Self-harming Behavior in Incarcerated Male Delinquent Adolescents

GREGORY D. CHOWANEC, PH.D., ALLAN M. JOSEPHSON, M.D., CHARLES COLEMAN, M.D.,

AND HARRY DAVIS. M. S .
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Abstract. This report describes self-harming behavior in males in a juvenile incarceration center. Three

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groups of adolescents were examined: self-harmers, those referred for a psychiatric examination, and the incarcerated
general population. Compared to the general population, the youth in the two mental health groups were younger,
had greater family needs, had more educational problems, were more likely to have escaped from a previous
placement, and committed more rule violations. The self-harming group, when compared with the psychiatrically
referred group, had a greater number of prior offenses, were more disruptive in school, performed worse on a
problem-solving task, and committed more rule violations. Issues of psychopathology and treatment are discussed.
J . Am. Acad. Child Adolesc. Psychiatry, 1991, 30, 2:202-207. Key Words: self-harm, adolescent male, delin-
quency.

Self-harming behavior (or self-mutilation) is a complex behavior and suicidality are “clinically distinct classes of
and difficult to manage clinical problem. In 1969, Pa0 wrote behavior. Lastly, they felt that, while self-harming be-
”

that ‘‘delicate cutters should be categorically diagnosed as
severe borderline states. ” DSM-III furthered this association
when it listed “physically self-damaging acts” as one of
the diagnostic criteria for borderline personality disorder.
Schaffer et al. (1982) have stated that once psychosis and
suicidal intent have been ruled out, psychiatric patients who
engage in self-mutilation are borderline personalities. In
addition to its intrapsychic elements, conceptualization of
the phenomenology of self-mutilation in borderline person-
alities has emphasized the interpersonal aspects of the be-
havior. Though some investigators feel it reflects the pa-
tient’s extreme “sensitivity to issues of separation, loss and
failure,” where the self-mutilating act is precipitated by
overwhelming feelings of rejection (Leibenluft et al., 1987),
others understand the internal state of these borderline pa-
tients in terms of “feelings of resentment, rage and impo-
tence,” where the self-mutilating act is one of “revenge”
toward the “important person” (Kernberg, 1987).
Pattison and Kahan (1983) surveyed the literature about
self-harming , directing their efforts toward description of
this behavior irrespective of etiological formulation. Citing
the work of Ross and McKay (1979), they stated that while
self-harming behavior occurs more frequently in borderline
and histrionic personality disorders, there is no direct as-
havior is sometimes associated with psychosis, the majority
of self-harming actions are not manifestations of a psychotic
process. Their work was consistent with the atheoretical
nosology of DSM-III and, in that genre, they argued that
because it meets the three essential features of disorders of
impulse control not elsewhere classified-“ 1) failure to re-
sist an impulse; 2) increasing tension before committing the
act; and 3) experience of pleasure, gratification, or release
at the time of committing the act”-the “deliberate self-
harm syndrome” should be considered an Axis I diagnosis.
Favazza (1988) has estimated that the prevalence of de-
liberate self-harm is approximately 750 per 100,000 (or
0.75%). For persons aged 15 to 35, thought to be the peak
years for self-mutilation, he estimated that the incidence
rate is closer to 1,800 per 100,000. Within correctional
facilities, the prevalence rates are placed at even higher
levels. Bach-Y-Rita (1974) commented that in psychiatric
clinics, self-harming is predominantly seen among women;
however, he also reported that when one turns from hospital
admissions to police records the situation reverses. While
it is often stated that deliberate self-harm begins in adoles-
cence, only a few investigations have focused on adoles-
cents, and of these only three have gone beyond anecdotal
reports (Ross and McKay 1979, Walsh et al., 1988, Schwartz

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sociation between this behavior and a specific personality
disorder. In addition, they emphasized that self-harming
Accepted November 8, 1990.
From the Medical College of Georgia, Augusta. Dr. Coleman is
now a resident in child psychiatry at Vanderbilt University.
An earlier draft of this paper was presented at the 36th Annual
Meeting of the American Academy of Child and Adolescent Psychiatry,
New York, October, 1989.
The authors wish to thank Dr. Robert C . Ness for his participation
in the early stages of this research, Dr. Elmer H . Davidson for his
support of this project, and Thomas Sherrer and Leon Murray for
their help in the data collection.
Reprint request to Dr. Josephson, School of Medicine, Department
of Psychiatry and Health Behavior, Medical College of Georgia, Au-
gusta, Georgia, 30912-7300.
0890-8567/91/3002-0202$03.OO/OO 1991by the American Academy
of Child and Adolescent Psychiatry.
202
et al., 1989).
Ross and McKay’s (1979) investigation was set in a train-
ing school for delinquent adolescent girls. The subjects were
drawn from the 136 girls in the institution, 86% of whom
had “carved” their bodies (i.e., cut on their skin) at least
once. From their findings, the authors concluded that, among
institutionalized girls, carving represents an interaction be-
tween psychopathology and social adaptation. Walsh and
Rosen’s (1988) study was based on data collected on 52
adolescents (42 female, 10 male) who had engaged in some
form of self-multilative behavior while in treatment. They
concluded that a self-mutilator was a “loss-vulnerable in-
dividual trained to be violent, impulsive, and substance
abusing” who also experienced feelings of body alienation.
In addition, these authors felt that the self-mutilative be-
havior discharged the adolescent’s tensions and frustrations
J . Am. Acad. Child Adolesc. Psychiatry, 30:2,March1991

in an impulsive self-defacing way that attracted solicitious
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attention from peers and adults. Schwartz and colleagues’
(1989) study was based on information gathered from 85
female adolescents in an outpatient drug treatment program.
Carving was found to be associated with feelings of depres-
sion, anger, intense loneliness, and emotional pain. How-
ever, when compared to noncarvers on eight social and
behavioral history variables, no significant differences (p
< 0.05) were found between the two groups.
While these studies have clearly broadened our knowl-
edge base in the area of self-harming behavior in adoles-
cents, they have focused almost exclusively on female ad-
olescents. Although there have been studies of adult male
prisoners who exhibited self-harming behavior (Panton,
1962, Bach-Y-Rita, 1974) and “suicidal behavior” in in-
carcerated youth (Alessi et al., 1984), to the authors’ knowl-
edge, the present study is the first report of a systematic
investigation of self-harming behavior in incarcerated male
adolescents.
The impetus for this study was the consultation work the
first two authors did with a state juvenile correctional fa-
cility. In particular, the staff at that facility were distressed
by the residents’ self-harming behavior and were very in-
terested in gaining a better understanding of how to manage
this behavior. Clinical impressions suggested that the self-
harming incident was more indicative of these youths’ per-
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vasive maladjustment than it was of a discrete psychiatric
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episode. This implied that the behavior could best be under-
stood as a poor problem solving strategy for handling psy-
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chological distress. Consequently, the present study was
conducted to systematically examine what characterized those
youth who evidenced psychological distress and, then, to
examine the differences between the self-harming boys and
boys who, though they evidenced other forms of psycho-
logical distress, did not engage in self-harming behavior.
Method
This research took place in a long-term stay facility in
Georgia (where such facilities are referred to as Youth De-
velopment Centers-YDCs) for delinquent male residents
aged 13 to 17. Three groups of residents were considered:
those who engaged in self-harming behavior during their
detention, those who were referred by YDC staff for a
psychiatric referral (excluding self-harmers), and a general
non-clinical group.
The definition of self-harming behavior used in this paper
is based on the facility’s working definition that implicitly
defines it as a deliberate act inflicting damage to the body
of the perpetrator or threatening its integrity. The definition
is a behavioral one and makes no assumptions about the
resident’s underlying motivations in relation to dying. The
reported acts of deliberate self-harming behavior ranged in
lethality from self-tattooing to one attempt at hanging, with
the most common form of the behavior being cutting on the
forearms.
Information on 432 consecutive admissions to the YDC
from February 1987 to February 1988 was obtained. All
residents were included in the study except for those who
were transferred during the intake process (usually within
J . Am. Acad. Child Adolesc. Psychiatry, 30:2, March 1991
SELF-HARMING BEHAVIOR IN ADOLESCENTS
the first week of admission); a few youth had two admissions
during the study period but were only included in the study
once. Four types of data were collected: background data
(e.g., the youth’s age), evaluations made by court service
workers before the incarceration, psychological evaluation
data routinely collected on the youth during the first week
of YDC detention, and behavioral reports collected during
the youth’s detention period. All of this data was routinely
collected for clinical purposes.
Measures
The data collected on each youth included basic back-
ground information in the areas of demographics (including
such information as age, race, family size), legal history
(age at first offense, age at first YDC incarceration, number
of prior offenses, number of previous YDC incarcerations)
and psychiatric history (number of previous psychiatric hos-
pitalizations, age at first psychiatric hospitalization). The
assigning court system’s evaluation of the youth’s problems
in the areas of interpersonal difficulties, familykesidential
support needs, medical problems, mental health needs, vo-
cational needs, educational needs, and alcohol and drug
intervention needs was based on five-point scales ranging
from less severe to more severe. The psychological eval-
uation data collected on each youth during his first week of
YDC detention included intelligence (Wechsler Intelligence
Scale for Children-Revised [WISC-R], Peabody Picture Vo-
cabulary Test-Revised [PPVT-R], and the Culture Fair In-
telligence Test [Cattell and Cattell, 19771); academic
achievement (Wide Range Achievement test [WRAT]);
symptomatology (Bipolar Psychological Inventory [Roe et
al., 1975; Konopasky, 19851); and impulsivity (Trail Mak-
ing Test, Part B). The Bipolar Psychological Inventory
measures 15 variables, utilizing scales, considered psycho-
logically and socially important, particularly in correctional
settings (e.g ., Depression-Optimism; Hostility-Kindness).
Lastly, the youth’s behavior during incarceration was re-
corded with reports kept on assaults, escapes, fire violations,
possession of contraband items, sexual assaults, refusal to
obey reasonable and lawful commands, serious law viola-
tions, stealing, terroristic threats, property damage/destruc-
tion, drug and substance violations, and on positive behav-
iors as well.
Results
The youths were divided into the three groups in the
following way: 44 (10.4%) engaged in at least one self-
harming behavior, documented by the YDC staff, during
their detention (referred to as the self-harming group); 124
(29.2%) referred for psychiatric evaluation but did not en-
gage in any self-harming behavior (referred to as the psy-
chiatrically referred group), and 256 (60.4%) neither en-
gaged in self-harming behavior nor were referred for a
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psychiatric evaluation (referred to as the general YDC group).
Conceptually, the authors were interested in first assessing
how the mental health group of residents (i.e., the combi-
nation of the self-harmers and the psychiatrically referred
residents) differed from the general YDC residents and then
viewing what factors differentiated the self-harmers from
203
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CHOWANEC ET AL.

the nonself-harming psychiatrically referred residents. Sta-

tistically, this translated into doing three group comparisons,
and when there was a significant difference looking at the
TABLE1 . Comparison of Mental Health Group
of Residents (MHG) with the General Youth Development
Center (YDC) Residents (GEN)*
a priori contrasts between the mental health group, which MHG (Boys) GEN (Boys)

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was comprised of self-harmers and psychiatrically referred R SD R SD

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residents, and the general YDC residents as well as the Younger 15.62 yrs 1.02 15.94 yrs 0.98
comparison of the self-harmers with the psychiatrically re- More likely to be white 51.5% of whites 48.5% of whites
ferred group. The following results, therefore, first give the than black 31.8% of blacks 68.2% of blacks
one-way analysis for the given variable and then the specific Younger at the time of
group contrasts. Given the large number of variables that their first offense 12.79 yrs 2.08 13.23 yrs 1.82
were analyzed, a p of < 0.01 was selected for the signif- Younger at the time of
icance level. Consequently, unless otherwise noted, all re- their first YDC detention 15.15 yrs 1.39 15.51 yrs 1.39
ported differences are significant at p < 0.01. Significance Less likely to have been in
of a priori contrasts are based on the separate variance es- regular school classes 40.6% 57.9%
timates. Pillai’s trace statistic is used for significance of More likely to have been in
behavior disordered
multivariate analysis of variance. school classes 41.8% 28.6%
Mental Health Group versus General YDC Group More likely to have es-
caped from a previous
As expected, residents in the mental health group (MHG) placement 33% 18.9%
exhibited more mental health difficulties than the group of Viewed as a greater public
general YDC (GEN) residents. They had a higher number risk 2.88 1.02 2.49 1.07
of previous psychiatric hospitalizations, F(2,418) = 10.74, Viewed as being a greater
(88.5) = -3.75. They were viewed by the court system containment problem 3.28 0.93 2.98 0.68
as having greater mental health needs than the general YDC Psychiatrically hospitalized
population, F(2,420) = 20.52, t(79.5) = -4.88. Also, at a greater number of
times 0.58 1.0 0.21 0.64
the time of intake at the YDC, they expressed more suicidal Reporting more depressive
ideation, x2(1) = 20.05. The three group breakdown, x2(2) symptomatology** 10.41 4.14 9.35 3.65
= 23.66, revealed 22.7% of those residents who later en- Viewed as having greater
gaged in self-harming behavior, 15.4% of those who were family and/or residential
later referred for a psychiatric evaluation, and 3.9% of the support needs 3.46 0.86 3.10 0.87
residents who did not fall into the other two groups reported Detained in the YDC for a
suicidal evaluation upon YDC intake. greater number of days 261.6 117.4 208.0 114.4
The MHG residents were younger than the GEN resi- More likely to report suici-
dents, F(2,421) = 5.68, t(123.3) = 3.09. They were also dal ideation at time of
younger at the time of their first offense, F(2,417) = 4.79, intake to the YDC 17.4% 3.9%
Written up for more rule
t(133.2) = 2.77; and at the time of their first YDC deten- violations (per day) 0.11 0.11 0.06 0.08
tion, F(2,419) = 5.21, t(124.9) = 2.95. There also was a
significant difference on the variable of race for the three * p < 0.01, ** p < 0.05.
group comparison, x2(2) = 17.51, with white youth more
likely to fall into the MHG than black youth, ~ ~ ( =1 15.70.
)
The youths’ behavior during previous placement was sig- F(30,806) = 0.94, with the only univariate F approaching
nificantly different, x2(2) = 11.09, with the MHG residents the 0.01 significance level being the depression scale,
more likely than the GEN residents to have engaged in an F(2,416) = 4.07, p < 0.05. The MHG residents reported
escape from a previous placement, x2(1) = 10.23. The more depressive symptomatology than the GEN residents,
MHG youth were viewed by the court system as a greater t = -2.23, p < 0.05. While in the YDC, the MHG group
public risk, F(2,421) = 6.80, t(156.7) = -3.20, and were of residents were written up for significantly more rule vi-
evaluated by the YDC as being a greater containment prob- olations per day, MANOVA F(26,740) = 3.55. Of the 13
lem, F(2,372) = 13.86, t(104.1) = -4.61. They were behavioral report areas, in nine of them the MHG residents
also seen as having greater family and/or residential support had significantly more reports (at the p < 0.01) than the
needs than the GEN residents, F(2,420) = 8.62, t(187.2) general YDC group of residents; including escape attempts,
= -4.17. fire violations, possession of contraband items, refusal to
The MHG residents had different school placements than obey reasonable and lawful commands, stealing, terroristic
the GEN residents [significant three group difference (i.e., threats, property damage/destruction, assaults, and deten-
self-harmers, psychiatrically referred group and GEN) ~ ~ ( 6 )tions. The four areas not significant (at p < 0.01) include
= 26.291; they were less likely to have been in regular sexual assaults, law violations, drug and substance viola-
classes than their GEN counterparts and more likely to have tions, and positive behavior reports. (For all behaviors, means
been in behavior disordered classes, x2(3) = 12.24. On a go from highest for self-harming to lowest for general YDC,
general personality inventory, there were no significant dif- with psychiatrically referred residents in the middle--except
ferences between the two groups of residents, MANOVA for positive reports where the latter are the lowest.) Lastly,

204 J.Arn.Acad. ChildAdolesc.Psychiatry,30:2,March1991

 TABLE 2 . Comparison of Psychiatrically Referred Group of
Residents with the Self-Harming Group of Residents*
Self-harming

x
Group
(Boys)
Psychiatrically
Referred Group

x
(Boys)
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SELF-HARMING BEHAVIOR IN ADOLESCENTS

Performance IQ was the only variable to produce a signif-

icant univariate F(2,349) = 5.74; the self-harming residents
scored significantly lower on this measure, t = 3.03, than
the psychiatrically referred group of residents.
During their YDC detention, the self-harming residents
were written up for significantly more rule violations per

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SD SD
Had a greater number of day, MANOVA F(26,740) = 3.55. Self-harming residents
prior offenses at the time had significantly (p < 0.01) more behavior reports than the
of this YDS detention 6.95 4.10 4.80 3.88 psychiatrically referred residents in the areas of escape at-
Were viewed as a greater tempts, refusal to obey reasonable and lawful commands,
containment problem 3.70 0.88 3.14 0.91 terroristic threats, property damage/destruction, assaults, and
Were less likely to have been detentions. These results are summarized in Table 2.
in regular school classes 36.4% 42.1%
Were less likely to have been Discussion
in learning disabled classes4 0.0% 15.7% Almost 40% of the incarcerated residents at this institution
More likely to have been in
behavior disorder classes 59.1% 35.5%
evidenced mental health difficulties (that is, the combination
Performed more poorly on of psychiatrically referred and self-harming residents). The
problem-solving tasks as emotional disorders were associated with troubled histories
evidenced by their lower (e.g., family dysfunction), symptom reports (e.g., depres-
scores on the WISC-R Per- sion), and the observation of problem behaviors (e.g., es-
formance Scale 85.76 14.68 94.89 14.78 cape attempts). While the self-harming and psychiatrically
Had a higher overall number referred groups were alike in many ways, the self-harming
of rule violations (per day) group demonstrated more aggressive and noncompliant be-
while in the YDCb 0.17 0.11 0.09 0.11 haviors. This was true in their school and community be-
* p < 0.01. havior before admission and in their behavior after admis-
Learning disabled classes only, if in both learning disabled and sion. The self-harming group also appeared to have poorer
behavior disordered classes considered to be in behavior disordered nonverbal problem-solving skills. This study, then, is con-
classes. gruent with a recent report by the American Medical As-
* These violations were most prominent in the areas of escape at- sociation’s Council on Scientific Affairs that identified in-
tempts, refusal to obey reasonable and lawful commands, terroristic
threats, property damage/destruction, assaults, and detentions.
carcerated youth as an “underserved population that is at
high risk for a variety of medical and emotional disorders”
(American Medical Association Council on Scientific Af-
fairs, 1990).
the MHG residents spent significantly more days at the The present findings contribute to the understanding of
YDC, F(2,385) = 10.0, t(124.7) = -4.27, even though deliberate self-harm, particularly in the understudied pop-
they were not sentenced to significantly longer periods of ulation of adolescent males in three ways. First, suicidal
detention. These results are summarized in Table 1. ideation and depression reported at the time of admission
did not discriminate between those who self-harmed and
Self-harming Group versus Psychiatrically those referred for psychiatric evaluation. This is consistent
Referred Group with recent literature that sees this behavior as neither su-
While the self-harming and the psychiatrically referred icidal (Bancroft et al., 1977; Kahan and Pattison, 1984;
residents appear to differ more from the GEN population Favazza, 1988; Walsh and Rosen, 1988) nor a depression
than they do from each other, they do differ from each other equivalent (Ennis et al., 1989). The present results suggest
in some significant ways. At the time of their present YDC that when incarcerated adolescents experience mental health
detention, the self-harming residents had a greater number difficulties, those engaging in self-harm are differentiated
of prior offenses than the psychiatrically referred residents, by their level of ego function or problem-solving skills.
F(2,420) = 4.79, t(72.4) = 3.03. They were evaluated by Second, the psychopathology of self-harming youth is
the YDC as being a greater containment problem, F(2,372) best understood as a type of “pan-pathology.” The mental
= 13.86, t(63.9) = 3.32. The self-harming residents had health group of residents (again, the combination of psy-
different school placements (significant three group differ- chiatrically referred and self-harming groups) seemed to
ence ~ ~ ( = 6 )26.29); they are less likely to have been in evidence more depressive symptoms than the general pop-
regular classes, less likely to have been in learning disability ulation of YDC youth-as indicated by a p < 0.05-and

classes, and more likely to have been in behavior disorder
classes, ~ ~ ( =3 )11.68. When a MANOVA was conducted
on the problem-solving variables (i.e., WISC-R Perform-
ance, Verbal and Full Scale IQs, the PPVT-R, the Culture
Fair Intelligence Test, the WRAT Reading, Spelling and
Arithmetic tests and the Trail Making Test, Part B), the
result was significant, F(18,684) = 2.08. The WISC-R
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they were more out of control behaviorally, as indicated by
their significantly higher (at p < 0.01) number of rule vi-
olations. However, within the mental health group, what
distinguished the self-harming residents from the psychiatri-
cally referred (nonself-harming) residents was not their level
of distress but their behavior. The self-harming residents
evidenced the most behavioral difficulties (Table 2). In other

J . Am. Acad. ChildAdolesc.Psychiatry, 30:2,March1991 205

CHOWANEC ET AL. zyxwvutsrqponm
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words, the self-harming boys can be viewed as manifesting
both internalizing symptoms (“problems with self‘’) and
externalizing symptoms (“conflicts with the environment”)
(Achenbach, 1982); they were distressed and their behaviors
distressed others. Assaultiveness and self-harming behav-
iors in the same individuals have infrequently been docu-
mented in the adult literature (Hagen, 1972; Bach-Y-Rita,
1974) and not in the adolescent literature. The practice of
categorizing adolescent psychopathology as either internal-
izing or externalizing (Achenbach and Edelbrock, 1983)
does not capture these youth. They defy such categorization.
The study of the overlap of internalizing and externalizing
disorders is just developing and appears warranted.
Third, the all male population of this study seemed even
more impulse ridden than the treatment adolescent (Walsh
and Rosen, 1988) and correction (Ross and McKay, 1979)
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populations described earlier. Those groups, almost entirely
female, demonstrated some impulsive behaviors primarily
in the area of substance abuse. Comparisons across studies
are difficult, yet it seems likely that the assaultiveness and
physical destructiveness of these male residents is a function
of their sex.
Clinical Conceptualization
The self-harming adolescents entered the YDC with his-
tories of noncompliance and poor problem-solving skills.
The challenge of this environment overwhelmed their in-
adequate coping capabilities. The accompanying dysphoric
state was intolerable. For this population, self-harm can be
conceptualized as as attempt at adaptation by psychobio-
logically vulnerable youth to a stressful situation. The au-
thors’ clinical experiences as consultants, reviewing many
of these cases, indicated that self-harm was used to mollify
intolerable affects (an intrapsychic adaptation) and to mo-
bilize the interpersonal field (an interactive adaptation). Or,
as described by Walsh and Rosen (1988), the event “dis-
charged tension” and attracted “solicitous attention. Thus,
” a number of self-harming individuals. The actual observa-
the self-harm event appeared to have internalizing and ex-
ternalizing aspects. This was consistent with the overall
psychopathology of the self-harming adolescents demon-
strating internalizing and externalizing features.
The experience at the time of the event typically was one
of intense, undifferentiated affect. This is consistent with
abundant literature regarding adult patients’ experience of
mounting tension and distress before the event (Bach-Y-
Rita, 1974; Kahan and Pattison, 1984; Ennis et al., 1989).
A rage-inducing, limit-setting incident often triggered self-
harming behavior. The meaning of limit setting to a non-
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compliant youth who feels trapped in an environment he
cannot control requires further study, although some rea-
sonable clinical inferences seem clear. For the adolescents
of this study, the self-harming behavior seemed to be “a
complex defensive maneuver abnormally employed to re-
lieve profoundly disturbing impulses, feelings, and thoughts”
(Casper et al., 1980). An intense, affective experience seems
to be at the core of the association between self-harm and
depersonalization (Pao, 1969) and self-harm and borderline
personality disorder (Leibenluft et al., 1987). It appears
likely that adolescent self-harm is one of several complex
206
behavior patterns that serve to defend against intolerable
affects.
Acute interpersonal difficulties are often at the core of
adult self-harm incidents (Bancroft et al., 1977), and chronic
family difficulties have been described in adolescents who
exhibit self-harming behavior (Miller et al., 1982). The
lability of behavior and containment challenge these youth
posed were evidence of problems in interactional adaptation
even when a self-harming gesture was not utilized. These
youth demanded an engagement with their environment.
Therapeutic Applications
This study is epidemiological in orientation. However,
the findings, when integrated with the authors’ experience
as consultants, suggest a therapeutic direction. Therapeutic
efforts with youths such as these must recognize that those
who exhibit self-harming behavior, at least in correctional
settings, are significantly disordered. While not lethal, this
is not an inconsequential symptom. Interestingly, many of
the youths define themselves, after the act, as suicidal if
the institution defines it as such. This lack of self-knowledge
is a core feature of their maladaption. It suggests a thera-
peutic approach that first identifies the behavior as not su-
icidal but rather is a way to solve problems. The resident
is then offered skills to deal with similar triggering events
in the future. Once the resident has improved his behavioral
repertoire through this educational approach, he is free to
identify the source of the disturbing affects and see the self-
harming behavior as an attempt at intrapsychic and inter-
actional adaptation. This self-development can then serve
as the basis for dealing with similar situations.
Future Directions
This study has the advantage of examining a large sample
of adolescent males in a population that, based on other
adult and adolescent studies, would be expected to include
tion of this behavior and these events-not self-report or
retrospective recount-ontributes to the objectivity of its
findings. However, the study carries with it the limitations
of employing only the data routinely gathered by the insti-
tution. Thus, no precise statements can be made about psy-
chiatric diagnoses or levels of symptoms, such as depres-
sion. In addition, though the Bipolar Psychological Inventory
has been reported to have reasonable psychometric qualities
(Roe, 1975; Konopasky, 1985), it may not have been sen-
sitive enough to differentiate levels of pathology within this
population. Finally, the clinical impressions of the self-
harming events were not buttressed by systematic investi-
gation of the residents’ phenomenology at the time of the
event.
In future research, the known neuropsychiatric vulnera-
bilities of these youths (Lewis et al., 1979) also should be
assessed and the findings incorporated into a more complete
biopsychosocial formulation. An assessment of nascent per-
sonality disorders appears to be indicated, assessing such
areas as cognitive distortion and unmet need states. Such
measurements would aid further differentiations of self-
harmers and nonself-harmers as well as being potentially
J . Am.Acad. Child Adolesc. Psychiatry, 30:2, March 1991
useful in developing a typology of self-harm. The associ-
ation of depression with self-harm, while present, was not
as striking as reported by others in psychiatric settings, adult
and adolescent (Clarkin et al., 1984; Robbins and Alessi,
1985). It appears that studying adolescent self-harmers of
both sexes in different settings and comparing the findings
would be a helpful next step in understanding the phenom-
enon.
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