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The Self-Harmful Child - Non-Suicidal Behaviour

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Introduction

 
The thought of children harming themselves "on purpose" is upsetting for any parent.  In reality, children who harm themselves do so for many different reasons, and often are not doing anything intentionally.   Anxiety, fear, and sadness can all lead children to unknowingly attempt to distract themselves or to soothe themselves.  Who hasn't bitten their nails or twirled their hair when stress becomes too much to handle?  Children are no different.  In fact, because of their immaturity, they are more prone to resort to physical outlets than psychological ones--they simply lack sophisticated coping strategies.
 
The hallmarks of a worrisome body-focussed repetitive behaviour are:
  • damage caused to the skin or other body parts
  • emotional distress which is increased, not relieved by the behaviour, and
  • interference with the activities the child should be engaging in because of time taken engaging in the behaviour or attempting to hide the behaviour 
 
How this plays out in the different age groups is described below.

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The pre-school period is associated with the very beginnings of independent behaviour.  Walking, toilet-training, speaking, drawing, and playing, are all skills the child is developing.  While these are very exciting and potential sources of pride for both parents and the child, they can also be sources of anxiety, especially if the child is having difficulty mastering these tasks.  Also, they are often associated with increased separation from parents--e.g., in day care or nursery school--which can also stir up fears in the child.  As a result, nervous habits like nail-biting, hair twirling, or biting on the inside of cheeks commonly appear.  If the child is developing at the expected pace, and if parents can be available as safety nets, these "symptoms" will usually disappear after a few weeks, and no particular intervention is required.
 



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Very active pre-schoolers or those who are "novelty-seekers" may be prone to accidents and injuries.  Certain children have a higher than average pain tolerance, and/or may be less fearful of danger than they should be.  They seem to "get into trouble" at day care or nursery school, with reports from the teacher that they are "aggressive" or don't know their limits. 
 
Other children, more prone to anxiety or fearfulness, may be overly-cautious and thus isolate themselves socially.  At home, parents may notice:
  • stuttering
  • tics (involuntary movements such as blinking or lip-biting)
  • nail-biting
  • hair-pulling
  • rocking, or
  • excessive masturbation
 


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Self-harm talk or behaviour is rare in this age group.  It is, however, associated with certain conditions such as autism, severe developmental delay, genetic disorders (e.g., Lesch-Nyhan syndrome), and severe/chronic abuse of any form (physical, sexual, emotional). 
 
Examples would include:
  • biting oneself
  • hitting oneself
  • picking/pulling at skin, nails, or hair
  • rocking, which includes head-banging
  • compulsive masturbation in public
  • eating inedible materials (pica), and
  • urinating/defecating in inappropriate places or at inappropriate times, after being toilet-trained


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  • Elementary school is the time for increased exploration.  Gross and fine motor skills will lead the child to engage in various sports activities such as team sports, riding a bike, or skateboarding, and increased use of computers/video-games. 
 
  • With these activities, bumps and bruises are to be expected.  You want to encourage your child to engage with the world, but also to take proper precautions: look both ways before you cross the street, don't talk to strangers, either on-line or in real life, wear a helmet, and use proper equipment. 
 
  • When unduly stressed, children may temporarily "regress" by wetting the bed or stuttering, for example.  With support and encouragement, and letting the child know that it's OK to make mistakes, accidents and injuries can usually be kept to a minimum.

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  • In the middle years (grade school), increased activity may result in more serious injuries like concussions, broken bones, or the need for stitches, especially if the child seems to court danger or ignore taking proper precautions before athletic activities.  Boys may demonstrate an undue interest in weapons, may become physical bullies, or start to behave cruelly towards animals.  While these actions may predict future problems in terms of harm to others, they have also been associated with future actions that are self-harming.
 
  • Girls start to become more aware of their bodies.  Reality TV shows such as "Toddlers and Tiaras" place undue emphasis on appearance, thinness, and sexuality.  As a result, girls may become overly-interested in fashion magazines/websites, and begin to restrict their food intake to "watch their weight". 
 
  • Anxieties that were present in the pre-school years may turn into more intense fears in middle childhood.  With the influence of media, grade school children may voice undue concerns about natural disasters, wars, or environmental dangers.  As a result, they may develop "tummy aches", headaches, or superstitious behaviours (like counting, checking, a need for symmetry) which lead to avoidance of normal activities.  They may skip school or drop out of extra-curricular activities.  While not physically self-harming, these actions are psychologically harmful because they get in the way of academic or social achievement.
 
 

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  • Unfortunately, eating disorders are starting at younger and younger ages.  Elementary school girls who say they are too fat (when they're not), voluntarily restrict their food intake, or binge and vomit, are in the "red" zone.  Weight loss in a growing child is a sign that something is wrong.
 
  • With boys, the trend may be opposite--in a desire to "bulk up", they may skew their diet towards high-caloric foods, or "concentrated protein".   Risk-taking behaviour that is self-harmful may include unsupervised rock-climbing, "extreme" sports, especially if not wearing proper protective gear, or provoking fights.
 

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  • By the time puberty hits, being accepted by peers is super important.  As a result, behaviours such as tattoos, piercings, hair dyeing, and other experimentation with make-up or hairstyle are very common.  Acne may become a problem, and with it, picking or squeezing skin.
 
  • While parents may not approve of the way their child looks, if he or she is doing well at school, and simply attempting to make or keep friends, then a judicious amount of limited freedom may be called for.  This is an opportunity for education about how the body functions, prevention of infection, and how to keep one's self clean.  As long as the child is open and communicative about these behaviours, there is usually little to worry about.
 

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  • The transition to "middle school" (Grades 6-8) often brings new pressures, especially social and academic.  For boys, who become aware of their bodies and who enter puberty at a later date than girls, one coping strategy can be to "man up" by becoming "tough".   Directly opposite to girls, most early teenaged boys want to gain weight.  They may do this through excessive exercising, body-building, or, in extreme cases, taking medications such as steroids to "bulk up".  Such behaviour definitely carries the risk of self-harm, as does enrolling in classes such as boxing, wrestling, or martial arts, if not done in the right spirit.
 
  • Tattoos and piercings can be normal, but if their location (e.g., nipples, genitals) or content (references to suicide/self-harm or pre-occupation with death) is unusual and out of keeping with local norms, then greater attention is warranted.
 
  • Picking at skin, for both boys and girls, if infrequent and minor, can be within the norm, especially if acne is significant.  However, if the teen has had an injury or other skin problem, and the picking prevents proper healing or leads to infection, then further assessment may be warranted. 
 
  • With “on-screen” behaviours (such as playing videogames, going to "chat rooms", surfing the Net, spending time on Facebook, texting), it can be difficult to draw the line between those that are normal/expected and those that are addictive).  These days, the use of social media has become so prevalent that groups of young teenagers may barely look at each other even if they are in close proximity.  If the time consumed interferes with other social, familial, or academic obligations, and/or is associated with increased distress, then further assessment may be warranted.
 
  • Alcohol use under a certain age range, varying by province, is illegal, as is marijuana use at any age.  The problem with marijuana, unlike alcohol, is that its production is not regulated.  Therefore, the purity and potency of it is unknown and unpredictable.  The pot may be mixed with very toxic compounds. 
    • While marijuana is used to stimulate appetite in cancer patients undergoing chemotherapy, and to facilitate pain relief in similar populations, that is always done under close medical supervision.  While anecdotal evidence exists for marijuana's ability to reduce anxiety, therapeutic benefits other than pain relief and appetite stimulation remain speculative and unproven.
  • Of greater concern is strong evidence that frequent, sustained pot use can impair short-term memory, visuo-motor coordination, and motivation (the so-called "apathy effect").  In individuals with a family history of schizophrenia, even small amounts may increase the likelihood of developing a psychotic illness.
  • For these reasons, parents should be aware of the following "yellow flags" as possible signs of marijuana or alcohol use:
  1. Unexplained changes in sleep, appetite, energy level, or concentration.
  2. Sudden decline in school marks.
  3. Change in peer group, especially to kids known as "druggies", or low achievers.
  4. "Not caring about" (and therefore dropping) extra-curricular activities other than "hanging out".
  5. Experimentation with pot or alcohol in the context of social gatherings on weekends is common.  This doesn't mean it should be condoned, but if you become aware of use of these substances during the week or as a solitary activity, then it may mean that the pattern has changed from one of trying to be accepted socially, to one of self-medication, self-harm, or addiction.  This warrants active intervention.
 
Any drug use other than marijuana should be regarded as unsafe, as should over-use of prescription medication or over-the-counter medication.
 
 
  • In middle school/early high school, teens generally do not have the maturity to handle relationships involving sexual intercourse.  Other forms of sexual activity, such as oral sex or mutual masturbation are becoming increasingly common, but often occur outside the context of a meaningful relationship and are in response to social pressures to be "cool".  Shame and guilt (more common amongst girls) frequently occur afterwards, and in this era of social media, rumours about real or imagined sexual activity can ruin reputations in mere seconds.  Cyber-bullying about sexual orientation is all too common, and can definitely lead to self-harm behaviour.

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  • Early teenagers have the hormonal push to "thrill-seek", without the capacity to judge consequences.  Parents may therefore see disturbing games such as "the choking game".  This has a number of variations, including putting a plastic bag over one's head, or experimenting with ropes or belts tied around the neck.  The point is not to commit suicide, but to experience "sexual asphyxia", in which sexual arousal occurs in association with lack of oxygen to the brain.  Needless to say, the likelihood of things going too far is extremely high.
  • The Internet is full of websites devoted to self-harm.  Chat rooms tell you how to cut or burn yourself, and there are "pro-ana" sites that offer justification for starvation.  Thus, a track record of visiting such sites should be cause for concern, as should the behaviours themselves.

  • Gaming can turn into pathological gambling, and this is a growing problem in adolescence, aided and abetted by gambling websites.
  • Unprotected sexual activity, with its twin risks of pregnancy and sexually-transmitted infections represents self-harm, as does drug/alcohol abuse, which interferes with social, academic, or family functioning, and/or results in memory lapses or blackouts.


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  • 25% of Grade 9 students are sexually active, 50% of Grade 11 students are, and 75% of 1st year university students are.  Ages 15-18 is the time for sexual education, if it hasn't already been covered in earlier grades at school.  Beyond practising "safe sex", parents can be helpful in talking about the emotional aspects of relationships, and how values can influence love.  Self-harm in this sense goes beyond the physical--Is your teenager choosing "good" partners as he or she embarks upon dating? 
  • Experimentation with drugs and/or alcohol also typically begins in high school.  Every parent needs to decide what they are comfortable with, both inside and outside the house, knowing that control of the adolescent is slowly ebbing away.  While abstinence may be your preferred choice, the context of these behaviours is all important.  If experimentation occurs as part of a social activity, and does not interfere with school or other responsibilities, there may be room for negotiation.  This, however, is very much an individual choice, and may be influenced by culture and religion.


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Studies have shown that mid-high school is actually a time of lower stress and greater stability than the early high school years.  The "storms" of puberty onset have subsided, and once kids are familiar with how high school works, it can be a time of great productivity.  However, the end of high school marks the transition to post-secondary activity, and that implies that difficult choices need to be made.  University?  Community College?  Work?  Travel?  What is the teenager going to do with the rest of their life?  Are they ready for independent living?
 
Most importantly, late adolescence is the time when major mental illnesses begin to appear, and so it is important to look out for warning signs.  New changes in sleep, appetite, or energy level (either increased or decreased) should be noted. 
 
"Moodiness" may include:
  • irritability
  • sadness
  • anxiety, or
  • "attitude"/anger
There may be:
  • reluctance to follow rules/authority
  • loss of involvement in extra-curricular activities
  • withdrawal from friends
  • retreat to their bedroom
  • unexpected/unexplained school absences, and
  • writing or singing with "dark" themes  
While these behaviours are not directly harmful to the self, they may be signs of brewing depression, which is itself a risk factor for self-harm.


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Once teenagers turn 16, they are eligible for various activities that can be self-harmful. 
 
 
Driving and sports

The most obvious example is driving a car.  Joy-riding, or extreme go-karting can be seen.  Bungee-jumping is another.  And the continuation of "extreme" sports can result in serious injury--broken bones, stitches, concussions, or a more aggressive and penalty-laden approach to the regular sports in which the teenager participates.
 
 
Body image

Both boys and girls may be unhappy or dissatisfied with various aspects of their body, not just weight.  Their nose seems too big (when it's not), or their ears seem to stick out (when they don't).  Such teens will seek out cosmetic surgery to alter their appearance, and this should be regarded as a form of self-harm (indicative of something called body dysmorphic disorder).
 
 
Hair pulling and skin picking

Hair pulling may turn into full-blown trichotillomania, which results in self-induced bald spots, or abnormally thin hair, which the teen may try to hide.  Picking at skin can result in infection, tissue damage, and scarring or discoloration of the skin.  Avoidance of gym classes, swimming pools, and beaches can be a clue, as well as skipping annual physical exams with the doctor.
 
 
Drugs

With increased access to money, as a result of being able to work part-time, drug use may escalate to more expensive and dangerous drugs such as "speed", cocaine, or narcotics.
 
 
Cutting
  • The most common form of direct self-harm is cutting.  Teens will use various methods to cut--scissors, knives, fingernails, other utensils. And they will cut in various locations on the body--most commonly the forearms, but also legs, thighs, chest, abdomen, etc.  Signs include blood stains/trails in the bathroom, excessive time taken in the bathroom, blood-stained clothes or bedding, and wearing long-sleeves even in hot weather. 
  • Typically, cutting is repetitive and superficial.  About half the time it is impulsive, and half the time it is well-planned/thought out.  Usually it is done as a solitary activity, but recently, cutting "groups" have appeared, both on-line and in reality. From a parent's perspective, it doesn't matter the method used or the location on the body--all such behaviour should be regarded as "red light" zone, because you have no way of determining how serious this is. 

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Children who talk about and engage in self-harm behaviour do so because of nature, nurture, culture, and chance.

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Nature
Both drug/alcohol abuse and eating disorders run in families, and this is thought to be at least partly due to inherited genetic factors.  Children with autism or severe developmental delay have brains that do not filter properly--they are overwhelmed by too much stimulation or in some cases, by too little.  The self-harm is a way of coping with this.  Novelty-seeking and high pain tolerance tend to be inborn personality traits, probably on a genetic basis, and can lead to some of the behaviours described in the “Actions” section.
 
Some children are either over-controlled (rigid, inhibited, perfectionistic) or under-controlled (impulsive, poorly regulated).  Both types use self-harm to "numb" unpleasant feelings and/or distract themselves. 

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Nurture
Abuse of any sort, and neglect causes low self-esteem ("I deserve to be punished.") or anger at the abuser whom the child is often afraid to confront.  Marital discord can put the child in the middle of loyalty binds or make them feel guilty for the fights of the parents.  Self-harm can be a (non-productive) attempt to get the parents to stop fighting.  A parent’s illness can sometimes cause a child to harm themselves out of a misguided effort to sympathize with the parent.


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Socially, being teased or bullied is a strong risk factor for self-harm.  Guilt and shame over being "different" and being excluded generates loneliness and envy of those who are "cool".  Self-harm can be a way of saying "I'll show you!", or an acknowledgement that the child has given up on trying to be accepted.  
 
Pressures to conform to stereotyped gender roles can lead to sexual acting out and eating disorders.

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Culture
Children from war-torn countries who have either witnessed or experienced violence sometimes self-harm to cope with the traumas, and or as evidence of "flashbacks".   Teenagers whose parents were born in a different country may feel trapped between a rock and a hard place in terms of loyalty to their peer group vs. loyalty to the values with which they were raised.  Self-harm may result.


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For general information pertaining to all age groups, please refer to the guidelines below.



It is important to do something about self-harm behaviour because, by definition, the actions interfere with the youth's growth, development, and safety.  It may be a sign of mental illness. The earlier it is identified, the easier it will be to treat.  The impact on the family (including siblings) can be minimized.   Frequent persistent self-harm is a cry for help.  And tragically, some teenagers miscalculate--even though they did not intend to die, games such as the "choking game", or superficial wrist-cutting, end up causing major injury or death.
 
It is normal for parents in such a situation to feel frightened, and occasionally, angry ("How could he do this to me?")  The dilemma is that you have no way of knowing if the child has done it "for attention" or out of genuine distress.  Therefore, it is always important to err on the side of caution.
 
DON'T:
  • Say something that will increase shame or guilt ("Why did you do that!")
  • Act shocked or appalled
  • Talk to your child in front of siblings or others
  • Judge them
  • Promise that you won't tell anyone else
  • Punish the behaviour
  • Make "deals" (bribery) to get them to stop
 
DO:
  • Approach the youngster in a calm, caring way
  • Convey that you still love them, even though you are concerned about the behaviour
  • Understand that this is their way of coping with emotional pain or stress--for now
 
The most important thing is to take the young person to a professional who can do a risk assessment.  This would logically start with the pediatrician or family doctor, who can make sure that no medical illnesses are contributing to the behaviour.  After that, a trained mental health professional (psychiatrist, psychologist, social worker) can help determine what course of action is necessary.
 
Since self-harm is like a fever--a non-specific indicator that something is wrong--it is important to get to the root of it, and find out why the child engaged in that behaviour.  There is no one approach, and often multiple strategies will be employed at once.
  • Individual therapy, especially forms of cognitive-behavioural therapy called habit reversal training or stimulus control, have proven effective.  
  • Sometimes medications such as anti-depressants will be indicated. 
  • Family therapy or parent counselling is usually part of the package. 
  • Occasionally, brief hospitalizations may be necessary, but this is infrequent.
 
Share the burden--the professional will be there to help and guide you.
 

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It is important to do something about self-harm behaviour because, by definition, the actions interfere with the youth's growth, development, and safety.  It may be a sign of mental illness. The earlier it is identified, the easier it will be to treat.  The impact on the family (including siblings) can be minimized.   Frequent persistent self-harm is a cry for help.  And tragically, some teenagers miscalculate--even though they did not intend to die, games such as the "choking game", or superficial wrist-cutting, end up causing major injury or death.
 
It is normal for parents in such a situation to feel frightened, and occasionally, angry ("How could he do this to me?")  The dilemma is that you have no way of knowing if the child has done it "for attention" or out of genuine distress.  Therefore, it is always important to err on the side of caution.
 
DON'T:
  • Say something that will increase shame or guilt ("Why did you do that!")
  • Act shocked or appalled
  • Talk to your child in front of siblings or others
  • Judge them
  • Promise that you won't tell anyone else
  • Punish the behaviour
  • Make "deals" (bribery) to get them to stop
 
DO:
  • Approach the youngster in a calm, caring way
  • Convey that you still love them, even though you are concerned about the behaviour
  • Understand that this is their way of coping with emotional pain or stress--for now
 
The most important thing is to take the young person to a professional who can do a risk assessment.  This would logically start with the pediatrician or family doctor, who can make sure that no medical illnesses are contributing to the behaviour.  After that, a trained mental health professional (psychiatrist, psychologist, social worker) can help determine what course of action is necessary.
 
Since self-harm is like a fever--a non-specific indicator that something is wrong--it is important to get to the root of it, and find out why the child engaged in that behaviour.  There is no one approach, and often multiple strategies will be employed at once.
  • Individual therapy, especially forms of cognitive-behavioural therapy called habit reversal training or stimulus control, have proven effective.  
  • Sometimes medications such as anti-depressants will be indicated. 
  • Family therapy or parent counselling is usually part of the package. 
  • Occasionally, brief hospitalizations may be necessary, but this is infrequent.
 
Share the burden--the professional will be there to help and guide you.
 


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