Month: October 2022

The notion that hurting yourself can make you feel better seems like a contradiction. But that’s exactly what drives skin cutting and similar forms of self-harm among adolescents, says Matthew Nock, chair of the department of psychology at Harvard University.

If you’re a parent, you may have heard about cutting or be wondering about red flags. Here are the basics on what to know, and how you can respond if you’re concerned about this form of self-harm.

What is self-harm?

“Self-harm is the intentional destruction of body tissue in the absence of any intent to die,” explains Nock, who specializes in treating self-injury behaviors in childhood to young adulthood. “Most often it happens on the arms and takes the form of cutting with some type of sharp object, such as a razor blade, pencil, or pocket knife. It might also include burning the skin or inserting objects under the skin, such as paper clips.”

How many teens engage in self-harm?

About 17% of teenagers engage in self-harm at least once, according to the American Psychological Association.

Many who do so begin between ages 12 and 14, when adolescence can deliver a one-two punch: combining a new mental health disorder with greater risk-taking behaviors, explains Nock.

What leads some teens to engage in cutting?

Cutting appears to affect all genders of adolescents equally, Nock notes. But what factors make teens more likely to do it? In addition to experiencing depression, anxiety, or other mental health issues, teens who cut themselves may be more apt to use drugs or alcohol.

A 2022 study in Child and Adolescent Mental Health suggests additional contributing factors, including family problems, school or job challenges, and struggling relationships with friends. Ultimately, cutting appears to have three contributing components, Nock says: psychological, biological, and social.

“Kids who engage in self-injury have difficulty tolerating emotional distress and are more likely to try to escape from those feelings,” he says. “It might be that their pain demands attention, and when they’re really upset, cutting themselves focuses on their physical pain and reduces their psychological pain.”

The sense of relief or release after cutting reinforces the behavior, leading teens to cut themselves again and again. “An adult who’s feeling upset may have a drink, go for a run, or engage in yoga to decrease their distress. When they feel better afterward, that behavior gets reinforced,” Nock says. “We think the same is true with self-injury: if you feel really bad and cut yourself, the feeling goes away.”

Will asking about cutting put ideas in a teenager’s head?

Parents often worry about this. But it’s safe to assume kids in middle school and high school are well aware of what self-harm involves, from social media and interactions with peers and others. “Asking kids about it isn’t going to give them the idea to do it — all of the data we have suggests that’s not the case,” Nock says.

What are key signs of cutting in teenagers?

Be alert for

• fresh cuts on a teen’s skin, or evidence that skin has been cut, burned, or had objects placed under it
• covering body areas — whether arms or legs — they didn’t tend to cover before.

Is there a connection between cutting and suicide?

While teens who engage in cutting don’t intend to end their lives that way, their willingness to hurt themselves might indicate a greater risk that they may attempt suicide. More than 50% of children and adolescents who die by suicide have previously self-harmed, according to the 2022 study described above.

“The more you intentionally hurt your body — which takes some amount of courage to do — the more likely you’ll target yourself in the future,” Nock says. “We also think there’s a self-hatred component to this — you’ll hurt your body when in distress rather than do something productive like go for a run. There’s a sort of self-criticism that leads people to hurt themselves and ultimately try to kill themselves.”

How can parents respond if they notice signs of cutting?

If they confide in anyone at all, teens who self-harm tend to tell their friends, not their parents or other adults. But parents can break through the secrecy and offer support with a calm, steadfast approach.

“Encourage them to talk to you about what they’re experiencing, knowing that you’re an open ear and will be as nonjudgmental as possible,” Nock says. “It’s not realistic that we’re going to root out all risky behaviors that kids engage in. But when death is a potential outcome, encourage friends and family not to honor that secrecy and to try to intervene to keep the person safe.”

Seeking appropriate resources can help:

• Take your child to a primary care doctor who can refer to a mental health professional, or go directly to a psychiatrist, psychologist, or social worker for evaluation.
• Ask your doctor or a mental health professional about local or telehealth options for cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT). Both approaches can help teens learn healthier strategies to cope with emotional distress.
• If your child’s self-injury seems severe or you’re concerned about the possibility of suicide, go to a hospital emergency room. “If our kids fall and suffer a break or accidental injury that needs medical attention, we go to the ER — and the same should happen for injuries that are self-inflicted,” Nock says.

About the Author

Maureen Salamon, Executive Editor, Harvard Women's Health Watch

Maureen Salamon is executive editor of Harvard Women’s Health Watch. She began her career as a newspaper reporter and later covered health and medicine for a wide variety of websites, magazines, and hospitals. Her work has … See Full Bio View all posts by Maureen Salamon

About the Reviewer

Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing

Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD

Prostate cancer is generally viewed as a disease of older men. Yet about 10% of new diagnoses occur in men age 55 or younger, and these early-onset cancers often have a worse prognosis. Biological differences partially explain the discrepancy. For instance, early-onset prostate cancers contain certain genetic abnormalities that don’t appear as often in older men with the disease.

But socioeconomic factors also play an important role, according to new research by investigators at Jacksonville College of Medicine (JCM) in Florida. The fact that poverty, educational status, and other factors governing socioeconomic status (SES) influence cancer survival is well established.

This is the first study to investigate how SES affects survival in early-onset prostate cancer specifically. The findings show that men with lower SES don’t live as long as the higher-SES patients do. “They’re more likely to be diagnosed at advanced stages,” says Dr. Carlos Riveros, a physician and research associate at JCM and the paper’s first author.

What the research found

During the investigation, Dr. Riveros and his colleagues evaluated data from the National Cancer Database (NCD), which is sponsored by the American College of Surgeons and the National Cancer Institute. The NCD captures data from over 1,500 hospitals in the United States. Dr. Riveros’s team focused specifically on long-term outcome data for 112,563 men diagnosed with early-onset prostate cancer between 2004 and 2018.

The researchers were able to determine the zip codes where each of these patients lived. Then they looked at per-capita income for those zip codes, as well as the percentage of people living within them who had not yet earned a high school diploma. Taken together, the income and educational data served as a composite SES measure for each zip code’s population. In a final step, the team looked at how the survival of early-onset prostate cancer patients across the zip codes compares.

The results were remarkable: Compared to high-SES patients, the low-SES men were far more likely to be African American, and less likely to have health insurance. More of the low-SES men lived in rural neighborhoods and had stage IV prostate cancer at diagnosis. Fewer low-SES patients were treated at state-of-the-art cancer centers, and less of them had surgical treatment.

After adjusting for age, race, ethnicity, cancer stage, treatment, and other variables, the lower-SES men were 1.5 times more likely than the higher SES men to have died over a median follow-up of 79 months.

Observations and comments

According to Dr. Riveros, the findings are consistent with evidence showing that social determinants of health — the conditions in places where people work and spend their lives — have broad impacts on cancer risk. “Many people in lower-SES areas have had poor diets since birth,” he says.

Lower-SES individuals may be limited in their ability to find, understand, or use health-related information, and therefore “might not know what advanced prostate cancer feels like, or when it’s time to go to a doctor,” Dr. Riveros says. He and his co-authors concluded that SES should be considered when implementing programs to improve the management of patients with early-onset prostate cancer.

“This paper underscores the importance of addressing issues related to diversity, equity, and inclusion when it comes to optimizing outcomes for men with prostate cancer,” says Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center.

Dr. Heidi Rayala, a urologist affiliated with Beth Israel Deaconess Medical Center in Boston, and a member of the Harvard Medical School Annual Report on Prostate Diseases editorial board, agrees, but adds that evaluating individual sociodemographic factors is challenging because many of them are coupled with disparities in insurance coverage. “What remains to be answered is whether there are unique underlying SES factors that would benefit from targeted cancer prevention strategies, or whether this all boils down to the 10% of the US population that remains uninsured,” she says.

About the Author

Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Charlie Schmidt is an award-winning freelance science writer based in Portland, Maine. In addition to writing for Harvard Health Publishing, Charlie has written for Science magazine, the Journal of the National Cancer Institute, Environmental Health Perspectives, … See Full Bio View all posts by Charlie Schmidt

About the Reviewer

Marc B. Garnick, MD, Editor in Chief, Harvard Medical School Annual Report on Prostate Diseases; Editorial Advisory Board Member, Harvard Health Publishing

Dr. Marc B. Garnick is an internationally renowned expert in medical oncology and urologic cancer. A clinical professor of medicine at Harvard Medical School, he also maintains an active clinical practice at Beth Israel Deaconess Medical … See Full Bio View all posts by Marc B. Garnick, MD

In this increasingly digital world, it’s not surprising that children are spending more and more of their time on some sort of device. And while there is certainly much to be learned, explored, and created using devices, there are skills that devices can’t always teach — and that children need to learn.

Play bolsters executive function and mood regulation skills

Executive function, emotional regulation, and general physical skills are important for children to learn — and practice — as they grow. The best way for children to learn these skills is through play; that’s why we say that play is the work of a child. As devices become more pervasive, and as many children become more scheduled with lessons and organized activities, making time for device-free play can become forgotten.

I think that also, parents and children are literally forgetting how to play. Parents used to bring toys to entertain their children while they waited to see me; now they just hand their child their phone. Devices are so ubiquitous and easy, it can take real effort to put them aside and find something else to do.

Play is essential to healthy development

Harvard’s Center on the Developing Child has developed excellent handouts for parents (note: automatic download) on different age-based games and activities to help support their child’s development. I particularly like those that involve the parent too — because that not only helps your child, it helps your relationship.

Great games to play with younger children: Ages 4 to 7

In the first three years of life, play is about literally building brain connections and basic skills. As kids grow, play builds on those skills and gives them opportunities to think, be creative, cooperate with one another, and use their bodies.

Here are some ideas for 4-to 7-year-olds (note: automatic download):

• Freeze Dance, Red Light Green Light, Simon Says, or Duck Duck Goose are all games that get kids active while reinforcing self-regulation and cooperation.
• I Spy, Bingo (or Opposites Bingo, where families make their own picture boards and kids have to match the opposite to what is said), and other matching games are great for building memory and cognitive skills.
• Try starting a story and having others add to it to see what plot twists emerge! It’s a great way to encourage creativity. You can do something similar with a drawing: start with something simple, like a house or a boat, and take turns embellishing this, narrating as you do.

Great games to play with older children: Ages 8 to 12

The 8-to 12-year-olds (note: automatic download) are capable of more complicated activities, like:

• Doing jigsaw puzzles, or solving crosswords or other puzzles together.
• Playing games like chess, Battleship, Go, or Clue that involve memory and planning.
• Playing a sport — play basketball together, go skating, practice yoga, or go for a run together. Being active together is not only healthy for both of you, it sets a good lifelong example.
• Learning an instrument — learn together!
• Making things. Teach them to cook, build, sew, crochet, grow a garden. This, too, can be play.

Opportunities to play help teens, as well

As kids grow into teens (automatic download), they naturally seek more independence and time with their peers. Opportunities for play take different forms depending on personal interests. Sports, cooking, music, theater, and even (within moderation) video games can encourage creativity, life skills, and fun.

For more information about how parents can build and encourage important life skills in their children, visit the Harvard Center on the Developing Child website.

Follow me on Twitter @drClaire

About the Author

Claire McCarthy, MD, Senior Faculty Editor, Harvard Health Publishing

Claire McCarthy, MD, is a primary care pediatrician at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. In addition to being a senior faculty editor for Harvard Health Publishing, Dr. McCarthy … See Full Bio View all posts by Claire McCarthy, MD