One of the more frightening child and adolescent issues is suicide. Suicide is a tragic event and is the third leading cause of death among adolescents (Somers-Flanagan & Somers-Flanagan, 2007, p. 155). Assessing suicidal children and adolescents as well as those who self-mutilate can be very difficult for many clinicians, and it takes skill to assess these issues accurately. Clinicians must be able to differentiate between suicidality and self-mutilation in order to assess the problem and develop interventions effectively.
In most cases, suicide and self-mutilation (self-harm) assessments are conducted using clinical interviews. The most foundational principle in evaluating for self-harm is for the clinician to establish a positive working relationship with the child or adolescent. A valid assessment flows from a good working relationship because trust is established and communication is open. A good relationship does not negate the need to assess clinically the severity of the issue; therefore, clinicians must be skilled in assessing for self-harm.
For this Assignment, review the media program Mood Disorders and Self-Harm,and consider the differences between suicidality and self-mutilation. Also, consider why it is critical to assess these two conditions accurately. Also, review Suicide Assessment Procedures, Documentation, and Risk Factors (Sommers-Flanagan & Sommers-Flanagan, 2007, p. 179–180) and Child and Adolescent Suicide Risk Factors and Warning Signs located in this week’s resources. Think about the importance of the suicide assessment to determine suicide risk in conjunction with common risk factors and warning signs.
The Assignment (2–3 pages):
Support your Assignment with specific references to all resources used in its preparation. You are asked to provide a reference list for all resources, including those in the week’s resources for this course.
Bosmans, G., Poiana, N., Van Leeuwen, K., Dujardin, A., De Winter, S., Finet, C., … & Van de Walle, M. (2016). Attachment and depressive symptoms in middle childhood: The moderating role of skin conductance level variability. Journal of Social and Personal Relationships, 33(8), 1135-1148.
As you review this article, focus on how a community takes action to prevent adolescent suicide.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2007). Tough kids, cool counseling: User-friendly approaches with challenging youth (2nd ed.). Alexandria, VA: American Counseling Association.
Tough Kids, Cool Counseling: User-friendly Approaches with Challenging Youth, 2nd Edition by Sommers-Flanagan, J.; Sommers-Flanagan, R. Copyright 2007 by American Counseling Association. Reprinted by permission of American Counseling Association via the Copyright Clearance Center.
Checklist of General Suicide Assessment Procedures Table 8.1 (p. 179) (PDF)These documents will guide you as you think about suicide assessment to determine suicide risk in conjunction with common risk factors and warning signs.
As you review this article, focus on the relationship among attachment, mood, and self-harm and how this might inform your professional practice.
Van de Walle, M., Bijttebier, P., Braet, C., & Bosmans, G. (2016). Attachment anxiety and depressive symptoms in middle childhood: The role of repetitive thinking about negative affect and about mother. Journal of Psychopathology and Behavioral Assessment, 38(4), 615-630.
Document: Child and Adolescent Suicide Risk Factors and Warning Signs (Word document)
This document guides you through a checklist of warning signs and risk factors for children and adolescents that are at risk. Focus on how you might use this document to assist you in your assessments.
Laureate Education (Producer). (2014b). Child and adolescent counseling: Mood disorders and self-harm [Video file]. Baltimore, MD: Author.
Note: The approximate length of this media piece is 21 minutes.
In this media program, Drs. John Sommers-Flanagan and Eliana Gil discuss their experiences when working with children and adolescents who demonstrate mood disorders and self-harm.
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Mood Disorders and Self-Harm Program Transcript [MUSIC PLAYING] NARRATOR: Counselors who work with children and adolescent clients must be prepared to respond to situations involving suicide, cutting, and self-harm. Doctors John Sommers-Flanagan and Eliana Gil talk about what they have experienced in working with children and adolescent clients who are experiencing symptoms of mood disorders and acts of self-harm. JOHN SOMMERS-FLANAGAN: Eliana, there are many different reasons why children and adolescents come for counseling, are referred for counseling, and occasionally even want to come themselves. And one of the prominent reasons has to do with mood, or affect, and their ability to manage those human experiences. And so I’m wondering some of your thoughts about this recent development, where many children and adolescents both seem to be engaging in some self-harm or self-mutilation behaviors. And I guess, to start with, what do you see as some of the differences between how children might exhibit some self-harm and how adolescents might exhibit self-harm? ELIANA GIL: Well I think that this issue about self-mutilation is very complicated and very individualized. And so it’s really important to do a very, very unique assessment with each child. Because I think we come into it, sometimes, with assumptions. So there’s lots of different possibilities. I think that some of the kids that I’ve worked with—the older kids in particular—are in a lot of pain. They have a lot of stressors. I think that they’re often involved in social relationships with others where they share this kind of information. And the thing, I guess, that really concerns me the most is that I think that kids start talking about selfmutilation to each other. And suddenly this begins to be part of their culture. That this is something that’s acceptable; it becomes almost normalized among the teenagers that I work with. And so it’s been interesting to explore, because sometimes I used to think that the best thing to do was to put kids in groups that had this particular issue. And what we found was, that as kids start, sort of describing the kinds of practices that they’re using, that lo and behold the kids come back the following week and they have the same kinds of scarring or injuries or whatever it is that they heard about the week prior. So I’ve kind of moved a little bit out of that group model because of that, because I do think there’s kind of a contamination thing that can occur. And I think that looking at the kids very much in individual therapy and maybe family therapy, some of the reasons, I think, that kids do it may have to do with their own discomfort with their affective state. So let’s say that they feel, for example, really angry, but they don’t have the mechanism to express that. And © 2016 Laureate Education, Inc. 1 Mood Disorders and Self-Harm so sometimes what they do is they will cut. And then somehow after they cut, they feel that they have somehow expressed something or discharged something. And they feel better. So one of the things I’ve tried to track is what you were doing and thinking and feeling right before, during, and right after. And then you begin to get some patterns that show that kids will feel sad, they’ll feel despair, they’ll feel worried, they’ll feel angry, and the cutting seems to serve the purpose of somehow discharging the affect, making them feel better, more relaxed, relieved, somehow not as tied up in knots. And then suddenly, because that is effective for them, then they continue to do it. When we do histories, either with teenagers or with adults, and we say to them, “So when’s the first time you remember hurting yourself or experiencing pain or thinking about pain as something that might shift some kind of emotion for you?” They’ll say things like, when I was four or six or seven. And so it’s been interesting to kind of keep that in the back of my mind when I work with little kids. Because sometimes with the little kids, we have what appears to be accidental injuries. Or they come in and they just have a ton of bruising on their legs, and kind of differentiating, there are very energetic kids. And these energetic kids can have little accidents and get all these kinds of marks on their bodies. But there are other kids where it’s almost—well it isn’t almost—it’s not an accidental kind of situation that’s occurring there. Literally, prone towards these accidents and are having a kind of different experience with pain and whatever happens after the pain occurs. One of the other things that we find with self-cutting is that often there’s a secondary gain. So we have children and adolescents who are really needing the attention of others—whether it’s peers or whether it’s their family system. But when I’m tracking what happens immediately afterwards, one of the things that comes into play is that they’ll go and talk to their parents or they’ll call their friends up. So I say, “Well describe what happens then.” Well then they sit down and talk with me, or then they really pay a lot of attention to me. Or then I get to really talk to them about something that’s important. And it’s almost like these things become a vehicle to get something else. And that’s really how I think about self-cutting, that it’s some kind of conduit to some outcome that they’re really looking for and needing. And we have to figure out what that might be. JOHN SOMMERS-FLANAGAN: I hear you saying that first, individualize, and that each child or adolescent might have unique reasons for doing the cutting. I also hear you saying, watch out for contagion. And sometimes if you work in groups with these children, adolescents, you might actually see them taking on some behaviors that are destructive, that other people have modeled for them. ELIANA GIL: Exactly. © 2016 Laureate Education, Inc. 2 Mood Disorders and Self-Harm JOHN SOMMERS-FLANAGAN: And then I also—and it’s kind of an interesting issue—but I hear the issue of attention. And that maybe some of the behavior might be attention seeking. And combined with that, that some of it is maybe helping them regulate affect. ELIANA GIL: Exactly. JOHN SOMMERS-FLANAGAN: And I know in my experience, and I’m interested in your comments on this, I’ve seen some young people—teenagers in particular—who are very private about their cutting. And it has seemed to me that they are more inclined to be doing it for the affect regulation, whereas others seem to like a little more attention, or public display. ELIANA GIL: Sometimes my association is, red badge of courage, you know? JOHN SOMMERS-FLANAGAN: Almost as a display. ELIANA GIL: As a display. And then the kids who are doing it very privately—and I think I started out by saying that I think there’s a lot of pain involved with all of these kids in some way or another. And there may be some very unique factors involved. Like one of them that I encounter a lot—partly because I think I work mostly with kids who’ve had trauma in their life—is this aspect of depersonalizing. And the fact that sometimes the kids are in these kinds of existences where they don’t feel like they’re really present. And they are in an altered state of consciousness. And that may be their best defensive mechanism. And sometimes the cutting actually serves the purpose of bringing them back to reality, making them feel something that makes them feel present again. And so that’s a very private, personal use of cutting. So that’s why the assessment becomes so important because unless you know really what’s going on, it’s very hard to help with that. And I think that there’s lots of variables right now. I think kids are exposed to the Internet. There are actually websites on cutting, how to cut. I saw something recently about teens kind of sharing this experience of implanting objects into their bodies. And so this information is pretty available to them. And I think it creates almost a hyper-arousal, because there’s all this explicit information. And kids talk to each other. And they form groups. And they begin to feel kind of bonded to each other. So I think the Internet, for all its wonderful things that it provides to us, also has these areas that we need to stay aware of and help the kids with. So I think that’s one of them. And I think there’s popular movies that kind of throw the cutting in as normalized. And that’s just what people do and that type of thing. It’s the overstimulation, I think, from the media often that gets these kids kind of thinking in these particular directions. And then the © 2016 Laureate Education, Inc. 3 Mood Disorders and Self-Harm access to the social support system that kind of validates this as something that’s kind of cool. The other is bisexuality. That somehow, within the teen population, became kind of a cool thing to do. And it’s much more prevalent now as a—I don’t know if you even think of it as a right of passage, but as something that kids get more involved with than, for example my age group or other times when kids were a little bit—the experimentation was of a different nature. So I think that those are some of the things that come into play in terms of this problem, and how pervasive it seems to be at this point. JOHN SOMMERS-FLANAGAN: It seems like lots of exposure, overstimulation, and then there’s kind of a social movement where, for one reason or another, children and adolescents actually feel supported in doing some self-harm. ELIANA GIL: Exactly. JOHN SOMMERS-FLANAGAN: And then your comment about how sometimes functions to bring someone to reality out of their numbness, I think is a really interesting idea. And I’ve also heard some young people say just the opposite. That they’re feeling too much and it helps to calm them down.ELIANA GIL: Absolutely. JOHN SOMMERS-FLANAGAN: And so that individualized assessment and treatment that you started with, I think it’s a crucial thing for us to think about. ELIANA GIL: Yes. And I also think that putting our assumptions to a side. Because I’ve worked with clinicians or talked with clinicians that say, “Well they’re just trying to get attention. That’s not a big deal.” And so they’re dismissive of it because of something that could be a factor, which is a secondary gain. But the reality is that the kids are doing it for that reason. That’s important in and of itself. The other is that some people jump to the conclusion that it’s suicidal behavior and so they treat it as such. Where for some children, it’s actually life affirming for them or it’s a way, a vehicle, to regulate their emotions or just cope in general. So we need to know exactly what it is before we can start trying to really assist that person in a way that’s going to engage them and in a way that’s going to be effective for them. JOHN SOMMERS-FLANAGAN: And so you’ve jumped right into what I wanted to ask you next. And that is, what is the relationship between some self-mutilation, cutting, self harm and suicidal behavior because the two are clearly not the same? Some people who cut are clearly not focused on killing themselves. ELIANA GIL: Exactly. And I think that it’s a very interesting problem to assess. Because again, we are so worried when we encounter it. And some of the things that kids do to themselves, you know we’re sitting there going, “Oh my goodness, is there any way I can”—If it helped to say, “Just stop it,” we would do that. And then the kids would stop. But it doesn’t work that way. You have to actually really listen and be sure that they’re engaged in some way that you don’t push them in the wrong direction. Probably their families are already saying to them, “Stop that. That’s not OK. It’s inappropriate.” And we have to be careful about that because if we become another person who just simply says, stop it, that’s not going to work. So the assessment around cutting, for me, is really important in terms of what is the outcome and the value to that child of it? So that’s why I try to track those behaviors and figure out, are there patterns? And what do we see as the primary outcome? And then, if that’s something I can identify, I can help with it. When kids are suicidal, I think there’s much more a sense of despair and isolation. So these are not kids who are involved in social peer groups and getting validation from their friends about what they’re doing. They’re disconnected. They’re much more flat. The cutting sometimes, when kids describe it to you, almost has a hyper-arousal component to it. Where they’re kind of excited and they’re– I think on some level—thinking they’re exciting you. When kids are suicidal, there’s—from my point of view and the experience I’ve had—there’s much more of a subdued, flat, disconnected despair that you can really feel. And so when you start talking to kids, the pain is overriding and what they’re talking about is really not wanting to feel that pain anymore. And having arrived at the conclusion that the only possibility, the only thing that they can possibly do to get this pain to stop, is to actually take their own life. Now with those children, often they’ve thought about how to do it. They have access to how to do it. They’ve looked at the Internet about suicide and what works and what doesn’t and what’s the most effective thing to do. They have access that, when I was a kid we just didn’t have. There’s access to drugs from friends. They can get the things they need if they want to kill themselves. And there’s other kind of aspects that become interesting. Like kids who are hanging themselves. That’s another little subculture, where there’s an autoerotic piece to that that kids are experimenting with. And sometimes kids hear about that and then that becomes maybe a mechanism for them. And so now we’re in a—I think—a very precarious time because of that. But I see a qualitative difference in the kids where the cutting is serving some other purpose and the kids who are really suicidal. Not to say that I haven’t worked with—I’ve worked with a couple of kids who started out by cutting and then the cuts got dangerously close to places in their bodies, where there would be a large disbursement of blood. And they started flirting with the idea of really doing more damage to themselves. And so sometimes it can be on a continuum, where kids can shift. If other things don’t come into play, like they start getting some relief or learning other ways to regulate their affect or getting the attention or the nurturing or whatever it is that they need out there from the environment. JOHN SOMMERS-FLANAGAN: I think the research absolutely supports what you’re saying in that, for many of the kids who are cutting, it’s just an affect regulation, numbness or affect-related activity. But for some others, they progressively move toward more dangerous and more dangerous activities. Probably related, to some extent, to the level of despair and depression. But one thing you said earlier that I think is really important for us to talk about briefly is the whole concept of it being an effort to deal with some psychological or emotional pain, and that they begin to see suicide as a viable alternative to this misery and pain that they’re feeling an experiencing inside. ELIANA GIL: It’s a very pervasive sense of helplessness. And I think that suicide becomes so attractive because kids think to themselves, the pain will stop. And actually I think, in terms of treatment, that’s one of the things that we can focus on, is that there are other ways to stop pain that are not permanent. And to have kids really, kind of walk through with you the permanency of some of the actions that they’re considering. Because I don’t think kids think about anything other than the here and now, the pain is intolerable, I’ve got to stop it. Little kids, when they’re talking about suicide, talk about things like going to sleep for a really long time or not waking up. They don’t necessarily have the methods or maybe can’t access that as well. But they start thinking about just going to heaven. I’ve had little kids who make pictures of how beautiful heaven would be. And this is a place where they don’t feel pain and where the stressors are not present. And again, having worked with a lot of trauma, and in particular interpersonal trauma, where someone’s hurting them, it’s almost like there’s nowhere else to escape. They really don’t have a way to stop what’s going on, to figure out how to share that with anyone. And so their despair just kind of grows. And their sense of isolation grows. And they stop reaching out to others. And it’s a really sad and unfortunate place to be. And the little kids often, again, can do things like begin to think about collecting pills or—you I read a study where sometimes kids were throwing themselves in front of traffic and things like this. So little kids may not be able to get all the methodology down, but they do things that are distressing, like drinking things they know to be bad for them or putting themselves in harm’s way. So with the little kids it’s a different kind of assessment, but still very worrisome to see that the pain can lead them to think that there’s just nothing else they can do. JOHN SOMMERS-FLANAGAN: Do you have particular warning signs or risk factors in children versus adolescents that you really look for in your practice? ELIANA GIL: Well I think that with the little kids, I like to use a lot more of the expressive therapies with them. I like to listen to their stories. So I may provide them with puppets and I may give them sand trays in which to make stories. But the idea is that often the stories that they tell are catastrophic. The stories that they tell are ones of hopelessness. There are no resources that can be found anywhere in their environment. So if you ask them to talk about, or to let you know about, the people who love them in their lives, there are none. But definitely you begin to see real signs of a pervasive sense of hopelessness. No ability to think about the future. Like even with little kids, if I say, so in five more years, how old will you be? And they say things like, maybe not here or I don’t know. And they can’t be future-oriented. So with little kids I look for that. And then also the pictures they draw, the stories they tell, their behaviors at school or with others, changes in their behavior. So those are the things I look at with little kids. And I think the teenagers are much more apt to do a greater range of acting out behaviors and get the attention of school personnel or others. And then it’s a question, again, of doing individualized assessments. So I use some of the same activities with the teens, but sometimes their behavior speaks louder than words in terms of the acting out whereas the little kids may go quiet more, so they’re less likely to be spotted by others.
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