Nonsuicidal self-injury in adolescence : attempts to improve and develop treatment

Abstract

Nonsuicidal self-injury (NSSI) and NSSI disorder are common in adolescence and associated with adverse outcomes, including suicide attempts. Detecting vulnerable children and adolescents is essential to decrease the risk of initiation as well as repetition of self-injury. Most individuals engage in NSSI to regulate difficult emotions; to effectively treat NSSI, targeting emotion regulation can thus be of importance. Accessibility to effective treatment is a challenge for adolescents engaging in NSSI. Internet-delivered treatment can increase access to treatment, but little is known about how such treatment is experienced and if it is efficacious for adolescents with NSSI or NSSI disorder. This thesis aimed to develop and evaluate the efficacy of Internetdelivered Emotion Regulation Therapy for Adolescents (IERITA), as well as to improve our understanding of early correlates of self-injurious behaviors.

Study I was a qualitative study where eleven adolescents with NSSI disorder and nine parents were interviewed regarding their experience of IERITA. The results showed that receiving support from an online therapist was essential to the treatment. Parents appreciated having their separate intervention, and adolescents accepted this form of parental involvement. Self-responsibility and the flexibility of the treatment were appreciated but could be distressing. Implementing new emotion regulation skills was relevant but perceived as challenging for some. Nevertheless, improved emotion regulation ability was a mentioned effect of IERITA that improved functioning and could hinder NSSI. It was concluded that IERITA is acceptable and can be developed to facilitate learning and address potential distress inherent to the treatment format.

Based on the findings from Study I and feedback from clinicians and patient organizations, we revised IERITA before conducting Study II. Study II was a randomized clinical trial comparing IERTA adjunctive to Treatment as Usual (TAU) to TAU only. Adolescents (N = 166) between 13 to 17 years old with NSSI disorder and past month NSSI were included. The IERITA plus TAU group reduced the NSSI frequency by 82% on average from pre- to posttreatment, significantly larger than the 47% reduction in the TAU-only group (blinded clinician-rated). Statistically significant improvements favoring ERITA plus TAU were also observed on most secondary outcomes, including other destructive behavior, emotion regulation difficulties, and functional impairment. In addition, the advantages of IERITA were maintained at the three-month follow-up. In line with theory, improvements in emotion regulation difficulties mediated reductions in NSSI. In addition, adolescents reported few adverse events concerning IERITA. It was concluded that IERITA can potentially improve access to evidence-based treatment for adolescents engaging in NSSI.

In Study III, as a secondary analysis of Study II, we investigated for whom IERITA was more or less helpful. Age, emotion regulation difficulties, depressive symptoms, function level, parental invalidation, prior NSSI frequency, sleep difficulties, and suicidality were measured before randomization and investigated as moderators and predictors of treatment effect (i.e., change in NSSI frequency). No significant moderation effects were found. High parental invalidation was predictive of a less favorable outcome regardless of treatment condition. It was concluded that there is preliminary support for the efficacy of IERITA for adolescents with NSSI disorder with varying patient characteristics. In addition, detecting and reducing parental invalidation is of importance in NSSI treatments for adolescents.

In Study IV, the focus shifted to childhood. We investigated the associations between Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms and NSSI as well as suicidal behaviors in children at risk of neurodevelopmental disorders (N = 391). The data came from an ongoing longitudinal cohort study of twins. At age 9 or 12, parents reported degree of ADHD symptoms and at age 15 clinicians assessed self-injury. Significant associations were found between childhood impulsivity and suicidal behavior, and inattention and NSSI. However, childhood hyperactivity was not significantly or meaningfully associated with either outcome. It was concluded that screening for and treating childhood impulsivity and inattention can be valuable to prevent self-injurious behaviors.

In sum, IERITA can be an efficacious, acceptable, and flexible treatment for adolescents engaging in NSSI. Nevertheless, additional support can be needed for those experiencing distress inherent to the online format. IERITA can increase access to evidence-based treatments for NSSI among a wide range of adolescents with NSSI disorder. Addressing difficulties in emotion regulation by adding IERITA to TAU can contribute to meaningful change for many with few adverse effects. Additional sufficiently powered trials are needed to understand the utility of IERITA across studies and samples. Inattention and impulsivity during childhood can, at least partly, help us understand self-injurious behaviors’ development. Further studies are needed to establish the temporal order and understand the pathways of these associations. The contributions from the included studies can, by extension, innovate how we treat NSSI among adolescents and generate new hypotheses on preventing self-injury.