What is the first line of treatment for self-harm cutting in adolescents?

First-Line Treatment for Self-Harm Cutting in Adolescents

Dialectical Behavior Therapy for Adolescents (DBT-A) is the first-line treatment for self-harm cutting in adolescents, as it is the only well-established treatment with strong evidence for reducing self-harming behaviors. 1, 2

Initial Assessment and Management

• A comprehensive assessment by a mental health professional should be undertaken after any episode of self-harm, including a formulation of contributing factors and a risk management plan 1
• Assessment should include information from multiple sources (not just the patient) and evaluation of suicidal intent, beliefs about lethality, and psychiatric comorbidities 3, 4
• Immediate safety planning should be implemented, including:
  • Removing access to lethal means (including explicit instructions to parents about securing medications and removing dangerous items) 3
  • Developing a collaborative crisis response plan with clear signs of crisis, self-management skills, and identification of support contacts 3

Evidence-Based Treatment Options

Primary Recommendation: DBT-A

• DBT-A combines cognitive-behavioral techniques, skills training, and mindfulness approaches 2
• It helps develop skills in emotion regulation, interpersonal effectiveness, and distress tolerance 3, 2
• DBT-A has been shown to reduce both suicidal and non-suicidal self-directed violence 3, 2
• It is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide 2

Alternative Option: CBT Adapted for Adolescents

• Cognitive-Behavioral Therapy (CBT) adapted to the adolescent context may be beneficial for some young people 1, 3
• CBT helps identify and change problematic thinking patterns and can reduce risk of post-treatment suicide attempts by half compared to treatment as usual 3
• This approach should be considered when DBT-A is not available or appropriate 1

Important Treatment Considerations

• Family involvement should be incorporated wherever possible to improve treatment engagement and outcomes 1
  • The extent of family involvement needs to be carefully tailored based on the young person's preferences and family dynamics 1
• The therapeutic relationship is a critical component of any treatment modality 1
• In settings with limited resources or time constraints (e.g., emergency departments):
  • Safety planning interventions may be effective in reducing suicidal behavior post-discharge 1
  • Brief, single-encounter interventions (e.g., safety planning, care coordination) may also be beneficial 1

Environmental Interventions

• Structured activity programs and adequate staffing during high-risk periods (particularly evenings) can help reduce self-harm in inpatient settings 5
• Creating a safe, supportive environment is essential, as negative experiences with clinical services may perpetuate the cycle of self-harm 1
• Staff training to ensure compassionate, person-centered care is important, particularly in emergency departments and general hospitals 1

What to Avoid

• Pharmacotherapy is not recommended solely for the prevention of self-harm in adolescents 1
  • There have been no published trials of pharmacological agents specifically for preventing self-harm/suicide in young people 1
  • Medications should only be used for treating specific psychiatric disorders (e.g., antidepressants for concurrent depression) 1

Follow-up Care

• Schedule definite, closely spaced follow-up appointments 3
• Maintain contact with patients even after referrals are made 3
• Be flexible in arranging appointments if a crisis arises 3
• Recognize the idiosyncratic nature of triggers and helpful coping strategies for each individual 6

DBT-A remains the gold standard treatment, though it is time and labor-intensive, requiring extensive training for therapists and significant time commitment from families (generally 6 months) 2. Future research is needed to identify less intensive but still effective treatment options for adolescents who self-harm 2.