Non-suicidal self-injury (NSSI) and suicidal ideation are major health concerns among adolescents worldwide [1-4]. Although suicidal ideation broadly refers to thoughts about dying or wanting to die as well as the formation of plans to die [5], NSSI is distinctive in that the intention is not to die. Specifically, NSSI refers to deliberate self-inflicted damage to one’ s own body tissue by methods such as cutting, scratching, and self-hitting that leads to tissue damage without conscious suicidal intent and for reasons not socially sanctioned [6].
In China, the problem of suicide and NSSI, especially among adolescents, is more severe compared to Western studies [3,4], yet much of the literature on life threatening behavior stems from research within Western populations [2, 7]. This has resulted in much of the present theory on life threatening behaviors as well as the clinical implications to be based on Western populations, which largely ignores the nuances found in other cultural contexts [8].
A study surveying nearly 1,000 university students in China revealed that 35.2% have engaged in NSSI behaviors in their lifetime [9], which is nearly double the prevalence rate among university students from the U.S. and Canada [10]. Furthermore, the prevalence of NSSI in China appeared quite higher among adolescents, where research based on a research sample of 2120 middle school students has found that 57.4% have engaged in NSSI behaviors [11]. This study also suggests a much higher rate of engagement in NSSI over the past year and an earlier age of onset relative to much of the research from Western contexts [9-11].
Meanwhile, relevant studies have also revealed the seriousness of suicidality in Chinese adolescents can not be ignored. The results of suicidal ideation and attempted suicide behavior surveys published after the year 2010 in different cities of China showed that the annual prevalence of suicidal ideation was between 13.2%-28.0%, and the prevalence of attempted suicide was between 1.2%-4.0% [12-14]. Moreover, Gao conducted a survey among 2,416 primary and middle school students in Shanghai and found that the prevalence of suicidal ideation was 15.23%, suicide plan was 5.84%, and attempted suicide was 1.74% [15]. Unlike most countries where the suicide rate of male adolescents is higher than that of females, the characteristics of suicidal behavior among Chinese adolescents were found to be somewhat different whereby the suicide rate is higher among females compared to males, and female adolescents report more suicidal ideation than male adolescents [12-15].
As such, there is a need for further investigations aimed at better understanding NSSI and suicidality among Chinese adolescents, and the possible mechanisms that might contribute to both increased suicidality and greater endorsement of NSSI behaviors. Several studies have found excessive Internet use to be associated with both NSSI and suicidality among young people [16-19], however, the exact mechanism by which Internet use contributes to either NSSI or suicidality remains unclear.
A link between Internet use frequency and NSSI/suicidal ideation among adolescents
Internet use is especially frequent and widespread among adolescents both in China and the United States, with about 80% of adolescents using the Internet regularly [19, 20]. Adolescents are increasingly relying on the Internet as a primary mode of communication, whether for emails or for social softwares. One particular purpose might be for support from others through discussion forums or private messaging. According to the results of a study based on 856 adolescents' Internet use frequency and preference, almost all adolescents have used the Internet to fufill their social and daily needs. Only 4 of them have never used any online media, and 852 people have actually used online media as a daily communication tool, accounting for 99.53%. Among the many ways of using Internet, social software is the most popular among adolescents, and more than half of them have used social software (474, 55.63%). Among them, 340 male users accounted for 73.27%, followed by Instant Messaging (IM) software (392 people, 46.01%), Video software (374 people, 43.90%), Shopping software (392 people, 46.01%) )Knowledge Sharing software (374 people, 43.90%), however, relevant research did not report whether gender differences exist in the above data [21]. Furthermore, mutiple studies also indicated that no significant difference was found in Internet usage preference among different age groups [21-24].
Theoretically speaking, this developmental phenomenon might be explained in two opposite sides: the potential benefits of the Internet the Internet itself provides a powerful resource for young people who want information on socially sensitive topics, such as sexual perplexity, interpersonal relationships and NSSI/Suicidal related issues [25]. This form of communication style is specifically beneficial for shy, socially anxious or marginalized young people, enabling them to improve their social communication skills without having to take the risks associated with "face to face" interactions [26, 27]. In addition, online communication may encourage more authentic communication, many adolescents admit that they are more willing to share their “real thoughts and feelings” online than when they are in real-life communication [28]. Obviously, the Internet is impacting on the social environment of adolescents, by affecting their ways of communication, establishment and maintenance of interpersonal relationship, and seeking for social support.
Notwithstanding the potential benefits of the Internet such as making communication more accessible, research has found the excessive reliance upon the Internet to be associated with psychological and physical harms (e.g., isolated, extreme and poor communication). For instance, several studies among Chinese middle school students who engaged in excessive Internet use reported adverse physical consequences such as shoulder pain caused by prolonged poor posture when sitting, decreased visual perception loss of appetite, decreased sleep quality as well as decreases in immune function [28]. Students also reported psychological consequences including difficulties with self-control, more social avoidance and negative coping [29], increased levels of perceived emotional and social loneliness which lead to lose oneself in social role [30].
Furthermore, research has focused on the effect of Internet use may have on the likelihood of adolescents engaging in life threatening behaviors [31]. Research suggests that adolescents who experience suicidal thoughts or engage in NSSI behaviors appear to use the Internet to seek out specific discussion forums for support [32]. A review of the Chinese instant messaging software QQ revealed that the popular online platform was hosting more than 600 groups pertaining to suicide and self-injury [33]. However, these forums and online spaces are often not monitored or moderated therefore individuals can be exposed to inaccurate and/or harmful information about suicide and NSSI [34]. As a result, the openness, virtuality and exemption of the Internet make information about NSSI or suicide online easily accessible [35], and discussing online with people who are also interested in suicide and NSSI related topics may lead to the encouragement of suicide and NSSI [36, 37]. According to Messias and her colleagues, daily use of the Internet for more than 5 hours was closely related with higher levels of depression and suicidality (both ideation and attempts) among adolescents [34]. Another critical phenomenon is that adolescents with potential NSSI thoughts or suicidal ideation might search the Internet for contents about NSSI or suicide related information. For example, those people who have the history of engaging in NSSI or suicidal behavior can easily connect with people who are now engaging in these health risk behaviors, while those who are curious about NSSI and suicidal behaviors will directly get linked to a unprotected world of content about NSSI and suicidal behaviors [36]. Thus, these related studies above indicate that excessive Internet use could be a risk factor for adolescents’ engagement in NSSI and suicidal behaviors [36-39]. Therefore, the Internet may play as a powerful double-edged sword in supporting individuals’ suicidality as well as their endorsement of NSSI behaviors.
Besides, although NSSI behaviors and suicidal ideation are two completely isolated and different concepts, their differences varied in intention, lethalities, methods, cognition, and results [40], studies have revealed that there is a highly similarity and inherent compatibility between NSSI behaviors and suicidal ideation. Firstly, individuals who had history of NSSI or suicidal ideaion had the same psychological characteristics, which may be a negative response to bad emotions, an extreme feedback to various problems in the growing stage, or a means to attract attention and obtain a sense of existence. Secondly, NSSI behaviors can be an effective power of avoidance and control against suicidal ideation [41].Thirdly, a large number of empirical data showed that there are links existing between NSSI and suicidal ideation. Laye-Gindhu conducted a survey among 424 adolescents in Canada, found that the intensity of suicide ideation among NSSI group was significantly higher than that of non NSSI group [42]. Meanwhile, 89% of the respondents who attempted suicide had experience of NSSI [43]; other research pointed out that many people who had NSSI also had suicidal ideation in the past [44, 45]. Finally, Firestone analyzed a negative thought pattern aiming at terminating the coherence of suicidality, then confirmed that there was a direct relationship between NSSI, suicidal ideation and the negative thought pattern [46]. Moreover, studies have found that different demographic variables (e.g., age, only-child, parents’s educational level, etc) had striking links between individual’s Internet usage and life-threatning behavior (e.g., NSSI, Suicidal ideation, etc). According to related studies, elder adolescents in Senior high school with higher reliance on the Internet seemed to have a higher possiblity of transformation of Internet addiction, which could be a risk factor to individual’s life-threatning behavior, comparing to those younger adolescents in Junior high school [47]; In Wang’s study, she claimed that with less family emotional care and attention, parents' divorce and lower education level of parents would increase the frequency on adolescents’ Internet usage, which could directly increase the risk level of their Internet addiction, causing higher possibility of life-threatning behavior to emerge [28]; Additionally, several Chinese studies have found that, compared with the only child, the non only child will receive less emotional care and attention from their parents, which will lead to more free time for them to have on-line activities, thus creating a higher possibility of Internet addiction, which also could be threatening to their physical and mental health [48-50]. Thus, it is necessary to analyze NSSI behaviors and suicidal ideation as common dependent variables to study the impacting mechanism of Internet use frequency and other demograhic variables with them furthermore.
The Gaps
Although Western literature hints that Internet use may be important variable to study when examining NSSI and suicidal behaviors [51-52], little is known about the role of Internet use frequency in NSSI and suicidal behaviors among Chinese adolescents. The consequences of Internet use frequency as a risk factor for NSSI engagement and suicidal thoughts and/or behaviors among Chinese adolescents remains to be investigated.
Meanwhile, findings using gender analysis reported gender differences in the prevalence of NSSI. The prevalence of NSSI behavior among female adolescents was higher than that of males, and therefore was viewed as a “feminine” behavior [53-55]. A recent meta-analysis also found a female bias in NSSI prevalence among adolescents worldwide [56].
For suicidality, Kõlves’s team found that in comparison with female adolescents, the risk of suicidal ideation among males has increased in recent years [57]. According to Freeman and colleagues, suicidal ideations were rated significantly more frequently in males than females [58].
But our recent research on NSSI and suicidality in China found no studies among adolescents have specifically analyzed gender differences in the context of Internet use frequency, NSSI and suicidal ideation. Since NSSI and suicidality have always been the forefront of related psychological, sociological and demographic research [59-64], which helps to explain this gender bias, it is suggested that special attention should be paid to whether there are gender differences in the relation between Internet use frequency, NSSI and suicidal ideation under Chinese context.
Thus, the overarching objective of this paper is to examine the relation between gender, Internet use frequency, NSSI, and suicidal ideation among adolescents in China. Specifically, this study seeks to (1) assess whether any gender differences in Internet use frequency, NSSI and suicidal ideations exist among adolescents ; (2) whether Internet use frequency will act as a risk factor for NSSI and suicidal ideation engagement within this group.
3 hypotheses associated which each of the 2 objectives above are as follows:
H1: There will be gender differences in different kinds of Internet use frequency.
H2: NSSI engagement and suicidal ideation will be more prevalent among females.
H3:Different categories of Internet use frequency will all positively predict engagement in NSSI and suicidal ideation among adolescents indicating them as risk factors.