Nonsuicidal self-injury among youth

Impact of mentalization, identity diffusion and psychopathology on nonsuicidal self-injury among adolescents

INTRODUCTION

Nonsuicidal self-injury (NSSI) has become a major public health issue in adolescents. This cross-sectional case-controlled study aims to assess the impact of identity diffusion, psychopathology, and mentalization on NSSI in adolescence.

METHODS

The study sample consisted of 153 adolescents (76.5% girls; Mage = 15.6 years). The sample included 56 clinical cases of NSSI, 45 psychiatric cases without NSSI, and 52 healthy controls, all recruited in Ankara, Türkiye, from June 1, 2022, to August 31, 2022. Mentalization was assessed by "The Movie for the Assessment of Social Cognition" (MASC) which categorizes mentalizing as "correct mentalizing" "hypermentalizing" "undermentalizing" and "no-mentalizing". All participants filled in the Self-Injurious Behavior Screening Questionnaire, Assessment of Identity Development in Adolescence (AIDA), and Youth Self Report (YSR), and Inventory of Statements About Self-injury (ISAS).

RESULTS

The NSSI group showed lower mentalizing capacity than the healthy control group (p = .011), and more no-mentalizing errors than the other two groups (p = .014). Identity diffusion scores were higher in the NSSI group than in the other two groups (p < .001). Multivariate logistic regression analysis showed that the presence of maternal psychiatric disorder (p = .019, OR = 5.21), identity diffusion (p = .007, OR = 1.02), no mentalizing (p = .049, OR = 1.28), and total psychopathology symptoms (p = .009, OR = 1.12) had a significant impact on NSSI.

CONCLUSIONS

Current findings suggest that transdiagnostic approaches, including mentalization and identity diffusion, may contribute to a more comprehensive understanding of NSSI and to the development of clinical interventions.

Typologies of Non-Suicidal Self-Injury Functions and Clinical Correlates Among Inpatient Youth

This study identified typologies of specific non-suicidal self-injury (NSSI) functions among youth admitted for psychiatric hospitalization and investigated clinically relevant correlates. Inpatient youth (n = 68) aged 10-17 years reported on their reasons to engage in NSSI, frequency and severity of NSSI, and symptoms of borderline personality disorder (BPD). A latent class analysis using youth's specific NSSI functions as indicators found two NSSI function typologies, which were differentially associated with clinical correlates. The Multiple Functions class (n = 28) endorsed to "feel something," "punish self," "escape feelings," "relieve anxiety," "stop feeling self-hatred," "stop feeling angry," "show much they are hurting," and "create a hurt that can be soothed." Conversely, the Single/Avoidant Function class (n = 40) endorsed one primary function-i.e., to "escape feelings." Youth in the Multiple Functions class reported significantly more frequent self-injury and greater BPD symptomology. The present study illustrates the importance of examining constellations of specific NSSI functions in inpatient care settings, given their unique associations with NSSI frequency and features of BPD. These findings could inform targeted psychological screening and, in turn, guide the implementation of interventions for elevated NSSI frequency and BPD symptomology among inpatient youth, based on NSSI functions endorsed.

How do professionals and non-professionals respond to non-suicidal self-injury? Lived experiences of psychiatric outpatients in Singapore

BACKGROUND

For young people who engage in non-suicidal self-injury (NSSI), receiving negative responses to their NSSI can pose a barrier to future help-seeking. This qualitative study aimed to explore helpful and unhelpful ways in which professionals and non-professionals respond to NSSI, from the perspectives of individuals with lived experiences of NSSI.

METHODS

Semi-structured interviews were conducted with 20 outpatients (6 males, 14 females) aged 17 to 29 years from a tertiary psychiatric hospital in Singapore, who had reported engaging in NSSI behavior in an earlier study. The interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify themes and subthemes in the data.

RESULTS

Professionals' responses were organized into three main themes: 'prescribing solutions without understanding needs', 'disapproval or judgment', and 'helpful responses'. Non-professionals' responses were organized into four main themes: 'emotionally charged responses', 'avoidance and inaction', 'poor understanding of reasons for NSSI', and 'providing tangible support and acknowledging NSSI'. Participants also described how unhelpful responses negatively impacted their willingness to seek help.

CONCLUSIONS

Our findings provide a better understanding of responses to NSSI that are considered helpful and unhelpful, and can be used to improve existing guidelines on responding to NSSI.

Trauma-Informed Approach to Qualitative Interviewing in Non-Suicidal Self-Injury Research

Non-suicidal self-injury (NSSI) is recognized as a public health concern owing to its chronic nature, association with suicide risk, and its growing prevalence rates across the globe. Including individuals living with NSSI in research is crucial as it offers opportunities to give primacy to participant voices and insights, further guiding therapeutic interventions. Research has established an association between history of traumatic events and adverse childhood experiences with subsequent risk of NSSI. When planning a qualitative research study with individuals with potential trauma history, researchers need to be aware of and sensitive to potential re-traumatization and distressing emotions that participants may experience during interviews, as well as complex trauma reactions that may affect individuals after study participation. The article emphasizes that researchers be cognizant of the multifaceted nature of trauma and how it can impact individuals and communities and be sensitive in their approach to interviewing vulnerable groups such as individuals with experiences of NSSI. The authors propose adopting a trauma-informed approach to ethically plan and conduct qualitative interviews exploring NSSI experiences. Trauma-informed recommendations for preparing and carrying out specific steps during different stages of NSSI interviews are detailed.

Reasons for recovery and readiness to change among adolescents and young adults engaging in self-injury

Background

Non-suicidal self-injury (NSSI) typically begins during adolescence and the process of treatment and recovery can be challenging. We examine NSSI through the lens of the Transtheoretical Model of Change, a framework that views the process of change as five stages, with differing degrees of readiness to change.

Methods

Thirty participants, both adolescents and young adults (14 to 35 years), were recruited from a tertiary care neuropsychiatric hospital. The participants were predominantly female and had self-injured at least once in the last year. They completed the Inventory of Statements about Self Injury, the University of Rhode Island Change Assessment and the Reasons to Stop Self-Injury Questionnaire.

Results

Seventy-three percent were in the contemplation stage with respect to their readiness to change, while the rest were in the pre-contemplation stage. Participants endorsed a range of vulnerability and resilience related reasons to stop injuring; reasons related to self-efficacy, the addictive nature of NSSI, self-efficacy and impact on interpersonal relationships were prominent levers for the recovery process. Preliminary trends indicated that participants in the contemplation stage endorsed reasons to stop self-injuring more strongly than those in pre-contemplation.

Conclusion

The findings carry implications for assessment, the amplification of reasons for recovery and individualized interventions to support the recovery process with individuals who engage in NSSI.

NSSI questionnaires revisited: A data mining approach to shorten the NSSI questionnaires

BACKGROUND AND OBJECTIVE

Non-suicidal self-injury (NSSI) is a psychological disorder that the sufferer consciously damages their body tissues, often too severe that requires intensive care medicine. As some individuals hide their NSSI behaviors, other people can only identify them if they catch them while injuring, or via dedicated questionnaires. However, questionnaires are long and tedious to answer, thus the answers might be inconsistent. Hence, in this study for the first time, we abstracted a larger questionnaire (of 662 items in total) to own only 22 items (questions) via data mining techniques. Then, we trained several machine learning algorithms to classify individuals based on their answers into two classes.

METHODS

Data from 277 previously-questioned participants is used in several data mining methods to select features (questions) that highly represent NSSI, then 245 different people were asked to participate in an online test to validate those features via machine learning methods.

RESULTS

The highest accuracy and F1 score of the selected features-via the Genetics algorithm-are 80.0% and 74.8% respectively for a Random Forest algorithm. Cronbach's alpha of the online test (validation on the selected features) is 0.82. Moreover, results suggest that an MLP can classify participants into two classes of NSSI Positive and NSSI Negative with 83.6% accuracy and 83.7% F1-score based on the answers to only 22 questions.

CONCLUSION

While previously psychologists used many combined questionnaires to see whether someone is involved in NSSI, via various data mining methods, the present study showed that only 22 questions are enough to predict if someone is involved or not. Then different machine learning algorithms were utilized to classify participants based on their NSSI behaviors, among which, an MLP with 10 hidden layers had the best performance.

The Effectiveness of Emotion Regulation Therapy for Adolescent Females With Nonsuicidal Self-Injury Disorder: A Mixed-Method Study

Given the prevalence and consequences of the nonsuicidal self-injury disorder (NSSID) among adolescents, this study aimed to analyze the effectiveness of emotion regulation therapy (ERT) among adolescents with NSSID. The present study is an after-trial, mixed-method intervention design. Six participants completed questionnaires at baseline, during their treatment, and follow-up. In-depth interviews were made after the intervention. The quantitative findings were consistent with the pattern of the qualitative findings that prominently supported the treatment efficiency concerning the difficulties in emotion regulation. The research findings indicated that ERT had a positive effect on adolescents with NSSID.

Self-Injury Is My Drug: The Functions of Describing Nonsuicidal Self-Injury as an Addiction

ABSTRACT

Adolescents and emerging adults who engage in nonsuicidal self-injury (NSSI) often participate in online activity regarding their self-injury. Of particular importance are the potential benefits and risks associated with online NSSI activity, including how individuals describe their NSSI experiences. One way that individuals describe these experiences is by discussing NSSI as an addiction. Accordingly, we used thematic analysis to explore why individuals may use addiction references to describe their NSSI experiences. To do this, we examined 71 posts from a popular NSSI social network. Four themes emerged: difficulty inherent in stopping, authentication, warn others, and communicate the plight of the behavior. Findings highlight a number of avenues for research as well as implications for clinicians working with clients who self-injure perceive NSSI as an addiction. Mental health professionals can leverage their understanding of clients' perceptions of NSSI to better serve this population.

Needs of Youth Posting About Nonsuicidal Self-Injury: A Time-Trend Analysis

PURPOSE

Many youth who engage in nonsuicidal self-injury (NSSI) go online for information, resources, and support. Although research has noted the potential benefits and risks of online NSSI activity, little is known about the NSSI-related needs that youth express on social media, and, importantly, when these posts occur. This study elucidates the nature of these NSSI-related needs and how they may vary temporally, by time of day or day of week.

METHODS

A total of 3,500 posts made by 2,799 users of an international mental health-focused social network app were analyzed for the presence of NSSI-related needs. Posts were coded using a rubric that was developed using existing knowledge about youth's online NSSI activity. Furthermore, prominently expressed needs were tested for associations with specific times of the day and days of the week.

RESULTS

Users' frequently posted about suicidal ideation and behaviors, and difficult emotions; documented NSSI urges and interpersonal difficulties; and expressed feeling misunderstood and isolated. Furthermore, specific needs occurred more frequently during different times of the day (e.g., users were more likely to express suicidal ideation and behaviors just before midnight).

CONCLUSIONS

These findings have important implications for mental health professionals and policy makers. Youth who post about NSSI could benefit from the provision of tailored, evidence-based resources during times of need. Furthermore, clinicians may need to assess youth's online activity to inform intervention strategies and meet their NSSI-related needs.

Association of Internet Addiction With Nonsuicidal Self-injury Among Adolescents in China

IMPORTANCE

Both nonsuicidal self-injury (NSSI), defined as the direct, deliberate damage of one's body tissue without suicidal intent, and internet addiction among adolescents are public health concerns. However, the possible association of NSSI with internet addiction is not well understood.

OBJECTIVE

To examine the occurrence of internet addiction with NSSI and any sex differences among Chinese adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter, cross-sectional, survey study was conducted from February 18 to October 15, 2015, among adolescents aged 11 to 20 years from 343 classes in 45 public high schools across 5 provinces of China. Data analysis was performed from August 1, 2018, to March 1, 2019.

EXPOSURES

Possible internet addiction and internet addiction.

MAIN OUTCOMES AND MEASURES

Less-frequent (1-4 times) NSSI and more-frequent (≥5 times) NSSI were surveyed using the Chinese version of the Functional Assessment of Self-Mutilation.

RESULTS

A total of 15 623 students (8043 male [51.5%] and 7580 female [48.5%]) aged 11 to 20 years (mean [SD] age, 15.1 [1.8] years) participated. Of these, 4670 participants (29.9%) met the criteria for possible internet addiction and 509 participants (3.3%) met the criteria for internet addiction. A total of 2667 students (17.1%) engaged in less-frequent NSSI, while 1798 students (11.5%) engaged in more-frequent NSSI in the 12 months preceding the survey. Both possible internet addiction and internet addiction were associated with less-frequent or more-frequent NSSI. The adjusted odds ratios were 1.29 (95% CI, 1.17-1.42) for possible internet addiction and 1.41 (95% CI, 1.11-1.80) for internet addiction for less-frequent NSSI; for more-frequent NSSI, the adjusted odds ratios were 1.75 (95% CI, 1.56-1.96) for possible internet addiction and 2.66 (95% CI, 2.10-3.38) for internet addiction. These associations were similarly observed among age groups of 11 to 14, 15 to 17, and 18 to 20 years. No sex disparities were found in the associations of internet addiction with NSSI, except among adolescents aged 11 to 14 years, where the odds ratios for possible internet addiction with less-frequent NSSI were higher in male adolescents (1.53; 95% CI, 1.25-1.88) than female adolescents (1.13; 95% CI, 0.90-1.47).

CONCLUSION AND RELEVANCE

Internet addiction appears to be associated with NSSI, and the findings of this study suggest that the association was similar between male adolescents and female adolescents. These data suggest that evaluation of the risk of NSSI for adolescents in association with internet addiction may help health care professionals in developing preventive interventions for NSSI.

Rethinking self-injury recovery: a commentary and conceptual reframing

A growing body of research has focused on understanding what may contribute to cessation of self-injury. Although these efforts are of value, cessation represents just one component of self-injury recovery. Exclusive or primary focus on cessation may foster unrealistic expectations for those with lived experience of non-suicidal self-injury (NSSI). Accordingly, this commentary discusses the importance of expanding the concept of NSSI recovery beyond cessation in both research and clinical domains. We conclude by presenting a person-centred and non-stigmatising conceptual reframing of recovery.

Narratives of Self-Harm at School: Identifying Trajectories of Intervention in Educational Contexts

Recent studies have shown that self-harming behaviour is increasingly widespread among adolescents, in particular at school. However, educational institutions perceive themselves unable to cope with the phenomenon, searching for protocols and guidelines to improve its management. Considering schools as useful contexts for intercepting the young malaise, this study aims at exploring the main meanings of self-harming behaviours made within the educational cultural contexts starting from the student’s narrations, in order to understand the possible trajectories of practice. In two high schools we have collected 96 narratives of self-harm written by adolescents (mean age 14; 74% females), who have been engaged in non-suicidal self-injury once in their life. The analysis of the narratives, produced with the help of a software for the automatic qualitative analysis of texts, has allowed to identify four prevalent themes organized into three sense vectors. The findings highlighted significant gender differences in the representation of the experience of self-harm between males and females, as well as the importance of meaningful relationships developed in familiar and educational contexts, which may allow the help seeking process. The emerging of culturally-shared meanings among adolescents within the investigated contexts may allow to think about possible protocols of preventive and clinical practices in schools.

Putting the "Self" in Self-Injury Research: Inclusion of People With Lived Experience in the Research Process

Worldwide, nonsuicidal self-injury has emerged as a paramount concern given its associations with psychiatric difficulties and suicide risk. Despite many gains in the understanding of self-injury, there remain numerous unanswered questions in the field, including how to enhance both treatment and service provision. With this in mind, this Open Forum represents a call to action, advocating and providing strategies for inclusion of people with lived experience in self-injury research. An inclusive approach to self-injury research can yield greater understanding about how to best serve the needs of those who self-injure and others who are affected by self-injury.

Mobile Apps for Self-Injury: A Content Analysis

A growing body of research points to the salience of the Internet and mobile material among individuals who self-injure. However, to date, no research has investigated the mobile apps related to nonsuicidal self-injury (NSSI). Such information would clarify which apps may be useful for those who self-injure while highlighting whether app-related content warrants improvement. The current study examined the content and usability of NSSI apps available on the two largest app-related platforms (Google Play and iTunes). Using content analysis, apps were examined regarding their content (e.g., presence of NSSI myths and types of coping strategies) as well as usability (e.g., app performance). Results indicate that NSSI apps have varied content, with few developed by, or affiliated with, a trusted source (e.g., university). NSSI apps tend to not propagate NSSI myths that vary with respect to the quality of coping strategies offered. They also tend to be rated favorably in terms of their usability. Overall, the present findings add to the NSSI literature and highlight several implications and avenues for future work, which are discussed.

Deliberate self-harm among adolescent psychiatric outpatients in Singapore: prevalence, nature and risk factors

BACKGROUND

Deliberate self-harm (DSH) is a prominent mental health concern among adolescents. Few studies have examined adolescent DSH in non-Western countries. This study examines the prevalence, types and associated risk factors of DSH in a clinical sample of adolescents in Singapore.

METHODS

Using a retrospective review of medical records, demographic and clinical data were obtained from 398 consecutive adolescent psychiatric outpatients (mean age = 17.5 ± 1.4 years, range = 13-19 years) who presented at Changi General Hospital from 2013 to 2015.

RESULTS

23.1% (n = 92) of adolescents engaged in at least one type of DSH. Cutting was the most common type of DSH reported. Females were three times more likely to engage in DSH than males. DSH was positively associated with female gender (odds ratio [OR] 5.03), depressive disorders (OR 2.45), alcohol use (OR 3.49) and forensic history (OR 3.66), but not with smoking behaviour, living arrangement, parental marital status, past abuse or family history of psychiatric illness.

CONCLUSION

Interventions targeting adolescent DSH should also alleviate depressive symptoms, alcohol use and delinquent behaviours.

The impact of YouTube peer feedback on attitudes toward recovery from non-suicidal self-injury: An experimental pilot study

Background

Non-suicidal self-injury (NSSI) is a serious public health concern facing adolescents and young adults worldwide. Despite growing concern that accessing NSSI content on the internet may negatively influence perceptions toward NSSI recovery, no studies have examined actual impacts.

Objectives

This experimental pilot study assessed the impact of exposure to hopeless versus hopeful peer messages on perceptions toward NSSI recovery. It was hypothesized that exposure to hopeless messages would lead to more negative perceptions about NSSI recovery whereas the opposite would occur for hopeful messages.

Methods

We developed fictional peer comments embedded in a screenshot of an NSSI-themed YouTube video and randomly assigned participants to either hopeless or hopeful recovery-oriented comments. Participants’ attitudes toward NSSI recovery, recovery-oriented subjective norms, and recovery self-efficacy were measured pre- and post-exposure using an online questionnaire.

Results

Sixty-one participants with a self-reported NSSI history (mean age 20.89 years) completed the online survey. There was a statistically significant effect for attitudes toward recovery. Within the hopeful comment condition, there was an increase in positive attitudes toward recovery and in recovery-oriented subjective norms. Participants exposed to hopeless peer messages did not report an increase in hopeless attitudes toward NSSI recovery.

Conclusions

Our pilot study indicated that exposure to hopeful online messages improved positive attitudes toward recovery and recovery-oriented subjective norms, while exposure to hopeless messages did not increase hopeless attitudes. Future research on the impacts of online peer comments on one’s attitude toward NSSI recovery and support-seeking behavior could further inform practices and policies.

Helping schools support caregivers of youth who self-injure: Considerations and recommendations

Non-suicidal self-injury (NSSI) is a significant international mental health concern, with consequences for not only youth who self-injure, but for their entire family system. Helping caregivers respond productively to their child’s self-injury is a vital part of effectively addressing NSSI. This paper will assist school-based mental health practitioners and other personnel support caregivers of youth who self-injure by reviewing current literature, highlighting common challenges faced by school-based professionals, and providing evidenced-informed recommendations for supporting caregivers of youth who self-injure. We posit that schools can best support caregivers by having clear and well-articulated self-injury protocols and by engaging caregivers early. Once engaged, helping caregivers to navigate first conversations, keep doors open, know what to expect, seek support for themselves and understand and address safety concerns will ultimately benefit youth who self-injure and the school systems that support them. We also review recommendations for working with youth whose caretakers are unwilling or unable to be engaged.

In Their Own Words: Perspectives on Nonsuicidal Self-Injury Disorder Among Those With Lived Experience

Nonsuicidal self-injury (NSSI) is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a condition warranting further study. Although potential advantages and disadvantages regarding this prospect have been documented, no study has examined the perspectives of those who self-injure. The goal of the current study was to give voice to these views. Seventy-six participants with an NSSI history completed quantitative and qualitative measures assessing perspectives about NSSI being included as a DSM disorder. Findings revealed mixed views overall. Thematic analysis of open-ended responses highlighted several unique advantages (i.e., enhanced understanding of NSSI, validation of the NSSI experience, facilitation of NSSI treatment, encouragement of NSSI help-seeking, reduction of NSSI stigma) and disadvantages (i.e., exacerbation of NSSI stigma, diminishment of underlying concerns). These findings speak to the need to consider the perceptions of those with lived NSSI experience; future directions and implications are discussed.

The Role of Basic Need Satisfaction in the Onset, Maintenance, and Cessation of Non-Suicidal Self-Injury: An Application of Self-Determination Theory

The present study applied self-determination theory to examine the onset, maintenance, and cessation of non-suicidal self-injury (NSSI) in adolescents. Specifically, the study examined the relationship between the basic psychological needs of autonomy, competence, and relatedness, and NSSI status. Participants were classified into the NSSI Maintain (n = 30), NSSI Start (n = 44), NSSI Stop (n = 21), or Control (n = 98) groups based on NSSI status over 2 time points within a 12-month period. Repeated measures multiple analysis of variance was employed. Satisfaction of the need for competence decreased over time in all adolescents. Adolescents who maintained NSSI behavior reported significantly lower levels of need satisfaction compared to adolescents reporting no history of NSSI engagement, and adolescents who began NSSI over the course of the study reported significantly lower levels of need satisfaction compared to those reporting no history of NSSI engagement. The findings suggest that need satisfaction varies as a function of NSSI status.

Position paper for guiding response to non-suicidal self-injury in schools

Around the world, school staff are increasingly expressing concern about nonsuicidal self-injury (NSSI) and how best to address this behavior in the school setting. However, there is a notable lack of informed guidance for schools, and clear inconsistencies in the practices school staff adopt. In this position paper we draw on our collective research and clinical expertise to provide best-practice guidelines for addressing NSSI in school settings. We outline the importance of a school protocol, and the key features all school protocols should contain. We also focus on how schools can minimize contagion of NSSI within their school environment. We believe these guidelines will be an important starting point for schools interested in developing an evidence-based approach to addressing NSSI.

Non-Suicidal Self-Injury in Our Schools: A Review and Research-Informed Guidelines for School Mental Health Professionals

Non-suicidal self-injury (NSSI), the immediate and deliberate destruction of one’s own body tissue, without suicidal intent, and not for purposes that are socially accepted, is a critical concern for youth in schools. Despite significant scholarly advances and increasing clinical awareness of NSSI, many school mental health professionals (MHPs) continue to report feeling ill equipped to support students who self-injure, and emphasize a need for formal education about NSSI and its management in schools. Thus, the first part of this article summarizes current NSSI research on prevalence, age of onset, gender differences, functions, risk factors, and associations with suicide. Emerging from this review, the second part offers research-informed recommendations for MHPs managing NSSI in schools, including guidelines for (a) identifying students at elevated risk of self-injury, (b) developing a protocol for school personnel’s initial response to student self-injury, (c) first-level assessment of NSSI, and (d) managing critical issues related to NSSI contagion and online activity.

Peer group impulsivity moderated the individual-level relationship between depressive symptoms and adolescent nonsuicidal self-injury

This study examined the influence of impulsive friendship group contexts on nonsuicidal self-injury (NSSI) and how peer group impulsivity (i.e. negative urgency and premeditation) moderated the individual level relationship between depression and NSSI among 1701 Chinese secondary school students (1147 females). Participants were assessed twice over a 6-month interval. After controlling for direct socialization effects for NSSI, multilevel analysis indicated that friendship group negative urgency exerted a significant influence on NSSI. Additionally, friendship group premeditation weakened the relation between individual depression and NSSI, while friendship group negative urgency strengthened the relation between depression and NSSI. The results suggest the contribution of indirect peer influence effects to NSSI.

The Overlooked Role of Self-injury Scars: Commentary and Suggestions for Clinical Practice

Nonsuicidal self-injury (NSSI) has emerged as a significant mental health concern over the past several years. Accordingly, it is imperative that mental health professionals be able to draw upon and use approaches that meet the needs of those who report NSSI enactment. Notwithstanding the utility inherent in published recommendations for NSSI assessment and intervention, the aspect of NSSI scarring and its potential impact on those who have self-injured seems to be largely overlooked. Indeed, there is emerging evidence that people's perceptions of their NSSI scars may thwart NSSI recovery. This commentary highlights what is currently known about NSSI scarring and its potential impact on individuals who have self-injured. From here, and based on the state of evidence in this nascent area, tentative albeit practical suggestions for assessment and intervention are presented.

Research with adolescents who engage in non-suicidal self-injury: ethical considerations and challenges

Non-suicidal self-injury (NSSI) has emerged as a significant psychiatric issue among youth. In addition to its high prevalence rates, NSSI is associated with a number of psychiatric issues and confers risk for varying degrees of physical injury. It is also a risk factor for attempted suicide. Thus, youth who engage in NSSI represent a vulnerable and high-risk population and researchers are likely to encounter a variety of ethical challenges when conducting NSSI research. Accordingly, it is critical that researchers be familiar with the major ethical issues involved in NSSI research and how to effectively account for and address them. This is important both prior to obtaining clearance from their Institutional Review Boards and when carrying out their research. To date, there is no consolidated resource to delineate the ethical challenges inherent to NSSI research and how these can be effectively navigated throughout the research process. The goals of this paper are to review international best practices in NSSI research across the various contexts within which it is studied, to offer guidelines for managing these issues, to identify areas in which variation in approaches prohibits decisive recommendations, and to generate questions in need of further consideration among scholars in this field.