In this Issue: Non-Suicidal Self-Injury: The Facts About Cutting. Leadership:

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1 March/April 2014 NEWS Non-Suicidal Self-Injury: The Facts About Cutting By Elaine Gottlieb Anne*, a 16-year-old junior at a private Catholic high school in suburban Boston, was a serious student, taking more than the required number of courses and getting straight As. Despite her academic success, she constantly worried about getting into the right college and became very anxious before exams. She began having nightmares and panic attacks and started scratching her forearms when she felt overwhelmed by schoolwork, then progressed to cutting her forearms, abdomen, and thighs. In this Issue: Why Wear a Green Ribbon? Primary Care Triple P Takes Off 4 5 Non-suicidal self-injury (NSSI) is a common coping mechanism among adolescents: recent community studies have found that one-third to one-half of U.S. adolescents have engaged in some type of NSSI. Self-injury typically begins in mid-adolescence, from 12 to 15 years old, and is slightly more common in girls than boys. Girls are more likely to engage in cutting or scratching while boys engage in self-battery or get into fights as a way to hurt themselves. Continued on page 2 Leadership: John Straus, MD Founding Director Barry Sarvet, MD Medical Director Marcy Ravech, MSW Director 1000 Washington St., Suite 310 Boston, MA mcpap@valueoptions.com

2 2 NSSI Continued from page 1 NSSI is prevalent in all demographic groups. Self-injury is not an uncommon teen response to intense emotional distress that crosses culture and socioeconomics. Social media has played a role in exposing teens to self-injury making it more universally prevalent, says Charles Moore, MD, medical director of the MCPAP McLean-Southeast Region and Mclean Southeast Adolescent Acute Residential Treatment (ART). Why Adolescents Injure Themselves Like substance use and eating disorders, NSSI is a maladaptive coping mechanism: research shows that self-harmers have disturbed emotional regulation (see below). They use NSSI to relieve distressing emotions, such as sadness, anxiety and anger. Teens are struggling to find their way and often lack support and don t know appropriate ways to deal with moods and emotional pain, says Kira L. Grant, DO, FAAP, a pediatrician at Bramblebush Pediatrics & Adolescents in Falmouth, Mass. Like Anne, self-harmers may injure themselves to deal with academic pressure, as well as other stressful situations, such as family conflict and rejection by peers or love interests. NSSI reactivity can occur for a variety of negative and difficult emotions. These include teens feelings of estrangement, emptiness, or feelings of abandonment as they struggle with intense interpersonal emotions. Other times NSSI may be a reaction to feelings of guilt and shame, as an expression of selfdirected anger or self-punishment. NSSI can become a habit or have addictive qualities becoming common in periods of boredom. Adolescents report that self-harm is relaxing and pleasurable: endogenous opiates, specifically beta-endorphin, which are released during intense physical exercise, may be released during self-injury. NSSI and Suicide While NSSI is not a suicide attempt, evidence suggests that self-harmers are more likely to attempt suicide than those who have never physically harmed themselves. Self-injury behavior is more often associated with suicide ideation when accompanied by emotional distress and the wish to self-punish. NSSI is considered a major risk factor for suicide: 70 percent Half of adolescents who engage in NSSI do not meet criteria for any psychiatric disorders. NSSI is considered a non-specific psychiatric symptom that may or may not be associated with a specific diagnosis. of people who engage in self-injury do eventually attempt suicide. Comorbid Psychiatric and Psychological Conditions NSSI is associated with a wide range of clinical conditions, including depression, anxiety, borderline personality disorder (BPD), substance use disorder, eating disorders and post-traumatic stress disorder (PTSD). Patients who self-injure frequently have a co-morbid diagnosis of depression, anxiety, and not infrequently trauma. Borderline personality traits including fear of abandonment and having overly intense relationships is common, says Dr. Moore. However, half of adolescents who engage in NSSI do not meet criteria for any psychiatric disorders. NSSI is considered a non-specific psychiatric symptom that may or may not be associated with a specific diagnosis. It was added to the DSM-5 as a research diagnosis. Continued on page 3

3 3 NSSI Continued from page 2 Like other maladaptive behaviors, NSSI can become addictive, which may be due in part to the release of beta-endorphins. When a behavior is reinforcing, it can be difficult to abstain, says Dr. Moore. However, compared to substance use disorder, NSSI evokes less-intense cravings that occur only in response to negative emotions and not in a variety of situations. intervention for adults with self-harming behavior, which teaches skills in emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self-management, is also effective with adolescents. DBT helps patients to cultivate more positive experiences and find ways other than self-injury to cope with intense emotional experiences, says Dr. Moore. Effective Treatments NSSI treatment needs to address the issues underlying the behavior, such as anxiety, depression, and difficulty managing emotions. Anti-depressants can be effective in treating depression and anxiety but have not proved effective in treating NSSI. Dr. Moore doesn t recommend prescribing benzodiazepines or naltrexone, a medication used to treat substance use disorder. Currently, there are no evidencebased treatments for NSSI in adolescents. However, dialectical behavioral therapy (DBT), an evidence-based therapeutic In Anne s case, after having persistent suicidal ideation, she entered the day treatment program at the McLean Southeast ART, where she participated in DBT and stress management. In family therapy, her parents demonstrated that they cared more about her happiness than her grades. Anne is back in school and doing well and no longer cutting. Working with Patients and Families Thorough mental health screenings at office visits can often identify self-injury. I ask patients about mood at every well visit and, if it s relevant, every sick visit as well. Self-injury should be a part of regular mental health screenings for teens: patients who engage in this behavior should be referred to therapy, and, if suicidal, sent to the ER. If you have questions, contact your MCPAP team. 70 % of people who engage in self-injury do eventually attempt suicide I ask about self-injury if the teen has problems with mood. Most teens are pretty open about it. If a teen engages in self-injury, I always ask about suicide, says Dr. Grant. Adolescents who self-injure should be referred to outpatient therapy and only sent to the ER if they have active suicidal ideation or suicide attempts. Pediatricians should ask about self-injury; it s more prevalent than they may realize, says Dr. Moore. If an adolescent does self-injure, it doesn t mean they should be sent to the ER right away. A slow approach is generally better than an emergency approach, except if the patient is suicidal. Continued on page 4

4 4 NSSI Continued from page 3 Pediatricians can consult with MCPAP about patients who practice NSSI and for referrals to therapists who use DBT. I always make sure patients have a therapy program in place and if I have any concerns, I consult with Dr. Moore, says Dr. Grant. *Name changed to protect patient confidentiality. Neurobiological Factors Recent research on the neurobiology of NSSI is providing a new understanding of the neurodevelopmental factors underlying this behavior. Some adolescents who engage in self-injury have elevated rates of emotional reactivity, intensity, and hyperarousal, which helps explain their difficulty regulating their emotions. Lower cerebrospinal fluid levels of serotonin metabolites have been found in patients with both major depression and NSSI compared with major depression without NSSI. However, in clinical trials, SSRI medications have shown limited efficacy in treating NSSI. While adolescents who engage in NSSI may overreact emotionally, research on physiological systems, such as the autonomic nervous system, have shown a pattern of under-responding rather than over-responding to stress, possibly suggesting an allostatic shift in physiological systems to accommodate chronic stress. Wear a Green Ribbon... In recognition of Children s Mental Health Awareness Week May 4-10, Why a green ribbon? To fight stigma! In the 1800s, the color green was used to brand people labelled insane. The children s mental health community chose to continue with the color green to signify new growth, new life, and new beginnings. By wearing a green ribbon you can raise awareness about the importance of children s mental health. The message: Mental health is essential to overall health and well-being. Wear a green ribbon and start the conversation on May 4 with patients and families. For additional resources, you can access these websites: Parent Professional Advocacy League (PPAL) National Federation of Families for Children s Mental Health Substance Abuse and Mental Health Services Administration To order How s Your Child s Mental Health. brochures, mcpap@valueoptions.com.

5 Primary Care Triple P Takes Off 5 In the last MCPAP newsletter, we introduced our new Triple P Parent Training Program. On March 18-19, 20 behavioral health clinicians, a developmental pediatrician, and a pediatric nurse practitioner began training to become accredited providers of Primary Care Triple P. Most of our trainees work full-time or part-time at pediatric primary care practices. Therapists from four of our six MCPAP Hubs and three additional clinicians are also being trained in order to provide access to Primary Care Triple P to pediatric practices that do not have on-site behavioral health capacity. Open referrals will be available in the Western, Greater Boston, Southeast, and Northeast areas of the state by calling your MCPAP Regional Hub. Ed Michel (Brockton Neighborhood Health Center) and Susan Betjemann (Yogman Pediatrics) role play a parent consultation session while Kayla Greenberg (UMass Memorial Pediatrics) acts as observer to provide feedback. Training participants had these comments following the first two-day training: I really appreciate the flexibility of this approach, its respectful and empowering stance toward parents, and the simplicity of the materials. Getting excited and inspired by this program. Looking forward to implementing this program. Trainees did not have to wait long as four of the clinicians have already received referrals for Primary Care Triple P services! What makes a good Primary Care Triple P referral? 1. Parents are seeking information about how to address a specific parenting or child behavior issue. 2. The problem behavior is relatively discreet. 3. The problem behavior is of mild to moderate severity. 4. The family situation is relatively stable (parents not in process of separating or divorcing). 5. The child does not meet clinical criteria for diagnosis of a pervasive developmental disorder or severe oppositional defiant disorder. MCPAP is focusing our Triple P program on pre-school age children to address the gap in services for this population. To refer a family for Primary Care Triple P, call your Regional MCPAP Hub.