# Evidence-based assessment/Self harm (assessment portfolio)/extended version

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
* Does all this feel like TMI? Click here to go to a condensed version.

## Preparation phase

It is important to recognize that measures of suicide-related thoughts and behaviors (i.e., suicidal ideation) and non-suicidal self injury (NSSI) are measure distinct constructs. NSSI items often specify a behavior with clarification that the behavior was not undertaken with intent of suicide. This distinction is important when identifying which measure to use to evaluate a client.

### Suicidal Ideation

Self-Injurious Thoughts and Behaviors Interview. Suicide has an article on Wikipedia.

### Diagnostic criteria for NSSI

   DSM-5 Criteria for NSSI
   * Nonsuicidal self-injury is currently a proposed disorder in need of further research in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
   * The criteria for NSSI can be found under Conditions for Further Study in DSM-5.
   ICD-11 Criteria for NSSI
   Intentional self-inflicted injury to the body, most commonly cutting, scraping, burning, biting, or hitting, with the expectation that the injury will lead to only minor physical harm.
   * For ICD-11, self-injury or self-harm is cited as a symptom or sign that is not classified elsewhere

### Base rates of NSSI in different populations and clinical settings

This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of the non-suicidal self injuries (NSSI) that they are likely to see in their clinical practice.
* To see prevalence rates across multiple disorders, click here.
| Demography | Setting | Base Rate | Diagnostic Method | Reference |
| International | Young adult non-clinical sample | 13.4% | Meta-analysis, controlling for methodological differences across studies | Lifetime frequency; Swannell et al., 2014 |
| All of U.S.A. | Adult community sample | 23% | Self-report measure (questions based on proposed DSM-V criteria for NSSI Disorder; FASM) | Lifetime frequency; Andover, 2015 |
| North East | Adolescent inpatient sample | 50% | Self-report measure (ISAS), based on DSM-V criteria for NSSI Disorder | Lifetime frequency; Glenn & Klonsky, 2013 |
| Sweden | Adolescent community sample | 43.4% | Combined self-report measure (FASM) and interview (SITBI) | Lifetime frequency; Zetterqvist et al., 2013 |
| U.S.A. | Adult outpatient sample | 11.4% | Chart review, not based on DSM-V criteria | Lifetime frequency; Selby et al., 2012 |
| All of U.S.A. | Adolescent epidemiological | 13.0%-23.2% | Variable assessment methods | Lifetime frequency; Jacobson & Gould, 2007 |
| North East | Adolescent non-clinical sample | 7.5% | Self-report measure | within the last year; Hilt et al., 2008 |
| North East | Adolescent inpatient sample | 60% | Self-report measure (FASM) | lifetime frequency; Nock et al., 2006 |
| United Kingdom | Incarcerated sample | 52% | Self-report measure (FASM) | Gray et al., 2003 |
| International | Adults from sexual minorities (LGBT) samples | 36.53% | Various self-report questionnaires | Liu et al., 2019 |
Search terms: [Non-suicidal self-injury or NSSI or Self harm] AND [children OR adolescents] AND [prevalence OR incidence OR epidemiological] in PsychInfo and Google Schola

## Prediction phase
### Scope of screening instruments for NSSI

Click here for cross-screening component analysis :
| Category of Screening | Instrument | No. Items |
| Omnibus | Suicidal Behaviors Questionnaire (SBQ) | 90 |
| Omnibus | Self-Harm Behavior Questionnaire (SHBQ) | 32 |
| Functional | Functional Assessment of Self-Mutilation (FASM) | 22 |
| Functional | Inventory of Statements About Self-Harm (ISAS) | 39 |
| Functional | Self-Injury Questionnaire (SIQ) | 30 |
| Functional | Self-Injury Motivation Scale (SIMS) | 35 |
| Functional | Self-Harm Reasons Questionnaire (SHRQ) - Revised | 21 |
| Behavioral | Deliberate Self-Harm Inventory (DSHI) | 17 |
| Behavioral | Self-Harm Inventory (SHI) | 22 |
| Brief | Schedule for Nonadaptive and Adaptive Personality (SNAP) Items | 2 |
| Brief | Trauma Symptom Inventory (TSI) Item | 1 |

### Psychometric properties of screening instruments of NSSI

The following section contains a list of screening and diagnostic instruments for non-suicidal self-injury. The section includes administration information, psychometric data, and PDFs or links to the screenings.
* Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
* For a list of more broadly reaching screening instruments, click here.
| Instrument (Reference) | Type of screeening | Internal Consistency | Interrater Reliability | Test-Retest Reliability | Construct Validity | Free and Accessible Measures |
| Suicidal Behaviors Questionnaire (SBQ) | Omnibus | G | NA | A | G | Printable PDF of SBQ |
| Self-Harm Behavior Questionnaire (SHBQ) | Omnibus | G | NA | A | G | Not free |
| Functional Assessment of Self-Mutilation (FASM) | Functional | A | NA | U | A | Printable PDF of the FASM |
| Inventory of Statements About Self-Harm (ISAS) | Functional | G | NA | G | G | Printable PDF of ISAS |
| Self-Injury Questionnaire (SIQ) *Not Free* | Functional | G | NA | U | A | Not free |
| Self-Injury Motivation Scale (SIMS) | Functional | G | NA | U | A | |
| Self-Harm Reasons Questionnaire (SHRQ) | Functional | G | NA | U | A | |
| Deliberate Self-Harm Inventory (DSHI) | Behavioral | G | NA | G | G | |
| Self-Harm Inventory (SHI) | Behavioral | A | NA | U | A | |
| SNAP Items | Brief | NA | NA | U | A | |
| Trauma Symptom Inventory (TSI) | Brief | NA | NA | U | A | |
| Scale for Suicide Ideation (SSI) | Other | G | U | U | G | |
| Suicide Behaviors Interview (SBI) | Other | E | E | U | A | |
| Child Suicide Potential Scales (CSPS) | Other | A | E | U | G | |
| Beck Scale for Suicide Ideation (BSI) | Other | E | NA | U | G | |
| Suicide Behaviors Questionnaire for Children (SBQ-C) | Other | G | NA | A | A | |
| Suicide Ideation Questionnaire for Children (SIQ-JR) | Other | G | NA | A | G | |
| Suicide Probability Scale (SPS) | Other | E | NA | U | A | |
| Columbia Suicide Screen (CSS) | Other | G | NA | L | A | |
| Harkavy Asnis Suicide Scale (HASS) | Other | E | NA | U | G | |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable
* Sources consulted: Klonsky, E. D., & Lewis, S. P. (2014). Assessment of nonsuicidal self-injury. In M. K. Nock, M. K. Nock (Eds.) , The Oxford handbook of suicide and self-injury (pp. 337-351). New York, NY, US: Oxford University Press.; Nock (Eds.), Understanding non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: Am. Psychol. Assoc.

### Likelihood ratios and AUCs of screening measures for NSSI

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure (Primary Reference) | AUC | LR+ (score) | LR- (score) | Clinical Generalizability | Download |
| Child Behavior Checklist (CBCL) Anxious/Depressed Scale T-score | .70 (N=470) | 3.78 (60+) | .39 (<60) | High. Large diverse sample with mixed depression sample compared to samples without depression. | Not free |

### Interpreting NSSI screening measure scores

* For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

* For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

### Coverage of interviews for NSSI

Scope of diagnostic interviews for NSSI :
| Instrument | No. Items | History | Methods | Frequency | Lethality | Intent of Functions | History of Suicidality |
| Omnibus Measures ||||||||
| Suicide Attempt Self-Injury Interview (SASII) | 31 | X | X | X | X | X | X |
| Self-Injurious Thoughts and Behaviors Interview (SITBI) | 169 | X | X | X | X | X | X |

### Recommended diagnostic instruments for NSSI

| Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | |
| Instrument (Reference) | Type of screeening | Format (Reporter) | Age Range | Administration Time | Internal Consistency | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Beck Scale for Suicidal Ideation (BSI) | | Self-report questionnaire | 17+ | 5-10 mins | | E | | A | G | | No Link to purchase |
| Suicidal Behaviors Questionnaire-Revised (SBQ-R) | | Self-report | 18+ | 5-10 mins | | | | .87 E | E | Yes | SBQ-R |
| Self-Harm Behavior Questionnaire (SHBQ) | | Self-report questionnaire | adolescents | Not Reported | | E | | G | G | | |
| Suicide Attempt Self-Injury Interview (SASII) | Omnibus | | | | G | E | E | G | | | SASII |
| Self Injurious Thoughts and Behaviors Interview (SITBI) | Omnibus | | | | NA | E | A | G | | | SITBI |
| Suicidal Ideation Questionnaire (SIQ) | | Self-report questionnaire | 12-18 years old | 10 minutes | NA | | | | | | SIQ |
| Suicidal Ideation Questionnaire (SIQ-JR) | | Self-report Questionnaire | Middle School aged children | 10 minutes | NA | | test-retest: r -0.93 (males) r = .87 (females) | | | | SIQ-JR |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

The following section contains a brief overview of treatment options for depression and list of process and outcome measures for non-suicidal self-injury. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

### Outcome and severity measures

* This table includes clinically significant benchmarks for NSSI specific outcome measures
* Information on how to interpret this table can be found here.
* Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
* For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for NSSI :
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms ||||||||
| | | A | B | C | 95% | 90% | SE$_{difference}$ |

### Treatment

* Please refer to the page on non-suicidal self injury for more information on available treatment for NSSI
* Go to Effective Child Therapy for a curated resource on effective treatments for NSSI.

## External resources

* Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provide
* Cornell resource on self-injury
* Effective Child Therapy page for Self-Injurious Thoughts and Behaviors
** Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP) (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
* Wikipedia page for non-suicidal self injury
* Mental Health First Aid page on non-suicidal self-injury