How to Respond When Teens Self-Harm with Zeyd Khan, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Growing up isn't easy, and kids often experience intense emotions as they work to find their way through an increasingly complicated world. This journey can be painful, and many teens try to dull that pain by inflicting a different kind of hurt, a physical hurt, upon themselves. This self-harm can be done through cutting, scratching, burning or other damaging actions. It's a behavior that is both shocking and scary. Today, we're going to talk with adolescent psychiatrist Zeyd Khan to better understand the why behind self-harm and how you can help children who are deliberately injuring themselves. Dr. Khan is one of the many experts at Cleveland Clinic who visit our weekly podcast to chat about health issues affecting families. So with that, let's explore why so many children turn to self-inflicted pain to deal with the struggles and stress in their lives. Welcome to the podcast Dr. Khan. Thanks for stopping by to chat.

Dr. Zeyd Khan:

Yeah, thanks so much for having me, John.

John Horton:

So when it comes to children and self-harm, and I mean, the numbers are just startling. Studies I saw show that almost 1 in 5 teens injure themselves. That's just way higher than I ever would've imagined.

Dr. Zeyd Khan:

Yeah, I think I felt the same way when I first heard about this, but the data's been pretty consistent over the years at around that 20% number you mentioned engaging in some level of self-harm, and actually, some of that data may be outdated — as well as recent studies over the pandemic are showing this number is increasing to over 27% of teens during the early years of the pandemic.

John Horton:

Wow. Well, that's why we're having a discussion like this and why it's so important to talk about it because I don't think people truly realize just how prevalent it is, even, I guess, if it's happening in your home. So given that, can you talk a little bit about how kids might harm themselves and then, what they do to hide it?

Dr. Zeyd Khan:

Yeah, so the most common thing we think of when it comes to self-harm is cutting or scratching, banging their heads, hitting objects or biting their limbs can be common. Burning with lighters or matches is something that I see fairly often. And then, there's also skin picking or hair pulling, which can be a form of self-harm, too. Less common in children, but often in adults, you see excessive body piercings or excessive tattoos. And then, there's a broader definition of self-harm that I think includes more maladaptive coping skills like overeating, like drug use and poor self-care. Though, to me, I think this is a little bit too broad. And the research that we use now has created a new term called “nonsuicidal self-injury,” which is intentional and nonsocially acceptable behavior that is meant to damage the body in minor or moderate ways without having suicidal intent and to decrease this feeling of psychological distress. As most of our data regarding self-harm now comes under that definition.

John Horton:

You've mentioned a lot of those things, and it may seem like the sort of actions that would leave some obvious marks. We talk about cutting and scratching and things like that, but then, I know a lot of what I read, too, said that a lot of times, people don't know that this is going on. So I take it there's some signs that when kids do this, they take steps to really conceal it and those are red flags for you.

Dr. Zeyd Khan:

Yeah, the first thing I'll say is it's really hard because kids are smart and they know how to hide things.

John Horton:

They're very smart when it comes to hiding things. I have three kids. Yeah.

Dr. Zeyd Khan:

And so obviously, adolescent patients controlling the placement of the cuts, in addition to finding creative ways to cover them up — so they'll attempt to cut in places that are less likely to be seen, such as their legs or their inner thighs or even their stomachs, areas that are typically covered. And I remember when I was in high school several years back, people would wear those slim black rubber bands on their wrists in large quantities, and that could often hide any sort of scarring from self-harm. But those I think, have gone away as fashion trends have changed. More typically now, you see long sleeves or pants all year round. The other piece is that some of these scars often last for many years. And so as adolescents transition to adulthood, 18, some people get tattoos so they can more permanently conceal it.

John Horton:

So if you see some of these later, as time goes on, obviously there's fresh wounds that you can see, but if you even see the scars later, you start noticing it on the arms or like you said anywhere — is that still something you should worry about?

Dr. Zeyd Khan:

I think it's hard to know, and it depends on, I guess, who's worrying. And so I think if this is a parent thinking about it's always OK to ask questions and try to learn more about it. But sometimes, this could be kind of a while ago, and many people who self-harm actually don't end up harming again.

John Horton:

When you start looking at this and this whole notion of harming yourself, it's just so difficult to imagine doing this to yourself. So what drives a kid to start dabbling in behavior that just seems like it hurts?

Dr. Zeyd Khan:

Yeah, that's such a good question. And I think my answer is that it depends. So nonsuicidal self-injury, though prevalent, is the end result of a large number of factors, including a child's personality — what we call adverse events in their childhood that are outside of their control — school stressors, interpersonal or relationship stressors, stressors at home, cyberbullying and interactions in social media. And I think the medical field has a tendency to pathologize the individual for systemic or societal issues, for example, nonbinary and transgender youth have some of the highest rates of nonsuicidal self-injury, and suicide attempts of any demographic, but there's nothing inherently suicidal about those groups. So it's how our society and our political system interact with marginalized communities that leads down the road to self-injury as well.

John Horton:

It speaks to the stresses, like you said, that you carry through life, and sometimes, it seems like it just gets too much at times, and the self-harm is a way of trying to address that.

Dr. Zeyd Khan:

Yeah. So the common story that my patients tell me is that self-harm is a way to see and show what they're experiencing internally. And so for some, this can decrease all the pressure they're feeling and they're able to move on from it, but others feel more intense feelings of rejection and guilt, shame or even anger afterward, which are really difficult to handle.

John Horton:

Yeah, I was going to ask you that. From when you've talked with people, when they do this, is it the sort of thing that when they're engaging in it, that it actually brings relief, which just seems so unnatural to think about it that way, but they basically use a different kind of pain to release another kind?

Dr. Zeyd Khan:

Yeah. And our body is well-adapted to pushing through physical pain. There's already a ready-made system of releasing certain things that decrease the pain in your body, that allow you to feel better, to feel more calm. And sometimes, I think people realize that that is something that's helpful even for the internal pain, which maybe we don't have a good system.

John Horton:

You had mentioned, too, just the overall stresses and that you, or that, I guess, studies saw an increase in self-harm during the pandemic. I mean, that really does seem to drive home the point that there are these external forces that just kind of add all this stress and it kind of grows out of it.

Dr. Zeyd Khan:

And that's absolutely true, though not everyone under a large weight of stress or even abuse and things like that will turn to self-harm. So it has to be the right mix of factors with the right person. So we start to understand the “why” of people self-harming. Researchers are trying to see if we can predict who is at risk to self-harm for the first time and maybe even intervene before it happens.

John Horton:

Wow. Are there any triggers that might indicate that somebody would be prone to doing that?

Dr. Zeyd Khan:

So the most recent research has studied how self-harm can be a way for people to distract from these rotating intrusive thoughts, as well as a way to avoid dealing with what's going on in their own lives. And so our knowledge is still evolving. We've known for some time that two things seem to predict nonsuicidal self-injury really well — those were disinhibition and what's called high-intensity negative moods. So for the first, disinhibition is measuring someone's ability to regulate their own emotions and their own behaviors, and those who self-harm feel this urgency to act and then struggle to inhibit those strong emotions. The other piece is the high-intensity low moods or what we call negative affect, that for these people, they use nonsuicidal self-injury as a means to cope with really intense emotions.

John Horton:

Now, can self-harming escalate over time or even lead to a potential suicide attempt?

Dr. Zeyd Khan:

Yeah, absolutely. So a nonsuicidal self-injury is one of the strongest predictors of a future suicide attempt, especially if this nonsuicidal self-injury would be considered severe with multiple instances, maybe using different methods like using the concealment that we talked about in terms of numbers — 70% of those who engage in nonsuicidal self-injury will attempt suicide once and 55% will attempt multiple times.

John Horton:

Wow, boy, that's a very staggering and sobering number.

Dr. Zeyd Khan:

And some have this escalating course because things are often kept secret, and so they're struggling on their own and because of that, they struggle to slow down or stop the self-harming, which is more likely to lead down the road of the suicidal thoughts as well.

John Horton:

Well, I mean, obviously, everything you've said … it's a very serious issue and it seems like a little bit of somebody asking for help. So if you see signs that a teen is self-harming, what should you do?

Dr. Zeyd Khan:

So this can be so hard because most parents have spent their whole lives trying to protect their kids from danger, and the impulse is try to fix the problem quickly. But often, that's not a very effective thing to do, at least initially. When it comes to talking to kids about self-harm, your primary goal is to gain information. So be curious, not judgmental, and asking questions and really trying to listen more than you speak. So try to find out how often it's happening. When was the last time, ask if they're having any sort of suicidal thoughts. If they are, this should lead to an immediate trip to the emergency room. But if they're not, there's other mental health professionals in every parent's life that can help out, one of which being the child's pediatrician.

John Horton:

And it does seem so hard bringing that up. I can't even imagine almost a more difficult discussion to have with your child when you notice that this is going on and you have to somehow address it.

Dr. Zeyd Khan:

And so, I think parents and caregivers may feel confused, angry or helpless when they see signs that their child or teen is engaging in self-harm and they realize their child needs help, but really have no idea where to begin. And so, I think talking about it really is the first place to start. And talking to your child about this is really hard. And I tell parents all the time, "You can do hard things. You already have and this is just another one thing to do." And as I said before, try your best to be curious, not judgmental. And if you're not sure what to say, try to reflect back what your child is saying to you rather than place your own judgments on what's being said.

John Horton:

Which is very difficult if you're a parent and you are that concerned, if you do see that this is happening, I know you mentioned seeking professional help. How soon should you do that? Once maybe you have this discussion and you realize that self-harm is happening.

Dr. Zeyd Khan:

So I really want parents to feel empowered to reach out to your doctors or therapists whenever you're concerned here. And so I would say try to find out more information as quickly as you can, and then, reach out to your doctor either through MyChart or through a phone call to the office with whatever information that you have. And then, they can decide what the next step might be, such as, do they need therapy? Do they need psychiatry? Do they need to be involved in some sort of intensive therapy or programming? And if your child has active suicide thinking or is feeling unsafe at home, that's a suicide risk and it's a good time to visit the emergency room.

John Horton:

Now, if you have this discussion with your child and you start talking about it and they say, "Oh, I'm going to stop." And do whatever, and they just don't, I take it, that's then an immediate … you try to get them in to see somebody.

Dr. Zeyd Khan:

Yeah. So like I said, I think going to your pediatrician is a really good place to start. They can start that process and see how often it's happening. Typically, parents aren't the first ones to find out, and it's often friends or a trusted family member. But yes, I think trying to get into a therapist or a psychiatrist or looking for those referrals is a good place to start.

John Horton:

Now, discovering that your kid is self-harming just has to be … just such an emotional and traumatic moment for parents and caregivers. What advice do you have for them as they kind of work through this process with their child?

Dr. Zeyd Khan:

Yeah, I think I would say two things. One is that, try to find the ways to look after yourself so that you're able to care for your children. If you're not caring for yourself, you're not able to do much for other people, and do the pieces of self-care that work best for you. Seek out support with your family. Consider seeking out your own therapist or additional support. And remember, your child's caregivers also have adult resources, too. And so that's a good place to start for you. And as most self-harm happens when teens are alone, this may be a chance to start to strengthen your relationship with your own child by spending more time together, doing things you both enjoy together and having more of that quality time.

John Horton:

Well, quality time is always, I think, a solution for so many things in life. So that's some great advice. So Dr. Khan, if you see that your child is self-harming, are there some resources available that you could lean on to help through this process?

Dr. Zeyd Khan:

Yeah, thank you for asking this. So I think one common resource I mention is the crisis text line 741741. You can text “home” to that number, and when you do that, a trained worker will reach out to you and you can discuss next steps and help with establishing safety when really in crisis.

There's also the National Alliance on Mental Illness, which has a greater Cleveland chapter, NAMI Greater Cleveland, and their website has lots of resources and information. You can chat on the website or there's a helpline to call as well for more help and information.

And then one of the child psychiatrists in our section at Cleveland Clinic, Dr. Tatiana Falcone recently wrote a book called A Parent's Guide: To Prevent Suicide in Your Loved One, which has really practical and actionable advice from an expert in the field. And you can find that on Amazon.

John Horton:

Those are great tips as far as resources people can lean on Dr. Khan. And gosh, we've covered so much here today. So is there anything else that we missed or that you'd like to add regarding children self-harming and what you can do to help them?

Dr. Zeyd Khan:

Yeah, so I think I would say that self-harm is primarily a way to cope with intense emotions when all else fails. And typically, self-harm peaks in early adolescence, so that 12, 13 years old, and then trails off as kids get older. So research shows a really large safety factor for a child is whether they have one trusted, caring adult in their lives. So try your best to be that person that they can turn to because our job as parents and caregivers is to help kids learn healthy adaptive ways to cope with stress as they grow. And if we can model caring conversation and strengthen our relationships along the way, our children will be better for it.

John Horton:

That's fabulous advice. So what a perfect way to end. So thank you very much for spending some time with us today and sharing this really, really important information.

Dr. Zeyd Khan:

Yeah, thanks so much for having me on here. This was a great discussion.

John Horton:

Signs of self-harm in children should not be ignored. Consider the actions a silent shout for help. Talk to your kid if you see signs of self-injury, get them evaluated by a healthcare professional. These aren't easy discussions or steps to take, but they're necessary.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.