Suicide and Self-Harm in Adolescence
Nonsuicidal Self-Injury (NSSI)
- Nonsuicidal self-injury (NSSI) is defined as the direct and deliberate destruction of one's own body tissue without the intent to die.
- Although NSSI and suicidal behavior are distinct constructs based on intent, they are highly comorbid; approximately 50% to 75% of adolescents with a history of NSSI will eventually make a suicide attempt.
- NSSI prevalence increases from childhood to adolescence (reaching ~18%) and is particularly high among transgender and gender-nonconforming teens, with up to 55% reporting past-year engagement.
- Cutting is the most commonly reported method of NSSI and is the most commonly repeated method.
- Other methods include scratching, burning, carving, piercing, hitting, biting, picking at wounds, and digging nails into the skin.
- Females are more likely to engage in cutting, scratching, and biting, whereas males are more likely to engage in burning and self-battery (e.g., hitting and head banging).
- The behavior serves multiple psychologic functions: it may be an impulsive response to internal distress, a self-reinforcing mechanism to gain a sense of mastery over negative emotions, a method to "feel something" when emotionally numb, a distraction from emotional pain, a form of self-punishment, or a way to communicate distress and gain peer affiliation.
- Youth often experience an irresistible urge to self-injure, which builds until the act is completed, leading to a dangerous dependence on the behavior.
- Because of the intense stigma and shame associated with NSSI, adolescents often go to great lengths to hide their injuries (e.g., wearing long sleeves in summer or bracelets to cover scars).
Suicide Epidemiology and Methods
- Suicide is the second leading cause of death in adolescents and young adults (aged 10โ24 years).
- While suicide attempts are more common in adolescent females, completed suicides are significantly higher in males, with the male-to-female ratio rising to approximately 4:1 in the 15- to 24-year-old age group.
- Ingestion (poisoning or overdose) is the most common method of attempted suicide among adolescents.
- Firearms, suffocation (hanging), and poisoning remain the most common methods of completed suicide, with firearms having a lethality rate of 80% to 90%.
- Suicide contagion is a recognized phenomenon where attempts are precipitated by exposure to news of another person's suicide, or by media portrayals that glorify suicide or detail specific lethal means.
Risk and Protective Factors
- The calculation of suicide risk is complex and cumulative; a history of a previous suicide attempt is universally recognized as the strongest predictive risk factor for future suicidal behavior.
- Approximately 90% of youths who complete suicide have a preexisting psychiatric illness, most frequently major depressive disorder.
| Category | Specific Clinical Factors |
|---|---|
| Dynamic Risk Factors (Changeable) | Psychiatric symptoms (anhedonia, hopelessness, impulsivity, insomnia, severe anxiety/panic, command hallucinations). Psychosocial stressors (loss of relationship, bullying, housing insecurity, disciplinary crisis). Intoxication or increased substance use. Recent discharge from a psychiatric hospital. |
| Static Risk Factors (Unchangeable) | Male sex (for completion); White, Indigenous American, or Alaskan Native race; LGBTQ+ identification. Preexisting psychiatric illness (depression, bipolar, conduct disorder, schizophrenia). History of trauma, abuse, or neglect. Family history of suicide attempts/completions. |
| Internal Protective Factors | Positive coping skills, frustration tolerance, religious faith, future-oriented thinking, fear of the consequences of an attempt. |
| External Protective Factors | Responsibilities for others (e.g., pets, younger siblings), living with others, strong social supports, positive mentoring relationships with adults. |
Clinical Warning Signs
- Threatening to hurt or kill oneself, or actively looking for ways to do so (seeking access to firearms or pills).
- Talking or writing about death, dying, or suicide out of the ordinary.
- Expressing feelings of hopelessness, being trapped ("no way out"), or uncontrolled rage seeking revenge.
- Engaging in reckless, risky behaviors seemingly without thinking.
- Withdrawing from friends, family, and society, alongside experiencing dramatic mood changes or severe sleep disturbances.
Clinical Assessment of Suicidality
- All suicidal ideation, planning, and attempts must be taken seriously and require thorough assessment.
- The interview must be conducted in a nonjudgmental, matter-of-fact manner, directly exploring the frequency and intensity of suicidal ideation, the specificity of the plan, parasuicidal behaviors (e.g., writing notes, giving away possessions), and the true intent to die.
- The reliability of the interview can be affected by the child's cognitive development; therefore, information must also be gathered independently from parents or caregivers in a separate interview.
- Discrepancies between parent and child reports are common, with adolescents generally more likely to disclose suicidal ideation than their parents realize.
- The Ask Suicide-Screening Questions (ASQ) tool, the Columbia-Suicide Severity Rating Scale (C-SSRS) Screener, and the Patient Health Questionnaire-9 (PHQ-9) are highly validated screening tools utilized to identify youth at risk.
Triage and Level of Care
- High/Imminent Risk: Youth with active thoughts of killing themselves, a specific plan, clear intent, preparatory acts, and impaired judgment represent an imminent danger. They require immediate inpatient psychiatric hospitalization (voluntary or involuntary) to ensure safety, clarify diagnosis, and initiate comprehensive treatment.
- Low/Moderate Risk: Youth with thoughts of death but without a specific plan or intent, who have an intact mental status, strong caregiver support, and the ability to participate in safety planning, may be managed in the outpatient setting with urgent mental health follow-up scheduled within 48 to 72 hours.
Management and Prevention Strategies
- Safety Planning: This is a brief, evidence-based psychosocial intervention that reduces suicidal behavior by working collaboratively with the patient and caregivers. It involves identifying personal warning signs, outlining healthy coping skills, listing distracting environments/people, establishing emergency contacts, and securing the home environment.
- Restriction of Lethal Means: Pediatric practitioners must counsel parents to definitively remove firearms from the home or securely lock guns and ammunition separately. Access to potentially lethal prescription and nonprescription medications (e.g., large quantities of acetaminophen) and alcohol must also be strictly restricted.
- Suicide Contracts: "No-suicide contracts" have repeatedly been shown to be ineffective in mitigating the risk of completed suicide and can actually be harmful to the therapeutic relationship; they should not be used in place of comprehensive safety planning.
- Psychotherapy: Dialectical Behavior Therapy (DBT) and Cognitive-Behavioral Therapy (CBT) are highly effective interventions for reducing self-harm and addressing the emotional and behavioral dysregulation associated with suicidality.
- Pharmacotherapy: While there are no specific medications to treat NSSI or suicidal ideation directly, psychotropic medications are utilized in conjunction with a child and adolescent psychiatrist to aggressively treat the underlying psychiatric disorders (e.g., major depressive disorder, severe anxiety) driving the distress.