Adolescent Self-Harm Increased In The Post-Pandemic Era

Teenager self-harm has become a prominent behavioral health concern reported in the health systems and schools in the post-COVID-19 era. Some studies have reported a rebound or increased rates of repeated youth self-harm following initial reports during the acute phase of the COVID-19 pandemic. Persistence of self-harm is a concerning indicator of potential emotional distress and later risk of suicidal behavior, school and family problems and repeated E.D. visits for self-harm. For this reason, prevention of self-harm cannot be considered secondary to treatment of self-harm and must be an integral component of all aspects of primary care and school health as well as effective crisis response and post-discharge follow-up. Effective systems of care will require early identification or screening, timely access to adequate outpatient mental health therapy, supportive family involvement, integrated school-based mental health, a safe supportive home environment, and effective care coordination and referral among E.D.s, pediatricians’ offices and community-based mental health programs.

Why It Matters

Self-harm is one of the most visible methods young people use to express their pain. It may or may not indicate suicidal intent and thus always requires assessment. The reasons for self- harm in adolescents are many and varied. Sometimes they are linked to clinical issues like depression and anxiety; or trauma and abuse. Self- harm may also be related to substance use, bullying, grief, family problems or issues linked to identity. Importantly self- harm should not be seen as attention-seeking or a passing phase. Young people who report self-harm need a full assessment of mental health as well as an understanding of reasons for the behaviour, a plan to support them and follow up to assess whether the young person is safe.

But for the young people and their families hit by the pandemic there is another statistic that will be equally important – the need for good quality mental health care. While a young person might need to go to A&E, receive urgent psychiatric assessment and treatment, there might then be a long wait for access to therapy. The lack of child and adolescent mental health specialists already means that many young people have to wait too long for help, and poor transitions from the hospital based psychiatric team to the community pediatrician and school can also increase the risk of harm to them. But families can see their children deteriorating before their eyes, going into crisis again and again, missing out on school, taking on debt, living in a state of high anxiety and uncertainty.

In addition to the management of the isolated episode of adolescent self-harm, there is the issue of the many young people for whom repeated self-harm is a way of trying to manage their mental health problems. The youth who attempts suicide once, or repeatedly, is not the only negatively affected young person. Repeated self-harm is associated with later suicidal behavior, poor school achievement, sleep problems, social isolation, and difficulties in functioning in multiple settings. Youth who attempt to manage their psychological pain by self-harming may withdraw from activities they love, from friends and family, or have trouble following lessons in school. The long-term effects of such attempts can include an inability to complete educational programs, challenges in developing and maintaining healthy social relationships, and negative effects on mental- and physical-health. Moreover, adolescent self-harm signals the need for a broader orientation to safety that locates the failure of systems to prevent harm within the failure to identify mental health problems and to provide continuum of care for these and other health problems.

After facing a global health crisis, the world is now in the grip of a crisis of inequity. Young people living in low resource settings face significant barriers to accessing mental health care including long distances to service providers and poor insurance coverage. While school-based counseling and other community-based interventions have great promise, they are often unavailable. Additional challenges to care include language and stigma-related barriers, transportation and accompaniment barriers, and challenges to taking time off from work for mental health appointments. In some countries, the only mental health service available is expensive and hospital-based. This exacerbates the situation for adolescents who are already shouldering a tremendous social and economic burden, and who are in dire need of support to treat their mental health distress.

Youth and young adolescents are coming to the attention of mental health professionals at an earlier age than in the past. In addition to earlier age of onset of psychiatric symptoms, many adolescents first come to mental health attention in non-traditional venues. These sites do not typically consider themselves to be mental health clinics (e.g. pediatric offices, school nurse offices, after school programs in community centers, counseling offices, hospital-based urgent care centers). While staff and administrators in these sites do not typically provide mental health treatment, they do need to have a sense of competence in initial screening and safety assessment, supportive interviewing of youth and families, and referring of youth and families for appropriate mental health evaluation and treatment. Therefore, the mental health professional providing care to this age group must envision an integrated system of care that may involve many different providers and sites (primary care and school-based mental health services, for example, as well as community-based inpatient psychiatric programs and outpatient programs in a variety of organizations).

Who It Affects

Youth with mental illness are primarily themselves affected. Many are struggling to manage their symptoms and find healthy ways to cope with painful or overwhelming emotions in a time of identity exploration, peer and romantic relationship building, increasing demands in school, and growing independence. However, youth do not come forward to share their problems with various adults because they perceive that doing so will have negative consequences, such as having their behavior dysregulated, being judged or stigmatized, or having their privacy invaded. However, signals of distress may manifest through sleep disturbances, decreased academic performance, withdrawal from activities and peers, increased irritability, physical ailments, or in and out conflicts with siblings and parents.

There are specific populations that are at higher risk for not receiving the necessary care in a timely manner. These include adolescents with depression, anxiety, trauma, eating disorders, or substance use disorders. Additionally, adolescents who have experienced bullying, abuse, neglect, loss (including parental death), discrimination, family violence, or extreme stress (including school related stress) are at risk for not receiving the necessary care in a timely manner. LGBTQ+ adolescents report increased levels of distress when experiencing rejection, stigma, or a lack of affirming support from family, schools, and communities. Teenagers and young adults in foster care, in the juvenile justice system, and from rural and other underserved communities are also at risk for not receiving the necessary care in a timely manner. While there are some differences, they do not necessarily mean that risk is concentrated in a particular group of young people; however, they do suggest areas where a focus on prevention and outreach may be particularly warranted.

Families and caregivers can also be affected. Parents and siblings of young people with mental health problems may feel guilty, fearful, confused or conflicted about how much to control the young person’s activities, when to intervene, and how to interact with the young person in a way that does not worsen their mental health symptoms. Families need to know the signs of mental health problems, how to manage a mental health crisis, how to remain calm and composed when the young person is not, how to remove access to dangerous items in the home, how to support the young person in treatment, and how to carry out the treatment plan. A good care plan can help families that are feeling out of control and in a state of panic to develop a plan of action.

While clinicians are feeling the pinch to manage more risk with fewer resources and less time to provide the best possible care and support to their clients and their families, clients and their families are feeling the greatest amount of risk. They need immediate help and support to make their homes safe for themselves and others. This program will provide pediatricians and primary care clinicians with practical, time-efficient, and effective screening tools and interventions for identifying depression, suicidal thoughts and self-harm, and beginning safety planning, as well as interventions for involving family members and caregivers and for follow-up after the initial screening visit.

School counselors and school nurses are often the first adult that informs a student that they are safe and that they can talk about what is going on in their life. However, many schools lack sufficient mental health trained staff to address the growing needs of students and families. This program will inform Emergency clinicians about balancing patient safety with placement in the least restrictive environment. Mental health specialists will learn about prioritizing the most at-risk cases within a system already at full capacity.

Youth and their families are not the only ones affected by the growing number of adolescents who engage in self-harm. Health care systems and schools as well as payers and policymakers are impacted. More adolescents are in need of crisis evaluations, observation beds, inpatient and outpatient psychiatric treatment, school-based interventions and care coordination. Health systems and payers are asking about reimbursement for evidence-based interventions such as group care, as well as telehealth and enhanced primary care delivered through collaborative care models, including follow-up phone calls in the emergency department following a visit for suicidal ideation. Some systems will respond effectively within the emergency department, while others will miss crucial opportunities to intervene early and find later, costlier, less optimal solutions. All of the systems tasked with caring for and protecting our young people will be impacted by this wave of self-harming adolescents.

What Changes

One crucial step the field needs to take is to screen for mental illness at an earlier point in the cycle of distress. Right now, many organizations are doing a great job connecting people with care at the point when mental illness has escalated into a medical emergency. But as this report shows, organizations need better systems for screening for mental illness early on, and clear protocols about what to do after a positive screen. What are the steps for assessment, how will the organization contact a family member to arrange for a parent to bring their child in for further evaluation, how will organizations make timely referrals to evaluators or treatment providers, and what steps will organizations take if they determine a child is at imminent risk of harming himself or herself? Screening should be practical, repeated over time, and connected to real options for follow-up.

When making clinical decisions about adolescents who report suicidal ideation and/or behaviors, clinicians should approach these decisions from a safety-focused and developmentally informed perspective. Adolescents who report suicidal ideation or behaviors should not automatically be considered to be at extreme risk for making a suicide attempt; equally important, serious danger should not be ruled out. Clinicians must understand the adolescent’s current risk for suicidal behavior by assessing several critical factors. These factors include: past suicidal behavior, current suicidal ideation (intention and plan), other psychiatric diagnoses, current stressors, access to methods of suicidal behavior, level of supervision (e.g., home, school), and protective factors including positive relationships with family, school, and other important adults. Writing out a safety plan with the adolescent can be a very helpful tool for clinicians when making such decisions. The plan should be easy for the adolescent to read and include several components such as: (1) the adolescent’s personal warning signs for increased risk of suicide; (2) strategies the adolescent is willing to use in response to his/her warning signs; (3) a list of supportive individuals and/or services the adolescent feels comfortable contacting for help; and (4) steps the adolescent should take should the risk for suicide increase.

In the post-crisis and post-disclosure stage, youth and their families require access to evidence-based psychological treatments in a timely manner. Cognitive behavioral therapies, particularly CBT adapted for adolescents, help youth to identify and challenge their negatively distorted or surface level thinkers and behaviors and acquire skills to cope with, solve, and manage a multitude of feelings and situations. The DBT skills for adolescents and their families assist in regulating emotions, increasing tolerance of extreme distress, and improving interpersonal interactions, including healthy communication and relationship skills. Family-based treatments are also effective as part of bereavement programs for adolescents, as caregivers and adolescent children learn to understand how each other’s behaviors affect them and work to decrease conflict and establish a safe home environment. Medication is often prescribed to treat underlying mood or anxiety disorders. It is important that any medication is part of a package of treatment and that the individual is closely monitored as to its effects.

Schools should take a more expansive role in addressing youth mental health. Schools are often the first to identify that a youth is in distress, and are a key setting for prevention efforts that reach hundreds, if not thousands, of youth and families. School-based mental health teams can provide early intervention and brief counseling as well as triage and linkage to acute or specialty mental health and crisis services as needed. Teachers and other school staff need training on how to approach a struggling youth with care and concern, how to monitor youth’s changes in behavior or academic performance, and how to quickly connect the student and family with the service provider following a hospitalization or absence from school. Schools also play a crucial role in promoting protective factors for mental health such as a sense of belonging, reduced bullying, a regular daily schedule, and healthy peer relationships. Strengthening school mental health infrastructure is one of the highest-yield investments a community can make in addressing youth mental health.

Youth in crisis need a system of care with alternatives to inpatient hospitalization. While many youth may need immediate response to a crisis situation, not all youth require inpatient hospitalization. Community and youth need 24/7 access to a crisis line, a mobile crisis team, an urgent outpatient appointment as needed, community stabilization services and a rapid access clinic. These services would link emergency services and quality outpatient care together, eliminating bottlenecks in the hospital system and providing consistent, quality services as services are matched to the level of crisis and risk of harm to self or others.

We encourage the continued use of Telehealth in settings where travel, stigma, or workforce shortages may interfere with providing services. Virtual follow-ups can be particularly useful in increasing the likelihood that families attend sessions as well as medication management and parent guidance appointments. Virtual sessions are especially useful in filling scheduling gaps caused by school schedules, transportation barriers, and/or clinic location for consumers and families. Telehealth is NOT appropriate for emergency evaluation for imminent risk of harm and is dependent on several factors including consumer and family privacy/stigma comfort, reliability of technology (smartphone, tablet, computer) and/or internet access. For some families, it may be most beneficial to incorporate a blended model of in-person and virtual visits in their children’s care.

PA and payment strategies must move beyond crisis response and invest in quality improvements to the mental health system. This includes paying for prevention and treatment delivered in pediatric settings and schools and for follow up after an emergency visit. It means reducing delays in prior authorization and eliminating narrow networks that deny patients timely access to therapy at the moment they need it most. Our strategy must include a robust investment in the pediatric mental health workforce, integrated models of care and consultation to primary care for both adult and child mental health. Finally, our strategy should link together schools, pediatric practices, mental health agencies and other social service agencies in a robust and sustainable way in order to identify and address problems as they are emerging, rather than as a crisis. For too many families experiencing mental health issues, there is a frequent sense of isolation and abandonment. We can change this.

There exists a tension between issues of confidentiality and family involvement in ethical adolescent care and treatment. Teenagers need to feel safe to reveal their most private and personal concerns to caregivers in confidence, while caregivers need to know information in order to keep the adolescent safe. Both caregivers and adolescents should understand what information will be maintained in confidence and what will be shared with family members, as well as how family members will be involved in treatment planning. Care and treatment must also avoid overmedicalization (seeing too much psychiatry) as well as under-recognition (seeing too little psychiatry) of adolescents’ mental health problems. A stepped-care approach may be indicated. Many interventions can be brief and targeted, while others require specialty care and are indicated for adolescents who are at risk or have more serious psychiatric disturbance.

Crisis response is important, but in the long run, we need to do a better job of prevention. We can arm communities with knowledge about connection, youth and caregiver coping skills and problem solving skills, reducing stigma around mental health care and supporting affected families and communities. Health education for caregivers of youth in schools, residential care, detention centers, foster care, mental health care settings, and juvenile justice could include: 1) The warning signs for suicidal behavior and what to do in that case; 2) Early intervention for at-risk youth and families; 3) Creating a safe environment for youth by storing medications and other potentially toxic substances out of reach. The post-pandemic adolescent spike in self-harm is a wake-up call to develop earlier, fairer, more connected, and more effective systems to support the healthy development of all young people.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC12491249/ https://pmc.ncbi.nlm.nih.gov/articles/PMC12150644/ https://www.cdc.gov/mmwr/volumes/71/su/su7103a3.htm