Abstract
Approximately 22.1% of youth would engage in Non-Suicidal Self-Injury (NSSI). While studies have examined the prevalence of NSSI in the local context, there is a lack of studies on the presentation and phenomenology of NSSI in Singapore. This study used the Non-Suicidal Self-Injury – Assessment Tool (NSSI-AT) to examine the functions, characteristics, and NSSI experiences of local youths. 121 youths between 12 and 25 years old were recruited. Outcomes for the NSSI-AT, including the actions, functions, frequency, age of onset, initial motivations, severity, practice patterns, and disclosure of self-harm, were reported using descriptive analysis. Personal reflections were analysed using thematic analysis. Participants engaged in NSSI actions such as cutting and scratching to manage agitating and depressive emotional states. Most participants started engaging in NSSI in early adolescence (mean = 13.0 years, SD = 2.37, range = 7–23) and had disclosed their NSSI with others’ initiation. When reflecting on NSSI experiences, participants gave encouragement to others and reported the negative aspects of self-harm. Findings support emotional regulation as a function of NSSI in the local population, who may be more vulnerable during early adolescence. This study also suggests the importance of having a person-centred treatment approach to effectively serve this age group and their challenges.
Plain language summary
Objective: About a quarter of youth engage in self-harm activities through their lives. Some studies have investigated the frequency and experiences of self-harm in Singapore. However, there is a lack of information on how self-harm is presented and experienced in the local youth population. This study examined the presentation of self-harm using the Non-Suicidal Self-Injury – Assessment Tool (NSSI-AT). This tool measures the functions, characteristics, and experiences of self-harm in Singaporean youths, to inform and improve quality of care for such youths. Method: The study included 121 youths aged between 12 and 25 years old from the National University Health System. We collected survey data on the actions, functions, frequency, starting age, motivations, severity, help-seeking behaviours, and treatment experiences of self-harm in youths. Personal reflections on the experience of self-harm were analysed together with the survey data. Results: Participants engaged in self-harm actions such as cutting, scratching, and banging on objects, to manage stressful emotions and low mood. Most participants started harming themselves when they were about 13 years old. When reflecting on their self-harm experiences, participants gave encouragement to others and reported the negative aspects of self-harm. Conclusion: The regulation of emotions was found to be a key reason why youths engage in self-harm in the local population. These youths may be more vulnerable to self-harm during early adolescence. Findings also suggest the importance of targeting interventions based on one’s self-harm experiences. Overall, this study highlights the need for interventions that can effectively serve this age group and their specific challenges to provide good quality of care.
Introduction
Non-Suicidal Self-Injury (NSSI) occurs when direct, intentional harm, such as cutting, burning, and scratching, is caused to one’s own physical body without intention of suicide (Kapur et al., 2013; Nock & Favazza, 2009; Zetterqvist, 2015). Worldwide, approximately 22.1% of children and adolescents would engage in NSSI at some point in their lives (Lim et al., 2019). Due to the increased risk of harm and future suicide attempts (Hamza & Willoughby, 2016; Samari et al., 2020), NSSI is a behaviour that warrants attention and has been identified as a condition in need of further study in the Statistical and Diagnostic Manual of Mental Disorders (DSM-5) (Zetterqvist, 2015). Studies identifying risk factors of NSSI have found it more prevalent among females (Kuentzel et al., 2012; Lauw et al., 2018; Shahwan et al., 2018), those with a history of abuse (Shahwan et al., 2018) and mental health conditions such as depressive disorders (Lauw et al., 2018).
In Singapore, 58.8% of a sample of youth psychiatric outpatients have engaged in NSSI at some point in their lives (Shahwan et al., 2018). Functions of NSSI commonly include the regulation of emotions (García-Nieto et al., 2015; Ong et al., 2017; Rodav et al., 2014; Shahwan et al., 2022), for self-punishment or redirection of anger inwards toward self (García-Nieto et al., 2015; Shahwan et al., 2022), and to gain a sense of control (Shahwan et al., 2022). While some studies have examined the prevalence and experiences of NSSI in the local context, there is a lack of detailed studies on the presentation, characteristics, and experiences of NSSI in the local setting that can broaden our understanding of the phenomenology of NSSI in Singapore.
Measures such as the Deliberate Self-Harm Inventory (DSHI) (Gratz, 2001) and the Functional Assessment of Self-Mutilation (FASM) (Lloyd-Richardson et al., 2007) have previously been used to examine NSSI characteristics. These measures collect basic information such as the type, frequency, and functions of NSSI, but lack detail in describing other characteristics of NSSI such as the severity of harm, disclosure to others, and treatment experiences. The Non-Suicidal Self-Injury – Assessment Tool (NSSI-AT) was developed to comprehensively assess both basic NSSI characteristics, such as frequency, and function, as well as secondary characteristics, such as the motivations for NSSI, contexts of practice, severity, disclosure, and help-seeking (Whitlock et al., 2014).
To capture detailed information about NSSI in Singapore, this study aims to assess the characteristics of NSSI using the NSSI-AT in a cross-sectional study design. More specifically, we aimed to investigate the functions, characteristics, and experiences of local youth and adolescents who engage in NSSI, as well as personal reflections for the development and improvement of patient-centred care. Having information on the overall experiences of youths and adolescents with NSSI can then help guide the development of appropriate care and support systems.
Methods
Participants
121 children and adolescents aged between 12 and 25 years old were recruited from the Department of Psychological Medicine at the National University Health System (NUHS). The study included patients seeking treatment for mood disorders and have self-reported NSSI behaviours such as cutting, hitting, and scratching prior to or at the time of visit. Patients that have an existing diagnosis of neurodevelopmental disorders or psychotic disorders were excluded, as those instances of NSSI behaviour is more likely due to the repetitive and stereotypical behaviours of neurodevelopmental disorders or are secondary to delusions and hallucinations of a psychotic state. Participants were seen by psychiatrists at NUHS and those who met the eligibility criteria were invited to join the study. Ethical approval was obtained before the start of participant recruitment from the National Healthcare Group (NHG) Domain Specific Review Board (DSRB; No.: 2019/00228).
Materials
This paper is part of a larger study on Non-Suicidal Self-Injury in Adolescents and Parenting Styles (pending publication). The study included a series of questionnaires to collect sociodemographic and historical data, as well as self-report forms for the variables examined. For this paper, we specifically reported outcomes from the Non-Suicidal Self-Injury – Assessment Tool (NSSI-AT) (Whitlock et al., 2014). The NSSI-AT (Whitlock et al., 2014) was used to measure the primary and secondary NSSI characteristics for research purposes. The characteristics include the type and purpose of self-harm, range and frequency of self-harm behaviours, age of onset and cessation (if applicable), wound locations, initial motivations for self-harm, the severity, patterns, manner, and habituation of the practice of self-harm, disclosure of the act of self-harm, as well as personal reflections.
In the NSSI-AT, statements asking for participants’ level of endorsement were rated either on a 4-point Likert scale ranging from (1) Strongly Disagree to (4) Strongly Agree or a 5-point Likert scale from (1) Strongly Disagree to (5) Strongly Agree with an option for (0) Does Not Apply. For the functions of NSSI, for example, participants rated their level of agreement with statements corresponding to the five functions of NSSI, namely for high pressure affective imbalance (i.e., to manage agitating or high energy affective states), low pressure affective imbalance (i.e., to manage depressive or dissociated emotion states), social communication and expression, self-retribution and deterrence (as self-punishment or alternative to more severe behaviours), and sensation seeking (i.e., as a stimulant). Other statements provided specific categorical options for participants to choose from, for instance, disclosure of the act of self-harm to specific persons such as a parent or custodian guardian, sibling, friend, significant other (boyfriend, girlfriend, or spouse/partner), other relative, teacher, coach, adult friend, therapist, physician, religious or spiritual leader (e.g., priest, pastor, rabbi), health care provider, or others.
Procedure
This study followed a cross-sectional design and was conducted from August 2019 to September 2021. Participants who met inclusion criteria were invited to take part in the study by psychiatrists at NUHS. The study was also advertised via recruitment posters placed at the clinic. As the study took place over the COVID-19 period, safe-distancing measures were still in place that prevented face-to-face data collection. Due to this, participants were contacted by a study team member and their written consent was taken on teleconferencing platform Zoom through electronic signatures. Informed consent was obtained from all individual participants included in the study or from their legal guardians for those aged below 21 years old. After consent was taken, participants were sent a link to complete the questionnaires on Qualtrics (https://www.qualtrics.com).
Descriptive analysis of the sociodemographic survey and NSSI-AT was conducted to summarise the characteristics, functions, and experiences of children and adolescents who engage in NSSI. For non-categorical variables such as the participants’ age, body-mass index (BMI), number of self-harm actions, as well as Likert scale responses, the mean, standard deviations, and range (if appropriate) were calculated. For categorical variables including responses to statements with specific options, the number of responses for each option were tabulated.
For the qualitative aspect of the NSSI-AT, namely the participants’ personal reflections and advice for others, responses were thematically analysed according to the Braun and Clarke’s methodology. The method involves six key steps, (1) familiarizing with the data through reading and rereading, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report (Braun & Clarke, 2006).
Results
Sample characteristics
Participant Sample Characteristics (N = 121).
*Note: 6 students were also working part-time at the time of survey.
Actions & functions of NSSI
On average, participants engaged in 5 types of self-harm actions (SD = 0.257, range = 1–14). The most common actions were cutting of the wrists, arms, legs, or other areas (n = 100, 83.3%), severely scratching or pinching to the point of bleeding or marks on the skin (n = 96, 80.0%), banging or punching objects to the point of bruising or bleeding (n = 62, 51.7%), intentionally preventing wounds from healing (n = 51, 42.5%) and biting self to the point of bleeding or marks on the skin (n = 48, 40.0%).
Participants were more likely to endorse the functions of NSSI for high pressure (mean = 3.41, SD = 0.573) and low-pressure affective imbalances (mean = 3.22, SD = 0.627), self-retribution (mean = 2.90, SD = 0.656), as well as sensation seeking (mean = 2.48, SD = 0.74) purposes, and less for social communication (mean = 1.67, SD = 0.627) reasons.
Participants were also less likely to endorse having engaged in self-harm with suicidal intent (mean = 2.06, SD = 1.02). However, approximately a sixth of participants (n = 20, 16.5%) reported that they had engaged in self-harm primarily for practising or attempting suicide (Figure 1). Distribution of responses endorsing self-harm for suicidal intention.
Recency, frequency, and age of onset of NSSI
Participants were an average of 15.8 years old (SD = 2.46, range = 9–24) at the last time they harmed themselves. The mean starting age of NSSI was 13.0 years old (SD = 2.37, range = 7–23). On average, the total frequency of NSSI was 48.4 (SD = 89.4, range = 1–500). An equal number of participants reported that they had engaged in NSSI less than 10 times and 11-20 times (n = 33, 27.3%). Some reported to have engaged in NSSI 21-50 times (n = 27, 22.3%) and approximately a quarter of participants reported more than 50 times (n = 28, 23.1%).
Most participants reported that they had last engaged in NSSI less than a week ago (n = 44, 36.4%) or a week to a month ago (n = 46, 38.0%). Fewer participants mentioned that their last act of NSSI was more than a month ago (n = 31, 25.6%). Almost half the participants reported they were unlikely to engage in NSSI again (n = 60, 49.6%), while some were likely to engage in NSSI again (n = 23, 19.0%), and others were not sure if they would engage in NSSI again (n = 38, 31.4%).
Wound locations and initial motivations of NSSI
The average number of body areas affected by NSSI was 4 (SD = 2.31, range = 1–15). Most participants engaged in self-harm to their wrists (n = 95, 78.5%), arms (n = 89, 73.6%), hands (n = 73, 60.3%), thighs (n = 72, 59.5%), and fingers (n = 40, 33.1%).
Most participants endorsed the following statements for their initial motivations to engage in NSSI: “I was angry with myself” (n = 96, 79.3%), “I was upset and decided to try it” (n = 93, 76.9%), and “It felt good” (n = 52, 43.0%). Fewer participants agreed with the following statements: “I accidently discovered it” (n = 30, 24.8%) and “I was angry at someone else” (n = 25, 20.7%).
Severity of NSSI
More than half of the participants reported that they have once hurt themselves more severely than expected (n = 79, 65.3%). Among this group, approximately a third of them have hurt themselves so severely that they required medical attention, even if they did not seek medical help (n = 41, 33.9%). While some reported that this had happened only once (n = 11, 26.8%), most reported that this had happened 2-3 times (n = 16, 39.0%), and some more than 4 times (n = 14, 34.2%). Approximately a fifth of participants sought medical help for NSSI at any point (n = 23, 19.0%).
During their most active phases of NSSI, a quarter of participants engaged in self-harm everyday (n = 31, 25.8%) and a third of them 2-3 times a week (n = 42, 35.8%). Others engaged in NSSI once a week (17, 14.2%), 1-3 times a month (n = 15, 12.5%), and once every few months or more (n = 14, 11.7%). During this phase, most participants reported that they were unable to keep themselves from self-harm for less than a week (n = 49, 41.2%). Fewer participants had a longer interval away from self-harm for less than a month (n = 22, 18.5%), 1–3 months (n = 26, 21.8%), and more than 4 months (n = 22, 18.5%).
Practice patterns of NSSI, habituation, and life interference
Participants, on average, reported low agreement with the social dimensions of NSSI practice (mean = 1.97, SD = 0.704, range = 0–5). Most of them endorsed the statement “I always intentionally hurt myself in private” (n = 111, 91.7%), while a minority agreed that “I sometimes intentionally hurt myself in the presence of others” (n = 27, 22.3%). Less than a third of participants reported that “I have intentionally physically hurt another person” (n = 40, 33.1%) and “I sometimes let other people intentionally hurt me physically” (n = 24, 19.8%).
On average, participants tended to follow routines for self-harm (mean = 3.01, SD = 1.08, range = 0–5). More than half agreed with the statements that “I have a regular routine I follow when I intentionally hurt myself” (n = 64, 52.9%) and “I have a particular place/room I prefer to be when I intentionally hurt myself” (n = 62, 51.2%). Some endorsed that “I tend to go through periods in which I intentionally hurt myself, then periods in which I do not, and this pattern repeats” (n = 29, 24.0%).
On average, participants were likely to endorse the habituation to NSSI (mean = 3.55, SD = 0.773, range = 0–5). The majority agreed that “I have had to fight the urge to start intentionally hurting myself again” (n = 85, 70.2%), “I have had to intentionally hurt myself more deeply and/or in more places on my body over time to get the same effect” (n = 83, 68.6%), “Nothing else works as well as [NSSI] to calm me down or give me relief” (n = 75,62.0%), and “I want to stop [NSSI] altogether, but have trouble stopping” (n = 68, 56.2%).
Participants were also likely to endorse that NSSI is a problem (mean = 3.37, SD = 1.21, range = 1–5) and has interfered with their lives (mean = 3.55, SD = 1.77, range = 1–5). Most participants agreed that NSSI has affected their sense of self-worth or self-esteem (n = 101, 83.5%), ability to take care of themselves (n = 72, 59.5%), important relationships (n = 70, 57.9%), ability to complete school or work obligations (n = 66, 54.5%), as well as their ability to engage in hobbies or interests (n = 54, 44.6%).
NSSI disclosure and experiences
Most participants had disclosed their NSSI to others (n = 110, 91.7%). These participants disclosed their NSSI to an average of 3 groups of people (SD = 2.15, range = 1–12). Most participants disclosed their NSSI to a friend (n = 87, 78.4%), parent (n = 69, 62.2%), or therapist (n = 59, 53.2%). Some of them disclosed to a teacher (n = 47, 42.3%) and sibling (n = 30, 27.0%). For these youth, the majority reported that the conversation on NSSI was initiated by others (n = 88, 86.3%).
While most participants were unsure if the people around them suspected their NSSI (n = 59, 48.8%), some reported that this was true (n = 51, 42.1%). Among these participants, most believed that a friend knew (n = 43, 86.0%). Some also suspected that their teacher (n = 22, 44.0%), parent (n = 18, 36.0%), sibling (n-12, 24.0%), or other relative (n = 9, 18.0%) knew about their NSSI before they talked about it. Most of these participants, however, did not want to talk about their NSSI with these groups of people (n = 30, 63.8%).
Personal reflections & advice
Participants had similar levels of endorsement for statements showing ambivalence toward NSSI and growth because of NSSI. On average, they endorsed 1.57 ambivalence statements (SD = 0.956, range = 0–4) such as “I still cannot talk about it and sometimes even thinking about it is difficult”, “The lasting marks/scars are constant reminders of a bad/rough time in my life” and “The remaining marks/scars are a source of embarrassment for me”. On the other hand, they also endorsed an average of 1.51 growth-oriented statements (SD = 1.36, range = 0–4) such as “I am now able to help others who intentionally hurt themselves”, “In thinking/discussing my experience around intentionally hurting myself, I have learned a lot about myself and because of it have mentally/emotionally grown”, and “My scars are my battle wounds – I made it through”.
Three themes were derived from participants’ open-ended responses on what others should know about NSSI, namely (1) encouragement for people with NSSI, (2) negative aspects of NSSI, (3) personal experiences of NSSI.
Theme 1: Encouragement for people with NSSI
Participants were supportive of others who may experiencing the same challenges of NSSI and wanted to encourage them to seek help from someone or figure out other ways of coping with stress that works for them instead of using NSSI as a coping mechanism. “i think it is important that the people put themselves in our shoes and try to understand the reason why we self harm and to try to find ways to replace that feeling we get when we self harm” (C206)
Some also assured that it takes a lot of strength and courage to talk to others about NSSI, and that they are not alone in their struggles with NSSI. Participants also mentioned that while recovery from NSSI takes time and effort, it can happen for those who receive the help that they need. “I understand and I am with you. These people who are wounded need your warm embrace, not criticism.” (C023)
Theme 2: Negative aspects of NSSI
Participants highlighted the struggles, suffering, pain, and challenges leading to self-harm and in coping with NSSI. There was particular focus on how people with NSSI have a tough time controlling how they feel and the urges to self-harm, to the point that it could even be addictive. “for me personally, i never wanted to do it in the first place but i felt like i had to. it was from a place of guilt and shame” (C103)
Some participants focused on the negative outcomes of NSSI and mentioned that NSSI might not be worth the pain or regret, for example, highlighting that the scars as a result of self-harm might be permanent (C01), as well as “That it doesn't help. Maybe it'll feel good after the first few times, but afterwards it would like you're slowly going insane. You'll end up hurting yourself more frequently.” (C042)
Many participants also highlighted the difficulty in opening to others about their NSSI and mentioned how others can be critical, judgmental, and blaming for their actions. Some also lamented that others could be more understanding of the feelings and experiences of those who engage in NSSI and to show care and concern toward them rather than being dismissive. “Its very serious and shouldnt be joked about. Ask for permission before talking about self harm” (C238)
Theme 3: Personal experiences of NSSI
Participants also mentioned the personal aspects of their experiences with NSSI and how every individual’s experience with NSSI is different and should be treated as such. For example, while methods such as removing the tools of self-harm work for some, it may not work for others (C07). Some also highlighted how others should not force individuals with NSSI to talk about their NSSI before they are comfortable with sharing. “I personally feel that it is important to know that there will be different circumstances for every individual and not just some “textbook case”. Every individual deserves to be heard.” (C044)
Many participants stated that NSSI happens for a reason, for example, to escape from mental suffering and pain and to bring relief when people cannot find any other ways to do so. Some also highlighted that self-harm is not for attention, for example, “it’s not a form of suicide or for attention purposes. It’s a form of control and emotional release” (C124).
Discussion
This paper examined the functions, characteristics, experiences, and personal reflections of youth and adolescents who engage in NSSI. Many participants engaged in NSSI actions, such as cutting, scratching, and banging on objects, to manage agitating and depressive emotional states. Most participants started engaging in NSSI in early adolescence and had self-harmed recently and frequently, especially during the active phase of NSSI. Many participants started engaging in NSSI as they were angry or upset, while a minority of them had self-harmed with suicidal intent. Over the course of their NSSI, some participants had hurt themselves more severely than expected, but only a fifth of them had sought medical help for NSSI at any point. Most participants did not agree to the social dimensions of NSSI. They agreed on its habitual aspects and how NSSI had affected many areas of life, including their sense of self-worth, self-care, and important relationships. Most participants had also disclosed their NSSI to a friend, parent, or therapist and their conversations and help seeking were mostly initiated by others and not themselves. When asked to reflect on their NSSI experiences, participants gave encouragement for others going through similar experiences, mentioned the negative aspects of self-harm, and reported their personal experiences with NSSI.
Our findings support that emotional regulation as a function of NSSI (García-Nieto et al., 2015; Rodav et al., 2014; Shahwan et al., 2022) in the local adolescent population. More specifically, youths engaged in NSSI to regulate both agitating or high-energy emotional states such as anger and frustration, as well as to get out of low-energy states such as depression (García-Nieto et al., 2015). Youths also engaged in NSSI as a form of self-punishment and to direct their anger inwards (Shahwan et al., 2022), and generally not for social communication or attention purposes (Ong et al., 2017; Shahwan et al., 2022), which corroborates with existing reviews (Cipriano et al., 2017; Taylor et al., 2018). This was also supported by the participants’ qualitative responses, where they mentioned that they engaged in NSSI to escape from mental suffering and pain and not for attention, as well as how initial experiences of anger or disappointment led to the start of their NSSI. In addition, our findings also indicate that youths engaged in NSSI routinely and in non-social or private ways, which was also reported in previous studies where individuals typically conceal their self-harm from others (Chen et al., 2020; Lindgren et al., 2022). This lends support to the finding that youths engage in NSSI not for attention-seeking purposes (Shahwan et al., 2022), but more for emotional regulation and coping with difficulties. This, in turn, supports the provision of emotional regulation-oriented treatment approaches such as Dialectical Behavioural Therapy (Calvo et al., 2022; DeCou et al., 2019) to help youths with NSSI.
The next key finding is that young people in Singapore may be more vulnerable to NSSI during early adolescence, as most participants in this study first engaged in NSSI in the 11–15-year-old age range and had self-harmed recently and frequently. This was especially so during their active self-harming phases, where many youths reported that they engaged in NSSI almost every other day and were unable to keep themselves from self-harming for more than a few days. This vulnerable age range was similarly found in previous studies (Cipriano et al., 2017) and corresponds to a time of transition and substantial life changes, where many youths in Singapore will be transiting from primary to secondary schools and adjusting to new environments, interpersonal relationships, and phase of life (Ministry of Education Singapore, 2021). Studies have also found associations between NSSI and various life stressors (De Luca et al., 2022; Liu et al., 2016) and it is possible that stressful life changes during this time can increase the risk of NSSI. This is substantiated by another study showing that perceived stressful life events predicted adolescents’ level of engagement with NSSI at a later timepoint (Baetens et al., 2021). In this study, youths also mentioned that they had faced challenges and difficulties that led to their NSSI. It was also concerning that a subset of participants reported engaging in self-harm for suicidal reasons, where a study on a similar population had found that engaging in five or more methods of self-harm, spending more time thinking about self-harm, and having more severe depressive symptoms increased the risk of suicidal attempts (Samari et al., 2020). Taken together, these findings support the vulnerability of youths in this age group to NSSI and highlights the need for interventions that can effectively serve this age group and their specific challenges.
Lastly, this study also demonstrates the individuality of NSSI experiences among the local youth population in Singapore. There was a wide range of responses and varying levels of endorsement for different statements about NSSI, indicating that NSSI was a highly personal experience for youths that require individualized and tailored approaches. For instance, while participants had similar average levels of endorsement towards both ambivalence and growth statements, some participants had more ambivalent views on NSSI, some were more growth oriented, while others endorsed a number of both statements. The personal experiences of participants were also reflected in their qualitative responses, where individual’s experiences with NSSI were viewed as different and should be treated as such. This fits with the clinical perspective of patient-centred care, where treatment and recovery is not based on a one-size-fit-all solution but tailored to every individuals’ specific needs (Catalyst, 2017), and is also reflected in a model of patient-centred recovery for NSSI (Lewis & Hasking, 2021). Having a better understanding of individuals’ experiences with NSSI, however, does not only apply to clinicians and professionals caring for individuals with NSSI. In this study, participants also expressed difficulties in opening up about their NSSI and mentioned that others could have been more understanding in showing care and concern rather than being dismissive of their challenges. This could have been due to the perceived stigma of NSSI and mental health conditions in general among the public in Singapore (Tan et al., 2020), as well as a lack of understanding toward individuals who self-harm and the reasons for NSSI (Klonsky et al., 2014). Overall, these findings support the importance of having a person-centred approach to helping individuals who engage in NSSI and may be especially important in the local population, where mental health stigma remains prevalent and may prevent self-disclosure of NSSI.
Strengths and limitations
This study was not without limitations. Firstly, this was an observational study using a cross-sectional design, so any causal inferences of relationship between the variables cannot be made. In addition, the self-report of past experiences was used as the main method of data collection, so findings from this study may have been affected by recall and information bias. Further studies could use more robust methods such as longitudinal data collection and randomized controlled trials to build on the findings from this study.
Next, participants were recruited from a psychiatric clinic at a hospital and given that these participants were already receiving medical treatment, they were likely to have had more severe symptoms of NSSI. As we only recruited a clinical sample of participants, findings from this study may not have captured the entire presentation of NSSI in youth and adolescents, some of which may have a milder form of NSSI that may not warrant hospital treatment. In addition, the disclosure rates of NSSI may have been inflated in this study as the youths would had to have at least disclosed their NSSI to healthcare professionals to receive treatment, whereas there is a possibility that lower rates of disclosure exist among the general population with NSSI. Future studies may consider expanding the recruitment strategy to include participants from other hospitals and settings, as well as the general population, to gain a more comprehensive understanding of the experiences of NSSI in the local context.
Lastly, this study included a wide age range of 12–25 years old, based on the World Health Organization’s definition of “young people” being between the ages of 10–24 years old (World Health Organisation, 2023). However, this age range includes children to adolescents to young adults from various developmental stages, each of which presents with different experiences, life events, emotional regulation levels, and coping skills. Future studies could examine the various age groups separately, for example, 12–16 years old, 17–19 years old and 20–25 years old, and in relation to challenges and experiences at different stages of their lives, to gain a more nuanced understanding of how NSSI is affected by various life changes at different timepoints.
Conclusion
This paper investigated the functions, characteristics, experiences, and reflections of youth and adolescents who engage in NSSI using the NSSI-AT questionnaire. Our findings support emotional regulation as a function of NSSI in the local adolescent population, where youths engaged in NSSI to regulate both agitating emotional states such as anger and frustration, and low-energy states such as depression. Youths also engaged in NSSI as a form of self-punishment, but not for social communication or attention purposes. This study also found that early adolescence may be a period of vulnerability of young people to NSSI and the need for interventions that can effectively serve this age group and their specific challenges. Lastly, findings support the importance of having a person-centred approach in supporting youths who self-harm to encourage self-disclosure and help-seeking for NSSI. Future studies may consider exploring how stigma affects individuals with NSSI in the local population, including a wider range of participants from the general population, as well as examining specific age groups in relation to their challenges and experiences at different life stages, in order to gain a more comprehensive and nuanced understanding of the experiences of NSSI in the local context.
Supplemental Material
Supplemental Material - Functions, characteristics, and experiences of non-suicidal self-injury: A cross-sectional study of youth and adolescents in Singapore
Supplemental Material for Functions, characteristics, and experiences of non-suicidal self-injury: A cross-sectional study of youth and adolescents in Singapore by Xiaowen Lin, Hui Ling Michelle Neo, Jiehan Jamie Ong, Ying Jie Fong and Tji Tjian Chee in Clinical Child Psychology and Psychiatry
Supplemental Material
Supplemental Material - Functions, characteristics, and experiences of non-suicidal self-injury: A cross-sectional study of youth and adolescents in Singapore
Supplemental Material for Functions, characteristics, and experiences of non-suicidal self-injury: A cross-sectional study of youth and adolescents in Singapore by Xiaowen Lin, Hui Ling Michelle Neo, Jiehan Jamie Ong, Ying Jie Fong and Tji Tjian Chee in Clinical Child Psychology and Psychiatry
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National University of Singapore Mind Science Centre (Grant No.: A-19-0005).
Ethical statement
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