Measurement of perceived functions of non-suicidal self-injury for Chinese adolescents.

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Measurement of Perceived Functions of Non-Suicidal Self-Injury for Chinese Adolescents a

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Choi Hong Leong , Anise M. S. Wu & Mary Man-yee Poon

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University of Macau , Macao SAR , China Accepted author version posted online: 25 Feb 2014.Published online: 08 May 2014.

Click for updates To cite this article: Choi Hong Leong , Anise M. S. Wu & Mary Man-yee Poon (2014) Measurement of Perceived Functions of Non-Suicidal Self-Injury for Chinese Adolescents, Archives of Suicide Research, 18:2, 193-212, DOI: 10.1080/13811118.2013.824828 To link to this article: http://dx.doi.org/10.1080/13811118.2013.824828

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Archives of Suicide Research, 18:193–212, 2014 Copyright # International Academy for Suicide Research ISSN: 1381-1118 print=1543-6136 online DOI: 10.1080/13811118.2013.824828


Measurement of Perceived Functions of Non-Suicidal Self-Injury for Chinese Adolescents Choi Hong Leong, Anise M. S. Wu, and Mary Man-yee Poon Due to the lack of validated assessment tools for motives of non-suicidal self-injury behaviors in the Chinese contexts, this study aims to evaluate the psychometric properties of the Chinese version of the Functional Assessment of Self-Mutilation (C-FASM). A total of 345 secondary school students (mean age ¼ 11.41 years), who reported non-suicidal self-injury in the past year, voluntarily participated in the questionnaire survey. Confirmatory factor analysis results supported a secondorder model of 4 motivational factors. The overall scale scores had significant correlations with depression, anxiety, impulsiveness, self-esteem, social support, and suicidal ideation. The internal consistency of the scale was also satisfactory. The C-FASM is a valid and reliable instrument for assessing non-suicidal self-injury among nonclinical Chinese adolescents. Keywords

adolescents, Chinese, measurement, non-suicidal self-injury, validation

rate of past-year NSSI ranged from 7.3% to a high of 39% in two adolescent college samples (Lloyd, 1997; Whitlock, Eckenrode, & Silverman, 2006). Moreover, the onset of NSSI typically begins in adolescence, and the average onset age of NSSI ranges from 12 to 15 years across samples (Muehlenkamp & Gutierrez, 2007; Nock & Prinstein, 2004). NSSI is considered to be a serious clinical problem with an increasing prevalence rate, and this has been raising concerns among researchers and practitioners (Jacobson & Gould, 2007; Whitlock Eckenrode, & Silverman et al., 2006). For instance, Nock, Joiner, Gordon et al. (2006) found that 70% of a clinical sample of adolescents who engaged in NSSI reported a suicide attempt.

Non-suicidal self-injury (NSSI) is defined as deliberate ‘‘destruction to body tissue without conscious suicidal intent’’ and which is not culturally and socially sanctioned (Gratz, 2001, p. 253). NSSI behaviors include skin cutting, burning, hitting, and severe skin scratching. NSSI is prevalent in the West, occurring in up to 4% of adult populations and as high as 21% of clinical adult samples (Briere & Gil, 1998). Adolescents are particularly at risk, as some studies of adolescents have suggested that NSSI lifetime prevalence rates range from 17% to 35% (Gratz, 2001; Muehlenkamp & Gutierrez, 2007; Whitlock, Eckenrode, & Silverman, 2006) in community samples and as high as 82% in the clinical samples (Nock & Prinstein, 2004). The prevalence

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Measurement of Non-Suicidal Self-Injury

Although NSSI research in Chinese contexts is relatively rare, the limited published research on Chinese NSSI shows that NSSI is also a prevalent problem among Chinese adolescents. Chen (2006) and Shek and Yu (2012) showed that approximately 23% and 33% of secondary school students engaged in one form of NSSI in Taiwan (in the past 6 months) and Hong Kong (in the past year), respectively. Two master theses conducted in Macao with different assessment tools found 10% (Kim, 2010) and 39% (Leong, 2002) of the respondents from junior high school samples reported NSSI experience. These findings consistently indicate that more research should be directed towards assessing and addressing NSSI in Chinese adolescents. In order to accurately capture the perceived functions of NSSI and to design proper interventions in future research, a valid and reliable NSSI assessment tool for Chinese populations is essential. This study aimed to evaluate the psychometric properties of the Chinese version of the Functional Assessment of Self-Mutilation (FASM; Lloyd, 1997; Nock & Prinstein, 2004), which is a popular assessment tool for functions (or motives) of NSSI in the West. Definition of NSSI

In the past, both researchers and clinicians have often used inconsistent terms and definitions for describing a wide range of self-injurious behaviors. Terms such as self-injury, self-harm, self-mutilation, selfpoisoning, self-cutting, and parasuicide have sometimes been used interchangeably to describe actions that people do to intentionally injure themselves with nonfatal outcomes (Hawton, Rodham, Evans et al., 2002; Hjelmeland, Hawton, Nordvik et al., 2002; Nock, 2009; Nock & Prinstein, 2004). Some research conducted in Europe

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(e.g., Hawton, Rodham, Evans et al., 2002; Hjelmeland, Hawton, Nordvik et al., 2002) and Australia (De Leo & Heller, 2004) employed a broader definition for deliberate self-harm: ‘‘any intentional self-injury or self-poisoning, regardless of whether or not the act was intended to result in suicide for’’ (Hawton, Bergen, Mahadevan et al., 2012, p. 44); whereas some studies conducted in the United States (e.g., Briere & Gil, 1998; Gratz, 2001) used a more narrower definition for deliberate self-harm. Such inconsistency should be noted because it may become an obstacle for an accurate comparison and integration of previous findings in the area. In the present study, NSSI and its perceived functions were assessed. The definition of NSSI suggested by Gratz (2001) was employed, and herein, NSSI refers to any behavior of deliberate ‘‘destruction to body tissue without conscious suicidal intent’’ (p. 253). The term NSSI and its definition clearly differentiate NSSI from attempted suicide and highlight that the target behavioral acts are those that are intentionally self-mutilative to one’s body but nonlife-threatening. This definition of NSSI was also generally adopted in the later studies of NSSI in the United States (e.g., Muehlenkamp & Gutierrez, 2007; Muehlenkamp, Williams, Gutierrez, & Claes, 2009) and Macao (e.g., Leong, 2002). Most practitioners, such as clinical psychologists, in this area in Macao are trained to use the Diagnostic and Statistical Manual of Mental Disorders and the diagnostic guidelines of the American Psychiatric Association, and they also generally apply the same definition for NSSI in their clinical practice. Functions of NSSI

Western researchers have attempted to not only assess the prevalence of, but also identify the motives for NSSI (e.g., Klonsky, Oltmanns, & Turkheimer, 2003;

VOLUME 18 NUMBER 2 2014


C. H. Leong, A. M. S. Wu, and M. M. Poon

Nock & Prinstein, 2004; Nock & Prinstein, 2005; Whitlock, Eckenrode, & Sullivan, 2006). In previous studies, self-injurers reported that NSSI can serve a wide range of functions. For example, negative emotionality is widely viewed as one of the psychological characteristics underlying NSSI, and NSSI is regarded as a way to manage intolerable feelings or as a way to experience some sense of feeling, such as an energy rush (Nock & Prinstein, 2004). Some people use NSSI to evoke emotions when they feel numb or dissociated, whereas some use it to increase energy or improve their mood. NSSI may also be used as a means of self-control, punishment, or distraction from stressors. NSSI is also viewed as an attention-seeking behavior that is used to solicit attention from adults or peers, or to be part of a group (Whitlock, Eckenrode, & Sullivan, 2006). For example, people will engage in NSSI in order to draw attention from a significant other or to elicit some reinforcing responses from others. Regarding NSSI in Macao, Leong (2002) reported in her master thesis that a sample of Chinese junior high school students commonly endorsed the following ‘‘reasons’’ an individual might engage in NSSI: break-up with partner, negative moods, frustration, lack of meaning in life, and conflict with family. Kim (2010), in her master thesis, also consistently found that romantic relationship issues, frustration, lack of meaning in life, and conflict with family are the factors most commonly endorsed by Chinese junior high school students to explain why people engage in NSSI. However, due to their measurement limitations, these two local studies only provided information regarding activating events of NSSI, while the actual functions of NSSI perceived by Chinese adolescents remained unclear. In order to create a more systematic understanding of NSSI, Nock and Prinstein (2004) further developed a measurement

inventory, called the FASM, based on the earlier work of Lloyd (1997) and suggested that NSSI is initiated and maintained through automatic and social reinforcement. They proposed a comprehensive four-factor functional model of NSSI, which posits proposed that NSSI may serve four types of functions. These functions can be categorized according to two dimensions: whether the reinforcement is positive or negative and whether the consequent events are intrapersonal or interpersonal. The four types of functions consist of (1) automatic positive reinforcement (A-PR; i.e., to experience something), (2) automatic negative reinforcement (A-NR; i.e., to remove tension or negative emotions), (3) social=interpersonal positive reinforcement (S-PR; i.e., to shape others’ behavior), and (4) social=interpersonal negative reinforcement (S-NR; i.e., to stop others demanding something from you). Nock and Prinstein (2004; 2005) provided evidence that FASM can empirically assess these four types of NSSI functions. As mentioned earlier, automatic functions have received the most empirical attention and have been shown to be the most common type of functions of NSSI. The Functional Assessment of Self-Mutilation (FASM)

The FASM is a self-report instrument that assesses not only the frequency and types of NSSI behaviors that have occurred in the previous 12 months, but it also shows the function that NSSI serves to the individual performing this behavior. It consists of two sections: (1) a behavioral checklist of NSSI (e.g., cutting, burning, hitting self on purpose); and (2) a list of possible reasons for NSSI (i.e., to stop bad feeling, to punish yourself, to feel relaxed) by using a 4-point Likert scale of responses, which range from never to often. In the present study, the psychometric properties of the Chinese version of the

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second section (i.e., the reasons for NSSI) of the FASM (C-FASM), was empirically examined among Chinese adolescents. Regarding the types and frequency of NSSI, another popular NSSI measurement tool, the Deliberate Self-harm Inventory (DSHI), was used in this study because it contains not only all the 11 types of NSSI suggested in the FASM but also seven additional NSSI behaviors (including rubbing sandpaper on skin, dripping acid on skin, rubbing glass into skin, breaking bones, banging head, interference with wound healing, and other forms of selfharm). However, the limitation of the DSHI is its sole behavioral focus; it does not measure any related factors, such as motives of NSSI. The FASM was first developed in an American high school student sample (Lloyd, 1997). The content of the FASM was developed through two steps. First, Lloyd selected various types of NSSI behavior, frequency, and reasons (i.e., functions) based on a review of previous literature on NSSI among adolescents, and then additional items were established based upon her clinical experience. The FASM was then validated by Nock and Prinstein in an American adolescent clinical sample in 2004. Nock and Prinstein demonstrated adequate internal consistency for the four subscales of the FASM, which assessed the four different types of possible functions of NSSI, with alpha coefficients ranging from .62 to .85. In addition, the FASM was also tested with 78 psychiatric adolescents sample in a juvenile correctional facility (Penn, Esposito, Schaeffer et al., 2003), who completed the FASM twice; the reliability of the scale was found to be high at both assessment waves. Both Lloyd (1997) and Penn, Esposito, Shaeffer et al. (2003) also reported that suicidal ideation and past suicide attempt was positively associated with the history and frequency of NSSI, but they did not test the association between the subscale scores of FASM

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and suicide ideation or attempts. However, Lloyd showed that severe self-injurers tended to endorse more items of perceived functions in FASM. Although Nock and Prinstein did not examine the association between suicidal ideation=attempt and the scale scores of the FASM in their validation study in 2004, they reported a significant correlation between suicidal attempt and the subscale A-NR in their 2005 study with a sample of 89 adolescent psychiatric inpatients. In the present study, the expected positive association of the FASM and its subscale scores with suicidal attempt was examined with a larger Chinese adolescent sample. The Present Study: Validation of the C-FASM

Translation without empirical validation of psychological instruments is widely observed in non-Western countries (Gudmundsson, 2009). However, a translated version of an instrument cannot be assumed to have the same psychometric properties as the original version. It is essential to examine the validity of a translated instrument before its use in another country=culture. Basic requirements for validity include content validity, construct validity, and criterion-related validity. After a welldeveloped inventory is selected for use, it should be translated by qualified translators with standardized translation procedures. Moreover, experts who are familiar with the content of the instrument should review the translated instrument to ensure the appropriateness of each item after translation. These two steps are necessary for ensuring content validity of a translated instrument, such as the C-FASM. The construct and criterion-related validities of the C-FASM was also investigated in the present study. Regarding construct validity, the four-factor model of the NSSI functions




suggested by Nock and Prinstein (2004) was examined by confirmatory factor analysis. The reliability of each factor was then evaluated. Regarding criterion-related validity, which refers to how well the test scores correlate with some type of related criterion or outcome (Sattler, 2008), the correlations between C-FASM scores and some risk factors of NSSI were examined. A review paper of Jacobson and Gould (2007) suggested several salient psychological risk factors of NSSI, including high impulsivity, low self-esteem, poor coping, and emotional dysregulation. In this study, impulsivity, self-esteem, negative emotions, and social support were also assessed and were expected to have significant correlations with the perceived functions of NSSI assessed by the C-FASM. Based on the functional approach of human behaviors, NSSI is postulated to be maintained by four reinforcement processes (i.e., intrapersonal= interpersonal positive=negative reinforcement; Nock, 2009). As a result, people are more likely to initiate and repeat NSSI if they perceive NSSI as more reinforcing. Impulsivity. Impulsivity has been consistently suggested to be a salient risk factor of NSSI (Cloutier, Martin, Kennedy et al., 2010; Glenn & Klonsky, 2010; Jacobson & Gould, 2007). For example, Carli and colleagues (2010) showed that male incarcerated individuals with high impulsivity engaged in NSSI more frequently. Since NSSI is a relatively fast and easily accessible method that serves various functions, such as emotional relief and attention (Nock, 2009), impulsive people, who have strong urges to take action immediately without forethought, may tend to endorse the psychosocial functions of NSSI. Therefore, the current study hypothesized a positive association between impulsivity and NSSI frequency, as well as C-FASM scores among Chinese adolescents.

Self-Esteem. Low self-esteem was also found to be a psychological risk factor of NSSI among adolescents (Klonsky, Oltmanns, Turkheimer et al., 2003; Lundh, Karim, & Quilisch, 2007). People with low self-esteem often experience more intrapersonal and interpersonal difficulties (e.g., family maltreatment), and thus it is plausible that they tend to perceive NSSI as more rewarding in general because of their existing psychological disturbance and interpersonal problems. Therefore, it was anticipated that, among Chinese adolescents, low self-esteem would be associated with higher NSSI frequency and C-FASM scores. Negative Emotions. Both negative emotionality and emotional dysregulation have been found to be the main reason for the positive association with depressive and anxiety disorders with NSSI (e.g., Guertin, LloydRichardson, Spirito et al., 2001; Jacobson & Gould, 2007; Klonsky & Muehlenkamp, 2007; Nock & Prinstein, 2005). Along the same lines, negative temperament, emotional dysregulation, and depression or anxiety symptoms have been found to have associations with NSSI in nonclinical samples (e.g., Klonsky, Oltmanns, & Turkheimer, 2003; Leong, 2002). People with negative emotions may be likely to engage in and maintain NSSI to distract themselves from negative moods (A-NR) or to gain a desired feeling or stimulation (A-PR). Therefore, we hypothesized that Chinese adolescents’ negative emotions would be positively correlated with not only higher NSSI frequency but also higher scores of overall C-FASM, A-NR, and A-PR. Social Support. Lack of social support has also been found to be correlated with NSSI (Klonsky, Oltmanns, Turkheimer et al., 2003). Similarly, NSSI by Chinese adolescents has been associated with poor relationships with parents and teachers (Chen, 2006; You & Leung, 2012).


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Logically, it was anticipated that adolescents who lacked support from peers, parents, and teachers would suffer from more interpersonal problems and thus engage in and maintain NSSI because of its two specific social=interpersonal functions via both positive and negative reinforcement (i.e., S-PR and S-NR). Therefore, it was hypothesized that low social support would be associated with high NSSI frequency, as well as high scores of overall C-FASM, S-PR, and S-NR among Chinese adolescents.

and good, respectively. There were 3.2% who perceived their academic performance to be very poor and 4.7% to be very good. In the overall sample (N ¼ 825), 41.8% of the respondents (n ¼ 345) reported self-injury in the past 12 months, while 58.2% of them (n ¼ 480) reported no such experience (i.e., non-self-injurers). The demographic characteristics of these two groups are summarized in Table 1. In the present study, only those respondents who reported engaging in NSSI (i.e., DSHI 1) were included in the subsequent statistical analyses (n ¼ 345). The range of DSHI scores of this sample was 1 to 27.

METHOD Respondents

Procedures

Students were recruited from four coeducational secondary schools located in different districts within Macao, China. Among the four schools, two were Catholic schools and two were not affiliated with a religion. For each school, questionnaires were distributed to two classes of each grade level, from Form 1 to Form 3. About 865 questionnaires were distributed, 825 of which were considered as valid (i.e., the respondent answered 70% or more of each measurement scale in the questionnaire). A total sample of 825 respondents was recruited for the study. The sample was composed of 423 (51.3%) male and 402 (48.7%) female junior high school students in Macao, with ages ranging from 11 to 18 years and a mean age of 14.11 years (SD ¼ 1.28). In this junior high school student sample, 29.8% of the respondents (n ¼ 246) were Form 1 students, 26.3% (n ¼ 217) were Form 2 students and 43.9% (n ¼ 362) were Form 3 students. When compared to other students, the majority of the respondents (56.1%) perceived their academic performance in the average range, while 17.9% and 18.1% of them perceived their performance as poor

The questionnaire was constructed by two psychologists, after which it was proof read by another clinical psychologist whose expertise was with Chinese adolescent NSSI. The clinical psychologist with expertise in Chinese adolescent NSSI searched for any inappropriate use of terms before the instrument was implemented in the study. After receiving the consent form from the junior high schools, questionnaire packets were distributed by the class teachers to students at a class time scheduled by the schools. A researcher, school counselor, or school personnel went to the scheduled class to fully inform the potential respondents verbally of the purpose of the study before the data collection started. The cover page of the questionnaire, which explained the purpose of the study, was reviewed with the students. Then a consent form, with a clear explanation of the respondents’ rights on it, was distributed to each student and all students returned the signed form before they participated in the study. Their voluntary participation was emphasized verbally, but none of the students refused to participate in the study. The students were assured that the questionnaire was anonymous and that

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TABLE 1. Demographic Characteristics of Non-Self-Injurers (n ¼ 480) and Self-Injurers (n ¼ 345) Non-self-injurer


Variable

Frequency %

Male Female Age Education level Form 1 Form 2 Form 3 Perceived academic Very poor Poor Average Good Very good

M

SD

Self-injurer Range

Frequency %

55.6 44.4

M

SD

Range

11.41

2.63

12–17

45.2 54.8 14.11

1.28

11–18

31.5 21.9 46.7

27.5 32.5 40.0

2.7 17.1 56.0 19.2 4.8

3.8 19.1 56.2 16.2 4.6

they could not be identified by the information they provided. The questionnaire packets had a title page in order to minimize the exposure of responses. Before submitting the questionnaire, respondents were asked to fold it and then put it inside a sealed box by themselves in order to ensure confidentiality. After completing the research packet, students were provided with a debriefing sheet that contained information about the study and ways to contact not only the researchers but also available mental health services if needed. Referrals to a clinical psychologist were also provided for those respondents who felt they needed further clinical follow-up after completing the questionnaire. Instruments

The Functional Assessment of Self-Mutilation. The FASM originally contained 22 functional reasons for engaging in NSSI (Lloyd, 1997). Based on the findings reported by Nock and Prinstein in 2004, Item 19 ‘‘to give yourself something to do with others’’

was removed from the analyses because of its failure to load on any factor of reasons for engaging in NSSI. Hence, 21 items describing the possible reasons for NSSI engagement were examined in the present study. The respondents were asked to circle the scale number that best described how often a particular reason drove them to engage in NSSI. The C-FASM was measured by a 4-point Likert scale, ranging from 0 to 3, where 0 indicated never, 1 indicated rarely, 2 indicated sometimes, and 3 indicated often. In this study, all scale items were translated into traditional Chinese with the standardized procedures of forward and backward translation by two professional translators, in order to retain the content validity of the scale. After the translation, the face validity of the Chinese version of the FASM (C-FASM) was evaluated by two Chinese psychologists, who made sure that the translated items were appropriate for assessing NSSI functions in the local Chinese context. Before finalizing the questionnaire, a pilot was also carried out with a small group of junior high


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school students (N ¼ 10), who were asked to complete and comment on the translated items, in order to ensure appropriate wording and high comprehensiveness of the C-FASM for Chinese adolescents. The Deliberate Self-Harm Inventory. The DSHI was used in this study as a behavioral checklist of NSSI behaviors in the past 12 months. There are 17 items, which assess the frequency of 16 specific types of NSSI (e.g., cutting and burning) and one additional NSSI behavior that was not assessed by the scale (i.e., others). The DSHI is solely a behaviorally based measure that does not account for any of the related factors that may contribute to NSSI. Respondents rated the frequency at which they had engaged in any types of NSSI on a 4-point Likert scale with the following responses, never, rarely, sometimes, often. A higher total score of the DSHI indicates that an individual has engaged in a greater variety of NSSIs with higher frequency. The reliability of the DSHI was satisfactorily high, with Cronbach’s alpha ¼ .72, in the present study. The Short Form of the Depression Anxiety Stress Scale (DASS-21). Negative emotions were assessed using Chinese version of the DASS-21. The DASS-21 is a self-report measure that assesses the negative emotional states of depression, anxiety, and stress, and has been used in studies with Chinese adolescents (e.g., Gong, Xie, Xu et al., 2010). It consists of 21 items taken from the original full version of the 42-item Depression Anxiety Stress Scale (DASS; Lovibond & Lovibond, 1995, as cited in Henry & Crawford, 2005). Sample items are, ‘‘I felt down-hearted and blue,’’ ‘‘I was aware of dryness of my mouth,’’ and ‘‘I felt I was close to panic.’’ Items are rated by participants on a four-point Likert scale, ranging from 0, indicating did not apply to 3, indicating, applied most of the time. A high score represents more negative emotions

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experienced. In the present study, the Cronbach’s alpha for this scale was .92. Impulsiveness Scale. Impulsivity was assessed using the Chinese version of the 19-item Eysenck and Eysenck’s Impulsiveness Scale (Tang & Wu, 2012). This scale defines impulsivity as a kind of risk-taking behavior, with a pattern of acting before considering the consequences of one’s actions. Sample items include, ‘‘Do you generally do and say things without stopping to think?’’ and ‘‘Do you often do things on the spur of the moment?’’ Respondents answer each item with ‘‘yes’’ or ‘‘no,’’ and affirmative responses are summed up to form a total impulsivity score ranging from 0 to 19, with higher scores indicating higher levels of impulsivity. In the present study, the Cronbach’s alpha of the impulsiveness scale was .64. Rosenberg Self Esteem Scale. Self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSE; Rosenberg, 1965 as cited in Lundh, Karim, & Quilisch, 2007) which is a 10-item Likert scale used to measure individual’s sense of self-worth and selfacceptance. This is a 4-point scale with answers ranging from 1, indicating, strongly disagree to 4, indicating strongly agree. Respondents were asked to choose how well the statements describe them. A sample item is, ‘‘I take a positive attitude toward myself.’’ Within the 10 statements, there are 5 statements that are reverse scored. After reversing the five negative statements, a total score can be summed up from 10 to 40. The higher score represents higher selfesteem. The Chinese version of this scale has been used in a Chinese community sample (Yu & Zhang, 2007), and its Cronbach’s alpha was .79 in the present study. Multidimensional Scale of Perceived Social Support. Perceived social support was assessed using the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet,




Dahlem, Zimet et al., 1988). The MSPSS is a 12-item self-report instrument that assesses an individual’s perceived support from family, friends, and significant others. Sample items are ‘‘My family really tries to help me’’ and ‘‘I can count on my friends when things go wrong.’’ Respondents rate the extent to which they agree with items on a 7-point Likert scale ranging from 1, indicating strongly disagree to 7, indicating strongly agree. The total score of the MSPSS is calculated by summing up the 12 items, yielding a score ranging from 12 to 84. A higher score represents greater perceived support. The Chinese version of the MSPSS in Chinese young adults was found to have high reliability (Zhang & Norvilits, 2002). In the present study, the Cronbach’s alpha of this scale was .93. Suicidal Ideation Questionnaire. Suicidal ideation were assessed by using the Suicidal Ideation Questionnaire (Ingram & Ellis, 1995, as cited in Coney, 2007), which is a binary response scale consisting of five questions designed to differentiate between the suicide attempter and nonsuicide attempter. A sample items was ‘‘I have seriously considered committing suicide in the past.’’ In the present study, the item, ‘‘I have never thought about committing suicide’’ was deleted so as to improve the reliability. The resultant Cronbach’s alpha for the scale was .78. Demographics. We also collected demographic data, including gender (1 ¼ Male, 0 ¼ Female) and age. Respondents were also asked to make a self-evaluation of current academic performance compared with other classmates on average (1 ¼ Very Good, 2 ¼ Good, 3 ¼ Average, 4 ¼ Poor, 5 ¼ Very Poor). Data Analysis

The four-factor model of the C-FASM was expected to be the best fit for the data.

By AMOS 16.0 for Windows, this factor structure of the C-FASM was tested through confirmatory factor analysis with the method of maximum likelihood estimation, and several methods were used for evaluation of the adequacy of fit of the model to the data, including chi-square test, the root mean square of approximation (RMSEA), Normed Fit Index (NFI), the Comparative Fit Index (CFI), and Incremental Fit Index (IFI). The fit of the model is generally regarded as satisfactory if the indexes are close to 1. A value of 0.09 or less of the RMSEA, and v2=degree of freedom value of less than 5 are also recognized as indicators of a good fit. Moreover, a nonsignificant chi-square statistic is also an indicator of an acceptable fit of the model to the data, but it is usually difficult to achieve (Kline, 2005). The factor loadings were also considered. The loading of 0.30 or higher is generally regarded as acceptable (Hair, Black, Babin et al., 2010). Reliability was determined by analyzing the internal consistency of C-FASM as well as other variables by using Cronbach’s alpha coefficient, which indicates the extent to which items correlate with one another within a scale. Bivariate correlation analyses were used to examine not only how the C-FASM subscales were correlated with each other, but also whether C-FASM correlated with psychological variables in the expected directions, which helped to evaluate its criterion related validity. Significant gender differences on C-FASM were also tested by correlational analysis. A hierarchical regression analysis was also conducted with the C-FASM total score as a dependent variable, in order to examine the relative explanatory power of demographic and psychological variables on it. Another hierarchical multiple regression analysis was used to examine the predictive validity of the C-FASM on suicidal ideation. These statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS) 16 for Windows.


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RESULTS

There were 189 females (54.8%) and 156 males (45.2%) who reported NSSI in the present study. Table 2 shows the proportion of the respondents’ NSSI by methods. The most frequently experienced types of NSSI included hitting self (48.5%), pulling out one’s own hair (46.6%), and biting self (44.6%). The endorsement rate of each function of NSSI is listed in Table 3. The most frequently endorsed functions of NSSI included to feel relaxed (54.2%), to avoid doing something unpleasant you don’t want to do (51.9%), to give yourself something to do when alone (45.8%), and to stop bad feelings (43.5%). A statistically significant gender difference in relation to the total DSHI score was found (r ¼ .17, p < .01). Female respondents endorsed more items of the DSHI (M ¼ 5.32 SD ¼ 4.58) when compared to male respondents (M ¼ 3.90

SD ¼ 3.18). However, no significant gender difference was found in the C-FASM total score and its subscales (p > .05). In addition, the results also showed that age was not significantly correlated with the DSHI (r ¼ .06, p > .05) or the C-FASM total or subscale scores (rs ranged from .02 to .02, .01, ps > .05). Confirmatory Factor Analysis

In this study, a series of confirmatory factor analyses (CFA) was conducted by Amos 18.0 to determine whether the four-factor model explained the dataset of Chinese adolescent self-injurers (N ¼ 345). First, the baseline of a general one-factor model was evaluated. All C-FASM items were set to load onto a single factor. The CFA results indicated that this baseline model did not satisfactorily fit with the dataset. The v2 statistic was significant,

TABLE 2. Frequency of Self-Injurers Endorsing Various Method in the DSHI (n ¼ 345) Gender Method of NSSI 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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Percentage of sample

Male

Female

34.8 41.1 48.5 26.2 44.6 9.9 7.2 1.4 2.6 46.6 18 3.2 1.7 29.7 15.2 0.6 1.2

40.2 42.6 35.3 37.8 38.3 29.4 40.0 40.0 44.4 38.7 38.7 27.2 50.0 46.1 34.6 0.0 75.0

59.8 57.4 64.7 62.2 61.7 70.6 60.0 60.0 55.6 61.3 61.3 72.7 50.0 53.9 65.4 100.0 25.0

Cutting or carving on skin Picking at a wound Hitting self Scraping skin to draw blood Biting self Picking areas of the body to the point of drawing blood Inserting objects under skin or nails Tattooing self Burning skin Pulling out one’s own hair Erasing skin to draw blood Rubbed sandpaper on your body Used bleach, comet, or even cleaner to scrub your skin Banged your head against something Prevented wound from healing Broken your own bones Others



TABLE 3. Frequency of Functional Reason for Engaging in NSSI (n ¼ 345)


Reason 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

To avoid school, work, or other activities To relieve feeling numb or empty To get attention To feel something, even if it was pain To avoid doing something unpleasant you don’t want to do To get control of a situation To try to get a reaction from someone, even if it’s negative To receive more attention from your parents or friends To avoid being with people To punish yourself To get other people to act differently or change To be like someone you respect To avoid punishment or paying the consequences To stop bad feelings To let others know how desperate you were To feel more a part of a group To get your parents to understand or notice you To give yourself something to do when alone To get help To make others angry To feel relaxed

v2(189) ¼ 864.401, p < .05, and all four fit indices were not adequately acceptable (NFI ¼ .784; CFI ¼ .822; IFI ¼ .823; RMSEA ¼ .102; v2=df ¼ 4.574). Moreover, the 90% confidence interval of RMSEA was .095–.109. All these values of its fit index suggested a poor fit of the model. Since the one-factor model results showed a poor fit of the model, the four-factor model suggested by Nock and Prinstein (2004) was examined. The fourfactor model was composed of four specific types of functions of NSSI, which corresponded to four subscales of the C-FASM, including automatic positive reinforcement, automatic negative reinforcement, social positive reinforcement and social negative reinforcement. No cross-loadings were postulated and all

Gender

Percentage of sample

Male

Female

41.4 35.1 38.3 32.2 51.9 37.4 33.6 36.8 22.3 30.7 33.0 29.3 35.7 43.5 28.4 35.4 37.7 45.8 26.1 16.8 54.2

41.2 41.3 42.4 39.6 38.5 46.5 44.8 37.0 42.9 36.8 43.9 41.6 39.8 42.0 39.8 45.9 41.5 43.7 38.9 43.1 43.8

58.7 58.7 57.6 60.4 61.5 53.5 55.2 63.0 57.1 63.2 56.1 58.4 60.2 58.0 60.2 54.1 58.5 56.3 61.1 56.9 56.1

factor correlations were free. The CFA results indicated that this four-factor model demonstrated a better fit than the onefactor model, although the v2 statistic was significant, v2(183) ¼ 761.223, p < .05, and all four fit indices did not reach satisfactory levels (NFI ¼ .810; CFI ¼ .847; IFI ¼ .848; RMSEA ¼ .096; 90% confidence interval ¼ .089–.103; v2=df ¼ 4.160). The chi-square change from the one-factor model to the four-factor model was v2(6) ¼ 103.178, p < .05 and indicated a significant improvement of the model fit. Since the four-factor model only showed a marginally satisfactory fit with the data collected among Chinese adolescent self-injurers, an additional CFA was conducted to examine whether a higherorder model would provide a better


203



explanation to the covariation among the four factors. Although each FASM item was designed to assess different NSSI functions, all items tapped the same and more generalized cognitive construct, that is, overall perception of functions of NSSI. Thus, the second-order model for the C-FASM was examined, with one higher order latent variable, which was specifically, the overall function of NSSI. The CFA results of this second-order model showed that the v2 statistic remained significant, v2(185) ¼ 776.059, p < .05 and all indices did not reach satisfactory level (NFI ¼ .806; .806; CFI ¼ .844; IFI ¼ .845; RMSEA ¼ .096; 90% confidence interval ¼ .089–.103; v2=df ¼ 4.195). However, the chi-square difference tests revealed that the secondorder model provided significantly better fit with the Chinese data than the previous four-factor model, with v2(2) ¼ 14.83, p < .05. Therefore, the second-order model was selected for further modification to account for the perceived NSSI functions in this Chinese sample. Nock and Prinstein (2004) suggested that the FASM may contain several pairs of items that all assess the same function of various NSSI behaviors and thus correlated residuals between several such items should be allowed to account for the nonrandom error. Based on the modification indices provided in the CFA results, 11 residuals items in the present second order model were set to be correlated. This modified model was tested by CFA again and the chi-square change test result indicated a significant improvement in model fit, v2(11) ¼ 235.077, p < .05. It was found that the goodness-of-fit of this modified model was adequate (NFI ¼ .865; CFI ¼ .903; IFI ¼ .904; RMSEA ¼ .078; 90% confidence interval ¼ .071–.086; v2=df ¼ 3.109), though the v2 statistic was significant, v2(174) ¼ 540.982, p < .05. In addition, all item loadings are satisfactorily high as above 0.40. The modified second-order model for the C-FASM is shown as Figure 1.

204

Reliability and Validity of the C-FASM

Reliability. Cronbach’s alpha of the overall C-FASM was .94. The reliabilities of the four subscales, that is, automatic negative reinforcement, automatic positive reinforcement, social negative reinforcement, and social positive reinforcement, were a ¼ .65, .44, .79, and .91, respectively. It should be noted that the internal consistency for three-item automatic-positive reinforcement scale was low. Nevertheless, as expected, all four subscale scores were positively correlated with each other (rs ranged from .63 to .76, p < .001). Validity. The criterion-related validities of the C-FASM and its subscales were examined by performing correlations of their scores with a range of variables (including NSSI frequency, self-esteem, perceived social support, impulsivity, negative emotions, and suicide ideation). Table 4 displays the correlation matrix of the major variables in the present study. As hypothesized, the results showed evidence of concurrent validity, with C-FASM total score being significantly and positively related to the DSHI score, negative emotions (including depressive, anxiety, and stress), impulsivity, and suicide ideation (rs ¼ .39, .51, .48, .51, .36 and .26, respectively, p < .001), and negatively associated with self-esteem and perceived social support (rs ¼ .25 and .15, p < .001). Regarding the C-FASM subscales, the results of correlation analysis showed that all subscale scores were significantly correlated with NSSI frequency, impulsivity, self-esteem, and suicide ideation in the expected direction (p < .05). In addition, as hypothesized, negative emotions was positively correlated with higher scores of A-NR, and A-PR, whereas perceived social support was negatively correlated with S-NR and S-PR (ps < .05).




FIGURE 1. Second-order model of factorial structure for the Chinese version of Functional Assessment of Self-Mutilation (C-FASM). Note: A-PR, automatic-positive reinforcement; A-NR, automatic negative reinforcement; S-PR, social-positive reinforcement; S-NR, social negative reinforcement. The C-FASM contained several pairs of items that are similar in content (i.e., item 1 and item 2, item 1 and item 5, item 2 and item 4, item 3 and item 8, item 4 and item 15, item 5 and item 21, item 8 and item 17, item 8 and item 22, item 9 and item 10, item 13 and item 22, item 16 and item 18) were set to be correlated.

With C-FASM total score set as the dependent variable and gender and age being controlled for in Block 1, negative emotions (i.e., depressive, anxiety, and stress), impulsivity, self-esteem, and perceived social support were entered into

Block 2 of the regression model to examine their total and relative explanatory power on C-FASM. The results showed that these psychological variables explained 33% of the variance of C-FASM total score, chisquare change ¼ .00, and .33 for the first


205

206


– .06 2.63 .01

.09 .02

.03 .01

3

.04 .02

4

.07 .01

5

7

.17 .11 .06 .12

6

9

10

11

12

.18 .15 .14 .20 .09 .11 .14 .04 .05 .02

8

–

14

15

.17 .11 – .05 .03 .00

13

Note: C-FASM ¼ The Functional Assessment of Self-Mutilation; A-PR ¼ Automatic-positive reinforcement; A-NR ¼ Automatic-Negative reinforcement; S-PR ¼ Social-positive reinforcement; S-NR ¼ Social-negative reinforcement; DSHI ¼ The Deliberate Self-Harm Inventory; DASS ¼ The Short Form of the Depression Anxiety Stress Scale; RSE ¼ Rosenberg Self Esteem Scale; MSPSS ¼ Multidimensional Scale of Perceived Social Support. p < .05. p < .01.

– 11.41

2

12.44 12.53 (.94) 2.00 1.92 .80 (.44) 1.32 1.64 .76 .66 (.65) 6.61 7.60 .96 .68 .63 (.91) 2.50 2.81 .87 .63 .65 .76 (.79) 4.68 4.06 .40 .43 .36 .32 .37 (.72) 8.03 8.61 .52 .51 .44 .47 .42 .37 – 7.94 7.31 .49 .48 .40 .46 .35 .36 .69 – 10.20 9.00 .52 .49 .42 .49 .37 .33 .75 .76 – 8.12 3.33 .37 .32 .33 .34 .31 .30 .45 .41 .45 (.64) 26.03 5.07 .26 .30 .21 .21 .23 .26 .49 .32 .34 .28 (.79) 53.01 15.22 .15 .20 .08 .12 .17 .09 .32 .17 .21 .03 .31 (.93) 0.06 1.27 .27 .25 .21 .22 .27 .35 .42 .35 .32 .30 .27 .16 (.76) 2.99 0.83 .05 .06 .07 .02 .08 .15 .23 .12 .12 .06 .33 .13 .10

C-FASM A-PR A-NR S-PR S-NR DSHI DASS-Depressive DASS-Anxiety DASS-Stress Impulsiveness RSE MSPSS Suicide ideation Perceived academic performance 15. Gender 16. Age

1

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

SD

Mean

Variable

TABLE 4. Alpha Coefficients, Means, Standard Deviations, and Correlations for the C-FASM, Four Subscales and Among the Variables (n ¼ 345)



TABLE 5. The Models of the Regression Analyses with C-FASM Total Score as Dependent Variable


Standardized coefficients Model 1: (Constant) Block 1: Gender Block 1: Age Model 2 (Constant) Block 1: Gender Block 1: Age Block 2: DASS-depressive Block 2: DASS-anxiety Block 2: DASS-stress Block 2: Impulsivity Block 2: Self-esteem Block 2: Perceived social support Note: p < .05.

p < .01.

.08 .00 .04 .08 .24 .16 .17 .13 .01 .00

t

Total R-square

1.77 1.21 0.12 1.75 0.84 1.84 3.08 2.17 2.16 2.41 0.13 0.09

.004

.330

F change 0.74

27.62

p < .001.

and second models respectively, F (6, 334) ¼ 27.62, p < .001. For this model, depressive symptom t(334) ¼ 3.08, p < .01, anxiety, t(334) ¼ 2.17, p < .05, stress t(333) ¼ 2.16, p < .05, and impulsivity, t(333) ¼ 2.41, p < .05 were all significant predictors of the C-FASM. The regression result is summarized in Table 5. In addition, two hierarchical regression analyses were further conducted in order to investigate the extent to which the C-FASM total and subscales scores explained suicidal ideation. Only gender was controlled for in Block 1 because gender, not age (r ¼ .05, p > .05), significantly correlated with the suicidal ideation in the prior correlation analysis (r ¼ .16, p < .05). In Block 2, either the C-FASM total score or the four subscale scores of C-FASM were entered into the model. The result of first regression analysis showed that gender accounted for 2.9% of the variance of suicidal ideation, while the C-FASM total score in Block 2 significantly explained an additional 6.6% of the variance, F Change (1, 342) ¼ 24.76, p < .001. The standardized coefficients of gender and C-FASM total score in the finalized model were .15 and .26, respectively

(p < .01). Consistently, the second regression analysis with all four C-FASM subscales as independent variables showed similar results in that the four C-FASM factors significantly accounted for 7.5% of the variance of suicidal ideation after gender was entered into the model, F Change (4, 339) ¼ 7.13, p < .001. Among four factors, social negative reinforcement emerged as the most significant factor of suicidal ideation (beta ¼ .19, p < .05). In sum, respondents who were female and who had higher C-FASM scores, particularly on social negative reinforcement, were more likely to report more suicidal ideation. The results of the two regression analyses are summarized in Table 6. DISCUSSION

The present study shows that NSSI is fairly common among Chinese adolescents in Macao, who use various methods to physically hurt themselves. In order to formulate effective programs for prevention and intervention of NSSI, it is necessary to have a better understanding of the perceived function of NSSI for them, which


207


TABLE 6. The Final Models of the Two Regression Analyses with Suicide Ideation as Dependent Variable


Regression analysis 1. (Constant) Gender C-FASM total score 2. (Constant) Gender A-PR A-NR S-PR S-NR

Standardized coefficients .15 .26 .15 .12 .01 .01 .19

t

Total R-square

F change

7.27 3.00 5.00 6.50 2.81 1.59 0.15 0.16 2.18

.095

24.76

.104

7.13

Note: C-FASM ¼ The Functional Assessment of Self-Mutilation; A-PR ¼ Automatic-positive reinforcement; A-NR ¼ Automatic-Negative reinforcement; S-PR ¼ Social-positive reinforcement; S-NR ¼ Social-negative reinforcement;. p < .05. p < .01. p < .001.

may determine whether they engage in NSSI. A valid tool for assessing those functions is important, and thus the present study tested the psychometric properties of C-FASM among Chinese adolescent selfinjurers. Consistent with the findings of Nock and Prinstein (2004), our findings provided further empirical support for the fourfactor model of perceived NSSI functions. The findings also indicated that the higher-level model had a better fit to the data of Chinese adolescent self-injurers, and hence those four factors of the NSSI functions (namely, automatic negative reinforcement, automatic positive reinforcement, social negative reinforcement, and social positive reinforcement) were suggested to be tapping the same construct. The total score computed from those four factors should be meaningful and represent how an individual favorably perceives the overall function of NSSI. In the present study, the reliability of the overall C-FASM was high and its total score was significantly correlated with the psychological risk factors of NSSI (e.g., low self-esteem, high impulsivity, less social support, and more negative emotions) in the expected

208

directions. These findings provide support to the validity of the C-FASM. Regarding the four subscales of C-FASM, the findings generally suggest that they adequately measure the four specific functions of NSSI among Chinese adolescents. The results showed that each of the four subscale scores was positively associated with DSHI total score, indicating that those who endorsed more functions of NSSI had used a greater variety of methods to hurt themselves and with greater frequency. Moreover, all four subscale scores were correlated with psychological risk factors of NSSI in the hypothesized directions. The reliabilities of the subscales were also adequately high, except the three-item subscale of automatic positive reinforcement. We suggest that the subscale of automatic positive reinforcement, if regarded as an individual assessment tool, should be used with great caution in a Chinese adolescent population. The present findings of the four-factor model suggest that Chinese adolescents engage in NSSI because of four distinct types of functions it serves. Among our Chinese adolescent self-injurer respondents, both automatic positive and negative




reinforcement functions were frequently cited. This finding is in line with previous literature (Klonsky & Muehlenkamp, 2007; Nock & Prinstein, 2004) that has found that people engage in NSSI commonly to regulate their emotions or psychological experiences, such as to stop bad feelings or to feel relaxed. The automatic reinforcements help self-injurers to alleviate negative emotions, and thus NSSI serves to make self-injurers feel some measure of relief or feeling of calm. On the other hand, we also observed that some Chinese adolescents engage in NSSI because of the socialpositive and negative reinforcement functions of NSSI, such as to avoid doing something or to give oneself something to do. Identification of NSSI functions perceived by self-injurers is valuable to providing clinical intervention and prevention. Because some Chinese adolescents who endorse the automatic functions of NSSI may engage in NSSI in order to regulate emotion, treatments with mood-regulation skill training would be effective; whereas, for those who engage in NSSI for reasons of social reinforcement, an intervention approach might focus on teaching them proper social and communication skills. The present findings also show that Chinese adolescents with psychological risk factors, such as negative moods and high impulsivity, are more likely to favorably perceive NSSI functions, which in turn may drive them to engage in NSSI. Therefore, some practical implications could be drawn from the present findings. For instance, previous findings have suggested that people suffering from mood and anxiety disorders are more likely to report NSSI because they generally lack emotional regulation skills and lack sufficient communication or social skills to appropriately express themselves (Csorba, Dinya, Plener et al., 2009; Klonsky & Muehlenkamp, 2007). Consistent with the Western findings, Leong (2002) also reported that Chinese adolescent self-injurers suffer from

more emotional dysregulation than nonself-injurers. They may not know how to externally express their emotional distress, and thus they internalize these negative emotions and engage in NSSI as a way to diminish them. As a result, some schoolbased campaigns can be conducted to educate Chinese adolescents, particularly the high-risk group, about emotion regulation skills, emotion communication skills, and problem-solving skills to help them better deal with emotional stress (Miller, Muehlenkamp, & Jacobson, 2009). Our results also indicate that impulsive people are more likely to endorse the functions and to engage in NSSI than others. Hence, it would be helpful to identify this risky trait among Chinese adolescents so as to provide early preventive intervention for this at-risk group. Glenn and Klonsky (2010) found that people with higher impulsivity tend to make quick decisions when they are experiencing negative mood states, as well as spend relatively less time thinking before acting in self-injurious ways to diminish the negative emotions. Therefore, for this at-risk group, intervention may involve teaching relaxation skills, constructive coping strategies, and decisionmaking skills (Miller, Muehlenkamp, & Jacobson, 2009). The present results show that Chinese adolescents with lower self-esteem and less social support were more likely to endorse various functions of NSSI, though neither self-esteem nor social support was a significant factor of C-FASM total score when other psychological factors were simultaneously considered. School-based interventions may promote adolescents’ self-awareness, self-esteem, and social support system through organizing workshops or extracurricular activities for them with different themes, such as assertiveness and communication skill training. The role of social support among Chinese adolescents who engage in NSSI should be further investigated in future


209



research because of inconsistent findings with previous research (e.g., Chen, 2006): social support was not significantly associated with NSSI behaviors and its autonomic negative reinforcement function (i.e., to remove negative feelings and tension) in the present study. However, Macao adolescents who reported better social support were less likely to endorse other functions of NSSI. Therefore, social support may play a major role in the intervention for adolescents who engage in NNSI because they appear to be influenced by social= interpersonal reinforcement of NSSI. In Macao, a large proportion of parents need to work on-shifts, which may negatively influence the amount and quality of the interaction with their children. Therefore, support from parents may be a potential focus in some NSSI intervention programs. A statistically significant gender difference in relation to the total DSHI score was found, with female respondents endorsing more items of the DSHI when compared to male respondents. Previous studies examining gender differences (e.g., Chen, 2006; Hawton, Rodham, Evans et al., 2002; Leong, 2002; Shek & Yu, 2012) have also observed that female Chinese adolescents tend to report more NSSI behaviors than their male counterparts. In some Chinese populations, skin cutting is also the most common method for those who engage in NSSI, and females tend to report cutting themselves with sharp objects at a relatively higher rate than males (Chen, 2006; Leong, 2002). In Macao culture, which is highly influenced by Chinese traditional gender roles, NSSI seems to be more socially ‘‘acceptable’’ for females because it is commonly perceived as a stress-related, avoidant, and attentionseeking behavior (Kim, 2010). The gender differences in NSSI behaviors in the present study may also be associated with female adolescent respondents experiencing more negative moods and higher impulsivity than males. However, no

210

significant gender differences were found in relation to the C-FASM scores, that is, male and female Chinese adolescents possessed similar perceptions toward functions of NSSI. This would indicate that regardless of differences in engagement in NSSI, and traits associated with gender, both genders engaged in NSSI for similar reasons. Limitations and Future Research

The present findings should be interpreted with caution because of two major limitations of the present study design. First, the homogeneity of the sample of this study may limit the generalizability of the findings. The current sample included only a community sample of junior high school students recruited by convenience sampling, which thus might not be representative of the general adolescent group in Macao. Future studies are suggested to assess the psychometric properties of the C-FASM with junior and senior high school samples by random sampling. Clinical samples can also be included to examine the discriminant validity of the C-FASM. Second, since the 21 items of C-FASM contained functions of NSSI perceived and reported by respondents in the West, they may not exhaustively represent the NSSI functions perceived by Chinese people, who may engage in NSSI due to some indigenous reasons in Chinese culture or local context. It is suggested that exploratory procedures, such as focus groups, should be conducted if a more Chinese-specific instrument for functions of NSSI is being developed. However, the C-FASM allows a more direct comparison with the research findings resulting from other language versions of the FASM. In conclusion, the present study showed that the C-FASM has adequate psychometric properties and has demonstrated preliminary reliability and validity when used to measure the NSSI functions perceived by Chinese adolescents. It is



suggested that the C-FASM is suitable for assessing NSSI functions among nonclinical Chinese adolescents, but the subscales independently should be used with caution. The C-FASM may be able to help the clinician to understand the reasons why Chinese adolescents engage in NSSI and to provide suitable interventions for NSSI.


AUTHOR NOTE

Choi Hong Leong, University of Macau, Macao SAR, China. Anise M. S. Wu, University of Macau, Macao SAR, China. Mary Man-yee Poon, University of Macau, Macao SAR, China. Correspondence concerning this article should be addressed to Anise M. S. Wu, Department of Psychology, Faculty of Social Sciences, University of Macau, Macao SAR, China. E-mail: [email protected] REFERENCES Briere, J., & Gil, E. (1998). Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry, 68, 609–620. Carli, V., Jovanovic´, N., Podlesek, A., Roy, A., Rihmer, Z., Maggi, S., . . . Sarchiapone, M. (2010). The role of impulsivity in self-mutilators, suicide ideators and suicide attempters—A study of 1265 male incarcerated individuals. Journal of Affective Disorders, 123, 116–122. Chen, Y. W. (2006). Environmental factors associated with self-mutilation among a community sample of adolescents. Formosa Journal of Mental Health, 19, 95–124. (In Chinese) Cloutier, P., Martin, J., Kennedy, A., Nixon, A. K., & Muehlenkamp, J. J. (2010). Characteristics and co-occurrence of adolescent non-suicidal selfinjury and suicidal behaviours in pediatric emergency crisis services. Journal of Youth and Adolescence, 39, 259–269. Coney, S. L. (2007). The development of self-injury self-report measure. ProQuest Dissertations and Theses 2008.

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Predicting suicide attempts by time-varying frequency of nonsuicidal self-injury among Chinese community adolescents.

Functions of nonsuicidal self-injury: exploratory and confirmatory factor analyses in a large community sample of adolescents.

Predicting Persistence of Nonsuicidal Self-Injury in Suicidal Adolescents.

Measurement equivalence of the language-brokering scale for Chinese American adolescents and their parents.

The Construct and Measurement of Perceived Risk of Nonremunerated Blood Donation: Evidence from the Chinese Public.

[Developing Perceived Competence Scale (PCS) for Adolescents].

Facial emotion recognition in adolescents with nonsuicidal self-injury.

Alexithymia, impulsiveness, and psychopathology in nonsuicidal self-injured adolescents.

An apparatus for indirect measurement of perceived distance.

The role of interpersonal conflict and perceived social support in nonsuicidal self-injury in daily life.

Perceived change of self among adolescents.

Perceived problems with computer gaming and internet use among adolescents: measurement tool for non-clinical survey studies.

Reaction-time procedure for measurement of hearing. I. Suprathreshold functions.

Reaction-time procedure for measurement of hearing. II. Threshold functions.

Psychiatric and self-injury profiles of adolescent suicide attempters versus adolescents engaged in nonsuicidal self-injury.

Chinese Migrant Adolescents' Perceived Discrimination and Psychological Well-Being: The Moderating Roles of Group Identity and the Type of School.

Frequency of Nonsuicidal Self-Injury in Adolescents: Differences in Suicide Attempts, Substance Use, and Disordered Eating.

Effects of perpetrator identity on suicidality and nonsuicidal self-injury in sexually victimized female adolescents.

A longitudinal moderated mediation model of nonsuicidal self-injury among adolescents.

Measurement of surface plasmon autocorrelation functions.

Proposed Diagnostic Criteria for the DSM-5 of Nonsuicidal Self-Injury in Female Adolescents: Diagnostic and Clinical Correlates.

Risk for suicidal ideation and attempt among a primary care sample of adolescents engaging in nonsuicidal self-injury.

Adolescents' alcohol use related to perceived norms.

Psychobiological response to pain in female adolescents with nonsuicidal self-injury.