Adolescent non-suicidal self-injury: A cross-national study of community samples from Italy, the Netherlands and the United States
Introduction
Non-suicidal self-injury (NSSI), defined as the socially unacceptable, direct, deliberate destruction of one's own body tissue without suicidal intentions, has been recently shown to be a widespread phenomenon among adolescents in several Western countries (Heath et al., 2008). An increasing number of studies from North America (Canada and United States) (e.g., Ross and Heath, 2002, Laye-Gindhu and Schonert-Reichl, 2005, Lloyd-Richardson et al., 2007) have reported that NSSI is not only related to psychiatric disorders (e.g., borderline personality disorders, anorexia nervosa), but also involves approximately 15% to 20% of non-clinical (i.e., community) adolescents (Heath et al., 2008). Evidence about adolescent self-injury (with or without suicidal intents) has been provided also outside North America, with studies conducted in Europe, primarily in the UK (e.g., Hawton et al., 2002, O'Connor et al., 2009) and Scandinavian countries (e.g., Lundh et al., 2007, Bjärehed and Lundh, 2008), as well as Australia (e.g., De Leo and Heller, 2004) and Asia (e.g., Matsumoto et al., 2008).
Despite the increasing amount of evidence on self-injury, different definitions and instruments used in the existing studies make it difficult to know the actual extent of the phenomenon across different cultural contexts. Specifically, while North American studies focused on self-injury according to the aforementioned definition (i.e., NSSI), the majority of the work conducted in Europe adopted a more comprehensive definition of self-injury (i.e., deliberate self-harm; DSH), which includes other forms of self-injurious behaviors, such as self-poisoning (e.g., drug overdose), and in particular does not distinguish between non-suicidal and suicidal behaviors (Rodham and Hawton, 2009). Yet, research has shown substantial differences between NSSI and suicidal self-injurious behaviors, in terms of rates, correlates, as well as functions, suggesting it is important to differentiate between these forms of self-injurious behaviors (Nock and Favazza, 2009, Baetens et al., 2011). Adopting the same definition and methodology in samples from different countries might provide comparable data contributing to extend the existing literature on NSSI.
To date, only three main studies have examined self-injury across different countries using the same assessment method. Two studies found substantial differences across countries with regard to DSH prevalence (the Child and Adolescent Self-harm in Europe – CASE – Study, Madge et al., 2008, Portzky et al., 2008). However, because they adopted a definition of self-injury which includes suicidal behaviors (i.e., DSH), it remains unclear whether such differences pertain to NSSI or, rather, to different rates in suicidal behaviors, as other evidence seems to suggest (Nock et al., 2008). The only study that specifically examined NSSI across nations showed similar prevalence rates in NSSI lifetime rates between German and U.S. adolescents (25.6% vs. 23.2%; Plener et al., 2009). Thus, cross-national studies clearly are needed to corroborate this evidence.
Identifying NSSI correlates across different contexts may provide further insight into the understanding of adolescent NSSI. In line with explanatory models of self-injury (for reviews, see Klonsky, 2007, Messer and Fremouw, 2008), several internal and interpersonal proximal factors may be expected to associate with NSSI among non-clinical adolescents. As NSSI may represent a maladaptive strategy for emotion regulation (i.e., automatic function), adolescents may engage in NSSI in order to reduce or avoid their negative emotional states (Nock and Prinstein, 2005, Chapman et al., 2006). Thus, internal distress, such as depressive symptoms and loneliness which are highly prevalent and commonly experienced among non-clinical adolescents (Heinrich and Gullone, 2006, Avenevoli et al., 2008), may be strongly related to NSSI. Prior work supported this hypothesis by showing that adolescents with a history of NSSI reported higher levels of depressive symptoms as compared to adolescents without NSSI experience (e.g., Hilt et al., 2008a, Hankin and Abela, 2011). Yet, although the link between loneliness and self-injury has been widely hypothesized within the existing literature, few studies directly examined it (Nock and Prinstein, 2005, Lasgaard et al., 2011). In particular, because adolescents may feel lonely when experiencing poor and unsatisfactory relationships with their peers as well as with their family (Heinrich and Gullone, 2006), and because difficult experiences with both peers (as detailed below) and family (e.g., parental alienation; Yates et al., 2008, Bureau et al., 2010) have been shown to be relevant for self-injury, both peer and family loneliness may uniquely and independently associate with NSSI.
During adolescence, interpersonal relationships with peers assume a central role for adolescents' psychosocial development. Conversely, negative peer relationships, in particular low peer preference (or peer rejection) and victimization, have been shown to be harmful experiences which may lead to different forms of distress and psychopathology (e.g., depression, low self-esteem, and externalizing behaviors; Laird et al., 2001, Lopez and DuBois, 2005). Hence, NSSI may be associated with peer rejection and victimization as it may serve to cope with the negative emotional states arising from these stressful peer experiences (i.e., automatic function). Moreover, the social functions which NSSI also may serve (Nock and Prinstein, 2005) provide an additional rationale for hypothesizing an association with interpersonal stressors. That is, adolescents who are rejected and victimized by their peers may endorse NSSI to communicate with others in order to gain attention or discourage external stimuli. Prior self-injury work paid limited attention to interpersonal stressors, with only a small number of studies showing an association between peer victimization and self-injury (Sourander et al., 2006, Hilt et al., 2008a, Hay and Meldrum, 2010, Jutengren et al., 2011). Moreover, previous studies have never simultaneously investigated the role of internal distress and interpersonal stressors in relation to NSSI using cross-national samples.
An analysis of adolescent health risk behaviors also may contribute to identifying those adolescents at-risk for NSSI. Indeed, adolescents that endorse NSSI may be more likely to engage in other health risk behaviors too. Here, different from internal distress and interpersonal stressors, the association between NSSI and substance use likely may be explained as the consequence of common underlying factors (i.e., common liability model; Donovan and Jessor, 1985, Vanyukov et al., 2003). For instance, as proposed by theoretical models of adolescent substance use (e.g., Khantzian, 1990, Boys et al., 1999, Wills et al., 2006), substance use, similar to NSSI, may serve multiple functions, internal (e.g., reduce negative emotional states) as well as social (e.g., avoid social rejection). Consequently the two behaviors may be expected to co-occur as they may represent different strategies to deal with similar situations. This hypothesis has found support in prior work among community-based adolescents in which self-injury has been shown to co-occur with other health risk behaviors, including substance use (e.g., Hilt et al., 2008b, Madge et al., 2008, Portzky et al., 2008). Although no previous studies compared the association between NSSI and substance use across different countries, cross-cultural evidence exists with regard to DSH, indicating country differences in the association between DSH and substance use (e.g., cannabis use; Rossow et al., 2009). Here, similar cross-national associations between NSSI and substance use may suggest that NSSI is another adolescent risk behavior and likely in each country serves similar functions as substance use does.
This study aimed to extend previous NSSI literature by exploring the rates and correlates of NSSI, including internal distress (depressive symptoms, family-related and peer-related loneliness) interpersonal stressors (peer victimization, low peer preference), and substance use (i.e., cigarette smoking, frequent binge drinking and marijuana use), across three samples from different nations (i.e., Italy, the Netherlands, and the United States). Based on existing theories suggesting that internal distress and interpersonal stressors may lead to NSSI (functional models, Nock and Prinstein, 2005) whereas substance use may co-occur with NSSI (common liability models, Donovan and Jessor, 1985), the associations between NSSI and these two groups of factors were examined in two separate models. To our knowledge, only one study to date investigated DSH among a community sample of Italian adolescents, reporting a lifetime rate of 46% (Cerutti et al., 2011), and two studies found evidence of DSH among non-clinical adolescents in the Netherlands, with a last year prevalence of 2.6% (Madge et al., 2008, Portzky et al., 2008). It is worth noting that although these countries are considered Western societies, differences exist between them with respect to socio-cultural norms, traditions, as well as substance use policies (Ciairano et al., 2009, Simons-Morton et al., 2010). Such differences may be reflected in adolescent interpersonal relationships as well as in their involvement in problem behaviors. For instance, prior work showed higher levels of substance use (i.e., alcohol use and cigarette smoking) among Italian and Dutch adolescents compared to U.S. adolescents (Hibell and Skretting, 2009, Simons-Morton et al., 2010). The purpose of this study was to explore whether correlates of NSSI would be similar across different cultures, suggesting similar models of risk that may apply more universally than what has been tested previously.
Section snippets
Procedure and participants
In all three countries, participants were recruited in secondary public schools. In accordance with the local policy of each country, an active consent procedure was adopted in Italy and United States and a passive one in the Netherlands. This study was approved by the respective university ethics committees for research involving human subjects.
In Italy, 1038 families of adolescents attending three schools located in the suburban area of the Northwest of Italy were asked to participate in the
Prevalence of NSSI in the three samples
Overall, approximately 24% of the adolescents (23.6% Italy; 25.8% the Netherlands; 21.9% United States) reported at least one NSSI experience during the previous months. The first chi-square test indicated no significant differences across the three samples in the percentages of adolescents involved in NSSI. However, due to several sample differences with respect to participants' socio-demographic characteristics (see Table 1), additional chi-square tests, each controlling for one
Discussion
This study examined non-suicidal self-injury behaviors among adolescents from Italy, the Netherlands, and the United States using the same methodology. We examined the prevalence of NSSI across samples from these three countries and extended previous literature by examining the associations between NSSI and both psychosocial factors and substance use cross-nationally. Overall, we found large sample similarities and revealed cross-national differences in the relation between NSSI and substance
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