The relationship between negative life events and non-suicidal self-injury (NSSI) among Chinese junior high school students: the mediating role of emotions

The main objective of this study was to investigate the interrelationship between negative life events, emotional symptoms (anxiety, depression) and NSSI, and the mediating role that emotional symptoms play between negative life events and NSSI. We found that negative life events and emotional symptoms all have a direct effect on NSSI. In addition, negative life events also have an indirect effect on NSSI via emotional symptoms, in which emotional symptoms play an incomplete mediating role.

In the present study, the prevalence of NSSI among Chinese junior high school students was 37.1%. Results from a previous study of rural Chinese adolescents showed a 29% prevalence of NSSI [48]. A study of adolescents in the United States showed that 6.4%-30.8% of adolescents had an NSSI in the past year [25]. In addition, the results of national studies on the prevalence of NSSI fluctuate from 17.1 to 38.6% [49]. The reason why the results of this study were higher than those of previous studies may be due to the differences in the criteria for defining and measuring NSSI. For example, in Tang et al.'s study, the criterion for self-injury was defined as “occurring more than 5 times per year”, whereas in Martin et al.'s study, the instrument used to measure NSSI was a question that asked, “During the past 12 months, how many times did you do something to purposely hurt yourself without wanting to die, such as cutting or burning yourself on purpose?” The prevalence of NSSI is higher in girls than in boys, which is the same as previous studies [50, 51]. Previous research has shown [52] that men are more likely to take direct action, i.e., action to change the problem, in response to life events than women, so that when faced with negative life events, boys are more likely to take action to solve the problem, whereas girls may need more time to deal with these negative life events. In addition, the differences in cognitive styles between men and women [53] may also have a certain degree of influence. In terms of the grade distribution of the subjects, the distribution of the group with NSSI was more skewed towards the lower grades, which is similar to the results of previous studies on Chinese secondary school students [54]. The reasons for this may be due to the fact that some adolescents' self-injurious behavior is only a one-time event, etc. The specific causes of which need to be further studied. The higher prevalence of NSSI among rural adolescents than urban supports the findings of previous studies [48]. Compared to urban families, rural families tend to face greater economic stress and therefore may be exposed to more external stimuli, such as being discriminated against by others, family economic difficulties, family exerted greater pressure on study, etc. Pulling hair, cutting the skin with objects such as knives and hitting harder objects such as walls with hands were the three most common ways of NSSI. Venting negative emotions is the most common purpose of NSSI, which is the same as the most common purpose of NSSI described in the DSM-5. Pulling hair, cutting skin with objects such as knives and hitting harder things such as walls with hands are all relatively easy ways to perform NSSI, so all three are the most common ways to perform NSSI. What we must recognize, however, is that any of the self-injury modalities, no matter how much or how little damage is caused, should be taken seriously by us. Any type of self-injury is a sign that the child is indeed self-injuring and sends the message that “this child is currently in distress” and needs our help. Poor academic performance, reprimands from parents or teachers, and too much academic or employment pressure were the most common external factors/events, which were related to our subjects' status as students. Middle school students are in the transition period between primary and high school, and parents often have high expectations for their children. A previous study of Chinese students showed that study stress is a risk factor for emotional problems [55]. Junior high school students face a sudden increase in academic pressure, which inevitably leads to fluctuations in academic performance and the psychological state, as well as possible reprimands from parents and teachers, so the three most common external stimuli are all related to studies.

In this study, negative life events include the interpersonal relationship factor, the academic stress factor, the punished factor, the loss factor and the other factors. For adolescents, interpersonal relationships are mainly reflected in getting along with peers at school, which is an important part of their social life. Learning plays an important role in the lives of adolescents. Junior high school students face increased pressure to study as well as the pressure of entrance exams and are vulnerable to punishment from their parents when their academic performance fluctuates. The loss factor is mainly reflected in the illness or death of a relative or friend, or the loss of something, all of which have a negative and pronounced effect on the adolescent. In particular, the death of a family member or friend can be a very serious psychological shock for adolescents who are exposed to such events for the first time. Other factors include dislike of school, unhappy relationships, fighting with others, and being scolded by parents, which are also common academic, emotional, social and family problems for adolescents.

The present study showed that negative life events, anxiety, and depression were all direct risk factors for NSSI, which validated our H1 hypothesis. The greater the number of negative life events, the greater the degree of NSSI, which is similar to previous studies. A previous study of Chinese children has shown that individuals who have experienced more negative life events are more likely to develop NSSI [56]. Emotional symptoms, mainly anxiety and depression, are widespread among adolescents [57,58,59]. A previous study of Australian students showed that the detection rate of anxiety co-morbid depression was 33.2% [60]. In addition, the findings for American students also demonstrated that the detection rate of anxiety co-morbid depression was higher [61], and anxiety and depression were risk factors for the occurrence of NSSI [62], and adolescents with more emotional symptoms also tend to have a higher prevalence of NSSI, which is similar to the results of this study.

In this study, negative life events and emotional symptoms can all have a direct impact on NSSI. At the same time, emotional symptoms play an incomplete mediating role in negative life events and NSSI. Previous studies have shown that when adolescents encounter negative life events, they can produce emotional symptoms such as anxiety and depression [63, 64], which in turn are closely associated with NSSI [65, 66]. This validates our H2 hypothesis that negative life events can have an effect on NSSI through anxiety or depression. In addition, Koen et al. mentioned that anxiety and depression can occur together, and in patients with co-morbid anxiety and depression, anxiety often precedes depression [67]. This also validates our H3 view that negative life events, when acting on emotional symptoms, can have an impact on depression through anxiety and thus on NSSI.

Negative events, no matter how big or small, are inevitable in the daily life of young people. As parents or teachers, they should reduce the occurrence of controllable negative life events as much as possible in their lives, such as avoiding physical punishment when children make mistakes and adopting rational education; when children encounter problems in school, parents should communicate with teachers in a timely manner and coordinate with each other to solve problems, etc. This can reduce the frequency of negative life events and thus reduce the impact of negative life events on NSSI. When a negative life event occurs, timely understanding of the child's psychological state and effective communication can effectively reduce the impact of the event on the child's psychological state and prevent the development of anxiety and depression. At the same time, it is important to develop resilience in the face of adversity in children's lives, as previous research [18] has shown that enhancing “resilience” can effectively buffer the link between negative life events and adverse outcomes in adolescents. The most effective way to address anxiety and depression in adolescents is to bring them to a medical professional in a timely manner, both to reduce the impact of negative life events on NSSI in a mediated way and to reduce the impact of emotional symptoms on NSSI directly.

This study has the strength of using a large sample of Chinese secondary school students and using structural equation modeling to explore the mediating role of emotional problems in the relationship between negative life events and NSSI. However, this study also has some limitations. First, the three schools participating in the study were chosen for convenience; second, this survey is a retrospective self-assessment survey, and there may be recall bias as well as the possibility of masking; last, the proportion of urban and rural samples included in this study is not balanced. In future studies, the sample size can be further expanded, the proportion of urban and rural children can be balanced, more longitudinal surveys can be conducted for comparison, and objective indicators such as relevant blood samples, genetic tests, and brain function scans can be improved to find changes in specific blood indicators, Genetic alterations or alterations in specific brain regions for targeted diagnosis and treatment.

In summary, NSSI in Chinese adolescents is still a behavioral problem that must be taken seriously and has a higher prevalence among girls and rural adolescents. Negative life events and emotional symptoms are all direct risk factors for NSSI, and emotional symptoms play a mediating role in the relationship between the effects of negative life events and NSSI. This indicates that for improving NSSI caused by negative life events, the desired outcome can be achieved by intervening on both negative life events and emotional symptoms. Therefore, in the developmental education of adolescents, it is important to both minimize the generation of negative life events, such as improving school rules and regulations to avoid school bullying; avoiding physical punishment to educate children, etc., and to pay attention to the emotional symptoms of children. A healthy child is not only physically healthy, but also psychologically healthy. As Bartoli et al. mentioned, good psychosocial intervention and suicide prevention should be carried out during adolescents' development [68], which reminds us that when serious emotional or behavioral problems arise, guardians should promptly take them to professional medical institutions for diagnosis and treatment to avoid self-injury or suicidal behavior. Early intervention for emotional and behavioral symptoms can also effectively promote the recovery of adolescents and help them return to a normal social life at an early stage.

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