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

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
* Want even 'more' information about this topic? There's an extended version of this page here.

## 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.

### Risk assessment

Here are some questions that could be included as a part of a clinical assessment:
* Have you been thinking about suicide recently? (start with ideation -- most common and least threatening opening question)
* When you think about suicide, what kinds of thoughts do you have? (open-ended question)
* Have you made any plans for attempting suicide? For example, have you obtained the means necessary to complete suicide, like purchasing a gun or obtaining pills? (exploring preparation)
* Do you have confidence that you could attempt suicide?
* Have you ever attempted suicide previously? (gathering past history)
* Have you ever harmed yourself intentionally? For example, cut yourself, swallowed pills, or burned yourself?
* What are some reasons that you would consider attempting suicide?
* Tell me about your support system. Do you feel isolated? Are you able to talk to friends and family about your problems? (Isolation is a risk factor; social support is protective)
* How do you feel when you think about the future? Are you hopeful that you can do something about your problems? (asking about hopelessness, an established risk factor)
Note. List adapted from Table 1 in Cukrowicz, Wingate, Driscoll, & Joiner (2004).

### 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 |
| International | Young adult non-clinical sample | 13.4% | Meta-analysis, controlling for methodological differences across studies |
| All of U.S.A. | Adult community sample | 23% | Self-report measure (questions based on proposed DSM-V criteria for NSSI Disorder; FASM) |
| North East | Adolescent inpatient sample | 50% | Self-report measure (ISAS), based on DSM-V criteria for NSSI Disorder |
| Sweden | Adolescent community sample | 43.4% | Combined self-report measure (FASM) and interview (SITBI) |
| U.S.A. | Adult outpatient sample | 11.4% | Chart review, not based on DSM-V criteria |
| All of U.S.A. | Adolescent epidemiological | 13.0%-23.2% | Variable assessment methods |
| North East | Adolescent non-clinical sample | 7.5% | Self-report measure |
| North East | Adolescent inpatient sample | 60% | Self-report measure (FASM) |
| United Kingdom | Incarcerated sample | 52% | Self-report measure (FASM) |
| International | Adults from sexual minorities (LGBT) samples | 36.53% | Various self-report questionnaires |

## Prediction phase
### 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.
Screening measures for (Self Harm) :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Where to Access |
| Suicidal Behaviors Questionnaire (SBQ) | Self-report | 13-18 | 5 minutes | Printable PDF of SBQ |
| Beck Scale for Suicide Ideation (BSI) | Self-report | 17+ | 5-10 minutes | Link to purchase BSI |
| Suicide Ideation Questionnaire for Children (SIQ-JR) | Self-report | 12-15 | 15 items | Link to purchase SIQ-JR |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

### 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.

### Recommended diagnostic instruments for NSSI

| Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | Diagnostic instruments for NSSI | |
| Measure | Format (Reporter) | Age Range | Administration Time | Where to Access |
| Suicide Behaviors Questionnaire-Revised (SBQ-R) | Self-report | 18+ | 5-10 mins | Link to free download:SBQ-R |
| Suicide Attempt Self-Injury Interview (SASII) | Structured interview | 18+ | Varies | Link to free download:SASII |
| Self Injurious Thoughts and Behaviors Interview (SITBI) | Structured interview | 11+ | 3-15 mins | Link to free download:SITBI |
Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

## 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.

### 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