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Interviewer: You've noticed some signs that your child is engaging in self-harm which can be scary and confusing as a parent. So what do you do?

Dr. Thomas Conover is a psychiatrist board-certified in both child and adolescent psychiatry and general pediatrics at Huntsman Mental Health Institute.

Find out how to identify if your child is engaging in self-harm, how you should respond, and resources for help and treatment. What is Self-harm?

Dr. Conover: Self-harm is any deliberate attempt or act to injure oneself. So the term is pretty straightforward, but self-harm includes, from a psychiatrist's standpoint, both non-suicidal self-injury, which is any self-harm that's inflicted without any intent to die and also suicide attempts. Suicide attempts are a form of self-harm, and the difference between the two as we define them is whether the person who's inflicting injury on themselves means to die by doing it.

Interviewer: When I hear self-harm, I tend to think of cutting. Is that the only type of self-harm, or are there other types?

Dr. Conover: Making cuts and scratches on oneself is the most common type of self-harm. We sometimes see teens do other forms such as burning themselves deliberately or hitting themselves, striking themselves with a fist, or headbanging. Those are other forms that are fairly frequently seen. There are numerous other less common acts, but cutting or scratching on oneself is definitely the one that we see most frequently in emergency rooms or psychiatric specialty care. Why do Teens Engage in Self-harm

Interviewer: What leads to that type of behavior?

Dr. Conover: We don't know the exact reasons why any individual might engage in self-harm. You know, for each teen, it may be different. Some of the reasons may be a distraction or relief from some other thought or emotion.

Sometimes it may be kind of the cliché or proverbial cry for help, you know, trying to express some emotion or demonstrate distress that is too difficult for the teen to articulate in words. Those are two of the most common reasons teens engage in self-harm behavior. How Do Parents Discover Their Children Are Engaging in Self-harm?

Interviewer: Have you experienced the teen talking about self-harm before engaging in it with any of your patients? You said that self-harm is a form of communication and could indicate to a parent that I want to have a conversation about something with you, I don't know how to do it, so I'm doing it this way. But could it happen in terms of words before behaviors?

Dr. Conover: It certainly can. It may often be expressed to someone other than the parent, a friend or acquaintance, somebody that the teen is communicating with over texts or social media. And that's often a way that parents discover that their teen is either thinking about or engaging in that behavior.

One warning sign and one piece of good advice for any parent of a teen is to monitor the teen's social media use and texts with some frequency because sometimes that's who they may try to talk about.

Now, if a teen is coming to a parent or other trusted adult and expressing thoughts that they may harm themself, I would say, while that's a concerning situation, it's certainly a situation where at least the teen feels trusting enough and supported enough to bring that up verbally before doing it or even after doing it. And in some sense, in that situation, the teen and their caregiver are a step ahead of where they might be if the self-harm thoughts or behavior are completely concealed. Recognizing Self-Harm

Interviewer: Is it generally pretty easy in your experience for parents to recognize if their teen is engaging in self-harm?

Dr. Conover: I don't think it is, but I think the barriers to recognizing it are complex. One of the main barriers is that no parent wants to think that their child is experiencing distress that would lead them to deliberately harm themselves or attempt suicide. And so a certain degree of conscious or unconscious denial is a huge barrier to recognition. So I think to anybody who is listening to a podcast like this, to anybody who wants to know more about teens' mental health, I think having awareness is a way to bring that barrier down. As much as a parent doesn't want to think that their child might be experiencing that distress, some awareness and a level of openness to the possibility brings that barrier down.

Supervision and support is another thing that brings that barrier down. When a parent pays attention to their teenage child, when a parent knows what they are doing, who they're hanging out with, who they're communicating with, when a parent inquires actively and openly with their teen in a way that lets the teen know that they're caring and concerned, those are also things that bring down the barrier and make it more likely that the teen might talk to the parent about such behaviors. How to Talk to Teens About Self-harm Concerns

Interviewer: I would imagine if somebody is listening to our conversation right now and they found it via an internet search, they probably should trust their instincts. Would you say that's a safe thing to say?

Dr. Conover: If the parent has suspicion or concern, they should not dismiss that. The most direct first step is to initiate a conversation. Initiating a conversation about self-harm needn't be accusatory. It shouldn't be because that's a sure-fire way to have a teen shut down in conversation for a parent to approach them and say, "Are you cutting yourself? You should never do that," implies a judgment or seems like you're interrogating.

A better opening line might move from the general to the specific: "You know, some teens might even think about hurting themselves or even hurting themselves on purpose when they're feeling upset or distressed. Have you ever thought of doing something like that?" You know you can hear the difference when you're saying, "Hey, this is not something that you alone might have thought of or done. This is not something that I'm expressing any judgment about. I'm just saying it's something that people might do, And I'm wondering if that's something you've ever thought about."

Asking about thoughts is a little bit of a softer entry too. Because the teen doesn't necessarily have to confess, "Oh, yeah, I did cut myself once." Maybe they're not ready to say that, but they might be ready to say, "Well, yeah, you know, I've known some people who have done that, or I've heard that people do that, or I've even thought about it myself." And then the conversation can proceed from there. It doesn't have to be accusatory or judgmental, and it shouldn't be, but is it going to be a difficult and crucial conversation? Absolutely. There's no way to make that kind of an inquiry easy.

Interviewer: You bring that up with your teen, you ask them if they've ever thought about it, but there are obvious signs that something, you know, is going on. Is that the point that you say, "Well, I couldn't help but notice that on your arm there are scratches or on your legs, there's bruises?"

Dr. Conover: Yeah. Being gentle in inquiry is important, but we don't have to take it to the point of absurdity, right. You know, if what the parent is concerned about is something concrete like, "I found a text where you said to your friend that you were thinking of hurting yourself, or when we were at the beach last Saturday, and you were wearing your shorts, I noticed that you had some cuts on your leg." I think that it's fair for a parent to start with the concrete thing that the parent observed. That's reasonable. Again, not being accusatory or judgmental, right? Not, "What on earth are those that I saw on your leg during our trip to the beach?"

Interviewer: Yeah. "What are you doing to yourself?"

Dr. Conover: "Who does something like that?" Exactly, right? But just saying, "I noticed this, or I found this, or when I was looking at your texts from last week, I saw something that concerned me." I think that mustering some calm and then inquiring with the child is perfectly appropriate. And I think that does point to signs that a parent may look for. You know, it is my experience that most often it isn't the case that the teen will come to a parent and simply say, "I'm thinking about this, or I'm engaged in this behavior." It would be nice if they did. It's a good sign about the parent and child's communication if a child can openly state that.

However, I often see parents discovering signs that this might be happening. Signs that one might look for include finding items that someone might use to harm themselves in a place where you wouldn't expect to find that thing, like a kitchen knife in a bedroom, or old-fashioned razor blades, you know, that you might use to peel paint or do things like that hidden somewhere in a child's room, pieces of glass or metal. Certainly, if any of those items look like they've been used because they have, you know, blood or something that looks like that on them.

So finding items that a youth might use to harm themselves, that's one very common sign that parents might first come upon. A very common way is through monitoring social media or texts. I think it's very important to note that monitoring social media and texts should be given and what I advise parents to do before they let kids use those technologies is to set down a very clear contract and expectation that they will be monitoring their activity because that's necessary and it also avoids the conflict that would arise if a parent was monitoring those things without having set that expectation. When Should a Parent Seek the Help of a Professional About Self-harm Concerns

Interviewer: When a parent recognizes these signs, and they have addressed them with their teen, and they've started out the way that you've recommended, being very non-accusatory, talking about the physical things that you're seeing as opposed to passing judgment and you get that conversation going, you had mentioned that sometimes self-harm is a way of communicating that there's something else going on. I love keeping that in mind. I think as you're having this conversation is ultimately the point then to get to what the actual problem is that's causing the symptom of self-harm or is that the time you would want to involve a professional, or where would you go from that point?

Dr. Conover: An older view in mental health was that deliberate self-harm or suicidal thoughts or acts were always secondary to some other problem or a symptom of another disorder, and that you would need to treat the disorder in order to treat the self-harm behavior or the suicidality. To an extent, that is true, but a more current and up-to-date view is that while self-harm and suicidal acts can be associated with another problem like depression, or trauma, or abuse being two of the most common, they do constitute a problem in and of themselves. I don't think that a parent is best served to then become the behavioral health provider or a detective, right? You know, to say, "I'm going to get to the bottom of this. I'm going to get to the bottom of this and find out what's ailing you and what's causing this problem you're having." That's not something a parent wants to pursue on their own.

I think the first step of asking your child, "Hey, what's going on? I noticed this, or I noticed that. I'm concerned about you." That is definitely the parent's job. The parent's next job is then to help their teen by seeking some additional help and support. Self-harm thoughts, self-harm behavior, those are always a concern and virtually always merit some further support, whether that be through seeking some crisis services, or counseling, seeking some outpatient therapy, getting some additional support from a medical provider like a primary care doctor or other practitioner who maybe already knows the family and the child as a first step are what I would advise if that first conversation happens, really, no matter how that conversation goes, because a parent can do the right thing and ask the question, but the teen may still respond with denial. And I don't think that I would be giving good advice if I said, "Okay, ask these questions and ask them in a non-judgmental way." And you think they might be hurting themselves and you ask, and they say, "No, mom, I'm not doing that." You can't really close the book on the conversation with just that negative reply if you've seen signs or have a strong suspicion.

Interviewer: So the purpose of this conversation is to really have a mutual acknowledgment that this thing is happening. That's the place that a parent wants to get to with their child, expressing concern them so then that they can have a conversation about what we're going to do about it, which is ultimately going to lead to going to a professional to assist at that point.

Dr. Conover: That would be the way that I would advise that things would go. Not all teens who deliberately harm themselves make suicide attempts, but there is a strong correlation between the two. So engaging in self-harm without an intent to die is a strong risk factor and has a strong correlation with eventually making a suicide attempt. And so taking it very seriously when there are signs of such behavior or when there is an admission or confirmation of such behavior is really important because ultimately, you know, we're not concerned about the long-term health implications of having a few cuts or scars on your arm or your leg. What we're concerned about is bigger issues of health and wellbeing and ultimately safety and preventing any very serious injury or death. Resources for Parents Concerned about Self-Harm

Interviewer: Do you have resources that could go beyond this conversation that could help a parent that finds themselves in the situation where they have to have this conversation?

Dr. Conover: Resources that a parent might reach out to would include primary care providers. I think that primary care providers are a great first resource for families for a number of reasons. Primary care providers such as a pediatrician or a family practitioner generally have an ongoing relationship with the teen and the family. And so any discussion or decisions that are made will have a lot of context, and that there's a higher likelihood that the teen and family will feel trusting and agreeable to any advice or interventions that a primary care provider can give. Also, unfortunately, we don't have enough mental health providers as far as specialty mental health providers like psychiatric providers and therapists, and so it may be easier and more accessible to start with primary care. At any point where self-harm thoughts or behavior, including suicidal thoughts or suicide attempts are a concern, a parent can always access the crisis services that are available.

Here locally in Salt Lake City and in the entire state of Utah, the Utah crisis line is one such resource and the Huntsman Mental Health Institute crisis line, which are actually staffed by the same, very skilled, highly-trained crisis-intervening staff.

A parent might question, "Oh, is this big enough of a problem for me to call the crisis line?" As a practitioner, I would always give the advice, don't second guess yourself on whether you think this is a crisis. You are not going to call the Utah crisis line with a question about your child's self-harm or potential suicidal behavior and be told, "Hey, this isn't a problem. Why did you call us?"

updated: March 1, 2022
originally published: July 9, 2021

Interviewer: You've noticed a change in your teenager's mood. They're angry, moody, defiant, irritable, and in addition, their school performance or maybe interest in other activity is significantly decreased. You're worried about depression. Is it okay to talk to them about it, or could it cause more harm than good?

Dr. Thomas Conover is a psychologist at University of Utah Health, and what is your advice for parents about how to talk to their teens about these tough topics? Or should they even talk to them about them?

Dr. Conover: Communication is a real key. It certainly is protective and helpful for parents to communicate and inquire with their teen as to what's going on and how they're feeling. And that's something that I think most parents strive for but may struggle with. How do I talk to my teen? What do I talk to my teen about? Is it okay to ask? I would advance to say that it's always okay to ask your child about how they're doing. You seem really sad lately. Is there something bothering you? Is there any way I can help?

Interviewer: No. I mean you probably have to dig a little bit sometimes, huh?

Dr. Conover: You may. I think that there's value in setting an example and leaving the door open by saying those two things. In terms of setting an example, certainly communicating openly oneself is important. Right? So I've talked about various areas of function that a parent might look at for a teen child and use to try to evaluate how serious a problem that they're suspecting maybe. But a parent can show that those things are important themself. Right? A parent can demonstrate that being engage with social activity and self-care and physical activity, you know, which boosts mood, all of those things are important. So a parent may set the stage in their own family by doing those things.

It's always okay to ask your child about how you're they're doing. And even though a lot of times teens may seem outwardly like they don't want someone to ask, I think most of the time people who are struggling even in a small way do want someone to ask. I think it's helpful not to badger. I think if you're met with that initial no on a first inquiry, it's good for a parent to perhaps say, "Well, okay. You know, I hear that you're saying that there's nothing about it that you want to talk about. But just know that I'd be happy to talk to you if you do . . . if you change your mind about that, if you do want to talk about."

I think that's a tough one. It's a tough balance to strike, because I think if a parent is a concerned at all about their child and they try to make that initial ask, first off that's a hard thing to do. You know, you might be thinking about it all day or all week and then, finally on Friday you say, "Oh, we're sitting at dinner and my kid's actually home with me. I'm going to ask." And then, the first thing that they snap back with this, "No. Everything's fine." And the parent might feel kind of rejected by that and, you know, they might respond by shutting down. Right? Going like, "Oh, well, okay. I guess I shouldn't have asked."

I wouldn't advocate for that black and white of a response, nor would I advocate for a parent then saying, "Well, no, I know something must be wrong. I've been watching you all this time, and you just aren't acting yourself. You need to talk to me right now." You know, in most cases, that's not going to be the best approach either. It's, I think, always appropriate to ask and it's always appropriate to maybe give a little space and a little time for the teen to be able to absorb the question and respond. Now, that would be with the exception of a true emergency, and those emergencies do include threats or acts of self-harm or threats or acts of a suicidal nature or serious aggression.

Interviewer: Are you concerned that your teen might be suffering from depression? Now, sometimes it can be difficult to tell the difference between moodiness and actual depression, and that moodiness can be common in a lot of teens.

But psychologist Dr. Thomas Conover says you should look at how your children are doing in what he refers to as key life areas. That's school, extracurricular activities, social, and family life.

Dr. Conover, let's just start with school. Why is school performance one of the clues that you use when evaluating children for depression?

Dr. Conover: For teens, school is their primary area of function. It's, in my mind, equivalent to holding down a job or a career for an adult, right? And so if an adult is still functioning in their primary vocation, then that's a good sign. Same way for a teenager. If he or she is still doing well in school and not seeing a decrement there, then whatever is going on with the teen, you've got some reassurance that things haven't gone completely south.

Interviewer: What about extracurricular activities? Some kids just aren't into school, or don't necessarily perform well in school.

Dr. Conover: Well, I look for their performance in school with comparison to earlier performance too. So if you have a kid who was somewhat of an indifferent student and just wasn't that academically inclined throughout their school life, kind of a solid B/C student, then that's what I would be looking for the child to be doing going forward. So I'm not concerned if there's sort of indifferent performance when that's been the norm.

It's really looking at, "Has that gone downhill?" Do you have a child who normally got straight As and is now getting Bs and Cs, or a child who normally gets Bs and Cs who is now failing or having incompletes? That would be more concerning in terms of school performance.

And for those youths . . . let's say you have a child who's an average student and maintaining that performance, but who is an avid athlete, plays a sport year-round, and is withdrawing from that. That could be a concern as well. So looking at function in the academic realm is important, but there are other areas of function too, right?

So other activities are very important to look at. Social function. A normally developing or typically developing teen is a very social creature. It's a time of life where you're learning how to be independent, and you're transitioning in typical development from being reliant on your family as a primary source of your activities and values to your peer group, which in my mind and experience serves as somewhat of a transition to being fully independent. Having your own ideas about things, your own values, your own priorities for your activities.

So, in that vein, your typically developing 15-year-old is going to really want to be out there and socializing with peers. A lot of times, nowadays, that does take place over cellphones, social media, and the like. And so it's important to take that into account, that just because a teen isn't going out all the time doesn't mean that they're not socially engaged.

But a parent can reasonably expect that their teen is going to be interested in what's going on out there with their peers. And if they're more withdrawn or less interested in that than they used to be, that's a concern.

Then there's also family function, and it is normal and expectable to have a teen be less interested or less enthusiastic about certain family activities than he or she used to be. That is normal and expectable.

Then I would go back to the idea of, "Well, just how pervasive and intense is it?" Do you have a teen who says, "I don't want to go to family dinner at grandma's this Sunday. My friends are going out. I want to meet up with them," but who ultimately you can cajole and negotiate and get the teen to do it? Or do you have a teen who has a big blowup over that and ends up leaving the house and you don't know where they went? I'm giving fairly stark examples, but the gray area in between can be evaluated.

I haven't mentioned the threat of self-harm, or aggression, or worse, suicide. That would be an obvious red flag. If inquiry into a teen's mood or a parent making a request or demand of the teen leads to any sort of threats or acts of self-harm or aggression, then that's something that a parent would want to seek help for urgently.

Interviewer: Moody teenager or depression? When is the time to seek help? That's what we're going to find out today.

Dr. Thomas Conover is a board-certified child and adolescent psychiatrist. He is also board-certified in general pediatrics, and he has taken care of teens with and without depression for over 20 years.

Dr. Conover, when a parent comes to you or walks up to you or sees you at a party or something like that, and they say, "Dr. Conover, I've got a question for you. I've got a teenager. I'm a little bit concerned," what kinds of words do they start to use to describe their concern with their teenager?

Dr. Conover: You'll often hear about moodiness or irritability, being more isolative than usual, simply not wanting to do things with the family the way that they used to. Those are some of the most frequent keywords that parents who are concerned about their child's behavior or mood as a teenager will say to me.

Interviewer: And when you hear those words . . . certainly, when I hear those words, I think, "Well, that's a teenager." Right? So is it a little difficult to determine when to be concerned and when not to be concerned?

Dr. Conover: It sure is. Even as a practicing psychiatrist all these years, if I hear a parent say that their teen is moody or irritable, I don't immediately jump to the assumption that he or she is depressed.

Interviewer: So then you would, I would imagine, start asking some questions, trying to get a little bit more information. What are some of those questions that you would start to ask to start to make the decision whether or not there was something to be concerned about?

Dr. Conover: One question is, "How long has it been going on?" That's a common question in medical inquiry in general. Another is severity. Just how bad of moodiness or irritability are we talking about here? I always think too about how is the youth functioning. That's a really important thing.

So particularly, in a casual setting, if a parent just asks me a question about their teenager, a lot of times I'll ask, "How are they doing in terms of their other life pursuits?" So if a youth seems to be more moody and irritable but he or she is still doing all the things that they would normally do, still functioning in school, still recreating with friends, still engaged in other activities, but just kind of crabby, I'm a lot less concerned.

Not unconcerned, because there are some youth or adults too who are suffering but still managing to eke out their function because it's that important to them to do well in school, or with their sports, or whatever else they do. But I am often reassured if a teen is still doing the things that he or she normally would do despite the apparent problem with mood.

Interviewer: At what point does a parent say, "You know what? We should go talk to somebody"? When does it become something that a parent can help? Because it would occur to me that any of these little symptoms would be something you might want to talk about anyway. If the grades are starting to fall, you might want to approach that topic. If they're defiant a lot more, you might want to say, "I've noticed a change in . . ." Or maybe you don't want to say it like that. Help me out.

Dr. Conover: It's always okay to ask your child about how they're doing. And even though a lot of times teens may seem outwardly like they don't want someone to ask, most of the time people who are struggling, even in a small way, do want someone to ask.

I think it's helpful not to badger. I think if you're met with that initial "no" on a first inquiry, it's good for a parent to say, "Well, okay. I hear that you're saying that there's nothing about it that you want to talk about. But just know that I'd be happy to talk to you if you change your mind about that, if you do want to talk about it."

It's, I think, always appropriate to ask, and it's always appropriate to maybe give a little space and a little time for the teen to be able to absorb the question and respond.

Now, that would be with the exception of a true emergency, and those emergencies do include threats or acts of self-harm, or threats or acts of a suicidal nature, or serious aggression.

Interviewer: So we have a pretty good idea of some of the different behaviors we might see that might indicate that a teen is depressed or heading towards depression. We've learned that the first step really is to try to talk about it and be genuinely concerned and not force, not corner. If you get met with some rejection, give the teen some space. At what point then does a parent seek professional help if they're just so frustrated, they are convinced something is up, and they just don't know what to do?

Dr. Conover: The primary care provider is equipped with enough training and understanding about childhood and teen depression to help to evaluate that and may then refer on to other resources.

Interviewer: I feel my approach would be I'd want to find out even more information. Maybe I might want to go to a professional on my own before I take the step of involving the teen in the process, because I'd be afraid that maybe doing that would somehow damage our relationship or cause problems. What's your take on that?

Dr. Conover: My take on that is twofold. On one hand, I think it's perfectly reasonable for a parent to seek education or support from other resources themselves. An initial inquiry in that fashion might mean that the parent would do some reading. They might get online and go to a reputable source such as the websites for the American Academy of Pediatrics or the American Academy of Child and Adolescent Psychiatry, both of which have really good information about child and teen development and kind of the presentation of various problems and resources for how to respond.

It might take the form of talking to a family member, a friend, a clergyperson, or the parent's own physician. All of those could be things that a parent could do.

On the other hand, I do think people may make the mistake of not asking, not saying something, not doing something for fear that it might damage the relationship. And it has very rarely been the case in my experience, even if asking or stating that observation leads to a fight or argument in the short term.

Interviewer: As that parent that asked you initially if they should be concerned about their teenager walks away, what would be the last thing that you would say to them?

Dr. Conover: "Let me know if there's more help that I could give." You can go off in one direction, make a decision to act, and maybe that initial effort comes up not as fruitful as you had hoped. So I would hope that people would feel open to asking for help again or talking more about it.

But it can be an uncomfortable topic. My experience both as a clinician and as a parent myself is that parents want their kids to be happy. They want them to feel okay. And it can be very, very troubling, very sad to contemplate that their child may not feel okay, that they might not be all right. And so it's really hard to ask and really hard to bring up, because you don't want it to be so.