SOARS model: Risk assessment of nonsuicidal self-injury
A new assessment tool helps physicians screen adolescents for self-harming behaviors, then develop a treatment plan or referral to therapy for these patients.
Medical providers, particularly pediatricians, are often the first to learn that their patients have been intentionally harming themselves.1,2 Nonsuicidal self-injury (NSSI) is defined as directly and intentionally inflicting damage to one’s own body tissue without intention of suicide and not consistent with cultural expectations or norms.3 Epidemiologic studies of community samples indicate an approximately 5.9% lifetime prevalence of NSSI among adults and 18% among adolescents, with rates even higher among psychiatric treatment-seeking youth.4-6 Nevertheless, only 1 in 4 clinicians routinely inquires about and addresses NSSI with his or her adolescent patients.7
Several authors have provided suggestions for how health care providers can respond to patients who self-injure.1,2,8,9 We developed the SOARS model for medical providers to use as a brief screening and assessment of NSSI. Each letter of SOARS represents an area to assess: Suicidal ideation; Onset, frequency, and methods; Aftercare; Reasons; and Stage of change (Figure 1). Using theory, research, and consideration of real-world practice, we highlight the most important questions to ask, the reasoning for these questions, and recommendations for how to ask them. Before screening and assessing NSSI, however, an important step for medical providers is to first evaluate their own values and beliefs about NSSI.8
Being empathic toward individuals who engage in a behavior typically considered contrary to protecting one’s health can be difficult at times. Any negative biases, misconceptions, or judgments about NSSI (eg, manipulative or done primarily for attention) may result in a poor response and lack of empathy for patients struggling with this behavior. Providers who are aware of their own emotions and perspectives are better able to monitor them and can help their patients more effectively.8
Screening for NSSI
Providers who use the HEEADSSS assessment [Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, Safety from injury and violence] to obtain a psychosocial history from adolescents would likely find the most opportune time to screen for NSSI prior to screening for suicide.10 It may seem easiest to simply ask if they have ever hurt themselves on purpose without intending suicide. Asking about NSSI using a broad question like this, however, typically results in lower prevalence rates of the behavior than does asking about NSSI in a checklist format.5 We recommend normalizing the behavior (eg, “I know that some people who experience stressors similar to yours think about hurting themselves on purpose without intending suicide.”), asking them directly about it (“Have you ever hurt yourself on purpose without intending to end your life or attempt suicide?”), and finishing the question by listing common forms of NSSI similar to checklist format (“like cutting, biting, burning, or hitting?”). If patients disclose engaging in NSSI, providers can do a brief assessment using SOARS. Similar to asking about suicide, no iatrogenic effects have been shown from asking about NSSI.11