Erik Loraas, MD
Program Director, Child and Adolescent Psychiatry Fellowship Spokane
Associate Program Director, Psychiatry Residency Spokane
Medical Director, Providence RISE Program
Non-suicidal self-injury (NSSI) involves intentional injury that occurs in the absence of suicidal intent. These behaviors are fundamentally perplexing to pediatric providers and parents of adolescents as they navigate the causes and consider solutions.
NSSI is prevalent among general adolescents, with an estimated 1 in 5 inflicting a self-injury at least once – and affects roughly half of the psychiatric patients in our care. NSSI is more common among females, with the onset in mid-adolescence and resolution typically by early adulthood (although patients with resolved repetitive NSSI show high levels of extended emotion regulation issues, frequently involving substance abuse). Other factors influencing NSSI are adverse childhood experiences, dysfunctional relationships, sub-culture identification and LGBTQ+ orientation.
Risk factors fall into several categories, including demographics, social factors, adverse childhood events, neurobiological factors and media influence.  Social media has proven to be a double-edged sword for adolescents experimenting with NSSI. While it features glorification of the behavior, it also offers resources for help. The scope of social media in NSSI is significant: Regarding the worldwide spread of NSSI, internet use and especially the use of social media has been of increasing interest to researchers to understand dissemination of NSSI content. It has been shown that NSSI-related search terms were sought 42 million times per year on Google.  The top 100 YouTube videos with an NSSI content were viewed over two million times, with 90% of non-character videos showing NSSI photographs and 28% of character videos showing NSSI action. 
Primary Care Provider Responses to NSSI
Providers evaluating patients who are engaging in NSSI behaviors can best help by posing non-judgmental questions based out of curiosity. By establishing a general relationship, asking about school, home life, friendships, and activities, the provider may better understand what benefit the behaviors provide, understand how the patient’s brain experiences pain, and also open the door for ongoing conversations.
A good first question is “What does your self-injury help you with?” This is the same as simply asking “Why do you self-injure?” but the former question is less likely to be perceived as accusatory. Phrased in this way, the question demonstrates an understanding of the use of NSSI as a solution or self-treatment. Thus, it can open the door to a more specific discussion of psychiatric symptoms (depression, anger, anxiety) and interpersonal stressors (strained relationships with parents, breakups, loss of friendships).  Note: This publication offers helpful sample questions for primary care providers.
It is common for a teen to engage in NSSI behaviors based on friendship dynamics or peer recognition. Those encounters typically occur just once or twice and are not a fulfilling coping mechanism to the teen. These are patients typically helped by a pediatrician who can normalize the experience and provide education. Providers who use the typical HEEADSSS assessment [Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, Safety from injury and violence] to obtain a psychosocial history from adolescents should consider screening for NSSI at this time.
Because NSSI, by nature, is not suicidal, it should not be confused with or misinterpreted as a suicide attempt. Some adolescents fear that disclosing their NSSI will unnecessarily lead to an inpatient psychiatric hospitalization. Nevertheless, immediately after screening for NSSI, and as part of the HEEADSSS assessment, it is important to assess any suicidal ideation concurrent or in tandem with NSSI. 
For the patients in which NSSI is the “go-to coping skill,” referral to a psychiatric provider is warranted. The first line of treatment includes therapy and evaluation for underlying psychological issues, typically depression and anxiety.
 Non-suicidal Self-Injury in Adolescence, Current Psychiatry Reports, March 17, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357256/
 Googling self-injury: the state of health information obtained through online searches for self-injury. JAMA Pediatrics, May 2014. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1850199
 The scope of nonsuicidal self-injury on YouTube. Pediatrics. March 2011. https://publications.aap.org/pediatrics/article-abstract/127/3/e552/65060/The-Scope-of-Nonsuicidal-Self-Injury-on-YouTube?
 Self-Injury: Why Teens Do It, How to Help, Contemporary Pediatrics, March 1, 2012. https://www.contemporarypediatrics.com/view/self-injury-why-teens-do-it-how-help
 SOARS model: Risk assessment of non-suicidal self-injury, Contemporary Pediatrics, July 1, 2016. https://www.contemporarypediatrics.com/view/soars-model-risk-assessment-nonsuicidal-self-injury