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Parents of youth who self-injure: a review of the literature and implications for mental health professionals

Child and Adolescent Psychiatry and Mental Healthvolume 9, Article number: 35 (2015) | Download Citation

Abstract

Non-suicidal self-injury (NSSI) is a common mental health concern among youth, and parents can be valuable supports for these youth. However, youth NSSI can have a significant impact on parents’ wellbeing, which may in turn alter parents’ ability to support the youth. To date, no single article has consolidated the research on parents of youth who self-injure. This review synthesizes the literature on parent factors implicated in youth NSSI risk, the role of parents in help-seeking and intervention for youth NSSI, and the impact of youth NSSI on parent wellbeing and parenting. Clinical implications for supporting parents as they support the youth are also discussed, and recommendations for future research are outlined.

Introduction

Non-suicidal self-injury (NSSI) is the intentional destruction of one’s own body tissue (e.g., cutting, burning) without conscious suicidal intention [1]. NSSI commonly takes the form of cutting, scraping, carving or burning the skin, hitting oneself, or biting oneself [2, 3], though other methods are also reported [4]. Approximately 18% of adolescents have a history of at least one episode of NSSI [5], and over a quarter of these adolescents engage in NSSI repeatedly [6]. Indeed, the average age at NSSI onset is in the early-to-mid teen years [7, 8]. Youth who engage in NSSI are more likely than those who do not self-injure to have at least one diagnosed mental illness (e.g., mood disorders, eating disorders) [9, 10], and to have a history of suicide ideation and suicide attempts [2, 9, 10]. It is common for youth who engage in NSSI to also engage in other maladaptive behaviours such as substance abuse and disordered eating [10–14].

NSSI has emerged as a prominent mental health concern among youth. However, NSSI not only affects the health of youth, it can also have a significant impact on parents’ wellbeing and ability to support their youth [15–17]. To date, no single paper has consolidated the literature on parents of youth who self-injure. A review paper which provides a thorough understanding of the role of parents in youth NSSI may better equip clinicians to treat youth NSSI by involving parents as valuable resources in the youth’s circle of care. Indeed, when parents are appropriately supported, they can be instrumental throughout a young person’s NSSI recovery process [18–20]. Such a review may also help to identify where research is needed to further understand how parent factors play a role in the context of NSSI onset and treatment among youth, and how to equip parents such that they are better able to support their youth. This review begins with a synthesis of the literature examining parents of youth who engage in NSSI, including the risks for NSSI associated with parents, the role of parents during help-seeking and treatment for NSSI, and the impact of youth NSSI on parent wellbeing and ability to support the youth. Next, clinical implications for supporting parents are explored. Finally, gaps in the literature are identified and avenues for further research are suggested.

Review

Papers for this review were identified through the Psych-Info and PubMed databases using the search query (parent* OR family OR interpersonal OR caregiver) AND (self-harm* OR self-injur* OR self-mutilat*) AND (child* OR youth OR adolescen* OR teen OR student OR young). References of resultant papers were also reviewed. Figure 1 outlines the study acquisition and inclusion process. The following inclusion criteria were used: studies had to be peer-reviewed, written in English, and examined NSSI or non-suicidal self-harm among children and/or adolescents (≤19 years). Included studies also had to examine the role of parents in relation to NSSI in at least one of four categories: youth NSSI risk factors; youth help-seeking for NSSI; intervention for youth NSSI; and parent experiences of youth NSSI. Articles were excluded for the following reasons: NSSI or self-harm was examined in young adults or college student populations; samples were drawn from populations with developmental disabilities, psychosis, or youth who were not living at home (e.g., incarcerated youth, street youth); the harm to self was accidental or socially sanctioned (e.g., salt and ice challenges).

Fig. 1
figure1

Flow diagram of identified studies.

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Although the initial intent of this review was to examine parents in relation to youth NSSI specifically, the review was expanded to include deliberate self-harm (DSH) in combination with NSSI. DSH encompasses NSSI behaviours as well as behaviours with indirect harm (e.g., self-poisoning, overdoses), and DSH may or may not include behaviours with suicidal intent. Thus, NSSI is subsumed under DSH. The focus was broadened for two reasons. First, there is a paucity of research examining the role of parents during help-seeking and treatment for NSSI specifically, and the authors were unable to locate any peer-reviewed study examining the impact of exclusive NSSI on parent wellbeing. Second, NSSI and DSH are often examined on a continuum of self-harming behaviours rather than as distinct categories [21, 22]. To this end, and for many studies, it was impossible to determine which behaviour (i.e., NSSI versus DSH) was measured based on the methodology provided in the text. Thus, expanding the scope of the review to include DSH as well as NSSI may provide a more comprehensive picture of the role of parents in youth NSSI. The term NSSI is used throughout this review when the study included NSSI behaviours; the reader should note that at times these studies may also have included behaviours that extended beyond the definition of NSSI. To best approximate the goals of the initial review, studies of DSH that clearly did not include NSSI (i.e., self-poisoning was the only method examined; only behaviours with suicidal intent were included; or suicide ideation confounded the measure of self-harm), were excluded. Furthermore, as there may be key differences between adolescents who engage in DSH with suicidal intent versus nonsuicidal intent [23–25], only studies measuring exclusively nonsuicidal DSH were included in the review of risks for NSSI associated with parents. A total of 82 articlesa were included in this review (Table 1). A visual summary of the role of parents in youth NSSI that emerged from this review is provided in Fig. 2.

Table 1 Studies included in the review of parents’ role in youth NSSI
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Fig. 2
figure2

Visual summary of the role of parents in youth NSSI.

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Risks for NSSI associated with parents

Fifty-three studies [2, 3, 11, 12, 23, 26–73] met the inclusion criteria for this section of the review. Table 2 outlines all potential NSSI risk factors associated with parents that have been measured across the included studies. A variety of background factors associated with parents (i.e., socio-economic status, family structure, parent health and mental health history), parent–child relationship factors (i.e., relationship quality, parent support, discipline and control, affect towards parents, adverse childhood experiences associated with parents specifically), and family system factors (i.e., family environment, adverse childhood experiences associated with the family system, family mental health history) have been associated with elevated risk for NSSI. Many background parent factors (e.g., parental level of education, family socioeconomic status, parent marital status, maternal depression) are widely used as covariates in youth NSSI research; as such, it is not unlikely that the authors may have missed some studies that should have been included in this review despite the intensive search and screening process.

Table 2 Risk factors for youth NSSI associated with parents
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Research examining youth NSSI risk beyond the use of correlations and group differences is still in its infancy. Cross-sectional research methods make it difficult to determine the direction of the effect (i.e., whether the parent factor influences youth NSSI, whether youth NSSI changes parent behaviour, or some combination). Although an increasing number of longitudinal studies have used factors associated with parents to predict NSSI risk (see Table 1), only three studies [12, 30, 65] have examined the associations between NSSI and future parent variables, regardless of parents’ awareness of the youth’s NSSI. Similarly, more research is needed to examine the full course of youth NSSI—including NSSI cessation—in relation to factors associated with parents; despite the role that parents and families have in treatment for youth NSSI, only one study in this review examined family factors in NSSI cessation [65]. Understanding the role of parents over the course of NSSI may allow clinicians to better equip parents to support their youth. Although there is no standard model for how parents and adolescents should interact to reduce risk for NSSI, some parental responses towards adolescent emotions (e.g., comfort, validation, support) may protect against NSSI [35] or may encourage NSSI cessation [65]. Thus, equipping parents with the skills necessary to model adaptive emotional acceptance, regulation and expression may be helpful in enhancing parents’ ability to support their youth.

Help-seeking and parents

Many youth who engage in NSSI tell no one about it [74, 75], and reported parental awareness rates of youth NSSI are considerably lower than actual youth NSSI rates [30, 76]. Those adolescents who seek help most frequently do so from peers and less frequently from family members, including parents [74, 75, 77–79]. One study found that youth with a history of NSSI were less likely to know how parents could help, more likely to suggest that nothing could be done by parents, and less likely to suggest that parents talk to youth who self-injure or that parents refer these youth to professional help [80].

Help from family may more frequently be sought after, rather than before, an episode of NSSI [74, 77], and has been associated with subsequent help-seeking from health services [81]. Youth may be more likely to seek help from parents when they feel as though their parents authentically care for them, and they are able to openly discuss self-injury with their parents [82, 83]. This highlights the need for clinicians who work with families in which a youth self-injures to foster open communication about emotions in family contexts early in the treatment process. Disclosure of NSSI is sometimes made to parents on behalf of the youth by school personnel or a physician [17], and parents who receive poor initial support from schools and health professionals may be unlikely to continue to seek help [17]. The period of initial NSSI discovery may represent a key opportunity for parents to gain knowledge about NSSI, and to encourage professional help-seeking for their youth when warranted.

Interventions involving parents

Parents may have an essential role in initiating and supporting treatments for youth NSSI [20, 81, 84], Youth may be more likely to accept professional help for NSSI when parents are supportive of treatment [20]. For example, parents’ expectations about the helpfulness of counseling may influence the youth’s decision to attend—or not attend—counseling sessions following presentation at an emergency department following NSSI [84]. A caring environment and open discussion about NSSI may contribute not only to help seeking [83], but also toward supporting the youth to understand, work through, and stop NSSI [20].

Only a handful of studies have examined interventions involving parents for NSSI behaviours specifically (i.e., measured as an outcome either in the absence of, or in combination with, DSH with suicidal intent). Studies of family-based therapies included multi-systemic therapy [85] and single-family therapeutic assessments [86]. Although attachment-based family therapy and family-based problem solving have some evidence of being efficacious for suicidal behaviours, outcomes related to NSSI have not yet been investigated [18, 19]. Mentalization-based treatment, which consists of both individual and family psychodynamic psychotherapy, has been examined in relation to NSSI in one study [87]. Studies assessing cognitive behaviour therapies (CBT) for youth NSSI have involved parents through family CBT in addition to individual CBT for the youth [88], or through a parent psycho-education component [89]; the inclusion of family problem solving sessions or parent training in CBT has not yet been assessed in relation to NSSI specifically [18]. Finally, dialectical behaviour therapy for adolescents [90] has gained recent empirical interest for youth NSSI [91–95]; this intervention consists of individual therapy for adolescents, family therapy as warranted, and a multifamily skills training group.

Reviews [18, 19] of interventions for youth DSH, including NSSI, have found that the inclusion of strong parent components in some interventions may result in significant reductions in youth DSH. However, an examination of the efficacy of these treatments is beyond the scope of this review; readers are referred to these review papers [18, 19] for treatment efficacy. Although few studies have assessed the benefits of these interventions on parents’ wellbeing and ability to support their youth, preliminary evidence suggests that parent [95] and family [96] functioning may significantly improve through participation even when youth NSSI behaviours may not [95].

Beyond interventions for youth specifically, parent education programs may have merit in assisting parents to cope with their youth’s NSSI and better support their youth. For example, a school-based program for parents [97] was found to reduce youth NSSI among students of parents who participated; this program consisted of parent education groups that empowered parents to assist each other to improve communication and relationships with youth. Similarly, two support programs (i.e., Resourceful Adolescent Parent Program (RAP-P); [96]; Supporting Parents and Carers (SPACE); [98]) have been reported for parents of youth who have engaged in, or expressed thoughts of, suicidal behaviour or DSH (including NSSI); RAP-P used a single-family format [96], whereas SPACE had a group format [98]. Both programs provided parents with information pertaining to DSH and NSSI in youth, parenting adolescents, and family communication and conflict. SPACE also provided explicit information about parental self-care. When combined with routine care, RAP-P resulted in significant improvements in family functioning. Similarly, parents in the SPACE pilot study reported subsequent decreased psychological distress and greater parental satisfaction. Parents and youth also reported that youth experienced fewer difficulties following parent participation [96, 98]. Taken together, parent participation in interventions pertaining to youth NSSI may have positive outcomes both for the youth and parent.

Impact on parent wellbeing

The process of supporting a youth who self-injures can be traumatic and emotionally taxing on parents [15–17, 20]. Parents report an abundance of negative emotions (e.g., sadness, shame, embarrassment, shock, disappointment, self-blame, anger, frustration) in relation to their youth’s NSSI [15–17]. Many parents have expressed feeling overwhelmingly alone, isolated and helpless [15–17]. These feelings can be exacerbated by the stigma surrounding NSSI and the perceived absence of services and supports for NSSI [15]. Parents have reported being unable to talk to anyone about the youth’s NSSI or being extremely selective in choosing to whom they disclose (e.g., disclosing to a close friend, but not to family members) [15]. Many parents have reported a desire for peer support from other parents of youth who self-injure [15, 20], with the anticipated benefits involving the sharing of similar circumstances, learning from each other, and relief from knowing that they are not alone [15].

Although parents may recognize that NSSI serves a function for the youth (e.g., to provide relief from distress), many parents have reported being unable to understanding NSSI as chosen behaviour [17, 99]. Indeed, many parents believe common misconceptions about this behaviour [15, 17, 99]. For example, one study assessing parent conceptions about NSSI found that many parents believed that cutting oneself—one of the more common methods of NSSI among youth who self-injure [2, 3]—is a typical phase of adolescence, occurs only in females, is synonymous with a suicide attempt, or is an indicator of a psychological disorder [99]. The availability of accurate information about NSSI has been identified as a priority by parents of youth who self-injure [15].

Youth NSSI may increase parenting burden and stress [17], and parents often report a loss of parenting confidence [15, 16]. Indeed, in families in which a youth self-injures, poor parental wellbeing has been predicted by poor family communication, low parenting satisfaction, and more difficulties for the youth [100]. Although a key developmental process during adolescence is to individuate from parents, many parents report believing their youth was more mature and capable than they really were [99], and many struggled to find and allow the youth an appropriate level of independence [16]. Nervousness about triggering NSSI (i.e., causing an episode of NSSI) can affect parents’ ability to set limits and maintain boundaries [17]. Parents have also reported that typical difficulties associated with parenting adolescents (e.g., bullying, peer pressure, monitoring Internet use) may be intensified when their youth self-injures, as the adolescent’s experiences in these domains may precipitate or maintain NSSI behaviours [15]. Indeed, parents of youth with NSSI have expressed a need for more effective parenting skills [15]. Despite the difficulties associated with NSSI, many parents hope to rebuild a positive relationship with the youth, recognize the importance of parent–child communication in the youth’s wellbeing, and want to help the youth develop emotion regulation and coping strategies [15].

Finally, parents may also experience difficulties balancing and meeting the varying needs of individual family members [15–17]. Disruptions in family dynamics may occur, and the youth with NSSI may be perceived to hold the central position of power within the family [15]. Some parents have reported that caring for the youth who self-harms led to changes in employment (e.g., reducing hours, leaving paid employment), which may have increased financial strain on families [16]. Finally, parents may deny their own needs, and change or limit their lifestyle to increase support for the youth who self-harms [17]. Taken together, youth NSSI and parent factors associated with NSSI risk may be bidirectional; NSSI can have a significant impact on parent wellbeing and parenting, which may in turn affect parents’ ability to support their youth. Accordingly, parents of youth who self-injure may benefit from additional support for themselves as they support their youth.

Clinical implications for supporting parents

Parents may be valuable members of the youth’s circle of care. One study found that among youth who presented to an emergency department for self-harm, ongoing parental concern was a better predictor of future DSH than clinical risk assessments [101]; thus, under some circumstances, parents may be in a position to gauge their youth’s ongoing wellbeing and alert health professionals about concerns when warranted [99, 101]. Indeed, another study found that many parents consider themselves to be the youth’s principal helper and advocate [20], which may have both positive and negative implications for both parent and youth wellbeing. For many parents, taking care of themselves while their youth struggles with NSSI is challenging [20, 98]. Thus, parents may need to be encouraged to practice self-care [98]. As parents may also benefit from receiving accurate information about NSSI, parenting skills, and social support [15], the inclusion of parents in empirically-informed treatments—such as those listed above—may be an optimal way to provide parents with education, skills training, and peer support that they can draw upon when supporting their youth at home. Parent education programs for parents of youth who self-injure may also have merit and should be investigated in future research.

The Internet may be a unique medium to support parents of youth who self-injure. Researchers have found that parents use the Internet to access both information related to their children’s medical conditions [102–105], and social support that is not being accessed offline [102, 106]. The Internet has the potential to be a particularly effective method to educate parents about more stigmatized mental health issues such as NSSI, and to equip parents to support their youth with these difficulties. Unfortunately, there is an abundance of non-credible and low-quality information about NSSI on the Internet [107]. Thus, clinicians need to be mindful of parents’ use of the Internet to access support for youth NSSI, and be prepared to recommend credible websites containing accurate NSSI information. Mental health professionals may find that the Self-Injury Outreach and Support [108] and Cornell Research Program on Self-Injury and Recovery [109] websites are particularly useful online resource for parents, as they provide credible and accurate information for parents seeking to understand their youth’s NSSI and how to support their youth (e.g., how to talk to their youth about NSSI, treatments for youth NSSI), as well as providing suggestions for additional online and offline resources specific to parents.

Implications for further research

There are several limitations in the cited studies that suggest avenues for future research. First, there is a paucity of research pertaining to parents of youth who engage in NSSI specifically; much of what is known about these parents is inferred from studies assessing parents of youth who engage in similar behaviours such as self-harm, which may or may not include a suicidal intent. Thus, more research is needed to determine to what extent parents of youth with NSSI differ from parents of youth who self-harm. This information may assist mental health professionals to develop empirically-informed programs for parents of youth who self-injure that may be modeled on programs already existing for parents of youth who self-harm [96, 98].

Next, studies linking parenting factors to NSSI risk are predominantly correlational, and thus causation cannot be inferred. Researchers should consider complex ways in which factors associated with parents might interact to increase risk for, or protect against, NSSI. Similarly, factors that may mediate or moderate the relation between youth NSSI and the effects of this NSSI on parents are not yet known. To date, studies examining the impact of youth NSSI on parent wellbeing and parenting have been almost exclusively qualitatively. Empirical studies are needed in this area to better understand the effects of youth NSSI on parenting and parents’ subsequent ability to support the youth.

Finally, the effects of parent and youth gender on NSSI risks and NSSI impact on parents are unclear. The impact of NSSI on parent wellbeing has almost exclusively been examined through mothers due to an inability to recruit adequate numbers of fathers; thus, these findings should be generalized cautiously to fathers and other caregivers. Similarly, there may be gender differences in NSSI risk and protective factors. For example, connectedness with parents may be particularly important in protecting adolescent females against NSSI [62], and parent–child relationship quality may confer different risks for NSSI when associated with mothers versus fathers [38]. Further research is needed to identify whether fathers have similar experiences to mothers in supporting youth who self-injure, and how factors associated with mothers and fathers may confer different risks or protection for youth NSSI.

Conclusions

Parents can play a key role in supporting youth who self-injure. However, youth NSSI affects parents’ wellbeing, which may, in turn, affect how parents can support their youth. Providing parents with accurate information about NSSI, parenting skills, and social support may help parents to better support their youth. When working with youth who self-injure, professionals should consider family dynamics and related contextual factors when selecting appropriate interventions for youth; parents may be valuable members of the circle of care. More research is needed to identify salient parent factors affecting youth NSSI risk and parent wellbeing, and to determine the most effective ways to support parents of youth who self-injure. Efforts in this regard may bolster the quality of clinical care provided to youth who self-injure.

Endnote

aA full table outlining the sample, methods, measures, and results for each study is available from the authors upon request.

Abbreviations

CBT:

cognitive behaviour therapy

DSH:

deliberate self-harm

NSSI:

non-suicidal self-injury

RAP-P:

Resourceful Adolescent Parent Program

SPACE:

Supporting Parents and Carers

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Authors’ contributions

AA conceived of the review, participated in the design of the review, conducted the review, and drafted the manuscript. SL participated in the design of the review and in critical revisions of the manuscript. Both authors read and approved the final manuscript.

Acknowledgements

The authors wish to thank Paul Grunberg for his research assistance. Funding towards this review has been provided by the Canadian Institutes of Health Research.

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Competing interests The authors declare that they have no competing interests.

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  1. University of Guelph, Guelph, ON, N1G 2W1, Canada

    • Alexis E Arbuthnott
    •  & Stephen P Lewis

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Keywords

  • Non-suicidal self-injury
  • Self-harm
  • Parents
  • Youth
  • Review
  • Mental health

Child and Adolescent Psychiatry and Mental Health

ISSN: 1753-2000