Can decoding the complex web of non-suicidal self-injury in adolescents pave the way for tailored interventions?

Abstract

Non-suicidal self-injury (NSSI) is a prevalent and concerning issue in adolescent mental health, often intertwined with depressive symptoms. Despite extensive research on NSSI, a comprehensive understanding of its multifaceted nature and the intricate interplay of risk and resilience factors remains crucial. This Letter to the Editor examines a novel study by Yang et al, which utilized latent profile analysis and network analysis to delineate distinct NSSI subtypes within a Chinese adolescent population and investigate the underlying dynamics of associated factors. The study identifies three distinct NSSI subtypes: NSSI with depression, NSSI without depression, and neither, underscoring bullying as a prominent risk factor. Concurrently, the findings emphasized the pivotal role of emotional regulation and family support as protective factors. The focus of this article is to contextualize these findings within the broader framework of adolescent mental health and to highlight their implications for developing targeted interventions. These insights not only advance our understanding of adolescent NSSI but also provide a foundation for the development of targeted interventions that address the identified risk and protective factors. By focusing on these critical areas, mental health professionals can implement more effective strategies to mitigate NSSI behaviors and cultivate resilience in this vulnerable population.

Key Words: Non-suicidal self-injury; Adolescents; Risk factors; Protective factors; Bullying; Emotional regulation

Core Tip: Adolescents engaging in non-suicidal self-injury exhibit distinct behavioral subtypes, as identified through innovative analytical methods. Recognizing bullying as a central risk factor, alongside emotional regulation and family support as critical protective elements, offers valuable insights for mental health professionals. By focusing on these nuanced dynamics, professionals can design and implement more effective, tailored interventions aimed at reducing non-suicidal self-injury behaviors and bolstering resilience in this vulnerable population. Understanding these intricate interactions is crucial to enhancing therapeutic strategies and outcomes for adolescents at risk.

TO THE EDITOR

Non-suicidal self-injury (NSSI) among adolescents is a critical concern in the realm of mental health, marked by deliberate self-inflicted harm without suicidal intent. This behavior often signals underlying psychological distress and is intricately linked with other mental health issues, including depression and anxiety. A study by Wilkinson et al[1] indicates that NSSI often serves as a behavioral marker for emerging psychiatric disorders, with recurrent instances predicting disorders such as depression and eating disorders, particularly highlighting its role in disrupting normal developmental trajectories during the pivotal adolescent years. The prevalence of NSSI among adolescents varies significantly, with studies identifying a lifetime prevalence rate between 15% and 20% within this demographic. NSSI behaviors have been associated with emotional regulation dysfunctions and self-punishment, indicating the complex psychological processes underlying this behavior[2]. These behaviors are often an expression of unresolved emotional distress, which is further compounded by social factors such as peer bullying and family dynamics. Notably, poor family functioning and low perceived social support have been identified as key factors increasing the likelihood of NSSI behaviors among adolescents[3].

Furthermore, NSSI is frequently linked to experiences of childhood maltreatment, which exacerbates mental health outcomes like anxiety and depression. The role of impulsivity in mediating the relationship between childhood trauma and NSSI suggests that emotional regulation strategies are crucial in addressing the psychological needs of adolescents engaging in self-injurious behaviors[4]. As mental health practitioners strive to develop effective intervention and prevention strategies, understanding the multifaceted nature of NSSI and its connections to broader mental health issues remains vital. Yang et al’s recent study[5] provides a groundbreaking exploration into the multifaceted nature of NSSI through advanced analytical techniques such as latent profile analysis (LPA) and network analysis. This research aimed to delineate distinct subtypes of NSSI among Chinese adolescents, offering a nuanced understanding of the behavioral and psychological profiles associated with each subtype. By identifying specific risk factors, such as bullying, and protective elements, including emotional regulation and family support, the study set out to uncover the complex interplay of these factors within the context of NSSI. The primary objective of this article is to contextualize Yang et al’s findings[5] within the broader framework of adolescent mental health and to underscore the implications for clinical practice and future research. This article synthesizes the insights gained from Yang et al’s study[5], discussing the potential pathways for intervention and the broader implications for mental health professionals. By advancing our understanding of the risk and resilience factors associated with NSSI, we aim to pave the way for more effective prevention strategies and therapeutic approaches that enhance the well-being of adolescents globally.

RISK FACTORS AND NSSI

Research into NSSI has extensively documented a range of risk factors that contribute to its onset and persistence among adolescents. Psychological distress, including symptoms of depression and anxiety, has been consistently linked to NSSI behaviors. A study by Qin et al[6] showed that adolescents often resort to self-injury as a maladaptive coping mechanism to manage intense emotional states, underscoring the critical role of emotional disorders in NSSI development. Peer influence, particularly negative experiences such as bullying, has been identified as a significant risk factor for NSSI, exacerbating feelings of isolation and hopelessness, which can lead to self-injurious behaviors. The social environment plays a pivotal role, as individuals who encounter bullying and rejection often exhibit increased vulnerability to NSSI, driven by a need to express or alleviate emotional pain[7].

Moreover, adolescents with certain identity affiliations, such as those identified with “alternative” subcultures like Gothic subculture or Emotional hardcore, particularly in Western countries such as the United States, United Kingdom, and parts of Europe, reportedly have higher incidences of NSSI. This suggests the influence of peer culture and identity in self-injury practices. These identities often serve both emotional regulation and social integration functions within their communities, indicating that NSSI behaviors can fulfill complex psychosocial needs beyond individual distress[8]. NSSI is also more prevalent among Aboriginal populations in countries such as Australia, New Zealand, the United States, and Canada[7,8]. This higher prevalence is often attributed to historical and ongoing systemic issues, including marginalization, discrimination, and intergenerational trauma, which contribute to heightened psychological distress and vulnerability within these communities. Communities at risk for NSSI also include those experiencing high levels of social and economic disadvantage, such as low-income urban areas[6-8]. These environments often lack access to mental health resources and support systems, increasing the likelihood of adolescents turning to self-injury as a coping mechanism. Furthermore, young migrants and refugees from underdeveloped countries who face cultural dislocation and identity crises in Western communities are also at heightened risk, as these factors can exacerbate feelings of isolation and distress. These findings highlight the importance of addressing these multifaceted risk factors in both prevention and intervention strategies for NSSI. Understanding the interplay of individual, social, and psychological elements is crucial for developing comprehensive approaches tailored to the needs of at-risk adolescents[9].

PROTECTIVE FACTORS AND RESILIENCE

Conversely, protective factors such as emotional regulation and family support play a crucial role in mitigating the risk of NSSI. Effective emotional regulation strategies enable adolescents to manage distress without resorting to self-injury. Studies highlight that strengthening coping skills, developing a safety plan, and treating comorbid disorders are critical in supporting adolescents who self-harm, providing them with alternative methods to handle stress and emotional turmoil[10,11]. Family support acts as a protective buffer against adverse experiences, promoting resilience and reducing the likelihood of NSSI behaviors. Research has shown that adolescents who perceive strong family support are less likely to engage in NSSI. For example, a study by Grigoryan and Jurcik[11] demonstrated that positive parenting attitudes and effective communication within the family significantly decreased the incidence of self-injury among adolescents. Another study by Rajhvajn et al[12] found that family cohesion and emotional support were linked to reduced NSSI behaviors, highlighting the importance of a supportive family environment in fostering emotional security and resilience. Moreover, better family financial status and supportive relationships have been linked to a cessation of prolonged NSSI behaviors, emphasizing the importance of familial support in recovery and prevention efforts[12].

Interventions focusing on enhancing these protective factors show promise in reducing the incidence and severity of NSSI. Programs aimed at educating parents to improve communication and emotional support have been shown to be effective, as evidenced by Bae and Sung[13], who found that parental training programs focusing on emotion coaching significantly improved adolescents’ emotional regulation abilities and reduced NSSI behaviors. Additionally, counseling interventions designed to manage emotional factors such as depression and anger have demonstrated efficacy in mitigating self-injury, as highlighted by Halpin and Duffy[14], who reported that cognitive behavioral therapy (CBT) effectively decreased NSSI frequency by addressing underlying emotional distress. The significance of a strength-based approach in prevention efforts underscores the need for targeted strategies that emphasize the development of resilience and adaptive coping mechanisms among adolescents at risk[14].

ANALYTICAL APPROACHES: LPA AND NETWORK ANALYSIS

The application of advanced analytical methods, such as LPA and network analysis, represents a significant advancement in NSSI research. These techniques allow for the identification of distinct subtypes of NSSI, facilitating a more nuanced understanding of the behavioral and psychological profiles associated with each subtype. By mapping the intricate relationships between risk and protective factors, these methods provide insights that can inform the development of tailored interventions[15]. While LPA is a powerful tool for identifying hidden subgroups within heterogeneous populations, other analytical methods can also be employed to achieve similar objectives. For example, cluster analysis is another technique used to classify individuals into groups based on shared characteristics. Unlike LPA, which uses model-based probabilistic approaches, cluster analysis relies on distance-based algorithms to determine groupings. Both methods have their advantages: LPA provides model fit indices that help in selecting the optimal number of profiles, whereas cluster analysis is often simpler and more intuitive to apply without assuming underlying distributional properties[16].

Additionally, factor analysis is a widely used method for data reduction and identifying underlying variable structures. While factor analysis is typically used to identify latent constructs that explain observed correlations, LPA focuses on classifying individuals based on observed patterns[17]. Each method offers unique insights, and the choice between them depends on the research question and the nature of the data. Network analysis further complements these approaches by examining the interconnectedness of risk factors and their influence on adolescent behavior, providing a comprehensive framework to understand how variables such as depression, anxiety, and social influences interrelate and impact NSSI[17,18]. The integration of these methodologies into NSSI research not only advances theoretical understanding but also enhances the practical application of this knowledge in clinical settings, ultimately aiming to improve intervention outcomes through targeted and individualized care strategies[19].

CULTURAL CONSIDERATIONS IN NSSI RESEARCH

The inclusion of cultural context is paramount in the study of NSSI. Cultural norms and values deeply influence both the expression and social perception of self-injury behaviors. Research like that conducted by Chen et al[20] emphasizes the impact of cultural factors such as sex-bias discrimination and unrealistic expectations, underlying the necessity for culturally sensitive prevention and assessment strategies. The cultural context can greatly influence mental health knowledge and attitudes, impacting not only the incidence of NSSI but also its diagnosis and treatment, as exemplified in the Indian context. Cultural norms and societal structures shape individual behaviors and perceptions, which in turn affect how self-injury is viewed and addressed. In India, studies like those conducted by Nebhinani et al[21] indicate that cultural and social factors deeply influence the prevalence and methods of NSSI, as well as the societal response to such behaviors. The stigma surrounding mental health and self-injury can deter individuals from seeking help, making culturally sensitive approaches crucial for effective intervention.

The integration of culturally appropriate tools and approaches in mental health research fosters a culturally competent paradigm essential for the effective management of such behaviors. Meheli et al[22] highlight the importance of incorporating local cultural understandings into mental health frameworks to enhance the efficacy of interventions and ensure that they resonate with the target population. Additionally, the development of culturally sensitive assessment tools and intervention strategies can help dismantle barriers to treatment and improve engagement and outcomes. Nath[23] emphasizes the necessity of culturally informed practices in mental health services to adequately address the complex interplay of social and psychological factors affecting NSSI.

To address the limited exploration of cultural factors in existing research, it is recommended that future studies conduct more in-depth investigations into cultural sensitivity and adaptive intervention strategies. This includes developing culturally tailored interventions that respect and incorporate local traditions and values, as well as evaluating their effectiveness in diverse cultural settings. Understanding how cultural nuances affect NSSI behaviors and treatment outcomes will enable the creation of more effective and inclusive intervention strategies. The collective evidence supports the assertion that integrating cultural sensitivity into NSSI research and interventions enhances the efficacy and relevance of outcomes across diverse populations. Developing culturally sensitive interventions, as shown in various studies[21-23], proves essential for addressing the complex interplay of sociocultural factors influencing NSSI behavior.

CLINICAL IMPLICATIONS

The study conducted by Yang et al[5] provides valuable insights into the behavioral subtypes of NSSI among Chinese adolescents, emphasizing the importance of tailored interventions based on distinct profiles. By employing LPA and network analysis, the study categorizes adolescents into three subtypes: NSSI with depression (NSSI-D), NSSI without depression (NSSI-ND), and non-NSSI (NNSSI-ND). The implications of these findings are profound, suggesting that interventions should be specifically designed to address the unique needs and characteristics of each subgroup. For instance, Yang et al’s study[5] highlights the central role of bullying in NSSI-D, suggesting the necessity for interventions that incorporate anti-bullying strategies along with treatments targeting depressive symptoms. The study conducted by Yang et al[5] provides valuable insights into the behavioral subtypes of NSSI among Chinese adolescents, underscoring the critical importance of developing tailored interventions based on distinct psychological profiles. By employing LPA and network analysis, the study categorizes adolescents into three subtypes: NSSI-D, NSSI-ND, and NNSSI-ND. The implications of these findings are profound, suggesting that interventions need to be specifically designed to address the unique needs and characteristics of each subgroup. For instance, the research highlights the central role of bullying in NSSI-D, indicating that efficacious interventions should integrate anti-bullying strategies alongside treatments addressing depressive symptoms.

Supporting these findings, research by Brown and Plener[24] confirms that adolescents exhibiting NSSI behaviors often demonstrate varied psychological profiles and that such distinctions can inform more effective, personalized treatment strategies. Their work employs a similar methodology to identify distinct risk factors associated with each subtype, further validating the necessity for customized therapeutic approaches. Similarly, a longitudinal study by Buelens et al[25] explores the developmental trajectories of adolescents with NSSI, emphasizing the dynamic interplay between external stressors and internal psychological states. They argue for the integration of ongoing stress management programs within intervention frameworks, particularly for individuals identified within the NSSI-D subgroup, to mitigate the compounded impact of these stressors. Finally, a meta-analysis by Liu et al[26] examining multiple studies across different cultural contexts found consistent patterns supporting the use of targeted interventions tailored to specific NSSI subtypes. This synthesis of research underscores the pivotal role of individualized therapeutic strategies in improving outcomes for adolescents engaging in self-injury. By leveraging these insights, mental health professionals can develop more effective, targeted strategies to mitigate NSSI behaviors and improve the overall well-being of adolescents.

RESEARCH METHODS AND STATISTICAL ANALYSIS

The cross-sectional study recruited 3967 participants with an average age of 13.58 years. These adolescents completed comprehensive questionnaires covering various aspects such as parenting styles, bullying, childhood maltreatment, depression, resilience, and NSSI behaviors. The use of LPA allowed the identification of the three distinct NSSI subtypes, whereas network analysis explored the interactions between risk and protective factors. The model fit indices, including Akaike information criterion, Bayesian information criterion, and adjusted Bayesian information criterion, supported the three-profile solution, with an entropy value of 0.89, indicating high classification accuracy.

INTERVENTION STRATEGIES

For adolescents in the NSSI-D subgroup (Table 1), characterized by both NSSI behaviors and depressive symptoms, a multi-faceted approach is essential (Figure 1). The intervention plan should include specific components such as CBT sessions focusing on cognitive restructuring and emotional regulation, with a recommended frequency of weekly sessions over a 6-month period. Additionally, anti-bullying programs should be integrated into school curricula, with periodic evaluations to assess their impact on reducing bullying incidents and NSSI behaviors. CBT can be effective in addressing negative thought patterns and enhancing problem-solving skills. Moreover, targeted anti-bullying programs that create a supportive school environment could significantly reduce the prevalence of NSSI by addressing a core risk factor identified in this group.

Figure 1 Centrality measures of key risk and resilience factors across non-suicidal self-injury subgroups. NNSSI-ND: No non-suicidal self-injury-without depression; NSSI-D: Non-suicidal self-injury-with depression; NSSI-ND: Non-suicidal self-injury-without depression.

Table 1 Summary of non-suicidal self-injury subtypes and intervention strategies.

NSSI subtype	Key characteristics	Intervention strategies
NSSI-D	NSSI with depression, high bullying incidence	CBT, anti-bullying programs, emotional regulation training
NSSI-ND	NSSI without depression, impulsive behaviors	Digital literacy programs, mindfulness, stress management
NNSSI-ND	No NSSI behaviors	General mental health promotion, family support enhancement

CBT: Cognitive behavioral therapy; NNSSI-ND: No non-suicidal self-injury-without depression; NSSI: Non-suicidal self-injury; NSSI-D: Non-suicidal self-injury-with depression; NSSI-ND: Non-suicidal self-injury-without depression.

By contrast, the NSSI-ND subgroup, which exhibits impulsive and externalizing behaviors but not depressive symptoms, may benefit from interventions focused on regulating technology use. Intervention plans for this group could involve digital literacy programs that educate adolescents about the risks of excessive smartphone use, incorporating workshops and interactive sessions to promote responsible digital habits. Effectiveness evaluations should track changes in smartphone usage patterns and associated NSSI behaviors over a 3-month intervention period. Digital literacy programs that educate adolescents about the risks of excessive smartphone use and provide tools for managing screen time could be beneficial. Additionally, incorporating mindfulness and stress management techniques can help adolescents develop healthier coping mechanisms.

Family-based interventions are crucial across all subgroups. These interventions should include structured family therapy sessions aimed at enhancing communication and emotional support within the family unit. Evaluating the effectiveness of these interventions can be achieved through pre- and post-intervention assessments of family dynamics and adolescent well-being. Enhancing communication within the family, increasing parental awareness of NSSI, and fostering supportive relationships can strengthen the protective role of the family environment. Parental training programs that focus on emotion coaching and responsive parenting may improve adolescents’ emotional regulation abilities and reduce NSSI behaviors.

CULTURAL CONSIDERATIONS

The study also highlights the influence of cultural factors, such as the collectivist orientation and strong familial ties prevalent in Chinese society, which can amplify the role of family support in adolescent behavior. The cultural emphasis on academic achievement and adherence to social norms may contribute to stress and emotional difficulties among adolescents. Understanding these cultural dynamics is essential for designing interventions that are culturally sensitive and resonate with adolescents and their families.

FUTURE DIRECTIONS

As the understanding of NSSI continues to evolve, it is imperative to explore new avenues of research and intervention that address the complexities of adolescent self-injury. Building on the foundational insights provided by studies like that of Yang et al[5], future research should aim to deepen and broaden our comprehension of NSSI behaviors and their underlying mechanisms. First, future research should prioritize longitudinal studies to explore the developmental trajectories of NSSI among adolescents. Longitudinal designs can provide valuable insights into the temporal dynamics of risk and protective factors, allowing researchers to identify which factors precede the onset of NSSI behaviors and how they evolve over time[27]. Second, there is a need to expand the demographic and cultural scope of NSSI research. While Yang et al’s study[5] contributes significantly to our understanding of NSSI in Chinese adolescents, future studies should include diverse populations to ensure findings are generalizable across different cultural contexts. This involves examining how cultural norms, values, and social structures influence NSSI behaviors and the effectiveness of interventions[28]. Thirdly, integrating qualitative research methods could enrich our understanding of the subjective experiences of adolescents who engage in NSSI. Qualitative studies can capture the nuanced personal and social factors that quantitative methods might overlook, providing a more comprehensive view of the motivations and circumstances surrounding NSSI behaviors[29]. In conclusion, the future directions for NSSI research and intervention are multifaceted and require a concerted effort to address the complexities of adolescent self-injury. By adopting longitudinal designs, expanding cultural perspectives, incorporating qualitative insights, and embracing multidisciplinary approaches, the field of psychiatry can advance toward more effective and inclusive strategies for mitigating NSSI and promoting adolescent well-being.

CRITICAL ASSESSMENT

The study conducted by Yang et al[5] offers several strengths, including the innovative use of LPA and network analysis to identify distinct NSSI subtypes among Chinese adolescents. This approach provides a nuanced understanding of the behavioral and psychological profiles associated with NSSI, allowing for the development of targeted interventions. Additionally, the study’s large sample size enhances the generalizability of its findings within the studied population. Despite these strengths, several limitations must be acknowledged, which can inform future research directions and enhance the robustness of subsequent studies. First, the study’s cross-sectional design limits the ability to draw causal inferences about the relationships between identified risk and protective factors and NSSI behaviors. While associations can be observed, the cross-sectional nature precludes conclusions about the temporal sequence of these factors. Longitudinal studies are essential to establish causal pathways and understand the progression of NSSI behaviors over time. Second, the reliance on self-reported data introduces potential biases, such as social desirability and recall bias, which may affect the accuracy of the reported behaviors and experiences. Adolescents might underreport or overreport NSSI behaviors and related factors due to stigma or memory inaccuracies. To mitigate these biases, future research could benefit from incorporating multiple informant reports, including data from parents, teachers, or clinical assessments, to validate and cross-check self-reported data. This approach would enhance the reliability and validity of the findings by providing a more comprehensive perspective on adolescents’ behaviors and experiences. Third, the study’s sample is limited to Chinese adolescents, which raises questions about the generalizability of the findings to other cultural contexts. Cultural factors play a significant role in the manifestation and interpretation of NSSI behaviors. Therefore, replication of this study in diverse cultural settings is necessary to determine the universality of the findings and to identify culturally specific dynamics that may influence NSSI. Fourth, the study primarily focuses on psychological and social factors, with limited consideration of biological or genetic influences on NSSI. To gain a more comprehensive understanding of the etiology of NSSI, it is recommended that future studies integrate biological indicators such as genetic markers or neuroimaging data. These biological measures can provide insights into the neurobiological underpinnings of NSSI, helping to elucidate the complex interactions between biological predispositions and environmental factors. Fifth, while the study employs advanced analytical techniques, such as LPA and network analysis, the complexity of these methods can pose challenges in terms of interpretation and replication. To improve transparency and facilitate replication, it is crucial to provide detailed methodological descriptions and open access to analysis scripts and data where possible. This would allow other researchers to validate the findings and apply these methods to similar datasets, thereby enhancing the credibility and utility of the research. Sixth, the study does not account for potential confounding factors, such as comorbid psychiatric conditions, other psychiatric disorders, or medication use, which could influence the observed relationships between risk factors and NSSI. Future research should consider these variables as potential confounders and control for them in the analysis to isolate the specific effects of the identified factors on NSSI behaviors. Incorporating a comprehensive assessment of these factors will provide a clearer understanding of the NSSI etiology and improve the robustness of the findings. Seventh, the study’s focus on a single developmental stage - adolescence - limits the understanding of how NSSI behaviors might differ across the lifespan. To gain a comprehensive perspective on NSSI behavior, future research should expand to include different age groups, such as childhood, adulthood, and older adults. This broader approach would provide insights into developmental variations in self-injury behaviors and inform age-appropriate interventions that can be tailored to the specific needs and challenges of each stage of life. Lastly, there is insufficient utilization of technology and digital platforms in the current study’s intervention strategies. Future research should explore innovative digital intervention strategies, such as mobile health applications, online support communities, and digital CBT programs. These platforms can provide scalable, accessible, and cost-effective solutions for delivering interventions to adolescents, particularly those in remote or underserved areas. Evaluating the effectiveness and engagement of these digital interventions will be crucial for integrating technology into comprehensive NSSI management plans. In summary, while Yang et al’s study[5] significantly advances the understanding of NSSI among adolescents, addressing these limitations in future research will enhance the validity and applicability of findings, ultimately contributing to more effective prevention and intervention strategies.

CONCLUSION

The study by Yang et al[5] provides a solid foundation for future research and clinical practice, paving the way for more personalized and culturally sensitive approaches to managing NSSI. By continuing to build on these insights, the field can make significant strides in mitigating the impact of NSSI and enhancing the well-being of adolescents worldwide. Future research should focus on integrating multidisciplinary perspectives and longitudinal methodologies to further elucidate the developmental pathways and contextual factors that influence NSSI, ensuring comprehensive and effective intervention strategies.