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School Year Can Increase Awareness of Self-Mutilating Behavior

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Posted: 9/27/2005

COLUMBUS, Ohio – The start of a new academic year gives teachers and other school staff exposure to what is believed to be a growing phenomenon among adolescents: self-mutilating behaviors.

Often referred to as cutting, the practice is most common among adolescent girls and can take other forms of self-injury, such as burning, picking skin or hitting themselves. In the most extreme instances, youths might bang their heads, bite or scratch themselves deeply or even break their own limbs.

The definition of the behavior is the act of hurting oneself without the intention of causing death. The behavior occurs in an estimated 4 percent of the general population and in as many as one in five children and adolescents undergoing psychiatric care.

The prevalence of self-mutilation has led Ohio State University Medical Center child psychiatrists to adopt a more comprehensive approach to targeting the behavior by screening all inpatient children and adolescents, including boys, for problems with self-injury, said Dr. Lily Spetie, a child psychiatrist at OSU Harding Hospital who specializes in mood disorders in children.

Spetie and her colleagues also have met with central Ohio teachers and guidance counselors in past years who faced issues associated with identifying the behaviors among their students. Interestingly, kids who injure themselves tend to be more likely to report the behavior or admit to it when asked about it, Spetie said. They also are more likely to seek help if they sense there is an adult in their support group who would be able to help or listen to them in a nonjudgmental way.

“This may explain why there is more awareness of this behavior,” Spetie said. “Children and adolescents want to feel better. Once they find a team to work with them, they are likely to get better. It’s safe to assume that with proper treatment and good participation of the child, family and others in the support system, the outcome is likely to be good.”

The first step in tackling the issue, however, is identifying the behavior. Adolescents tend to try to hide signs of self-mutilation. However, some classic warning signs include:

* Unexplained bruising or injuries

* Social isolation and depression or avoiding social activities

* Change in appearance and clothing choices – including long sleeves and long pants during hot weather or lots of bracelets and wristbands

* Avoiding gym class or swimsuits.

Once the behavior is identified, children who self-mutilate need a comprehensive mental health evaluation – covering emotions, any psychiatric illnesses and the possibility of stress associated with academic trouble or learning disorders – and development of a treatment plan, Spetie said. Ideally, a comprehensive plan will address all areas of dysfunction – counseling, therapy, identification of stressors, improvement of coping skills and family therapy. Dialectical behavior therapy can also be effective by involving family and other people in the adolescent’s environment to coordinate interventions.

“Cutting can be a way of expressing oneself. It’s often seen in families that have trouble with communication,” said Marybeth McDonald, a licensed social worker at OSU Harding Hospital. “When these children face a crisis, they may not have adequate tools to comfort themselves and they may not believe that adults are willing or able to help them. In treatment, it can be important to see the entire family cooperate in learning coping strategies, talking more, listening more and criticizing less.”

Other elements of treatment in OSU’s program include reducing injury options – eliminating access to razors, broken glass, cigarettes, lighters and other tools that are easy to hide – and emphasizing the expression of feelings in words rather than actions. Art therapy also can be effective by helping with the expression of pain through art, McDonald said.

Though it is difficult for practitioners to pinpoint distinct causes of the behavior, Spetie and McDonald said children with self-mutilating behaviors often report feeling overwhelmed, isolated, depressed, lonely and in despair.

“The intensity of feelings may be much more severe than sadness most adolescents deal with,” Spetie said. “They may also suffer from psychiatric illnesses, ranging from depression and anxiety to mood swings and even psychosis. And a history of sexual abuse is common.”

The adolescents also may be re-experiencing abuse or a past trauma or the loss of a loved one. Some youths report different identifying triggers, having problems verbalizing their feelings and otherwise not knowing how to cope in healthier ways with their negative feelings. They also commonly report the self-mutilating behavior itself helps them calm down and let go of their bad feelings, and also tend to report diminished pain perception, numbness and a sense of detachment from their body.

Though the average age of onset for these behaviors is prepuberty and adolescence, the behavior can continue into adulthood among between one-third and one-half of adolescents who injure themselves. “Some give up this maladaptive behavior, but some do this for years. It can decrease as adolescents age and develop other coping skills,” Spetie said.

Spetie said there are plans at OSU Harding Hospital to eventually conduct research identifying and following adolescents who injure themselves to develop a better understanding of all facets of the behavior.

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Emily Caldwell
Medical Center Communications

Behavioral Health; Mental Health; OSU Medical Center