Introduction
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 culture1. NSSI is a fatal public health problem worldwide, studies have found that NSSI is very common among adolescents, with international lifetime prevalence rates of approximately 17.2%2. A recent Meta-analysis found that the global lifetime prevalence of NSSI in children and adolescents is 22.1%3. The literature has found that some psychosocial factors are significantly related to NSSI in youth, such as risk factors for self-harm include low socioeconomic status, female gender, sex orientation, impulsivity, low self-esteem, educational level and mental disorder4, anxiety and depression5,6,7, childhood maltreatment (CM)8. Therefore, it has great significance to explore risk factors of NSSI for developing targeted prevention programs, especially for adolescents.
Nowadays, a lot of prior work has supported that childhood maltreatment is a robust predictor of NSSI9,10. CM is typically defined as any action of commission or omission by parents or other caregivers that brings direct or potential harm, which generally encompasses four core subtypes: physical abuse (PA), emotional abuse (EA), sex abuse (SA), neglect11. CM is generally considered a risk factor for many psychopathological and behavioural problems. Researchers have shown that exposure to any adverse CM, regardless of the type of event, increases the risk of self-harm by 2.7 to 6.1 times12. As a widespread global health problem, CM is strongly associated with and increases the risk of negative mental health outcomes later in life13, such as depression and anxiety14. So far, we may know more about the association between CM and NSSI, but cultural backgrounds in different countries may influence this association and deserve further study in China.
In addition to CM, depressive symptoms (DS) have been examined as another important risk factor for adolescents’ NSSI. DS refer to low mood, decreased interest, and physical discomfort15. A general term for a series of symptoms, long-term depressive symptoms can develop into depression, and the incidence of depressive symptoms among Chinese adolescents reached 24.3% in 201916. The inner world of teenagers changes dramatically, and they are psychologically fragile and sensitive. There is a significant correlation between the mental health status of adolescents and their risk behavior tendency and extreme behavior. In the absence of appropriate psychological intervention, the pattern of undesirable behavior often continues into adulthood and has lasting negative effects on individual development17. In recent years, domestic and foreign scholars have consistently found that there is a high correlation and co-occurrence between adolescent depressive symptoms and NSSI18,19. Another previous study revealed that adolescents with depressive symptoms had 3.32 times the odds ratio (OR) of NSSI compared to adolescents without depressive symptoms in rural China20. Depressive symptoms in adolescents not only lead to poor academic performance and impaired social functioning, but are also independent risk factors for NSSI21. DS were a significant predictor of NSSI frequency. For every increase in the number of DS, the risk of developing NSSI increased by 18%22.
Adolescents are in an important stage of physical and mental development, and are susceptible to the influence of growth environment factors, resulting in mental health problems23. Beyond to NSSI, emerging research has found a positive correlation between CM and depressive symptoms24,25, and CM is a significant predictor of depressive symptoms26,27. A study in Hong Kong found that depressive symptoms were associated with childhood maltreatment and all its dimensions28.
Given the positive correlation between CM and NSSI, depressive symptoms and NSSI, and CM and depressive symptoms, it is reasonable to assume the indirect effect of CM on NSSI through the mediating role of depressive symptoms. Moreover, recent studies also suggest that depressive symptoms have mediating properties in the relationship between CM and NSSI. Brown et al.29 found a partial mediating effect of EA and full mediating effects of SA and PA by depressive symptoms on NSSI. The above indicates that depressive symptoms may indeed be important factors explaining the pathway from CM to NSSI. However, it is important to note that the participants in the aforementioned studies were all adults, which limits the direct applicability of these findings to the adolescent population. Therefore, it is worth exploring whether depressive symptoms can also play a mediating role in the relationship between CM and NSSI in adolescents. The findings will help better understand the development of NSSI and largely benefit the efficient prevention of NSSI.
Much existing evidence supports that gender is independently associated with depressive symptoms, and NSSI20,30. For instance, Zhang et al.30found that the level of depressive symptoms was significantly higher in females than in males30. Luo et al.20 found that the prevalence of NSSI among females was significantly higher than among males (33.0% vs. 27.3%)20. Therefore, it is necessary to examine gender differences when exploring the mediation of depressive symptoms between CM and NSSI.
Similarly, an increasing number of researchers have noted that the place of residence is also an influencing factor of the three variables mentioned above. Compared to urban children, rural children had higher rates of exposure to the majority of the CM31. Zeng et al.32found that on average, rural adolescents reported higher depression levels than urban peers32. Until now, there is a dearth of research exploring the NSSI between Chinese adolescents in different place of residence. While aforementioned information is helpful and useful to screen high risk population of NSSI. Therefore, it is crucial to take into account the confounding influence of gender and residence in the relationship between CM and NSSI.
In order to address the gaps mentioned above, we conducted a cross-sectional study among junior high school students in Chongqing, China. The first aim of the current study is to explore the independent effect of CM on NSSI. Then, the second purpose is to examine the indirect effect of CM on NSSI. Last, since there are debatable findings about the risk of NSSI between males and females20,30, and there is no previous study to compare the difference of NSSI between urban and rural adolescents. Thus, our third objective is to explore the interaction of gender and residence. Based on the above purposes, we speculated that CM could significantly increase the risk odds of NSSI (Hypothesis 1). We anticipated that depressive symptoms could mediate the relationship between CM and NSSI (Hypothesis 2). We expected that the direct and/or indirect effects of CM on NSSI might differ between urban male, urban female, rural male, and rural female participants (Hypothesis 3).
Methods
Procedures and participants
This study uses a combination of stratified cluster sampling and convenience sampling for the period May-June 2023. In Stage 1, by the method of stratified cluster sampling and convenient sampling, the districts and counties are divided into good, medium, and poor levels according to the economic income level of Chongqing. In Stage 2, a convenient sampling method was used to select 1 district and county from each level, and 2 middle schools from each district and county from urban and rural areas, totaling 12 schools. In Stage 3, four to five classes were selected from grade 1 to grade 3 in each school by convenient sampling method. Finally, we took all the students in school on the class day as the survey object. A total of 7491 students were recruited. Then, 335 were excluded due to the missing data was > 15% of all variables in the study. Finally, 7156 students’ questionnaires were qualified and the actual response rate was 95.53% (7156/7491).
Measures
NSSI
The questionnaire for evaluating non-suicidal self-injury behavior of adolescents compiled by Wan et al.33was used. The scale has good reliability and validity and can be used in Chinese adolescents. Respondents were asked whether they had committed any of the following non-suicidal self-harm behaviors in the past 12 months, including 12 questions such as “intentionally choking oneself” and “burns or scalds.” The options are defined as “0 times, 1 time, 2–4 times, ≥ 5 times”, and are assigned 0, 1, 2, and 3 in turn. According to the diagnostic and statistical manual of mental disorders 5th (DSM-5) standard34, subjects with cumulative frequency of ≥ 5 times were classified as having NSSI. The Cronbach’s α of the scale was 0.889.
Childhood maltreatment
Using the childhood maltreatment questionnaire modified by Peng et al.11, the scale has good reliability and validity, and can be used in Chinese adolescents. The scale contains 27 items (including 24 clinical items and 3 validity items). It is divided into four dimensions: emotional abuse (EA), physical abuse (PA), sex abuse (SA) and neglect (Neglect). Each item of the scale is evaluated using a 5-point scale (1 point for “never”, 2 points for “occasionally”, 3 points for “sometimes”, 4 points for “often” and 5 points for “always”). Seven of the entries (2, 5, 7, 13, 19, 26, 28) required reverse scoring. The criteria for determining positivity for each dimension were, physical abuse > 8 points, emotional abuse > 11 points, sex abuse > 7 points, neglect > 26 points. A positive test for either type of abuse or neglect indicates that the subject is positive for childhood maltreatment. The Cronbach’s α of the total scale was 0.711. The Cronbach’s α of each dimension ranged from 0.696 to 0.815.
Depressive symptoms
The CES-D (The Center for Epidemiological Studies Depression Scale, CES-D), compiled by Radloff35, was used to measure depression within the last week. The scale has good reliability and validity and can be used in Chinese adolescents. A 4-level scale was used to fill in the form, with the scale score ranging from 0 to 60, and the higher the score, the higher the degree of depression. There are 20 items in the scale, among which 4, 8, 12 and 16 are scored in reverse. Each item has 0 to 3 points, 0 indicating almost no (< 1d),1 indicating sometimes (1 to 2d), 2 indicating often (3 to 4d), and 3 indicating most of the time (5 to 7d). Generally, a score of ≥ 20 is determined as certain depressive symptoms. The Cronbach’s α of the scale was 0.877.
Demographic variables
Demographic variables included gender (1 = male, 2 = female), grade (1 = 7th, 2 = 8th, 3 = 9th), residence (1 = urban, 2 = rural), only child (1 = no, 2 = yes), family economic situation (1 = poor, 2 = medium, 3 = good), academic performance (1 = bad, 2 = medium, 3 = good), academic pressure (1 = heave, 2 = medium, 3 = light), and close partners (1 = 0–2, 2 = 3–5, 3 = ≥ 6).
Statistical analysis
First, the sociodemographic characteristics of the participants and the prevalence of NSSI were summarized by descriptive statistics. Second, the chi-square test was used to compare the prevalence of NSSI in different categorical variables. One-way ANOVA was used to compare the prevalence of depressive symptoms, NSSI and differences in four types of childhood maltreatment between the four groups of gender × place of residence (rural male, rural female, urban male, and urban female). Third, to examine the independent effects of childhood maltreatment and depressive symptoms on NSSI (0 = No, 1 = Yes), binary logistic regression analysis was adopted to assess odds ratios (ORs) and 95% confidence intervals (95% CIs) with childhood maltreatment and depressive symptoms as two independent variables. In addition, we included grade, family economic situation, academic performance, academic pressure, and close partners as confounding variables. Fourth, a subgroup analysis was conducted to assess the potential role of gender × place of residence, and a set of binary logistic regression analyses was performed among rural males, rural females, urban males, and urban females separately. The significance level was set at P < 0.05, and all tests were two-sided. All data were analyzed with IBM SPSS, version 26.0.
Fifth, we performed structural equation modeling (SEM) to evaluate the mediating effects of depressive symptoms (DS score) on the relationship between childhood maltreatment (CM score) and NSSI. In model 1, we ran SEM with the total sample. In models 2 to 5, we ran SEM among rural males, rural females, urban males, and urban females separately to assess the influence of gender × place of residence in the mediation model. The parameters used in the model Fit Index include Chi-square (χ2), Degree of Freedom (df), Comparative Fit Index (CFI), and Tuck-Lewis Index (TLI), Root Mean Square of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR), The criteria for good fitting index were χ2 / df< 5, CFI/TLI > 0.90, RMSEA < 0.06, SRMR < 0.0836. The sample size had a significant effect on χ2 / df. In the case of large samples, the chi-square statistic is more sensitive to the sample size. Even if the actual fitting deviation between the model and the data is small, the chi-square value may increase significantly due to the increase of the sample size, resulting in chi-square degrees of freedom greater than 537. Therefore, in this study, Chi-square degrees of freedom are not used as a reference for model fitting index, which will not be further described in the following paper.
All models were adjusted for variables that had significant associations with NSSI in the binary logistic regression analysis. All models of SEM were analyzed using IBM SPSS Amos 28.0.
Results
Sample information
Among the 7,156 participants, 3,498 boys (48.9%), 3,658 girls (51.1%). The mean age (SD) was 14.43 (0.96). The detection rate of NSSI in adolescents was 19.10% (1,367/7,156). The detection rate of adverse childhood maltreatment was 25.77% (1,844/7,156), physical abuse 7.87% (563/7,156), emotional abuse 8.73% (625/7,156), sex abuse 5.79% (414/7,156) and neglect 15.29% (1,094/7,156). Other characteristics of the sample were depicted in Table 1.
Univariate analysis of suicide behaviors
Compared to participants without depressive symptoms, participants with depressive symptoms reported a higher prevalence of NSSI (44.1% vs. 7.6%, P < 0.001). Participants with physical abuse had a higher prevalence of NSSI than those who without (44.0% vs. 17.0%, P < 0.001). Participants with emotional abuse had a higher prevalence of NSSI than those who without (61.6% vs. 15.0%, P < 0.001). Participants with sex abuse had a higher prevalence of NSSI than those who without (37.7% vs. 18.0%, P < 0.001). Participants with neglect had a higher prevalence of NSSI than those who without (33.7% vs. 16.5%, P < 0.001). Females reported more NSSI than males (23.7% vs. 16.0%, P < 0.001). The proportion of NSSI was significantly different in terms of all variables, except for residence and only child (Table 1).
The difference of gender × residence
Participants across gender × residence had significantly different proportion of depressive symptoms and NSSI involvement (Table 2). Particularly, rural females had the highest proportion of depressive symptoms (40.3%) and NSSI (22.7%) according to pairwise comparisons. Besides, four childhood maltreatment subtypes were significantly different between males and females across urban and rural areas.
Logistic regression analysis of NSSI
Results of binary logistic regression analysis were shown in Tables 3 and 4. For total participants, all subtypes of childhood maltreatment were significantly associated with NSSI involvement (P < 0.01), In subgroup analysis, sex abuse was significantly associated with NSSI for urban males (OR = 2.01, 95% CI 1.26–3.21, P = 0.004), urban females (OR = 1.89, 95% CI 1.08–3.28, P = 0.025), except for rural males (P = 0.835) and rural females (P = 0.098). Both physical abuse and emotional abuse were significantly associated with the four groups. Notably, none of the four types of child maltreatment in rural males was associated with NSSI. Moreover, neglect was not associated with any of the four groups.
The mediating effect of depressive symptoms between childhood maltreatment and NSSI
Since all models are saturated models, that is, all the parameters to be estimated are exactly equal to the elements in the covariance matrix, and the degrees of freedom are 0, no longer Estimate its fit index, focusing only on its path coefficient38. After controlling for covariates, there were direct effects of the physical abuse (β = 0.170, 95% CI = 0.132–0.212, P < 0.001) and the depressive symptoms (β = 0.493, 95% CI = 0.464–0.520, P < 0.001) on NSSI. The total effect of physical abuse on NSSI was 0.314 (95% CI = 0.272–0.356, P < 0.001), and the indirect effect was 0.143 (95% CI = 0.129–0.158). The mediation ratio was 45.5% (Table 5). There were direct effects of the emotional abuse (β = 0.245, 95% CI = 0.209–0.283, P < 0.001) and the depressive symptoms (β = 0.408, 95% CI = 0.373–0.440, P < 0.001) on NSSI. The total effect of emotional abuse on NSSI was 0.471 (95% CI = 0.438–0.502, P < 0.001), and the indirect effect was 0.226 (95% CI = 0.206–0.244). The mediation ratio was 48.0% (Table 6). There were direct effects of the sex abuse (β = 0.088, 95% CI = 0.046–0.133, P < 0.001) and the depressive symptoms (β = 0.524, 95% CI = 0.494–0.550, P < 0.001) on NSSI. The total effect of sex abuse on NSSI was 0.191 (95% CI = 0.145–0.239, P < 0.001), and the indirect effect was 0.103 (95% CI = 0.088–0.118). The mediation ratio was 53.9% (Table 7). There were direct effects of the neglect (β = 0.034, 95% CI = 0.010–0.059, P < 0.01) and the depressive symptoms (β = 0.529, 95% CI = 0.498–0.557, P < 0.001) on NSSI. The total effect of neglect on NSSI was 0.251 (95% CI = 0.226–0.275, P < 0.001), and the indirect effect was 0.217 (95% CI = 0.200–0.233). The mediation ratio was 86.5% (Table 8).
The direct effect of sex abuse on NSSI was not significant in rural males (P > 0.05). Moreover, the direct effect of neglect on NSSI was not significant in rural males, rural females and urban males (P > 0.05). The mediation ratios of the depressive symptoms between physical abuse and NSSI from high to low were 49.9% (urban female), 49.3% (rural male), 48.1% (rural female), and 34.5% (urban male) respectively. The mediation ratios of the depressive symptoms between emotional abuse and NSSI from high to low were 53.4% (rural male), 50.2% (urban female), 48.5% (rural female), and 38.7% (urban male) respectively. The mediation ratios of the depressive symptoms between the sex abuse and NSSI from high to low were 66.2% (rural male), 61.7% (rural female), 55.8% (urban female), and 27.1% (urban male) respectively. The mediation ratios of the depressive symptoms between neglect and NSSI from high to low were 101.5% (rural male), 88.3% (rural female), 85.7% (urban male), and 77.0% (urban female) respectively.
These results suggest that depressive symptoms fully mediate the relationship between sex abuse and NSSI in rural males. Moreover, the depressive symptoms were complete mediator between neglect and NSSI in rural males, rural females and urban males. The mediating effects of other parts were significant (P < 0.05).
Discussion
This study explored the direct and indirect effects of childhood abuse on NSSI of middle school students through the mediating role of depressive symptoms. There were several major findings. First, different types of childhood abuse can significantly increase the risk of non-suicidal self-injury behavior. Second, depressive symptoms partially and completely mediate between self-injury and different types of maltreatment in child maltreatment. Third, the relationship between childhood maltreatment, depressive symptoms, and self-injury was evident and unique between men and women in rural and urban areas. For example, none of the four types of child maltreatment among rural men were associated with self-injury. These findings expand our understanding of the development of NSSI and help educators, clinicians, and policymakers develop effective and targeted NSSI prevention strategies for adolescents.
The results of this study found that different types of childhood abuse significantly increased the risk of non-suicidal self-harm behaviors. The results support hypothesis 1. In line with some previous studies39,40, our results demonstrated that CM was independently related to NSSI in Chinese adolescents after controlling for covariates. Some children who have experienced maltreatment may display one or more of several different types of problems, such as aggressive behaviors, risky sex behavior, depression, self-harm, and suicidality41. Furthermore, the association between the four subtypes of childhood maltreatment and NSSI was surprisingly not significant in rural males. The association between sex abuse and NSSI was not significant only in rural females, and the association between neglect and NSSI was not significant in any of the four populations. However, a study in China showed that neglect was significantly associated with NSSI in rural adolescents42. The underlying cause of these findings was unclear. The new findings may broaden the literature in the field and have practical implications for intervention strategies for NSSI in populations with different demographic characteristics. At the same time, longitudinal studies are needed to look again at these associations, as the results of longitudinal studies may be more reliable. Future research should further verify the results and explore the underlying mechanism.
Our study is the first to show that depressive symptoms could fully mediate the relationship between sex abuse, neglect and NSSI in rural males, as well as neglect and NSSI in rural females and urban males. All other mediating effects were partial mediating effects. The results of this study support hypothesis 2. Our findings potentially aligned with the biological conceptual model of NSSI43. According to this theory, early exposure to CM impairs the emotion regulation circuit of the brain through environmental-biological interactions in long-term adolescent development, causing depression. Then, adolescents may adopt NSSI as a coping strategy for regulating aversive emotional experiences. Of course, this requires further imaging and biological research.
With regard to sex abuse and physical neglect, the current study founding supported for these factors to play a role in the etiology of NSSI. However, these effects were fully mediated by the presence of depressive symptoms. These results added on to findings44,45 that presenting sex abuse as rather having an indirect than a direct effect on the development of NSSI. Moreover, physical and emotional abuse were mediated in part by depressive symptoms, results concerning emotional abuse were in line with previous studies46,47,48and support theoretical approaches like the Developmental Psychopathology Network49 or the Biopsychosocial Model by Marsha Linehan50, both linking adverse childhood experiences with primary caregivers with the development of dysfunctional emotion regulation and thus developing dysfunctional coping skills like NSSI. 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 emotions51,52. Therefore, depression predicts NSSI because individuals may take more self-injurious behavior to cope with the depression to relieve such unpleasant experiences53,54. Therefore, it is necessary to evaluate adolescents who have experienced childhood maltreatment for depressive symptoms. In addition, effective interventions should be undertaken to reduce depressive symptoms in adolescents experiencing childhood maltreatment to weaken the association between CM and NSSI.
Our study shows for the first time that depressive symptoms can adequately mediate the relationship between sexual abuse, neglect and self-harm in rural men, and neglect and self-harm in rural women and urban men. All other mediating effects are partial mediating effects. The results of this study support hypothesis 3. The relationship between childhood maltreatment, depressive symptoms, and self-harm is distinct and unique between men and women in rural and urban areas.
Our results supported that female adolescents had a higher prevalence and risk of NSSI than male adolescents. In addition, participants living in rural areas reported a slightly higher incidence of NSSI than participants in urban areas. The analysis further revealed that within the various subgroups examined, rural females had the highest prevalence of NSSI, whereas rural males exhibited the lowest prevalence. Some females may harm themselves in a conspicuous way to attract attention from more people and hence to obtain emotional support55,56. This phenomenon needs to be understood in the specific social and cultural context of China. China’s traditional patriarchal family structure and gender role expectations often restrict women from expressing their emotional needs through normal channels. Gender differences in NSSI may be influenced by social gender inequality factors. Studies have shown that compared with male groups, women are under greater psychological pressure in academic achievement, peer relationship maintenance and social interaction, which may lead to more intense negative emotional experience, and thus increase the risk of NSSI57. At present, the literature on the incidence of NSSI in rural female may be limited. Future surveys with more representative samples should therefore be conducted to understand why NSSI varies by gender and place of residence.
Despite the theoretical and practical implications of the current study, some limitations should be noted. First, as a cross-sectional study design, it is not possible to determine the causality between CM and NSSI. A longitudinal study is warranted to confirm the causal relationship of the variables in the study. Second, since the participants in our study were from one city in China, the sample may hardly represent all Chinese adolescents. Third, in this study, we only focused on depressive symptoms. However, there may be other factors that can mediate CM and NSSI, such as anxiety, which were not considered in this study. More studies are needed to examine other mediating factors in the future. Fourth, participants in the NSSI (non-suicidal self-injury) group included in this study did not undergo rigorous clinical diagnostic screening for mental disorders, and did not conduct standardized evaluation and matching of personality characteristics. This may result in potential psychiatric comorbidity or confounding variables of personality traits not being controlled for, affecting the purity of the results. Fifth, the study did not assess and control for participants’ current use of psychotropic drugs or psychotherapy. Since these interventions may significantly affect self-injurious behavior through symptom relief or improved emotional regulation, these unmeasured effects could be potential confounding factors affecting the study results. Future studies should document treatment status through medical records and standardized self-reporting systems to better control for the effects of these treatment factors.
Conclusion
Our results indicate that higher levels of CM are associated with an increased risk of NSSI among Chinese middle-school students. Moreover, depressive symptoms partially and completely mediated the effects of four types of childhood maltreatment on NSSI, respectively. In addition, the relationship of CM, depressive symptoms, and NSSI may differ between males and females across rural and urban areas. Furthermore, NSSI prevention strategies should be tailored by gender and place of residence, and particular attention should be paid to sex abuse, neglect and depressive symptoms in rural males and neglect and depressive symptoms in rural females and urban males.
Data availability
Data is provided within the manuscript or supplementary information files.
References
Brown, R. C. & Plener, P. L. Non-suicidal Self-Injury in adolescence. Curr. Psychiatry Rep. 19 https://doi.org/10.1007/s11920-017-0767-9 (2017).
Swannell, S. V., Martin, G. E., Page, A. & Hasking, P. St John, N. J. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression. Suicide Life-Threat. Behav. 44, 273–303. https://doi.org/10.1111/sltb.12070 (2014).
Lim, K. S. et al. Global lifetime and 12-Month prevalence of suicidal behavior, deliberate Self-Harm and Non-Suicidal Self-Injury in children and adolescents between 1989 and 2018: A Meta-Analysis. Int. J. Environ. Res. Public Health. 16 https://doi.org/10.3390/ijerph16224581 (2019).
Nielsen, G. et al. Specialist physiotherapy for functional motor disorder in England and Scotland (Physio4FMD): a pragmatic, multicentre, phase 3 randomised controlled trial. Lancet Neurol. 23, 675–686. https://doi.org/10.1016/s1474-4422(24)00135-2 (2024).
Björkenstam, E., Helgesson, M., Amin, R. & Mittendorfer-Rutz, E. Mental disorders, suicide attempt and suicide: differences in the association in refugees compared with Swedish-born individuals. Br. J. Psychiatry: J. Mental Sci. 217, 679–685. https://doi.org/10.1192/bjp.2019.215 (2020).
Chartrand, H., Sareen, J., Toews, M. & Bolton, J. M. Suicide attempts versus nonsuicidal self-injury among individuals with anxiety disorders in a nationally representative sample. Depress. Anxiety. 29, 172–179. https://doi.org/10.1002/da.20882 (2012).
Culbreth, R., Swahn, M. H., Osborne, M., Brandenberger, K. & Kota, K. Substance use and deaths by suicide: A latent class analysis of the National violent death reporting system. Prev. Med. 150, 106682. https://doi.org/10.1016/j.ypmed.2021.106682 (2021).
McMahon, K. et al. Childhood maltreatment and impulsivity as predictors of interpersonal violence, self-injury and suicide attempts: A National study. Psychiatry Res. 269, 386–393. https://doi.org/10.1016/j.psychres.2018.08.059 (2018).
Liu, Y. et al. The mediating effects of school bullying victimization in the relationship between childhood trauma and NSSI among adolescents with mood disorders. BMC Pediatr. 24, 524. https://doi.org/10.1186/s12887-024-04986-7 (2024).
Vatanparast, A., Shakiba, S., Momeni, F. & Kamrani, A. The relationship between childhood maltreatment and self-harm: the mediating roles of alexithymia, dissociation, internalizing and posttraumatic symptoms. Eur. J. Psychotraumatology. 15, 2378642. https://doi.org/10.1080/20008066.2024.2378642 (2024).
Peng, C., Cheng, J., Rong, F., Wang, Y. & Yu, Y. Psychometric properties and normative data of the childhood trauma questionnaire-short form in Chinese adolescents. Front. Psychol. 14 https://doi.org/10.3389/fpsyg.2023.1130683 (2023).
Duke, N. N., Pettingell, S. L., McMorris, B. J. & Borowsky, I. W. Adolescent violence perpetration: associations with multiple types of adverse childhood experiences. Pediatrics 125, e778–786. https://doi.org/10.1542/peds.2009-0597 (2010).
Chesney, E., Goodwin, G. M. & Fazel, S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry: Official J. World Psychiatric Association (WPA). 13, 153–160. https://doi.org/10.1002/wps.20128 (2014).
Taylor, P. J. et al. A meta-analysis of the prevalence of different functions of non-suicidal self-injury. J. Affect. Disord. 227, 759–769. https://doi.org/10.1016/j.jad.2017.11.073 (2018).
Fried, E. I. Corrigendum to The 52 symptoms of major depression: lack of content overlap among seven common depression scales, [Journal of Affective Disorders, 208, 191–197]. Journal of affective disorders 260, 744. https://doi.org/10.1016/j.jad.2019.05.029 (2020).
Hou, C., Liang, M., liu, Z., Zhang, X. & Sun, Z. Association between latent classes of health risk bahaviours and depressive symptoms among junior middle school students in Tianjin. Chin. J. Sch. Health. 44, 423–427. https://doi.org/10.16835/j.cnki.1000-9817.2023.03.024 (2023).
Clark, H. et al. A future for the world’s children? A WHO-UNICEF-Lancet commission. Lancet (London England). 395, 605–658. https://doi.org/10.1016/s0140-6736(19)32540-1 (2020).
Li, J. et al. Meta-Analysis of relationship between depression and Non-Suicidal Self-Injurt. J. Nanchang University(Medical Sciences). 56, 40–45. https://doi.org/10.13764/j.cnki.ncdm.2016.06.011 (2016).
Lan, T., Jia, X., Lin, D. & Liu, X. Stressful life events, depression, and Non-Suicidal Self-Injury among Chinese Left-Behind children: moderating effects of Self-Esteem. Front. Psychiatry. 10, 244. https://doi.org/10.3389/fpsyt.2019.00244 (2019).
Luo, Y. et al. Association of sleep quality, depressive symptoms with non-suicidal self-injury among rural school students. Chin. J. Sch. Health. 44, 224–228. https://doi.org/10.16835/j.cnki.1000-9817.2023.02.015 (2023).
Jiao, T. et al. Associations of depressive and anxiety symptoms with non-suicidal self-injury and suicidal attempt among Chinese adolescents: the mediation role of sleep quality. Front. Psychiatry. 13, 1018525. https://doi.org/10.3389/fpsyt.2022.1018525 (2022).
Sun, K. et al. A cross-sectional study of non-suicidal self-injury in a Chinese adolescent inpatient cohort. Front. Psychiatry. 14 https://doi.org/10.3389/fpsyt.2023.1109334 (2023).
Wang, A., Zhang, T., Guo, S. & Zhang, F. The relationship between adverse childhood experiences and depressive symptoms of junior middle school students: the mediating role of self-esteem and the regulating role of social support. Mod. Prev. Med. 51, 842–847. https://doi.org/10.20043/j.cnki.MPM.202306367 (2024).
Yang, X. & Zhou, Z. Effects of childhood maltreatment on depressive symptoms in adolescents. Psychologies Magazine. 19, 47–49. https://doi.org/10.19738/j.cnki.psy.2024.16.014 (2024).
Haim-Nachum, S. et al. Childhood maltreatment and its associations with trauma-related psychopathology: disentangling two classification approaches. Npj Mental Health Res. 3 https://doi.org/10.1038/s44184-024-00082-x (2024).
Chen, Y. et al. Effects of childhood abuse experience, recent life events and coping styles on depressive symptoms of medical students. J. Hyg. Res. 53, 711–717. https://doi.org/10.19813/j.cnki.weishengyanjiu.2024.05.005 (2024).
Haim-Nachum, S. et al. Self-stigma mediates the relationships between childhood maltreatment and symptom levels of PTSD, depression, and anxiety. Eur. J. Psychotraumatology. 15, 2370174. https://doi.org/10.1080/20008066.2024.2370174 (2024).
Wu, J. A study on the relationship between childhood abuse, depression and adolescents’ self-injurious behavior. J. Western 72–75. https://doi.org/10.16721/j.cnki.cn61-1487/c.2022.10.011 (2022).
Brown, R. C. et al. The impact of child maltreatment on non-suicidal self-injury: data from a representative sample of the general population. BMC Psychiatry 18 https://doi.org/10.1186/s12888-018-1754-3 (2018).
Zhang, X., Yang, Y., Lei, H., Dong, D. & Feng, Z. Network analysis of the relationship between sleep problems and depressive symptoms in adolescents. Chin. J. Clin. Psychol. 32, 824–830. https://doi.org/10.16128/j.cnki.1005-3611.2024.04.019 (2024).
Crouch, E., Radcliff, E., Probst, J. C., Bennett, K. J. & McKinney, S. H. Rural-Urban differences in adverse childhood experiences across a National sample of children. J.Rural Health. 36, 55–64. https://doi.org/10.1111/jrh.12366 (2020).
Zeng, J. & Xu, Y. Family socioeconomic status and adolescent depression in urban and rural China: A trajectory analysis. SSM - Popul. Health. 25, 101627. https://doi.org/10.1016/j.ssmph.2024.101627 (2024).
Wan, Y., Liu, W., Hao, J. & Tao, F. Development and evaluation on reliability and validity of adolescent Non-suicidal Self-injury assessment questionnaire. Chin. J. Sch. Health. 39, 170–173. https://doi.org/10.16835/j.cnki.1000-9817.2018.02.005 (2018).
Battle, D. E. Diagnostic and statistical manual of mental disorders (DSM). CoDAS 25, 191–192. https://doi.org/10.1590/s2317-17822013000200017 (2013).
Chen, Z., Yang, X. & LI, X. Psychometric features of CES-D in Chinese adolescents. Chin. J. Clin. Psychol. 17, 443–445 (2009).
Wolf, M. G. & McNeish, D. Dynamic: an R package for deriving dynamic fit index cutoffs for factor analysis. Multivar. Behav. Res. 58, 189–194. https://doi.org/10.1080/00273171.2022.2163476 (2023).
S, S. & Mohanasundaram, T. Fit indices in structural equation modeling and confirmatory factor analysis: reporting guidelines. Asian J. Econ. Bus. Acc. 24, 561–577. https://doi.org/10.9734/ajeba/2024/v24i71430 (2024).
Steeger, C. M. & Gondoli, D. M. Mother-adolescent conflict as a mediator between adolescent problem behaviors and maternal psychological control. Dev. Psychol. 49, 804–814. https://doi.org/10.1037/a0028599 (2013).
Wu, G. et al. Study on the correlation between non-suicidal self-injury behavior and big five personality, childhood abuse and emotional intelligence in adolescents. J. Psychiatry. 36, 629–633 (2023).
Liu, W., Wan, Y., Tao, F. & Hao, J. Mediating effect of social support on relationship between childhood abuses and non-suicidal self-injuries in adolescents. Chin. Mental Health J. 31, 230–234 (2017).
Wilson, K. R., Hansen, D. J. & Li, M. The traumatic stress response in child maltreatment and resultant neuropsychological effects. Aggress. Violent. Beh. 16, 87–97. https://doi.org/10.1016/j.avb.2010.12.007 (2011).
Chen, Y. et al. Associations of neglect and physical abuse with non-suicidal self-injury behaviors among adolescents in rural China. Chin. J. Sch. Health. 40, 984–986. https://doi.org/10.16835/j.cnki.1000-9817.2019.07.007 (2019).
Kaess, M. et al. Advancing a Temporal framework for Understanding the biology of nonsuicidal self- injury: an expert review. Neurosci. Biobehav. Rev. 130, 228–239. https://doi.org/10.1016/j.neubiorev.2021.08.022 (2021).
Klonsky, E. D. & Moyer, A. Childhood sexual abuse and non-suicidal self-injury: meta-analysis. Br. J. Psychiatry: J. Mental Sci. 192, 166–170. https://doi.org/10.1192/bjp.bp.106.030650 (2008).
Maniglio, R. The role of child sexual abuse in the etiology of suicide and non-suicidal self-injury. Acta Psychiatry. Scand. 124, 30–41. https://doi.org/10.1111/j.1600-0447.2010.01612.x (2011).
Thomassin, K., Shaffer, A., Madden, A. & Londino, D. L. Specificity of childhood maltreatment and emotion deficit in nonsuicidal self-injury in an inpatient sample of youth. Psychiatry Res. 244, 103–108. https://doi.org/10.1016/j.psychres.2016.07.050 (2016).
Glassman, L. H., Weierich, M. R., Hooley, J. M., Deliberto, T. L. & Nock, M. K. Child maltreatment, non-suicidal self-injury, and the mediating role of self-criticism. Behav. Res. Ther. 45, 2483–2490. https://doi.org/10.1016/j.brat.2007.04.002 (2007).
Kaess, M. et al. Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth. Psychiatry Res. 206, 265–272. https://doi.org/10.1016/j.psychres.2012.10.012 (2013).
Yates, T. M. The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation. Clin. Psychol. Rev. 24, 35–74. https://doi.org/10.1016/j.cpr.2003.10.001 (2004).
Linehan, M. M. Dialectical behavior therapy for treatment of borderline personality disorder: implications for the treatment of substance abuse. NIDA Res. Monogr. 137, 201–216 (1993).
Kooiman, C. G. et al. Childhood adversities as risk factors for alexithymia and other aspects of affect dysregulation in adulthood. Psychother. Psychosom. 73, 107–116. https://doi.org/10.1159/000075542 (2004).
Wang, Y. J. et al. Risk factors for non-suicidal self-injury (NSSI) in adolescents: A meta-analysis. EClinicalMedicine 46, 101350. https://doi.org/10.1016/j.eclinm.2022.101350 (2022).
Wilkinson, P., Kelvin, R., Roberts, C., Dubicka, B. & Goodyer, I. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the adolescent depression antidepressants and psychotherapy trial (ADAPT). Am. J. Psychiatry. 168, 495–501. https://doi.org/10.1176/appi.ajp.2010.10050718 (2011).
Barrocas, A. L., Giletta, M., Hankin, B. L., Prinstein, M. J. & Abela, J. R. Nonsuicidal self-injury in adolescence: longitudinal course, trajectories, and intrapersonal predictors. J. Abnorm. Child. Psychol. 43, 369–380. https://doi.org/10.1007/s10802-014-9895-4 (2015).
Tschan, T., Schmid, M. & In-Albon, T. Parenting behavior in families of female adolescents with nonsuicidal self-injury in comparison to a clinical and a nonclinical control group. Child Adolesc. Psychiatry Mental Health 9 https://doi.org/10.1186/s13034-015-0051-x (2015).
Plener, P. L., Schumacher, T. S., Munz, L. M. & Groschwitz, R. C. The longitudinal course of non-suicidal self-injury and deliberate self-harm: A systematic review of the literature. Borderline Personality Disorder and Emotion Dysregulation. https://doi.org/10.1186/s40479-014-0024-3 (2015).
Yong, Y. et al. Correlation analysis between non-suicidal self-injury behavior and depressive symptoms in adolescents. Chin. JSch Health. 44, 659–663. https://doi.org/10.16835/j.cnki.1000-9817.2023.05.005 (2023).
Acknowledgements
The authors would like to acknowledge the efforts of the research team and the kindness of the participants for their participation. This research was supported by the Humanities and Social Sciences Research Planning Fund of the Ministry of Education (22YJA840010). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the paper. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Funding
This research was supported by the Humanities and Social Sciences Research Planning Fund of the Ministry of Education (22YJA840010), the National Natural Science Foundation of China (82404288) and the Postdoctoral Fellowship Program of CPSF (GZC 20242134). The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the paper. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
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AL: Conceptualization, Formal analysis, Data curation, Writing original draft. RZ: Conceptualization, Data curation. SY: Investigation, Methodology. YL：Investigation, Methodology. ZW: Conceptualization. CP: Conceptualization, Data curation, Supervision, Writing - review &editing. HW：Conceptualization, Data curation, Project administration, Supervision, Writing - review & editing.All authors reviewed the manuscript.
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Liu, A., Zhang, R., Yang, S. et al. The mediation of depressive symptoms between different types of childhood maltreatment and non suicidal self-injury. Sci Rep 15, 15270 (2025). https://doi.org/10.1038/s41598-025-99601-9
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DOI: https://doi.org/10.1038/s41598-025-99601-9
