Skip to main content
Download PDF

Current status of nonsuicidal injuries and associated factors among junior high school students in Hainan Province, China: a cross-sectional study

BMC Psychology volume 11, Article number: 199 (2023) Cite this article

Abstract

Background

To summarize the general status of nonsuicidal self-injury (NSSI) behaviour and the characteristics of junior high school students and to determine the risk factors associated with NSSI behaviour.

Methods

Five middle schools in the rural and urban areas of Hainan Province were randomly selected for this cross-sectional study, and junior high school students were administered questionnaires, including the General Sociodemographic Questionnaire, Ottawa Self-Injury Scale, Anxiety Self-Rating Scale, Depression Self-Rating Scale, Adolescent Lifestyle Scale, and Parenting Style Scale.

Results

The NSSI rate among junior high school students in Hainan Province was 28.9%, with a higher prevalence among girls than boys (P < 0.05). The age range was 11–16 years, with a mean age of 13.08 ± 0.911 years. The most common form of self-injury was scratching/bruising, followed by hitting oneself, pulling out hair, biting, head banging, and cutting. The NSSI methods of scratching/bruising, hitting oneself and cutting more commonly occurred in girls than boys (P < 0.05). The most common sites of self-injury were the face, scalp, lips, forearm/elbow, axilla/wrist, hands/fingers, and thighs/knees. Significant differences were observed in the distribution of self-injury sites (nose, lips, genitals, and axillae/wrists) between the two genders (p < 0.05). The most important motivation for undertaking NSSI behaviours was to release negative emotions. The risk factors affecting NSSI behaviours were female gender (OR = 1.793), depression (OR = 1.961), anxiety (OR = 1.495), interpersonal relationship factors (OR = 1.099), academic stress factors (OR = 1.062), maternal emotional warmth (OR = 0.97), and maternal overinterference (OR = 1.036).

Conclusions

The NSSI rate among junior high school students in Hainan was 28.9%, affecting girls more than boys. The form and site of self-injury between boys and girls were significantly different. The motivation for committing self-injurious behaviours was mainly to regulate bad emotions. Risk factors for NSSI behaviours included female gender, anxiety, depression, interpersonal relationship factors, academic stress factors, and maternal emotional overinterference, while maternal emotional warmth was a protective factor.

Peer Review reports

Background

Nonsuicidal self-injury (NSSI) refers to intentional damage to one’s own body tissues without suicidal intent, the purpose of which is not socially sanctioned [1]. NSSI can be self-perpetuating; thus, repeated NSSI behaviours deepen wounds and cause new wounds or even suicide [1,2,3]. According to previous epidemiologic data, NSSI is prevalent in people of all ages, among which adolescents have a very high prevalence rate [1,2,3,4,5,6]. In the US adult clinical population, the prevalence of NSSI is between 19% and 25% [7]. Of the clinical adolescent population of concern to psychologists, ≥ 40% have reported NSSI behaviours [5], while the prevalence of NSSI in the nonclinical adolescent population < 18 years of age (who do not turn to psychologists for help) is estimated to be approximately 14% [6]. In 2015, a large epidemiologic study on NSSI in the United States demonstrated that the lifetime incidence of NSSI among community adolescents was 17.6% [8]. In 2018, a global epidemiologic survey showed that the incidence of NSSI among adolescents in the past year was 19.5%, and the NSSI rate in Asian countries was significantly higher than the NSSI rate in European and American countries [9]. A meta-analysis indicated that the total incidence of NSSI per year among junior high school students from mainland China is 27.4% [10]. Another study showed that 22.1% of NSSI participants had repeated NSSI behaviour at the 1-year follow-up evaluation [11]. According to previous studies [5, 6, 8,8,9,10,11,12], NSSI is highly prevalent among adolescents at home and abroad. Therefore, NSSI is now considered a serious public health issue and has attracted considerable attention worldwide. Due to the large population base in China and the high incidence of NSSI, a large number of NSSI events are observed among Chinese adolescents. It is necessary to conduct in-depth research on NSSI among Chinese adolescents.

According to Nock’s comprehensive theoretical model, NSSI behaviour is an adaptive means to regulate aversive emotional experiences and interpersonal relationships [13]. The risk factors for NSSI in adolescents include the following: individual internal/interpersonal vulnerability (e.g., aversive emotional experience and poor emotional regulation), distal risk factors (e.g., childhood abuse, family dysfunction, and parental criticism), and proximal risk factors (e.g., negative life events) [13]. Previous literature has shown that emotional regulation is one of the most common functions of NSSI, and individuals with mood disorders are at significantly higher risk of developing NSSI [8, 14,15,16,17]. Depression and anxiety are proven risk factors for NSSI in adolescents [14,15,16,17]. The distal risk factors for NSSI are mainly related to the quality of the individual’s family and social environment. Family is the main place for individual socialization. According to attachment theory, parenting styles profoundly shape the development of adolescents’ cognitive, social, and emotional regulation functions [18, 19]. Poor parenting has been shown to be associated with a variety of psychopathological disorders, including internalized emotions (anxiety, depression, anger) and externalized behaviours (aggression, impulsive behaviour) [20, 21]. An effective parenting style can deliver more emotional warmth and support, which is conducive to the development of children’s emotional regulation ability. In contrast, a negative parenting style causes insecure parent‒child attachment, leads to emotional and social dysfunction in adolescents, and makes adolescents prone to NSSI and other negative behaviours [20, 21]. Domestic and foreign studies have shown that parental punishment, criticism and excessive control are important risk factors for the occurrence of NSSI, and positive parenting styles such as parental emotional warmth can reduce the risk of NSSI in adolescents [6, 18,19,20,21,22,23,24]. As a proximal risk factor for NSSI, negative life events are also closely associated with NSSI in adolescents, which causes psychological distress in individuals. According to the stress-exposure model of psychopathology, experiencing high levels of life stress is an important psychosocial factor leading to emotional problems such as depression [25, 26]. As teenagers are mentally immature and lack self-control ability, they may adopt NSSI to adjust to the negative emotions brought by pressure [27, 28]. A study on Chinese adolescents showed a significant positive correlation between stressful life events and NSSI [29].

However, there are few previous studies on the above risk factors for NSSI among Chinese adolescents. Previous domestic studies on NSSI among adolescents were mainly conducted in mainland China, while few studies have focused on NSSI behaviours among adolescents in coastal areas [10, 11, 17]. Therefore, in the present study, we analysed the current status of NSSI behaviours among junior high school students in Hainan, a coastal area in China. In addition, based on Nock’s comprehensive theoretical model, we focused on the NSSI behavioural characteristics, patterns, motivations, and risk factors in these subjects.

Subjects and methodology

Subjects and questionnaire survey

A questionnaire survey was administered using multistage cluster sampling in this cross-sectional study. In the first stage, three areas in Hainan Province with social, economic, and cultural differences (rural areas, towns, and cities) were selected. In the second stage, 1 ~ 2 public junior high schools were randomly selected from the three regions. In the third stage, 2–3 classes from the first-third grades of each junior high school were randomly selected to respond to questionnaires (Supplemental file 1) as part of the investigation. Finally, one junior high school was chosen from rural areas, two from towns, and two from cities. The cities had a permanent population of > 200,000 and extensive housing, transportation, health, utilities, land use, commodity production, and communication systems. Towns had a permanent population of > 2000 and < 100,000, and 50% of the population was nonagricultural. 90% of the workers lived together and mainly engaged in agricultural production in rural areas.

The survey was active for 1 month. The questionnaires were distributed to students in the first, second, and third years of junior high school on a class-by-class basis. Before the survey commenced, the guardians of the subjects signed the informed consent form; anonymity was assured. Considering the young age of the subjects, guidance on the survey was provided by two graduate students majoring in clinical psychology and one psychology professor with > 3 years of psychology work experience. Any subjects who had doubts about questions in the questionnaire could ask the graduate students and professor for help. The subjects were instructed on the method of using the scales and self-scoring. One-to-many explanations were provided on a class-by-class basis.

Sample estimation

According to the literature, the NSSI behaviour detection rate among junior high school students in China is approximately 27.4% [10]. In the current study, the sample size was estimated according to the detection rate of 27.4%. The test level α = 0.05 was adopted, and the allowable error was 10% of the prevalence rate. The sample size of 1018 cases was calculated according to the sample size formula for simple random sampling. It was estimated that the design efficiency was 1.2, and the sample size was the sample size calculated by simple random sampling multiplied by the design efficiency (1018*1.2 = 1222). To increase the representativeness of the sample, the additional sample size was approximately 50%, so it was determined that the required sample size was approximately 1900. Sample size was calculated by the following formula:

$$N={\left[\frac{Z\alpha /2}{\delta }\right]}^{2}\rho (1-\rho),$$

where N = sample size, ρ = the expected positive rate calculated with a detection rate of 27.4%, 1 - rho = 1-0.274 = 0.726, δ = tolerance error (i.e., 10% of the expected positive rate), and Zα/2 = 1.96 when the confidence limit of the sample positive rate was 95% (α = 0.05).

Survey tools

A self-prepared questionnaire was administered to collect the sociodemographic data of the subjects, including general information, academic performance, place of residence, and religious belief.

Ottawa self-injury inventory

The subjects completed a self-assessment using the Chinese version of the Ottawa Self-injury Inventory (OSI) [30]. The OSI consists of 26 items to assess the severity, behavioural characteristics, impulsivity, and source of NSSI ideas.

The 14th question on the OSI is the Ottawa Self-injury Inventory-Functions (OSI-F) item, which is used to determine the motivations for the first and present episodes of self-injury. The OSI-F evaluates various motivations for primary and sustained NSSI in subjects based on 25 items using a 5-point Likert scale (0 = never; 1 ~ 3 = sometimes; 4 = always). The 25 items that comprise the four motivation categories underlying NSSI behaviours (external emotion regulation, social influence, internal emotion regulation, and sensation-seeking functions) were examined. The internal consistency of Cronbach’s α for the four factors varied between 0.637 and 0.896. The internal consistency of the Chinese OSI-F had a Cronbach’s α = 0.952.

The 20th question of the OSI is the Ottawa Subscale of Characteristics of Self-injury Addiction item, which is used to assess NSSI addiction. The scoring criteria are consistent with the OSI-F; the internal consistency Cronbach’s α = 0.87.

The OSI scale took 15–20 min to complete.

Adolescent self-rating life events checklist

Another self-assessment was conducted using the Adolescent Self-rating Life Events Checklist (ASLEC) [31]. The duration examined by the evaluation depends on the purpose of the study and can be the most recent 3, 6, 9, or 12 months. This measure consists of 27 items and 6 dimensions covering interpersonal relationships, study pressure, punishment, loss, health adaptations, and others (nonspecified). For each event, the answer first determines whether the event happened within the limited time frame. If the event did not occur, a “0” is entered next to the item that did not occur. If the event did occur, a 5-point Likert scale is adopted according to the psychological feelings at the time of the event occurred: (1), mild (2), moderate (3), severe (4) or extremely severe (5). The higher the factor score is, the greater the impact of this type of life event. These six dimensions collectively explained 44% of the variability of the entire measure. The Cronbach’s alpha coefficient was 0.85. The Spearman-Brown corrected split-half reliability was 0.88. The test-retest reliability coefficient was 0.69.

The ASLEC scale took 5–10 min to complete.

Perceived parental rearing patterns scale

The Chinese version of the Perceived Parental Rearing Patterns Scale (Egma Minnen av Bardndosnauppforstran [EMBU]) was administered to subjects [32]. The perceived parental patterns of the subjects were assessed during the previous 12 months using the EMBU. The EMBU consists of two sections (parenting styles of the father and mother), covering 15 parental rearing patterns, as follows: abuse, parental alienation, punishment, humiliation, rejection, overprotection, overinterference, tolerance, orientation of action, attribution style, encouragement, preference for one’s siblings, preference for the subject, and nonspecific behaviours. EMBU consists of mother’s rearing patterns scale and father’s rearing patterns scale. Mother’s rearing patterns scalecan be divided into five dimensions: rejection and denial, emotional warmth, favouritism, punishment, and overprotection and interference. Father’s rearing patterns scale can be divided into six dimensions: rejection and denial, emotional warmth, favouritism, punishment, overprotection and interference. The Chinese version of the EMBU had an internal consistency reliability of 0.50–0.88, a split-half reliability of 0.50–0.82, and a test-retest reliability of 0.58–0.82. Each item was rated on a 4-point scale, depending on the frequency of events, as follows: never, occasional, often, and always. The entire EMBU scale took 15–20 min to complete.

Self-rating anxiety scale and self-rating depression scale

The Self-rating Anxiety Scale （SAS） and the Self-rating Depression Scale (SDS) took 5 min each to complete.

The Self-rating Anxiety Scale was administered to the subjects to evaluate their anxiety levels [33]. The scale consists of 20 statements and corresponding questions and uses a 4-point Likert scale, as follows: 1 = never or occasionally, 2 = sometimes, 3 = often, and 4 = always. Of the 20 items, 5 (5, 9, 13, 17, and 19) are scored in reverse order, and the remaining items are scored in positive order. The cumulative items are divided into the total score. The total score is multiplied by 1.25 to obtain the standard score. A score < 50 is normal, a score between 50 and 60 indicates mild anxiety, a score between 61 and 70 is moderately anxious, and a score ≥ 70 is severely anxious.

The SDS was administered to the subjects to evaluate their depression levels [34]. The scale contains 20 questions, each reflecting a depression-related symptom, but the 20 items can be divided into 4 depression-specific symptoms: (1) emotional symptoms, including depressive mood and crying; (2) physical disorders, including daytime differences in mood, sleep disorders, loss of appetite, loss of libido, weight loss, constipation, tachycardia, and fatigue; (3) psychomotor disorders, including psychomotor hysteresis and agitation (two items); and (4) psychological disorders of depression, including confusion, hopelessness, irritability, indecision, self-depreciation, emptiness, repeated thoughts of suicide, and dissatisfaction (8 items) [35].

The SDS uses a 4-point Likert scale, as follows: 1 = never or occasionally, 2 = sometimes, 3 = often, and 4 = always. Among the 20 items, 10 (2, 5, 6, 11, 12, 14, 16, 17, 18, and 20) are scored in reverse order, and the remaining 10 items are scored in positive order. The total score is the sum of the score for all items and is multiplied by 1.25 to obtain the standard score. A standard score < 50 points is normal, a score between 50 and 60 is mildly depressed, a score between 61 and 70 is moderately depressed, and a score ≥ 70 is severely depressed.

Statistical analysis

The completed questionnaires were retrieved and reviewed, checked, and coded. A database was built using Epidate 3.1 software. Descriptive analysis was performed for the basic demographic data. A t test, one-way ANOVA, and multiple logistics regression were carried out. All of the above analyses were performed using SPSS 22.0. A p value < 0.05 was statistically significant.

Results

Baseline information of the samples

A total of 1900 questionnaires (380 for each school) were distributed, and 1885 completed copies were retrieved and validated for a completion rate of 99.2%. The basic demographic data of the samples are shown in Table 1. The age range of the 1885 subjects was 11–16 years, with an average age of 13.08 ± 0.911 years. There were 921 boys and 964 girls.

Table 1 Basic demographic data
Full size table

Gender, age, and geographic features of subjects committing NSSIs

The gender, age, and geographic features of subjects committing NSSIs are shown in Table 2. Five hundred forty-four subjects admitted that they had at least one NSSI episode in the past 12 months, accounting for 28.9% of all subjects surveyed. The 544 students committing NSSIs (average age, 13.08 ± 0.883 years) included 172 boys and 372 girls. Of the 544 students, 228 were from rural areas, 169 were from towns, and 147 were from cities. The NSSI rate was 18.7% among boys and 38.6% among girls in the previous 12 months. One-way ANOVA indicated that girls had significantly more NSSI behaviours than boys (p < 0.001). The incidence of NSSIs did not differ significantly across the age groups (p > 0.05) or among rural areas, towns, and cities (p > 0.05).

Table 2 Gender, age, and geographic features of subjects committing NSSIs
Full size table

A total of 125 students had the idea of self-injury only but did not commit NSSI behaviours. The other 1216 students had neither ideas of self-injury nor NSSI behaviours.

People informed about the NSSI episodes

According to our survey, 544 junior high school students committed 737 NSSI events in total; however, of these events, 309,309 (41.9%) were kept secret. The friends of NSSI subjects were informed about 160 events (160/737 [21.7%]) and someone else was informed about 150 events (150/737 [20.4%]). Psychologists or other types of mental health professionals were informed about 41 events (41/737 [5.6%]), family members were informed about 27 events (27/737 [3.7%]), and other individuals were informed about 50 events (50/737 [6.8%]).

Methods and sites of self-injury

The most common method of self-injury among 544 junior high school students committing NSSIs was scratching/bruising, followed by hitting oneself, pulling out hair, biting, head banging, and cutting (Table 3). The NSSI methods of scratching/bruising, hitting oneself and cutting more commonly occurred in girls than boys (p < 0.05; Table 3).

Table 3 Gender-based differences in the self-injury method
Full size table

The most common sites of self-injury were the face, scalp, lips, forearm/elbow, axilla/wrist, hands/fingers, and thighs/knees (Table 4). The interaction analysis indicated significant differences in the distribution of self-injury sites (nose, lips, genitals, and axillae/wrists) between the two genders (p < 0.05; Table 4).

Table 4 Gender-based comparison of the site of self-injury
Full size table

Motivations for self-injury

The results of the OSI were statistically analysed, and the most common reason for NSSI was to manage negative emotions (Table 5). Girls compared to boys had significantly more of the following negative emotions and related NSSI motivations: “to vent unbearable nervousness,“ “to make my parents no longer angry with me,“ “to punish myself,“ “to distract my attention from unhappy memories,“ “to release anger,“ “to relieve sadness or stop feeling down,“ “to stop thinking about killing myself,“ “to stop myself from committing suicide” “to make myself feel a sense of realness when I feel numb and unreal,“ “to release frustrated feelings,“ and “to prove how much pain I can tolerate” (all p < 0.05; Table 5).

Table 5 Motivations for self-injury
Full size table

Factors influencing the NSSI and non-NSSI groups

According to the rank-sum test, the scores were significantly higher in the NSSI group than in the non-NSSI group in each life event dimension: interpersonal relationships, study pressure, punishment, health adaptation and others (p < 0.05; Table 6), which demonstrated that negative life events greatly influenced the students.

Table 6 Comparison of life event dimensions between the NSSI and non-NSSI groups
Full size table

In addition, the parental education level was significantly lower in the NSSI group than in the non-NSSI group based on the rank-sum test (p < 0.05; Table 7). There were also significant differences in the frequency of NSSI behaviours between subjects with varying levels of academic performance. Multiple comparisons showed a significant difference in the frequency of NSSI behaviours between subjects with good and fair academic performance. NSSI behaviours were more common in subjects with fair academic performance than in subjects with good academic performance (p < 0.05; Table 7).

Table 7 Factors influencing the NSSI and non-NSSI groups
Full size table

Comparison of depression and anxiety levels between the NSSI and non-NSSI groups

The depression and anxiety levels of the NSSI and non-NSSI groups were significantly different. Depression and anxiety were more severe in the NSSI group than in the non-NSSI group (both p < 0.05; Table 8). The ratings of depression and anxiety were higher, and the NSSI rate was higher.

Table 8 Comparison of depression and anxiety levels between the NSSI and non-NSSI groups
Full size table

The depression and anxiety levels also varied significantly between the genders, with greater severity in girls than boys (all p < 0.05; Table 9). Girls were also prone to more negative moods than boys.

Table 9 Comparison of depression and anxiety levels between genders
Full size table

Binary logistic regression of risk factors for NSSI behaviours

Based on t tests, the scores of the NSSI group were significantly lower than those of the non-NSSI group in the dimensions of parental emotional warmth and mother’s emotional warmth (both P < 0.01, Table 10). The scores of the NSSI group were significantly higher than those of the non-NSSI group in the dimensions of father punishment, father overinterference, father rejection, father overprotection, mother overinterference, mother rejection, and mother punishment (all P < 0.01, Table 10).

Table 10 Comparison of parental rearing patterns between the NSSI and non-NSSI groups (x ± s)
Full size table

A binary logistic regression analysis was carried out by treating gender, depression rating, anxiety level, life event dimensions, and mother’s rearing pattern. Notably, the father’s rearing pattern was strongly correlated with the mother’s rearing pattern, and the former dramatically interfered with the statistical results. Therefore, only the mother’s rearing pattern was included in the regression analysis, with academic performance as an independent variable and NSSI behaviour as the dependent variable. Female gender, anxiety level, depression level, interpersonal relationships, study pressure, mother’s emotional warmth, and mother’s overinterference predicted NSSI episodes longitudinally (Table 11).

Table 11 Binary logistic regression of risk factors for NSSI behaviours
Full size table

Discussion

NSSI rate and characteristics of NSSI behaviours

Five hundred forty-four subjects admitted that they had at least one NSSI episode in the previous 12 months, accounting for 28.9% of all subjects surveyed. This incidence agreed with the overall NSSI rate (27.4%) reported from an epidemiologic survey among high school students in mainland China in 2021 [10]. In addition, 125 subjects had self-injury ideations, constituting another population at higher risk for NSSIs. These subjects may continue to commit NSSIs without timely psychological intervention and help [36].

We reported a higher frequency of NSSI behaviours in girls than boys, which agreed with the findings from other studies [11, 39, 40]. Several previous studies have reported gender-related differences in NSSI surveys using different samples and found that the probability of females committing NSSIs is higher than that of males [2, 8, 11, 22, 37, 39]. Such a prevalent gender-related difference can be attributed to the fact that NSSI is a way to eliminate negative emotions [37]. Emotional disorders, such as anxiety and depression, are also factors that influence NSSI behaviours [41, 42]. According to studies at home and abroad, mood disorders, such as anxiety and depression, are more prevalent in females than males [43]. Therefore, girls commit NSSI more commonly than boys.

Our study found that junior high school students committing NSSIs were 11–16 years of age, with an average age of 13.08 ± 0.911 years, which is consistent with a previous report that the average age of the first NSSI was 11–15 years [44].

Methods and sites of NSSIs

The most common method of NSSI was scratching/bruising, followed by hitting oneself, pulling out hair, biting, head banging, and cutting in the sample population. The NSSI methods of scratching/bruising, hitting oneself and cutting more commonly occurred in girls than boys. Some researchers have suggested that cutting is the most common method of self-injury, but biting and hitting oneself are also common [14, 17, 40]. Most studies involving NSSIs agree that cutting is the most common method of self-injury among females. Males, in contrast, prefer more violent ways to harm themselves, such as hitting, burning, or banging one part of the body [6, 14, 40]. The above disagreement in study findings might be explained by the difference in the proportion of males and females committing self-injury. In the current study, girls committing NSSIs outnumbered their male counterparts, which is similar to a previous report [38]. Some females may harm themselves in a conspicuous way to attract attention from more people and hence to obtain emotional support [5, 6, 8, 39, 45].

Unlike studies on self-injury methods, few studies have included self-injury sites. In this study, the most common sites of self-injury were the face, scalp, lips, forearm/elbow, axilla/wrist, hands/fingers, and thighs/knees. Significant differences in the distribution of self-injury sites (nose, lips, genitals, and axillae/wrists) were found between the two genders. Boys were more likely to injure their genitals than girls, which agrees with the findings from a previous study [46].

Motivations and risk factors for NSSI behaviours

Our survey proved that releasing negative emotions is the most common motivation for NSSIs, which agreed with previous studies involving NSSIs at home and abroad [14, 16, 17]. Considering and using NSSIs as a strategy to regulate emotions is highly correlated with emotional instability and dysregulation. For example, Ross et al. [47] administered a survey to 400 adolescents and showed that those committing NSSIs were more likely to have defects in emotion recognition and integration. Biologically, some parts of the brain change due to rapid physical development during adolescence. Such changes are usually related to cognitive functions, especially emotional regulation [48]; however, the ability to control behaviours and regulate emotions (i.e., executive function) usually matures at varying rates on the physiologic scale. Neurologic development related to behavioural control takes place at a much lower rate. The above two facts jointly explain the weaker ability to control impulsive behaviours and emotions among adolescents [9, 47, 48].

The percentage of girls committing NSSIs was significantly higher than that of boys, and gender was a risk factor for NSSI behaviours in adolescents. The above finding agreed with other studies at home and abroad [2, 8, 14, 39, 49]. It has been established that the oestrogen level increases significantly in adolescent girls, resulting in higher emotional reactivity. Therefore, adolescent girls are more likely to have violent mood swings than their male counterparts [8, 27, 43, 52].

The mainstream theories relating to NSSIs generally hold that negative emotions are among the most important factors inducing NSSIs. Multivariate logistic regression showed that depression and anxiety symptom scores were positively correlated with NSSI behaviours. Depression and anxiety are proven risk factors for NSSIs in adolescents. The above results agreed with other studies at home and abroad [14,15,16,17, 49, 50].

The correlations between anxiety and depression and NSSI behaviours in adolescents can be explained by the mainstream theories related to NSSIs. Bentley and Nock [37] proposed a four-function model of NSSIs that suggests that the most important intrinsic motivation to trigger NSSI behaviours is to alleviate the intense negative emotions deep inside. It has been emphasized by other studies that according to the experiential avoidance model, NSSI is an avoidance behaviour that enables individuals to avoid unwanted emotions, thoughts, memories, and/or somatic sensations and to narrow attention to immediate sensations [51].

Notably, our gender-based analysis of negative emotions showed that girls had higher anxiety and depression levels than boys. Our results agreed with those on the gender-based differences in emotional functions at home and abroad. Compared with males, females are more likely to internalize external pressures into their own emotional disturbance, resulting in negative emotions, such as anxiety and depression [25, 27, 53, 45]. Higher levels of pressure from interpersonal relationships or other life events may be closely related to an increase in the frequency of NSSI episodes and expectations about depression symptoms among females [25].

Life events refer to social experiences or changes with a specific onset and course that have a psychological impact on the individual. Previous studies have demonstrated that negative life events may serve as proximal risk factors for NSSIs and can be used to predict NSSI episodes [26,27,28, 54]. The NSSI group scored significantly higher in all life event dimensions than the non-NSSI group. Further analysis showed that for the NSSI group, the life event dimensions of interpersonal relationships, study pressure, and something else were positively correlated with NSSI behaviours. These results agreed with other studies at home and abroad [26,27,28,29, 54]. According to the Bentley and Nock four-function model, NSSI behaviours are a maladaptive coping strategy for individuals to adjust interpersonal relationships or avoid interpersonal pressure [38]. Given the psychological immaturity of adolescents, they may resort to NSSI to cope with conflicts with parents or peers when they feel interpersonal pressure [23, 38].

The parental rearing pattern refers to a fixed mode of action that can be perceived in parents rearing their children. The results of this survey showed that mothers’ emotional warmth was a protective factor for NSSIs, while mothers’ overinterference was a risk factor for NSSIs. Negative parental rearing patterns are considered important risk factors for NSSIs, while positive parental rearing patterns reduce the incidence of NSSIs among adolescents [4, 5, 22, 24, 55, 56]. It has been shown that parents play a crucial role in guiding children’s emotional socialization. According to family invalidation theory, parental rearing patterns lie at the core of family invalidation. Negative parental rearing patterns, such as punishment, neglect, criticism, and denial, may result in failure to respond to children’s basic emotional needs. Children brought up in such a family environment may be unable to express their emotions via healthy pathways. Rather, children’s ability to regulate and express their emotions will be repressed, and their emotional regulation function tends to become pathologic [57]. Adolescents growing up in an invalidating family are vulnerable to emotional and cognitive defects and usually fail to adopt adaptive coping strategies in the face of overwhelmingly negative emotions but resort to NSSI [22, 56]. As analysed above, NSSI behaviours may be the result of specific parental rearing patterns.

This study has provided new information on the risk factors associated with NSSIs by investigating the influence of internal and external factors so that parents, teachers, and psychological professionals can better understand the epidemiologic characteristics of adolescent nonsuicidal NSSIs and the possible causes of NSSIs. In addition, our study has provided a reference for early prevention and intervention measures for nonsuicidal NSSIs. Additionally, to be clear, this was not a clinical study because the subjects were adolescents in a school setting, not patients in a health care setting.

Limitations

NSSI behaviours are usually concealed and associated with a sense of shame. These reasons might have resulted in a low exposure rate of NSSI behaviours. The prevalence of NSSIs might have been underestimated in the present study. In addition, all of the scales used were self-rating scales, and the subjects were asked to recall whether they had committed NSSIs in the past 12 months. In this case, report and recall biases were inevitable. Finally, all samples were collected from multiple centres located in the same geographic region, and the findings may not apply to other geographic regions.

Conclusion

The NSSI rate among junior high school students in Hainan was 28.9%, affecting girls more than boys. The form and site of self-injury between boys and girls were significantly different. The motivation for committing self-injurious behaviours was mainly to regulate bad emotions. Risk factors for NSSI behaviours included female gender, anxiety, depression, interpersonal relationship factors, academic stress factors, and maternal emotional overinterference, while maternal emotional warmth was a protective factor.

Data Availability

All data analysed during this study are included in this published article.

Abbreviations

ASLEC:

Adolescent Self-rating Life Events Checklist

NSSI:

Nonsuicidal self-injury

OSI-F:

Ottawa Self-injury Inventory-Functions

OSI:

Ottawa Self-injury Inventory

References

  1. Vega D, Sintes A, Fernández M, Puntí J, Soler J, Santamarina P, et al. Review and update on non-suicidal self-injury: who, how and why? Actas Esp Psiquiatr. 2018;46:146–55.

    PubMed  Google Scholar 

  2. Baetens I, Claes L, Onghena P, Grietens H, Van Leeuwen K, Pieters C, et al. Non-suicidal self-injury in adolescence: a longitudinal study of the relationship between NSSI, psychological distress and perceived parenting. J Adolesc. 2014;37:817–26.

    Article  PubMed  Google Scholar 

  3. Mannekote Thippaiah S, Shankarapura Nanjappa M, Gude JG, Voyiaziakis E, Patwa S, Birur B, et al. Non-suicidal self-injury in developing countries: a review. Int J Soc Psychiatry. 2021;67:472–82.

    Article  PubMed  Google Scholar 

  4. Bureau JF, Martin J, Freynet N, Poirier AA, Lafontaine MF, Cloutier P. Perceived dimensions of parenting and non-suicidal self-injury in young adults. J Youth Adolesc. 2010;39:484–94.

    Article  PubMed  Google Scholar 

  5. Tschan T, Schmid M, In-Albon T. Parenting behavior in families of female adolescents with nonsuicidal self-injury in comparison to a clinical and a nonclinical control group. Child Adolesc Psychiatry Ment Health. 2015;9:17.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Baetens I, Claes L, Hasking P, Smits D, Grietens H, Onghena P, Martin G. The relationship between parental expressed emotions and non-suicidal self-injury: the mediating roles of self-criticism and depression. J Child & Family Studies. 2015;24:491–8.

    Article  Google Scholar 

  7. Briere J, Gil E. Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry. 1998 Oct;68(4):609–20. https://doi.org/10.1037/h0080369. PMID: 9809120.

  8. Monto MA, McRee N, Deryck FS. Nonsuicidal self-Injury among a representative sample of US adolescents, 2015. Am J Public Health. 2018;108:1042–8.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lim KS, Wong CH, McIntyre RS, Wang J, Zhang Z, Tran BX, et al. Global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-Injury in children and adolescents between 1989 and 2018: a meta-analysis. Int J Environ Res Public Health. 2019;16:4581.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Han A, Xu G, Su P. A meta-analysis of the prevalence of non-suicidal self-injury among middle school students in mainland China. Chin J School Health. 2017;38:1665–70.

    Google Scholar 

  11. Liu X, Liu ZZ, Jia CX. Repeat self-harm among chinese adolescents: 1-year incidence and psychosocial predictors. Soc Psychiatry Psychiatr Epidemiol. 2021;56:1979–92.

    Article  PubMed  Google Scholar 

  12. Kiekens G, Hasking P, Claes L, Boyes M, Mortier P, Auerbach RP, et al. Predicting the incidence of non-suicidal self-injury in college students. Eur Psychiatry. 2019;59:44–51.

    Article  PubMed  Google Scholar 

  13. Nock MK. Why do people hurt themselves? New insights into the nature and functions of self-Injury. Curr Dir Psychol Sci. 2009;18:78–83.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Naidoo S. The prevalence, nature, and functions of non-suicidal self-injury (NSSI) in a south african student sample. S Afr J Educ. 2019;39:1–10.

    Google Scholar 

  15. Nock MK, Mendes WB. Physiological arousal, distress tolerance, and social problem-solving deficits among adolescent self-injurers. J Consult Clin Psychol. 2008;76:28–38.

    Article  PubMed  Google Scholar 

  16. Taylor PJ, Jomar K, Dhingra K, Forrester R, Shahmalak U, Dickson JM. A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J Affect Disord. 2018;227:759–69.

    Article  PubMed  Google Scholar 

  17. You J, Lin MP, Leung F. A longitudinal moderated mediation model of nonsuicidal self-injury among adolescents. J Abnorm Child Psychol. 2015;43:381–90.

    Article  PubMed  Google Scholar 

  18. Yang J, Chang LJ, Li YD. Influence of parental rearing patterns on individual psychology and brain development. Psychologies Magazine. 2022;17:237–40.

    Google Scholar 

  19. Cai M, Hardy SA, Olsen JA, Nelson DA, Yamawaki N. Adolescent-parent attachment as a mediator of relations between parenting and adolescent social behavior and wellbeing in China. Int J Psychol. 2013;48:1185–90.

    Article  PubMed  Google Scholar 

  20. Garcia OF, Serra E. Raising children with Poor School performance: parenting Styles and short- and long-term consequences for adolescent and adult development. Int J Environ Res Public Health. 2019;16:1089.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Braza P, Carreras R, Munoz JM, Braza F, Azurmendi A, Pascual-Sagastizabal E et al. Negative maternal and paternal parenting styles as predictors of children’s behavioral problems: moderating effects of the child’s sex. J Child Fam stud. 2015; (24 – 4).

  22. Haine RA, Wolchik SA, Sandler IN, Millsap RE, Ayers TS. Positive parenting as a protective resource for parentally bereaved children. Death Stud. 2006;30:1–28.

    Article  PubMed  Google Scholar 

  23. Victor SE, Hipwell AE, Stepp SD, Scott LN. Parent and peer relationships as longitudinal predictors of adolescent non-suicidal self-injury onset. Child Adolesc Psychiatry Ment Health. 2019;13:1.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Emery AA, Heath NL, Rogers M. Parents’ role in early adolescent self-injury: an application of self-determination theory. Sch Psychol Q. 2017;32:199–211.

    Article  PubMed  Google Scholar 

  25. Burke TA, Hamilton JL, Abramson LY, Alloy LB. Non-suicidal self-injury prospectively predicts interpersonal stressful life events and depressive symptoms among adolescent girls. Psychiatry Res. 2015;228:416–24.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Nishikawa S, Fujisawa TX, Kojima M, Tomoda A. Type and timing of negative life events are associated with adolescent depression. Front Psychiatry. 2018;9:41.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Gao Y, Wang H, Liu X, Xiong Y, Wei M. Associations between stressful life events, non-suicidal self-injury, and depressive symptoms among chinese rural-to-urban children: a three-wave longitudinal study. Stress Health. 2020;36:522–32.

    Article  PubMed  Google Scholar 

  28. Lan T, Jia X, Lin D, Liu X. Stressful life events, depression, and non-suicidal self-injury among chinese left-behind children: moderating effects of self-esteem. Front Psychiatry. 2019;10:244.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Mo J, Wang C, Niu X, Jia X, Liu T, Lin L. The relationship between impulsivity and self-injury in chinese undergraduates: the chain mediating role of stressful life events and negative affect. J Affect Disord. 2019;256:259–66.

    Article  PubMed  Google Scholar 

  30. Zhang F, Cheng W, Xiao Z, Liu W. Study on reliability and validity of chinese version of Ottawa self-injury inventory. J Shanghai Jiao Tong Univ (Medical Science). 2015;35:460–4.

    Google Scholar 

  31. Liu X, Liu L, Yang J, Chai F, Wang A, Sun L, et al. The adolescent self-rating life events checklist and its reliability and validity. Chin J Clin Psychol. 1997;5:34–6.

    Google Scholar 

  32. Yue D. Egma Minnenav Bardndosnauppforstran in Chinese. 2011.

  33. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12:371–9.

    Article  PubMed  Google Scholar 

  34. Zung WW. A self-rating depression scale. Arch Gen Psychiatry. 1965;12:63–70.

    Article  PubMed  Google Scholar 

  35. Zung WW, Richards CB, Short MJ. Self-rating depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry. 1965;13:508–15.

    Article  PubMed  Google Scholar 

  36. Watanabe N, Nishida A, Shimodera S, Inoue K, Oshima N, Sasaki T, et al. Help-seeking behavior among japanese school students who self-harm: results from a self-report survey of 18,104 adolescents. Neuropsychiatr Dis Treat. 2012;8:561–9.

    PubMed  PubMed Central  Google Scholar 

  37. Bentley KH, Cassiello-Robbins CF, Vittorio L, Sauer-Zavala S, Barlow DH. The association between nonsuicidal self-injury and the emotional disorders: a meta-analytic review. Clin Psychol Rev. 2015;37:72–88.

    Article  PubMed  Google Scholar 

  38. Bentley KH, Nock MK, Barlow DH. The four-function model of nonsuicidal self-Injury. Clin Psychol Sci. 2014;2:638–56.

    Article  Google Scholar 

  39. Plener PL, Schumacher TS, Munz LM, Groschwitz RC. The longitudinal course of non-suicidal self-injury and deliberate self-harm: a systematic review of the literature. Borderline Personal Disord Emot Dysregul. 2015;2:2.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Zetterqvist M, Lundh LG, Dahlström O, Svedin CG. Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. J Abnorm Child Psychol. 2013;41:759–73.

    Article  PubMed  Google Scholar 

  41. Xiao Y, He L, Chen Y, Wang Y, Chang W, Yu Z. Depression and deliberate self-harm among chinese left-behind adolescents: a dual role of resilience. Asian J Psychiatr. 2020;48:101883.

    Article  PubMed  Google Scholar 

  42. Zhu J, Chen Y, Su B, Zhang W. Anxiety symptoms mediates the influence of cybervictimization on adolescent non-suicidal self-injury: the moderating effect of self-control. J Affect Disord. 2021;285:144–51.

    Article  PubMed  Google Scholar 

  43. Bangasser DA, Cuarenta A. Sex differences in anxiety and depression: circuits and mechanisms. Nat Rev Neurosci. 2021;22:674–84.

    Article  PubMed  Google Scholar 

  44. Glenn CR, Lanzillo EC, Esposito EC, Santee AC, Nock MK, Auerbach RP. Examining the course of suicidal and nonsuicidal self-injurious thoughts and behaviors in Outpatient and Inpatient Adolescents. J Abnorm Child Psychol. 2017;45:971–83.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Karen D, Rudolph (2002) Gender differences in emotional responses to interpersonal stress during adolescence Journal of Adolescent Health 30(4) 3–13. https://doi.org/10.1016/S1054-139X(01)00383-4.

  46. Veeder TA, Leo RJ. Male genital self-mutilation: a systematic review of psychiatric disorders and psychosocial factors. Gen Hosp Psychiatry. 2017;44:43–50.

    Article  PubMed  Google Scholar 

  47. Ross S, Heath NL, Toste JR. Non-suicidal self-injury and eating pathology in high school students. Am J Orthopsychiatry. 2009;79:83–92.

    Article  PubMed  Google Scholar 

  48. Giedd JN. The teen brain: insights from neuroimaging. J Adolesc Health. 2008;42:335–43.

    Article  PubMed  Google Scholar 

  49. Hankin BL, Abela JR. Nonsuicidal self-injury in adolescence: prospective rates and risk factors in a 2½ year longitudinal study. Psychiatry Res. 2011;186:65–70.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Uh S, Dalmaijer ES, Siugzdaite R, Ford TJ, Astle DE. Two pathways to self-harm in adolescence. J Am Acad Child Adolesc Psychiatry. 2021;60:1491–500.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav Res Ther. 2006;44:371–94.

    Article  PubMed  Google Scholar 

  52. Yang X, Feldman MW. A reversed gender pattern? A meta-analysis of gender differences in the prevalence of non-suicidal self-injurious behaviour among chinese adolescents. BMC Public Health. 2017;18:66.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Keenan K, Hipwell AE, Stepp SD, Wroblewski K. Testing an equifinality model of nonsuicidal self-injury among early adolescent girls. Dev Psychopathol. 2014;26:851–62.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Steinhoff A, Bechtiger L, Ribeaud D, Eisner M, Shanahan L. Stressful life events in different social contexts are associated with self-injury from early adolescence to early adulthood. Front Psychiatry. 2020;11:487200.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Liu Y, Xiao Y, Ran H, He X, Jiang L, Wang T, et al. Association between parenting and non-suicidal self-injury among adolescents in Yunnan, China: a cross-sectional survey. PeerJ. 2020;8:e10493.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Wadman R, Vostanis P, Sayal K, Majumder P, Harroe C, Clarke D, et al. An interpretative phenomenological analysis of young people’s self-harm in the context of interpersonal stressors and supports: parents, peers, and clinical services. Soc Sci Med. 2018;212:120–8.

    Article  PubMed  Google Scholar 

  57. Mantovani M L, Sanza M. Marsha M. Linehan, Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press, 1993, pp. 55[J]. Psicoterapia e Scienze Umane, 1994, 28(2): 131–137.

Download references

Acknowledgements

None.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Hospital Infection-control, the First Hospital of Hainan Medical University, Haikou City, Hainan Province, 570102, China

    Siying Ma

  2. Department of Psychology, the First Hospital of Hainan Medical University, No. 29 Yilong West Road, Longhua District, Haikou City, Hainan Province, 570102, China

    Zhaoxia Su

Authors
  1. Siying Ma
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Zhaoxia Su
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SYM: guarantor of integrity for the entire study, literature search, data acquisition, data analysis, manuscript editing, definition of intellectual content, study concepts, and study design; ZXS: guarantor of integrity for the entire study, literature search, data acquisition, statistical analysis, manuscript editing, manuscript review. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Zhaoxia Su.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the First Hospital of Hainan Medical University. Before the survey formally began, the guardians of the subjects signed the informed consent form; anonymity was assured. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ma, S., Su, Z. Current status of nonsuicidal injuries and associated factors among junior high school students in Hainan Province, China: a cross-sectional study. BMC Psychol 11, 199 (2023). https://doi.org/10.1186/s40359-023-01227-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s40359-023-01227-x

Keywords

BMC Psychology

ISSN: 2050-7283

Contact us