What are the treatment guidelines for self-harm in children and adolescents with potential underlying mental health issues, such as depression or anxiety, and impaired emotional regulation?

Treatment Guidelines for Self-Harm in Children and Adolescents

Dialectical Behavior Therapy for Adolescents (DBT-A) is the most evidence-based intervention for reducing self-harm in children and adolescents, demonstrating a significant reduction in repetition rates (30% vs 43% in controls) and should be offered where indicated. 1, 2

Comprehensive Assessment and Initial Management

Every adolescent presenting with self-harm must receive a comprehensive psychosocial assessment by a mental health professional, including:

• Screening for suicidal ideation, specific plans, access to means, and intent 2
• Formulation of contributing factors including interpersonal difficulties with family, romantic partners, and peers, negative attributional style, and symptoms of depression 1
• Development of a detailed safety plan that must be regularly updated, incorporating identification of warning signs, specific coping strategies, social supports, means restriction, and emergency contacts 2
• Immediate removal of all potentially lethal means from the home environment 2

First-Line Treatment: DBT-A

DBT-A demonstrates the strongest evidence for reducing both absolute repetition and frequency of self-harm (OR 0.46,95% CI 0.26 to 0.82) 1, 3. The treatment comprises:

• Four essential modules that must all be delivered: Core Mindfulness Skills, Interpersonal Effectiveness Skills, Distress Tolerance, and Emotion Regulation Skills 2
• Weekly individual therapy plus group skills training for the full 24-week protocol 2
• Family involvement is mandatory to improve the home environment and model adaptive behaviors 2
• Weekly group, family, and individual sessions, as well as telephone calls 1

Important Caveat About DBT-A

While DBT-A shows the most promise, it is unlikely to be realistic for most young people due to its time- and labor-intensive nature, requiring extensive training for therapists and a significant time commitment for families (generally 3-6 months) 1. Approximately half of young people offered therapy for self-harm do not attend all planned sessions, making engagement strategies critical 2, 4.

Alternative Psychotherapeutic Approaches

When DBT-A is unavailable or not feasible:

• Cognitive Behavioral Therapy (CBT) adapted to the adolescent context may be of benefit for some young people 1, though current evidence shows no clear difference compared to treatment-as-usual (OR 0.93,95% CI 0.12 to 7.24) 1, 3
• Specific psychological treatments (SPT) significantly improve treatment engagement compared to treatment-as-usual (28.4% non-completion vs 45.9% in TAU) 4
• Family therapy shows no evidence of difference compared to treatment-as-usual or enhanced usual care on repetition of self-harm at post-intervention (OR 1.00,95% CI 0.49 to 2.07) 3

Critical Therapeutic Elements Across All Modalities

Regardless of the specific therapeutic approach chosen, the following components are essential:

• Greater attention to the therapeutic relationship is an important consideration irrespective of the specific therapeutic modality 1
• Family involvement wherever possible is a critical component of any therapeutic approach 1
• Screen for suicidal ideation, self-harm urges, and safety at every session, with monitoring for repeat self-harm and reassessment of patient goals periodically 2

Pharmacotherapy Considerations

Pharmacotherapy is not recommended solely for the prevention of self-harm in young people 1. Key points include:

• No evidence supports the use of medications specifically for self-harm prevention 1
• Medications should only be prescribed for their indication for specific psychiatric disorders (e.g., antidepressants for concurrent depression) 1
• SSRIs carry a black box warning for increased risk of suicidal thinking and behavior in children, adolescents, and young adults (ages 18-24) with major depressive disorder 5
• If ADHD is present, continue stimulant treatment (e.g., lisdexamfetamine) as stimulants are first-line even in patients with self-harm and have lower lethal potential than alternatives 2

Staff Training and Service Delivery

Negative experiences of clinical services may perpetuate a cycle of self-harm, requiring attention to:

• Staff training to ensure all clinical staff feel equipped to treat young people in a person-centred and compassionate manner 1
• Easy access to immediate mentoring and supervision of emergency department staff who are involved with young people presenting after self-harm 1
• Consideration of dedicating a separate area within the emergency department to triage and assess these presentations 1
• Attitudes of professionals in clinical services may influence outcomes and are an important consideration in training 1

Common Pitfalls to Avoid

• Do not rely on mentalisation-based therapy for adolescents (MBT-A) as evidence is very uncertain (OR 0.70,95% CI 0.06 to 8.46; very low-certainty evidence with substantial heterogeneity I² = 68%) 3
• Do not prescribe medications solely for self-harm prevention, as there is no evidence supporting this approach and potential for harm with SSRIs 1, 5
• Do not assume one single treatment approach will work for all young people, as self-harm results from a complex interplay of genetic, biological, psychological, psychiatric, social, and cultural factors 1
• Do not underestimate engagement challenges, as approximately 50% of young people do not complete treatment, necessitating active engagement strategies and family involvement 2, 4