Evidence-based assessment/Rx4DxTx of self harm

Evidence-based Analysis of Suicidality and Related Non-Suicidal Self-Injury

Two related but often confusing topics are suicidality and non-suicidal self-injury (NSSI). Suicidality refers to intentional seeking to end one's life, while NSSI refers to the intentional harming of one's body without the intent to end one's life. NSSI is related to suicidality, and increased NSSI can be a moderate predictor of future suicide risk. However, NSSI is not exclusive to suicidal individuals, and many people practice NSSI with no intention to end their life. The following two sections help elucidate trends in suicidality and NSSI in hope of better distinguishing between the two. Resources are also provided for each topic to help spread awareness that help exists and is accessible. This page also seeks to explore the effects social media has on prevalence and risk factors of each topic.

Resources for Suicidality and Non-suicidal Self-injury
Anyone in crisis should feel free to reach out to the National Suicide Prevention Lifeline (1-800-273-8255) or the Crisis Text Line (text HELLO to 741741). Volunteer operators for these organizations receive thorough training to address mental health crises with special emphasis on suicide, and provide these services free of charge 24/7, 365 days a year.

Two of the most prominent organizations using science to inform policy and other interventions in the United States are the National Institutes on Mental Health (NIMH) and the American Foundation for Suicide Prevention (AFSP). In addition to developing their own resources, they provide funding to research groups who are also committed to the mission of addressing and eliminating suicide.

For basic information on self-injury, feel free to visit the Mayo Clinic here. The American Foundation for Suicide Prevention also contains good resources for helping cope with suicidality. For help with social media addiction, please visit the addiction center here. For help with finding a therapist specializing in cognitive behavioral therapy, dialectical behavior therapy, or others, please visit Psychology Today here.

For adolescents local to the Chapel Hill area, the UNC Child and Family Clinic (919-962-6906) offers evidence-based assessment and treatment options with options for reduced fees. The clinic can also provide referrals to other providers based on individual needs.

Helping Give Away Psychological Science (HGAPS) is an incorporated 501(c)(3) non-profit that was founded at the University of North Carolina at Chapel Hill by Eric Youngstrom, PhD., and his former graduate student, Mian-Li Ong, PhD in 2016. This organization is a largely student-run start-up with the mission of giving away the highest quality psychological information and resources to the people who need it most, with an emphasis on finding and compiling the “best of the free”. While HGAPS started out focusing on evidence-based assessments, we quickly came to realize that that is not all that people look for and need – after the Parkland school shooting, we started curating crisis response pages. After the release of the hit Netflix series 13 Reasons Why, we created these resources bringing together evidence-supported research to address the myriad of issues and problematic illustrations in the show. Even now, the group is working remotely to compile resources for supporting mental health during the COVID-19 outbreak that has disrupted daily life across the globe.



Assessment Table for Suicidality and NSSI
Note: "y" indicates that yes, this instrument covers this content; * indicates that the SITB characteristic was specified on a rating scale or within the question (i.e., a specific form of preparation)

= Suicidality in Adolescents and the Effects of Social Media = Despite the incredible medical advances and interventions that have been developed in recent decades to prevent death from various conditions, suicide rates across all demographic categories have remained relatively untouched in the United States. Adolescent suicide has regrettably been on the rise, with a 33% increase in rates between 1999 and 2014, securing its place as the second leading cause of death for youth ages 10 to 19. The current cohort of those adolescents, often referred to as Generation Z, has grown up in the age of social media and constant social connection via the internet. Given their elevated rates of suicide along with other mental illnesses, psychologists and concerned parents alike posit that social media may be at least partly to blame for the adverse mental health outcomes of this age group. In this paper, I will explore the available literature on suicidality in adolescents, the role that social media may play in influencing suicidal thoughts and behaviors, and what can be done to reduce the tragedy of suicide in youths.

Diagnostic Criteria
Within the broader context of self-injurious thoughts and behaviors (SITB), this paper will focus on the suicidal category as opposed to non-suicidal. As suicidal ideation and behaviors are not in and of themselves an independently classified disorder, they are not “diagnosed” in the typical sense. However, developing a common language to better describe and accordingly treat SITB is still critical to identifying these problems, especially for adolescents who most likely lack the terminology that mental health professionals frequently use. A more detailed overview of the assessments used to measure suicidality will be provided in a later section.

Within the context of the DSM, some SITB are incorporated in criteria for some diagnoses, notably in major depressive disorder and borderline personality disorder, and there is an additional suicidal behaviors disorder that was proposed in DSM-V but lacks extensive research. Some of the arguments for a separate suicidal behavior diagnosis include that suicidal behavior occurs outside of currently defined psychiatric conditions, creating a separate diagnosis could improve identification as well as integration into clinical practice, and that suicidal behavior independently meets criteria for diagnostic validity and reliability criteria. There has even been data supporting the presence of genetic risk factors for suicidal behavior as well as biological risk markers. However, some concerns about creating a suicidal behavior diagnosis include that it may have an adverse effect of increasing stigma and create potential liabilities for clinicians or otherwise undermine the therapeutic relationship. The consensus seems to be that suicidal behavior deserves greater and more focused recognition within the DSM and other classification systems, but it is unclear whether the potential benefits outweigh the risks in creating a separate diagnosis.

Prevalence
Based on a large-scale representative sample of youth ages 13 to 18, researchers identified the rates of suicide ideation (12.1%), suicide planning (4.0%), and suicide attempts (4.1%) in the United States. The most current available results of the Youth Risk Behavior Surveillance System (YRBSS) showed that in the 12 months before taking the survey, 19.0% of high schoolers had been bullied on school property and 7.4% had attempted suicide. Suicidal SITB in this age group is prevalent enough that it presents a public health concern for the availability of and access to mental health resources for adolescents.

Research also seems to support the observed gender differences of adults in adolescents such that while boys who attempt suicide are more likely to die due to choosing more lethal means, girls are more likely to attempt suicide. An international study of young adolescents in 40 low- and middle-income countries indicated that the prevalence for suicide attempts for girls (18.2%) was significantly higher than for boys (16.2%). The same study illustrated that factors associated with suicide attempts in these adolescents included being of low SES background, history of loneliness and bullying, substance use, and poor social relationships, and it appears that the likelihood of attempts (especially attempts with prior planning) increase with age. German researchers found that adolescents with a migration background showed a significantly higher prevalence of suicidal ideation, attempts, and direct self-injurious behaviors. While college students are beyond the age of adolescence, data collected in college-aged populations indicates that those were not enrolled full-time in college were at higher risk of attempting suicide than those who were, which may have relevance to high school students who are comparably less occupied and engaged with getting higher education. All of these findings suggest that greater attention needs to be paid to adolescents of historically disadvantaged backgrounds who are often the least likely to be able to get help.

Common Comorbidities
The disorder most commonly associated with suicidality is depression. The continuity and duration of depressive symptoms in adolescents with MDD is positively correlated with SITB, which suggests that the processes underlying depressive symptoms likely play a key role in suicidal thoughts and behaviors.

ADHD has also been shown to be an independent risk factor in attempting suicide and an even stronger predictor of repeated attempts. It has been hypothesized that this may be due to shared neurobiological processes in the mesolimbic pathway that determines responses and sensitivity to reward, specifically deficits in dopamine production or reception. Another possible reason ADHD may be related to suicidal behavior and especially repeated attempts may be its core characteristic of impulsivity.

Impulsivity has been consistently implicated as a strong risk factor for suicide, especially in adolescents whose brains have not fully developed to mitigate impulses. Personality traits like impulsivity and neuroticism may predispose certain youths more than others who may be experiencing the same severity of psychiatric symptoms, which indicates that suicidality is highly complex with several interacting variables of risk. This may be driving the difficulty of identifying people and especially adolescents who are at risk for suicidal behavior given that they may not have a history of prior attempts or SITB.

Prognosis or Developmental Course
Unfortunately, very little is known about the temporal course of SITB and specifically suicidal ideation and behavior in adolescents. Latent growth curve analyses of a study of 12 to 15 years following psychiatric inpatient hospitalization illustrated what may be a period of remission from suicidal ideation up to 6 months following their discharge, with reemergence 9 to 18 months postdischarge. It has been suggested that adolescent suicide may result as a failure of biological responses to acute stress that youths may not be equipped to handle on their own. Stressors that uniquely contribute to SITB in adolescents include the hormonal changes of pubertal development as well as social network reorganization and family conflicts.

Based on the little longitudinal research that is available for adolescent suicidality, it appears that higher self-reported depressive symptoms, lower parent-reported externalizing symptoms, and more frequent non-suicidal self-injury (NSSI) predicted more adverse outcomes in the form of weaker remission from suicidal ideation after hospitalization. In order to gather a more accurate picture of the long-term effects and prognosis of adolescent suicidality, more longitudinal research needs to be conducted with the population of suicidal adolescents, with special attention to those from disadvantaged backgrounds as outlined above.

Evidence-based Assessment for Suicidality
While suicidal behavior is not in and of itself a diagnosis, assessments can help clarify specific risks and targets for intervention. The most commonly used initial assessments for youths include the Columbia-Suicide Severity Rating Scale (C-SSRS), which has been validated for use in adolescents and assesses for all suicidal outcomes including ideation (passive and active), planning, attempts (including aborted and interrupted) as well as present intensity of ideation and explicit intent, and the Self-Injurious Thoughts and Behaviors Interview (SITBI) which serves a similar purpose as the C-SSRS with additional considerations for severity, frequency, recency, and motivations which also make it a longer assessment to administer.

Another assessment that can be particularly helpful for case conceptualization for adolescents who endorse suicidality is the Reasons for Living for Adolescents (RFL-A). Given that the most relevant protective factor in suicidal SITB is an individual’s personal reasons for living, the RFL-A was created to check for reasons not to attempt suicide that are relevant to adolescents. In a therapy setting, these responses could be used to foster a conversation with the adolescent about how to put more weight on these reasons or find new reasons to live.

Assessment can also be used to develop a treatment plan. In particular, risk management is critical for treating SITB as it presents serious risk for physical harm. Asking about access to lethal means and initiating means safety counseling has been shown to reduce suicide in populations of all ages. Some support has been shown for the use of more frequent assessment on a daily or even hourly basis to pinpoint specific risk and predictive factors. In particular, changes in suicidal ideation over two days were found to significantly predict 22.6% of NSSI cases. Increasing frequency of assessment can help delineate the complex interactions of different risk factors and better prevent SITB.

Evidence-based Treatment for Suicidality
Clinical practice guidelines from the U.S. Department of Veteran Affairs (VA), which encounters a high volume of suicidal cases, gives support for several approaches to treatment. While pharmacologic therapies are an option, this may not be appropriate for adolescents and their parents, especially given the risk of antidepressants increasing the risk of suicide in youths under 18. Among adults, SSRIs seem to have a beneficial effect on people over the age of 24, but a neutral effect on those between 18 and 24 (Näslund et al., 2018). Thus, a nonpharmacologic treatment will likely be much more appropriate for use in adolescents. The VA guidelines indicate three nonpharmacologic treatments with good evidence: CBT, DBT, and crisis response planning. A particularly interesting approach to safety planning makes the daily assessment of SITB a reality through the use of smartphones. The Continuous Assessment for Suicide Prevention and Research (CASPAR) study innovatively integrates smartphones in the monitoring of risk for suicidal patients. The CASPAR research group based in Amsterdam will be using a mobile app to develop a safety plan and track daily self-monitoring (including the RFL-A and SITBI measures discussed previously) in a sample of 80 adults. If effective, the smartphones that are often touted as harmful to mental health may be able to be utilized for a positive impact on the treatment and monitoring of SITB. Given that today’s adolescents are more comfortable using smartphones than any prior generation, mobile platforms may be particularly useful in treating this population.

Social Media and Suicide
What exactly is the impact of social media use on suicide? A study conducted in Japan on the Werther Effect by using machine learning analyses of over 1 million Twitter messages showed that the emotional responses to prominent suicide deaths were correlated with subsequent deaths by suicide at the national level: reactions expressing surprise were more correlated with increased deaths, while those expressing condolences were negatively correlated with suicide counts. These results suggest that more attention should be given to the content of social media responses to prominent suicide deaths, which is of particular concern for adolescents who use social media more often than any other age group. Their findings could also suggest that mainstream media such as news outlets may need to take into consideration the emotional tone of their coverage of suicide.

Data from social media can also provide valuable insight into understanding the behaviors of suicidal individuals and adolescents. Natural language processing of social media posts can be used to detect people who are at risk of suicide by detecting signals around suicide attempts through an automated system estimating risk that can be used by people without specialized mental health training. This means that people like primary care doctors could use social media to more accurately and effectively assess for risk of suicide. Even if social media cannot be harnessed to improve treatment for adolescents, it is at least necessary to provide guidelines for young people to talk about suicide on social media. The #chatsafe project is working to provide those guidelines, because it is inevitable that it will come up as a topic of discussion, and talking about it safely can destigmatize the issue and encourage more adolescents to seek help.

Non-suicidal Self-Injury in Adolescents and the Effects of Social Media
Self-harm and suicide have been a growing public health problem, with suicide being the second most common cause of death in adolescents worldwide. Those who are at a socioeconomic disadvantage and have psychiatric illnesses are most at risk. However, self-harm in adolescents is used as a means of expressing extreme pain rather than a method of reaching out for help or to end one’s life. Due to the inherent non-suicidal aspect of this form of self-harm, psychologists have coined the term “non-suicidal self-injury” (NSSI) to discuss this topic. NSSI is a proxy for internal and interpersonal pain, so understanding the relationships between adolescents and NSSI can help us know more about failed coping mechanisms and underlying biological conditions that lead to suicide. While NSSI is not exclusive to suicide attempts, it can be understood as a proxy for suicide attempts as NSSI increases the likelihood of a person attempting suicide, though this is not considered a causal relationship. Because of inconsistency in the literature regarding self-harm, there have been difficulties in standardizing practices and resources leading to inefficiencies in research practices. By taking steps to standardize terminology and therapeutic approaches, the field can aim to decrease horrifying statistics and further delve into the unexplored relationships between various social, biological, and psychological factors that impact NSSI tendencies. A particular focus of this paper is the effect of peer socialization, peer relationships, and social media use on NSSI outcomes.

Diagnostic Criteria
Because of the significant differences in terminologies surrounding NSSI and suicidal ideation, creation of specific diagnostic criteria for Non-Suicidal Self-Injury Disorder (NSSI-D) was difficult. In the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) an attempt was made at categorizing this disorder:


 * A. More than minimal exposure to alcohol during gestation, including prior to pregnancy recognition. Confirmation of gestational exposure to alcohol may be obtained from maternal self-report of alcohol use in pregnancy, medical or other records, or clinical observation.


 * B. Impaired neurocognitive functioning as manifested by one or more of the following:
 * 1) Impairment in global intellectual performance (i.e., IQ of 70 or below, or a standard score of 70 or below on a comprehensive developmental assessment).
 * 2) Impairment in executive functioning (e.g., poor planning and organization; inflexibility; difficulty with behavioral inhibition).
 * 3) Impairment in learning (e.g., lower academic achievement than expected for intellectual level; specific learning disability).
 * 4) Memory impairment (e.g., problems remembering information learned recently; repeatedly making the same mistakes; difficulty remembering lengthy verbal instructions).
 * 5) Impairment in visual-spatial reasoning (e.g., disorganized or poorly planned drawings or constructions; problems differentiating left from right).


 * C. Impaired self-regulation as manifested by one or more of the following:
 * 1) Impairment in mood or behavioral regulation (e.g., mood lability; negative affect or irritability; frequent behavioral outbursts).
 * 2) Attention deficit (e.g., difficulty shifting attention; difficulty sustaining mental effort).
 * 3) Impairment in impulse control (e.g., difficulty waiting turn; difficulty complying with rules).


 * D. Impairment in adaptive functioning as manifested by two or more of the following, one of which must be (1) or (2):
 * 1) Communication deficit (e.g., delayed acquisition of language; difficulty understanding spoken language).
 * 2) Impairment in social communication and interaction (e.g., overly friendly with strangers; difficulty reading social cues; difficulty understanding social consequences).
 * 3) Impairment in daily living skills (e.g., delayed toileting, feeding, or bathing; difficulty managing daily schedule).
 * 4) Impairment in motor skills (e.g., poor fine motor development; delayed attainment of gross motor milestones or ongoing deficits in gross motor function; deficits in coordination and balance).


 * E. Onset of the disorder (symptoms in Criteria B, C, and D) occurs in childhood.


 * F. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.


 * G. The disorder is not better explained by the direct physiological effects associated with postnatal use of a substance (e.g., a medication, alcohol or other drugs), a general medical condition (e.g., traumatic brain injury, delirium, dementia), another known teratogen (e.g., fetal hydantoin syndrome), a genetic condition (e.g., Williams syndrome, Down syndrome, Cornelia de Lange syndrome), or environmental neglect.

The DSM does not label NSSI as an official diagnosis. The proposed name for NSSI diagnoses is Non-suicidal Self-Injury Disoder (NSSI-D). Due to a lack of confidence in the validity and reliability of the proposed criteria, NSSI-D has been placed in “Conditions for Further Study” as well as a special “V-Codes” section, indicating a necessity in standardization of terminology and further testing of criteria. The "V-Codes" is a section used to describe circumstances that are not necessarily mental illnesses such as parent-child relational problems, relationship distress, academic problems, and homelessness. This V-Code status is very important for insurance billing purpose as most insurance companies will not pay for any condition listed in "Conditions for Further Study," but will pay for some conditions labelled in the V-Code section. According to Ben Caldwell from the Self-Injury Institute, this placement of NSSI is strategic to allow for billing potential as well as reduced stigma from receiving an official diagnosis of a mental disorder.

In an attempt to operationalize the proposed criteria in DSM-5, Zetterqvist et al. (2015) highlighted the need for an independent NSSI disorder while also stating that the criteria need a lot more work. They showed that 85.5% of participants met criterion A, and there were a “high endorsement” (99.5%) of adolescents who met criterion B. Similarly, criteria C and D had high endorsement rates. Criteria E and F need the most work, stating Criterion E is "difficult to assess" due to the relieving properties of NSSI. At the same time, a lot of the studies they reviewed did not measure Criterion F.

Prevalence
Many have worked to describe trends in NSSI and self-harm. Results have shown that self-harm is rare before puberty but becomes more prevalent throughout adolescence, with the most common age of onset at 16 years old. The same review also found that women ages 15-24 and men ages 25-34 are most likely to go to the hospital for self-harm related issues, with 15% of harmers being seen in a hospital setting again within 12 months. I suspect that differential societal influences experienced during both times are responsible for the gender differences experienced here. Overall prevalence rates of NSSI for adolescents are between 7.5% and 46.5%; in college students, the prevalence rate is about 38.9%; in adults, the prevalence rate is between 4% and 23%. Conventional methods of NSSI are cutting (70-90%), banging on body parts (21-44%) and burning (15-35%) with adolescent girls generally choosing methods associated with blood and adolescent boys more often choosing burning or hitting methods.

For the individual, evidence shows that harmers report thoughts of NSSI every day but only experienced two NSSI actions per week. To further highlight the idea that NSSI-D is distinct from suicidal ideation, evidence also shows that thoughts of NSSI and thoughts of suicide are rarely concurrent. Research now shows that the idea that girls were more likely to have NSSI and self-harm tendencies is false. Repeated trials have found this not to be true. Cipriano and their team (2017) attributed this myth to the idea that “self-injury” is highly associated with the method of cutting and that more women chose to cut as a means of NSSI, giving a false notion that more women commit NSSI overall.

Common Comorbidities
Many mental illnesses are associated with NSSI, suggesting that functions of NSSI are universal and apply to a variety of mental health contexts. Nitkowski and Petermann (2011) examined a variety of these potentially comorbid disorders. They reviewed 1298 studies and found 21 reviews that fit their five inclusion criteria. They also reviewed terminology present in each study and found inconsistencies in definitions. Mental disorders analyzed were major depressive disorder, recurring major depression, dysthymia, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, eating disorders, externalizing symptoms, substance use and abuse, borderline personality disorder, and antisocial personality disorder. I grouped disorders based on broad categorization in order to simplify discussion. Their team found the highest comorbidity in the following disorders, in order from most comorbid to least comorbid in adolescents with NSSI behaviors: NEED TO ADD FULL CHART FROM PAPER Borderline personality disorder was the most common of the personality disorders, at 35.30% of cases. This trend is probably due to other personality disorders having a decreased likelihood of adolescent diagnosis. Nitkowski and Petermann also looked at gender and prevalence. They found more adolescent boys experienced social behavior disturbances, more substance abuse, and higher rates of depression. For women, they found anxiety and eating disorders to be more common comorbid disorders. Interestingly, when strictly controlling for high validity and reliability in reviews, they found that research involving adolescents had much higher validity than research involving adults, possibly highlighting the more strenuous procedures when working with children. Eating disorders and OCD are also associated with NSSI. A common theme in all these disorders is the necessity of a coping mechanism. As the Mayo Clinic webpage for NSSI states, the “purpose of NSSI” is to “manage or reduce severe distress, provide a distraction from painful emotions, feel a sense of control over his or her body, express internal feelings in an external way”. Also, of all self-harmers, 82% report performing NSSI to mitigate negative effects. NSSI is associated with externalizing disorders more-so in adolescents than in adults (20% vs 5%, respectively); generally, NSSI is more common in adolescents than in adults.
 * 1) affective disorders (48.19% of cases)
 * recurring major depression (51.68%)
 * dysthymia (28%)
 * 1) personality disorders (43.95%)
 * 2) substance abuse/addiction disorders (21.13%)
 * 3) anxiety disorders (18.01%)
 * GAD (15.2%)
 * PTSD (12.40%)

Prognosis or Developmental Course
The forecast for suicidal ideation and self-injury is grim, with 5% of hospitalized people committing suicide within nine years. NSSI is seen as a symptom rather than a discrete disorder, leading to many treatment options focusing on the underlying pathology. To further highlight this point, other factors that may contribute to the presence of NSSI include “both environmental and individual” risk factors such as “a history of child maltreatment and abuse,” childhood trauma, and “stressful life experiences” which could “disrupt emotional regulation [functioning]”. The emphasis tends to be on the factors that lead to the self-injurious patterns. This connection to emotional regulation is also present in comorbid disorders, as seen in the sections above. Miller and Prinstein’s 2019 article "Adolescent Suicide as a Failure of Acute Stress-Response Systems" proposes a developmental perspective on the etiology of NSSI and its functioning. It asks the question of why adolescence is a particularly vulnerable time. They begin with puberty, stating that adolescents experience a time in their life where they are more susceptible to their social environment due to an increase in neurotransmitter receptors related to reward and punishment. The increase in receptors along with social factors leads to hyper-awareness of social standing and practices. This period overlaps with other developmental processes in the brain, specifically myelinization. As we age through adolescence, our brain is being further developed. This development takes on the form of myelination and starts in the back of the brain and proceeds towards the front. This myelinization path has the effect of leaving decision-making and emotion-regulation areas in the frontal cortex undeveloped for parts of adolescence. The intersection between social-hyperawareness and an underdeveloped prefrontal cortex leads to a different period of increased perception of social environments as harmful with an inability to accurately regulate the emotions required to effectively deal with social pressure.

Miller and Prinstein (2019) then go to discuss four biological proxies for stress response: the autonomic nervous system, the hypothalamic-pituitary-adrenal axis (HPA), peripheral stress response, and neural responses. I would like to focus on the HPA axis, as it is responsible for releasing cortisol in the blood. High levels of cortisol in the blood correlated with high levels of stress and poor health outcomes. So far, we have discussed NSSI in adolescence. Now I would like to connect Miller’s developmental perspective with Geronimus’ 1992 concept of a "Weathering Hypothesis" to show a potential connection between adolescent stress response and later health outcomes in adults.

Geronimus' Weathering Hypothesis (1992) originally purposed an explanation for how stressors get under the skin of African American women. Mostly, they were trying to explain how systemic injustices impact the individual through stress. The Weathering Hypothesis proposes that allostatic load is the mechanism through which stress confers negative health consequences, especially over the life course. Allostatic load can be conceptualized as the cumulative impact of stress. As biological mechanisms, such as Miller's HPA axis, continuously activate due to life circumstances, they begin to degrade. Over time, this increase in allostatic load causes many biological pathways to respond less to stress responses at the cellular, tissue, organ, and hormonal level. Further support for this claim is if any of the above biological responses discussed in Miller’s work are not functioning, it confers a lower “threshold for stress tolerance in the future." In summary, pairing the HPA axis with Geronimus' Weathering Hypothesis, we can see how repetitive stress in early adolescence confers adverse mental health outcomes later into life. These adverse health outcomes even pass to later generations through mechanisms such as low birth weight and premature births. Cumulative disadvantage due to excessive stress exposure ensures that people who are vulnerable to NSSI also experience some form of mental health disorder later in life.

Evidence-based Assessment for NSSI
While we may have an idea of which disorders are comorbid to NSSI, consequently giving an idea of which psychotherapies may be useful, we must focus on the quality of the assessments we design for NSSI. As Youngstrom et al. (2017) state in their “Evidence-Based Assessment as an Integrative Model for Applying Psychological Science to Guide the Voyage of Treatment,” we see that we still have much work to do in our voyage of finding proper assessment for NSSI. They highlight that the need for better assessment in research is tremendous. Better implementation of evaluation and technology would lead to "greater efficiency, more accurate decisions, better outcomes, and increased service accessibility." These necessary steps will help to address the inconsistencies discussed in the beginning of this paper and create accurate criteria for a proper DSM diagnosis. A need for standardization is highlighted in work by Cipriano et al. (2017). One of the limitations mentioned in this systematic review is how assessment methods in their reviewed papers heavily influenced the estimates of NSSI prevalence. They found that checklists would provide higher prevalence rates than single-item questions. I have identified four types of assessment that show promise with regards to NSSI: the Ottawa Self-injury Inventory (OSI), Self-Injurious Thoughts and Behaviors Interview (SITBI), Achenbach Child Behavior Checklist (CBCL), and The Ecological Momentary Assessment (EMA).

The Ottawa Self-injury Inventory
The Ottawa self-injury inventory is a comprehensive question batter for NSSI covering four domains: internal emotion regulation, social influence, external emotion regulation, and sensation seeking. The OSI focuses measurements on the function of NSSI and its addictive features and can be used to standardize assessment regarding these specific fields. Overall, it shows high reliability and validity in each of the four domains.

The Self-injurious Thoughts and Behaviors Interview
The SITBI is a structured interview that assesses "presence, frequency, and characteristics" of a wide range of NSSI thoughts and actions: suicidal ideation, suicide plans, suicide gestures, suicide attempts, and NSSI. The SITBI has shown strong reliability and validity over a long period of time. It also makes a successful attempt at distinguishing between different types of self-injurious thoughts and behaviors, helping to clarify confusion and making steps towards standardized definitions.

The Child Behavior Checklist
The CBCL by Achenbach is a caregiver questionnaire designed to get a parent’s perspective on their child's behavior. Other versions of the form were produced to capture different perspectives as well. It has made great strides in providing common terminology for a variety of child disorders. Tested areas include aggressive actions, anxious/depressed, attention problems, rule-breaking behavior, somatic complaints, social problems, thought problems, withdrawn/depressed. The broad tested areas allow for a general sense of a child’s wellbeing and can be used to assess comorbid disorders to NSSI.

The fourth and final assessment tool I would like to highlight addresses a significant drawback in the previous three types of assessments. In essence, there is much temporal distance between the person's experience and the report. Personality and social psychologists who acknowledged this pitfall in the assessments designed the Ecological Momentary Assessment. They needed a way to reduce memory reliance as memories are notoriously inaccurate. To circumvent this, social psychologists created a method of data recording that allowed patients to record thoughts on symptoms as they happened. A few standard methodologies are journaling once daily, journaling multiple times daily, or journaling directly after significant events. It can “both complement and replace existing methods."

As Youngstrom et al. (2017) stated, technological advances increase the efficiency and accuracy of scoring and feedback. As we see in the EMA, technological advances such as the use of smartphones have allowed psychologists to get more accurate timestamps with relation to incidents. Because of the quick utility of EMA paired with technology, researchers are better able to predict factors that precede transitions from NSSI thoughts to NSSI behaviors. Other uses in NSSI have shown an increase in negative affect before NSSI engagement and decreases in negative affect following NSSI activities, adding support to NSSI as a failed coping strategy. This same paper also found support that NSSI occurs in solitude with high levels of rejection and anger. The team then goes on to say that NSSI and addiction have similarities in patterns of reinforcement present in the beginning and maintenance of actions: positive reinforcement to start responses and negative reinforcement to sustain it.

Evidence-based Treatment for NSSI
Much evidence supports the focus of treatment on underlying psychopathology. Guidelines for treatment implementation include teaching coping skills to patients and their support team, screening at-risk populations, psychosocial interventions, restriction of means of suicide, and decreased stigma through public awareness. Potential psychotherapy includes talk therapy, psychological counselling, cognitive-behavioral therapy, dialectical behavioral therapy, mindfulness therapy, skills training, medication for comorbid diagnoses, contingency management strategies, relapse prevention plans, specialized care for treatment-resistant depression, and acceptance and commitment therapy.

Work by Washburn et al. (2012) establishes that developing proper assessment tools for NSSI is fundamental in determining treatment paths. Like many other researchers, this team emphasizes treating underlying psychological conditions that accompany NSSI. They say that cognitive and behavioral interventions are "very valuable to treat underlying conditions." Skills training, understanding social context, and contingency management are also considered in this work to be practical tools for treatment. An especially at-risk population are adolescents with treatment- and medication-resistant depression. There are higher rates of NSSI in these patients, and even though CBT with medication shows some short-term effects, only about 20% of patients experienced positive results after 12 weeks with relapses following in those who dropped off. Treatment-resistant depression correlates to higher suicide attempts in later life. A Cochrane review analyzing the effects of various psychotherapies (CBT, DBT, IPT, etc.) on treatment-resistant depression showed that the presence of therapy added to antidepressants was associated with positive short-term and long-term outcomes when compared to just using antidepressants. This review adds evidence that these psychotherapies are effective against treatment-resistant depression.

A promising treatment coming from a recent clinical trial is Acceptance and Commitment Therapy (ACT). This therapy builds on the theoretical framework detailing how forceful and “rigid” approaches to treatment often "contribute to symptom development and maintenance of anxiety and self-injury." There are three parts to ACT: 1) education about the current theoretical framework, 2) using acceptance to promote mindfulness appreciation of one’s anxiety, which validates the patient's emotions while developing healthier coping strategies, and 3) giving patients in-session and between-session exercises to be attentive to one’s thoughts and feelings. Through this, the coping mechanism of acceptance/mindfulness meditation can help change cognitions and alleviate the need to perform NSSI behaviors.

Social Media and NSSI
As examined before, Miller and Prinstein (2019) help to shed light on the impact of peer socialization in the context of social media. The unique period discussed shows the more significant social awareness with the caveat that adolescents are not fully able to regulate emotions. In the context of social media, we see how adolescents are experiencing increased connectedness, thereby increasing opportunities for social interactions that may result in positive or negative consequences. As an adolescent's use of social media grows, they compare their lives to an increasing volume of unrealistic standards. Unfavorable comparisons may lead to increased stress responses, feelings of inadequacies, and a fear of missing out. Social media also determines cultural norms through the socialization of its participants. There is evidence that when people encourage vulnerable youth to engage in NSSI, it doubles of odds of NSSI behaviors, showcasing the high power that social influence has. In a similar vein, adolescents may be more likely to perform NSSI actions when peers are also doing so. Primarily, a normalizing effect arises out of peer groups and social media where like-minded adolescents who participate in NSSI may encourage others to do so as well. This shared coping mechanism may also form some sense of community. The effects of a community can have positive and negative impacts on individuals. For instance, interpersonal stress in teenage girls is associated with higher rates of depressive symptoms later in life. Other negative impacts include maintenance of NSSI and depressive symptoms when peers in friend groups moderate each other’s symptoms. Later work by Giletta et al. (2017) shows that community may also have protective factors. In essence, the impact of friendship and social support decreased suicidal ideation, highlighting the importance of support symptoms in the treatment of NSSI and its underlying conditions.

Resources
There are a variety of national resources for helping manage risk of self harm. We also provide some examples of local resources, as a template of what types of services might be available at other localities.

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