DOI: https://doi.org/10.21203/rs.3.rs-1860490/v1
Background: Although child maltreatment (CM) experiences are recognized risk factors for Nonsuicidal self-injury (NSSI), the mechanisms underlying this relationship remain unclear. The purpose of this study was to examine if difficulty in emotion regulation (DER) and depressive symptoms mediate between child maltreatment experiences and NSSI severity, adjusting for demographic variables.
Method: Participants were 224 adolescent inpatients recruited from a hospital in China (mean age 15.30 years, SD=1.83; 78.6% females). Study measures included Clinician-Rated Severity of Nonsuicidal Self-Injury (CRSNSSI), Childhood Trauma Questionnaire (CTQ-SF), Difficulties in Emotion Regulation Scale (DERS), and Patient Health Questionnaire-9 (PHQ-9). The hypothesized chain mediation model was tested using the structural equation model.
Results: 146 (65.18%) adolescents reported engaging in NSSI during the past 12 months and 103 (45.98%) participants met the DSM-5 diagnostic criteria for NSSI. emotional neglect (48.1%) and emotional abuse (46.1%) had the highest prevalence, followed by physical neglect (43.1%) and physical abuse (24.1%) and sexual abuse (12.5%) was the least prevalent form of CM. The DER or depressive symptoms significant-ly mediated the association between CM and NSSI, DER was the strongest mediator with an indirect effect of 49.40% (p=0.014). At the same time, we also proved a potential chain-mediated pathway of DER and depression between CM and NSSI.
Conclusion: Child Maltreatment and NSSI are indeed, common among Chinese psychiatric patients. DER may be an important proximal mechanism linking CM and adolescent NSSI, but not depressive symp-toms, findings from the study have implications for preventing and treating NSSI in youth with CM history.
Nonsuicidal self-injury (NSSI) refers to deliberately damaging one's body tissue without lethal intent; NSSI typically involves cutting, scratching, burning, and banging(Nock, 2010). Epidemiological research consistently indicates higher prevalence rates of NSSI in teenagers than in adults (Swannell, Martin, Page, Hasking, & St John, 2014). The overall lifetime prevalence of NSSI is 19.4–26.7% among adolescents, and it is more common in girls than in boys (risk ratio 1.72) (Bresin & Schoenleber, 2015; Gillies et al., 2018). NSSI is increasingly recognized as a significant public health concern because of its high prevalence and because NSSI is associated with several internalizing and externalizing disorders(MeszarosHorvath & Balazs, 2017)and is considered to be a strong predictor of suicidal behavior(Mars et al., 2019). Identifying risk factors for adolescent NSSI is critical to understanding its mechanism, early prevention, and treatments.
Growing researches focus on potential mechanisms of child maltreatment (CM) experiences leading to NSSI. As distal risk factors for NSSI (Nock, 2010), CM includes five aspects: emotional abuse (EA), physical abuse (PA), sexual abuse (SA), emotional neglect (EN), and physical neglect (PN). CM is generally considered a risk factor for many psychopathological and behavioral problems. A substantial amount of research has demonstrated that CM experiences are associated not only with higher rates of NSSI (Brown et al., 2018; Johnstone et al., 2016; Martin, Raby, Labella, & Roisman, 2017) but also with depression (LeMoult et al., 2020) and difficulty in emotion regulation (DER) (Wolff et al., 2019).
Although the association between CM exposure and NSSI behavior is well-established, the mechanisms linking CM to adolescent NSSI remain unclear (Bentley, Nock, & Barlow, 2014; Nock, 2009). Nonetheless, adolescents with NSSI behavior are often accompanied by obvious depressive symptoms, and the primary purpose of self-injury is to regulate emotions (Taylor et al., 2018). Therefore, DER and depression appear to be two more promising pathways supported by the current body of studies (Brown et al., 2018; ShenkNoll & Cassarly, 2010). However, these studies have only been conducted in nonclinical or small samples (Titelius et al., 2018).
DER is a comprehensive concept, including six aspects such as impulse control difficulties, self-perceived limited access to strategies, lack of emotional clarity, and others. DER is commonly caused by genetic disposition and adverse social environments such as CM (Paulus, Ohmann, Möhler, Plener, & Popow, 2021). DER exacerbates various mental disorders, like depression (Demirci, 2018; Paulus et al., 2021). Therefore, DER is generally believed to precede the onset of depressive symptoms (Crow, Cross, Powers, & Bradley, 2014; Folk, Zeman, Poon, & Dallaire, 2014), but other research has also shown that DER is a mediator between childhood emotional abuse and current depression (Crow et al., 2014).
In summary, multiple pathways linking NSSI and CM have been proposed for the adolescent population. The current study aimed to test the mediational roles of depressive symptoms and DER to identify different pathways between NSSI and CM to develop relevant clinical targets when treating such behavior. There were two main hypotheses tested in this study. First, depression and DER will mediate the relationship between CM and NSSI when estimated in individual mediator tests. Second, CM would also reveal indirect effects on NSSI via the chain mediating effect of DER and depression. Simultaneously, each direct or indirect path will be estimated to determine its effect size in explaining the pathway from CM to NSSI.
A total of 245 adolescents from the Affiliated Hangzhou First People's Hospital of Zhejiang University in Hangzhou city of China were enrolled in our study. Participants were adolescents (aged 12 to 18 years) admitted to a psychiatric inpatient unit. The recruitment period lasted more than two years, from August 2019 to November 2021. Two trained clinical psychiatrists independently conducted the patient's psychiatric history and made a diagnosis for the same patient according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria. Exclusion criteria were a current or past diagnosis of schizophrenia spectrum disorders, mental retardation, or gross cognitive impairment. Eligible participants and their guardians were asked whether they were willing to participate. After providing their written informed consent, the participants were asked to complete a comprehensive questionnaire to collect demographic information and data on child maltreatment, emotion regulation difficulties, and the severity of depression. The severity of NSSI behaviors was assessed by clinicians using Clinician-Rated Severity of NonSuicidal Self-Injury (CRSNSSI-DSM-5) through structured interviews at hospital admission. The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of the Affiliated Hangzhou First People’s Hospital of Zhejiang University (IRB: 2020-K008–01, January 2020).
Twenty-one participants were excluded as they did not complete the questionnaire. Finally, a total of 224 participants were included in the current analysis. In this study, the mean age of the sample was 15.30 years (SD = 1.83, range:12–18 years), 78.6% were female, and the mean education of the sample was 9.54 years (SD = 1.97, range:6–13 years). Around 31.2% of the sample had more than one diagnosis, including depressive disorders (72.3%), anxiety disorders (18.8%), and trauma and stressor related disorders (18.8).
The Clinician-Rated Severity of Nonsuicidal Self-Injury was developed by the American Psychiatric Association, which assesses the severity of nonsuicidal self-injurious behaviors or problems as experienced by the individual in the past year. The clinician completes the measure on a 5-point scale (Level 0 = None; 1 = Subthreshold; 2 = Mild;3 = Moderate; and 4 = Severe). Each level is described as follows: None (No NSSI acts or NSSI acts on fewer than 3 days and no urge to self-injure again.); Subthreshold (NSSI acts on 2–4 days or has self-injured in the past on 5 or more days and has reported urges to self-injure again.); Mild (NSSI acts on 5–7 days using a single method and not requiring surgical treatment.); Moderate (NSSI acts on 8–11 days using a single method and not requiring surgical treatment [other than cosmetic] or NSSI acts on 5–7 days using more than one method.); Severe (At least 1 NSSI act that required surgical treatment [other than cosmetic] or NSSI acts on 12 or more days using a single method or NSSI acts on 8 or more days using more than one method.) (APA, 2013).
The CTQ-SF is administered to assess CM in participants (Bernstein et al., 2003). It includes five dimensions: physical abuse (PA), physical neglect (PN), emotional abuse (EA), emotional neglect (EN), and sexual abuse (SA). Respondents are asked to rate each item on a 5-point Likert-type scale1 (never true) to 5 (very often true). High scores indicate high levels of childhood maltreatment. The Chinese version of this questionnaire has been demonstrated to be a reliable and valid measurement (LiZhao & Yu, 2020). It accounts for maltreatment before the age of 12 years. Patients were identified as positive for CM if any one of these factors exceeded their cutoff score as mentioned: EA > 12, PA > 9, SA > 7, EN > 14, and PN > 9 (Jugessur et al., 2021). Each subscale demonstrates good-to-excellent internal consistency (Cronbach’s alpha = 0.723–0.933).
The DERS (Gratz & Roemer, 2004), which includes 36-item self-report items, is used to assess the following six emotion regulation difficulties: non-acceptance of emotions, difficulties engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, self-perceived limited access to strategies, and lack of emotional clarity. All 36 items are scored along a five-point scale from 1 (Rarely) to 5 (Almost always). The DERS total score is used as an indicator of emotional regulation difficulties. Cronbach’s alpha for the DERS in the present study was 0.957.
PHQ-9 is a self-administered instrument that was developed by Kroenke, Spitzer, and Williams (KroenkeSpitzer & Williams, 2001) to measure the severity of an individual's depression by evaluating the depressive episodes using nine criteria based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The scale consists of nine items that assess the frequency with which nine depressive symptoms had occurred in the past two weeks, with items rated on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day). The scale is recommended by the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) as an assessment tool for depression in adolescents (Zuckerbrot, Amy, Jensen, Stein, & Laraque, 2018). The Chinese version of PHQ-9 has demonstrated good psychometric properties in adolescent samples(Leung, Mak, Leung, Chiang, & Loke, 2020).
We first used SPSS 26.0 to compute descriptive statistics for all study variables and the bivariate correlations between them. Next, we tested the hypothesized chain mediation model with structural equation modeling using Amos 26.0. In this model, CM (as indicated by NA, PA, SA, EN, and PN) served as predictor variable; the observed variables of DER (as indicated by DERS total score) and severity of depression (as indicated by PHQ-9 score) served as mediating variables; and the observed variable of the severity of NSSI behaviors served as the outcome variable. Model fit was assessed using multiple complementary fit indices. These indices included the comparative fit index (CFI), Tucker Lewis index (TLI), and the root mean square error of approximation (RMSEA). The cut-off criteria for a well-specified model are CFI > 0.95, TLI > 0.95, and RMSEA < 0.06, and the cut-off criteria for an acceptable model are CFI > 0.90, TLI > 0.90, and RMSEA < 0.08 (Browne & Cudeck, 1992). Mediation was considered significant if the 95% CI of indirect effect did not include zero. Bootstrapped confidence intervals (CI) based on 5000 bootstrapped samples were used to determine the significance of indirect effects.
224 adolescents (48 boys and 176 girls) were included in the current analysis, with a mean age of 15.30 years (SD = 1.83). 146 (65.18%) adolescents reported engaging in NSSI during the past 12 months, 88 (39.29%) adolescents reported engaging in NSSI during the past one month, and 103 (45.98%) participants met the DSM-5 diagnostic criteria for NSSI. The prevalence of CM in our sample was 70.80%. EN (48.1%) and EA (46.1%) had the highest prevalence, followed by PN (43.1%) and PA (24.1%), and SA (12.5%) was the least prevalent form of CM. (See Table 1)
Variable |
Mean (SD)/n (%) (Valid) Value |
|
---|---|---|
Age (years), Mean (SD) |
15.30(1.83) |
|
Gender |
Boy, /n (%) |
48(21.4%) |
girl, /n (%) |
176(78.6%) |
|
Education(years), Mean (SD) |
9.54(1.97) |
|
DERS, Mean (SD) |
119.30(22.69) |
|
Childhood Maltreatment |
EA, Mean (SD) |
12.80(5.21) |
PA, Mean (SD) |
7.87(3.63) |
|
SA, Mean (SD) |
6.11(2.69) |
|
EN, Mean (SD) |
14.60(5.49) |
|
PN, Mean (SD) |
9.62(4.18) |
|
Depression |
PHQ-9, Mean (SD) |
18.33(5.45) |
NSSI (CRSNSSI) |
None, /n (%) |
78(34.8%) |
Subthreshold, /n (%) |
43(19.2%) |
|
Mild, /n (%) |
17(7.6%) |
|
Moderate, /n (%) |
40(17.9%) |
|
Severe, /n (%) |
46(20.5%) |
|
Diagnosis |
Depressive Disorders, /n (%) |
162(72.3%) |
Anxiety Disorders, /n (%) |
42(18.8%) |
|
Trauma and Stressor Related Disorders, /n (%) |
42(18.8%) |
|
Bipolar and Related Disorders, /n (%) |
23(10.3%) |
|
Borderline personality disorder, /n (%) |
14(6.3%) |
|
Disruptive, Impulse Control and Conduct Disorders, /n (%) |
12(5.4%) |
|
Obsessive compulsive disorders, /n (%) |
5(2.2%) |
|
DERS: Difficulties in Emotion Regulation Scale, PA: physical abuse, PN: physical neglect, EA: emotional abuse, EN: emotional neglect, SA: sexual abuse, CRSNSSI: Clinician-Rated Severity of NonSuicidal Self-Injury. |
Correlations among all latent constructs are shown in Table 2. As predicted, all constructs were significantly positively associated (p < 0.001) (except SA). The correlation between CM (EA, PA, EN, and PN) severity (independent variable) and NSSI severity (outcome variable) ranged from 0.37 to 0.55. The correlation coefficients between the postulated mediators (DER and Depression) and CM ranged from 0.399 to 0. 662. The associations between NSSI severity and the mediators ran between 0.371 and 0.662, whereby the highest correlation was found with EA.
NSSI |
DER |
EA |
PA |
SA |
EN |
PN |
|
---|---|---|---|---|---|---|---|
DER |
.633** |
||||||
EA |
.552** |
.656** |
|||||
PA |
.371** |
.399** |
.604** |
||||
SA |
0.083 |
.178** |
.296** |
.312** |
|||
EN |
.494** |
.585** |
.665** |
.420** |
.185** |
||
PN |
.391** |
.444** |
.658** |
.500** |
.243** |
.739** |
|
Depression |
.698** |
.793** |
.662** |
.440** |
.149** |
.553** |
.469** |
* p < 0.05, ** p < 0.01, DER: difficulty in emotion regulation, PA: physical abuse, PN: physical neglect, EA: emotional abuse, EN: emotional neglect, SA: sexual abuse, NSSI: NonSuicidal Self-Injury. |
As expected, the hypothesized chain mediation model was just identified and provided fit to the data well, χ2 (30, n = 224) = 62.60, p < 0.001, CFI = 0.94, TLI = 0.91, and RMSEA = 0.069. More specifically, the three indices showed a moderate fit. This model accounted for 27.6% (p < 0.001) of the total variance in NSSI frequency (Fig. 1.and Table 3). In line with our hypothesis, a mediation of the association between CM and NSSI through DER and depression was found. The total indirect effect was highly significant (β = 0.298; p = 0.015), while there was no significant direct effect from CM to NSSI anymore in the model (β = 0.101, p = 0.213). In order to test the specific indirect effects. As predicted, DER and depression symptom severity were all found to be significant mediators. We also found a significant chain mediation effect for the DER to NSSI via depression symptoms. Among the different indirect paths, the DER was the strongest mediator with an indirect effect of β = 0.197 (p = 0.009), and the indirect effect of depression symptom severity was β = 0.048 (p = 0.009). The indirect effect of DER on the association of CM and NSSI via depression symptom severity was β = 0.052 (p = 0.006). All total, direct, total indirect, and specific indirect effects are displayed in Table 3.
Path |
Effect |
BC 95% CI |
p |
|
---|---|---|---|---|
Lower |
Upper |
|||
Direct effect |
0.101 |
-0.085 |
0.319 |
0.213 |
Total Indirect effect |
0.298 |
0.159 |
0.45 |
0.015 |
Mediating effect of DER |
0.197 |
0.090 |
0.390 |
0.009 |
Mediating effect of Depression |
0.048 |
0.012 |
0.086 |
0.009 |
Chain mediating effect |
0.052 |
0.022 |
0.092 |
0.006 |
Total effect |
0.399 |
0.199 |
0.693 |
0.008 |
R1 |
13.10% |
0.038 |
0.272 |
0.011 |
R2 |
49.40% |
0.265 |
0.789 |
0.014 |
R3 |
12.10% |
0.023 |
0.371 |
0.012 |
R1: Chain mediating effect/ Total effect; R2: Mediating effect of DER/ Total effect; R3: Mediating effect of Depression/ Total effect |
This study aimed to examine the mediation pathway from CM exposure to adolescent NSSI behaviors based on a sample of adolescent patients in a psychiatric setting. The findings supported our hypothesis: CM exposure reveals indirect effects on the severity of NSSI via the mediating effect of DER severity and depressive symptoms. To our knowledge, this is the first investigation of the distal effects from CM to NSSI severity via the chain mediating effect of DER and depression.
In our study, the prevalence of NSSI is over forty percent, girls have higher rates of NSSI, and depressive disorder is the primary psychiatric diagnosis. This is consistent with characteristics in previous adolescent samples (Tuisku et al., 2009; Wang, Liu, Yang, & Zou, 2021). From our results, it is evident that the new generation born in the 2010s reported more emotional abuse and less sexual abuse in childhood, which is consistent with other recent reports in China (Chen et al., 2021; Titelius et al., 2018; Zhang et al., 2013). Nationwide "one-child policy" and the traditional child-rearing practices in China urged the parents to provide their only child with more economic support and safety guards. On the other hand, those who sexually abuse children will be punished in law practice. However, Chinese parents pay more attention to their children's academic performance but less to their emotional needs. In addition, many parents support the traditional belief that boys should be treated strictly for their future development and social roles. In summary, compared with safety or sexual threats, children in Chinese families suffer more emotional abuse and neglect, which may increase depression and emotional dysregulation.
According to previous research results, CM is a distal associative factor of NSSI and a shared risk factor for depression and DER. For the distal risk properties of CM, the time-bound for maltreatment was before the age of 12. So, we speculate that CM mainly affects NSSI through these recent risk factors. The chain mediation model supports our hypothesis, and we found a mediation of the association between CM and NSSI with a significant indirect but no remaining direct effect. Whether CM is understood as a direct risk factor for NSSI is still debated (Brown et al., 2018; Paul & Ortin, 2019). However, CM as a distal factor creates more indirect vulnerability for Mental Disorders, which increases the likelihood of engaging in NSSI (Kaess et al., 2021).
The DER was the strongest mediator, followed by the depressive symptoms. Regardless, our findings are consistent with several previous studies, which showed DER mediates the relationship between CM and NSSI rather than depressive symptoms (Peh et al., 2017; Shenk et al., 2010). Early exposure to abusive or neglectful environments may disrupt children’s development of healthy emotion regulation skills and socioemotional competencies (Maughan & Cicchetti, 2002; Yates, 2009). Individuals with CM experience tend to use more maladaptive strategies, including inhibition and rumination (Weissman et al., 2019), and impaired ability to use adaptive emotion regulation strategies, such as acceptance, reassessment, and problem-solving, which are associated with enhanced positive emotions and better mental health outcomes (Weissman et al., 2019). Without adaptive emotion regulation skills, self-harm behaviors may function as compensatory strategies to cope with overwhelming emotions. Specifically, self-harm may be used to distract oneself from distress and to regain a sense of control and self-efficacy (Lang & Sharma-Patel, 2011). We also proved a potential chain-mediated pathway of DER and depression between CM and NSSI, which may add to our understanding of the relationship between CM and NSSI. The chain mediating of DER and depression was in line with the CM’s role, as it impaired the development of self-regulation on emotional cognitive levels, resulting in poor emotional regulation and a depressogenic attributional style. Significantly, these cognitive and emotional sequelae of CM then increase the risk for later development of depression symptoms (Huh, Kim, Lee, & Chae, 2017; Schierholz, Krüger, Barenbrügge, & Ehring, 2016) and finally contribute to an increasing possibility of NSSI (BaidenStewart & Fallon, 2017).
The above findings potentially align with the biological conceptual model of NSSI (Kaess et al., 2021). Chronic child abuse and neglect lead to alterations in the hypothalamic-pituitary-adrenal (HPA) axis (Kuhlman, Chiang, Horn, & Bower, 2017), brain structure, and function (Teicher, Samson, Anderson, & Ohashi, 2016). These neuroimaging findings overlapped with those of NSSI (Ando et al., 2018; Auerbach, Pagliaccio, Allison, Alqueza, & Alonso, 2021; Schreiner et al., 2020),which are centrally involved in emotion regulation and expression (Kaess et al., 2021) including the anterior cingulate gyrus (ACC ) (Ando et al., 2018), amygdala (Cullen et al., 2020), prefrontal cortex (PFC) and the hippocampus (Dahlgren et al., 2018; Lupien, McEwen, Gunnar, & Heim, 2009). Therefore, we speculate that early exposure to CM impairs the emotion regulation circuit of the brain through environmental-biological interactions in long-term adolescent development, causing DER and depression. Then, adolescents may adopt NSSI as a coping strategy for regulating aversive emotional experiences.
Our findings also have some clinical implications. First, our results contribute to the understanding that CM and NSSI are common among Chinese adolescents with psychiatric disorders. Many adolescents feel reluctant to talk about their CM or NSSI experiences in face-to-face settings. Hence, a mixed battery of self-reports and assessments by physicians may be more suitable in Chinese culture. Second, the distal risk factors (i.e., CM) and proximal risk factors (especially DER) might work together to induce the onset of NSSI. So, assessing DER and depressive symptoms in adolescents with NSSI behaviors is also of practical importance, and we should enhance healthy emotion regulation strategies. Current interventions facilitating healthy emotion regulation might help modify maladaptive cognitions and behaviors (e.g., Dialectical Behavior Therapy, DBT) (Adrian et al., 2019; Tebbett-Mock, Saito, McGee, Woloszyn, & Venuti, 2020). However, more study is needed as research on NSSI prevention is preliminary.
Overall, this study explored the mechanism between distal risk factors CM and NSSI behavior using a sample of inpatient adolescents in China, demonstrating simple and chained mediating effect of DER or/and depressive symptoms. Importantly, our research shows DER being the strongest mediator with an indirect effect, but not depressive symptoms. Furthermore, we chose CRSNSSI(DSM-5) as the NSSI evaluation index through structured interviews, which better reflects the severity of NSSI than self-rating scales of NSSI. Despite such strengths, several limitations of the current study need to be acknowledged. Firstly, the participants were patients in one hospital in Hangzhou, and male participants were under-represented. So, the sample source would limit the generalizability of these findings. Second, although we control the CM's time boundaries, we used cross-sectional data on DER and depression, and correlational data were used to test a causal model. Future research should utilize a longitudinal design while considering other possible mediators (e.g., life stressors). Third, we employed retrospective self-report questionnaires, which might mean our data were not sufficiently objective. Therefore, these data may be affected by bias to some extent. Future studies should employ a large sample, multicenter, longitudinal design, and adopt tools other than self-report questionnaires (e.g., expert opinions or other objective evidence). Future research should also examine subdomains of DER and their roles in NSSI behaviors.
The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of the Affiliated Hangzhou First People’s Hospital of Zhejiang University (IRB: 2020-K008–01, January 2020).
The patients or their guardians provided their written informed consent to participate in this study.
The data that support the findings of this study are available from the corresponding author upon reasonable request.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This manuscript has not been published nor is it being considered for publication elsewhere. There are no conflicts of interest to declare, associated with the publication of this manuscript.
This work was supported by the Jiangsu Provincial Key Research and Development Program (grant number: BE2019748) and the National Natural Science Foundation of China (grant number: 81971277). Special thanks to the adolescents, youth, and families for their time and effort.
Changchun Hu: Conceptualization, methodology, writing original draft preparation, project administration. Jialing Huang, Yushan Shang and Tingting Huang:investigation, resources, data curation. Wenhao Jiang: writing review and editing, supervision. Yonggui Yuan: validation, formal analysis, writing review and editing, supervision. All authors have read and agreed to the published version of the manuscript.
Special thanks to the adolescents, youth, and families for their time and effort.