Nonsuicidal Self-Injury and Suicidal Behaviors in Girls: The Case for Targeted Prevention in Preadolescence

Abstract

Nonsuicidal self-injury (NSSI) affects 15% to 20% of adolescents—disproportionately girls—and is a strong predictor of eventual suicide attempts and suicide. Many girls now initiate NSSI before age 10. These early starters exhibit greater frequency of NSSI, use more diverse methods, and are hospitalized more often than later starters, yet there are no empirically supported prevention programs for preadolescents. Obstacles to prevention include ascertaining who is sufficiently vulnerable and specifying mechanistic intervention targets. Recent research indicates that (a) preadolescent girls with ADHD who are also maltreated are at alarming risk for NSSI and suicide attempts by adolescence and (b) the conjoint effects of these vulnerabilities are sufficiently potent for targeted prevention. Research also indicates that existing interventions are effective in altering child- and family-level mechanisms of NSSI. These interventions alter neurobiological markers of vulnerability, which can be used as proximal efficacy signals of prevention response without waiting for NSSI and suicide attempts to emerge.

Borderline personality disorder and emotion dysregulation

“…The emerging picture of the complex developmental processes contributing to BPD and ED have important implications for prevention and treatment. Beauchaine, Hinshaw, et al (2019) have outlined several key steps for the prevention and treatment of adolescent NSSI and suicidal behavior, arguing in particular that prevention should target the invalidating environment through evidence-based parenting interventions, and that treatment should address ED (which may be more influenced by environmental factors and easier to address) rather than trait impulsivity (which could be a fairly stable tendency). Beauchaine, HInshaw, et al (2019) have argued that we know enough about key precursors and risk factors for NSSI and suicidal behavior that preventative interventions or treatments should target these precursors before the behaviors begin to emerge.…”

Long-term outcomes of females with attention-deficit hyperactivity disorder: increased risk for self-harm

“…2 Further, many girls with ADHD (particularly those with high impulsivity in childhood) follow a heterotypically continuous developmental pathway, such that they are at a strikingly high risk for self-harm, including both NSSI and suicide attempts. 2,3 Given the high rates of suicide globally, escalating in many countries (and especially among adolescent girls), a serious public health issue is at hand. Of even further concern, internalising disorders and suicide rates may well spike in the next few years, given increases in economic stress, social isolation, and other toxic psychosocial stressors associated with the COVID-19 pandemic.…”

“…Crucially, girls with ADHD who had also experienced childhood maltreatment (physical abuse, sexual abuse and/or neglect) had a substantially higher risk of attempted suicide (33% had made an attempt) by early adulthood than those without a maltreatment history (13%) or than the matched comparison sample (6%). 2,3 Thus, even for a condition as heritable as ADHD, exposure to early abuse experiences substantially compounds risk for self-harm. Such findings parallel another condition with strong heritability, bipolar disorder.…”

“…affective instability, chronic suicidality) in adulthood, require additional longitudinal research to supplement existing cross-sectional research. 3 Moreover, the intergenerational transmission of risk for similar negative outcomes in the offspring of females with ADHD remains a priority area for future research efforts. Overall, we contend that the extraordinarily high risk for self-harm incurred by girls with ADHD as they mature requires a shift in clinical perspective.…”

“…Despite the growing body of evidence that females with ADHD are at high risk for self-harm, no evidence-based prevention programmes for self-harm currently exist for preadolescents. 3 Once established, self-harmful behaviours are self-reinforcing and difficult to treat. Access to specialised treatment (e.g.…”