CASP 2025

School-based suicide risk assessment as a process:  Understanding drivers to suicide in adolescents

Understanding and Responding to Self-Injury in the Schools

Self-injury is often first noted by school personnel (Lieberman, Poland & Niznik, 2019) as it occurs among 14-18% of adolescents in the school environment (Farkas, et al., 2022; Glenn, Franklin, & Nock, 2015; Hasking et al., 2016; Walsh, 2012; Whitlock & Rodham, 2013).  School mental health professionals can feel ill-equipped to effectively respond to students that self-injure, particularly without guidelines to assist them (Hasking et al., 2016; Heath, Toste, & Beettam, 2006).  Given that the majority of school counselors report that they have counseled a student who had engaged in self-injury (Darosh & Lloyd-Richardson, 2013; Heath & Lewis, 2013), the need for school-based strategies is evident. Schools are well-positioned to play a central role in mitigating self-injury.

Considered a coping device to manage overwhelming emotions and psychological distress (Walsh, 2012), “self-injury is intentional, self-effected, low-lethality bodily harm of a socially unacceptable nature, performed to reduce and/or communicate psychological distress” (Walsh, 2012, p. 4).  It is comprised of a continuum of behaviors ranging from having no intention to die to behaviors with increasing suicidal intent (Farkas et al., 2022).

Research converges on the idea that “there is no one profile for an individual who self-injures (Whitlock & Rodham, 2013, p. 95).”  Though adolescents with psychiatric issues have historically been at higher risk for self-injury, more recently, self-injury is increasingly found outside the context of psychological illness (Walsh, 2012).

The relationship between self-injury and suicide is complex (Ribeiro et al., 2016; de Neve-Enthoven et al., 2023; Dickstein, et al., 2015) and warrants attention in schools.  The distinction previously made is that self-injury does not include the desire to die, whereas suicide attempts often involve at least some intent to die (de Neve-Enthoven et al., 2023; Schatten, Morris, Wren, & Andover, 2013).

The development of ideation-to-action theoretical models and the exploration of potential pathways connecting self-injury to suicide are consistently indicating that a history of self-injury is a strong predictor of suicide regardless of other risk factors (de Neve-Enthoven et al., 2023; Glenn et al., 2017; Glenn, Franklin & Nock, 2015; Guan, Fox, & Prinstein, 2012; Nock et al., 2006). In fact, the comorbidity of self-injury with suicidal behaviors has been found to be 50% for non-clinical populations and 70% among clinical populations (Farkas et al., 2022) making it critically important for school psychologists, counselors, and other school-based mental health providers to assess for suicidal ideation regularly among each and every student who presents with self-injury (Dickstein et al., 2015; Glenn, et al., 2017; Hasking, et al., 2017).

Despite an increased understanding of individual risk factors associated with self-injury, a broad comprehension of contextual factors that impact specific adolescent groups is just emerging (Shinn, 2023). The intersectionality of internal, environmental, and other salient factors that disproportionally impact groups (e.g., race, gender, class, sexual orientation, among others) are necessary components to culturally competent self-harm risk assessment in the schools and need to be considered (JED Foundation, 2023).

School procedures for managing contagion are also necessary (Shinn, 2023). Within school settings, the proximity of peers can encourage multiple students in the same group to engage in acts of self-injury within a short period of time (Lieberman, Toste, & Heath, 2009; Lieberman & Poland, 2006; Walsh, 2012).  Research has found that having a friend who self-injures is a strong predictor of self-injury and that adolescents may trigger self-injury in each other (Walsh & Muehlenkamp, 2013). This can also be true in online communities that mimic real-life communities (Mahdy & Lewis, 2013; Reddy, Rokito, & Whitlock, 2016).  Therefore, school professionals need to have familiarity with online self-injury activity in order to determine the positive and/or potentially negative effects on these students (JED Foundation, 2023; Lieberman, 2010).

Experts suggest that schools should have a systematic approach to manage self-injury (Bubrick, Goodman, & Whitlock, 2010; Lieberman, Toste, & Heath, 2009; Miller & Brock, 2011).  A collaboratively written school protocol, based on guidelines from current research, is suggested to meet the unique needs of each educational environment in order to facilitate consistent, appropriate, timely responses to self-injury in the schools.  The protocol should: train staff on recognizing signs of self-injury; define roles/responsibilities of school personnel; establish procedures for risk assessment; offer guidelines for parental notification and referrals; and delineate methods for managing potential contagion (Bubrick, Goodman, & Whitlock, 2010; Hasking et al., 2016).

Schools do not commonly have clearly articulated protocols and strategies for intervening with students with self-injury.  This session will equip practitioners with a research-based framework and strategies they can develop and use as part of a systematic school protocol.

Reference List:

Bubrick, K., Goodman, J., & Whitlock, J. (2010).  Non-suicidal self-injury in schools: Developing and implementing school protocol [Fact Sheet] Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults.  Retrieved from http://crpsib.com/userfiles/NSSI-schools.pdf

Darosh, A.G., & Lloyd-Richardson, E.E. (2013).  Exploring why students self-injure: The functions of nonsuicidal self-injury. School Psychology Forum: Research in Practice, 7 (4), 111-120.

de Neve-Enthoven, N.G.M., Ringoot, A.P., Jongerling, J., Boersma, N., Berges, L.M.,Meijnckens, D., Hoogendijk, W.J.G., & Grootendorst-van Mil (2024).  Adolescent nonsuicidal self-injury and suicidality: A latent class analysis and associations with clinical characteristics in an at-risk cohort.  Journal of Youth and Adolescence, 53, 1197-1213.

Dickstein, D.P., Puzia, M.E., Cushman, G.K., Weissman, A.B., Wegbreit, E., Kim, K.L., Nock, M.K., & Spirito, A. (2015).  Self-injurious implicit attitudes among adolescent suicide attempters versus those engaged in nonsuicidal self-injury.  Journal of Child Psychology and Psychiatry, 56 (10), 1127-1136.

Farkas, B.F., Takacs, Z.K., Kollarovics, N., & Balazs (2022).  The prevalence of self injury in adolescence: A systematic review and meta-analysis.  European Child and Adolescent Psychiatry. doi.org/10.1007/s00787-023-02264-y

Glenn, C.R., Franklin, J.C., & Nock, M.K. (2015).  Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth.  Journal of Clinical Child & Adolescent Psychology, 44 (1) 1-29.

Glenn, C.R., Lanzillo, E.C., Esposito, E.C., Santee, A.C., Nock, M.K., & Auerbach, R.P. (2017).  Examining the course of suicidal and nonsuicidal self-injurious thoughts and behaviors in outpatient and inpatient adolescents.  Journal of Child Psychology, 45, 971-983. doi 10.1007/s10802-016-0214-0

Guan, K., Fox, K.R., & Prinstein, M.J. (2012). Nonsuicidal self-injury as a time-variant predictor of adolescent suicide ideation and attempts in a diverse community sample.  Journal of Consulting and Clinical Psychology, 80 (5), 842-849.

Hasking, P.A., Heath, N.L., Kaess, M., Lewis, S.P., Plener, P.L., Walsh, B.W., Whitlock, J., & Wilson, M.S. (2016).  Position paper for guiding response to non-suicidal self-injury in schools.  School Psychology International, 37 (6), 644-663.

Heath, N., & Lewis, S.P. (2013).  Nonsuicidal self-injury in our schools, from research to practice: Introduction to the special issue (2013).  School Psychology Forum: Research in Practice, 7 (4), 89-92.

Heath, N., Toste, J., & Beettam, E. (2006).  “I am not well-equipped”: High school teachers’ perceptions of self-injury.  Canadian Journal of School Psychology, 21, 73-92.

JED Foundation (2023).  Can the metaverse be good for youth mental health? Retrieved from https://jedfoundation.org/wp-content/uploads/2023/07/Can-The-Metaverse-Be-Good-For-Youth-Mental-Health-Jed-Foundation.pdf

Lieberman, R. (2010).  General guidelines for administrators intervening with self-injurious youth.  Los Angeles County Youth Suicide Prevention Project

http://preventsuicide.lacoe.edu

Lieberman, R.A., & Poland, S. (2006).  Self-mutilation.  In G.G. Bear & K.M. Minke (Eds.), Children’s Needs III: Development, prevention, and intervention (pp. 965-976).  National Association of School Psychologists.

Lieberman, R.A., Poland, S., & Niznik, M. (2019).  Nonsuicidal self-injury: Handout for School. In G.G. Bear and K.M. Minke (Eds).  Helping Handouts: Supporting Students at School and Home (S3H10). National Association of School Psychologists.

Lieberman, R.A., Toste, J.R., & Heath, N.L. (2009).  Non-suicidal self-injury in the schools: Prevention and intervention.  In M.K. Nixon & N.L. Heath (Eds)., Self-injury in youth: The essential guide to assessment and intervention (pp. 195-215).  Routledge.

Mahdy, J.C., & Lewis, S.P. (2013).  Nonsuicidal self-injury on the internet: An overview and guide for school mental health professionals.  School Psychology Forum: Research in Practice, 7 (4), 148-160.

Miller, D.N. & Brock, S.E. (2011).  Identifying, assessing, and treating self-injury at school.  Springer Science and Business Media.

Nock, M.K., Joiner, T.E., Gordon, K.H., Lloyd-Richardson, E., & Prinstein, M.J. (2006). Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts.  Psychiatry Research, 144, 65–72.

Reddy, N., Rokito, L., & Whitlock, J. (2016).  What is the link? The relationship between non-suicidal self-injury and social media.  Information Brief Series, Cornell Research Program on Self-Injury and Recovery, Cornell University.

Ribeiro, J.D., Franklin, J.C., Fox, K.R., Bentley, K.H., Kleinman, E.M., Chang, B.P., & Nock, M.K. (2016).  Self-injurious thought and behaviors as risk factors for future suicide ideation, attempts, and death: A meta-analysis of longitudinal studies.  Psychological Medicine, 46 (2), 225-236.  doi.org.10.1017/S0033291715001804

Schatten, H.T., Morris, B.W., Wren, A.L., & Andover, M.S. (2013).  Mental health issues and nonsuicidal self-injury among youth: Implications for mental health professionals in the school system.  School Psychology Forum: Research in Practice, 7 (4), 136-147.

Shinn, M. M. (2023). Nonsuicidal self-injury: A brief overview [handout]. National Association of School Psychologists.

Walsh, B.W. (2012).  Treating self-injury: Second edition: A practical guide.  The Guilford Press.

Walsh, B.W., & Muehlenkamp, J.J. (2013).  Managing nonsuicidal self-injury in schools: Use of a structured protocol to manage the behavior and prevent social contagion.  School Psychology Forum: Research in Practice, 7 (4), 161-171.

Whitlock, J., & Rodham, K. (2013).  Understanding nonsuicidal self-injury in youth.  School Psychology Forum: Research in Practice, 7 (4), 93-110.