An Analysis of Nonsuicidal Self-Injury Among Children and Adolescents in Inpatient Psychiatric Hospitals and Units in Pennsylvania
Keywords:nonsuicidal self-injury, self-injurious behavior, patient safety, inpatient, children, adolescents, autism spectrum disorder
Nonsuicidal self-injury (NSSI), which is defined as the direct, deliberate destruction of one’s own body tissue to inflict harm or pain without an underlying suicidal intent, is common among adolescents in both the community and the clinical setting. Although NSSI does not always progress to or predict future suicidal behaviors, there is believed to be a link between the two, which makes this an important patient safety concern. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 640 patient safety events involving NSSI among children and adolescents in the inpatient psychiatric setting that occurred in 2019. Most patients were female (71%; 457 of 640), and they ranged in age from 5 to 17 years. The most common methods of NSSI were hitting, punching, kicking, or body slamming a surface; scratching or cutting self with fingernails or an object; and head banging. Most patients sustained only minor injuries as a result of NSSI. Interpersonal interactions, including family, peer, and healthcare provider interactions, were among the most common contributors to NSSI. Few event reports (n=47) explicitly stated that the patient had a diagnosis of autism spectrum disorder (ASD), but we did conduct a subgroup analysis of these patients to identify relevant trends and found that they most often were male (64%; 30 of 47) and that head banging and hitting self were the most common methods of self-harm. In order to keep patients safe during inpatient stays in psychiatric facilities or units, future research should focus on prevention strategies that reduce risk of NSSI among children and adolescents, as well as the potential for immediate harm and future mortality.
Nock MK, Favazza AR. Nonsuicidal Self-Injury: Definition and Classification. In: Nock MK, editor. Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment. Washington, DC: American Psychological Association; 2009. p. 9-18.
Brown RC, Plener PL. Non-Suicidal Self-Injury in Adolescence. Curr Psychiatry Rep. 2017;19(3):20. Epub 2017/03/21. doi: 10.1007/s11920-017-0767-9. PubMed PMID: 28315191; PubMed Central PMCID: PMCPMC5357256.
Klonsky ED, Victor SE, Saffer BY. Nonsuicidal Self-Injury: What We Know, and What We Need to Know. Can J Psychiatry. 2014;59(11):565-8. Epub 2015/01/08. doi: 10.1177/070674371405901101. PubMed PMID: 25565471; PubMed Central PMCID: PMCPMC4244874.
Hornor G. Nonsuicidal Self-Injury. J Pediatr Health Care. 2016;30(3):261-7. Epub 2016/04/21. doi: 10.1016/j.pedhc.2015.06.012. PubMed PMID: 27094986.
Vaughn MG, Salas-Wright CP, Underwood S, Gochez-Kerr T. Subtypes of Non-Suicidal Self-Injury Based on Childhood Adversity. Psychiatr Q. 2015;86(1):137-51. Epub 2014/08/16. doi: 10.1007/s11126-014-9313-7. PubMed PMID: 25124121.
Diagnostic and Statistical Manual of Mental Disorders. Fifth ed. Arlington, VA: American Psychiatric Association; 2013.
Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002).
Liberatore K, Rose CM. Patient self-harm in the nonpsychiatric setting. Pennsylvania Patient Safety Advisory. 2019;16(1). Available from: http://patientsafety.pa.gov/ADVISORIES/documents/201903_SelfHarm.pdf
Barrocas AL, Hankin BL, Young JF, Abela JR. Rates of Nonsuicidal Self-Injury in Youth: Age, Sex, and Behavioral Methods in a Community Sample. Pediatrics. 2012;130(1):39-45. Epub 2012/06/13. doi: 10.1542/peds.2011-2094. PubMed PMID: 22689875; PubMed Central PMCID: PMCPMC3382916.
Alfonso ML, Kaur R. Self-injury Among Early Adolescents: Identifying Segments Protected and At Risk. J Sch Health. 2012;82(12):537-47. Epub 2012/11/16. doi: 10.1111/j.1746-1561.2012.00734.x. PubMed PMID: 23151115.
Esposito C, Bacchini D, Affuso G. Adolescent Non-Suicidal Self-Injury and Its Relationships With School Bullying and Peer Rejection. Psychiatry Res. 2019;274:1-6. Epub 2019/02/19. doi: 10.1016/j.psychres.2019.02.018. PubMed PMID: 30776706.
Buser TJ, Buser JK, Rutt CC. Predictors of Unintentionally Severe Harm During Nonsuicidal Self‐Injury. J Couns Dev. 2017;95(1):14-23.
Horváth LO, Győri D, Komáromy D, Mészáros G, Szentiványi D, Balázs J. Nonsuicidal Self-Injury and Suicide: The Role of Life Events in Clinical and Non-Clinical Populations of Adolescents. Front Psychiatry. 2020;11:370. Epub 2020/05/22. doi: 10.3389/fpsyt.2020.00370. PubMed PMID: 32435210; PubMed Central PMCID: PMCPMC7218062.
Timberlake LM, Beeber LS, Hubbard G. Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text]. J Am Psychiatr Nurses Assoc. 2020;26(1):10-26. Epub 2019/10/09. doi: 10.1177/1078390319878878. PubMed PMID: 31592703.
Maenner MJ, Shaw KA, Baio J, EdS, Washington A, Patrick M, et al. Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016. MMWR Surveill Summ. 2020;69(4):1-12. Epub 2020/03/28. doi: 10.15585/mmwr.ss6904a1. PubMed PMID: 32214087; PubMed Central PMCID: PMCPMC7119644
Bloom CM, Holly S, Miller AM. Self-Injurious Behavior vs. Nonsuicidal Self-Injury: The CNS Stimulant Pemoline As a Model of Self-Destructive Behavior. Crisis. 2012;33(2):106-12. Epub 2012/02/22. doi: 10.1027/0227-5910/a000127. PubMed PMID: 22343062.
Huisman S, Mulder P, Kuijk J, Kerstholt M, van Eeghen A, Leenders A, et al. Self-Injurious Behavior. Neurosci Biobehav Rev. 2018;84:483-91. Epub 2017/07/12. doi: 10.1016/j.neubiorev.2017.02.027. PubMed PMID: 28694012.
Siegel M, Doyle K, Chemelski B, Payne D, Ellsworth B, Harmon J, et al. Specialized Inpatient Psychiatry Units for Children With Autism and Developmental Disorders: A United States Survey. J Autism Dev Disord. 2012;42(9):1863-9. Epub 2011/12/23. doi: 10.1007/s10803-011-1426-3. PubMed PMID: 22189962.
Steenfeldt-Kristensen C, Jones CA, Richards C. The Prevalence of Self-injurious Behaviour in Autism: A Meta-analytic Study. J Autism Dev Disord. 2020. Epub 2020/04/17. doi: 10.1007/s10803-020-04443-1. PubMed PMID: 32297123.
Handen BL, Mazefsky CA, Gabriels RL, Pedersen KA, Wallace M, Siegel M, et al. Risk Factors for Self-injurious Behavior in an Inpatient Psychiatric Sample of Children with Autism Spectrum Disorder: A Naturalistic Observation Study. J Autism Dev Disord. 2018;48(11):3678-88. Epub 2018/01/26. doi: 10.1007/s10803-017-3460-2. PubMed PMID: 29368233; PubMed Central PMCID: PMCPMC6057836.
Minshawi NF. Behavioral Assessment and Treatment of Self-Injurious Behavior in Autism. Child Adolesc Psychiatr Clin N Am. 2008;17(4):875-86, x. Epub 2008/09/09. doi: 10.1016/j.chc.2008.06.012. PubMed PMID: 18775375.
Mahatmya D, Zobel A, Valdovinos MG. Treatment Approaches for Self-Injurious Behavior in Individuals With Autism: Behavioral and Pharmacological Methods. J Early Intensive Behav Interv. 2008;5(1):106.