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Repeat self-harm among Chinese adolescents: 1-year incidence and psychosocial predictors

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Abstract

Purpose

Self-harm in adolescents is prevalent and is the most significant predictor of future self-harm and suicide. Longitudinal data on the incidence and predictors of repeat self-harm in the general population of adolescents are limited. This study investigated 1-year incidence and psychosocial predictors of repeat self-harm in Chinese adolescents.

Methods

Shandong Adolescent Behavior and Health Cohort is a longitudinal study of behavior and health in adolescents in Shandong Province, China. Of 7072 participants who were assessed in 2015 and again 1 year later in 2016, 1879 reported a history of self-harm at the baseline survey and were included for this analysis. A self-administered structured questionnaire was used to assess behavioral and emotional problems, sleep, life stress, previous history of self-harm and suicidal thought, and family factors at baseline and self-harm at 1-year follow-up.

Results

Mean age of the sample was 14.86 (SD 1.36) years and 54.6% were female. At 1-year follow-up, 22.1% participants engaged in repeat self-harm. Multiple logistic regression analyses showed that female gender (OR 1.45, 95% CI 1.11–1.89), alcohol use (OR 1.95, 95% CI 1.48–2.57), frequent nightmares (OR 1.61, 95% CI 1.14–2.28), elevated depression score (OR 1.59, 95% CI 1.05–2.42), and prior suicidal thought (OR 1.79, 95% CI 1.37–2.34) were independently and significantly associated with an increased risk of repeat self-harm.

Conclusion

More than one in five Chinese adolescents who had a history of self-harm engaged in self-harm at 1-year follow-up. Multiple psychosocial factors including female gender, alcohol use, frequent nightmares, depression, and prior suicidal thought appeared to be significant predictors of repeat self-harm. Our findings highlight the importance of comprehensive psychosocial assessment and intervention of repeat self-harm in adolescents.

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Data availability

Data available upon request.

References

  1. Schmidtke A, Bille-Brahe U, DeLeo D et al (1996) Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand 93(5):327–338

    Article  CAS  PubMed  Google Scholar 

  2. Swannell SV, Martin GE, Page A, Hasking P, St John NJ (2014) Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav 44(3):273–303

    Article  PubMed  Google Scholar 

  3. Kann L, McManus T, Harris WA et al (2018) Youth risk behavior surveillance—United States, 2017. MMWR Surveill Summ 67(8):1–114

    Article  PubMed  PubMed Central  Google Scholar 

  4. Cheung YT, Wong PW, Lee AM, Lam TH, Fan YS, Yip PS (2013) Non-suicidal self-injury and suicidal behavior: prevalence, co-occurrence, and correlates of suicide among adolescents in Hong Kong. Soc Psychiatry Psychiatr Epidemiol 48(7):1133–1144

    Article  PubMed  Google Scholar 

  5. Liu X, Liu ZZ, Chen RH et al (2019) Nightmares are associated with future suicide attempt and non-suicidal self-injury in adolescents. J Clin Psychiatry. https://doi.org/10.4088/JCP.18m12181

    Article  PubMed  Google Scholar 

  6. Hawton K, Saunders KE, O’Connor RC (2012) Self-harm and suicide in adolescents. Lancet 379(9834):2373–2382

    Article  PubMed  Google Scholar 

  7. Gould MS, Greenberg T, Velting DM, Shaffer D (2003) Youth suicide risk and preventive interventions: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 42(4):386–405

    Article  PubMed  Google Scholar 

  8. Olfson M, Wall M, Wang S et al (2018) Suicide after deliberate self-harm in adolescents and young adults. Pediatrics 141(4):e20173517

    Article  PubMed  Google Scholar 

  9. Hawton K, Bergen H, Kapur N et al (2012) Repetition of self-harm and suicide following self-harm in children and adolescents: findings from the Multicentre Study of Self-harm in England. J Child Psychol Psychiatry 53(12):1212–1219

    Article  PubMed  Google Scholar 

  10. Harris IM, Beese S, Moore D (2019) Predicting repeated self-harm or suicide in adolescents and young adults using risk assessment scales/tools: a systematic review protocol. Syst Rev 8(1):87

    Article  PubMed  PubMed Central  Google Scholar 

  11. Carroll R, Metcalfe C, Gunnell D (2014) Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS ONE 9(2):e89944

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  12. Hawton K, Bergen H, Waters K et al (2012) Epidemiology and nature of self-harm in children and adolescents: findings from the multicentre study of self-harm in England. Eur Child Adolesc Psychiatry 21(7):369–377

    Article  PubMed  Google Scholar 

  13. Michelmore L, Hindley P (2012) Help-seeking for suicidal thoughts and self-harm in young people: a systematic review. Suicide Life Threat Behav 42(5):507–524

    Article  PubMed  Google Scholar 

  14. Hawton K, Rodham K, Evans E, Weatherall R (2002) Deliberate self harm in adolescents: self report survey in schools in England. BMJ 325(7374):1207–1211

    Article  PubMed  PubMed Central  Google Scholar 

  15. Kidger J, Heron J, Lewis G, Evans J, Gunnell D (2012) Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: a self-report survey in England. BMC Psychiatry 12:69

    Article  PubMed  PubMed Central  Google Scholar 

  16. Tzeng WC, Lipson JG (2004) The cultural context of suicide stigma in Taiwan. Qual Health Res 14(3):345–358

    Article  PubMed  Google Scholar 

  17. Kwok CL, Yip PS, Gunnell D, Kuo CJ, Chen YY (2014) Non-fatal repetition of self-harm in Taipei City, Taiwan: cohort study. Br J Psychiatry 204:376–382

    Article  PubMed  Google Scholar 

  18. Owens D, Horrocks J, House A (2002) Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry 181:193–199

    Article  PubMed  Google Scholar 

  19. Knipe D, Metcalfe C, Hawton K et al (2019) Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study. Lancet Psychiatry 6(8):659–666

    Article  PubMed  PubMed Central  Google Scholar 

  20. Kapur N, Cooper J, King-Hele S et al (2006) The repetition of suicidal behavior: a multicenter cohort study. J Clin Psychiatry 67(10):1599–1609

    Article  PubMed  Google Scholar 

  21. Ivey-Stephenson AZ, Demissie Z, Crosby AE et al (2020) Suicidal ideation and behaviors among high school students—youth risk behavior survey, United States, 2019. MMWR Suppl 69(1):47–55

    Article  PubMed  PubMed Central  Google Scholar 

  22. Liu X, Uchiyama M, Okawa M, Kurita H (2000) Prevalence and correlates of self-reported sleep problems among Chinese adolescents. Sleep 23(1):27–34

    Article  PubMed  Google Scholar 

  23. Chung CH, Lai CH, Chu CM, Pai L, Kao S, Chien WC (2012) A nationwide, population-based, long-term follow-up study of repeated self-harm in Taiwan. BMC Public Health 12:744

    Article  PubMed  PubMed Central  Google Scholar 

  24. Asarnow JR, Bai S, Babeva KN et al (2020) Sleep in youth with repeated self-harm and high suicidality: does sleep predict self-harm risk? Suicide Life Threat Behav 50(6):1189–1197

    Article  PubMed  Google Scholar 

  25. Harris IM, Beese S, Moore D (2019) Predicting future self-harm or suicide in adolescents: a systematic review of risk assessment scales/tools. BMJ Open 9(9):e029311

    Article  PubMed  PubMed Central  Google Scholar 

  26. King CA, Grupp-Phelan J, Brent D et al (2019) Predicting 3-month risk for adolescent suicide attempts among pediatric emergency department patients. J Child Psychol Psychiatry 60:1055–1064

    Article  PubMed  PubMed Central  Google Scholar 

  27. Liu XC, Chen H, Liu ZZ, Wang JY, Jia CX (2019) Prevalence of suicidal behaviour and associated factors in a large sample of Chinese adolescents. Epidemiol Psychiatr Sci 28(3):280–289

    Article  CAS  PubMed  Google Scholar 

  28. Liu X, Chen H, Bo QG, Fan F, Jia CX (2017) Poor sleep quality and nightmares are associated with non-suicidal self-injury in adolescents. Eur Child Adolesc Psychiatry 26(3):271–279

    Article  PubMed  Google Scholar 

  29. Liu X, Tein JY (2005) Life events, psychopathology, and suicidal behavior in Chinese adolescents. J Affect Disord 86(2–3):195–203

    Article  PubMed  Google Scholar 

  30. Madge N, Hewitt A, Hawton K et al (2008) Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study. J Child Psychol Psychiatry 49(6):667–677

    Article  PubMed  Google Scholar 

  31. Liu X (2004) Sleep and adolescent suicidal behavior. Sleep 27(7):1351–1358

    Article  PubMed  Google Scholar 

  32. Russell K, Rasmussen S, Hunter SC (2018) Insomnia and nightmares as markers of risk for suicidal ideation in young people: investigating the role of defeat and entrapment. J Clin Sleep Med 14(5):775–784

    Article  PubMed  PubMed Central  Google Scholar 

  33. Pigeon WR, Pinquart M, Conner K (2012) Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry 73(9):e1160-1167

    Article  PubMed  Google Scholar 

  34. Liu X, Liu ZZ, Wang ZY, Yang Y, Liu BP, Jia CX (2019) Daytime sleepiness predicts future suicidal behavior: a longitudinal study of adolescents. Sleep. https://doi.org/10.1093/sleep/zsy225

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hysing M, Sivertsen B, Stormark KM, O’Connor RC (2015) Sleep problems and self-harm in adolescence. Br J Psychiatry 207(4):306–312

    Article  PubMed  Google Scholar 

  36. Liu ZZ, Chen H, Bo QG et al (2018) Psychological and behavioral characteristics of suicide attempts and non-suicidal self-injury in Chinese adolescents. J Affect Disord 226:287–293

    Article  PubMed  Google Scholar 

  37. Cloutier P, Martin J, Kennedy A, Nixon MK, Muehlenkamp JJ (2010) Characteristics and co-occurrence of adolescent non-suicidal self-injury and suicidal behaviours in pediatric emergency crisis services. J Youth Adolesc 39(3):259–269

    Article  PubMed  Google Scholar 

  38. Shek DT, Yu L (2012) Self-harm and suicidal behaviors in Hong Kong adolescents: prevalence and psychosocial correlates. Sci World J 2012:932540

    Google Scholar 

  39. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L (1999) Age- and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry 38(12):1497–1505

    Article  CAS  PubMed  Google Scholar 

  40. Zhang J, Ma J, Jia C et al (2010) Economic growth and suicide rate changes: a case in China from 1982 to 2005. Eur Psychiatry 25(3):159–163

    Article  CAS  PubMed  Google Scholar 

  41. China MoH (2013) China health statistics yearbook (in chinese). Beijing Peking Union Medical College Publishing House

    Google Scholar 

  42. Sun J, Guo X, Zhang J, Jia C, Xu A (2013) Suicide rates in Shandong, China, 1991–2010: rapid decrease in rural rates and steady increase in male-female ratio. J Affect Disord 146(3):361–368

    Article  PubMed  Google Scholar 

  43. Sha F, Yip PS, Law YW (2016) Decomposing change in China’s suicide rate, 1990–2010: ageing and urbanisation. Inj Prev 23:40–45

    Article  PubMed  Google Scholar 

  44. Liu X, Zhao Z, Jia C, Buysse DJ (2008) Sleep patterns and problems among Chinese adolescents. Pediatrics 121(6):1165–1173

    Article  PubMed  Google Scholar 

  45. Chen H, Bo QG, Jia CX, Liu X (2017) Sleep problems in relation to smoking and alcohol use in Chinese adolescents. J Nerv Ment Dis 205:353–360

    Article  PubMed  Google Scholar 

  46. Liu XC, Yang YY, Liu ZZ, Chen H, Fan F, Jia CX (2017) Psychometric assessment of the Chinese adolescent daytime sleepiness scale (CADSS). Sleep Biol Rhythms 15:207–216

    Article  Google Scholar 

  47. Chen H, Wang XT, Bo QG et al (2017) Menarche, menstrual problems and suicidal behavior in Chinese adolescents. J Affect Disord 209:53–58

    Article  PubMed  Google Scholar 

  48. Radloff LS (1977) The CES-D scale: a self report depression scale for research in the general population. Appl Psychol Meas 1:385–401

    Article  Google Scholar 

  49. Liu J, Liu C, Wu T, Liu BP, Jia CX, Liu X (2019) Prolonged mobile phone use is associated with depressive symptoms in Chinese adolescents. J Affect Disord 259:128–134

    Article  PubMed  Google Scholar 

  50. Chen X, Wang T, Busch SH (2019) Does money relieve depression? Evidence from social pension expansions in China. Soc Sci Med 220:411–420

    Article  PubMed  Google Scholar 

  51. Eysenck SBG, Easting G, Pearson PR (1984) Age norms for impulsiveness, venturesomeness and empathy in children. Personality Individ Differ 5(3):315–321

    Article  Google Scholar 

  52. Buysse DJ, Rush AJ, Reynolds CF 3rd (2017) Clinical management of insomnia disorder. JAMA 318(20):1973–1974

    Article  PubMed  Google Scholar 

  53. Liu X, Liu ZZ, Liu BP, Sun SH, Jia CX (2020) Associations between sleep problems and ADHD symptoms among adolescents: findings from the Shandong Adolescent Behavior and Health Cohort (SABHC). Sleep. https://doi.org/10.1093/sleep/zsz294

    Article  PubMed  PubMed Central  Google Scholar 

  54. Levin R, Fireman G (2002) Nightmare prevalence, nightmare distress, and self-reported psychological disturbance. Sleep 25(2):205–212

    PubMed  Google Scholar 

  55. Liu X, Kurita H, Uchiyama M, Okawa M, Liu L, Ma D (2000) Life events, locus of control, and behavioral problems among Chinese adolescents. J Clin Psychol 56(12):1565–1577

    Article  CAS  PubMed  Google Scholar 

  56. Liu BP, Wang XT, Liu ZZ, Wang ZY, Liu X, Jia CX (2019) Stressful life events, insomnia and suicidality in a large sample of Chinese adolescents. J Affect Disord 249:404–409

    Article  PubMed  Google Scholar 

  57. Pompili M, Goracci A, Giordano G et al (2015) Relationship of non-suicidal self-injury and suicide attempt: a psychopathological perspective. J Psychopathol 21(4):348–353

    Google Scholar 

  58. Larsson B, Sund AM (2008) Prevalence, course, incidence, and 1-year prediction of deliberate self-harm and suicide attempts in early Norwegian school adolescents. Suicide Life Threat Behav 38(2):152–165

    Article  PubMed  Google Scholar 

  59. Brunner R, Kaess M, Parzer P et al (2014) Life-time prevalence and psychosocial correlates of adolescent direct self-injurious behavior: a comparative study of findings in 11 European countries. J Child Psychol Psychiatry 55(4):337–348

    Article  PubMed  Google Scholar 

  60. Wacker MJ, Godard MP, McCabe EH, Donnelly JE, Kelly JK (2008) Sex difference in the association of the angiotensin converting enzyme I/D polymorphism and body mass index. Med Sci Monit 14(7):353–357

    Google Scholar 

  61. Di Pierro R, Sarno I, Perego S, Gallucci M, Madeddu F (2012) Adolescent nonsuicidal self-injury: the effects of personality traits, family relationships and maltreatment on the presence and severity of behaviours. Eur Child Adolesc Psychiatry 21(9):511–520

    Article  PubMed  Google Scholar 

  62. Wan YH, Hu CL, Hao JH, Sun Y, Tao FB (2011) Deliberate self-harm behaviors in Chinese adolescents and young adults. Eur Child Adolesc Psychiatry 20(10):517–525

    Article  PubMed  Google Scholar 

  63. Winters DE, Brandon-Friedman R, Yepes G, Hinckley JD (2020) Systematic review and meta-analysis of socio-cognitive and socio-affective processes association with adolescent substance use. Drug Alcohol Depend 219:108479

    Article  PubMed  PubMed Central  Google Scholar 

  64. Levin R, Nielsen TA (2007) Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model. Psychol Bull 133(3):482–528

    Article  PubMed  Google Scholar 

  65. Nadorff MR, Nazem S, Fiske A (2011) Insomnia symptoms, nightmares, and suicidal ideation in a college student sample. Sleep 34(1):93–98

    Article  PubMed  PubMed Central  Google Scholar 

  66. Kearns JC, Coppersmith DDL, Santee AC, Insel C, Pigeon WR, Glenn CR (2020) Sleep problems and suicide risk in youth: a systematic review, developmental framework, and implications for hospital treatment. Gen Hosp Psychiatry 63:141–151

    Article  PubMed  Google Scholar 

  67. Speed KJ, Drapeau CW, Nadorff MR (2018) Differentiating single and multiple suicide attempters: what nightmares can tell us that other predictors cannot. J Clin Sleep Med 14(5):829–834

    Article  PubMed  PubMed Central  Google Scholar 

  68. Titus CE, Speed KJ, Cartwright PM, Drapeau CW, Heo Y, Nadorff MR (2017) What role do nightmares play in suicide? A brief exploration. Curr Opin Psychol 22:59–62

    Article  PubMed  Google Scholar 

  69. Liu ZZ, Wang ZY, Bo QG et al (2018) Suicidal behaviours among Chinese adolescents exposed to suicide attempt or death. Epidemiol Psychiatr Sci 29:e12

    Article  PubMed  PubMed Central  Google Scholar 

  70. Keeton CP, Caporino NE, Kendall PC et al (2019) Mood and suicidality outcomes 3–11 years following pediatric anxiety disorder treatment. Depress Anxiety 36(10):930–940

    Article  PubMed  Google Scholar 

  71. Zhang J (2019) Suicide reduction in China. Am J Public Health 109(11):1533–1534

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors would like to thank staff members at Yanggu County Center for Disease Control and Prevention, Lijin County Center for Disease Control and Prevention, and Zoucheng City Center for Disease Control and Prevention, Shandong Province, China, and all participating class teachers for their help with data collection and all students for their voluntarily participating in the study.

Funding

This work was funded in part for data collection by National Natural Science Foundation of China (Grant number 81573233).

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Authors and Affiliations

  1. Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, 19104, USA

    Xianchen Liu

  2. Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China

    Zhen-Zhen Liu & Cun-Xian Jia

  3. Department of Psychology, REACH Institute, Arizona State University, Tempe, AZ, USA

    Zhen-Zhen Liu

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  1. Xianchen Liu
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Contributions

XL conceptualized the study, performed data analysis, and drafted the manuscript. Z-ZL participated in the study design, collected data, managed data, and reviewed and revised the manuscript. C-XJ contributed to the study design, supervised data collection and data management, and reviewed and revised the manuscript.

Corresponding author

Correspondence to Xianchen Liu.

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All authors have no conflicts of interest/competing interests to declare.

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Liu, X., Liu, ZZ. & Jia, CX. Repeat self-harm among Chinese adolescents: 1-year incidence and psychosocial predictors. Soc Psychiatry Psychiatr Epidemiol 56, 1979–1992 (2021). https://doi.org/10.1007/s00127-021-02085-x

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