Home Browse Recent advances in understanding and managing self-harm in adolescents
ALL Metrics
-
Views
-
Downloads
Get PDF
Get XML
Cite
Export
Track
▬
✚
Review

Recent advances in understanding and managing self-harm in adolescents

[version 1; peer review: 2 approved]
Stephanie Clarke1, Lauren A. Allerhand1, Michele S. Berk
https://orcid.org/0000-0002-2405-6821
1
Stephanie Clarke1, Lauren A. Allerhand1, Michele S. Berk
https://orcid.org/0000-0002-2405-6821
1
PUBLISHED 24 Oct 2019
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Keywords

suicide, adolescent, self-harm

Corresponding author: Stephanie Clarke
Competing interests: No competing interests were disclosed.
Grant information: Dr. Berk is currently receiving research funding from the Stanford University Department of Psychiatry.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:  © 2019 Clarke S et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Clarke S, Allerhand LA and Berk MS. Recent advances in understanding and managing self-harm in adolescents [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.12688/f1000research.19868.1) First published: 24 Oct 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.12688/f1000research.19868.1) Latest published: 24 Oct 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.12688/f1000research.19868.1)

Introduction

Suicide is a significant public health problem in the United States. Over the last 15 years, suicide rates have increased across all age groups; however, the greatest increase has been found in females aged 10–14 (200%)1,2. Suicide is the second leading cause of death among 10–24 year olds3. Despite decades of research on suicide prevention in this age group, suicide rates among 10–19 year olds increased by 56% between 2007 and 2016. A 2017 national survey found that 17.2% of high school students seriously considered making a suicide attempt (SA), 13.6% made a suicide plan, and 7.4% made one or more SAs4. Historically, males are more likely to die by suicide; however, incident rate ratios comparing deaths by suicide between adolescent males and females have been decreasing since 2007, with findings demonstrating that numbers of adolescent female suicides are catching up to those of their male counterparts2. An alarmingly large percentage of adolescents experience suicidal ideation (SI), and SI has been shown to confer significant risk for future SAs. Adolescents who experience SI are 12 times more likely than adolescents who do not experience SI to attempt suicide by age 30, with 86.1% of adolescents making a SA within 12 months of SI onset5. More than one-third of adolescents who experience SI go on to attempt suicide5.

Rates of non-suicidal self-injury (NSSI; e.g. scratching or cutting oneself; see below) are also high, particularly among adolescents, with approximately 18% of high school students overall and 24% of high school girls in the U.S. reporting at least one episode of NSSI within the past 12 months6. While, by definition, the purpose of NSSI is not to end one’s life (see below), NSSI is a significant risk factor for future SAs7,8. We will describe important differences and similarities among types of self-injurious behaviors (i.e. NSSI and SA), risk factors for self-injury among adolescents, and evidence-based management and treatment intervention strategies for these behaviors.

Definitions of self-injurious behaviors

SAs and NSSI can be grouped into the overarching category of self-harm (SH). SAs are potentially self-injurious behaviors conducted with some intent to die (i.e. to cause one’s own death) as a result of the behavior9. NSSIs are self-injurious behaviors performed without any intent to die9 and include such behaviors as scratching the skin, cutting, burning, head banging, hitting oneself, and so forth9. The purposes, or functions, of NSSI are typically to reduce or distract from negative emotions, punish oneself, and/or reduce feelings of numbness or dissociation10. While some studies have examined SA and NSSI as separate outcomes, differentiated by the presence (SAs) or absence (NSSI) of intent to die as a result of the behavior, other studies have used the broader category of SH, in part, because of the challenge of accurately determining whether or not SH included an intent to die11. Inconsistencies in how SH and suicidal behaviors are studied—as an overall category of SH versus separate entities of NSSI and SA—has made it difficult to compare outcomes between studies and has therefore hampered progress in furthering our understanding of these constructs. See Table 1 for a list of terms, abbreviations, and definitions of SH used in this review.

Table 1. Definitions of types of self-injurious behaviors.

TermAbbreviationDefinition
Suicide attemptSAPotentially self-injurious behaviors conducted deliberately with some intent to die (i.e. to
cause one’s own death) as a result of the behavior8.
Non-suicidal self-injuryNSSISelf-injurious behaviors performed deliberately without any intent to die8. Common methods
of NSSI include scratching the skin, cutting, burning, head banging, and hitting oneself9.
Self-harmSHBroader category including all intentional self-injury, with or without intent to die (i.e. SA and
NSSI).

Similarities and differences between suicide attempt and non-suicidal self-injury

Research in recent years has focused on the similarities and differences between SAs and NSSI. As noted above, SA and NSSI are similar in that both are types of deliberate SH. While the major differentiator between NSSI and SAs is the presence or absence of intent to die, other factors differentiate these behaviors (e.g. function, lethality, medical severity, prevalence rate, and frequency of the behavior; see Table 1)12,13. SAs and NSSI were previously addressed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV only as symptoms of other mental disorders, such as major depressive disorder (MDD) and borderline personality disorder (BPD)14. DSM 514 includes new diagnostic categories, NSSI disorder and suicidal behavior disorder, as “condition[s] for further study”14. The inclusion of these disorders increases consistency with the extant treatment literature, which generally holds that NSSI and SAs must be targeted directly, rather than as secondary to other diagnoses. This is in opposition to views that NSSI and suicidality are symptoms of other disorders, such as depressive disorders, that will remit independently as depression is treated15.

While there are important distinctions between SAs and NSSI, the relationship between these behaviors is important. Research shows that most adolescents engage in NSSI and SAs concurrently16. In fact, the majority of adolescents who have engaged in NSSI have also attempted suicide17, and NSSI is a robust predictor of future SA among youth with depressive disorders7,8. Recent findings elucidated a temporal order to SI, SAs, and NSSI, such that adolescents have already thought about suicide prior to the first onset of NSSI, and NSSI typically precedes the first SA13. It has been posited that NSSI serves as a “gateway” to SA by way of eroding natural tendencies of self-preservation and increasing comfort with SH16.

Risk factors for suicidal behavior in adolescents

In November of 2016, the American Psychological Association (APA) released a statement titled, “After Decades of Research, Science Is No Better Able to Predict Suicidal Behaviors”18. This was based on a meta-analysis of 50 years of research on risk factors for suicidality in which the authors found that the ability of identified risk factors to predict suicidal thoughts and behaviors was only slightly better than chance19. At this time, there is not a standardized suicide risk assessment that accurately predicts suicidal behavior. Currently, any attempt to apply a standardized risk assessment to determine who is at imminent risk for suicide will yield a high number of false positives20. This is because many of the risk factors for suicide are also found in individuals who are not suicidal; in other words, identified risk factors and warning signs for suicide are neither sensitive nor specific enough to accurately predict who is at imminent risk for suicide21,22. While it has generally been determined that risk for suicidal behavior increases with the number of risk factors present23, it is also not yet known what combinations of risk factors are most likely to lead to suicidal behavior and death by suicide19. While a full review of risk factors for suicidality are beyond the scope of this paper, the adolescent literature has identified several risk factors for suicidal behavior, many of which—but not all—are listed in Table 2.

Table 2. Risk factors for suicidal behavior and deaths by suicide.

Risk factor
Suicidal ideation23,47–49
Previous suicide attempt23,50–52
Suicide intent (i.e. extent to which an individual wishes to die)51,52
Non-suicidal self-injury7,46,50,53,54
Precipitating events
        e.g. family conflict25,55–57; loss of parent through death or divorce or living away from one or both parents56,58,59; other interpersonal
conflict60; being a victim or perpetrator of bullying61–64
Sexual orientation and gender identity65–70
Psychopathology
        e.g. MDD71,72/MDD severity73–75/symptoms of MDD, such as feelings of worthlessness73, hopelessness76,77, and low positive
expectancies76; bipolar disorders78; alcohol use disorder and other substance use disorders49; anxiety disorders52,79; post-
traumatic stress disorder52,79; psychosis52,79; eating disorders52,79; ADHD52,78–80; conduct disorder52,80,81; personality disorders and
characteristics (e.g. antisocial, borderline, histrionic, and narcissistic personality disorders); psychiatric comorbidity (i.e. more than
one psychiatric disorder)56,82
Psychological and personality factors
        e.g. impulsivity83–85; impulsive aggression86,87; neuroticism87–90; perceived burdensomeness91; poor coping and problem-solving
abilities24; low self-esteem58; high levels of anger23,86; perception of expectation of perfectionism92; negative self-referential thinking
(i.e. processing bias that over-emphasizes negative information) and negative inferential style (i.e. believing negative events predict
negative outcomes in the future)93
Sleep problems93–95
Family history of suicide96–99
Childhood maltreatment100–105
Psychiatric hospitalization37,106
Contagion107–112

ADHD, attention-deficit hyperactivity disorder; MDD, major depressive disorder

In recent years, research has aimed to elucidate which risk factors are modifiable24 (i.e. can be changed) and when they occur in time prior to suicidal behavior19. With this information, clinicians will be able to target dynamic risk factors (e.g. family conflict)25 for suicidal behavior more accurately in order to reduce suicide risk. Furthermore, identifying proximal risk factors (e.g. sleep disturbance)26 will help clinicians determine who is at immediate risk of engaging in suicidal behavior. Presently, there are several websites with lists of warning signs (i.e. behavioral indicators that a SA is imminent or likely to happen within hours to days)27 for adolescent suicidal behavior; however, there is little research to support these as indicators of imminent suicidal behavior.

Strategies for managing suicidal youth in outpatient settings

There are several strategies that can be used across diagnoses and outpatient treatments to manage safety concerns when working with suicidal adolescents and their families.

Written safety plan

Because patients may have difficulty identifying and implementing adaptive coping strategies in the place of SH when they are in the midst of a suicidal crisis and overwhelmed by strong negative emotions, the written safety plan helps the suicidal individual to select and use coping strategies in crisis situations28–31. Safety plans have been used in the context of short-term, empirically supported treatments that have been found to reduce suicide risk, such as cognitive therapy31,32 and cognitive behavior therapy for suicide prevention (CBT-SP)30. It is critical to note that the written safety plan is not a “no-suicide” contract, which has been shown to be ineffective in preventing suicidal behavior and death by suicide33,34.

Means restriction

Means restriction includes removing or limiting access to potentially life-threatening settings or objects, such as firearms, tall buildings, bridges, trains/traffic, sharps, and any medications and toxic substances that could be used to overdose35. It has been documented that removing the suicidal individual’s access to lethal means is a highly effective suicide prevention strategy with a robust empirical basis36,37. Access to firearms, in particular, is a significant predictor of death by suicide, independent of all other factors38. Of note, between 1996 and 2010, firearms were the most common method used in death by suicide in the U.S. (51%)39. This statistic is underscored by findings demonstrating that limited access to firearms explains the significantly smaller number of deaths by suicide among on-campus college students, who have a nearly ninefold decrease in access to firearms when compared to age- and gender-matched controls40. Furthermore, psychological autopsy studies of adolescents who died by suicide in the absence of psychopathology have suggested that access to a loaded firearm is a significant risk factor for death by suicide41. In states within the U.S. and other countries, greater firearm regulations are associated with reductions in suicide deaths by firearms42.

Increased monitoring/supervision

Several studies have linked low parental supervision and monitoring (i.e. physical supervision of the adolescent as well as awareness of the adolescent’s activities and schedule) to increased risk for suicidal behavior among adolescents43,44. The American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter for suicidal youth recommend that suicidal children and adolescents be monitored closely by a trustworthy and supportive adult45.

Reducing risk factors

Reducing malleable risk factors related to adolescent suicide, such as decreasing family conflict, seeking treatment for sleep problems, and addressing peer victimization and bullying with the school, requires parental involvement.

Working with parents

Strengthening the parent–teen relationship and improving family functioning are critical when treating suicidal youth31. We ultimately want the adolescent to communicate with parents when they are in a suicidal crisis so that parents can help keep the adolescent safe and obtain appropriate help. Additionally, family conflict is a known risk factor for adolescent suicide and suicidal behavior while family cohesion serves as a protective factor against suicide and suicidal behavior46. Finally, parents have a significant role in implementing strategies outside of treatment to try to prevent the adolescent from making a SA, such as removing access to lethal means, providing supervision and monitoring, and seeking emergency services when needed.

Treatment approaches

A 2015 meta-analysis of 19 studies of therapeutic interventions (TIs) for SH behavior in adolescents found TIs to be superior to control conditions for decreasing SH. The strongest effect sizes were found for DBT, mentalization-based therapy (MBT), and CBT113. As noted earlier, working with parents as part of the treatment of teens who SH is of critical importance. The same meta-analysis also found that effect sizes were greatest for treatments that included family-based components53. As previously mentioned, family conflict is a significant risk factor for suicidal behavior in adolescents25,55–57 and must be addressed when working with suicidal youth. Additionally, the relationship between the suicidal adolescent and parent or caregiver is important given that, as discussed above, parents play a crucial role in safety planning.

A 2018 systematic review examined 21 randomized controlled trials (RCTs) and assessed 18 distinct treatment interventions, five of which reported significant results in reducing SH or SAs when compared to treatment as usual114. These five interventions included DBT for adolescents, MBT, safe alternatives for teens and youth, integrated CBT, and developmental group psychotherapy (DGP). Two replication studies of DGP did not find significant results. Common elements of the five interventions with significant results included family involvement or support, emotion regulation skills, communication skills, and problem-solving skills114.

A 2019 review of 26 RCTs published prior to June 2018 found nine new studies since the 2015 review discussed above115. Integrated family therapy also joined other interventions with RCTs yielding significant results. The most significant change was that DBT, based on a second RCT with significant results from a different research group, meets the threshold of a “well-established”116 treatment for reducing SH.

Dialectical behavior therapy

At this time, DBT is the first and only “well-established” treatment for suicidal and SH adolescents. DBT targets both SA and NSSI by identifying the function of the behavior (e.g. reducing emotional distress) for the given individual and finding ways to obtain that function safely using DBT-based coping skills. Components of standard DBT are the same for adolescents and adults (see Table 3), with the exception of there being parenting and family sessions with the individual therapist as needed and the skills class including both teens and parents117–119.

Table 3. Components of stage I standard dialectical behavior therapy for adolescents116–118.

ComponentFunctionStructure
Individual psychotherapy
(At least 1 per week)		1) Enhance capacities related to skills modules
2) Skills application to patient’s unique circumstances
3) Improve motivation and reduce dysfunctional behavior
4) Structure the environment to reinforce effective behavior
and positive change		Treatment hierarchy:
1) Life-threatening behavior
2) Therapy-interfering behavior
3) Quality-of-life interfering behavior
Multifamily group skills training
(1 per week)		Teach skills:
1) Mindfulness
2) Distress tolerance
3) Emotion regulation
4) Interpersonal effectiveness
5) Middle path skills		1) Mindfulness exercise
2) Homework review
3) Teaching of new skill
Telephone coaching
(Available 24/7 for youth and
parents)		1) Help with skills application in context (e.g. in a crisis)
2) Unavailable for 24 hours after patient engages in self-
injurious behavior		Brief, focused calls for
1) Skill use in a crisis
2) Addressing therapist–patient
rupture
3) Reporting good news
Therapist consultation team
(1 per week)		Support therapist’s motivation, adherence, and effectiveness1) Mindfulness exercise
2) Clinical concerns, including
therapist’s TIB

Mehlum and colleagues (see Table 4)120,121 completed a multisite RCT in Oslo, Norway, comparing 19 weeks of outpatient DBT with enhanced usual care (EUC; i.e. any non-DBT therapy plus suicide risk assessment). DBT was superior to EUC in reducing the frequency of SH behaviors, severity of SI, and depressive symptoms, with this DBT condition showing large effect sizes with regard to treatment outcome, whereas the EUC condition resulted in weak to moderate outcomes. At 1-year follow-up, DBT remained superior to EUC in reduction of SH frequency; however, there were no significant differences between treatment conditions for SI, hopelessness, depressive symptoms, and BPD features120,121.

Table 4. Mehlum et al. 2014120; 2016121.

Sample size (at
randomization)		Sample
characteristics		Recruitment settingInclusion criteriaExclusion criteriaMajor diagnoses
Total = 77;
T = 39, C = 38		12–18 years old;
88% female; 85%
Norwegian		OutpatientLifetime SH ≥2
episodes; ≥1 SH
episode in past 16
weeks; ≥2 DSM-IV
BPD criteria or 1
BPD criteria and 2
subthreshold-level
criteria; fluent in
Norwegian		BP; SZ; SCAD;
psychotic disorder not
otherwise specified;
intellectual disability;
Asperger syndrome		ANX (43%); other
depressive disorder
(38%); MDD (22%); BPD
(21%); PTSD (17%); PD
(9%); ED (8%); SUD (8%)
SH outcome
measures		Treatment
condition		Control conditionAssessmentsTreatment attrition
and completion		Results
SH (LPC);
SI (SIQ-Jr)		DBT: individual
sessions,
multifamily skills
training, family
therapy, or
telephone coaching
as needed

Dose: 19 weeks of
weekly individual
(1 hour) and
multifamily skills
training (1.5 hour)		EUC (any enhanced,
non-DBT treatment
plus suicide risk
assessment, and
therapist agrees to
minimum dose)

Dose: 19 weeks
minimum of weekly
individual sessions		Pretreatment
(baseline), mid-
treatment (9
and 15 weeks),
post-treatment
(19 weeks), and
follow-up at 71
weeks (1 year post-
treatment)		Treatment completion
(≥50% of sessions):
DBT: 74.4%
EUC: 71%

Attrition post-treatment:
DBT: 0%
EUC: 0%
71-week follow-up:
DBT: 2.6%
EUC: 2.6%		Significantly fewer SH
episodes, significantly
greater decrease in SI,
significant decrease in
depressive symptoms for
DBT (compared to EUC)
at post-treatment.

Significantly fewer SH
episodes from post-
treatment to 71-week
follow-up.

NS between-group
differences in SI,
hopelessness, depressive
symptoms, and BPD at
71-week follow-up.

ANX, anxiety disorder (type not specified); BP, bipolar disorder; BPD, borderline personality disorder; C, control condition; DBT, dialectical behavior therapy; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition; ED, eating disorder; EUC, enhanced usual care; LPC, lifetime parasuicide count; MDD, major depressive disorder; NS, non-significant; PD, personality disorder; PTSD, post-traumatic stress disorder; SCAD, schizoaffective disorder; SH, self-harm; SIQ-Jr, suicide ideation questionnaire, junior; SUD, substance use disorder; SZ, schizophrenia; T, treatment condition.

In the U.S., McCauley and colleagues (see Table 5)122 conducted a multisite RCT with adolescents at high risk for suicide (i.e., with a history of at least one lifetime SA and repetitive SH) to determine whether DBT is effective in reducing SAs, in addition to SH. Participants received either 6 months of comprehensive DBT or individual and group supportive psychotherapy (IGST), a manualized, client-centered approach that included individual and group components. Internal validity was enhanced by IGST’s match to DBT for hours of treatment, modalities (i.e. both individual and group therapy), therapy drop-out policies, therapist expertise, and availability of supervision123. Results demonstrated that youth in the DBT condition reported significantly fewer SAs, NSSI, total SH and SI at the end of the treatment than youth in IGST. While both groups continued to demonstrate improvements at 12-month follow-up, there were no significant differences between DBT and IGST122. Taken together, these studies support DBT as the only replicated treatment with demonstrated efficacy at reducing SH in adolescents.

Table 5. McCauley et al.122.

Sample size (at
randomization)		Sample characteristicsRecruitment
setting		Inclusion criteriaExclusion criteriaMajor diagnoses
Total=173; T=86,
C=87		12–18 years old; 95%
female; 56% Caucasian;
27% Hispanic; 7% African
American; 6% Asian
American; <1% Native
American; 2% other		Emergency
department,
inpatient,
outpatient,
community		Lifetime SA ≥1;
elevated SI over past
month (SIQ-Jr ≥24);
lifetime SH ≥3, with
≥1 SH episode in
past 12 weeks; ≥3
BPD criteria		IQ <70; psychosis;
mania; anorexia
nervosa; life-threatening
conditions; youth not
fluent in English; parent
not fluent in Spanish or
English		MDD (84%); ANX
(54%); BPD (53%);
ED (<1%)
SH outcome
measures		Treatment conditionControl conditionAssessmentsTreatment attrition
and completion		Results
SI (SIQ-Jr); SA
(SASII); NSSI
(SASII); SH (SASII)		DBT: individual sessions;
multifamily skills training;
youth and parent phone
coaching; individual
parent sessions; family
sessions as needed

Dose: 6 months of weekly
individual and group
sessions; weekly therapist
team consultation		IGST: individual
and group
sessions, parent
sessions (as
needed)

Dose: 6 months of
weekly individual
and group
sessions; weekly
therapist team
consultation		Pretreatment
(baseline), mid-
treatment (3 months),
post-treatment (6
months), follow-up at
9 and 12 months 		Treatment completion
(≥24 adolescent
sessions):
DBT: 45.4%
IGST: 16.1%

Attrition post-treatment:
DBT: 10.5%
IGST: 24.1%

12-month follow-up:
DBT: 19.8%
IGST: 26.4%		Significantly
greater decrease
in SI, SA, NSSI,
and SH frequency
for DBT (compared
to IGST) at post-
treatment

NS between-group
differences in SI,
SA, NSSI, and
SH from post-
treatment to 12-
month follow-up

ANX, anxiety disorder (type not specified); BPD, borderline personality disorder; C, control condition; DBT, dialectical behavior therapy; ED, eating disorder; IGST, individual and group supportive therapy; MDD, major depressive disorder; NS, non-significant; SA, suicide attempt; SASII, suicide attempt self-injury inventory; SH, self-harm; SI, suicide ideation; SIQ-Jr, suicide ideation questionnaire, junior; T, treatment condition.

In the McCauley et al. (2018) study, DBT was not superior to control at 12-month follow-up at reducing SA and SH122, suggesting that more work is needed to determine how to sustain significant effects of DBT after active treatment has ended. Additionally, DBT is a time- and labor-intensive treatment. It generally requires a 4–6-month commitment from adolescents and families and includes at least two sessions per week (one individual session and one multifamily skills group). Further, DBT is a complex treatment that requires significant provider training. Thus, dismantling studies will be useful in determining what aspects of DBT yield significant effects, and establishment of shorter, less training-intensive treatments for SH/suicidal adolescents will be particularly useful for communities where—based on access to training or financial resources—comprehensive DBT training is not an option, and for those families who are unable to make the time and/or potential financial commitment DBT requires.

Hospitalization

The AACAP’s Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior recommends that psychiatric hospitalization be considered if an adolescent is determined to be at high risk of imminent suicidal behavior45. At present, however, there is no research supporting the effectiveness of hospitalization at reducing future SAs18,117. In fact, Chung and colleagues’ recent meta-analysis reviewed 100 studies of patients hospitalized for suicidality and found the highest rates of death by suicide in the first 3 months after discharge. These rates are 100 times the global suicide rate18. Data have also shown that rehospitalization rates are high: 13% at 90-day follow-up124, 38% at 6-month follow-up125, and 30–43% at 1-year follow-up126. These data suggest that hospitalization is not an adequate intervention for lowering risk for subsequent suicidal behavior29 and, in fact, may confer greater risk for future suicidal behavior.

Conclusion

Suicide is the second leading cause of death among adolescents3. Not only is NSSI a risk factor for SAs in teens7,8 but also recent research revealed a temporal relationship between these behaviors, such that NSSI increases the likelihood of future SA, and SI often precedes the first onset of NSSI13. While, by definition, the intent of NSSI is not death, these findings underline the importance of taking NSSI seriously and performing ongoing assessment of, and intervention for, suicidal behavior.

There are several evidence-based and evidence-informed interventions for managing suicide risk in adolescents (e.g. written safety plan, means restriction, and increased monitoring by a parent or trusted adult). While hospitalization is at times unavoidable for individuals who are unable to commit to the use of a written safety plan and have active SI with intent and plan, it has been found that risk for suicide increases significantly immediately post-hospitalization. Further work on how to enhance the effectiveness of hospitalization and to reduce the increased risk associated with it is a critical next step.

Overall, there is a small number of empirically supported treatments for decreasing SAs and NSSI in adolescents. DBT is the first and only well-established treatment (i.e. significant results compared to control in at least two RCTs performed by two independent research groups)116 for SH adolescents at high risk for suicide127. Replication trials are needed for several other treatments that have shown promise in decreasing SH in adolescents. Common elements of the interventions with significant results from at least one RCT included family involvement or support, emotion regulation skills, communication skills, and problem-solving skills; however, replications and dismantling studies are necessary to better understand the effects of these interventions and their components on reducing adolescent SH and SAs28.

F1000 recommended

References

  • 1.  Ruch DA, Sheftall AH, Schlagbaum P, et al.: Trends in Suicide Among Youth Aged 10 to 19 Years in the United States, 1975 to 2016. JAMA Netw Open. 2019; 2(5): e193886. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 2.  Curtin SC, Warner M, Hedegaard H: Increase in Suicide in the United States, 1999-2014. NCHS Data Brief. 2016; (241): 1–8. PubMed Abstract
  • 3.  Center for Disease Control and Prevention: 10 leading causes of death by age group, United States-2017. Reference Source
  • 4.  Kann L, McManus T, Harris WA, et al.: Youth Risk Behavior Surveillance - United States, 2017. MMWR Surveill Summ. 2018; 67(8): 1–114. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 5.  Nock MK, Green JG, Hwang I, et al.: Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013; 70(3): 300–10. PubMed Abstract | Publisher Full Text | Free Full Text
  • 6.  Monto MA, McRee N, Deryck FS: Nonsuicidal Self-Injury Among a Representative Sample of US Adolescents, 2015. Am J Public Health. 2018; 108(8): 1042–8. PubMed Abstract | Publisher Full Text | F1000 Recommendation
  • 7.  Asarnow JR, Porta G, Spirito A, et al.: Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: findings from the TORDIA study. J Am Acad Child Adolesc Psychiatry. 2011; 50(8): 772–81. PubMed Abstract | Publisher Full Text | Free Full Text
  • 8.  Wilkinson P, Kelvin R, Roberts C, et al.: Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry. 2011; 168(5): 495–501. PubMed Abstract | Publisher Full Text
  • 9.  Nock MK: Self-Injury. Annu Rev Clin Psychol. 2010; 6: 339–63. PubMed Abstract | Publisher Full Text
  • 10.  Klonsky ED: The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007; 27(2): 226–39. PubMed Abstract | Publisher Full Text
  • 11.  Ougrin D, Tranah T, Leigh E, et al.: Practitioner review: Self-harm in adolescents. J Child Psychol Psychiatry. 2012; 53(4): 337–50. PubMed Abstract | Publisher Full Text
  • 12.  Nock MK, Borges G, Bromet EJ, et al.: Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008; 192(2): 98–105. PubMed Abstract | Publisher Full Text | Free Full Text
  • 13.  Glenn CR, Lanzillo EC, Esposito EC, et al.: Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents. J Abnorm Child Psychol. 2017; 45(5): 971–83. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 14.  American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington,VA: American Psychiatric Association, 2013. Publisher Full Text
  • 15.  Meerwijk EL, Parekh A, Oquendo MA, et al.: Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: a systematic review and meta-analysis. Lancet Psychiatry. 2016; 3(6): 544–54. PubMed Abstract | Publisher Full Text
  • 16.  Whitlock J, Muehlenkamp J, Eckenrode J, et al.: Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health. 2013; 52(4): 486–92. PubMed Abstract | Publisher Full Text
  • 17.  Nock MK, Joiner TE Jr, Gordon KH, et al.: Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006; 144(1): 65–72. PubMed Abstract | Publisher Full Text
  • 18.  Sliwa J: After decades of research, science is no better able to predict suicidal behavior [American Psychological Association website]. 2016; Accessed February 1, 2018. Reference Source
  • 19.  Franklin JC, Ribeiro JD, Fox KR, et al.: Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychol Bull. 2017; 143(2): 187–232. PubMed Abstract | Publisher Full Text
  • 20.  Fowler JC: Suicide risk assessment in clinical practice: pragmatic guidelines for imperfect assessments. Psychotherapy (Chic). 2012; 49(1): 81–90. PubMed Abstract | Publisher Full Text
  • 21.  Lester D, McSwain S, Gunn JF 3rd: A test of the validity of the IS PATH WARM warning signs for suicide. Psychol Rep. 2011; 108(2): 402–4. PubMed Abstract | Publisher Full Text
  • 22.  Ramchand R, Franklin E, Thornton E, et al.: Opportunities to intervene? “Warning signs” for suicide in the days before dying. Death Studies. 2017; 41(6): 368–75. PubMed Abstract | Publisher Full Text
  • 23.  Lewinsohn PM, Rohde P, Seeley JR: Psychosocial risk factors for future adolescent suicide attempts. J Consult Clin Psychol. 1994; 62(2): 297–305. PubMed Abstract | Publisher Full Text
  • 24.  Steele IH, Thrower N, Noroian P, et al.: Understanding Suicide Across the Lifespan: A United States Perspective of Suicide Risk Factors, Assessment & Management. J Forensic Sci. 2018; 63(1): 162–71. PubMed Abstract | Publisher Full Text | F1000 Recommendation
  • 25.  Holland KM, Vivolo-Kantor AM, Logan JE, et al.: Antecedents of Suicide among Youth Aged 11–15: A Multistate Mixed Methods Analysis. J Youth Adolesc. 2017; 46(7): 1598–610. PubMed Abstract | Publisher Full Text | Free Full Text
  • 26.  Goldstein TR, Bridge JA, Brent DA: Sleep disturbance preceding completed suicide in adolescents. J Consult Clin Psychol. 2008; 76(1): 84–91. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 27.  Rudd MD, Berman AL, Joiner TE, et al.: Warning signs for suicide: theory, research, and clinical applications. Suicide Life Threat Behav. 2006; 36(3): 255–62. PubMed Abstract | Publisher Full Text
  • 28.  Berk M: Evidence-Based Treatment Approaches for Suicidal Adolescents: Translating Science into Practice. Washington, DC: American Psychiatric Association Publishing, 2019. Reference Source
  • 29.  Berk MS, Henriques GR, Warman DM, et al.: A cognitive therapy intervention for suicide attempters: An overview of the treatment and case examples. Cogn Behav Pract. 2004; 11(3): 265–77. Publisher Full Text
  • 30.  Stanley B, Brown G, Brent DA, et al.: Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. J Am Acad Child Adolesc Psychiatry. 2009; 48(10): 1005–13. PubMed Abstract | Publisher Full Text | Free Full Text
  • 31.  Spokas M, Wenzel A, Stirman SW, et al.: Suicide risk factors and mediators between childhood sexual abuse and suicide ideation among male and female suicide attempters. J Trauma Stress. 2009; 22(5): 467–70. PubMed Abstract | Publisher Full Text | Free Full Text
  • 32.  Brown GK, Ten Have T, Henriques GR, et al.: Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005; 294(5): 563–70. PubMed Abstract | Publisher Full Text | F1000 Recommendation
  • 33.  Garvey KA, Penn JV, Campbell AL, et al.: Contracting for safety with patients: clinical practice and forensic implications. J Am Acad Psychiatry Law. 2009; 37(3): 363–70. PubMed Abstract
  • 34.  Wortzel HS, Homaifar B, Matarazzo B, et al.: Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014; 20(1): 63–7. PubMed Abstract | Publisher Full Text
  • 35.  Miller DN: Lessons in suicide prevention from the Golden Gate Bridge: means restriction, public health, and the school psychologist. Contemp Sch Psychol. 2013; 17(1): 71–79. Reference Source
  • 36.  Mann JJ, Apter A, Bertolote J, et al.: Suicide prevention strategies: a systematic review. JAMA. 2005; 294(16): 2064–74. PubMed Abstract | Publisher Full Text
  • 37.  Barber CW, Miller MJ: Reducing a suicidal person's access to lethal means of suicide: a research agenda. Am J Prev Med. 2014; 47(3 Suppl 2): S264–72. PubMed Abstract | Publisher Full Text
  • 38.  Brent DA, Bridge J: Firearms availability and suicide: evidence, interventions, and future directions. Am Behav Sci. 2003; 46(9): 1192–210. Publisher Full Text
  • 39.  Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al.: Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatr. 2015; 169(5): 466–73. PubMed Abstract | Publisher Full Text | Free Full Text
  • 40.  Schwartz AJ: Rate, relative risk, and method of suicide by students at 4-year colleges and universities in the United States, 2004-2005 through 2008-2009. Suicide Life Threat Behav. 2011; 41(4): 353–71. PubMed Abstract | Publisher Full Text
  • 41.  Marttunen MJ, Henriksson MM, Isometsä ET, et al.: Completed suicide among adolescents with no diagnosable psychiatric disorder. Adolescence. 1998; 33(131): 669–81. PubMed Abstract
  • 42.  Lewiecki EM, Miller SA: Suicide, guns, and public policy. Am J Public Health. 2013; 103(1): 27–31. PubMed Abstract | Publisher Full Text | Free Full Text
  • 43.  King RA, Schwab-Stone M, Flisher AJ, et al.: Psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation. J Am Acad Child Adolesc Psychiatry. 2001; 40(7): 837–46. PubMed Abstract | Publisher Full Text
  • 44.  Kostenuik M, Ratnapalan M: Approach to adolescent suicide prevention. Can Fam Physician. 2010; 56(8): 755–60. PubMed Abstract | Free Full Text
  • 45.  American Academy of Child and Adolescent Psychiatry: Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry. J Am Acad Child Adolesc Psychiatry. 2001; 40(7 Suppl 1): 24S–51S. PubMed Abstract | Publisher Full Text
  • 46.  Bridge JA, Goldstein TR, Brent DA: Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006; 47(3–4): 372–94. PubMed Abstract | Publisher Full Text
  • 47.  Lewinsohn PM, Rohde P, Seeley JR: Adolescent Suicidal Ideation and Attempts: Prevalence, Risk Factors, and Clinical Implications. Clinical Psychology: Science and Practice. 1996; 3(1): 25–46. Publisher Full Text
  • 48.  Miranda R, Ortin A, Scott M, et al.: Characteristics of suicidal ideation that predict the transition to future suicide attempts in adolescents. J Child Psychol Psychiatry. 2014; 55(11): 1288–96. PubMed Abstract | Publisher Full Text | Free Full Text
  • 49.  Negron R, Piacentini J, Graae F, et al.: Microanalysis of Adolescent Suicide Attempters and Ideators During the Acute Suicidal Episode. J Am Acad Child Adolesc Psychiatry. 1997; 36(11): 1512–9. PubMed Abstract | Publisher Full Text
  • 50.  Reinherz HZ, Giaconia RM, Silverman AB, et al.: Early psychosocial risks for adolescent suicidal ideation and attempts. J Am Acad Child Adolesc Psychiatry. 1995; 34(5): 599–611. PubMed Abstract | Publisher Full Text
  • 51.  Chesin MS, Galfavy H, Sonmez CC, et al.: Nonsuicidal Self-Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders. Suicide Life Threat Behav. 2017; 47(5): 567–79. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 52.  Goldston DB, Daniel SS, Reboussin DM, et al.: Suicide attempts among formerly hospitalized adolescents: a prospective naturalistic study of risk during the first 5 years after discharge. J Am Acad Child Adolesc Psychiatry. 1999; 38(6): 660–71. PubMed Abstract | Publisher Full Text
  • 53.  Brent DA, McMakin DL, Kennard BD, et al.: Protecting adolescents from self-harm: a critical review of intervention studies. J Am Acad Child Adolesc Psychiatry. 2013; 52(12): 1260–71. PubMed Abstract | Publisher Full Text | Free Full Text
  • 54.  Hawton K, Harriss L: Deliberate self-harm in young people: characteristics and subsequent mortality in a 20-year cohort of patients presenting to hospital. J Clin Psychiatry. 2007; 68(10): 1574–83. PubMed Abstract | Publisher Full Text
  • 55.  Wilkinson PO: Nonsuicidal self-injury: a clear marker for suicide risk. J Am Acad Child Adolesc Psychiatry. 2011; 50(8): 741–3. PubMed Abstract | Publisher Full Text
  • 56.  Asarnow JR, Carlson GA, Guthrie D: Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. J Consult Clin Psychol. 1987; 55(3): 361–6. PubMed Abstract | Publisher Full Text
  • 57.  Brent DA: Risk factors for adolescent suicide and suicidal behavior: mental and substance abuse disorders, family environmental factors, and life stress. Suicide Life Threat Behav. 1995; 25 Suppl: 52-63. PubMed Abstract | Publisher Full Text
  • 58.  Fergusson DM, Lynskey MT: Childhood circumstances, adolescent adjustment, and suicide attempts in a New Zealand birth cohort. J Am Acad Child Adolesc Psychiatry. 1995; 34(5): 612–22. PubMed Abstract | Publisher Full Text
  • 59.  Agerbo E, Nordentoft M, Mortensen PB: Familial, psychiatric, and socioeconomic risk factors for suicide in young people: nested case-control study. BMJ. 2002; 325(7355): 74. PubMed Abstract | Publisher Full Text | Free Full Text
  • 60.  Grøholt B, Ekeberg O, Wichstrøm L, et al.: Youth suicide in Norway, 1990-1992: a comparison between children and adolescents completing suicide and age- and gender-matched controls. Suicide Life Threat Behav. 1997; 27(3): 250–63. PubMed Abstract
  • 61.  Beautrais AL: Risk factors for suicide and attempted suicide among young people. Aust N Z J Psychiatry. 2000; 34(3): 420–36. PubMed Abstract | Publisher Full Text
  • 62.  Kim YS, Leventhal B: Bullying and suicide. A review. Int J Adolesc Med Health. 2008; 20(2): 315–54. PubMed Abstract | Publisher Full Text
  • 63.  Holt MK, Vivolo-Kantor AM, Polanin JR, et al.: Bullying and suicidal ideation and behaviors: a meta-analysis. Pediatrics. 2015; 135(2): e496–509. PubMed Abstract | Publisher Full Text | Free Full Text
  • 64.  Selkie EM, Fales JL, Moreno MA: Cyberbullying Prevalence Among US Middle and High School-Aged Adolescents: A Systematic Review and Quality Assessment. J Adolesc Health. 2016; 58(2): 125–33. PubMed Abstract | Publisher Full Text | Free Full Text
  • 65.  Geoffroy MC, Boivin M, Arseneault L, et al.: Associations Between Peer Victimization and Suicidal Ideation and Suicide Attempt During Adolescence: Results From a Prospective Population-Based Birth Cohort. J Am Acad Child Adolesc Psychiatry. 2016; 55(2): 99–105. PubMed Abstract | Publisher Full Text
  • 66.  Russell ST, Joyner K: Adolescent sexual orientation and suicide risk: evidence from a national study. Am J Public Health. 2001; 91(8): 1276–81. PubMed Abstract | Publisher Full Text | Free Full Text
  • 67.  Borowsky IW, Ireland M, Resnick MD: Adolescent suicide attempts: risks and protectors. Pediatrics. 2001; 107(3): 485–93. PubMed Abstract | Publisher Full Text
  • 68.  Garofalo R, Wolf RC, Wissow LS, et al.: Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999; 153(5): 487–93. PubMed Abstract | Publisher Full Text
  • 69.  Hatzenbuehler ML: The social environment and suicide attempts in lesbian, gay, and bisexual youth. Pediatrics. 2011; 127(5): 896–903. PubMed Abstract | Publisher Full Text | Free Full Text
  • 70.  Liu RT, Mustanski B: Suicidal ideation and self-harm in lesbian, gay, bisexual, and transgender youth. Am J Prev Med. 2012; 42(3): 221–8. PubMed Abstract | Publisher Full Text
  • 71.  Mustanski B, Liu RT: A longitudinal study of predictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Arch Sex Behav. 2013; 42(3): 437–48. PubMed Abstract | Publisher Full Text
  • 72.  Goldston DB, Daniel SS, Erkanli A, et al.: Psychiatric diagnoses as contemporaneous risk factors for suicide attempts among adolescents and young adults: developmental changes. J Consult Clin Psychol. 2009; 77(2): 281–90. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 73.  Nrugham L, Larsson B, Sund AM: Specific depressive symptoms and disorders as associates and predictors of suicidal acts across adolescence. J Affect Disord. 2008; 111(1): 83–93. PubMed Abstract | Publisher Full Text
  • 74.  Giletta M, Calhoun CD, Hastings PD, et al.: Multi-Level Risk Factors for Suicidal Ideation Among at-Risk Adolescent Females: The Role of Hypothalamic-Pituitary-Adrenal Axis Responses to Stress. J Abnorm Child Psychol. 2015; 43(5): 807–20. PubMed Abstract | Publisher Full Text | Free Full Text
  • 75.  Ran MS, Zhang Z, Fan M, et al.: Risk factors of suicidal ideation among adolescents after Wenchuan earthquake in China. Asian J Psychiatr. 2015; 13: 66–71. PubMed Abstract | Publisher Full Text
  • 76.  Vander Stoep A, Adrian M, Mc Cauley E, et al.: Risk for Suicidal Ideation and Suicide Attempts Associated with Co-occurring Depression and Conduct Problems in Early Adolescence. Suicide Life Threat Behav. 2011; 41(3): 316–29. PubMed Abstract | Publisher Full Text | Free Full Text
  • 77.  Horwitz AG, Berona J, Czyz EK, et al.: Positive and Negative Expectations of Hopelessness as Longitudinal Predictors of Depression, Suicidal Ideation, and Suicidal Behavior in High-Risk Adolescents. Suicide Life Threat Behav. 2017; 47(2): 168–76. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 78.  Tsypes A, Burkhouse KL, Gibb BE: Classification of facial expressions of emotion and risk for suicidal ideation in children of depressed mothers: Evidence from cross-sectional and prospective analyses. J Affect Disord. 2016; 197: 147–50. PubMed Abstract | Publisher Full Text | Free Full Text
  • 79.  Lan WH, Bai YM, Hsu JW, et al.: Comorbidity of ADHD and suicide attempts among adolescents and young adults with bipolar disorder: A nationwide longitudinal study. J Affect Disord. 2015; 176: 171–5. PubMed Abstract | Publisher Full Text
  • 80.  Chronis-Tuscano A, Molina BS, Pelham WE, et al.: Very Early Predictors of Adolescent Depression and Suicide Attempts in Children With Attention-Deficit/Hyperactivity Disorder. Arch Gen Psychiatry. 2010; 67(10): 1044–51. PubMed Abstract | Publisher Full Text | Free Full Text
  • 81.  Swanson EN, Owens EB, Hinshaw SP: Pathways to self-harmful behaviors in young women with and without ADHD: A longitudinal examination of mediating factors. J Child Psychol Psychiatr. 2014; 55(5): 505–15. PubMed Abstract | Publisher Full Text | Free Full Text
  • 82.  Wei HT, Lan WH, Hsu JW, et al.: Risk of Suicide Attempt among Adolescents with Conduct Disorder: A Longitudinal Follow-up Study. J Pediatr. 2016; 177: 292–6. PubMed Abstract | Publisher Full Text
  • 83.  Yen S, Weinstock LM, Andover MS, et al.: Prospective predictors of adolescent suicidality: 6-month post-hospitalization follow-up. Psychol Med. 2013; 43(5): 983–93. PubMed Abstract | Publisher Full Text | Free Full Text
  • 84.  Gunnell D, Murray V, Hawton K: Use of paracetamol (acetaminophen) for suicide and nonfatal poisoning: Worldwide patterns of use and misuse. Suicide Life Threat Behav. 2000; 30(4): 313–26. PubMed Abstract
  • 85.  Kashden J, Fremouw WJ, Callahan TS, et al.: Impulsivity in suicidal and nonsuicidal adolescents. J Abnorm Child Psychol. 1993; 21(3): 339–53. PubMed Abstract | Publisher Full Text
  • 86.  Kingsbury S, Hawton K, Steinhardt K, et al.: Do adolescents who take overdoses have specific psychological characteristics? A comparative study with psychiatric and community controls. J Am Acad Child Adolesc Psychiatry. 1999; 38(9): 1125–31. PubMed Abstract | Publisher Full Text
  • 87.  Apter A, Gothelf D, Orbach I, et al.: Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry. 1995; 34(7): 912–8. PubMed Abstract | Publisher Full Text
  • 88.  Beautrais AL, Joyce PR, Mulder RT: Personality traits and cognitive styles as risk factors for serious suicide attempts among young people. Suicide Life Threat Behav. 1999; 29(1): 37–47. PubMed Abstract
  • 89.  Enns MW, Cox BJ, Inayatulla M: Personality predictors of outcome for adolescents hospitalized for suicidal ideation. J Am Acad Child Adolesc Psychiatry. 2003; 42(6): 720–7. PubMed Abstract | Publisher Full Text
  • 90.  Fergusson DM, Woodward LJ, Horwood LJ: Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychol Med. 2000; 30(1): 23–39. PubMed Abstract | Publisher Full Text
  • 91.  Roy A: Family history of suicide and neuroticism: a preliminary study. Psychiatry Res. 2002; 110(1): 87–90. PubMed Abstract | Publisher Full Text
  • 92.  Boergers J, Spirito A, Donaldson D: Reasons for adolescent suicide attempts: associations with psychological functioning. J Am Acad Child Adolesc Psychiatry. 1998; 37(12): 1287–93. PubMed Abstract | Publisher Full Text
  • 93.  Bernert RA, Kim JS, Iwata NG, et al.: Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep. 2015; 17(3): 554. PubMed Abstract | Publisher Full Text | Free Full Text
  • 94.  Burke TA, Connolly SL, Hamilton JL, et al.: Cognitive Risk and Protective Factors for Suicidal Ideation: A Two Year Longitudinal Study in Adolescence. J Abnorm Child Psychol. 2016; 44(6): 1145–60. PubMed Abstract | Publisher Full Text | Free Full Text
  • 95.  Drapeau CW, Nadorff MR: Suicidality in sleep disorders: prevalence, impact, and management strategies. Nat Sci Sleep. 2017; 9: 213–26. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 96.  Fitzgerald CT, Messias E, Buysse DJ: Teen sleep and suicidality: results from the youth risk behavior surveys of 2007 and 2009. J Clin Sleep Med. 2011; 7(4): 351–6. PubMed Abstract | Publisher Full Text | Free Full Text
  • 97.  Brent DA, Mann JJ: Family genetic studies, suicide, and suicidal behavior. Am J Med Genet C Semin Med Genet. 2005; 133C(1): 13–24. PubMed Abstract | Publisher Full Text
  • 98.  Brent DA, Brunwasser SM, Hollon SD, et al.: Effect of a Cognitive-Behavioral Prevention Program on Depression 6 Years After Implementation Among At-Risk Adolescents: A Randomized Clinical Trial. JAMA Psychiatry. 2015; 72(11): 1110–8. PubMed Abstract | Publisher Full Text | Free Full Text
  • 99.  Lizardi D, Sher L, Sullivan GM, et al.: Association between familial suicidal behavior and frequency of attempts among depressed suicide attempters. Acta Psychiatr Scand. 2009; 119(5): 406–10. PubMed Abstract | Publisher Full Text | Free Full Text
  • 100.  Melhem NM, Brent DA, Ziegler M, et al.: Familial pathways to early-onset suicidal behavior: familial and individual antecedents of suicidal behavior. Am J Psychiatry. 2007; 164(9): 1364–70. PubMed Abstract | Publisher Full Text | Free Full Text
  • 101.  Borowsky IW, Resnick MD, Ireland M, et al.: Suicide attempts among American Indian and Alaska Native youth: risk and protective factors. Arch Pediatr Adolesc Med. 1999; 153(6): 573–80. PubMed Abstract | Publisher Full Text
  • 102.  Brent DA, Baugher M, Bridge J, et al.: Age- and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry. 1999; 38(12): 1497–505. PubMed Abstract | Publisher Full Text
  • 103.  Stewart JG, Kim JC, Esposito EC, et al.: Predicting suicide attempts in depressed adolescents: Clarifying the role of disinhibition and childhood sexual abuse. J Affect Disord. 2015; 187: 27–34. PubMed Abstract | Publisher Full Text | Free Full Text
  • 104.  Salzinger S, Rosario M, Feldman RS, et al.: Adolescent suicidal behavior: associations with preadolescent physical abuse and selected risk and protective factors. J Am Acad Child Adolesc Psychiatry. 2007; 46(7): 859–66. PubMed Abstract | Publisher Full Text
  • 105.  Marshall BD, Galea S, Wood E, et al.: Longitudinal associations between types of childhood trauma and suicidal behavior among substance users: a cohort study. Am J Public Health. 2013; 103(9): e69–75. PubMed Abstract | Publisher Full Text
  • 106.  Friestad C, Åse-Bente R, Kjelsberg E: Adverse childhood experiences among women prisoners: relationships to suicide attempts and drug abuse. Int J Soc Psychiatry. 2014; 60(1): 40–6. PubMed Abstract | Publisher Full Text
  • 107.  Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al.: Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017; 74(7): 694–702. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 108.  Asarnow JR, Baraff LJ, Berk M, et al.: Pediatric emergency department suicidal patients: two-site evaluation of suicide ideators, single attempters, and repeat attempters. J Am Acad Child Adolesc Psychiatry. 2008; 47(8): 958–66. PubMed Abstract | Publisher Full Text
  • 109.  Crepeau-Hobson MF, Leech NL: The impact of exposure to peer suicidal self-directed violence on youth suicidal behavior: a critical review of the literature. Suicide Life Threat Behav. 2014; 44(1): 58–77. PubMed Abstract | Publisher Full Text
  • 110.  Gould MS: Suicide and the media. Ann N Y Acad Sci. 2001; 932: 200–21; discussion 221–4. PubMed Abstract | Publisher Full Text
  • 111.  Gould MS, Wallenstein S, Kleinman M: Time-space clustering of teenage suicide. Am J Epidemiol. 1990; 131(1): 71–8. PubMed Abstract | Publisher Full Text
  • 112.  Gould MS, Wallenstein S, Kleinman MH, et al.: Suicide clusters: an examination of age-specific effects. Am J Public Health. 1990; 80(2): 211–2. PubMed Abstract | Publisher Full Text | Free Full Text
  • 113.  Ougrin D, Tranah T, Stahl D, et al.: Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2015; 54(2): 97–107.e2. PubMed Abstract | Publisher Full Text
  • 114.  Iyengar U, Snowden N, Asarnow JR, et al.: A Further Look at Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: An Updated Systematic Review of Randomized Controlled Trials. Front Psychiatry. 2018; 9: 583. PubMed Abstract | Publisher Full Text | Free Full Text | F1000 Recommendation
  • 115.  Glenn CR, Esposito EC, Porter AC, et al.: Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth. J Clin Child Adolesc Psychol. 2019; 48(3): 357-92. PubMed Abstract | Publisher Full Text | Free Full Text
  • 116.  Chambless DL, Hollon SD: Defining empirically supported therapies. J Consult Clin Psychol. 1998; 66(1): 7-18. PubMed Abstract | Publisher Full Text
  • 117.  Linehan MM: Cognitive behavioral treatment of borderline personality disorder. Guilford Press, New York, 1993. Reference Source
  • 118.  Miller AL, Rathus JH, Linehan MN, et al.: Dialectical Behavior Therapy Adapted for Suicidal Adolescents. J Psychiatr Pract. 1997; 3(2): 78–86. Publisher Full Text
  • 119.  Miller AL, Rathus JH, Linehan MM: Dialectical behavior therapy with suicidal adolescents. Guilford Press, New York, NY. 2007. Reference Source
  • 120.  Mehlum L, Tørmoen AJ, Ramberg M, et al.: Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. J Am Acad Child Adolesc Psychiatry. 2014; 53(10): 1082–91. PubMed Abstract | Publisher Full Text | F1000 Recommendation
  • 121.  Mehlum L, Ramberg M, Tørmoen AJ, et al.: Dialectical Behavior Therapy Compared With Enhanced Usual Care for Adolescents With Repeated Suicidal and Self-Harming Behavior: Outcomes Over a One-Year Follow-Up. J Am Acad Child Adolesc Psychiatry. 2016; 55(4): 295–300. PubMed Abstract | Publisher Full Text
  • 122.  McCauley E, Berk MS, Asarnow JR, et al.: Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA Psychiatry. 2018; 75(8): 777–785. PubMed Abstract | Publisher Full Text | Free Full Text
  • 123.  Berk M, Adrian M, McCauley E, et al.: Conducting Research on Adolescent Suicide Attempters: Dilemmas and Decisions. Behav Ther (N Y N Y). 2014; 37(3): 65–9. PubMed Abstract | Free Full Text
  • 124.  Vigod SN, Kurdyak PA, Dennis CL, et al.: Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. Br J Psychiatry. 2013; 202(3): 187–94. PubMed Abstract | Publisher Full Text | F1000 Recommendation
  • 125.  Owen C, Rutherford V, Jones M, et al.: Psychiatric rehospitalization following hospital discharge. Community Ment Health J. 1997; 33(1): 13–24. PubMed Abstract | Publisher Full Text
  • 126.  Loch A: Discharged from a mental health admission ward: Is it safe to go home? A review on the negative outcomes of psychiatric hospitalization. Psychol Res Behav Manag. 2014; 7: 137–45. PubMed Abstract | Publisher Full Text | Free Full Text
  • 127.  Introduction to a Special Issue Dialectical Behavior Therapy: Evolution and Adaptations in the 21st Century.Miller AL: Am J Psychother. 2015; 69(2): 91–5. PubMed Abstract | Publisher Full Text

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 24 Oct 2019
Comment
Author details Author details
Competing interests
Grant information
Article Versions (1)
Copyright
Download
 
Export To
metrics
Views Downloads
F1000Research - -
PubMed Central
Data from PMC are received and updated monthly.
 - -
Citations
SEE MORE DETAILS
CITE
how to cite this article
Clarke S, Allerhand LA and Berk MS. Recent advances in understanding and managing self-harm in adolescents [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.12688/f1000research.19868.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.

Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 24 Oct 2019
Views
1
Cite
Reviewer Report 24 Oct 2019
Daniel Sampaio, Department of Psychiatry, Faculty of Medicine, University of Lisbon, Lisboa, Portugal 
Approved
VIEWS 1
https://doi.org/10.5256/f1000research.21797.r55409
I confirm that I have read this submission and believe that I have an ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Sampaio D. Reviewer Report For: Recent advances in understanding and managing self-harm in adolescents [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.5256/f1000research.21797.r55409)
The direct URL for this report is:
https://f1000research.com/articles/8-1794/v1#referee-response-55409
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Report a concern
Views
1
Cite
Reviewer Report 24 Oct 2019
Dennis Ougrin, Child and Adolescent Psychiatry, King's College London, London, UK 
Approved
VIEWS 1
https://doi.org/10.5256/f1000research.21797.r55410
I confirm that I have read this submission and believe that I have an ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Ougrin D. Reviewer Report For: Recent advances in understanding and managing self-harm in adolescents [version 1; peer review: 2 approved]. F1000Research 2019, 8(F1000 Faculty Rev):1794 (https://doi.org/10.5256/f1000research.21797.r55410)
The direct URL for this report is:
https://f1000research.com/articles/8-1794/v1#referee-response-55410
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Report a concern

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 24 Oct 2019
Comment

Open Peer Review

Reviewer Status

Alongside their report, reviewers assign a status to the article:

Approved
The paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved
Fundamental flaws in the paper seriously undermine the findings and conclusions

Reviewer Reports

Invited Reviewers
1 2
Version 1
24 Oct 19 		read read
  1. Dennis Ougrin, King's College London, London, UK
  2. Daniel Sampaio, University of Lisbon, Lisboa, Portugal

Comments on this article

All Comments(0)

Add a comment
Sign up for content alerts

Browse by related subjects

    keyboard_arrow_left Back to all reports
    keyboard_arrow_left Back to all reports
    Alongside their report, reviewers assign a status to the article:
    Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
    Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
    Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
    Sign In
    If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password.

    The email address should be the one you originally registered with F1000.
    Email address not valid, please try again

    You registered with F1000 via Google, so we cannot reset your password.

    To sign in, please click here.

    If you still need help with your Google account password, please click here.

    You registered with F1000 via Facebook, so we cannot reset your password.

    To sign in, please click here.

    If you still need help with your Facebook account password, please click here.

    Code not correct, please try again
    Email us for further assistance.
    Server error, please try again.