Childhood maltreatment and self-harm in Chinese adolescents: moderation and mediation via resilience

Childhood maltreatment (CM) is physical, sexual, psychological abuse or neglect of children, especially by parent(s) or caregiver(s). CM has been identified as a major public health issue. It is reported that each year, 4–16% and 5–10% of children are physically and sexually abused, and one-tenth of children suffered from emotional abuse or neglect by their parents [1]. CM is also prevalent in China: a single site survey of 7702 participants revealed that, for children under 16 years old, a staggering 31.1% reported had been abused [2]. CM can impose multiple detrimental impacts on the victims, from deficits in educational achievement, mental problems (such as depression, anxiety, post-traumatic stress symptoms), to low self-esteem, dissociation, and personality disorders, all of which can persist into the adulthood [1, 3].

Self-harm (SH) normally defined as intentional, direct destruction of body tissue, with or without suicidal intent [4]. Although it can occur within any period of life, a higher prevalence has been found in pubertal age [5]. SH has long been considered a major problem among youths [6], affecting 17% of those aged between 12 and 18 years in China [7]. Though non-fatal, SH always indicative of tragic outcomes: it has been repeatedly verified as the strongest indicator of future suicide [8]. Besides, following the index episode of SH, self-injurers are inclined to develop repeated and frequent SH, and about 2–7% of them will commit suicide in the following years [9, 10].

Among all adverse psychosocial factors, CM has been linked to elevated risk of SH in adolescents [11]. Given the fact that, CM can increase not only the risk of SH but also the probability of suicidal behaviors [12], CM related SH in youths should be effectively intervened. Except for direct measures on preventing CM in general, interventions which targeting on crucial mediators or moderators in CM-SH association can also be considered. Resilience is gradually attracting attention in the recent years, especially among children and adolescents. It reflects the ability to well adapt the adversities [13]. It has been found that resilient individuals tended to report decreased risk in negative consequences (like depression, anxiety) after exposed to CM [14]. Similarly, a higher level of resilience was related to lower risk of internalizing problems [15]. Therefore, it is reasonable to postulate that resilience may also protect against SH among adolescents who had experienced CM [16]. Also, a meta-analysis concluded that, the detrimental effect of CM can be moderated or even averted under the premise of effectively consolidated resilience of the victims [14]. Therefore, we put forward the assumption that, resilience plays a prominent role in CM-SH association, possibly as a mediator, or a moderator, or both. Nevertheless, no published studies have investigated this assumption so far.

In this cross-sectional study, we intended to discuss this issue in a large representative sample of Chinese adolescents. We tested the hypothesized mediation and moderation of resilience in the association between CM and SH.

In agreement with our anticipation, resilience may simultaneously mediate and moderate the association between childhood maltreatment and self-harm in Chinese adolescents: although the moderation was week, nearly one-third of the CM-SH association can be mediated via resilience. Besides, except for positive perception, all the rest 4 dimensions of resilience presented as prominent mediators, specifically, emotion regulation and family support showed the strongest mediation.

As hypothesized, resilience was identified as a prominent moderator in CM-SH association, although the moderation was weak, to be specific, a higher resilience of the victim tended to attenuate this association. Existing literature is supportive of the interaction between resilience and childhood trauma in predicting depression [20‐22], the most significant risk factor for SH [6]. According to the theory proposed by Nock, SH emerges with the attempt to cope with adverse events [16]. As a defensive mechanism to cope with adversity, resilience is built on the integration of physical, psychological, social, and intellectual resources [23]. These resources consequently are helpful for an individual to cope with environmental stresses [24], like childhood maltreatment. Therefore, it is possible that highly resilient adolescents are more capable of acquiring and mobilizing these resources to help them antagonizing the negative influence of abusive or neglectful family environments. In previous studies, researchers also found that more resilient victims of negative life encounters reported less severe psychological problems or SH engagement [25‐27]. Working with a sample of boarding undergraduate students, however, Madden and Shannon did not find resilience as a moderating variable in the association between CM and SH [28]. One possible explanation could be that the limited sample size (N = 285) hampers statistical efficiency in detecting significant relationship. Moreover, drawn from a residential school, participants in that research enjoyed more chances to seek assistance or consult from their roommates in coping with CM, which may potentially reduce SH risk, as social support is considered a protective factor of SH among adolescents [29]. Future studies of larger sample sizes and longitudinal design are expected to further discuss this issue.

Another important finding is that, aside from moderation, resilience also presented as a strong mediator in CM-SH association. Moreover, specific dimensions of resilience acted discordantly in this mediation, with emotion regulation emerged as the strongest mediator. Attachment theory suggests that growing up in attachment threatening environments, such as abusive or neglectful families, children can exhibit a propensity to suppress their feelings instead of confiding to their parents. The long-term suppression in mood may impose a detrimental effect on emotion regulatory function [30, 31]. Besides, given the fact that self-injurers always adopt SH as a method to vent negative feelings [32], it is reasonable that emotionally dysregulated young victims of family abuse or neglect may resort to SH. Besides, individuals with childhood traumatic experiences presented increased risk in developing disordered sensory processing patterns, such as low self-registration, sensory sensitivity, and sensation avoidance, all are related to increased risk of depression [33‐36], a well-recognized and most important risk factor of SH.

For other dimensions of resilience, family support and interpersonal assistance also showed conspicuous mediation in CM-SH association. From an empirical perspective, it is a consensus that children experienced CM are more difficult in establishing secure parent-child attachments [37]. Insecure parent-child relationship can lead to lower levels of self-esteem, self-efficacy, and reflective functioning [38‐40], all of which increase vulnerability to mental symptoms like depression in adolescence [41‐43]. Moreover, school-aged children with intimate parent-child bonds tend to have lower presence, frequency, and severity of SH [44]. Prospective studies have identified a connection between childhood abuse and future dysfunctional social relationships and interpersonal problems [45]. Therefore, it is possible that victims of CM may be less willing to seek assistance from the others under stressful situations, which may in turn result in an increased risk of SH.

Our results shed new light on intervention strategies of SH in adolescents with CM experiences. On one hand, measures aiming at reinforcing emotion regulation ability among maltreated youths may be effective in curtailing SH. Two types of intervention that focusing on improving emotion dysregulation to antagonize SH have been developed in clinical practice, one is dialectical behavior therapy, the other is acceptance-based emotion regulation group therapy. Besides, a telephone-based therapy has been found effective in positive emotion regulation among patients with bipolar depression [46, 47]. On the other hand, as both family support and interpersonal assistance are primary sources of social support, enhancing social support might be another promising direction in preventing CM associated SH among teenagers. At first, problem-solving therapy from which individuals can learn how to seek interpersonal assistance might be beneficial, as such therapy has been proved effective in reducing helplessness and suicidal ideation in depressive patients, though in small-sized samples [48]. However, evidence from a large pragmatic trial recommended problem-solving therapy as an alternative only for patients with repeated SH attempt [49]. Moreover, promoting positive comprehension of family support can also be considered, as an interventional study has proved its effectiveness among Chinese adolescents from impoverished areas [50].

Our study is among the first to test the moderating and mediating effect of resilience in the association between CM and SH in a large sample of Chinese adolescents. However, several limitations should be noticed. First, the cross-sectional nature prevents causal conclusions. Second, self-reported questionnaires are prone to information bias. Third, study subjects were chosen from a single province in southwest China, therefore a limit should be set for the generalization of study results. Future studies with expanded sampling sources and prospective design are warranted.

In this cross-sectional study of Chinese adolescents, we found that childhood maltreatment was prominently associated with SH, besides, resilience exhibited significant moderation and mediation in CM-SH association. Among all dimensions of resilience, emotion regulation, family support and interpersonal assistance emerged as the strongest mediators. The present study offers new perspectives for the prevention of CM related SH among Chinese adolescents: measures for strengthening psychological resilience, especially for improving emotion regulation ability, consolidating family support and interpersonal assistance should be considered in reducing the risk of SH among adolescent CM victims.