intent: self-harm (NSSI) is typically not intended to result in death, but rather to cope with distress.
Management
Initial Management:
Prioritize safety: Immediate medical stabilization and treatment of any physical injuries
Ensure a safe environment, removing potential means of harm
Conduct a thorough risk assessment for suicide
Initiate suicide precautions if high risk is identified
Engage the child/adolescent and family/caregivers in a collaborative manner
Provide a calm, supportive, and non-judgmental setting for the assessment and discussion.
Medical Management:
Pharmacological management is directed at co-occurring psychiatric conditions
For depression: Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line, with caution regarding potential initial increase in suicidality in adolescents (requires close monitoring)
Examples include Fluoxetine (20 mg/day initially, titrate up to 60 mg/day), Escitalopram (10 mg/day initially, titrate up to 20 mg/day)
For anxiety: SSRIs or SNRIs may be used
For disruptive behaviors: Mood stabilizers or atypical antipsychotics may be considered
For psychosis: Antipsychotics
All psychotropic medications require careful monitoring for efficacy and side effects, especially increased suicidal ideation
Always consult child psychiatry for medication management.
Psychosocial Intervention:
This is the cornerstone of management
Dialectical Behavior Therapy (DBT) is highly effective for self-harm and suicidal behavior, focusing on distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness
Cognitive Behavioral Therapy (CBT) is also beneficial for addressing maladaptive thoughts and behaviors
Family therapy can improve communication and support systems
Psychodynamic psychotherapy can explore underlying conflicts
Therapeutic rapport and a strong alliance are crucial.
Safety Planning:
A collaborative, written plan developed with the individual to help them cope with suicidal urges and self-harm
Key components include: recognizing warning signs, internal coping strategies (e.g., relaxation techniques, distractions), identifying supportive people and social settings to go to, contacting mental health professionals, and making the environment safe
The plan should be accessible and regularly reviewed
It is NOT a substitute for emergency care but a tool to manage immediate crises.
Complications
Early Complications:
Infection of wounds
significant bleeding leading to hypovolemic shock
nerve damage
tendon or muscle injury
functional impairment
severe allergic reactions to disinfectants or dressings
unintentional death (escalation of self-harm to a suicide attempt).
Late Complications:
Scarring and disfigurement
chronic pain
recurrent self-harm
increased risk of suicide attempts and completion
development or exacerbation of psychiatric disorders (e.g., depression, anxiety, PTSD, personality disorders)
social isolation
academic difficulties
substance use disorders
impaired interpersonal relationships
stigma.
Prevention Strategies:
Early identification and intervention for mental health concerns
Providing psychoeducation on coping skills and emotional regulation
Fostering supportive environments in families, schools, and communities
Reducing access to lethal means
Implementing robust screening protocols for self-harm and suicidality in healthcare settings
Training healthcare professionals in risk assessment and management of self-harm
Promoting help-seeking behavior and reducing stigma associated with mental health issues.
Prognosis
Factors Affecting Prognosis:
Severity and frequency of self-harm
presence of suicidal ideation and intent
co-occurring psychiatric disorders (especially depression, bipolar disorder, psychosis, substance use disorders)
history of abuse or trauma
lack of social support
family history of suicide
poor treatment engagement
impulsivity.
Outcomes:
With effective, comprehensive treatment including psychotherapy (especially DBT) and management of co-occurring conditions, the prognosis can be significantly improved
Many individuals can learn to manage their distress and reduce or eliminate self-harm
However, self-harm can be a chronic issue for some, requiring ongoing support
The risk of suicide remains elevated, necessitating vigilant monitoring and continued care.
Follow Up:
Regular follow-up with mental health professionals is essential
Frequency depends on risk level and treatment phase, ranging from weekly to monthly
Close monitoring for self-harm urges, suicidal ideation, and adherence to treatment plans
Ongoing assessment and adjustment of treatment strategies
Family involvement and support remain critical
Transitioning care between different levels (e.g., inpatient to outpatient) requires careful planning and coordination.
Key Points
Exam Focus:
Always ask directly about self-harm and suicidal ideation
Differentiate between NSSI and suicide attempts
Recognize NSSI as a significant risk factor for suicide
Understand the functions of self-harm (coping, communication, self-punishment)
Know the principles of safety planning and its components
Be familiar with evidence-based psychotherapies like DBT for self-harm
Recognize the importance of treating co-occurring mental health conditions.
Clinical Pearls:
Build rapport and trust
a non-judgmental stance is crucial
Validate the individual's pain and distress without condoning the behavior
Involve family/caregivers as a supportive resource, where appropriate and safe
Use safety plans as a collaborative tool, not a directive
Remember that self-harm is a symptom of underlying distress, not the primary problem
Regular, brief check-ins can be more effective than infrequent, lengthy ones for some individuals.
Common Mistakes:
Failing to ask directly about self-harm or suicide
Dismissing self-harm as attention-seeking behavior
Focusing only on physical injuries and neglecting the psychological distress
Not developing a personalized safety plan or failing to review it
Underestimating the risk of suicide in individuals who self-harm
Prescribing psychotropic medications without adequate psychosocial support and monitoring for suicidality
Lack of interdisciplinary collaboration (e.g., between pediatricians, psychiatrists, psychologists).