Monday, August 30, 2010

Why Are So Many Girls Cutting Themselves?

A guest blog by Leonard Sax, MD, PhD

Dr. Sax will be presenting “Boys Adrift and Girls on the Edge” as a full day conference in St. Paul on October 26th and “Gender Matters: The Importance of Gender in Early Intervention in At-Risk Youth” as a full day conference in Rochester on October 27th. Register here!


I remember my first psychiatry rotation, back in 1985 when I was a medical student at the University of Pennsylvania. A young woman was admitted to the psych unit. She had been cutting herself with razor blades. "Weird," I breathed. "Weird," the psychiatry resident agreed. The attending psychiatrist put her in the locked ward, on full suicide precautions. He explained to us that this behavior was a "cry for help." That's what many people thought back then. In ancient times.


Today we know better, or we think we do. Most of these girls and young women are not suicidal, and they don't want anybody to find out. They don't want to be discovered. That's why they wear long sleeves, so nobody will see their wrists; or, more often nowadays, they cut themselves on the upper inner thigh, where nobody will look. Cutting themselves with razor blades, or burning themselves with matches, becomes compulsive, almost addictive for some of these girls. There is now evidence that for at least some of these girls, this behavior triggers a release of endogenous opiates (for a review of this evidence, please see chapter 3 of my book Girls on the Edge). Cutting delivers a weird kind of disembodied rush. "I felt like I was up on the ceiling, watching myself do it," another girl told me. "I was literally high."


How common is it? Much more common than it used to be. Studies from the 1990's suggested rates of 3% or lower. But more recent studies suggest that as many as one in five girls between 10 and 18 years of age are now cutting themselves with razor blades or burning themselves with matches, etc. For example, researchers at Yale University recently reported that 56% of the 10- to 14-year-old girls they interviewed reported engaging in NSSI at some point in their lifetime, including 36% in the past year.



“The Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition” – usually referred to as “DSM-IV” – provides the definitive listing of every recognized psychiatric disorder, along with diagnostic criteria for each disorder. The American Psychiatric Association is now in the process of revising and updating the DSM. They have recently published their first draft of DSM-V. The draft includes an entirely new diagnosis, which the psychiatrists are calling “Non-Suicidal Self-Injury (NSSI).” You can read the proposed DSM-V criteria for NSSI here.


I have some problems with the proposed DSM-V criteria for NSSI. There's no mention of gender differences in the presentation of self-injury. Let me illustrate why I think that’s a problem with an example. Imagine a teenage boy who's not doing well in life: he doesn't have any friends, he's getting bad grades at school, he spends most of his free time playing first-person-shooter video games. Let's suppose this teenage boy repeatedly hits the wall with his fist during arguments with his parents. This boy would meet all the proposed DSM-V criteria for NSSI.


Now imagine a teenage girl who secretly cuts herself with a razor blade. She's the golden girl: she's pretty, she has lots of friends, she's successful academically, she seems to be doing well. The growing prevalence of such girls among cutters is well-documented; see for example Adler and Adler (2007), who assert that these girls are exhibiting a "voluntarily chosen deviant behavior" rather than true psychopathology. I don't agree with Adler and Adler, but that's beside the point. Such a girl would also meet the proposed DSM-V criteria for exactly the same psychiatric diagnosis as the boy who breaks a bone in his hand when he slams his fist into a wall. But a "loser" boy who publicly slams his fist into a wall is experiencing an inner turmoil very different from the golden girl who secretly cuts herself with a razor blade. Lumping these two teenagers together, and pretending that they have the same problem, is not likely to be very helpful to anybody.


Many researchers who study self-injury have minimized gender differences in their own data. For example, in one recent survey of young people 14 to 21 years of age (Nixon et al. 2008), researchers reported that 16.9% of those surveyed had engaged in self-injury. Read the abstract of that paper: you won't find any mention of gender differences. But when you read the full text (available at no charge by clicking here), you find that 24.3% of girls were self-injuring, compared with 8.4% of the boys. You'll find those data in Table I of the paper. The authors acknowledge the finding (in a single sentence) but they do not discuss it or try to understand it. Furthermore, this study -- like most studies of NSSI - conflates the boy who publicly smashes the wall with his fist, with the girl who secretly cuts herself with a razor, in the same category -- a blurring of reality which further masks the magnitude and significance of the underlying gender differences.


In my experience, boys who are deliberately hurting themselves usually fall in a narrow demographic. Bluntly, those boys tend to be the weirdos, the losers, the lonely outsiders. Not so for girls. The most popular girl, the pretty girl, the girl who seems to have it all together, may also be the girl at greatest risk for cutting herself. The most successful boy, the star football player with lots of friends, is not secretly cutting himself with razor blades. But the most successful girl might be.


The stereotype is that kids who cut themselves are depressed. While that stereotype is usually accurate for boys, it's less reliably accurate for girls. Most boys who cut themselves are depressed, but many girls are not. Janis Whitlock and her colleagues at Cornell (Whitlock et al. 2008) found that college women injure themselves differently, and for different reasons, compared to college men. Cheng et al. (2010) recently developed a screening questionnaire to identify college students who were engaging in NSSI. They found that some of the best questions for screening the women were useless for screening the men, and vice versa. Other researchers have found that girls are more likely than boys to self-injure as a means of self-punishment, while boys are more likely to self-injure in the aftermath of a romantic break-up (Adler & Adler 2007; Rodham et al. 2004). But most research on NSSI overlooks these gender differences. Boys who are failing in every aspect of their life, who hit the wall during an argument, are lumped into the same category with girls who seem to be doing great, but who are cutting themselves in secret.


It's risky to look at celebrity culture for any insights into the human condition, but in this case I think the stories of celebrities illustrate reasonably well what I'm hearing from young people, female and male, around the United States and Canada. Megan Fox told Rolling Stone that she had deliberately cut herself as a teenager. Angelina Jolie, Lindsay Lohan, Amy Winehouse, and the late Lady Diana Spencer, all have been identified as women who repeatedly and deliberately injured themselves. By contrast, the best-known male celebrity who cuts himself is Marilyn Manson. I think Mr. Manson would agree that he takes pride in being a weirdo. And he likes to cut himself - on stage.


In other words, the girls who are most successful at meeting gender-specific societal expectations appear to be just as likely as other females to be cutting themselves. Not so for boys. How come? That's one of the questions I try to answer in my book Girls on the Edge. My bottom line is that these girls are searching for a sense of self that's not about how they look, but about who they are. We reward them for how they look but we -- i.e. American society -- are much less interested in what's going on inside. Self-cutting fills that need for some of these girls -- just as anorexia does for others, and obsessive perfectionism does in others (see Sara Rimer's insightful article for the New York Times about "anorexia of the soul" among hyperachieving 'amazing' girls for more on this point).


Of course some girls who cut themselves ARE depressed, or are unhappy with their appearance, or may be lonely, etc. And of course we need to be just as concerned about girls who are NOT pretty, girls who do NOT meet society's stereotyped notions of what girls should look like, and who are cutting themselves. But I think that ignoring gender differences in NSSI disadvantages many of those who are struggling with this issue -- especially girls.


I'm bothered that so few people want to address the gender differences in NSSI - which I think are absolutely central to understanding why these young people are hurting themselves, and essential to intervening effectively with them. Marilyn Manson is not Megan Fox. Marilyn Manson's issues are not Megan Fox's issues. Interventions which might have helped Marilyn Manson stop cutting would be unlikely to benefit Megan Fox, and vice versa. Nevertheless, even people who truly seem to care about NSSI tend to overlook or deliberately understate gender issues here. The leading non-profit organization concerned with NSSI, "To Write Love On Her Arms," asserts on their web site that self-injury ". . .has the same occurrence between males and females." Not true.


Gender matters. Why are people so afraid to talk about it?


Leonard Sax MD PhD is a physician, psychologist, and author of "Boys Adrift" (Basic Books, 2007) and "Girls on the Edge" (Basic Books, 2010).


References

Adler P, Adler P. 2007. The demedicalization of self-injury. Journal of Contemporary Ethnography, 36, 537-370.

Cheng H-L, Mallenckrodt B, Soet J, Sevig T. 2010. Developing a screening instrument and at-risk profile for nonsuicidal self-injurious behavior in college women and men. Journal of Counseling Psychology, 57, 128 - 139.

Hilt LM, Cha CB, Nolen-Hoeksema S. 2008. Nonsuicidal self-injury in young adolescent girls: moderators of the distress-function relationship. Journal of Consulting and Clinical Psychology, 76, 63-71.

Nixon MK, Cloutier P, Jansson SM. 2008. Nonsuicidal self-harm in youth: a population-based survey. CMAJ, 178, 306-312.

Rodham K, Hawton K, Evans E. 2004. Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 80-87.

Whitlock J, Muehlenkamp J, Eckenrode J. 2008. Variation in nonsuicidal self-injury: identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child and Adolescent Psychology, 37, 725-735.

Monday, August 23, 2010

Online Resources for Youth

As youth gear up for heading back to school and youth programs prepare for switching gears to fall programming, we thought we’d share a small compilation of some great youth-focused, interactive sites where youth can learn and do good while in front of the computer screen. Youth service professionals may consider incorporating these resources into fall programming or just sharing with the youth they serve.
  • www.bankit.com/. - This is an awesome site for helping teens manage money and think about finances. It also has resources for parents.
  • www.at15.com/ - This is Best Buy’s youth site. Youth members get points and use them to vote on what projects Best Buy’s foundation will fund.
  • www.dosomething.org/ - This site is one of the best out there for youth engagement! Every young person should know about the resources at this site.
  • www.freerice.com - Take fun quizzes and gain points that become grains of rice that are donated to help feed people all over the world.
  • www.refresheverything.com/ - At the Pepsi Refresh site young people can vote on great ideas for Pepsi to fund.
  • www.pongoteenwriting.org/home.html - This incredibly inspiring site features the writing of young people who are living in prisons, detention centers, mental heath facilities and on the street. It also includes great writing prompts and ideas about starting a writing group.
  • http://kidshealth.org/teen/ - This site is full of great information from strength training tips to healthy recipes to advice about friendship and peer pressure.
  • www.newglobalcitizens.org/ - This is the site for an international youth movement that shows how young people can address the great challenges facing the world today.
  • www.genv.net/ - This site supports young social entrepreneurs and helps young people start achieving big dreams.
  • www.bam.gov/ - The Body and Mind site for young people from the CDC??. It has lots of great information and ideas about healthy living.
  • www.youthnoise.com/ - This is a social networking site for youth causes with lots of blogs, videos and information about youth-led movements.
  • www.rootsandshoots.org/ - This is the youth site connected to the Jane Goodall Center that has lots of resources about environmental activism.
YIPA and your youth service professional colleagues would appreciate learning from you what websites you have found valuable to share with your youth. Please share by commenting below.

Friday, August 13, 2010

August Members of the Month: Senior Chores Programs Exemplify Unique Networking Opportunities

We have all heard about Minnesota’s rising senior population. Minnesotans are getting older and the workforce is retiring. While this may have profound implications for our personal lives, there is a risk that youth workers might not see this as being “our problem.”

Three YIPA members illustrate beautifully why this aging population is deeply connected to youth intervention. Indeed, it may not be “our problem,” but it is certainly part of our solution! These three programs have found a way to provide needed help for seniors in their communities, give supervised community service hours to court-ordered youth, train and employ young people and create intergenerational bonds even where there was once distrust and skepticism.

For those of you who are familiar with DARTS, it may seem odd that one of the oldest and most prominent senior services organizations in the metro area is a member of YIPA. Meeting Mary Richardson makes this connection clear. She is the driving force behind DARTS’ current senior chores program. While the over 30-year long program was around long before Mary came to DARTS, she has put her own stamp on senior chores – often working side by side with her young volunteers!

White Bear Lake Area Community Counseling Center is just getting started with their senior chores program. This fledgling program is up and running thanks in large part to the help its coordinator Sally Cain received from DARTS and from Northwest Youth and Family Services (another YIPA member program). Hearing about successful senior chores projects at YIPA quarterly membership meetings, White Bear staff got inspired to start one of their own. Sally went with Mary Richardson to five DARTS chore sites and saw what a great program looks like. She also went and visited the 30-year NYFS senior chores program and its coordinator, Debbie Peterson. Sally took ideas back with her to White Bear, but also made the program her own in order to fit her community’s needs.

Sitting down over coffee these three inspiring women jumped immediately into conversation with each other. How is your summer going? Did you figure out how to do that form? I’m going to be full-time now! Yay! and so on. They shared stories of surprising successes and things they have learned along the way.

One story that stuck out was about a group of young men who had been court ordered to do community service with their probation officer. On the way over the boys complained, “I don’t want to do anything with old people!” But after a few hours helping an elderly man maintain his home (something he surely could not have done alone), the boys changed their tune. “That was so cool!” they exclaimed on the van ride home.

Thinking of starting a senior chores project at your organization? These three women have the collective knowledge and experience to set you on the right path. From grant writing to the minimum age for lawn mowers, from working with probation officers to interviewing seniors – they are an amazing resource for any question you might have.

Here are just a few things that we have learned after sharing a cup of coffee with Mary, Debbie and Sally:
1. Take a picture of the senior’s yard and put it in their file. That way if they call back for more help you know what kind of garden they have, how big their yard is, etc. Also, it makes them feel like you remember them!
2. Make sure to take the time (even just a few minutes) to have the young people talk to the seniors they are helping. These connections can have lasting effects.
3. Don’t reinvent the wheel. Looking at forms and procedures from other senior chores programs helped save time and effort so that new programs could get off the ground faster.
4. Programs like these make seniors feel safer, because they see the positive side of youth. It helps young people show their community that they are not “problems,” but real assets.
5. Look for connections in unlikely places. These programs connect with senior services, diversion programs, church groups and police departments. It is within these seemingly separate spheres that senior chores programs flourish.

We believe that one of greatest benefits to YIPA membership is the opportunity to connect with other service providers. Sometimes those other providers may seem like they are approaching their work in early intervention in a way completely different from your own. But more often than not, our members are able to learn from each other, improve their services because of the skills they have learned from other – and often save themselves much time and energy when they discover they do not have to “reinvent the wheel,” as is shown here with the seniors’ chores programs within YIPA membership.

Friday, August 6, 2010

What do Gubernatorial Candidates say about Children and Youth? By the Minnesota Children’s Platform Coalition


We have discussed YIPA’s involvement with the Minnesota Children’s Platform Coalition several times on this blog. Now, YIPA is excited to present the results on the MNCPC Governor’s Candidate Survey!


The Minnesota Children’s Platform Coalition (MNCPC) is a collaboration of organizations and individuals who care about Minnesota children and youth. The questions in this survey were created by the MNCPC following a “World CafĂ©” meeting in January 2010 of coalition partners who discussed issues they thought were important for a Minnesota governor to attend to.

We asked all candidates for governor to respond to a set of 6 questions that followed from that meeting. Here is what we asked them…..


We believe that children and youth in Minnesota deserve a comprehensive approach to youth services with a focus on the whole child. As a candidate for Governor of Minnesota, you have a vital role to play in improving the lives of Minnesota’s young people. Please take a few moments to respond to our questions. Please feel free to include links to news articles, websites or other online resources to support your points. Your answers will be shared with our extensive statewide network of children and youth service providers, educators, advocates and parents via written and Internet communications.


We are listing responses to the questions in the order in which we received them. If a candidate is not listed, it means that he or she did not send us a response.


Curious about what characteristics that YIPA would like to see in a governor? Most importantly the new governor should:

1) Be a champion for all youth

2) Understands the needs for continuum of care from birth to age 21

3) Have a focus on children that expands far beyond schools

4) Be action oriented – willing to take bold steps to ensure that funding for children and youth services grows rather than shrinks as it has during the past decade.

5) Understands the concept of early intervention youth services and how it keeps youth from progressing through the Juvenile justice System.


We hope you will look at these responses before the primary elections on August 10. Please note that at primary elections you will not be able to choose from among all of these candidates. Primary elections are only for the purpose of allowing members of a political party decide who will be on the ballot in November.


MNCPC Board of Directors/Committee


Sue Fust, Minnesota Organization on Adolescent Pregnancy, Prevention & Parenting

J. Scott Beaty, Youth Intervention Programs Association

Connie Skillingstad, Prevent Child Abuse Minnesota

Jim Scheibel, Hamline University

Jim Meffert, Minnesota Optometric Association

Rod Halvorson, Minnesota Social Service Association

Jennifer Rison, Children’s Leadership Council

Clare Ryan, MNYIPA Promise Fellow

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