Understanding Self-Harm for Foster and Adoptive Parents

Rachel Bithell M.S. and Grace Bithell LCSW

After experiencing neglect during the first year of her life, Evelyn (name has been changed) was welcomed by a resource family on her first birthday. Within just a few days, her caregivers noticed several concerning behaviors, but the most troubling were frequent attempts to hurt herself. Evelyn would bang her head on furniture, walls, and floors. She left bruises on her foster mother’s chest from the impact of her skull against the foster mom’s sternum. She also pulled her own hair out. Though Evelyn was barely a toddler, she was exhibiting self-harming behaviors.

Understanding self-harm is important for caregivers who work with children and adolescents. Studies have found varying rates of self-harm depending on the demographics of their population and their methods of reporting. However, among young people ages 10-21in the United States, probably 10-20% have self-harmed in the previous year. Having good information about self-harm is especially important for caregivers who work with young people who have experienced out of home care. While self-harm can impact anyone, the following factors increase risk:

• abuse

• neglect

• being part of the LGBTQIA+ community

• having mental illness,

• having friends who self-harm (including online contacts)

• being bereaved by suicide

• weak social networks and supports

This list means virtually every young person impacted by foster care has elevated risk for self-harm.

What is Self-Harm?

Self-harm is any behavior in which a person intentionally injures themselves. Cutting with a sharp implement, such as a razor, is the most common form of self-harm, but scratching, burning, hitting, biting, head-banging, hair-pulling, and non-lethal overdose are also reported. These behaviors are a response to overwhelming, painful emotions like sadness, anger, fear, guilt, and shame. The act of self-injuring is a way to cope with or release these emotions. Some people describe the physical pain, which is within their control, as a distraction or break from their emotional pain, which seems out of control. Other self-injuring people describe the action as a way to punish or control themselves. Some people who have withdrawn from relationships and emotions in order to protect themselves, may use self-harm as a way to “feel something”.

Self-harm affects the brain in ways that can be habit forming. Growing evidence shows that self-harm can stimulate the release of endorphins that help to reduce physical pain and elevate mood. But the effect is short-lived and is often then replaced by disappointment, guilt, or shame. This increase in negative emotion then makes the person more likely to use self-harm again. For some, the compulsion to self-harm becomes very strong and frequent.

What Self-Harm is NOT

Self-harm is usually not a suicide attempt. In fact, it is often referred to by researchers as non-suicidal self-injury (NSSI). Most people who self-harm are using the behavior as a tool that helps them stay alive. However, many of the risk factors that make young people more likely to self-harm, also make them more likely to consider or attempt suicide. Also, some research suggests a history of self-harm is itself a risk factor for suicide. For these reasons, self-harm should be taken seriously, treated compassionately, and addressed with the support of professionals.

Self-harm itself is not a mental illness. It is a behavior. However, self-harm is associated with some mental illnesses such as depression, anxiety, and borderline personality disorder (BPD). Please note that many clinicians are hesitant to diagnose BPD in people younger than 18 because the changes and instability that often accompany adolescent development may mimic symptoms of BPD. Self-harm is also associated with substance use. This may be because substance use makes people more impulsive and less able to anticipate negative consequences. It may also be because substance use and self-harm share many risk factors.

Self-harm is not a way to get attention. Many people who self-harm are careful to hide the behavior. Self-harm should also be understood as a way of internalizing difficult emotions. For many, it is an alternative to externalized behaviors like aggression and blaming. However, positive attention from trusted friends and family can help people find other coping strategies. Even if self-harm were used by an individual to seek attention, compassionate caregivers should recognize that attention is a valid need and try to meet that need.

Self-harm is not just a problem for teenage girls. Adolescents are more likely than young children or older adults to use self-harm, and many studies have found self-harm is more common in females than males. However, self-harm may affect males and females of any age. Even infants, like Evelyn, may exhibit self-harming behaviors such as banging their heads, pulling their hair, and biting themselves.

How To Help

As a caregiver, be aware of risk factors and pay attention for signs of self-harm. These signs include:

• scars from injuries

• keeping arms and/or legs covered even in hot weather to hide injuries

• changes in relationships and activities (including withdrawing from these)

• changes in sleep

• substance use

• depression (including feelings of sadness, hopelessness, failure, guilt, low interest, and low self-esteem)

• talking or seeking information about self-harm or suicide (often this happens online)

Many of these signs could also be associated with other issues, but, in any case, should be cause for concern. If you are concerned about self-harm, ask sincere and open-ended questions.

“You don’t seem yourself lately. Anything going on you’d like to talk about?”

“You seem sad today. Can I help?

“I noticed you have a cut on your shoulder, but I’m not sure how you got it. Do you want to tell me about it?”

If someone discloses their self-harm behavior, stay calm. Honor their trust and courage. Validate their feelings and don’t judge. Keep confidences, unless you are concerned the person may be a threat to their own safety or someone else’s safety. If you must share the information, let the person know whom you are telling and why. Give them the opportunity to make the disclosure themselves. Encourage them to seek support from mental health professionals. You can ask caseworkers, medical providers, school counselors, or your insurance plan for referrals. In a crisis situation, you can get immediate support from the national Suicide and Crisis Lifeline by calling 988, or text HOME to 741741 to reach the Crisis Text Line. Many states and cities also have help lines. Adding a crisis line the contacts on your phone is smart for caregivers.

While self-harm is not usually a suicide attempt, the stakes are too high to take unnecessary risks. To the degree possible, eliminate access to lethal means such as firearms and other weapons and prescriptions drugs.

Do not ask for promises or give ultimatums related to self-harm. It takes more than will-power to change the behavior.

Occasionally, especially when self-harm is occurring with severe mental illness, inpatient treatment may be recommended. Usually, self-harm can be treated with outpatient therapies. Treatment options for self-harm include psychodynamic therapy, cognitive behavioral therapy, and dialectical behavioral therapy. In the short-term, these therapies teach strategies to distract from the compulsion to self-harm or replace the self-harming behavior with a less risky behavior. In the long-term, they help people process and cope with the very difficult emotions that lead to self-harm.

Evelyn and her caregivers got help and support from an early childhood developmental interventionist, an occupational therapist, and their caseworker. They focused on creating secure attachments and soothing sensory experiences for Evelyn and giving her other ways to express her painful emotions. Five years later, she is a happy and healthy kindergartener.

A version of this article originally appeared in a 2022 issue of Fostering Families Today