Study into cutting behavior and suicidality found that exposure to physical or sexual abuse or neglect during childhood, were reliable predictors of self-injury.

Past trauma/invalidation as an antecedent
Van der Kolk, Perry, and Herman (1991) conducted a study of patients who exhibited cutting behavior and suicidality. They found that exposure to physical abuse or sexual abuse, physical or emotional neglect, and chaotic family conditions during childhood, latency and adolescence were reliable predictors of the amount and severity of cutting. The earlier the abuse began, the more likely the subjects were to cut and the more severe their cutting was. Sexual abuse victims were most likely of all to cut. They summarize, ...

neglect [was] the most powerful predictor of self-destructive behavior. This implies that although childhood trauma contributes heavily to the initiation of self-destructive behavior, lack of secure attachments maintains it. Those ... who could not remember feeling special or loved by anyone as children were least able to ...control their self-destructive behavior.

In this same paper, van der Kolk et al. note that dissociation and frequency of dissociative experiences appear to be related to the presence of self-injurious behavior. Dissociation in adulthood has also been positively linked to abuse, neglect, or trauma as a child.

More support for the theory that physical or sexual abuse or trauma is an important antecedent to this behavior comes from a 1989 article in the American Journal of Psychiatry. Greenspan and Samuel present three cases in which women who seemed to have no prior psychopathology presented as self-cutters following a traumatic rape.

Invalidation independent of abuse

Although sexual and physical abuse and neglect can seemingly precipitate self-injurious behavior, the converse does not hold: many of those who hurt themselves have suffered no childhood abuse. A 1994 study by Zweig-Frank et al. showed no relationship at all between abuse, dissociation, and self-injury among patients diagnosed with borderline personality disorder. A follow-up study by Brodsky, et al. (1995) also showed that abuse as a child is not a marker for dissociation and self-injury as an adult. Because of these and other studies as well as personal observations, it's become obvious to me that there is some basic characteristic present in people who self-injure that is not present in those who don't, and that the factor is something more subtle than abuse as a child. Reading Linehan's work provides a good idea of what the factor is.

Linehan (1993a) talks about people who SI having grown up in "invalidating environments." While an abusive home certainly qualifies as invalidating, so do other, "normal," situations. She says:

An invalidating environment is one in which communication of private experiences is met by erratic, inappropriate, or extreme responses. In other words, the expression of private experiences is not validated; instead it is often punished and/or trivialized. the experience of painful emotions [is] disregarded. The individual's interpretations of her own behavior, including the experience of the intents and motivations of the behavior, are dismissed...

Invalidation has two primary characteristics. First, it tells the individual that she is wrong in both her description and her analyses of her own experiences, particularly in her views of what is causing her own emotions, beliefs, and actions. Second, it attributes her experiences to socially unacceptable characteristics or personality traits.

This invalidation can take many forms:

• "You're angry but you just won't admit it."
• "You say no but you mean yes, I know."
• "You really did do (something you in truth hadn't). Stop lying."
• "You're being hypersensitive."
• "You're just lazy." "
• I won't let you manipulate me like that."
• "Cheer up. Snap out of it. You can get over this."
• "If you'd just look on the bright side and stop being a pessimist..."
• "You're just not trying hard enough."
• "I'll give you something to cry about!"

Everyone experiences invalidations like these at some time or another, but for people brought up in invalidating environments, these messages are constantly received. Parents may mean well but be too uncomfortable with negative emotion to allow their children to express it, and the result is unintentional invalidation. Chronic invalidation can lead to almost subconscious self-invalidation and self-distrust, and to the "I never mattered" feelings van der Kolk et al. describe.

Biological Considerations and Neurochemistry

It has been demonstrated (Carlson, 1986) that reduced levels of serotonin lead to increased aggressive behavior in mice. In this study, serotonin inhibitors produced increased aggression and serotonin exciters decreased aggression in mice. Since serotonin levels have also been linked to depression, and depression has been positively identified as one of the long-term consequences of childhood physical abuse (Malinosky-Rummell and Hansen, 1993), this could explain why self-injurious behaviors are seen more frequently among those abused as children than among the general population (Malinosky-Rummel and Hansen, 1993). Apparently, the most promising line of investigation in this area is the hypothesis that self-harm may result from decreases in necessary brain neurotransmitters.

This view is supported by the evidence presented in Winchel and Stanley (1991) that although the opiate and dopaminergic systems don't seem to be implicated in self-harm, the serotonin system does. Drugs that are serotonin precursors or that block the reuptake of serotonin (thus making more available to the brain) seem to have some effect on self-harming behavior. Winchel and Staley hypothesize a relationship between this fact and the clinical similarities between obsessive-compulsive disorder (known to be helped by serotonin-enhancing drugs) and self-injuring behavior. They also note that some mood-stabilizing drugs can stabilize this sort of behavior.

Serotonin

Coccaro and colleagues have done much to advance the hypothesis that a deficit in the serotonin system is implicated in self-injurious behavior. They found (1997c) that irritability is the core behavioral correlate of serotonin function, and the exact type of aggressive behavior shown in response to irritation seems to be dependent on levels of serotonin -- if they are normal, irritability may be expressed by screaming, throwing things, etc. If serotonin levels are low, aggression increases and responses to irritation escalate into self-injury, suicide, and/or attacks on others.

Simeon et al. (1992) found that self-injurious behavior was significantly negatively correlated with number of platelet imipramine binding sites (self-injurers have fewer platelet imipramine binding sites, a level of serotonin activity) and note that this "may reflect central serotonergic dysfunction with reduced presynaptic serotonin release. . . . Serotonergic dysfunction may facilitate self-mutilation."

When these results are considered in light of work such as that by Stoff et al. (1987) and Birmaher et al. (1990), which links reduced numbers of platelet imipramine binding sites to impulsivity and aggression, it appears that the most appropriate classification for self-injurious behavior might be as an impulse-control disorder similar to trichotillomania, kleptomania, or compulsive gambling.

Herpertz (Herpertz et al, 1995; Herpertz and Favazza, 1997) has investigated how blood levels of prolactin respond to doses of d-fenfluramine in self-injuring and control subjects. The prolactin response in self-injuring subjects was blunted, which is "suggestive of a deficit in overall and primarily pre-synaptic central 5-HT (serotonin) function." Stein et al. (1996) found a similar blunting of prolactin response on fenfluramine challenge in subjects with compulsive personality disorder, and Coccaro et al. (1997c) found prolactin response varied inversely with scores on the Life History of Aggression scale.

It is not clear whether these abnormalities are caused by the trauma/abuse/invalidating experiences or whether some individuals with these kinds of brain abnormalities have traumatic life experiences that prevent their learning effective ways to cope with distress and that cause them to feel they have little control over what happens in their lives and subsequently resort to self-injury as a way of coping.

Knowing when to stop -- pain doesn't seem to be a factor

Most of those who self-mutilate can't quite explain it, but they know when to stop a session. After a certain amount of injury, the need is somehow satisfied and the abuser feels peaceful, calm, soothed. Only 10% of respondents to Conterio and Favazza's 1986 survey reported feeling "great pain"; 23 percent reported moderate pain and 67% reported feeling little or no pain at all. Naloxone, a drug that reverses the effects of opioids (including endorphins, the body's natural painkillers), was given to self-mutilators in one study but did not prove effective (see Richardson and Zaleski, 1986). These findings are intriguing in light of Haines et al. (1995), a study that found that reduction of psychophysiological tension may be the primary purpose of self-injury. It may be that when a certain level of physiological calm is reached, the self-injurer no longer feels an urgent need to inflict harm on his/her body. The lack of pain may be due to dissociation in some self-injurers, and to the way in which self-injury serves as a focusing behavior for others.

Behavioralist explanations

NOTE: most of this applies mainly to stereotypical self-injury, such as that seen in retarded and autistic clients.

Much work has been done in behavioral psychology in an attempt to explain the etiology of self-injurious behavior. In a 1990 review, Belfiore and Dattilio examine three possible explanations. They quote Phillips and Muzaffer (1961) in describing self-injury as "measures carried out by an individual upon him/herself which tend to 'cut off, to remove, to maim, to destroy, to render imperfect' some part of the body." This study also found that frequency of self-injury was higher in females but severity tended to be more extreme in males. Belfiore and Dattilio also point out that the terms "self-injury" and "self-mutilation" are deceiving; the description given above does not speak to the intent of the behavior.

Operant Conditioning

It should be noted that explanations involving operant conditioning are generally more useful when dealing with stereotypic self-injury and less useful with episodic/repetitive behavior.

Two paradigms are put forth by those who wish to explain self-injury in terms of operant conditioning. One is that individuals who self-injure are positively reinforced by getting attention and thus tend to repeat the self-harming acts. Another implication of this theory is that the sensory stimulation associated with self-harm could serve as a positive reinforcer and thus a stimulus for further self-abuse.

The other posits that individuals self-injure in order to remove some aversive stimulus or unpleasant condition (emotional, physical, whatever). This negative reinforcement paradigm is supported by research showing that the intensity of self-injury can be increased by increasing the "demand" of a situation. In effect, self-harm is a way to escape otherwise intolerable emotional pain.

Sensory Contingencies

One hypothesis long held has been that self-injurers are attempting to mediate levels of sensory arousal. Self-injury can increase sensory arousal (many respondents to the internet survey said it made them feel more real) or decrease it by masking sensory input that is even more distressing than the self-harm. This seems related to what Haines and Williams (1997) found: self-injury provides a quick and dramatic release of physiological tension/arousal. Cataldo and Harris (1982) concluded that theories of arousal, though satisfying in their parsimony, need to take into consideration the biological bases of these factors.

What kind of person would cut or burn themselves? It turns out there are some common traits amongst self-injurers.

Most self-injures are women and they seem to have some psychological characteristics in common. They are people who:

• strongly dislike/invalidate themselves
• are hypersensitive to rejection
• are chronically angry, usually at themselves tend to suppress their anger have high levels of aggressive feelings, which they disapprove of strongly and often suppress or direct inward
• are more impulsive and more lacking in impulse control tend to act in accordance with their mood of the moment
• tend not to plan for the future
• are depressed and suicidal / self-destructive
• suffer chronic anxiety
• tend toward irritability
• do not see themselves as skilled at coping
• do not have a flexible repertoire of coping skills
• do not think they have much control over how/whether they cope with life
• tend to be avoidant
• do not see themselves as empowered

People who self-injure tend not to be able to regulate their emotions well, and there seems to be a biologically-based impulsivity. They tend to be somewhat aggressive and their mood at the time of the injurious acts is likely to be a greatly intensified version of a longstanding underlying mood, according to Herpertz (1995). Similar findings appear in Simeon et al. (1992); they found that two major emotional states most commonly present in self-injurers at the time of injury -- anger and anxiety -- also appeared as longstanding personality traits. Linehan (1993a) found that most self-injurers exhibit mood-dependent behavior, acting in accordance with the demands of their current feeling state rather than considering long-term desires and goals. In another study, Herpertz et al. (1995) found, in addition to the poor affect regulation, impulsivity, and aggression noted earlier, disordered affect, a great deal of suppressed anger, high levels of self-directed hostility, and a lack of planning among self-injurers:

We may surmise that self-mutilators usually disapprove of aggressive feelings and impulses. If they fail to suppress these, our findings indicate that they direct them inwardly. . . . This is in agreement with patients' reports, where they often regard their self-mutilative acts as ways of relieving intolerable tension resulting from interpersonal stressors. (p. 70). And Dulit et al. (1994) found several common characteristics in self-injuring subjects with borderline personality disorder (as opposed to non-SI BPD subjects): more likely to be in psychotherapy or on medications more likely to have additional diagnoses of depression or bulimia more acute and chronic suicidality more lifetime suicide attempts less sexual interest and activity In a study of bulimics who self-injure (Favaro and Santonastaso, 1998), subjects whose SIB was partially or mostly impulsive had higher scores on measures of obsession-compulsion, somatization, depression, anxiety, and hostility.

Simeon et al. (1992) found that the tendency to self-injure increased as levels of impulsivity, chronic anger, and somatic anxiety increased. The higher the level of chronic inappropriate anger, the more severe the degree of self-injury. They also found a combination of high aggression and poor impulse control. Haines and Williams (1995) found that people engaging in SIB tended to use problem avoidance as a coping mechanism and perceived themselves as having less control over their coping. In addition, they had low self-esteem and low optimism about life.

Demographics Conterio and Favazza estimate that 750 per 100,000 population exhibit self-injurious behavior (more recent estimates are that 1000 per 100,000, or 1%, of Americans self-injure). In their 1986 survey, they found that 97% of respondents were female, and they compiled a "portrait" of the typical self-injurer. She is female, in her mid-20s to early 30s, and has been hurting herself since her teens. She tends to be middle- or upper-middle-class, intelligent, well-educated, and from a background of physical and/or sexual abuse or from a home with at least one alcoholic parent. Eating disorders were often reported. Types of self-injurious behavior reported were as follows:

• Cutting: 72%
• Burning: 35%
• Self-hitting: 30%
• Interference w/wound healing: 22%
• Hair pulling: 10%
• Bone breaking: 8%
• Multiple methods: 78% (includes all the above)

On average, respondents admitted to 50 acts of self-mutilation; two-thirds admitted to having performed an act within the past month. It's worth noting that 57 percent had taken a drug overdose, half of those had overdosed at least four times, and a full third of the complete sample expected to be dead within five years. Half the sample had been hospitalized for the problem (the median number of days was 105 and the mean 240). Only 14% said the hospitalization had helped a lot (44 percent said it helped a little and 42 percent not at all). Outpatient therapy (75 sessions was the median, 60 the mean) had been tried by 64 percent of the sample, with 29 percent of those saying it helped a lot, 47 percent a little, and 24 percent not at all. Thirty-eight percent had been to a hospital emergency room for treatment of self-inflicted injuries (the median number of visits was 3, the mean 9.5).

Why Are Most Self-Injurers Women?

Although the results of an informal net survey and the composition of an e-mail support mailing list for self-injurers don't show quite as strong a female bias as Conterio's numbers do (the survey population turned out to be about 85/15 percent female, and the list is closer to 67/34 percent), it is clear that women tend to resort to this behavior more often than men do. Miller (1994) is undoubtedly onto something with her theories about how women are socialized to internalize anger and men to externalize it. It is also possible that because men are socialized to repress emotion, they may have less trouble keeping things inside when overwhelmed by emotion or externalizing it in seemingly unrelated violence. As early as 1985, Barnes recognized that gender role expectations played a significant role in how self-injurious patients were treated. Her study showed only two statistically significant diagnoses among self-harmers who were seen at a general hospital in Toronto: women were much more likely to receive a diagnosis of "transient situational disturbance" and men were more likely to be diagnosed as substance abusers. Overall, about a quarter of both men and women in this study were diagnosed with personality disorder.

Barnes suggests that men who self-injure get taken more "seriously" by physicians; only 3.4 percent of the men in the study were considered to have transient and situational problems, as compared to 11.8 percent of the women.

Source:

• Secret Shame website

More info: Self-Injury and Associated Mental Health Conditions

---

---

next:   Psychological and Medical Treatment of Self-Injury

Many children with ADHD have problems with self-esteem. Why? And how can you improve your child's self-esteem?

What is Self-esteem?

There are so many definitions bandied around. We like to think of it simply as being comfortable in your own skin. In children, we like to see it as a kind of protective covering that protects them from the sometimes harshness of life making more able to weather the storm, more able to cope with conflict in life, more realistic and more optimistic too. And as parents, we play a crucial role in determining how our kids see themselves.

Self-esteem is about self-value. It's not about being bigheaded or bragging. It is about how we see ourselves, our personal achievements and our sense of worth.

Self-esteem is important because it helps children feel proud of who they are and what they do.

It gives them the power to believe in their abilities and the courage to try new things. It helps them develop respect for themselves, which in turn leads to being respected by other people.

We can all get some comfort from knowing that there are no absolute right or wrongs in parenting, no expert can give advice about our own particular situation, as every parent and child is totally unique, it would be impossible to know accurately what each individual situation was like and therefore impossible for any expert to have THE answer.

The thing about nourishing self-esteem in our children is that it starts with us as the parent and our own self-esteem. As the quote goes:

'Worry not so much what you say to your child but what you do when you're around them'

Our children notice how we are all the time, which is why we promote the concept of being great role models to our kids and 'being the behaviour you want to see'

So as we move on we must all start off by recognising that we are all doing the best we can for our children and therefore we need to start by giving ourselves a pat on the back for what we are doing well. We need to celebrate our successes with our child and if there are things we read, we would like to have a go at or like to do more of, then make a mental note and start practicing in small steps. We must also celebrate our progress along the way and be kind to ourselves if we get it wrong or fall down along the way.

How is Self-esteem Affected by ADHD?

Your child's self-esteem is shaped by:

• how s/he thinks
• what s/he expects of his/herself
• how other people (family, friends, teachers) think and feel about him/her

Many children with ADHD have problems in school and with teachers and sometimes have difficulties at home. They find it difficult to make and keep friends.

People often don't understand their behaviour and judge them because of it. They disrupt situations, often gaining punishments, so they may find it easier not to bother trying to fit in or do work at school.

All this means children with ADHD often feel bad about themselves. They might think they're stupid, naughty, bad or a failure. Not surprisingly, their self-esteem takes a battering and they find it hard to think anything positive or good about themselves.

The Problem of Exclusion

Hyperactive, disruptive behaviour is a key factor of ADHD. Children with ADHD can't help behaving this way, but teachers trying to cope with a disruptive child may deal with it by excluding her from the classroom.

Birthday parties and social events are a natural part of growing up, but other parents may not want to invite a child who is known to have bad behaviour. Again, this can lead to a child with ADHD being excluded.

Exclusion only adds to your child's negative feelings and reinforces the idea that they are naughty.

How Can You Improve Your Child's Self-esteem?

If your child is lacking in self-esteem, there are things you can do to help.

Praise and reward: you need to make your child feel positive about them self, so try and give praise wherever possible. This can be for large or small actions - for example, if they have tried hard at school or helped clear up after a meal. As well as verbal praise, giving small rewards can highlight accomplishments. Get them to exercise their own judgment and praise themselves.

Love and trust: don't attach conditions to your love. Your child needs to know you love her no matter how she behaves. Tell your child she's special and let her know you trust and respect her.

Goals: set goals that are easily achieved and watch your child's confidence grow.

Sports and hobbies: joining a club or having a hobby can build self-esteem. Depending on your child's interests, the activity could be swimming, dancing, martial arts, crafts or cooking. No matter what the hobby, your child will gain new skills to be proud of - and for you to praise. Sometimes children with ADHD will go off their activity, so be prepared to come up with new ideas.

Focus on the positive: get your child to write a list of everything they like about them self, such as their good characteristics and things they can do. Stick it on their bedroom wall or in the kitchen, so they see it every day. Encourage your child to add to it regularly.

---

---

---

How Can We Promote Self Esteem in Our Children

Allow your children some opportunities to be themselves, letting them choose an activity: remember the story about the parent who went to the zoo and let their child explore the zoo on their agenda. It was so frustrating for the parent who wanted the child to see as much as possible and so rewarding for the child who wanted to spend 2 hours with the penguins!

• Help them develop their own tools for problem-solving, resist the temptation to solve for them, and offer support instead.
• Involve your children in discussions, if they are old enough, about what to do if they misbehave, ask them what they could do to prevent it happening again, and what support, if any, do they need from you. Avoid labeling or name calling, even in your mind.
• Remain firm, fair and consistent with discipline.
• To be consistent takes resources, so spend time doing what you need to do to stay calm and patient.
• Listen to your child, pay full attention, with lips shut to show them that what they say really matters to you.
• Use the language of self-esteem, 'decide', 'choice', and stress the consequences of choices with your child.
• Make it safe to fail, for you and for them, remember it's OK to apologise if you get it wrong.
• Respect is a 2-way thing - we cannot expect a child to learn to respect others if we do not show them respect from which they can learn this from.
• Become a positive role model, if you are excessively harsh on yourself; pessimistic or unrealistic about your abilities your child may eventually mirror you. In contrast, if you nurture your own self-esteem your child will have a great role model.
• Show your love to your child.

Remember just like us, children do not acquire self-esteem at once, nor do they always feel good about themselves in every situation. If your child is feeling down you could try this small exercise. You could help them to write a letter to a make-believe child who is also having a bad day, let your child advise the make-believe child on how to feel good about themselves.

Getting and Giving Criticism

There are times when criticism is necessary, but children with low self-esteem aren't good at accepting criticism - or giving it nicely.

How you give criticism is important. Criticism is the other part of making your child feel loved: sarcastic, negative comments can undo all your hard work to be encouraging. So is there such a thing as good criticism?

If you want to teach your child how to accept criticism, you need to give it in a constructive way.

This means being calm, not angry, and focusing on the behaviour you want to change instead of criticising the person. It also helps if you can find positive things to say to balance the criticism. Using 'I' tends to be less aggressive than 'you'.

So if your child is struggling with a piece of school work, don't say 'you're stupid', but 'I loved the way you read the first page. It's only a couple of words you're stumbling on. That word is...'

All these things apply when your child gives criticism. For example, 'I like playing with you, but it's too cold to play outside today.'

Dealing with Criticism

The best way for your child to deal with criticism is to:

• listen to what's being said. Don't interrupt to contradict or make excuses.
• agree with it, where possible.
• ask questions if unsure about anything.
• admit mistakes and apologise.
• calmly disagree if it's unfair, e.g. by politely saying, 'I don't agree with you'.

---

 

---

 

Learn about mental health conditions associated with self-injury and the types of self-harm.

Self-injurious behavior is common in the following conditions:

• Borderline Personality Disorder
• Mood Disorders
• Eating Disorders
• Obsessive-Compulsive Disorder
• Posttraumatic Stress Disorder
• Dissociative Disorders
• Anxiety Disorders and/or Panic Disorder
• Impulse-control Disorder Not Otherwise Specified
• Self-injury as a diagnosis

Self-injury Itself as a Diagnosis

Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome.

The diagnostic criteria for Repetitive Self-Harm Syndrome include: preoccupation with physically harming oneself repeated failure to resist impulses to destroy or alter one's body tissue increasing tension right before, and a sense of relief after, self-harm no association between suicidal intent and the act of self-harm not a response to mental retardation, delusion, hallucination

Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome.

As described in Women Who Hurt Themselves, TRS sufferers have four common characteristics:

1. a sense of being at war with their bodies ("my body, my enemy")
2. excessive secrecy as a guiding principle of life
3. inability to self-protect
4. fragmentation of self, and relationships dominated by a struggle for control.

Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles:

1. the abuser (the one who harms)
2. the victim
3. the non-protecting bystander

Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in tandem with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping.

---

Types of Self-Harm

Self-injury is separated by Favazza (1986) into three types. Major self-mutilation (including such things as castration, amputation of limbs, enucleation of eyes, etc) is fairly rare and usually associated with psychotic states. Stereotypic self-injury comprises the sort of rhythmic head-banging, etc, seen in autistic, mentally retarded, and psychotic people. The most common forms of self-mutilation include:

• cutting
• burning
• scratching
• skin-picking
• hair-pulling
• bone-breaking
• hitting
• deliberate overuse injuries
• interference with wound healing
• and virtually any other method of inflicting damage on oneself

Compulsive Self-harm

Favazza (1996) further breaks down superficial/moderate self-injury into three types: compulsive, episodic, and repetitive. Compulsive self-injury differs in character from the other two types and is more closely associated with obsessive-compulsive disorder (OCD). Compulsive self-harm comprises hair-pulling (trichotillomania), skin picking, and excoriation when it is done to remove perceived faults or blemishes in the skin. These acts may be part of an OCD ritual involving obsessional thoughts; the person tries to relieve tension and prevent some bad thing from happening by engaging in these self-harm behaviors. Compulsive self-harm has a somewhat different nature and different roots from the impulsive (episodic and repetitive types).

Impulsive Self-harm

Both episodic and repetitive self-harm are impulsive acts, and the difference between them seems to be a matter of degree. Episodic self-harm is self-injurious behavior engaged in every so often by people who don't think about it otherwise and don't see themselves as "self-injurers." It generally is a symptom of some other psychological disorder.

What begins as episodic self-harm can escalate into repetitive self-harm, which many practitioners (Favazza and Rosenthal, 1993; Kahan and Pattison, 1984; Miller, 1994; among others) believe should be classified as a separate Axis I impulse-control disorder.

Repetitive self-harm is marked by a shift toward ruminating on self-injury even when not actually doing it and self-identification as a self-injurer (Favazza, 1996). Episodic self-harm becomes repetitive when what was formerly a symptom becomes a disease in itself. It is impulsive in nature and often becomes a reflex response to any sort of stress, positive or negative.

Should self-injurious acts be considered botched or manipulative suicide attempts?

Favazza (1998) states, quite definitively, that self-mutilation is distinct from suicide. Major reviews have upheld this distinction. A basic understanding is that a person who truly attempts suicide seeks to end all feelings whereas a person who self-mutilates seeks to feel better. Although these behaviors are sometimes referred to as parasuicide most researchers recognize that the self-injurer generally does not intend to die as a result of his/her acts. Many professionals continue to define acts of self-harm as merely and totally being symptomatic of borderline personality disorder instead of considering that they may well be disorders in their own right.

Many of those who injure themselves are strongly aware of the fine line they walk but are also resentful of doctors and mental health professionals who define their incidents of self-harm as suicide attempts instead of seeing them as the desperate attempts to release the pain that needs to be released in order to not end up suicidal.

Author Chris Zeigler Dendy shares struggles and challenges of raising teenagers with ADHD and provides tips for parenting ADHD teens.

Part I: The first in a two part series.

Parenting a teenager with ADHD may be compared to riding a roller coaster: there are many highs and lows, laughs and tears, and breathtaking and terrifying experiences. Although parents crave calm uneventful weeks, unsettling highs and lows are more likely the norm with these teenagers.

The Challenges

Without a doubt, raising sons with ADHD has been the most humbling and challenging experience of my life. Even with my background as a veteran teacher, school psychologist, mental health counsellor and administrator with over thirty years experience, I often felt inadequate and doubted my parenting decisions.

Parenting these children is not easy for anyone! A wise child psychiatrist once observed, "I'm so glad I had the opportunity to raise 'an easy child' in addition to my child with ADHD. Otherwise I would have always doubted my parenting skills." Obviously, there are no simple parenting or counselling answers. We all--the child, parents, and professionals--struggle with the best way to treat this condition.

During adolescence, the "job descriptions" for parents and teens are often in conflict. The parents' primary job is to gradually decrease their control, "letting go" of their teenager with grace and skill. In contrast, the teenager's main job is to begin the process of separating from his parents and becoming an independent, responsible adult. For better or worse, part of the teen's job is to experiment with making his own decisions, testing limits, and exercising his judgment. When the teen starts this process, parents may feel they are "losing control". Ironically, the natural tendency is to exert even more control. After all, giving freedom and responsibility to teenagers with ADHD is enough to unnerve even the most stout-hearted parent.

Unfortunately, for teens with ADHD, several factors complicate the process of growing up. First and foremost, the four to six year developmental delay exhibited by most teens with an attention deficit often causes problems. A 15 year-old may act as though he were 9 or 10 but thinks he should have the privileges of a 21 year-old. They are more impulsive than their classmates and seldom think of consequences before they act. Chronologically (by virtue of age), teenagers are ready to assume their independence; developmentally (by virtue of maturity) they are not.

Secondly, they are more difficult to discipline than their peers; they do not learn from rewards and punishment as easily as other teens. Early on, parents learn that punishment alone is ineffective. Furthermore, use of physical punishment is no longer a viable parenting strategy. Behavioural interventions effective in childhood such as, "time out" or "stars and charts", lose much of their effectiveness during the teen years. Unfortunately, their emotionality, low frustration tolerance, and tendency to "blow up" make it difficult to resolve problems calmly.

Third, coexisting problems such as, learning disabilities, sleep disturbances, depression, or executive function deficits are extremely common and make it more difficult to develop an effective treatment plan.
With all these challenges, we parents worry and worry some more about our children. What does the future hold? Will our teenager ever graduate from high school, much less go to college? Will he be able to hold down a steady job? Does he have the skills to cope with life?

Looking Back On the Teenage Years

During the teen years, our sons both struggled terribly. As expected, my husband and I faced the typical teen challenges associated with ADHD: poor school performance, forgetfulness with chores and homework, disorganization, losing things, messy rooms, disobedience, talking back, low frustration tolerance, lack of awareness of time, and having a sleep disturbance.

1. School was always the major source of conflict with our sons. Both our boys did okay in elementary school. However, they fell apart in middle school when they had more classes and teachers, had greater academic demands placed on them and were expected to be more responsible and independent. Developmentally they were not ready to complete their work independently. Both boys struggled academically in middle and high school and were in real danger of failing classes. Failure to complete homework or chores was a source of daily battles. The zeros for failure to turn in homework alternately baffled and infuriated us. It was not unusual to go into final exams with a passing grade hanging in the balance. Will they pass or fail? We didn't always know.

2. Emotionally charged conflicts were also common. Our children didn't always do as we asked. Obviously, their disobedience and our yelling battles were frustrating and a major source of embarrassment. As a result we often harboured grave doubts about our own parenting skills. Fear and frustration were our constant companions and at times overwhelmed us. Our reactions ranged from anger and depression to verbal attacks upon our children.

3. Sleep problems were the underlying cause of ongoing fights before school each morning. I can't believe it took us so long to recognize that our son's sleep disturbance--difficulty falling asleep and waking up--was a serious handicap. Unfortunately, most treatment professionals never addressed this issue. But the problem is so obvious: if a student is experiencing sleep deprivation, he cannot do well in school.

---

---

---

Behaviours That Worry Parents the Most

When our sons were teenagers we were frightened by some of their actions. In those days we lacked basic information about the challenging behaviors teenagers with ADHD often exhibit. Subsequently, Dr. Russell Barkley's research has been especially helpful. Awareness of these potential trouble spots often helps parents anticipate problem areas, implement preventive strategies, avoid being unnecessarily frightened and subsequently overreacting to misbehaviour. Here are a few of the more serious behaviours about which we worried the most, along with brief tips from Teenagers with ADD and ADHD.

1. Driving and ADHD. Both our boys received more than their share of speeding tickets. Initially we were baffled by this behaviour. At the time, we were not aware of Dr. Barkley's research that our ADHD teens are four times more likely to get speeding tickets than other drivers.

Tips:

1. Send to driver training classes.
2. Gradually increase driving privileges as they drive safely and without tickets.
3. Talk with the doctor about taking medicine while driving during the early evening.
4. Link driving privileges to responsible behaviour, e.g. for child who is failing a class, try "When you bring home a weekly report with all work completed, you will earn the privilege of driving to school next week." This gives parents greater leverage to influence behaviour. Helpful tips are also available in ADHD and Driving by Dr. Marlene Synder.

2.Substance Use and ADHD. Experimenting with substances is also something many parents worry about a great deal. Children with ADHD may be more likely to experiment with substances plus tend to start at earlier ages. Substance experimentation may progress to abuse and eventually evolve into the more serious medical problem of addiction. The greatest risk for substance abuse is among children with more complex coexisting conditioning, e.g., ADHD and Conduct Disorder or ADHD and Bipolar.

Several factors are often linked to substance abuse:

• having friends who use substances
• being aggressive and hyperactive
• school failure
• low grades
• poor self-esteem

Keep in mind, even if the teenager wants to stop using substances, he may not be able to take that step. So nagging will not help. Don't be judgmental or preachy! If your child is experiencing serious substance abuse problems, convey a sense of deep concern and help him find professional help.

Tips:

1. Be aware of your child's friends and subtly influence his choice of companions as much as possible, e.g., "Would you like to invite John or Mark?"
2. "Fine-tune" the treatment plan until serious aggression and hyperactivity are brought under control, e.g. teach anger management or adjust medications for better results.
3. Educate yourself and your child about substances and signs of abuse.
4. Avoid scare tactics.
5. Provide supervision.
6. Ensure success at school.

3.Suicide Risk and ADHD. Underneath their tough "I don't care" veneer, these teenagers are often very sensitive and hide a lot of pain and hurtful life experiences. The risk of a suicide attempt is a very serious concern. One research study indicated that attempts occurred in between 5-10 percent of students with ADHD. On a couple of occasions we personally came face to face with the frightening knowledge that our sons were so depressed and their self-esteem so battered that they were at risk for a suicide attempt. One parent shared this personal story: "We could never quite see misbehaviour the same after hearing our son say, 'I wish I could go to sleep and never wake up.' I sat up all night reassuring him we would work out whatever problems he faced. We were humbled, realizing that we needed to re-evaluate our parenting styles."

Tips:

1. Become familiar with the warning signs of suicide risk.
2. Take any threat to commit suicide seriously and seek professional help.
3. In the interim, listen to him talk about his concerns.
4. Ask about suicidal thoughts. "Have you considered harming yourself?
5. Tell him how devastated you would be if anything happened to him.
6. Remove potential weapons or dangerous medications from home.
7. Keep him busy plus provide supervision (engage in sports, movies, or video games).

---

---

---

4.Brushes with law enforcement are not uncommon. These ADHD children act impulsively, which may result in their being "invited" to juvenile court. If that happens in your family, don't overreact and assume that your child is going to be a delinquent. Obviously, brushes with the law often give parents a clear signal that the teenager is struggling and needs more guidance and supervision.

Tips:

1. Be aware of the factors contributing to delinquency. "Deviant" friends who are breaking the law and abusing substances are influential factors. Here's a piece of interesting trivia: the peak time for juvenile crime is right after school.
2. Keep your teenager busy after school or provide supervision. If necessary, hire a cook/housekeeper to keep an eye on things at home.
3. Some mothers may decide to work part-time so they can be home when their children are home.
4. Identify the problem behaviours, implement an intervention strategy, and believe that you and your child will cope with the crisis.

Generally speaking, my husband and I were watchful of our sons' activities, tried to keep them busy with wholesome activities, knew their friends, knew where they were and with whom, provided inconspicuous supervision, offered our home as a place for teenage friends to congregate, and sought "win-win" compromises when they proposed unacceptable activities.

In Closing:

In spite of the challenges these children with ADHD present, my view of the long-term outcome of adults with ADHD is probably more positive than most people. ADHD runs in my family and the people I know with this condition have been successful in their chosen careers. By sharing my family's experiences, both the good and bad, it is my goal to give you critical information about your teenager plus a sense of optimism that your family will cope successfully with ADHD. Like most parents of children with ADHD, my husband and I were victims of a code of silence regarding our children's behaviour. We thought we were the only family to experience these ADHD behaviours and were too embarrassed to tell anyone about our children's failures and misbehaviour. So we share this information with you now, so that you will know that you are not alone on this journey. Because we have survived the ride, we can offer a sense of hope for a brighter future based upon our own first-hand experience.

References:

Barkley, Russell A. Attention Deficit Hyperactivity Disorder. New York: The Guilford Press, 1998.
Dendy, Chris A. Zeigler Teaching Teens with ADD and ADHD (Summary 28). Bethesda, MD: Woodbine House, 2000 Dendy, Chris A. Zeigler Teenagers with ADD. Bethesda, MD: Woodbine House, 1995.

About the author: Chris Dendy has over 35 years experience as a teacher, school psychologist, mental health counselor and administrator plus perhaps more importantly, she is the mother of two grown sons with ADHD. Ms. Dendy is the author of two popular books on ADHD and producer of two videotapes, Teen to Teen: the ADD Experience and Father to Father. She is also cofounder of Gwinnett County CHADD (GA) and a member and Treasurer of the national CHADD Board of Directors.

For more information contact CHADD at 8181 Professional Place, Suite 201, Landover, MD 20875; http://www.chadd.org/

---

 

---

next: Natural Alternatives: Passionflower, Pedi-Active for ADHD
~ back to adders.org homepage
~ adhd library articles
~ all add/adhd articles

Believing a child's behavior problem is always the result of bad parenting is simply not true. But parents can get help to better deal with the behavior problem.

We've all seen it - a little girl throwing a fit in the bread aisle or a little boy kicking and screaming in front of the fragrance counter. Most parents have seen their own child behave the same way from time to time. Yet, it's common for people to react to this kind of behavior by blaming the parent.

Being a parent is hard, and all parents are bound to make some mistakes. Different parents use different parenting techniques. Some parents try to negotiate. Others use "time-out." Sadly, some parents become so frustrated and embarrassed by their child's behavior that they do resort to slapping, shaking or yelling at the child. Some seem to do nothing.

However, believing that a child's behavior problem is always the result of bad parenting is like believing poor grades are always the result of an ineffective teacher. Even the best teachers have students who get poor grades, and even the best parents can have a child with a behavior problem. The fact is that behavior problems can be a sign of mental and emotional problems.

Some parents simply do not have the knowledge, skills or support they need to help them manage a child's behavior problem. Parents often are dealing with their own issues, such as unemployment, poverty or illness.

In spite of these challenges, all parents have strengths. Most parents know from experience what a child needs most. Parents are committed to both their child and their community. Parents are dedicated to helping children grow healthy and strong. Most of all, parents have a "built-in" motivation to do what's best for their child (read some Parenting Quotes for inspiration.).

By building on these kinds of strengths, parents can develop better ways to take charge of their lives and to succeed. The key, however, is to find out what those strengths are.

"I don't see dysfunctional families," says Barbara Huff, Executive Director of the Federation of Families for Children's Mental Health. "I see families that are over-stressed and under-supported."

There are many resources available to parents who have a child with a mental, emotional or behavioral problem. The federal Center for Mental Health Services, a component of the Substance Abuse and Mental Health Services Administration, can tell you about services and support programs in your area. Many of these organizations have mentoring programs, support groups, parenting classes or respite care.

How do we know these kinds of programs work?

"When you build on child and family strengths," says Huff, "what you get is what kids do best and what families do best."

Sources:

• National Mental Health Information Center

Visualization is used to treat alcohol and drug addictions, depression, panic disorder, phobias, and stress. Learn more about visualization.

Before engaging in any complementary medical technique, you should be aware that many of these techniques have not been evaluated in scientific studies. Often, only limited information is available about their safety and effectiveness. Each state and each discipline has its own rules about whether practitioners are required to be professionally licensed. If you plan to visit a practitioner, it is recommended that you choose one who is licensed by a recognized national organization and who abides by the organization's standards. It is always best to speak with your primary health care provider before starting any new therapeutic technique.

• Background
• Theory
• Evidence
• Unproven Uses
• Potential Dangers
• Summary
• Resources

Background

Visualization involves the controlled use of mental images for therapeutic purposes. It has been proposed that the use of imagery in visualization may correct unhealthy attitudes or views. People who practice this mind-body technique call on memory and imagination. In some regards, visualization is similar to hypnosis or hypnotherapy. The technique is usually practiced alone. Visualization audiotapes are available.

Theory

The theoretical basis of visualization is that the mind is able to cure the body when visualized images evoke sensory memory, strong emotions or fantasy. There has been limited scientific study of the effectiveness or safety of visualization. Visualization is sometimes considered a subtype of guided imagery.

---

 

---

Evidence

There is no evidence for this technique.

Unproven Uses

Visualization has been suggested for many uses, based on tradition or on scientific theories. However, these uses have not been thoroughly studied in humans, and there is limited scientific evidence about safety or effectiveness. Some of these suggested uses are for conditions that are potentially life-threatening. Consult with a health care provider before using visualization for any use.

Anxiety Bone marrow transplant (adjunct therapy) Cancer Depression Immune activity

Neurological rehabilitation Pain Psychological disorders Psychological disorders associated with nursing homes Stress-related disorders

Potential Dangers

Visualization is generally regarded as safe in most people, although safety has not been thoroughly studied. In theory, inward focusing may cause pre-existing psychological disorders to surface. Use of visualization should not delay the time it takes to see a health care provider for potentially severe medical conditions.

Summary

Visualization has been suggested for a number of health conditions, although there has been limited scientific study in this area. It is not recommended that you rely on visualization alone to treat potentially severe illnesses. Speak with your health care provider if you are considering visualization.

The information in this monograph was prepared by the professional staff at Natural Standard, based on thorough systematic review of scientific evidence. The material was reviewed by the Faculty of the Harvard Medical School with final editing approved by Natural Standard.

Resources

1. Natural Standard: An organization that produces scientifically based reviews of complementary and alternative medicine (CAM) topics
2. National Center for Complementary and Alternative Medicine (NCCAM): A division of the U.S. Department of Health & Human Services dedicated to research

Selected Scientific Studies: Visualization

Natural Standard reviewed more than 35 articles to prepare the professional monograph from which this version was created.

Some of the more recent studies are listed below:

1. Cohen MH. Regulation, religious experience, and epilepsy: a lens on complementary therapies. Epilepsy Behav 2003;4(6):602-606.
2. Crow S, Banks D. Guided imagery: a tool to guide the way for the nursing home patient. Adv Mind Body Med 2004;20(4):4-7.
3. Kimura H, Nagao F, Tanaka Y, Sakai S. Beneficial effects of the Nishino breathing method on immune activity and stress level. J Altern Complement Med 2005;11(2):285-291.
4. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000;355(9214):1486-1490.
5. Miyake A, Friedman NP, Rettinger DA, et al. How are visuospatial working memory, executive functioning, and spatial abilities related? A latent-variable analysis. J Exp Psychol Gen 2001;130(4):621-640.
6. Morganti F, Gaggioli A, Castelnuovo G. The use of technology-supported mental imagery in neurological rehabilitation: a research protocol. Cyberpsychol Behav 2003;6(4):421-427.
7. Sahler OJ, Hunter BC, Liesveld JL. The effect of using music therapy with relaxation imagery in the management of patients undergoing bone marrow transplantation: a pilot feasibility study. Altern Ther Health Med 2003;9(6):70-74.

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Getting Off The Rollercoaster

Included with this book is an option to purchase an Audio Cassette of seven inspirational songs I have composed. You will find the words printed for your convenience in these closing pages.

The following is a list of seven inspirational songs I have composed

1. Don't Let Go of Your dreams
2. The Believing Way
3. Miracles Matter
4. Breakaway
5. Don't be Afraid
6. Talk to Me
7. It's gonna be Alright

Don't Let Go of Your dreams

by Adrian Newington. © 1991

This is the day,
the rest of your life will begin.
A new world of Love,
a new world of Peace to live in.
And the walls that you've built can come down.
And the Love in your heart can come out.

(Chorus)

Don't let go of your dreams.
Always believe, in the freedom they'll bring.
Don't let go of your dreams.
In your Love is your Life,
and your life has meaning and worth.

Quite and still,
this is the way you will learn.
There in your heart,
a Love to help you return.
From the many rods, you have crossed.
While searching for Love never lost.

(Chorus)

Don't let go of your dreams.
Always believe, in the freedom they'll bring.
Don't let go of your dreams.
In your Love is your Life,
and your life has meaning and worth.

So long you've been away,
trying to find your love.
So long you've been confused,
from daring to be,
what you thought you should be.

(Chorus)

Don't let go of your dreams.
Always believe, in the freedom they'll bring.
Don't let go of your dreams.
In your Love is your Life,
and your life has meaning and worth.

---

Getting Off The Rollercoaster

The Believing Way

by Adrian Newington. © 1990

Composed by my Awakening to the value of Persistence of Faith in ones own abilities, and the Actions of Life which respond to those who maintain such attitudes.

Let me tell you 'bout a way to change your life.
That can make your dreams unfold before you eyes.
But you've got to break the link.
and change the way you think.
For there's a chain that binds,
and it'll drag you down each time.

First of all you've got to open up your heart.
And let go of feelings locked within your past.
Then a wonderful peace,
will come when you release,
and you start to see,
how your life can turn around.

(Chorus)

It's the believing way.
And it'll bring you happy days.
And it's a Giving way,
it's a Loving way
It's the believing way.
And you will come to understand.
That your destiny can change,
by your own hand.

Anything that you believe in can come true.
But your Patience and your Faith must see you through.
Keep your head up high.
Don't let the world deny,
all the things,
that you believe can come your way.

(Repeat Chorus)

Miracles Matter

by Adrian Newington. © 1989

Many times in our lives we are graced with simple gifts that tend to go un-noticed as we live our complex lives. But in the stillness of True Self, we will find much beauty abounding. That beauty is all around us and within us.

The scarlet light,
of evening skies,
the moon that softens up the night.
The mountain snows,
the wind that blows,
the changes to our lives.
In a Yellow Rose,
is what nature knows,
and nature is God's wisdom out on show.

(Chorus)

Miracles matter, they help you believe.
Miracles Matter, they're what we need.
Miracles matter, open your eyes.
Miracles matter, understand why.

An answered prayer,
people who care,
someone who's got some Love to share.
The will to strive,
when things aren't right,
a helping hand at the right time.
A baby's cry,
and happy times,
the Love between you and I.

(Repeat Chorus)

---

Getting Off The Rollercoaster

Breakaway

by Adrian Newington. © 1987.

This song was a gift to myself and a dear friend of mine, to help us get by the early stages of Separation and Divorce that we were both experiencing at the same time.

Well I've been thinkin' about you,
and been wondering what's going through your mind.
I guess you're thinkin' about me,
Well I'm alright and I am doin' fine.
We were forced to the wall,
but still we found the strength to go on.

(Chorus)

It's time to breakaway from the old ways.
It's time, to make way for the new days,
it's time, it's time to breakaway.
It's time to breakaway... Breakaway!

Well I've been thinkin' about you,
and I can see you've got yourself back in line.
I guess you're thinkin' about me,
I'll play it cool and make the most of time.
We were hopelessly lost,
but still we found our way to the top.

(Repeat Chorus)

Well I've been thinkin' about you,
You'll be right just give yourself some time.
I guess you're thinkin' about me,
I'll play it cool and make the most of time.
We've got to follow our dreams,
this time 'round it's gonna work out.

(Repeat Chorus)

Don't be Afraid

by Adrian Newington. © 1987

This song was composed from the feelings of compassion I experienced after a friend revealed to me, that her Father had behaved in the most inappropriate way possible that any Father could with a young Daughter. Though the song was meant for one, I sing it for many in the hope that my Love through my music, may touch your heart with friendship and understanding.

Don't be afraid of the nightime.
Don't let your fears take you over.
If you want to,
I can show you,
a brand new day.
So you don't have to be afraid,
of the nightime, anymore.

You said to me,
you've been living, in a shadow.
I thought that I could bring you,
into sunlight.
If you hear, what I'm sayin'
I'll offer you a way.
So you don't have to be afraid,
of the nightime, anymore.

My wish for you is to lead a life,
in the sunshine.
And if you need, a helping hand,
you can have mine.
At the dawn, there's no sorrow,
all things are passing by.
So you don't have to be afraid,
of the nightime, anymore.

---

Getting Off The Rollercoaster

Talk to Me

by Adrian Newington © 1990

I composed this song for a dear friend of mine and her family. My friends niece developed a serious medical condition which sent the young girl into a coma, and this my way of saying that I was always thinking of them in my heart and in my prayers.

The song is Jesus singing to my friend and her family.

I am what your troubled heart yearns for.
I have seen your tears,
and I know your fears.
I have life and Love to give to you.
If you would talk to me,
if you'd believe in me.

(Chorus)

Anytime you call,
trust that I can hear,
when your heart aches,
for one you Love.
I have only Love,
I long to give to you,
but all I ask of you,
is Love me too.

Simple words I long to hear from you.
No matter where you are,
No matter what you do.
Freedom in your heart I'll give to you.
To know my Love with ease.
To walk in three fold peace.

(Repeat Chorus)

I am what your troubled heart yearns for.
If you would talk to me.

It's gonna be Alright

by Adrian Newington. © 1990

This song will always remind me of a profound Peace that descended upon me in a period of sorrow. In an touch, I was transported from sorrow to joy, and could not help but immediately respond to this new peace and joy by the expression through song. Within five or so minutes, I had the essence of the song, and the rest just followed very soon after.

A peaceful feeling came to me today.
What I needed most, to take my tears away.
In a touch the shadows deep inside,
made way for Love as tears subside,
by a voice that whispered gently to my heart.
And it said...

(Chorus)

It's gonna be alright.
Everything is gonna work out fine.
It's gonna be alright.
Everything is work out fine.
It's gonna be alright,
it's gonna be alright.

I never knew this peace could ever be.
To think it's always been inside of me.
There when I was most in need,
gentle thoughts would come to me.
To teach me how to listen to my heart.

(Repeat Chorus)

Download the FREE book

next: Getting Off the Roller Coaster Bibliography

Three studies reveal ways to help kids get to healthier weights.

Childhood obesity is growing at an alarming rate, but experts say parents are more powerful than they imagine at helping kids fight the problem.

About 17 percent of US children and teens, ages two to 19, are overweight, according to the US National Center for Health Statistics.

But three studies presented at the Pediatric Academic Societies annual meeting offer ways to help kids get to healthier weights.

Helping your child have good self-esteem can motivate him or her to lose weight, found Kiti Freier, Ph.D., a pediatric psychologist at Loma Linda University in Loma Linda, Calif.

When she interviewed 118 overweight children participating in a 12-week program, she found that good self-image was even more important than how much excess weight they carried in predicting whether they were ready to lose excess weight.

"Their readiness to change relates to whether they felt supported, not how big they were," she says.

The message for parents of overweight children is clear: Do not point out how overweight they are. Instead, try something like this: "We love you so much. We want you to be healthy and have a long life," says Dr. Freier. Then offer them a plan and support.

Understanding What Overweight Means

The second study revealed that parents may have the mistaken belief that a child is not overweight when he or she actually is overweight.

Dr. Elena Fuentes-Afflick, at the University of California San Francisco, tracked the attitudes of Latina mothers with preschool-age children on their children's weight.

She analyzed data from interviews with 194 women and children taking part in the Latino Health Project.

The women were recruited during pregnancy and then interviewed annually for three years.

By the time they were three years old, more than 43 percent of the children were statistically overweight.

But, "in the group of kids overweight by our measure, three-quarters of those mothers thought their child's weight was just fine," says Dr. Fuentes-Afflick.

"We are living in a society where two-thirds of adults in the US are overweight or obese," says Dr. Fuentes-Afflick. "What concerns me is the risk that we are normalizing overweight body images."

Low Income Linked to High-Calorie Foods

In a third study, mothers in families where food is sometimes scarce due to money problems have a tendency to give their children high-calorie foods to boost overall calories or foods to stimulate the appetite.

These two practices should be avoided if they want their child to remain at a healthy weight, says Emily Feinberg, an expert at Boston University School of Public Health.

In her study, Feinberg interviewed 248 mothers of normal and overweight African-American and Haitian children, ages two to 12.

She found that 28 percent of them had shortages of food from time to time.

When that happened, 43 percent used nutritional drinks such as high-calorie instant breakfast drinks, and 12 percent used substances to stimulate appetite, such as traditional Haitian teas.

Feinberg says this was a well-meaning effort to be sure the children got adequate nutrition.

Instead, Feinberg says, these low-income mothers should "try in general not to focus as much on calories but on the quality of the diet. Instead of a nutritional drink supplement, we would recommend increasing the intake of fruits and vegetables."

Awareness Key for All

The studies provide valuable information for researchers and parents, according to Connie Diekman, a registered dietitian and director of university nutrition at Washington University in St. Louis.

The study relating a child's self-esteem to their readiness to lose weight also makes sense, comments Diekman.

"Self-esteem is a major factor in the establishment of healthy behaviors and [a lack of it] can contribute to overeating and eating disorders," she says.

The second study confirms the key role mothers play in determining what a child eats and weighs, says Diekman.

Finally, the last study on scarce food, "provides some support to why the prevalence [of overweight] is higher" in poorer populations, she says.

Always consult your physician for more information.

Sources:

• MUSC Children's Hospital (St. Petersburg, Fl.) press release

Unlike other forms of self-injury, suicidal self-injury has special meaning, particularly in the context of borderline personality disorder. How is suicidal self-injury differentiated from non-suicidal self-injury in these patients, and how can their behavior be properly assessed and treated?

Borderline personality disorder (BPD) is characterized by unstable relationships, self-image and affect, as well as impulsivity, that begin by early adulthood. Patients with BPD make efforts to avoid abandonment. They often exhibit recurrent suicidal and/or self-injuring behavior, feelings of emptiness, intense anger, and/or disassociation or paranoia. Suicidal and non-suicidal self-injury are extremely common in BPD. Zanarini et al. (1990) found that over 70% of patients with BPD had self-injured or made suicide attempts, as compared to only 17.5% of patients with other personality disorders. Nevertheless, clinicians consistently misunderstand and mistreat this aspect of BPD.

There has been considerable controversy surrounding the diagnosis of BPD, ranging from a sense that the term itself is misleading and frightening, to the fact that the diagnosis is often made in an inconsistent manner (Davis et al., 1993), to a lack of clarity about whether the diagnosis should be Axis I or Axis II (Coid, 1993; Kjellander et al., 1998). Furthermore, these patients are often excluded from clinical trials due to perceived risk.

More important, however, is the fact that suicidal self-injurious behavior is usually understood within the context of major depressive disorder, while the phenomenology of this behavior within BPD is quite different. In addition, self-injurious non-suicidal behavior is often understood by clinicians to be synonymous with suicidal behavior, but again, it may be distinguished separately, particularly within the context of BPD. It is possible that, although self-injury and suicidal behavior are distinct, they may serve similar functions. This phenomenon has important implications for treatment recommendations.

Suicidality in BPD Versus Major Depression

In traditional conceptualizations developed from suicidality seen as an aspect of major depression, suicidal behavior is usually understood to be a response to a deep sense of despair and desire for death, which, if unsuccessful, typically results in a persistence of depression. Vegetative signs are prominent, and the suicidal feelings subside when the major depression is successfully treated with antidepressants, psychotherapy or their combination. In contrast, suicidality in the context of BPD seems to be more episodic and transient in nature, and patients often report feeling better afterward.

Risk factors for suicidal behavior in Borderline Personality Disorder show some differences, as well as similarities, with individuals who are suicidal in the context of major depression. Brodsky et al. (1995) noted that dissociation, particularly in patients with BPD, is correlated with self-mutilation. Studies of comorbidity have produced unclear results. Pope et al. (1983) found that a large number of patients with BPD also display a major affective disorder, and Kelly et al. (2000) found that patients with BPD alone and/or patients with BPD plus major depression are more likely to have attempted suicide than patients with major depression alone. In contrast, Hampton (1997) stated that the completion of suicide in patients with BPD is often unrelated to a comorbid mood disorder (Mehlum et al., 1994) and to degree of suicidal ideation (Sabo et al., 1995).

Conceptualizing Self-Harm

Suicidal behavior is usually defined as a self-destructive behavior with the intent to die. Thus, there must be both an act and intent to die for a behavior to be considered suicidal. Non-suicidal self-harm generally implies self-destructive behavior with no intent to die and is often seen as being precipitated by distress, often interpersonal in nature, or as an expression of frustration and anger with oneself. It usually involves feelings of distraction and absorption in the act, anger, numbing, tension reduction, and relief, followed by both a sense of affect regulation and self-deprecation. Confusion in the field regarding the definition of the term parasuicide can lead to a misunderstanding of the differences in function and danger of suicidal and non-suicidal self-injury. Parasuicide, or false suicide, groups together all forms of self-harm that do not result in death--both suicide attempts and non-suicidal self-injury. Many people who engage in non-suicidal self-harm are at risk for suicidal behavior.

We propose that non-suicidal self-injury in BPD uniquely resides on a spectrum phenomenologically with suicidality. Perhaps the most distinguishing factor, as pointed out by Linehan (1993), is that self-injury may help patients to regulate their emotions--an area with which they have tremendous difficulty. The act itself tends to restore a sense of emotional equilibrium and reduces an internal state of turmoil and tension. One striking aspect is the fact that physical pain is sometimes absent or, conversely, may be experienced and welcomed, as validation of psychological pain and/or a means to reverse a sense of deadness. Patients often report feeling less upset following an episode. In other words, while the self-injury is borne out of a sense of distress, it has served its function and the patient's emotional state is improved. Biological findings pointing to relationships among impulsivity and suicidality support the notion that suicidality and self-mutilation, particularly within the context of BPD, may occur on a continuum (Oquendo and Mann, 2000; Stanley and Brodsky, in press).

It is crucial to recognize, however, that even if patients with BPD self-mutilate and attempt suicide for similar reasons, death may be the accidental and unfortunate result. Because patients with BPD try to kill themselves so often, clinicians often underestimate their intent to die. In fact, individuals with BPD who self-injure are twice as likely to commit suicide than others (Cowdry et al., 1985), and 9% of the 10% of outpatients who are diagnosed with BPD eventually commit suicide (Paris et al., 1987). Stanley et al. (2001) found that suicide attempters with cluster B personality disorders who self-mutilate die just as frequently but are often unaware of the lethality of their attempts, compared to patients with cluster B personality disorders who do not self-mutilate.

Treatment of Suicidal Behavior and Self-Injury

While non-suicidal self-harm can result in death, it is more likely not to and, in fact, only occasionally leads to serious injury such as nerve damage. Yet, patients are often hospitalized on a psychiatric unit in the same way that they would be for a frank suicide attempt. In addition, while the intent is most often to alter the internal condition, as opposed to an external condition, clinicians and those in relationships with self-injurers experience this behavior as manipulative and controlling. It has been noted that self-injury can elicit quite strong countertransference reactions from therapists.

Although there is clearly a biological component to this disorder, the results of pharmacologic interventions have been inconclusive. Different classes and types of medications are often used for different aspects of the behavior (e.g., sadness and affective instability, psychosis and impulsivity) (Hollander et al., 2001).

One class of psychological intervention has been cognitive-behavioral therapy (CBT), of which there are a few models, e.g., Beck and Freeman (1990), cognitive-analytic therapy (CAT) developed by Wildgoose et al. (2001), and an increasingly well-known form of CBT called dialectical behavior therapy (DBT), developed by Linehan (1993) specifically for BPD. Dialectical behavior therapy is characterized by a dialectic between acceptance and change, a focus on skill acquisition and skill generalization, and a consultation-team meeting. In the psychoanalytic arena, there is controversy as to whether a confrontative, interpretative approach (e.g., Kernberg, 1975) or a supportive, empathic approach (e.g., Adler, 1985) is more effective.

Concluding Thoughts

This paper addresses contemporary conceptual and treatment issues that come into play in understanding suicidal and self-injuring behavior in the context of BPD. Diagnostic issues and the phenomenology of self-injurious behavior are important to consider. Treatment approaches include pharmacologic interventions, psychotherapy and their combination.

About the Authors:

Dr. Gerson is a research scientist in the department of neuroscience at the New York State Psychiatric Institute, an assistant project director at Safe Horizon and in private practice in Brooklyn, N.Y.

Dr. Stanley is a research scientist in the department of neuroscience at the New York State Psychiatric Institute, professor in the department of psychiatry at Columbia University and professor in the department of psychology at the City University of New York.

Source: Psychiatric Times, December 2003 Vol. XX Issue 13

References

Adler G (1985), Borderline Psychopathology and Its Treatment. New York: Aronson.

Beck AT, Freeman A (1990), Cognitive Therapy of Personality Disorders. New York: The Guilford Press.

Brodsky BS, Cloitre M, Dulit RA (1995), Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatry 152(12):1788-1792 [see comment].

Coid JW (1993), An affective syndrome in psychopaths with borderline personality disorder? Br J Psychiatry 162:641-650.

Cowdry RW, Pickar D, Davies R (1985), Symptoms and EEG findings in the borderline syndrome. Int J Psychiatry Med 15(3):201-211.

Davis RT, Blashfield RK, McElroy RA Jr (1993), Weighting criteria in the diagnosis of a personality disorder: a demonstration. J Abnorm Psychol 102(2):319-322.

Hampton MC (1997), Dialectical behavior therapy in the treatment of persons with borderline personality disorder. Arch Psychiatr Nurs 11(2):96-101.

Hollander E, Allen A, Lopez RP et al. (2001), A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder. J Clin Psychiatry 62(3):199-203.

Kelly TM, Soloff PH, Lynch KG et al. (2000), Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder. J Personal Disord 14(4):316-326.

Kernberg OF (1975), Borderline Conditions and Pathological Narcissism. New York: Aronson.

Kjellander C, Bongar B, King A (1998), Suicidality in borderline personality disorder. Crisis 19(3):125-135.

Linehan MM (1993), Cognitive-Behavioral Treatment for Borderline Personality Disorder: The Dialectics of Effective Treatment. New York: The Guilford Press.

Mehlum L, Friis S, Vaglum P, Karterud S (1994), A longitudinal pattern of suicidal behavior in borderline disorder: a prospective follow-up study. Acta Psychiatr Scand 90(2):124-130.

Oquendo MA, Mann JJ (2000), The biology of impulsivity and suicidality. Psychiatr Clin North Am 23(1):11-25.

Paris J, Brown R, Nowlis D (1987), Long-term follow-up of borderline patients in a general hospital. Compr Psychiatry 28(6):530-535.

Pope HG Jr, Jonas JM, Hudson JI et al. (1983), The validity of DSM-III borderline personality disorder. A phenomologic, family history, treatment response, and long-term follow-up study. Arch Gen Psychiatry 40(1):23-30.

Sabo AN, Gunderson JG, Najavits LM et al. (1995), Changes in self-destructiveness of borderline patients in psychotherapy. A prospective follow-up. J Nerv Ment Dis 183(6):370-376.

Stanley B, Brodsky B (in press), Suicidal and self-injurious behavior in borderline personality disorder: the self-regulation model. In: Borderline Personality Disorder Perspectives: From Professional to Family Member, Hoffman P, ed. Washington, D.C.: American Psychiatric Press Inc.

Stanley B, Gameroff MJ, Michalsen V, Mann JJ (2001), Are suicide attempters who self-mutilate a unique population? Am J Psychiatry 158(3):427-432.

Wildgoose A, Clarke S, Waller G (2001), Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy. Br J Med Psychol 74(pt 1):47-55.

Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL (1990), Discriminating borderline personality from other axis II disorders. Am J Psychiatry 147(2):161-167.