1. Phenomenon of Pediatric Self-Harm: Non-Suicidal Self-Injury
Amanda Robinson & Madeline Chambers
Georgetown University School of Nursing & Health Studies, Washington, D.C.
Abstract
Non-suicidal self-injury (NSSI) is a maladaptive behavior that has steadily increased within the two
last decades among school-aged youth. Despite the increasing problem, it is rare for schools to have
“well-articulated protocols for detecting, intervening in, and preventing self-injury” (Bubrick,
Goodman, Whitlock, 2010). This makes it difficult for the school staff, including nurses, educators and
counselors to know the best practices for detecting and responding to these students who self-injure
and as a result these students go undetected and untreated. The school setting, while highly
undervalued as an avenue to promote good mental health among students, serves as a perfect
environment for preventing, detecting, and intervening in NSSI. Though a universal protocol for NSSI is
not realistic, we will discuss the importance of developing a protocol that focuses on and includes the
education of staff and students, the role of the nurse, and how to effectively detect, assess and
intervene in cases of NSSI.
Introduction
Non-suicidal Self Injury (NSSI) is defined
as the deliberate, self-inflicted destruction of
body tissue without suicidal intent and for
purposes not socially sanctioned. Behaviors
include intentional cutting, carving, or
puncturing of the skin, scratching, burning,
ripping or pulling skin or hair, and self-bruising
(Bubrick, et al., 2010). The population of focus is
school-aged youth, specifically pre-adolescent
to adolescent, ages 12-18. According to the
Cornell Research Program on Self-Injury and
Recovery, among secondary school and young
adult populations, studies typically find that
12% to 24% of adolescents have reported self-
injury at least once in their life and about 6%-
8% of adolescents and young adults report
current, chronic self-injury (Whitlock, 2014).
While NSSI typically begins in mid-adolescents,
there is “no one profile” or “one group to
categorize” for being more at risk for NSSI
(Whitlock, 2014). However, there are factors
identified that predispose or possibly trigger
self-harming behaviors including bullying,
traumatic life events, a death in the family,
knowledge of self-harm among peers or
discomfort regarding their sexual identity
(Peterson, Freedenthal, Sheldon & Anderson,
2008).
Considering a specific profile is
unidentified, this growing phenomenon of NSSI
among adolescents may be explained simply by
this stage in life. In fact, this period of life is
generally the most common period of onset for
major mental health disorders (Whitlock &
Rodham, 2013). The developmental stage of an
adolescent is kind of the “perfect storm” for
engaging in self-harming behaviors. According
to the literature, “adolescence show high
physiological and neurological sensitivity to
external emotional cues, particularly social
rejection and acceptance.” They also tend to feel
emotions, especially negative emotions, more
intensely. Unfortunately—hence the “perfect
storm”—adolescence have not been taught and
have not mastered effective coping mechanisms
to manage the daily stressors of normal life and
upsets, much less traumatic experiences. So, in
an attempt to maintain “emotional equilibrium”
a rather sensible coping mechanism in their
mind can understandably be self-injury
(Whitlock, et al., 2013).

2. 2
Background
NSSI vs. Suicide
NSSI is distinguished from suicide in its
intention meaning that self-injury is intended to
relieve emotional pain or “to feel something in
the presence of nothing,” while suicide is
intended to cause death (Bubrick et al., 2010).
Understanding the distinction between the two
is a fundamental prerequisite for understanding
NSSI, however, one must understand, that NSSI
ultimately is a risk factor for suicide.
Furthermore, as the severity of self-injury
increases, one’s risk of suicidality increases as
well (Bubrick et al., 2010). Over 50% of
adolescents who engage in NSSI report no
suicidal thoughts or behaviors. While 35%-45%
will report some level of suicidality that is
either present in the same general period of
NSSI behaviors or after periods of life where
these behaviors have stopped (Whitlock et al.,
2015). NSSI is considered a risk factor because
the act of self-injury itself “lowers the
inhibition” to the rather non-instinctual acts of
suicidal behaviors. Human nature, in and of
itself, makes it difficult to overcome the
psychological and physical barriers of choosing
to intentionally end one’s life. However, NSSI
“provides practice [in] damaging the body…
making it easier to carry out suicidal intention”
(Whitlock, 2010). Therefore, no matter the
severity of self-injury when discovered, even
one act of self-injury is concerning and should
be taken seriously.
Why do adolescents self-injure?
NSSI is a difficult behavior to understand
and possibly an even harder one to confront
because the behavior is instinctively confusing,
as it appears to defy “deep instinctual human
drives for self-preservation” (Whitlock, 2013).
In the literature, researchers have not agreed
upon a set of primary reasons for self-injury
perhaps because the nature of this complex
behavior seems to provide many different
functions depending on each individual
situation (See Box 1). Nevertheless, the reasons
for “why” the adolescent started to self-injure
may not be as important as understanding
“why” self-injury has the potential to evolve into
a chronic, maladaptive coping behavior. In fact,
it is clear according to the literature that
“reasons for continuing to self-injure may have
little to do with how it was discovered in the
first place” (Whitlock et al., 2013).
Box1. Possible Reasons forSelf-Injury
 Feelings of overwhelming negative emotions
or emotional pressure
 Emotional numbness and sadness
 A means of coping with anxiety or other
negative feelings and to relieve stress or
pressure
 To cope withanxiety or other negative feelings
 To relieve stress or pressure
 To feel in control overone’s body and mind
 To cope withanxiety or other negative feelings
 Express feelings
 Distract oneself from other problems
 Communicate needs
 Create visible and noticeable wounds
 Purify oneself
 Reenact a trauma in an attempt to resolve it
 Protectothers fromone’s emotional pain
 A release fornegative emotion
(Whitlock,2010)
Theory: Pain, Offset, Relief
Most people go through great lengths in
their life to avoid and protect themselves from
unwanted painful situations or experiences and
so the question remains: why are adolescents,
in particular, attracted to self-injury, that is
physical pain, as this defies the human instinct
to be afraid of truly feeling pain? (Franklin,
2014). The attraction to physical pain may be
explained by the theory of “pain, offset, relief.”
This theory suggests that a person who engages
in self-injury does experience uncomfortable,
unpleasant and possibly excruciating pain,
contrary to popular belief. However, “once
whatever is causing the pain is removed or even

3. 3
reduced slightly,” the person feels better. In fact,
“there is something about the removal of
physical pain that brings a strong sense of relief
in and of itself.”
Even more importantly though, once the
painful stimulus is removed, which is referred
to as “pain offset,” the person feels significantly
better than they had before. This more pleasant,
more manageable, and less overwhelming
feeling is called “relief.” This occurs because
researchers have found that the brain cannot
actually distinguish the difference between
“feeling hurt physically” compared to “feeling
hurt emotionally.” This shows that the brain,
while not only feeling “relief” from physical pain
also interprets the removal of pain as a “relief”
from emotional pain (Franklin, 2014). This
theory in some way, answers the question
above that every human being can relate to:
everyone at some point in their life will suffer
and feel pain in some capacity and everyone
instinctively copes so that their suffering will
hurt less, feel less overwhelming and seem less
scary. Therefore, for some, physical pain hurts
less and the removal of it even provides relief.
What are the barriers to seeking help?
NSSI tends to be a particularly secretive
behavior, one that can go undetected for years
because adolescents are afraid to seek help.
These barriers to seeking help vary from
student to student (See Box 2). No matter the
reason, it is concerning that the society in which
these children grow up in, the schools they
attend, the activities they participate in and the
families in which they grow up in, create a
culture of fear making asking for help seem
nearly impossible.
Dr. Stephen Lewis, the co-director of
Self-injury Outreach & Support Foundation
(SiOS), spoke about his own personal struggles
with NSSI on Tedx: In his speech, Dr. Lewis
explained that his self-injury eventually turned
into a “viscous cycle” that lead him to “isolation,
despair, emptiness and hopelessness,” and
eventually thoughts of suicide. He said that his
wounds and scars, at least to him, “seemed to
say so much and speak so loudly but
paradoxically silenced” him. He was silenced by
his “own shame” because he feared that people
would view him differently, he was afraid of
people’s reactions and worse he said, he was
afraid that “people would see me as I saw
myself…worthless.” Dr. Lewis’ testimony is an
example of how the experience of “relief” is only
temporary because he found that using self-
harm as a way to regulate emotions or “to gain a
sense of control” inevitably broke down and
became less effective (Peterson et al., 2008).
This further shows that regardless of any
positive benefits one initially receives from self-
harm, it appears that self-harm further
“perpetuate[s] their negative feelings about self,
creating further anxiety and the need to
punish”—thus, a vicious cycle emerges
(McAndrew & Warne, 2014).
Box2. Barriers to seeking help
 Belief that others would not understand their
self-harming behavior
 Fear of confidentiality being breached
 Fear of being seen as “attention-seeking”
 Uncertainty of whether parents or teachers
could do anything to help
 Fear that others wouldreact negatively if self-
harm was disclosed
 Fear of being stigmatized
 Depression, anxiety, suicidal ideation
 Minimization of self-harm as a problem
 The belief that one could or should be able to
cope on one’s own
(Roweet al, 2014)
Importance of a School Protocol
School protocols, in general, can be
created in an effort to guide the actions of
school personnel in circumstances where a
situation with a student may be uncomfortable
or life threatening. The protocol provides a
guideline for safe practices so that students are
more effectively and appropriately cared for
and supported. Establishing a school protocol

4. 4
also ensures that a school’s “legal
responsibilities and liabilities are addressed”
because it provides school staff with the
knowledge of how to respond to a situation in a
systematic and strategic way (Bubrick, 2010).
While many schools have a protocol and an
action plan in place for suicide, the growing
prevalence and subsequent risks of self-injury
proves that it is equally important for schools to
develop and implement a protocol for non-
suicidal self-injury (NSSI). The following
protocol is adapted from the Cornell Research
Program on Self-Injury and Recovery and the
essential components of a NSSI protocol are
summarized in Box 3.
Box3. What is included in the school protocol?
 Designate a crisis team and establish roles of
team members.
 Designate a point person to be the liaison
between the student, parent, nurse and school.
 Educate staff and students about self-injury
 Identify/detectself-injury
 Assess self-injury
 Determine under what circumstances the
parents should be contacted
 Manage active student self-injury (with self-
injurious student, peers, parents, and external
referrals)
 Identify/determine when and how to issue
outside referrals
 Identify appropriate community resources
(Bubrick et al., 2010).
Introduction to Protocol
When creating a protocol, the first step is
identifying a school crisis team: possibly
consisting of guidance counselors, school
nurses, school social workers, school
psychologists, administrators, and teachers who
feel comfortable and desire to form
relationships with and help students who self
injure. Each group member in the team will
serve a particular purpose, whose roles are
clearly established. However, each school,
depending on available resources, will have a
crisis team that looks differently. Regardless of
the team make-up, a person must be specifically
appointed “to serve as the main liaison”
between the student, nurse, parent and school
administration (Whitlock, 2013). Another
essential individual is the school nurse, whose
main role is to establish an initial relationship
and perform the initial assessment.
Staff Education
Educating staff members about NSSI is an
essential part of the protocol because staff, in
particularly teachers, play a role in detecting
students who self-injure, as they spend a
considerable amount of the day with students.
As a result, school staff members need to be
acutely aware of the NSSI protocol and be
trained in how to follow the procedures.
Included in their education is how to identify
signs and symptoms of NSSI (See Box 4), how to
recognize the difference between self-injury and
suicidal behavior, how to respond if a student
requires immediate attention, and who the
appropriate point person the student should be
referred to.
Box4. Signs and Symptoms
 Arms, fists, and forearms opposite dominant
hand are the most likely sites of injury but may
appear anywhere on the body
 Inappropriate dress for season (wearing long
sleeves or pants in summer)
 Constant use of wrist bands/coverings
 Unwillingness to participate in events or
activities whichrequire less body coverage
(swimming, gym class)
 Frequent bandages, odd or unexplainable
paraphernalia (razorblades)
 Heightened burns, cuts, scars, or other clusters
of similar markings on the skin (Bubricket al.,
2010)

5. 5
School protocol: Action plan
There are a couple of ways the crisis team
can detect self-injury: a staff member suspects
student self-injury, a peer discloses a student’s
self-injury to staff member, or a student
discloses personal self-injury to staff member.
Regardless of how this behavior was detected
and regardless of which staff member
encounters the student first, the adolescent
should be treated as someone who is
experiencing some level of distress and it
should always be a cause for concern. Further, a
student should be treated in a nonjudgmental,
nonthreatening and validating manner. This
staff person needs to be directly honest with the
student about school protocol, which requires
he/she to share their knowledge with the
“designated point person,” but should assure
the student that all information will remain
strictly confidential (Bubrick et al., 2010).
An essential part of educating teachers is
explaining what to do when self-injury is
suspected: a teacher should be “direct and
honest” about what he/she observes and about
what concerns he/she has. It is important to
respect the student’s privacy and make it clear
to the student that their privacy is protected. If
the student denies self-injury in any way, do not
push or aggravate the student. Instead, keep the
conversation open, making it clear to the
student that he/she has support and someone
to talk to if ever desired. It is important for the
teacher to “stay connected to the student and
look for further opportunities to ask” questions
(Whitlock, 2009).
School Nursing Implications
The next proposed step in the protocol is a
nursing assessment. Research suggests that
there is an appropriate and effective way to
approach the assessment. To build trust and
establish an honest communication between the
nurse and student, the nurse should, as Dr.
Barry Walsh calls it, have “respectful curiosity.”
Respectful curiosity is defined as having a
“dispassionate manner,” while having “genuine
curiosity and willingness to know and
understand” the student’s self-injury (Bubrick
et al., 2010). It should be assumed the first
assessment with the nurse, especially if it is the
first time the student is accepting help, is a
rather emotional, scary moment that puts the
adolescent in a particularly vulnerable position.
To approach this assessment with respectful
curiosity, it would be wise then to start by
asking simple, open-ended questions, which
gives the student freedom to answer the way
he/she feels comfortable. It is also important to
choose your words wisely and make your
intentions clear—possibly accomplished by
asking permission to ask questions or by
starting statements using “I” (Whitlock &
Purington, 2013).
Nursing Assessment
The first priority of the nursing
assessment is to evaluate the immediate harm
that self-injury poses to the student. This
includes assessing the severity of the student’s
self-injury, which is determined by the
“frequency of the behavior and the number of
different methods used” (Kerr, 2010). This also
includes assessing a student’s risk for suicide by
inquiring about the presence of suicidal
thoughts or current plans of suicide. After the
assessment of immediate danger, the nurse
should inspect the student’s wounds and assess
for risks of infection. The nurse should treat
unhealed wounds first and then take a moment
to discuss ways in which the student can safely
care for possible future wounds (Whitlock,
2010). The complete nursing assessment is
summarized in Box 6. According to the protocol,
the action plan and goal, after detecting a self-
injurer and then performing an initial
assessment, is to refer the student to the
appropriate point person, such as school
counselor to create a plan of care individualized
to the student’s needs. The action plan of the
school protocol is represented in Diagram 1.

6. 6
School Implications
Student Education
The implementation of student
education and prevention of NSSI is arguably
the most important aspect of the protocol,
because it is the foundation in which the school
can most effectively create a positive change. In
regards to student education, it is important to
know that students should not be given detailed
information about NSSI behavior. The basic
education recommended includes providing
students with the knowledge of how to
recognize and respond to a friend in distress “as
well as how to deal with common mental and
emotional health challenges in themselves”
(Whitlock & Purington, 2013). Furthermore,
student education includes addressing the
“underlying issues that engender” NSSI
behaviors in the first place. Primarily that
adolescent’s find it difficult to identify, accept
and manage emotion, often have “negative
thinking styles (pessimism, learned
helplessness, rumination)” and have no coping
alternatives. Schools should feel responsible for
teaching students positive coping skills as well
as for empowering students to learn what they
are good at and in turn find ways to use these
strengths to cope with hard situations so they
can thrive.
Changing the culture of mental health
Although a world without pain, hurt and
disease does not exist and is one that this
protocol cannot create, it can offer an
opportunity to draw society closer to a more
compassionate, understanding and healthy
environment all humanity desires. “Schools are
uniquely poised to raise awareness about NSSI
and about mental health issues in general
among their students” (Whitlock & Purington,
2013). If schools did follow through with this
responsibility, they have the power to create an
environment where mental health issues are no
longer stigmatized. Schools have the power to
start conversations in an effort to give students
the knowledge and skills they need to thrive,
even through challenges and adversities.
Perhaps the first place to start to improve the
quality of life among all students is creating a
safe environment void of all judgment, shame
and fear but instead full of compassion, charity
and hope. Start by making it perfectly clear to
students that asking for help is OK, that it is not
a sign of weakness and they do not need to
suffer alone.
Box 5. Nursing Assessment
 Suicidal ideations during or before self-injury
 Types/methods of self-injury
 Onset of self-injury
 Location on the body that is injured
 Severity and extent of damage caused by self-
injury
 Ask if wounds were ever more severe than
intended
 Intensity of self-injury urges
 Episodic frequency of self-injury
 Extent of support system
(Kerr, 2010)

7. 7
Diagram 1. Action Plan Protocol
Adapted from: Bubrick, K., Goodman, J. & Whitlock, J. (2010).
Detect student
who self-injures:
Staff suspects
student self-
injury;
Peer disclosure of
self-injury;
Self-disclosure
Nurse
treats
wounds and
assesses
lethality
Contact
emergency
services if
wounds are
severe or
student is
suicidal, or
student's life
is in danger
Nurse
assesses
student
Assessment:
-Types/methods
of self-injury
-Onset of self-
injury
-Location on the
body that is
injured
-Severity and
extent of damage
caused by self-
injury
-Intensity of self-
injury urges
-Episodic
frequency of self-
injury
-Extent of support
system
Nurse identifies student as low risk:
-Refer student to point person (e.g. school counselor)
-Discuss functions of the behavior
-Discuss triggers that lead to self-injury
-Make care-plan with student. Student identifies needs.
-Encourage contact with family
-Nurse follows up with student 2 weeks later
Nurse identifies student as moderate or high risk:
-Refer student to to point person (e.g. school
counselor)
-Discuss functions & triggers of behavior
-Student identifies what support he/she needs
-Point person encourges contact with family &
encourages a family meeting
-Encourage student to seek outside professional
care/services
-Point person offers student time to talk at any point in
school day.
-Nurse follow-ups 2 weeks later

8. 8
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