Journal of Affective Disorders 295 (2021) 63–71

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Different profiles with multiple risk factors of nonsuicidal self-injury and

their transitions during adolescence: A person-centered analysis
Qianqian Gao a, Jiaqi Guo a, Huijiao Wu a, Jialing Huang a, Nini Wu b, Jianing You a, *
a
Center for Studies of Psychological Application, Guangdong Key Laboratory of Mental Health and Cognitive Science, Key Laboratory of Brain, Cognition and Education
Sciences (South China Normal University), Ministry of Education, & School of Psychology, South China Normal University, Guangzhou, 510631, PR China
b
Department of Psychology, School of Education, Guangdong University of Education, No.351 XinGangZhong Road, 510303 Guangzhou, PR China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Nonsuicidal self-injury (NSSI) is a serious public health concern among adolescents. However, ad­
Nonsuicidal self-injury olescents with different combinations of NSSI risk factors may constitute different subgroups that vary in sub­
Risk factors sequent risks of NSSI engagement, and the membership in these subgroups may change during early adolescence.
Profiles and transitions
Gender differences related to risk profiles and transition patterns may also exist. This study thus aimed to address
Gender differences
these three questions.
Person-centered approaches
Chinese early adolescents Methods: A total of 2,942 participants ranging from 12 to 17 years old (55.2% females; Mage = 14.60, SD = 1.21)
completed a series of questionnaires about NSSI and its risk factors on three occasions, every six months. Latent
profile and latent transition analyses were used to examine NSSI risk profiles (subgroups), their transition pat­
terns, and gender differences.
Results: Three distinct risk profiles were identified: Low-risk profile, Medium-risk profile, and High-risk profile.
The profile membership was fairly stable over one year, and the shift across profiles represented a “resilient”
pattern. Regarding gender differences, boys were less likely to be in either the Medium- or the High-risk groups,
but more likely to transition from the Medium- to the Low-risk group, relative to girls.
Limitations: This study relied upon self-report measures. Additional research is needed to investigate the
generalizability of the results to other populations, and to examine more predictors of class membership and
transitions.
Conclusions: The results highlight the importance of considering subgroup differences in understanding NSSI
risks. Differentiated interventions with multi-pronged approaches tailoring to different risk classes and gender
groups may therefore prove more efficient and effective.

1. Introduction 2018). In light of these challenges, a better understanding of NSSI risk

Nonsuicidal self-injury (NSSI), defined as the deliberate, direct, and
culturally sanctioned destruction of body tissue in the absence of sui­
cidal intent (Nock, 2010), has become a widespread public health
problem. It can not only incur personal, economic, and social costs, but
also increase the likelihood of future suicide attempts (You and Lin,
2015). Notably, adolescence is a high-risk period for NSSI engagement
(Dahl et al., 2018), and the lifetime prevalence of NSSI among com­
munity adolescents is 17.2% worldwide (Swannell et al., 2014). In
China, NSSI is also a prevalent phenomenon among adolescents, with
the 12-month incidence rates ranging from 17.0% to 29.2% (Tang et al.,
factors is of great importance to inform prevention and treatment of such
behaviors.
Previous studies have identified independent risk factors of NSSI
(Brown and Plener, 2017). These factors include distal, general predis­
posing, and specific vulnerability factors. Yet, little is known about how
all of those risks work together to impact NSSI and how their effects
might vary across different subpopulations. Furthermore, given the
occurrence of a broad range of psychosocial, biological, and environ­
mental changes in early adolescence, this period may be characterized
by significant fluctuations in psychopathological symptoms (Sontag
et al., 2011). Thus, it is important to examine whether the profiles or

* Corresponding author at: School of Psychology, South China Normal University, Guangzhou, 510631, PR China.
E-mail addresses: 17865526786@163.com (Q. Gao), gjqm77@163.com (J. Guo), 706576925@qq.com (H. Wu), 961120124@qq.com (J. Huang), nini713@126.
com (N. Wu), youjianing@gmail.com (J. You).

https://doi.org/10.1016/j.jad.2021.08.004
Received 4 June 2021; Received in revised form 2 August 2021; Accepted 3 August 2021
Available online 8 August 2021
0165-0327/© 2021 Elsevier B.V. All rights reserved.
Q. Gao et al.
subgroups observed vary during this critical developmental period. The
aim of this study, therefore, is to explore the potentially distinct risk
profiles contributing to NSSI and the transitions of the profiles over time
among Chinese early adolescents. While both girls and boys are exposed
to the same risk factors, NSSI appears to be a more severe behavior in
girls characterized by higher engagement in NSSI and higher longitu­
dinal stability. Thus, this study will also investigate how gender may be
related to the risk profiles and their transitions.
1.1. The multiple risk factors of NSSI
According to the integrated theoretical model proposed by Nock
(2010), NSSI is caused by the complex interplay of multiple risk factors.
Distal risks, general predisposing risks, and specific vulnerability risks
jointly affect the onset and continuity of NSSI. Distal risk factors include
familial hostility and genetic predisposition for high emotional reac­
tivity. The link between the invalidating relationships with parents in
childhood and later self-injury has been extensively supported (Bureau
et al., 2010; Martin et al., 2011). For example, adolescents with a history
of NSSI reported perceiving their parents as being more intrusive and
expressing more criticism compared to those without NSSI (Ammerman
and Brown, 2018). Beyond the familial risks, emotional reactivity is also
a strong distal predictor of NSSI in adolescence (Dawkins et al., 2019).
General predisposing factors for NSSI comprise both intrapersonal
and interpersonal factors, just mapping onto the intrapersonal and
interpersonal functions of this behavior. On the one hand, previous work
has demonstrated that intrapersonal functions, mainly referring to the
emotion-regulation functions, are endorsed by the majority of adoles­
cents with NSSI (Klonsky et al., 2015). Negative emotions have been
identified as particularly salient triggers of NSSI (Boyes et al., 2020). So
does the ability to tolerate the distress arising from the negative
emotional experiences (Slabbert et al., 2018). On the other hand,
interpersonal functions, such as escaping from social situations and
eliciting attention, are also endorsed by a substantial portion of ado­
lescents (Turner et al., 2016). Thus, relationship disturbance is also
regarded a precursor to NSSI. Substantial studies have shown that
relationship disturbance is negatively associated with NSSI both
concurrently and longitudinally (Brickman et al., 2014; You et al.,
2012).
With regard to the NSSI-specific vulnerability factors, self-criticism
and impulsivity, stemming from the self-punishment and pragmatic
hypotheses respectively, are especially important. Self-critical cogni­
tions are concomitantly and prospectively associated with NSSI (Burke
et al., 2021; Xavier et al., 2016), and self-punishment was among the
primary reasons those who had NSSI gave for engaging in this behavior
(Nock and Prinstein, 2004). Besides, NSSI has also long been considered
an impulse control problem. Individuals who had NSSI are more likely to
engage in other impulsive behaviors, such as aggressive behavior (Claes
et al., 2015). A meta-analysis has revealed that individuals who engaged
in NSSI self-reported greater impulsivity than those who did not, and
these differences were most pronounced for negative urgency, a facet of
impulsivity (Hamza et al., 2015).
Taken together, these studies indicate the key role distal risks (i.e.,
parental hostility and emotional reactivity), general predisposing risks
(i.e., negative emotions, distress intolerance, and relationship distur­
bance), and specific vulnerability risks (i.e., self-criticism and negative
urgency) play in NSSI development, and these risk factors would be
included in the present study.
1.2. Profiles of NSSI risks and transitions related to the risk profiles
While ample research have established the relationships of these risk
factors to the engagement in NSSI, the majority of them have only
focused on the effects of a single risk factor or at the most two-factor
interactions. However, these multiple risks may be interrelated and
work together in NSSI. In the developmental psychopathology
64
Journal of Affective Disorders 295 (2021) 63–71
framework of self-injurious behavior, Yates (2004) proposed that
adverse childhood experience (e.g., parental hostility) undermines
positive adaption at emotional, attitudinal, and relational levels of
competence. Specifically, an invalidating environment may deprive the
child’s opportunity of learning adaptive emotion regulation methods
and render her/him internalize a negative self-image. Moreover, an
invalidating environment may also compromise the child’s relational
competence by distorting the sense of self–other boundaries. Thus, it
seems necessary to investigate the combined effect of these multiple risk
factors in understanding adolescent NSSI.
To data, only a very limited number of studies considered the
simultaneous effects of multiple risk factors on NSSI, and they usually
used the cumulative risk index approach (Evans et al., 2013). For
instance, Bedi et al. (2014) calculated a cumulative risk index by sum­
ming up the scores of six internal risk factors, and this index predicted
the frequency of deliberate self-harm. Such studies, however, still suf­
fered the limitation of relying primarily on the variable-centered ap­
proaches, assuming homogeneity in adolescents (Howard and Hoffman,
2018). But in fact, adolescents with multiple risk factors are heteroge­
neous (Lanza et al., 2010).
In such a case, scholars have called for studies using the person-
centered approach to examine the multiple risk profiles of psychopa­
thology (Bergman and Lundh, 2015; Bogat et al., 2016). A commonly
applied person-centered approach, the latent profile analysis (LPA),
presents an opportunity to address some limitations inherent to the
variable-centered approach. LPA is designed to identify mutually
exclusive latent profiles derived from a set of observed continuous in­
dicators (Peugh and Fan, 2013). Using this method, Li et al. (2017)
identified four distinct risk profiles (i.e., Low Risk, Medium Risk, High
Risk, and Peer Risk) based on 14 risk factors (e.g., low parental moni­
toring) across family, school, peer, and individual domains, and found
that these risk profiles predicted differential individual propensities of
internet addiction. Similarly, Newcomb-Anjo et al. (2017) identified
four patterns of risk (i.e., Low Risk, Low Social Support Risk, Financial
Risk, and Multiple Risk) for compromised wellbeing. Several studies of
NSSI have also used this approach (Case et al., 2020; Somer et al., 2015),
but they derived the profiles from the manifestations of NSSI itself, and
thus are not helpful for the prediction of at-risk adolescents. To address
this significant gap, this study employed the LPA to identify the distinct
subgroups of adolescents with multiple NSSI risk factors, and to examine
how these identified risk profiles related to actual NSSI engagement.
In addition, we would like to explore whether the risk profiles vary
over time. Early adolescence is an important transition period when
adolescents experience frequent psychosocial, biological, and environ­
mental changes. All these changes may contribute to changes in mental
health outcomes (Blum et al., 2014). The previous studies based on both
negative indicators (e.g., emotion distress) and positive indicators (e.g.
life satisfaction) had identified four mental health subgroups in ado­
lescents: Flourishing (i.e., low psychopathology and high well-being),
Vulnerable (i.e., low psychopathology and low well-being), Symptom­
atic but content (i.e., high psychopathology and high well-being), and
Troubled (i.e., high psychopathology and low well-being) groups
(Moore et al., 2019; Zhou et al., 2020). These studies examined the
stability and transitions of the mental health groups and suggested that
patterns of instability were evident among all groups, with the Troubled
group exhibiting the lowest levels of stability over one year. Thus, we
would use the latent transition analysis – a longitudinal extension of LPA
–to examine the instability of membership in the identified risk profiles.
1.3. Gender differences in risk profiles and transitions
Gender differences exist in relation to NSSI. In general, girls are more
likely to engage in NSSI than boys (Sornberger et al., 2012). The
engagement in NSSI is also more stable in girls than in boys (Wang et al.,
2017). These gender differences may be accounted for by two reasons.
One explanation may involve the hormone differences between genders.
Q. Gao et al.
For example, estradiol increases at pubertal onset appears to increase
girls’ vulnerability to the development of internalizing problems (Balzer
et al., 2015; Rutter et al., 2003). Another explanation may involve the
gender differences in emotion regulation. Specifically, girls tend to use
more self-focused thinking (e.g., rumination) and more passive re­
sponses to their emotions (e.g., NSSI) than boys (Nolen-Hoeksema,
2012). However, little is known about how the subgroups based on
multiple risks and the membership transitions across groups vary be­
tween girls and boys. Thus, this study will investigate the gender dif­
ferences related to the risk profiles and transitions of the profiles.
1.4. The current study
This study has three aims. The first aim is to identify distinct risk
profiles based on a combination of distal, general predisposing, and
specific vulnerability risks using the person-centered approach, and to
examine whether these risk profiles differentially relate to later NSSI.
We expect to identify at least two profiles: one characterized by rela­
tively low levels of all risk factors and the other characterized by rela­
tively high levels of all risk factors. We also hypothesize that adolescents
within the high-risk profile report higher probability for NSSI engage­
ment than those in the low-risk profile. The second aim is to characterize
the development of the identified risk profiles. We hypothesize that
variability will exist in all identified risk profiles, and the high-risk
profile will be more unstable. The third aim is to explore the gender
differences in the profiles and transitions. We hypothesize that the high-
risk group will include a higher probability of girls, and that girls will be
less likely than boys to transition from the high- to the low-risk group.
2. Method
2.1. Participants
Participants were recruited from eight secondary schools in Hong
Kong and were surveyed semiannually for three times (for the full
recruitment details see You et al., 2016). All testing materials and the
procedures were approved by the ethical board of the Chinese University
of Hong Kong and the participating schools’ authorities. At Time 1 (T1),
5,423 students aged between 12 and 17 years (52.7% females; Mage =
14.63 years, SD = 1.25) participated. Overall student participation rates
were close to 99 % in all schools. We re-assessed the Time 1 sample after
a 6-month (Time 2) and a 12-month (Time 3) interval, respectively. At
Time 2 (T2), 6,911 adolescents (52.6% females) participated, and 3,999
(55.4% females) of them were retained from the T1 sample. At Time 3
(T3), 6,831 adolescents (52.6% females) were included. Overall, we
successfully followed 3,600 adolescents over the three waves. Attrition
was mainly due to students transferring to other schools or being absent
from school on the day of assessment. The Missing Completely at
Random test (Little, 1988) was conducted, and results (a normed χ 2/df
of 1.09) indicated that the missing of data was a random pattern (Bollen,
1989).
We removed 658 adolescents who had engaged in NSSI at T1, so that
the prospective relationship between the risk profiles and the occurrence
of NSSI could be examined. Finally, 2,942 adolescents (55.2% females;
Mage = 14.60 years, SD = 1.21) were included in the analyses.
2.2. Measures
2.2.1. Nonsuicidal self-injury (NSSI)
Seven NSSI behaviors, i.e., self-cutting, burning, biting, punching,
scratching skin, inserting objects into the nail or skin, and banging the
head or other parts of the body against the wall, were assessed in this
study. These behaviors were selected because they were found to be
relatively common among adolescents (Nock, 2010) and displayed good
psychometric properties in previous studies (You and Lin, 2015). At T1,
participants were asked, “In the past 12 months, have you engaged in the
65
Journal of Affective Disorders 295 (2021) 63–71
following behaviors to deliberately harm yourself but without suicidal
intent?” At T2 and T3, the period for assessing NSSI was the past 6
months. All seven items were rated on a 4-point scale ranging from 1 =
never to 4 = six times or more. To facilitate interpretation, this variable
was re-coded into a dichotomous variable that classified participants as
having engaged in NSSI or not. The Cronbach’s alphas were 0.72 and
0.75 for the T2 and T3 data, respectively.
2.2.2. Parental hostility
The 10-item Hostile/Coercive subscale of Parent Behavior Inventory
(PBI; Lovejoy et al., 1999) was used to assess perceived parental hostility
(e.g., “My parents spank or use physical punishment with me”). Re­
sponses were made on a 6-point scale ranging from 1 = never to 6 =
always. The total score was calculated with higher scores indicating
more perceived parental hostility. This scale has demonstrated good
reliability and validity among Chinese adolescents (You et al., 2017).
The Cronbach’s alpha value was 0.88 for all three waves.
2.2.3. Emotional reactivity
Emotional reactivity was assessed by the 21-item Emotion Reactivity
Scale (ERS; Nock et al., 2008), which has demonstrated good reliability
and validity with Chinese adolescents (Liu et al., 2020). It has three
subscales: sensitivity (10 items; e.g., “I tend to get emotional very
easily”), intensity (7 items; e.g., “When I experience emotions, I feel
them strongly”), and persistence (4 items; e.g., “When I am upset, it
takes me much longer than most people to calm down”). Responses were
made on a 5-point Likert scale, ranging from 1 = not at all like me to 5 =
completely like me. A total score was calculated with higher scores indi­
cating higher levels of emotional reactivity. The Cronbach’s alphas were
0.96, 0.96 and 0.97 at T1, T2, and T3, respectively.
2.3.4. Negative emotions
The Chinese version of the short Depression Anxiety Stress Scale
(DASS21; Taouk et al., 2001) was used to assess the three common
negative emotions: depression (7 items; e.g., “I couldn’t seem to expe­
rience any positive feelings at all”), anxiety (7 items; e.g., “I find myself
getting agitated”), and stress (7 items; e.g., “I find it difficult to relax”).
Participants responded on a 4-point scale ranging from 0 = do not apply
to me at all to 3 = applies to me very much or most of time. The sum of the
21 items was taken, with a higher score indicating higher levels of
negative emotions. The DASS-21 has demonstrated high internal con­
sistency and adequate test-retest reliability (Zhang et al., 2017). In this
study, the Cronbach’s alphas were 0.93, 0.94, and 0.94 for the T1, T2,
and T3 data, respectively.
2.3.5. Distress intolerance
Distress intolerance was measured by the 15-item Distress Tolerance
Scale (DTS; Simons and Gaher, 2005). The scale included four subscales:
tolerance (3 items; e.g., “Feeling distressed or upset is unbearable to
me”), absorption (3 items; e.g., “My feelings of distress are so intense
that they completely take over”), appraisal (6 items; e.g., “My feelings of
distress or being upset scare me”), and regulation (3 items; e.g., I’ll do
anything to avoid feeling distressed or upset”). Participants responded
on a 5-point Likert scale, ranging from 1 = strongly disagree to 5 =
strongly agree. The sum of the 15 items was taken, with item 6 reverse
scored. This scale has proved to be suitable for Chinese adolescents
(Kang et al., 2018). The Cronbach’s alphas were 0.91, 0.93 and 0.94 at
T1, T2, and T3, respectively.
2.3.6. Relationship disturbance
A 7-item scale extracted from the Revised Diagnostic Interview for
Borderlines (DIB-R; Zanarini et al., 1989) was used to assess relationship
disturbance (e.g., “My relationship with other people are very unsta­
ble”). Participants indicated their responses to each item on a 4-point
scale, ranging from 1 = strongly disagree to 4 = strongly agree. A total
score was calculated with higher scores indicating higher levels of
Q. Gao et al. Journal of Affective Disorders 295 (2021) 63–71

relationship disturbance. This scale has demonstrated good validity

23.35
among Chinese adolescents (Ren et al., 2018). In this study, its Cron­

6.33
21
bach’s alphas were 0.85, 0.84, and 0.86 at T1, T2, and T3, respectively.

–
29.88
10.29
0.48
2.3.7. Self-criticism

20

–
The self-critical thinking style was measured by the 9-item Self-
Criticism subscale of the Depressive Experiences Questionnaire (DEQ;

13.02
0.60
0.55

4.12
Blatt et al., 1976). A sample item is “I often find that I don’t live up to my

19

–
own standards or ideals”. Participants responded on a 7-point Likert

34.58
10.61
scale, ranging from 1 = not at all like me to 7 = like me very much. A total

0.59
0.60
0.58
18
score was calculated with item 9 reverse scored. Demonstrating good

–
reliability and validity, this scale has been widely used in studies with

0.54
0.48
0.61
0.46
8.50
9.03
Chinese adolescents (Gong et al., 2019). The Cronbach’s alphas were

17

–
0.86, 0.88, and 0.89 at T1, T2, and T3, respectively.

44.81
17.43
0.60
0.71
0.65
0.63
0.57
16
2.3.8. Negative urgency

–
The 12-item Negative Urgency subscale of the UPPS Impulsive

18.25
0.27
0.40
0.25
0.26
0.34
0.20

7.64
Behavior Scale (Whiteside and Lynam, 2001) was administrated to the

15

–
participants. A sample item is “I have trouble controlling my impulses”.
Responses were made on a 4-point scale ranging from 1 = strongly

23.06
0.20
0.46
0.38
0.45
0.45
0.42
0.53

6.45
disagree to 4 = strongly agree. The sum scores, with higher scores indi­

14

–
cating higher levels of negative urgency, were used in the analyses.

30.51
10.21
Previous studies have supported its reliability and validity within Chi­

0.54
0.25
0.48
0.46
0.45
0.44
0.63
0.37
13
nese adolescents (You et al., 2016). In this study, the Cronbach’s alphas

–
were 0.85, 0.89, and 0.94 at T1, T2, and T3, respectively.

12.17
0.56
0.58
0.25
0.46
0.40
0.40
0.54
0.42
0.39

4.05
12

–
2.3. Analytic strategy

35.12
11.53
0.59
0.58
0.56
0.25
0.48
0.44
0.52
0.42
0.44
0.38
11

Data analyses using Mplus version 7.2 (Muthén and Muthén, 2017)

–
were proceeded in three stages corresponding to the three research aims.

10.66
In the first stage, a series of latent profile models were run separately for

0.53
0.51
0.63
0.53
0.26
0.48
0.60
0.44
0.41
0.51
0.39

9.98
10

–
each wave’s data. In order to facilitate interpretation, all raw scores of
indicator variables were converted into Z scores. To determine the

38.04
15.84
0.69
0.57
0.57
0.58
0.57
0.27
0.59
0.54
0.46
0.46
0.47
0.42
optimal number of latent profiles, we considered both multiple com­
9

plementary fit indices and substantive interpretation of the profiles –

22.21
(Collins and Lanza, 2009). Evaluation criteria includes: a) Low Bayesian
0.37
0.37
0.31
0.31
0.36
0.27
0.58
0.24
0.26
0.22
0.25
0.29
0.18

8.35
Information Criterion (BIC) and Sample-Size Adjusted BIC (aBIC); b)
8

significant Lo-Mendell-Rubin Likelihood Ratio Test (LMR-LRT); c) high

24.85
0.14
0.35
0.32
0.35
0.34
0.31
0.47
0.12
0.38
0.27
0.36
0.34
0.31
0.47

5.60
Entropy (> .80); and d) appropriate class proportions (> 5.0%). After
7

identifying the best latent profile solution for each wave’s data, we used
the Block-Croon-Hagenaars (BCH) approach to examine the association

33.28
0.46
0.22
0.39
0.43
0.37
0.34
0.53
0.36
0.19
0.36
0.32
0.34
0.33
0.50
0.32

9.31
between profiles and the probabilities of adolescents engaging in NSSI at
6

T2 and T3 (Asparouhov and Muthén, 2014).

12.79
In the second stage, an LTA was conducted with the data of all three
0.48
0.46
0.21
0.43
0.40
0.39
0.51
0.39
0.42
0.17
0.42
0.34
0.35
0.47
0.36
0.37

4.15
waves combined, examining if and how membership of each group
5

changed across waves (Nylund-Gibson et al., 2014). The latent profile 37.52
10.39
0.43
0.47
0.46
0.17
0.35
0.32
0.50
0.34
0.34
0.34
0.15
0.36
0.30
0.41
0.31
0.29
0.28

variables (C) were regressed onto the same variables from the previous
4

time points (i.e., C3 on C2, C3 on C1, and C2 on C1), and the transition
Descriptive statistics for all indicator variables (N = 2,942).

probabilities were estimated to describe the degree of stability of NSSI

12.01
10.08
0.43
0.50
0.55
0.44
0.22
0.46
0.56
0.38
0.33
0.41
0.38
0.17
0.38
0.47
0.36
0.32
0.39
0.34

risk over time.

3

Note. All correlations are significant at p < .01 level.

In the third stage, we examined how gender was related to the latent
41.58
16.73

profiles at T1, T2, and T3. We also examined how gender was related to
0.65
0.44
0.46
0.50
0.50
0.22
0.56
0.46
0.40
0.38
0.38
0.42
0.18
0.49
0.41
0.38
0.37
0.37
0.36

the probabilities of transitioning between the latent profiles in T1 and

2

those in T2 and T3, and between the profile in T2 and that in T3. The
23.61
0.30
0.30
0.23
0.30
0.31
0.19
0.57
0.24
0.24
0.20
0.23
0.24
0.20
0.47
0.19
0.23
0.17
0.20
0.26
0.15

8.90

inclusion of gender in LCA and LTA models was conducted using logistic
1

regression analysis.
12. Relationship Disturbance (T2)

19. Relationship Disturbance (T3)

5. Relationship Disturbance (T1)

3. Results
11. Distress Intolerance (T2)

18. Distress Intolerance (T3)

16. Emotion Reactivity (T3)
10. Negative Emotions (T2)

17. Negative Emotions (T3)

4. Distress Intolerance (T1)
2. Emotion Reactivity (T1)

9. Emotion Reactivity (T2)

14. Negative Urgency (T2)

21. Negative Urgency (T3)

3. Negative Emotions (T1)

15. Parental Hostility (T3)

7. Negative Urgency (T1)
1. Parental Hostility (T1)

8. Parental Hostility (T2)

Descriptive statistics, including correlation matrix, means (M) and

13. Self-criticism (T2)

20. Self-criticism (T3)

6. Self-criticism (T1)

standard deviations (SD), for all indicator variables were presented in

Table 1. In the current sample, the proportion of adolescents reporting
having engaged in NSSI was 6.7% (n = 196) at T2 and 3.9% (n = 116) at
T3. Among the participants who have engaged in NSSI, the most prev­
Variable
Table 1

alent method was biting at T2 (n = 69, 2.3%) and cutting at T3 (n = 52,

SD
M

1.8%). In addition, 2.8 % (n = 83) of adolescents at T2 and 1.4% (n = 41)

66
Q. Gao et al.
of adolescents at T3 used more than one method to injure themselves.
3.1. Latent profile solution
As shown in Table S1 (see Supplementary Material), we estimated
solutions including 2-5 profiles at each time point. Results indicated that
the 3-class solution was the most appropriate. At T1, although the values
of BIC and aBIC decreased with each additional class, a relative leveling
off occurs after the three-profile model. Furthermore, the LMR-LRT p-
values for the 4- and 5- class models were not significant (p > 0.01), and
the entropy of the 3-class model was greater than those of the 4- and 5-
class models. Similarly, at T2 and T3, the 3-class model was also the
most appropriate.
Fig. 1 presents the estimated mean plots for the final 3-class solu­
tions. Although varying slightly in indicator means over time, the three
Fig. 1. Latent profiles of NSSI risk by wave. PH = perceived parental hostility;
ER= emotional reactivity; NE = negative emotions; DI = distress intolerance;
RD = relationship disturbance; SC = self-criticism; NU = negative urgency.
67
Journal of Affective Disorders 295 (2021) 63–71
classes maintained a substantively similar pattern across the three
waves. Profile 1 reflected a Low-risk profile, consisting of individuals
with the lowest means on parental hostility, emotional reactivity,
negative emotions, distress intolerance, relationship disturbance, self-
criticism, and negative urgency. This profile increased in size from T1
to T2, and then decreased from T2 to T3 (35.8%, 41.8%, and 33.9% at
T1, T2, and T3, respectively). In contrast, Profile 2 reflected a High-risk
profile, consisting of individuals with the highest means on all risk fac­
tors, especially on negative emotions. This profile included 15.4%,
14.1%, and 17.0% of the participants at T1, T2, and T3, respectively.
Profile 3 reflected a Medium-risk profile that displayed moderate levels of
all risk factors. This profile was the largest across waves, comprising
48.8%, 44.1%, and 49.1% of the samples at T1, T2, and T3, respectively.
3.2. Risk profiles and NSSI
We examined the associations between the identified risk profiles
and adolescent NSSI. As shown in Table 2, there were significant dif­
ferences in the probability of NSSI across the multiple risk profiles for
each time point. Post-hoc tests demonstrated that the High-risk groups
showed higher probability of NSSI than the Medium- and the Low-risk
groups; and the Medium-risk groups showed higher probability of
NSSI than the Low-risk groups.
3.3. Changes in profile membership over time
The three-wave first-order and second-order LTA was conducted to
investigate changes in adolescents’ profile membership. Table 3 presents
the three transition probability matrices generated by this procedure:
one for the T1 to T2 transition, one for the T1 to T3 transition, and one
for the T2 to T3 transition. As shown, from T1 to T2 and T1 to T3, the
Low-risk group showed the highest stability, followed by the Medium-
risk group and the High-risk group. From T2 to T3, the Medium-risk
group showed the highest stability, followed by the Low-risk group
and the High-risk group.
Of those who exhibited instability from T1 to T2 and T1 to T3, ad­
olescents initially fitting a Low-risk group all transitioned to the
Medium-risk group. Adolescents fitting a Medium-risk group were more
likely to transition to the Low-risk group than to the High-risk group.
Among adolescents who transitioned out of the High-risk group, most of
them transitioned into the Medium-risk group, followed by the Low-risk
group.
Regarding the instability from T2 to T3, similarly, adolescents in the
Low-risk group all transitioned to the Medium-risk group. Also, ado­
lescents in the High-risk group were more likely to transition to the
Medium-risk group than to the Low-risk group. However, if adolescents
transitioned out of the Medium-risk group, they were more likely to
transition to the High-risk than to the Low-risk group.
Table 2
Proportion of adolescents within each groups reporting NSSI at T2 and T3.
Latent status T2 T3
a
T1 Low-risk 0.02 0.02a
Medium-risk 0.07b 0.03a
High-risk 0.16c 0.10b
T2 Low-risk 0.02a 0.02a
Medium-risk 0.06b 0.04b
High-risk 0.22c 0.11c
T3 Low-risk – 0.01a
Medium-risk – 0.04b
High-risk – 0.11c
Note. Values with different superscripts are significantly different at the p < 0.05
level.
Q. Gao et al. Journal of Affective Disorders 295 (2021) 63–71

Table 3 scores on all indicators). The finding echoes those of prior studies
Unconditioned latent transition probability. showing that multiple psychosocial risk factors generally co-occur
T2 T3 (Buehler and Gerard, 2013; Copeland et al., 2009).
Low- Medium- High- Low- Medium- High-
risk risk risk risk risk risk 4.2. Risk profiles and NSSI
T1 Low-risk 0.81 0.19 0.00 0.68 0.32 0.00
Medium- 0.23 0.66 0.11 0.18 0.66 0.16
In order to validate the meaningfulness of the different risk profiles,
risk we examined how these risk profiles related to adolescents’ actual
High-risk 0.08 0.35 0.57 0.07 0.36 0.57 engagement in NSSI. In line with our hypothesis, adolescent NSSI can be
T2 Low-risk – – – 0.69 0.31 0.00 meaningfully predicted by their risk profile membership. Specifically,
Medium- 0.12 0.72 0.16
adolescents within the High-risk profile did report the highest proba­
– – –
risk
High-risk – – – 0.03 0.30 0.67 bility of NSSI at present or at a later time point. This finding provided
support for a cumulative risk perspective that high co-occurrence of risk
factors contributes to more negative outcomes relative to low occur­
3.4. Gender differences in profiles and transitions rence of risk factors (Evans et al., 2013). Notably, despite the fact that
adolescents within the Medium-risk profile did not display any obvious
Once the optimal class model had been identified for each time point, risk characteristic, they had relatively high probability of engaging in
this study examined whether the proportion of boys and girls differed NSSI. This finding is particular important because such groups might
across classes. As shown in Table 4, the logistic regression analysis have been overlooked in traditional problem-focused assessment sys­
revealed that boys were less likely to be in the Medium-risk group than tems in which individuals in these groups may be classified as “low risk”.
in the Low-risk group at T1, T2, or T3 (OR = 0.77, 0.65, and 0.71). Also, Taken together, these results highlight the usefulness of latent profile
boys were less likely than girls to be in the High-risk group at T2 or T3 analysis in understanding the patterns of risk and identifying adoles­
(OR = 0.78 and 0.69). cents who are most in need of targeted interventions (Lanza and Cooper,
In the final LTA model, gender was added as a covariate into the 2016).
logistic regression analysis. As shown in Table 5, gender differences only
occurred in the transition from T1 to T2 and T3. Boys in the Medium-risk 4.3. Transition patterns of risk profiles over time
profile at T1 were more likely than girls in the same profile to transition
to the low-risk profiles at T2 and T3 (OR = 2.41 and 1.70). Due to the dynamic nature of development during early adolescence,
it was expected that instability existed among all risk groups. Out of our
4. Discussion expectation, there was a high probability that adolescents remained in
the same groups over time. One explanation may be that some risk in­
Using the person-centered approaches with a longitudinal design dicators were relatively stable. For example, previous study had pro­
among Chinese early adolescents, the present study identified three posed that distress tolerance is a trait-like, temporally stable
heterogeneous groups (i.e., Low-risk group, Medium-risk group, and characteristic (Cummings et al., 2013). Another explanation may be that
High-risk group) of adolescents based on multiple risk factors of NSSI. one year is too short to capture the developmental changes. Additional
These groups had differential stabilities and unique transition patterns. research with much longer followed-up period is required to replicate
This study also found that genders were both differentially associated the results of the current study.
with profile membership and transitions among profiles. Partially in line with our hypothesis, however, significant transitions
among groups still occurred. Specifically, the High-risk group showed
the highest instability, with 33.0%-43.0% of adolescents transitioned
4.1. Multiple risk profiles out of this group. Such results were consistent with the previous studies
revealing the lowest over time stability of the Troubled group of mental
Overall, the latent profile analyses revealed the heterogeneity of health (characterized by high psychopathology and low well-being;
early adolescents based on multiple risks of NSSI. In particular, three Moore et al., 2019; Zhou et al., 2020). Notably, 30.0%-36.0% of ado­
distinct risk profiles were identified at each time point: Low-risk profile, lescents within the High-risk group transitioned into the Medium-risk
Medium-risk profile, and High-risk profile. Similar to those obtained group, and 3.0%-8.0% of them transitioned into the Low-risk group.
from a previous study (Li et al., 2017), this study found that the Moreover, 12.0%-23.0% of adolescents within the Medium-risk group
Medium-risk profile emerged as the most common profile. More transitioned into the Low-risk group. Such transition patterns may
importantly, results showed great consistency at levels of all risk factors represent a “resilient” developmental tendency (Clinton, 2008). At the
within the same profile (e.g., High-risk group had the highest mean same time, it should be cautioned that still a few adolescents
(11.0%-16.0%) in the Medium-risk groups transitioned into the
Table 4 High-risk group. Taken together, these findings offered continued sup­
Gender distribution within each risk profiles at T1, T2 and T3. port for the developmental heterogeneity of adolescents with NSSI risk.
a
Latent Status Number of Girls Number of Boys OR p

T1 Low-risk b
555 505 – –
4.4. Gender differences in risk profiles and transitions
Medium-risk 826 619 0.77 <0.001
High-risk 246 210 0.94 0.59 Regarding gender differences, girls were more likely to be in the
T2 Low-risk b 618 620 – – Medium- and High-risk groups and had higher stability. These results
Medium-risk 774 533 0.65 <0.001
provide further support for the finding that NSSI shows a marked female
High-risk 235 181 0.78 <0.05
T3 Low-risk b 500 511 – – preponderance (Bresin and Schoenleber, 2015). Several factors may
Medium-risk 838 612 0.71 <0.01 contribute to the gender differences. First, estrogen and progesterone
High-risk 289 211 0.69 <0.001 may delay girls’ ability to recover from stress (Zahn-Waxler et al., 2008).
Note. a Odd ratios reflect the gender differences on profiles distribution; OR < 1 Second, girls tend to experience more affect intensity and reactivity than
indicates boys have lower odds to be in the Medium- or High-risk groups than boys, because they are more aware of and attentive to their emotions
girls. (Nolen-Hoeksema and Aldao, 2011). Third, girls prefer to use more
b
Low-risk groups are served as the reference groups in logistic regression. internally focused responses to their emotions (Nolen-Hoeksema, 2012).

68
Q. Gao et al.
Table 5
Gender differences in the probabilities of transition between groups.
T2
Low-risk Medium-risk
T1 Low-risk – 1.11
Medium-risk 2.41*** – 1.44
High-risk 1.76 1.34
T2 Low-risk
Medium-risk
High-risk
Note. The values in the table are odd ratios (OR); OR > 1 indicates boys have higher odds of transitioning from the original group to that particular group than girls, and
OR <1 indicates boys have the lower odds of transitioning from the original group to that particular group than for girls.
The odds of remaining in the same group served as reference in logistic regression.
**p < 0.01, ***p < 0.001.
N/A = not available, because the proportion of adolescents who transitioned from Low- to High-risk group is too small to be analyzed.
Taken together, these biological, cognitive, and social-emotional char­
acteristics combined in adolescence leave girls more vulnerable than
boys to NSSI.
4.5. Implications
The results have important implications for interventions that aim to
reduce adolescent NSSI. First, the current study argues against the “one
size fits all” intervention approach, and encourages “this-approach-fits-
this-profile” interventions by using information about subgroup-specific
effects (Wang and Peck, 2013). Specifically, the adolescents in the
High-risk group should receive remedial interventions immediately.
Although some high-risk adolescents are likely to transition out of their
risk for NSSI, a significant proportion will not. Given that the highest
level of negative emotions are a major characteristic for the High-risk
group, dialectical behavior therapy (DBT) that includes
emotion-regulation skills training may be helpful (Fassbinder et al.,
2016). The current results also suggest that a multi-pronged approach
may be more effective than those targeting singular risk factors (Fox
et al., 2019). In addition to emotion-regulation skills training, school
professionals and parents should also consider teaching adolescents
support-seeking strategies and modifying their unreasonable cognitions
(e.g., self-critical cognition).
Second, given that quite a few adolescents transitioned into High-risk
group over time, screening the NSSI risk only once at entry into school,
as most schools do, is not able to follow the dynamic changes in NSSI
risk. It is of great necessity to periodically monitor the multiple risk
indicators and determine if these indicators have changed over time.
Third, despite that programs directed toward girls may be more efficient
in reaching larger groups of individuals who have engaged in NSSI
(Bresin and Schoenleber, 2015), boys may benefit more from interven­
tion programs than girls because they are more likely to transition out of
the Medium-risk group and into the Low-risk group.
4.6. Limitations and directions for further research
The current study has some limitations, leaving opportunities for
future research. First, it should be acknowledged that all the measures in
this study are self-reported and thus may be subject to respondent bias.
However, adolescents themselves may be the most reliable source when
it comes to reporting on their own experiences and feelings (Wu et al.,
2021). Second, the person-centered analyses depend to a larger degree
on specificities of the sample than variable-based approaches. Thus,
future studies should replicate the present findings to determine if
similar profiles would emerge in different cultural contexts using more
diverse samples. Third, beyond gender, the survey did not investigate
other determinants in the profiles and transitions. For example, what
factors differentiate the adolescents who were in the High-risk group at
T1 but transitioned to the Low-risk group from those adolescents in the
High-risk group at T1 and remained in the same group one year later?
69
Journal of Affective Disorders 295 (2021) 63–71
T3
High-risk Low-risk Medium-risk High-risk
N/A – 0.74 N/A
1.70** – 0.91
– 1.57 1.16 –
– 0.80 N/A
1.29 – 1.12
1.87 1.32 –
Thus, future researchers are advised to investigate more individual and
environmental characteristics that confer risk and resilience beyond
gender.
CRediT authorship contribution statement
Qianqian Gao: Conceptualization, Formal analysis, Writing – orig­
inal draft, Writing – review & editing. Jiaqi Guo: Data curation, Su­
pervision. Huijiao Wu: Data curation, Supervision. Jialing Huang:
Data curation, Supervision. Nini Wu: Writing – review & editing.
Jianing You: Data curation, Writing – review & editing.
Declaration of Competing Interest
All authors declare that they have no conflict of interest.
Role of the funding source
This research was supported by the National Natural Science Foun­
dation of China (Grant No. 31771228), the National Social Science
Foundation of China (Grant No. 19ZDA360), and the National education
sciences planning project (Grant No. CBA210235). The funders had no
role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Acknowledgments
This study was also supported by Research Center for Crisis Inter­
vention and Psychological Service of Guangdong Province, South China
Normal University and the base of psychological services and counseling
for “Happiness” in Guangzhou.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2021.08.004.
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