DESCRIPTION OF THE STRATEGY
Self-injurious thoughts and behaviors in children and adolescents represent an enormous
public health concern around the world. In the United States, for example, completed suicide
is currently the sixth leading cause of death among children (5–14 years) and the third leading
cause of death among adolescents and young adults (15–24 years). Nonfatal self-injurious
behaviors are even more common. Approximately 20% of high school students report
seriously considering suicide, and 9% report making an actual suicide attempt in the previous
12 months. Moreover, up to 40% of adolescents in the community and 60% of adolescent
psychiatric inpatients report engaging in self-mutilative behavior. Despite the high prevalence
and serious physical and psychological damage associated with these behaviors, information
about effective evaluation and treatment practices is limited.
The evaluation and treatment of self-injurious behaviors is often hindered by a failure to
carefully distinguish among and assess the different self-injurious constructs of interest. For
instance, what does it mean to say a child or adolescent is suicidal? The following
nomenclature has been recommended by researchers to clarify such issues. Suicide refers to
death from a self-inflicted injury in which the individual intended to die. Suicide attempt
refers to potentially selfinjurious, but currently nonfatal, behavior in which the individual
intended to die. Suicidal ideation refers to self-reported thoughts of making a suicide attempt.
Self-mutilative behavior refers to intentional destruction of one's own body tissue in which
there is no intent to die. Evaluation of self-injurious thoughts and behaviors should include
the collection of data related to each of these constructs.
Evaluation should also focus on factors known to be associated with self-injurious thoughts
and behaviors. Self-injurious thoughts and behaviors are multidetermined events, and
etiological factors will vary somewhat from case to case; however, research has identified
several variables associated with increased risk. These include the presence of a mood
disorder, particularly with hopelessness and anhedonia; a substance use disorder; a psychotic
disorder; anxiety and agitation; difficulties with problem solving and cognitive flexibility; and
a previous history of self-injurious behaviors, particularly previous suicide attempts. The
evaluation should also include an examination of the degree of planning of and preparation
for self-injurious behavior. In addition, the individual's ability to implement any identified
plan should be taken into consideration (e.g., does the individual have access to a firearm,
pills, sharp object, or other means of self-injury?).
Cognitive-behavioral treatment strategies for modifying self-injurious thoughts and behaviors
center on reducing the frequency of these thoughts and behaviors, as well as on modifying
correlates or risk factors that are present that might play a role in the generation or
maintenance of self-injurious thoughts and behaviors. Perhaps the most common component
in cognitivebehavioral treatments for self-injurious thoughts and behaviors is a focus on
improving interpersonal problem-solving skills. This typically involves teaching the
individual several steps for identifying problems, generating potential solutions, evaluating
the probable consequences associated with each solution, choosing and implementing a
solution, and engaging in self-evaluation.
Cognitive-behavioral treatments for self-injurious thoughts and behaviors also typically
emphasize improving emotion regulation and distress tolerance skills. It is believed that those
who resort to self-injury often do so to relieve distress due to an inability to inhibit impulsive
responding to provocative events. Thus, alternative, more adaptive skills for relieving or
tolerating distress and for inhibiting impulsive responding are taught and practiced. Emotion
regulation skills taught in such treatments include identifying and labeling emotions (both
positive and negative), expressing emotions (both verbally and nonverbally), and engaging in
pleasurable activities. Distress tolerance skills include engaging in distraction and relaxation
exercises. Consistent with the cognitivebehavioral approach, throughout each of these
components there is also an emphasis on self-monitoring of the individual's thoughts,
behaviors, and emotions and special attention to the antecedents and consequences of the selfinjurious thoughts and behaviors.
Cognitive-behavioral treatments are also aimed at relieving the psychiatric symptoms that
may be contributing to the self-injurious thoughts and behaviors, such as those mentioned
above. Most cognitivebehavioral treatments for self-injurious thoughts and behaviors also
stress the importance of careful and continuous evaluation of self-injurious thoughts and
behaviors, as well as an emphasis on the importance of facilitating treatment attendance and
There is a growing body of research on psychosocial treatments aimed at decreasing suicidal
ideation and suicide attempts. Overall, several brief cognitivebehavioral treatment packages
have demonstrated some success at decreasing suicidal ideation as well as depressed mood
and negative cognitions, but not suicide attempts. These treatments vary in structure and
content; however, most include a problem-solving skills training component. One long-term
treatment package, dialectical behavior therapy (DBT), had demonstrated success in reducing
the frequency of suicide attempts and hospitalization time. DBT included a problem-solving
skills training component as well as components focused on teaching emotion regulation,
distress tolerance, and interpersonal communication skills. Unfortunately, this treatment had
no effect on reducing suicidal ideation compared to a treatment-as-usual condition. To date,
no treatment packages or techniques have satisfied the criteria for empirically supported
treatment status for reducing suicidal ideation, suicide attempts, or self-mutilative behaviors.
It is notable that research on the treatment of selfinjurious thoughts and behaviors has focused
almost exclusively on adult populations. Few treatment studies have attempted to address selfinjurious thoughts and behaviors in child and adolescent samples, and there are currently no
empirically supported treatments for this group.
RELEVANT TARGET POPULATIONS AND
Self-injurious thoughts and behaviors occur across all diagnostic, developmental, and
socioeconomic groups and are thus relevant to all populations. Nevertheless, research has
identified factors associated with increased risk of self-harm thoughts and behaviors. In terms
of developmental level, rates of self-mutilation, suicidal ideation, suicide attempts, and
completed suicide, all increase significantly as children transition into adolescence. For
example, the rate of completed suicide increases sixfold during the transition from early (10–
14 years) to late (15–19 years) adolescence.
Those with an identified psychiatric diagnosis are at greatly increased risk of self-harm.
Although a psychiatric diagnosis obviously is not required for a child or adolescent to engage
in self-injurious thoughts or behaviors, research has demonstrated that most individuals who
engage in self-injurious thoughts or behaviors (whether death is intended or not) have a
diagnosable psychiatric disorder at the time. Those diagnosed with a mood disorder, psychotic
disorder, substance use disorder, and conduct disorder are at particularly high risk.
In terms of gender, among children and adolescents, girls report suicidal ideation and selfmutilation at a higher rate than boys and make suicide attempts approximately twice as often
as boys. However, adolescent boys are approximately four to five times more likely to die by
suicide than girls, perhaps as a function of the more lethal methods of self-harm typically
employed by boys (e.g., firearms and jumping) compared to girls (e.g., overdose).
A number of factors can complicate the evaluation and treatment of self-injurious thoughts
and behaviors. Perhaps the greatest difficulty involves the reliability and validity of riskassessment throughout the course of treatment. Introducing uncertainty into the evaluation
process is the low agreement among informants in the assessment of self-injurious thoughts
and behaviors. Children/adolescents, parents, teachers, and clinicians often disagree as to
whether self-injurious thoughts and behaviors are present, and if so, to what degree. Another
complicating factor is the rapidity and unpredictability with which self-injurious thoughts and
behaviors often occur. Such events often occur impulsively and with little warning. It is not
uncommon for a child or adolescent to fail to inform a parent, friend, or clinician that a
stressor has occurred or that self-injury is being contemplated, planned, or implemented.
These complications and the associated risk of self-harm can be minimized by frequent and
thorough assessment of key constructs. Such assessment always should draw from multiple
informants (i.e., involve the child/adolescent, parents, teachers, and clinician) and
measurement methods (i.e., interview, rating scale, observation).
“Donna” was a 13-year-old African American girl who was brought to an emergency room by
her mother after Donna reportedly ingested 20 aspirin tablets. After receiving medical
intervention in the emergency room, Donna was admitted to an adolescent psychiatric
inpatient unit where she stayed for 3 days before being discharged and referred to a child and
adolescent outpatient clinic for psychosocial treatment.
Donna presented to the outpatient clinic with her mother 1 day after discharge from the
hospital. Donna and her mother were interviewed together and separately. The diagnostic
interview was guided by a semistructured diagnostic measure. In addition, Donna's mother
completed several rating scales relevant to psychiatric diagnosis as well as aspects of Donna's
past history and current risk of self-injurious thoughts and behaviors. With Donna and her
mother's consent, the clinician also contacted her current teacher and school guidance
counselor, who provided historical information via telephone and completed several rating
scales via postal mail, and her inpatient treatment team, which provided detailed records of
her inpatient assessment and treatment. In addition to the diagnostic interview, Donna
completed several self-report and clinicianadministered rating scales focused on past history
and current risk of self-injurious thoughts and behaviors, including the Children's Depression
Inventory, the Beck Hopelessness Scale for Children, the Scale for Suicidal Ideation, the
Suicide Intent Scale, and the Functional Assessment of Self-Mutilation. In addition, Donna
participated in a clinical interview focused on obtaining information about her history of selfinjurious thoughts and behaviors and current risk of self-harm.
Evaluation data yielded several inconsistent findings. Donna's mother, teachers, and inpatient
treatment team reported that this was Donna's first episode of suicidal ideation and her first
suicide attempt. Donna's report on the clinical interview was consistent with this. However,
Donna indicated on the selfreport rating scales that she had made two previous suicide
attempts (both by overdose, neither reported or requiring medical intervention) and that she
had contemplated suicide on many occasions in the past, suggesting a higher risk for future
suicide attempt than previously assumed. Donna denied a history of contemplating or
engaging in self-mutilative behavior.
Follow-up assessment of Donna's suicidal ideation and suicide attempts revealed that most
episodes of suicidal ideation and all three suicide attempts were immediately preceded by
verbal arguments with her mother in which Donna was told she would be “thrown out of the
house” if she continued to disobey her mother's commands. Donna reported that she
contemplated and attempted suicide as a way to escape from her situation and from the
intense, negative affect she experiences when arguing with her mother because she could not
think of any other way to improve her feelings or her situation.
Treatment focused immediately on ensuring Donna's safety throughout the treatment period.
The clinician met with Donna and her mother to develop a plan for safety, which included
reaching an agreement about the focus and structure of treatment and the importance of
honesty and adherence to the treatment program, the generation of a list of “go to” people
Donna could approach if she began to experience thoughts of selfharm, and a discussion of
how and under what circumstances Donna and her mother should seek immediate
professional assistance. Donna and her mother also received psychoeducation about selfinjurious thoughts and behaviors, particularly about their course and effects of current
treatment approaches, and Donna received instruction in self-monitoring of thoughts, feelings,
and self-injury related thoughts and behaviors. Donna began self-monitoring practices
immediately to facilitate continuous assessment of the antecedent and consequent events
related with her self-injurious thoughts and behaviors.
Given Donna's difficulties generating alternative, adaptive solutions to her problems,
treatment focused on improving her problem-solving skills. She was taught basic steps for
identifying problems, generating alternative solutions, evaluating the probable consequences
of each solution, and selecting and implementing a solution. She practiced these problemsolving steps with her clinician both verbally and in role-play situations. She was also
assigned problem-solving situations for homework in which she was required to practice her
problem-solving steps in real-life situations.
Given Donna's difficulties with affect regulation and distress tolerance, she was taught
emotion regulation and distress tolerance skills. These focused on teaching Donna to identify
and label her emotions and to communicate these effectively to others. Donna also learned to
tolerate negative affective states via the use of exposure exercises as well as through
practicing relaxation techniques.
In addition, Donna was taught and practiced interpersonal communication skills to improve
her ability to effectively and assertively communicate her thoughts and feelings to her mother
as well as to others around her. For instance, Donna and her clinician practiced basic
conversational skills and discussed and roleplayed the use of empathy, validation,
compromising, and collaborative problem-solving in sessions. Donna later used these skills in
homework assignments with her mother, teachers, and friends.
Donna did not make any additional suicide attempts over the course of treatment, although
she did experience brief periods of suicidal ideation on several occasions. However, in the
context of her strong treatment attendance and adherence, she demonstrated increasing
abilities for affect regulation, distress tolerance, and interpersonal communication. Donna also
developed an impressive ability to generate proactive, adaptive solutions to problems she had
with her mother and other people around her, which decreased the frequency with which she
considered suicide a solution to her problems.
—Matthew K. Nock
Nock, Matthew K. "Self-Injury and Suicide." Encyclopedia of Behavior Modification and
Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr. 2008. <http://sageereference.com/cbt/Article_n2112.html>.