Network analysis of the relationship between non-suicidal self-injury, depression, and childhood trauma in adolescents

doi:10.21203/rs.3.rs-3804909/v1

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Research Article

Network analysis of the relationship between non-suicidal self-injury, depression, and childhood trauma in adolescents

https://doi.org/10.21203/rs.3.rs-3804909/v1

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Journal Publication

published 24 Apr, 2024

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Background

Non-suicidal self-injury seriously harm the physical and mental health of adolescents. The aim of the current study was to explore the relationship between non-suicide self-injury, depression, and childhood trauma from the perspective of symptoms in adolescents.

Methods

A cross-sectional survey was conducted in four junior high middle schools and collected 2640 valid questionnaires. Non-suicidal self-injury (NSSI), depressive symptoms, and childhood trauma were assessed using the Adolescent Self-Harm Scale, the Childhood Depression Scale, and the Childhood Trauma Questionnaire, respectively. A network analysis was performed.

Results

In the network, NSSI, depressive symptoms and childhood trauma are closely related. Negative Self Esteem in the depressive symptoms and emotional Abuse in the childhood trauma categories were the most central nodes. Negative self-esteem and negative mood were directly connected to NSSI, other nodes of depressive symptoms appeared to be indirectly connected to NSSI through these two nodes. Emotional Abuse was the only node in the childhood trauma categories directly connected to NSSI. The shortest pathways form other categories of childhood trauma (physical neglect, physical abuse, emotional neglect, and sexual abuse) to the NSSI through the effect of emotional abuse.

Conclusions

Our findings indicate that targeting negative self-esteem, negative mood and emotional abuse as intervention targets may alleviate depression and reduce NSSI in adolescents to the greatest extent.

Adolescent

Non-suicidal self-injury

Depression

Childhood trauma

Network analysis

Non-suicidal self-injury (NSSI) is the behavior of an individual who intentionally and repeatedly hurt themselves without committing suicide, and such actions are not accepted by social culture [1]. NSSI has become a serious and common problem among adolescents. The detection rate of NSSI in non-clinical adolescents worldwide from 1989 to 2018 was 19.5% [2]. Meta-analysis showed that the detection rate of NSSI in Chinese adolescents was 22.37% [3], and the detection rate of NSSI was higher in adolescent clinical samples [4]. NSSI is often viewed as a way to relieve negative emotions [1], while depression is a common negative emotional experience characterized by significant and persistent mood depression, with symptoms including sadness, anxiety, guilt, attention deficit, etc. [5]. A study showed that 24.3% of adolescents suffer from depressive symptoms [6]. Depression and NSSI not only cause great pain to adolescents and impair their current development and adaptation, but also have negative effects that may extend into adulthood, increase the risk of serious psychological disorders, and lead to various behavioral problems, such as suicidal behaviors [7], which seriously harm the physical and mental health of adolescents.

Previous studies have shown that the relationship between NSSI and depression presents a mutually predictive pattern. Based on the four-function model of NSSI [8] and the experience avoidance model of NSSI [9], NSSI is considered as a way to relieve depression. Individuals escape or avoid depression through NSSI i.e. depression predicts NSSI [10–13]. It has also been found that depression is a consequence of self-injury and that individuals produce self-injurious behaviors due to certain factors and in turn produce emotional experiences such as guilt as a result of self-injury, which exacerbates depressive symptoms, i.e., NSSI predicts depression [14, 15].

In addition to the above relationship, a longitudinal analysis of NSSI and depression in adolescents also found that NSSI was significantly associated with depression in the second measurement, but it was not mutually predictive, i.e., the relationship between NSSI and depression may not be a simple predictive one, but rather an interaction between symptoms [16]. Depression and NSSI may present another relationship model, that is, different symptoms of depression may have different degrees of association with NSSI. Therefore, we need to further explore which symptoms of depression are more closely related to NSSI, and which symptoms of depression are directly related to NSSI so that we can take prompt action for prevention when the corresponding symptoms appear. This study intends to analyze the relationship between NSSI and depression from the perspective of symptoms, in order to provide new ideas for the study of the relationship between NSSI and depression and to provide new inspiration for more targeted mental health interventions and education for adolescents.

Previous studies have found that multiple factors can predict depression and NSSI symptoms, such as genetics, childhood trauma, parental conflict, etc.[17–22]. Individuals who have experienced childhood trauma tend to show stronger depression [23] and a tendency to self-injury [24]. Overall, depression and NSSI are heavily influenced by childhood trauma. Some scholars have found that there is a significant positive correlation between childhood trauma and NSSI in general [24], while others have found that emotional abuse in childhood trauma is a risk factor affecting the physical and mental health development of adolescents [25]; Steine et al. [26] has found that individuals who have experienced sexual abuse are more prone to NSSI. Wang et al. [27] measured childhood trauma in young people with depression and found that high levels of emotional neglect and emotional abuse had a significant impact on aphasia. Therefore, different dimensions of childhood trauma have different effects on individual mental health.

In recent years, the network analysis model has gained widespread attention in the fields of psychiatry and psychology. Network analysis theory shifts the focus to direct interactions between symptoms [28]. The network analysis approach is to find the more central or important variables in the network by using nodes to represent the observed variables and using lines to represent the correlation between the observed variables under the drive of data. Some scholars have used network analysis to examine the network structure of the callousness trait in Chinese juvenile and community youth samples, identifying the callousness trait as the most central characteristic of the callousness trait and finding differences between community and offender samples [29]. A node with high centrality has the characteristic that when it is activated, it is likely to spread the activation to the entire network through the edges connecting other nodes, thus affecting the entire symptom network [30]. That is, if an intervention is performed on nodes with high cardinality, it may reduce the severity of the entire symptom network. Network analysis can also describe the complex relationships between observed variables, such as the co-morbidity between obsessive-compulsive disorder and depression in adolescents [31], and the relationship between eating disorders and self-esteem and depression among Iranian adolescents [32], etc. It provides a theoretical basis for explaining the mechanism of action between variables and targeted intervention.

In summary, this study intends to investigate the complex relationship among adolescents’ non-suicidal self-injury behavior, depression, and childhood trauma utilizing network analysis, with a particular focus on the indicators of high central nodes in the network, to provide new explanations for the relationships and pathways of action among non-suicidal self-injury, depression, and childhood trauma, and to provide visualization results for understanding the relationships among the variables, as well as to provide concrete directions for future interventions..

2.1. Settings and participants

A cluster sampling method was adopted to investigate four junior middle schools in Zhangjiajie, China, and questionnaires were administered to students in class units. In this study, 2640 valid questionnaires were received, including 1329 male students (50.3%) and 1311 female students (49.7%). 974 students (36.9%) in the first grade, 863 students (32.7%) in the second grade, and 803 students (30.4%) in the third grade. The age of the subjects ranged from 11 to 17 years old, with a mean age of 13.3 (± 0.94) years. All participants and their guardians were required to provide written informed consent. This study was conducted in compliance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of Hunan Agricultural University.

2.2. Measurements

2.2.1 The Adolescent Self-Injury Scale (ASIS)

The ASIS was revised by Jiang et al. [33]. There are 18 items in total, and the scale applies to adolescents. The evaluation of self-injury behavior is divided into four levels: 0 times, 1 time, 2–4 times, and more than 5 times (including 5 times). The questionnaire has good internal consistency coefficients and criterion correlation validity. In addition, most Chinese researchers have used this questionnaire in their self-injurious behavior surveys. The Cronbach's alpha coefficient of this scale in in our sample was 0.94.

2.2.2 The Childhood Depression Scale (CDI)

The CDI was used to assess depressive symptoms in children and adolescents. The scale was developed by Kovacs [34] and translated by Wu et al. [35]. Wu et al. [35] analyzed the reliability and validity of the Chinese version in middle school students and found that the CDI scale was suitable for the assessment of depressive symptoms in Chinese middle school students. The scale applies to ages 7–17 and has 27 items divided into five subscales: anhedonia, negative emotions, negative self-esteem, ineffectiveness, and interpersonal problems. Each item has three options describing different degrees of depressive symptoms, which are calculated as 0 to 2 points, in which 0 means the least degree of depressive symptoms, followed by 1, and 2 means the most severe degree of depressive symptoms. The total score on the scale is 54 points, with higher scores indicating greater depression. The Cronbach's alpha coefficient of the CDI was 0.90 in our sample.

2.2.3 The Childhood Trauma Questionnaire-Short Form (CTQ-SF)

The CTQ-SF, developed by Bernstein et al. [36], and translated by Zhao et al. [37], was used for the measurement of childhood trauma. A total of 28 questions are included in the CTQ-SF, each rated on a five-point scale: never = 1, occasionally = 2, sometimes = 3, often = 4, and always = 5, with a total score range of 28 to 140. The questionnaire contains 5 types of trauma assessment: physical abuse (PA), physical neglect (PN), emotional neglect (EN), emotional abuse (EA), and sexual abuse (SA). The scores for each childhood trauma type range from 5 to 25. The Cronbach's alpha of this scale was 0.72 in our sample.

2.3. Network estimation

Statistical analysis was performed using SPSS24.0 and R Studio software. Descriptive statistics were first performed on the sample. The relationship between depression, self-injury, and childhood trauma in adolescents was studied by network analysis.

Network analysis is a data-driven analysis method that allows exploring not only the independent relationship between every two variables but also the independent role of multiple variables in a complex system [38]. Firstly, the qgraph package of R studio software [39] was used to establish a partial correlation network model among adolescent non-suicidal self-injury, five factors of depression, and five factors of childhood trauma. The network structure includes nodes and edges. The nodes represent the observed variables, and the edges represent the biased correlation coefficients between two nodes after controlling for all other variables [40]. The strength of the relationship between two nodes is presented by the thickness of the connected edge. The stronger the relationship between two nodes, the thicker the connected edge. The weaker the relationship between two nodes, the thinner the connected edge. Positive correlations are shown by solid green lines, while negative correlations are shown by dotted red lines. The partial correlation coefficient between the nodes is calculated using the ppcor package of R studio software. Next, the importance of each node in the network is calculated, i.e., the importance of each node in the network is measured by node strength [41]. We usually consider the node with the highest node strength as the most important node in the whole network, and the stronger the centrality is. Finally, we use the bootnet package of R studio software to assess the stability of the network. The stability of node centrality is evaluated by calculating the correlation stability (CS) coefficient through the sample descent self-help method. Previous studies have shown that the CS coefficient ≥ 0.5 indicates sufficient stability [42].

Eleven nodes are included in this study: Anhedonia (Anh), Negative Mood (NgM), Negative Self-Esteem (NSE), Ineffectiveness (Inf), Interpersonal Problem (InP), ASIS (ASI), Physical Neglect (PN), Physical Abuse (PA), Emotional Neglect (EN), Emotional Abuse (EA), Sexual Abuse (SA).

The biased correlation network model was shown in Fig. 1 and Table 1. Among the five factors of adolescent depression, the strongest linkage weights were anhedonia and negative mood (r = 0.32); Among the five factors of childhood trauma, physical neglect and emotional neglect (r = 0.38) had the strongest wired weight. The strongest weight of the linkage between NSSI and depressive symptoms were ASIA and Negative Mood (r = 0.13); while ASIA and emotional abuse (r = 0.16) were the strongest weight of the linkage between NSSI and childhood trauma categories.

Table 1

Weight of connections of each node in the network.
	M	SD	1	2	3	4	5	6	7	8	9	10	11
1	3.97	2.97	0
2	2.70	2.22	0.32	0
3	2.56	1.90	0.19	0.20	0
4	2.88	1.89	0.18	0.17	0.28	0
5	1.65	1.26	0.23	0.14	0.06	0.04	0
6	5.28	13.16	0.06	0.13	0.09	0.00	0.05	0
7	9.18	3.00	0.08	-0.01	0.05	0.03	0.01	0.00	0
8	6.04	2.24	-0.03	-0.01	-0.06	0.04	0.03	0.04	0.04	0
9	11.91	4.77	0.06	-0.01	0.16	0.03	0.03	0.01	0.38	0.03	0
10	7.77	3.30	0.06	0.10	0.14	0.03	-0.06	0.16	0.07	0.34	0.15	0
11	5.55	1.91	0.01	-0.02	-0.05	-0.04	0.04	0.03	0.12	0.38	-0.07	0.14	0
Note: 1 = Anhedonia, 2 = Negative Mood, 3 = Negative Self Esteem, 4 = Ineffectiveness, 5 = Interpersonal Problem, 6 = ASIS, 7 = PN(Physical Neglect), 8 = PA(Physical Abuse), 9 = EN(Emotional Neglect), 10 = EA(Emotional Abuse), 11 = SA(Sexual Abuse).

As shown in Fig. 1, negative self-esteem and negative mood were directly connected to NSSI, other nodes of depressive symptoms appeared to be indirectly connected to NSSI. For example, node Ineffectiveness itself did not affect the NSSI, but it worked through the node negative self-esteem. Similarly, the node emotional abuse was the only node in the childhood trauma categories directly connected to NSSI. The shortest pathways form other categories of childhood trauma (physical neglect, physical abuse, emotional neglect, and sexual abuse) to the NSSI through the effect of emotional abuse.

Centrality indicators for the network were presented in Fig. 2. For the depressive symptoms, node negative self-esteem had the greatest degree of direct connection with other nodes (i.e., having the highest level of strength) and the greatest indirect connection with other nodes in the network (i.e., the highest level of closeness). Also, node negative Self Esteem was directly or indirectly involved in processing of the network during the interaction of variables (i.e., the highest level of betweenness). For the childhood trauma, node emotional abuse showed the highest levels of strength, closeness, and betweenness centrality indices.

Further stability tests of the network centrality measures found (Fig. 3) that the correlation stability (CS) coefficients of node strength, node tightness, and node intermediation were 0.75, 0.67, and 0.59, respectively, with node strength having the best stability and CS coefficients all greater than 0.5, indicating that all the node centrality measures of this network have good stability.

In this study, the relationship between NSSI, depression, and childhood trauma was explored using network analysis, and the important nodes in the network were analyzed.

NSSI, depressive symptoms, and childhood trauma were closely linked in the network, suggesting that the symptoms have an interactive influence on each other rather than being independent of each other. First, there is a close relationship between childhood trauma and NSSI and depression. Previous studies reported that childhood trauma can predict depression [43] and NSSI [44, 45]. The results of our study confirm the idea proposed by Karen Horney's personality theory: if parents or caregivers treat their children with forms of indifference, neglect, or abuse, the children will lack the necessary sense of belonging and security, and then produce negative emotions such as depression. From the theory and our results, they will fight against negative emotions in unique ways, such as NSSI, to protect themselves. Second, different childhood traumatic experiences have different effects on depression and NSSI: Heleniak et al. [46] found a strong association between childhood pleasure deficit mood disorder and child maltreatment in the sample of community adolescents; Zhang et al. [25] found that the risk factor for NSSI was emotional abuse. Finally, there is a reciprocal predictive relationship between NSSI and depression in adolescents [47]. The present study further found that adolescent NSSI was more strongly linked to the depression network and relatively more weakly linked to the childhood trauma network. This may be due to the early occurrence of childhood trauma, and the effect on adolescent NSSI behavior may be weakened with the passage of time. However, depression, as a persistent negative emotion, has a more immediate and significant impact on adolescents' NSSI behavior.

In the depressive symptoms of adolescents, negative self-esteem had the strongest node-centrality. This result indicate that negative self-esteem is more likely to cause depression in adolescents. The cognitive susceptibility model of depression suggests that when individuals hold negative self-perception, they are more likely to adopt a negative attitude to anticipate the future, resulting in depression [48]. Low self-esteem is a cognitive tendency like negative self-evaluation, which has a great impact on the occurrence and maintenance of depression [49].

Emotional abuse was the strongest centrality node in the childhood trauma, which was closely related to both physical abuse and sexual abuse. Emotional abuse may destroy an individual's ability to regulate negative emotions. Individuals who experience emotional abuse tend to adopt dysfunctional coping mechanisms, such as NSSI, to relieve painful emotions if they experience other types of abuse again in the absence of positive resilience to negative emotions [50, 51]. This finding is different from a recent study [52]. Misiak et al. found that a history of childhood sexual abuse was the most central node in the network and the shortest pathways from other types of childhood trauma were connected to the lifetime characteristics through the sexual abuse. It may be caused by regional or cultural differences. Our findings are also different from the traditional parents' thoughts in China. Parents in China may think that physical abuse such as corporal punishment is the culprit of childhood trauma, so they commonly choose negative words that seem harmless to educate their children, but this behavior eventually leads to more serious emotional abuse of children. Our results also suggest that emotional abuse like physical abuse will do indelible harm to children, so parents should not ignore the negative effects of emotional abuse on children's physical and mental development.

We also found that emotional abuse was a very important node in the network that connected adolescent NSSI, depression, childhood trauma. Firstly, other childhood traumas established contact with NSSI through it. This indicates that emotional abuse and other types of abuse will continuously increase emotional abuse behaviors and lead to NSSI. Secondly, emotional abuse can lead to depressive symptoms such as negative self-esteem and negative mood to indirectly induce NSSI, so we need to pay particular attention to children who have suffered emotional abuse. Heleniak et al. [46] also found in their study of the relationship between psychological abuse and children's pleasure deficits that psychological abuse and children's pleasure deficits were positively correlated, suggesting that emotional abuse can, to some extent predict the production of depression.

In the same way, negative self-esteem and negative mood were also two important nodes in the network, which were not only important central nodes in the depressive symptoms but also played a bridging role in the whole network, i.e., other depressive symptoms acted on NSSI through these two symptoms. Therefore, the intervention for NSSI needs to focus on these two depressive symptoms. Network analysis is important for more targeted prevention of adolescent NSSI behaviors, and can play its role in the practical application of psychotherapy. When important nodal symptoms appear in the network, we can quickly take measures to intervene in other nodal symptoms that are most closely linked to them and achieve prevention of the emergence of psychological disorders or risky behaviors. For example, in this study, node emotional abuse is most closely associated with nodes negative self-esteem, negative mood, and NSSI, so when dealing with adolescents who have experienced childhood emotional abuse, it is important to focus on whether they show low self-esteem and negative emotions to help us make a quick diagnosis or intervention.

The current study has three limitations. First, this study used cross-sectional data and cannot determine the causal relationships between nodes. To describe the directivity of the relationship, we can use the network analysis method to analyze the longitudinal data and explore the temporal causality between nodes in future studies. Second, the questionnaires of the study were all retrospective, and recall bias could not be avoided. Third, the survey population of this study was limited to China, and it is unclear whether the results are applicable to teenagers from other countries or different cultural backgrounds.

In conclusions, we used the network analysis to explore the relationship between NSSI, depression, and childhood trauma in adolescents, and found that adolescent NSSI, depression, and childhood trauma interacted with each other. The two depressive symptoms, including negative self-esteem and negative mood, and emotional abuse were important node. These findings indicate that targeting negative self-esteem, negative mood and emotional abuse as intervention targets may alleviate depression and reduce NSSI in adolescents to the greatest extent.

NSSI

Non-suicidal self-injury

1. Ethics approval and consent to participate

This study has been performed in accordance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of Hunan Agricultural University, and a written informed consent was obtained from the participants or their legal guardians.

2. Consent for publication

Not applicable.

3. Data availability

The datasets supporting this study’s findings are available from the corresponding author upon reasonable request.

4. Competing interests

The authors declare no competing interests.

5. Funding

This study was supported by grants from the Philosophy and Social Science Foundation of Hunan Province, China (21YBA006) and the Natural Science Foundation of Changsha, China (Grant No. kq2202408).

6. Author Contributions

H. Lei and Y. Yang drafted the article and analyzed data; Y. Yang, T. Zhu and X. Zhang collected data; J. Dang and X. Zhang revised the draft; X. Zhang designed research. All authors contributed to data interpretation and approved the final version of the manuscript.

7. Acknowledgements

We are grateful for the generosity of time and effort by all the participants, and all researchers who make this project possible.

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No competing interests reported.

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Network analysis of the relationship between non-suicidal self-injury, depression, and childhood trauma in adolescents

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Journal Publication

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Abstract

Background

Methods

Results

Conclusions

Figures

1. Background

2. Methods

2.1. Settings and participants

2.2. Measurements

2.2.1 The Adolescent Self-Injury Scale (ASIS)

2.2.2 The Childhood Depression Scale (CDI)

2.2.3 The Childhood Trauma Questionnaire-Short Form (CTQ-SF)

2.3. Network estimation

3. Results

4. Discussion

5. Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1