Parents of youth who self-injure: a review of the literature and implications for mental health professionals

Papers for this review were identified through the Psych-Info and PubMed databases
using the search query (parent* OR family OR interpersonal OR caregiver) AND (self–harm* OR self–injur* OR self–mutilat*) AND (child* OR youth OR adolescen* OR teen OR student OR young). References of resultant papers were also reviewed. Figure 1 outlines the study acquisition and inclusion process. The following inclusion criteria
were used: studies had to be peer-reviewed, written in English, and examined NSSI
or non-suicidal self-harm among children and/or adolescents (?19 years). Included
studies also had to examine the role of parents in relation to NSSI in at least one
of four categories: youth NSSI risk factors; youth help-seeking for NSSI; intervention
for youth NSSI; and parent experiences of youth NSSI. Articles were excluded for the
following reasons: NSSI or self-harm was examined in young adults or college student
populations; samples were drawn from populations with developmental disabilities,
psychosis, or youth who were not living at home (e.g., incarcerated youth, street
youth); the harm to self was accidental or socially sanctioned (e.g., salt and ice
challenges).

Fig. 1. Flow diagram of identified studies.

Although the initial intent of this review was to examine parents in relation to youth
NSSI specifically, the review was expanded to include deliberate self-harm (DSH) in
combination with NSSI. DSH encompasses NSSI behaviours as well as behaviours with
indirect harm (e.g., self-poisoning, overdoses), and DSH may or may not include behaviours
with suicidal intent. Thus, NSSI is subsumed under DSH. The focus was broadened for
two reasons. First, there is a paucity of research examining the role of parents during
help-seeking and treatment for NSSI specifically, and the authors were unable to locate
any peer-reviewed study examining the impact of exclusive NSSI on parent wellbeing.
Second, NSSI and DSH are often examined on a continuum of self-harming behaviours
rather than as distinct categories 21], 22]. To this end, and for many studies, it was impossible to determine which behaviour
(i.e., NSSI versus DSH) was measured based on the methodology provided in the text.
Thus, expanding the scope of the review to include DSH as well as NSSI may provide
a more comprehensive picture of the role of parents in youth NSSI. The term NSSI is
used throughout this review when the study included NSSI behaviours; the reader should
note that at times these studies may also have included behaviours that extended beyond
the definition of NSSI. To best approximate the goals of the initial review, studies
of DSH that clearly did not include NSSI (i.e., self-poisoning was the only method
examined; only behaviours with suicidal intent were included; or suicide ideation
confounded the measure of self-harm), were excluded. Furthermore, as there may be
key differences between adolescents who engage in DSH with suicidal intent versus
nonsuicidal intent 23]–25], only studies measuring exclusively nonsuicidal DSH were included in the review of
risks for NSSI associated with parents. A total of 82 articles
^a
were included in this review (Table 1). A visual summary of the role of parents in youth NSSI that emerged from this review
is provided in Fig. 2.

Table 1. Studies included in the review of parents’ role in youth NSSI

Fig. 2. Visual summary of the role of parents in youth NSSI.

Risks for NSSI associated with parents

Fifty-three studies 2], 3], 11], 12], 23], 26]–73] met the inclusion criteria for this section of the review. Table 2 outlines all potential NSSI risk factors associated with parents that have been measured
across the included studies. A variety of background factors associated with parents
(i.e., socio-economic status, family structure, parent health and mental health history),
parent–child relationship factors (i.e., relationship quality, parent support, discipline
and control, affect towards parents, adverse childhood experiences associated with
parents specifically), and family system factors (i.e., family environment, adverse
childhood experiences associated with the family system, family mental health history)
have been associated with elevated risk for NSSI. Many background parent factors (e.g.,
parental level of education, family socioeconomic status, parent marital status, maternal
depression) are widely used as covariates in youth NSSI research; as such, it is not
unlikely that the authors may have missed some studies that should have been included
in this review despite the intensive search and screening process.

Table 2. Risk factors for youth NSSI associated with parents

Research examining youth NSSI risk beyond the use of correlations and group differences
is still in its infancy. Cross-sectional research methods make it difficult to determine
the direction of the effect (i.e., whether the parent factor influences youth NSSI,
whether youth NSSI changes parent behaviour, or some combination). Although an increasing
number of longitudinal studies have used factors associated with parents to predict
NSSI risk (see Table 1), only three studies 12], 30], 65] have examined the associations between NSSI and future parent variables, regardless
of parents’ awareness of the youth’s NSSI. Similarly, more research is needed to examine
the full course of youth NSSI—including NSSI cessation—in relation to factors associated
with parents; despite the role that parents and families have in treatment for youth
NSSI, only one study in this review examined family factors in NSSI cessation 65]. Understanding the role of parents over the course of NSSI may allow clinicians to
better equip parents to support their youth. Although there is no standard model for
how parents and adolescents should interact to reduce risk for NSSI, some parental
responses towards adolescent emotions (e.g., comfort, validation, support) may protect
against NSSI 35] or may encourage NSSI cessation 65]. Thus, equipping parents with the skills necessary to model adaptive emotional acceptance,
regulation and expression may be helpful in enhancing parents’ ability to support
their youth.

Help-seeking and parents

Many youth who engage in NSSI tell no one about it 74], 75], and reported parental awareness rates of youth NSSI are considerably lower than
actual youth NSSI rates 30], 76]. Those adolescents who seek help most frequently do so from peers and less frequently
from family members, including parents 74], 75], 77]–79]. One study found that youth with a history of NSSI were less likely to know how parents
could help, more likely to suggest that nothing could be done by parents, and less
likely to suggest that parents talk to youth who self-injure or that parents refer
these youth to professional help 80].

Help from family may more frequently be sought after, rather than before, an episode
of NSSI 74], 77], and has been associated with subsequent help-seeking from health services 81]. Youth may be more likely to seek help from parents when they feel as though their
parents authentically care for them, and they are able to openly discuss self-injury
with their parents 82], 83]. This highlights the need for clinicians who work with families in which a youth
self-injures to foster open communication about emotions in family contexts early
in the treatment process. Disclosure of NSSI is sometimes made to parents on behalf
of the youth by school personnel or a physician 17], and parents who receive poor initial support from schools and health professionals
may be unlikely to continue to seek help 17]. The period of initial NSSI discovery may represent a key opportunity for parents
to gain knowledge about NSSI, and to encourage professional help-seeking for their
youth when warranted.

Interventions involving parents

Parents may have an essential role in initiating and supporting treatments for youth
NSSI 20], 81], 84], Youth may be more likely to accept professional help for NSSI when parents are supportive
of treatment 20]. For example, parents’ expectations about the helpfulness of counseling may influence
the youth’s decision to attend—or not attend—counseling sessions following presentation
at an emergency department following NSSI 84]. A caring environment and open discussion about NSSI may contribute not only to help
seeking 83], but also toward supporting the youth to understand, work through, and stop NSSI
20].

Only a handful of studies have examined interventions involving parents for NSSI behaviours
specifically (i.e., measured as an outcome either in the absence of, or in combination
with, DSH with suicidal intent). Studies of family-based therapies included multi-systemic
therapy 85] and single-family therapeutic assessments 86]. Although attachment-based family therapy and family-based problem solving have some
evidence of being efficacious for suicidal behaviours, outcomes related to NSSI have
not yet been investigated 18], 19]. Mentalization-based treatment, which consists of both individual and family psychodynamic
psychotherapy, has been examined in relation to NSSI in one study 87]. Studies assessing cognitive behaviour therapies (CBT) for youth NSSI have involved
parents through family CBT in addition to individual CBT for the youth 88], or through a parent psycho-education component 89]; the inclusion of family problem solving sessions or parent training in CBT has not
yet been assessed in relation to NSSI specifically 18]. Finally, dialectical behaviour therapy for adolescents 90] has gained recent empirical interest for youth NSSI 91]–95]; this intervention consists of individual therapy for adolescents, family therapy
as warranted, and a multifamily skills training group.

Reviews 18], 19] of interventions for youth DSH, including NSSI, have found that the inclusion of
strong parent components in some interventions may result in significant reductions
in youth DSH. However, an examination of the efficacy of these treatments is beyond
the scope of this review; readers are referred to these review papers 18], 19] for treatment efficacy. Although few studies have assessed the benefits of these
interventions on parents’ wellbeing and ability to support their youth, preliminary
evidence suggests that parent 95] and family 96] functioning may significantly improve through participation even when youth NSSI
behaviours may not 95].

Beyond interventions for youth specifically, parent education programs may have merit
in assisting parents to cope with their youth’s NSSI and better support their youth.
For example, a school-based program for parents 97] was found to reduce youth NSSI among students of parents who participated; this program
consisted of parent education groups that empowered parents to assist each other to
improve communication and relationships with youth. Similarly, two support programs
(i.e., Resourceful Adolescent Parent Program (RAP-P); 96]; Supporting Parents and Carers (SPACE); 98]) have been reported for parents of youth who have engaged in, or expressed thoughts
of, suicidal behaviour or DSH (including NSSI); RAP-P used a single-family format
96], whereas SPACE had a group format 98]. Both programs provided parents with information pertaining to DSH and NSSI in youth,
parenting adolescents, and family communication and conflict. SPACE also provided
explicit information about parental self-care. When combined with routine care, RAP-P
resulted in significant improvements in family functioning. Similarly, parents in
the SPACE pilot study reported subsequent decreased psychological distress and greater
parental satisfaction. Parents and youth also reported that youth experienced fewer
difficulties following parent participation 96], 98]. Taken together, parent participation in interventions pertaining to youth NSSI may
have positive outcomes both for the youth and parent.

Impact on parent wellbeing

The process of supporting a youth who self-injures can be traumatic and emotionally
taxing on parents 15]–17], 20]. Parents report an abundance of negative emotions (e.g., sadness, shame, embarrassment,
shock, disappointment, self-blame, anger, frustration) in relation to their youth’s
NSSI 15]–17]. Many parents have expressed feeling overwhelmingly alone, isolated and helpless
15]–17]. These feelings can be exacerbated by the stigma surrounding NSSI and the perceived
absence of services and supports for NSSI 15]. Parents have reported being unable to talk to anyone about the youth’s NSSI or being
extremely selective in choosing to whom they disclose (e.g., disclosing to a close
friend, but not to family members) 15]. Many parents have reported a desire for peer support from other parents of youth
who self-injure 15], 20], with the anticipated benefits involving the sharing of similar circumstances, learning
from each other, and relief from knowing that they are not alone 15].

Although parents may recognize that NSSI serves a function for the youth (e.g., to
provide relief from distress), many parents have reported being unable to understanding
NSSI as chosen behaviour 17], 99]. Indeed, many parents believe common misconceptions about this behaviour 15], 17], 99]. For example, one study assessing parent conceptions about NSSI found that many parents
believed that cutting oneself—one of the more common methods of NSSI among youth who
self-injure 2], 3]—is a typical phase of adolescence, occurs only in females, is synonymous with a suicide
attempt, or is an indicator of a psychological disorder 99]. The availability of accurate information about NSSI has been identified as a priority
by parents of youth who self-injure 15].

Youth NSSI may increase parenting burden and stress 17], and parents often report a loss of parenting confidence 15], 16]. Indeed, in families in which a youth self-injures, poor parental wellbeing has been
predicted by poor family communication, low parenting satisfaction, and more difficulties
for the youth 100]. Although a key developmental process during adolescence is to individuate from parents,
many parents report believing their youth was more mature and capable than they really
were 99], and many struggled to find and allow the youth an appropriate level of independence
16]. Nervousness about triggering NSSI (i.e., causing an episode of NSSI) can affect
parents’ ability to set limits and maintain boundaries 17]. Parents have also reported that typical difficulties associated with parenting adolescents
(e.g., bullying, peer pressure, monitoring Internet use) may be intensified when their
youth self-injures, as the adolescent’s experiences in these domains may precipitate
or maintain NSSI behaviours 15]. Indeed, parents of youth with NSSI have expressed a need for more effective parenting
skills 15]. Despite the difficulties associated with NSSI, many parents hope to rebuild a positive
relationship with the youth, recognize the importance of parent–child communication
in the youth’s wellbeing, and want to help the youth develop emotion regulation and
coping strategies 15].

Finally, parents may also experience difficulties balancing and meeting the varying
needs of individual family members 15]–17]. Disruptions in family dynamics may occur, and the youth with NSSI may be perceived
to hold the central position of power within the family 15]. Some parents have reported that caring for the youth who self-harms led to changes
in employment (e.g., reducing hours, leaving paid employment), which may have increased
financial strain on families 16]. Finally, parents may deny their own needs, and change or limit their lifestyle to
increase support for the youth who self-harms 17]. Taken together, youth NSSI and parent factors associated with NSSI risk may be bidirectional;
NSSI can have a significant impact on parent wellbeing and parenting, which may in
turn affect parents’ ability to support their youth. Accordingly, parents of youth
who self-injure may benefit from additional support for themselves as they support
their youth.

Clinical implications for supporting parents

Parents may be valuable members of the youth’s circle of care. One study found that
among youth who presented to an emergency department for self-harm, ongoing parental
concern was a better predictor of future DSH than clinical risk assessments 101]; thus, under some circumstances, parents may be in a position to gauge their youth’s
ongoing wellbeing and alert health professionals about concerns when warranted 99], 101]. Indeed, another study found that many parents consider themselves to be the youth’s
principal helper and advocate 20], which may have both positive and negative implications for both parent and youth
wellbeing. For many parents, taking care of themselves while their youth struggles
with NSSI is challenging 20], 98]. Thus, parents may need to be encouraged to practice self-care 98]. As parents may also benefit from receiving accurate information about NSSI, parenting
skills, and social support 15], the inclusion of parents in empirically-informed treatments—such as those listed
above—may be an optimal way to provide parents with education, skills training, and
peer support that they can draw upon when supporting their youth at home. Parent education
programs for parents of youth who self-injure may also have merit and should be investigated
in future research.

The Internet may be a unique medium to support parents of youth who self-injure. Researchers
have found that parents use the Internet to access both information related to their
children’s medical conditions 102]–105], and social support that is not being accessed offline 102], 106]. The Internet has the potential to be a particularly effective method to educate
parents about more stigmatized mental health issues such as NSSI, and to equip parents
to support their youth with these difficulties. Unfortunately, there is an abundance
of non-credible and low-quality information about NSSI on the Internet 107]. Thus, clinicians need to be mindful of parents’ use of the Internet to access support
for youth NSSI, and be prepared to recommend credible websites containing accurate
NSSI information. Mental health professionals may find that the Self-Injury Outreach
and Support 108] and Cornell Research Program on Self-Injury and Recovery 109] websites are particularly useful online resource for parents, as they provide credible
and accurate information for parents seeking to understand their youth’s NSSI and
how to support their youth (e.g., how to talk to their youth about NSSI, treatments
for youth NSSI), as well as providing suggestions for additional online and offline
resources specific to parents.

Implications for further research

There are several limitations in the cited studies that suggest avenues for future
research. First, there is a paucity of research pertaining to parents of youth who
engage in NSSI specifically; much of what is known about these parents is inferred
from studies assessing parents of youth who engage in similar behaviours such as self-harm,
which may or may not include a suicidal intent. Thus, more research is needed to determine
to what extent parents of youth with NSSI differ from parents of youth who self-harm.
This information may assist mental health professionals to develop empirically-informed
programs for parents of youth who self-injure that may be modeled on programs already
existing for parents of youth who self-harm 96], 98].

Next, studies linking parenting factors to NSSI risk are predominantly correlational,
and thus causation cannot be inferred. Researchers should consider complex ways in
which factors associated with parents might interact to increase risk for, or protect
against, NSSI. Similarly, factors that may mediate or moderate the relation between
youth NSSI and the effects of this NSSI on parents are not yet known. To date, studies
examining the impact of youth NSSI on parent wellbeing and parenting have been almost
exclusively qualitatively. Empirical studies are needed in this area to better understand
the effects of youth NSSI on parenting and parents’ subsequent ability to support
the youth.

Finally, the effects of parent and youth gender on NSSI risks and NSSI impact on parents
are unclear. The impact of NSSI on parent wellbeing has almost exclusively been examined
through mothers due to an inability to recruit adequate numbers of fathers; thus,
these findings should be generalized cautiously to fathers and other caregivers. Similarly,
there may be gender differences in NSSI risk and protective factors. For example,
connectedness with parents may be particularly important in protecting adolescent
females against NSSI 62], and parent–child relationship quality may confer different risks for NSSI when associated
with mothers versus fathers 38]. Further research is needed to identify whether fathers have similar experiences
to mothers in supporting youth who self-injure, and how factors associated with mothers
and fathers may confer different risks or protection for youth NSSI.