Original Study

A 6-year Longitudinal Study of Self-harm and Suicidal Behaviors

among Chinese Adolescents in Hong Kong
Ben M.F. Law PhD 1,*, Daniel T.L. Shek PhD, FHKPS, BBS, SBS, JP 2,3,4,5,6
1
Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, P.R. China
2
Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, P.R. China
3
Centre for Innovative Programmes for Adolescents and Families, The Hong Kong Polytechnic University, Hong Kong, P.R. China
4
School of Social Development, East China Normal University, Shanghai, P.R. China
5
Kiang Wu Nursing College of Macau, Macau, P.R. China
6
Division of Adolescent Medicine, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky College of Medicine, Lexington, Kentucky

a b s t r a c t
Study Objective: To examine the trajectories of self-harm and suicidal behaviors among Chinese adolescents in Hong Kong and to inves-
tigate the related predictors, including gender, family nonintactness, economic disadvantage, positive youth development, and family
functioning.
Design: We used quantitative data from a large sample of adolescent participants. Participants initially joined this study when they were in
grade 7 (wave 1), and they were followed from grade 8 (wave 2) to grade 12 (wave 6).
Setting, Participants, and Interventions: The participants consisted of 2023 grade 12 students from 28 secondary schools in Hong Kong.
A multistage cluster random sampling method was adopted.
Main Outcome Measures: Self-harm and suicidal behaviors.
Results: The trajectories of self-harm and suicidal behaviors in general declined from grade 7 to grade 12. Regarding the effect of gender,
whereas adolescent girls showed a higher prevalence for self-harm and suicidal behaviors at baseline and other waves, adolescent boys
showed a pronounced decline in self-harm rates. Adolescents from nonintact families were more likely to self-harm or engage in suicidal
behaviors at wave 6. Economic disadvantage at wave 4 predicted higher suicidal behavior among adolescents but not self-harm at wave 6.
Regarding positive youth development, several protective factors that include cognitive-behavioral competencies, prosocial attributes,
general positive youth development qualities, and positive identity could help reduce self-harm and suicidal behaviors at different time
points. Regarding the role of family functioning, more family conflicts predicted higher suicidality in adolescence (self-harm and suicidal
behaviors), and family communication affected self-harming behaviors at wave 6.
Conclusion: The trajectories of self-harm and suicidal behaviors decline from early to late adolescence among Chinese adolescents. Positive
youth development and constructive family functioning are critical to help reduce suicidal behaviors. Regarding increased risk, more
attention should be paid to adolescent girls and adolescents from nonintact and economic disadvantaged families.
Key Words: Self-harm, Suicide, Chinese adolescents, Positive youth development, Family functioning, Developmental trajectory

Introduction of actual suicide attempt ranges from 3.2% to 7.5%, and 1

In this study we explored the trajectories of self-harm
and suicidal behaviors among Chinese adolescents in Hong
Kong on the basis of a large-scale, 6-year longitudinal study.
Predictors that include gender, family nonintactness, eco-
nomic disadvantage, positive youth development, and family
functioning related to self-harm and suicidal behaviors were
explored.
Self-harm refers to the intentional destruction of one's
body without apparent suicidal intent, whereas suicide is
defined as a fatal self-inflicted destructive act with explicit
or inferred intent to die.1e6 Recent studies have shown that
the prevalence of self-harm in young people ranges from
3.7% to 23.5%.1,2,4,7e13 Moreover, the rate of suicidal idea-
tion among young people is between 15% and 45%, the rate
The authors indicate no conflicts of interest.
* Address correspondence to: Ben M.F. Law, PhD, Department of Social Work and
Social Administration, The University of Hong Kong, Hong Kong, PR China; Phone:
(852) 3917-2087
E-mail address: blaw@hku.hk (B.M.F. Law).
1083-3188/$ - see front matter Ó 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.jpag.2015.10.007
suicide is completed for every 25 attempts.1,4,7,10,14,15
Adolescent suicide figures in the international contexts
are also on an increasing trend. In Hong Kong, the preva-
lence rate of self-harming behavior (23.5%) among Chinese
adolescents is higher than the figures reported by other
countries, but the rate of suicide attempts (4%) is relatively
low.7 Hong Kong's adolescent suicide rates are also in the
middle range compared with those in other developed
countries.
Despite some scientific literature that addressed the
prevalence rates of these 2 behaviors, studies on the related
trajectories are limited. Rueter and Kwon16 found that sui-
cidal ideation increased from early adolescence to mid-
adolescence, and then decreased. Apart from this study, to
our knowledge, no other study has explored the trend of
self-harm in adolescence. In particular, we found no longi-
tudinal study on the trend among Chinese adolescents.
Against this background, this study fills this knowledge gap.
Using the findings from the West as a basis, in this study
we proposed that an increase in self-harm and suicidal
 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48
behavior occurs in the junior secondary year, followed by a
gradual decline (hypothesis 1).
Gender is one of the commonly cited predictors of
adolescent self-harm and suicidal behaviors. In general,
many studies have shown that adolescent girls have a higher
risk of both self-harming4,7,11e13,17e20 and suicidal behav-
iors13,14,19,21e26 than do adolescent boys. However, some
studies found that the gender difference for self-harm is
insignificant.4,27,28 At the biological level, pubertal changes
might cause more stress for early maturing girls. They also
become more sensitive to interpersonal relationships and
more prone to hide negative emotions.7 Therefore, adoles-
cent girls are more likely than boys to become depressed
when exposed to the same level of stress, and depression
is associated with suicidal behaviors.9 However, to our
knowledge, no study to date has explored the trajectories
of self-harm and suicidal behaviors in both genders. The
current study aimed to fill this knowledge gap. In this study
we hypothesized that girls have higher self-harm and sui-
cidal behaviors than do boys (hypothesis 2).
Family nonintactness might also affect adolescent self-
harm and suicidal behaviors. Some studies have noted
that the death of parents, parental separation, and divorce
of parents are the risk factors for adolescent self-harm be-
haviors4,29 and suicidal behavior.1,30,31 Xing and colleagues
suggested that parental separation restricts opportunities of
parent-child interactions and affects adolescents' psycho-
logical wellbeing, and thus adolescents become more
vulnerable to suicide.32 Remarried parents also increase the
likelihood of self-harm and suicide among the youth,33
because these young people have to face a more compli-
cated living situation that requires them to communicate
with their original family as well as stepfamilies.34 According
to the existing literature, adolescents from nonintact fam-
ilies have a higher prevalence of self-harm and suicidal
behaviors than adolescents who grow up in intact families
(hypothesis 3).
Some studies have shown that economically disadvan-
taged families have an increased risk of deliberate self-harm
in adolescents.35 However, some contrary findings have
been reported that indicate that self-harm is not related to
family economic status.2,4,20 Yates et al found that the rate
of nonsuicidal self-injury is high among adolescents from
high socioeconomic status.36 On the contrary, family eco-
nomic adversity significantly affects adolescent suicidal
behaviors.17,31,37,38 This phenomenon suggests that adoles-
cents in poverty lack different types of support resources
(physical and psychosocial) and that they are also isolated
by peers and society, thus resulting in their great hope-
lessness.39,40 In fact, the extant scientific literature generally
suggests that economic disadvantage is associated with
adolescent risk behavior, including self-harm and suicide.
Therefore, in the current study we hypothesized that poor
adolescents display more self-harm and suicidal behaviors
than do nonpoor adolescents (hypothesis 4).
Adolescents need to develop positive youth develop-
ment qualities that can help them maintain healthy life
attitudes and deal with various stressors caused by pubertal
changes or school life challenges during the transition from
childhood to adulthood. Therefore, these qualities can
S39
contribute to adolescents going through that transitional
period more smoothly.24 Resilience, self-efficacy, prosocial
bonding, spirituality, recognition of positive behaviors, and
social, moral, and emotional competencies can prevent
adolescents from engaging in self-destructive behaviors.7,41
However, to our knowledge, no study has yet been con-
ducted to explore the relationships between positive youth
development qualities and self-harm or suicidal behaviors.
This study fills this significant knowledge gap. In the current
study we hypothesized that positive youth development
qualities are negatively related to adolescent self-harm and
suicidal behaviors (hypothesis 5).
Family functioning has been found to be related to
adolescent self-harm and suicidal behaviors. When poor
family communication and interactions occur, adolescents
experience a high level of distress, increased negative emo-
tions, and strong feelings of guilt, shame, or self-hatred.42 In
addition, maladaptive family functioning, such as a low
level of cohesion, poor family adaptability, high rate of
family conflicts, inadequate communication skills, and lack
of support, increases the likelihood of self-harm and sui-
cide among adolescents.1,4,7,9,17,20,43e48 Because this topic
suffers from a dearth in longitudinal studies, in this study
we attempted to explore the relationships among family
functioning, self-harm, and suicidal behaviors in a more
in-depth manner on the basis of longitudinal data. The
general expectation was that family functioning is nega-
tively related to adolescent self-harm and suicidal behav-
iors (hypothesis 6).
Materials and Methods
The data reported in this study were derived from the 6
waves of a 6-year longitudinal study on adolescent devel-
opment and their families in Hong Kong. The participants
were recruited from 28 randomly selected secondary
schools in Hong Kong using a multistage cluster random
sampling method. A total of 2032 students completed all 6
wave surveys.
During data collection, the students were informed about
the purpose of the study. Consent from schools, parents, and
students were obtained before data collection. With the pres-
ence of a trained research assistant throughout the process,
all of the participants responded to all scales in the question-
naire in a self-administered format with adequate time.
Positive youth development was measured using the
trimmed version of the Chinese Positive Youth Develop-
ment Scale. The scale consists of 44 items on 15 positive
youth development qualities that represent 15 factors.34
A 6-point Likert scale ranging from strongly disagree (1)
to strongly agree (6) was used to assess the responses of
the participants. Shek and Ma performed confirmatory
factor analysis and reported that the factors are subsumed
under 4 higher-order factors, namely, cognitive-behavioral
competencies (CBC), prosocial attributes (PA), general
positive youth development qualities (GPYDQ), and posi-
tive identity (PI). CBC includes self-determination, behav-
ioral competence, and cognitive competence.41 PA consists
of prosocial involvement and norms. GPYDQ includes
resilience, self-efficacy, prosocial bonding, spirituality,
S40 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48
recognition of positive behavior, and social, moral, and
emotional competence. PI consists of belief in the future
and self-identity. The Cronbach a of the 4 constructs at wave
1 were 0.81 (CBC), 0.73 (PA), 0.87 (GPYDQ), and 0.82 (PI).
Family functioning was measured using the trimmed
version of the Chinese Family Assessment Inventory, a 9-item
self-report instrument developed to assess family func-
tioning. Three subscales, including mutuality (mutual sup-
port, love, and concern among family members), conflicts
(presence of conflicts and harmonious behavior in the fam-
ily), and communication (frequency and nature of interaction
among family members), were used to index family func-
tioning. The 5 response options are “very similar,” “some-
what similar,” “neither similar nor dissimilar,” “somewhat
dissimilar,” and “very dissimilar.” A higher total score on the
mutuality and communication subscales indicates a higher
level of positive family functioning, whereas a higher total
score on conflicts indicates a lower level of positive family
functioning. The Cronbach a of the 3 constructs at wave 1 were
0.87 (mutuality), 0.76 (conflict), and 0.81 (communication).
Checklists were adopted for measurement of the preva-
lence of self-harm and suicidal behaviors in the past
12 months. The self-harm behavior checklist included wrist
cutting, burning with a cigarette or fire, carving words or
marks on the body, self-scratching, self-biting, rubbing
sandpaper against the body, acid dripping, bleach scrub-
bing, putting sharp objects into the body, rubbing glass
against the body, breaking bones, head banging, self-
punching, and prevention of wounds from healing. Sui-
cidal behaviors were assessed in terms of suicidal thoughts,
plans, and attempts. The response options are “yes” and
“no.” The Cronbach a for self-harm for the 6 waves were
0.84, 0.82, 0.81, 0.78, 0.87, and 0.86, respectively, and those
for suicidal behaviors are 0.67, 0.62, 0.62, 0.67, 0.65, and
0.68, respectively. In this study, we included gender, family
nonintactness, and economic disadvantage measured at
wave 1 or wave 4 as predictors. Family nonintactness was
measured according to whether the parents of the partici-
pants were in their first marriage (1 5 intact family) or not
(eg, parents separated, divorced, or in their second marriage
or more; 0 5 nonintact family). Economic disadvantage was
measured according to the use of Comprehensive Social
Security Assistance, which is a scheme run by the Hong
Kong Special Administrative Region government to subsi-
dize people who cannot support themselves financially.
Economic disadvantage indicates whether the participant's
family received Comprehensive Social Security Assistance
(0 5 no; 1 5 yes).
Statistical Analyses
Latent growth modeling (LGM) and multiple regression
analyses were used in this study. LGM was implemented in
Mplus version 7.2 (Muthe
n & Muthe
n, Los Angeles, CA) to
estimate the change in self-harm and suicidal behaviors
across these 6 years separately.49 Because the data were
collected from 28 schools, the data were considered non-
independent. Thus, we defined school as a clustering value
and set the analysis to “Type 5 Complex” in Mplus to
remove the variances due to school effects. We first ran an
unconditional model to examine the average trajectories
of self-harm (or suicidal) behaviors by estimating the
growth factors (ie, intercept and slope) as latent variables.
In the next step, we ran a conditional model in which we
added predictors to determine how gender, family non-
intactness, economic disadvantage, positive youth devel-
opment, and family functioning affect the intercept and
growth rate. Figures 1 and 2 show the outcome variables
modeled separately using LGM. As shown in both figures,
the intercept was fixed at 1. The time score of the linear
slope was specified as 0, 1, 2, 3, 4, and 5, and the time score
of the quadratic slope was specified as 0, 1, 4, 9, 16, and 25.50
Therefore, the intercept was defined by the 0 time score of
the linear slope at wave 1 as the baseline. The linear and
quadratic slopes were set as the linear change and the
nonlinear change across time.
Because c2 is sensitive to sample size,51,52 we used the
following fit indices to evaluate the model fit: (1) compar-
ative fit index (CFI $ 0.95)53; (2) P value of close fit (Cfit;
P $ .05)54; (3) root mean square error of approximation
(RMSEA # 0.05)53 and its associated 90% confidence inter-
val (CI)54; and (4) standardized root mean square residual
(SRMR # 0.06).53
We also ran 4 sets of multiple regressions to examine: (1)
how the 4 variables of positive youth development and the
3 variables of family functioning at wave 1 predicted: (a) the
self-harming behaviors at wave 6 and (b) suicidal behaviors
at wave 6; and (2) how this same set of predictors measured
at wave 4 predicted (a) the self-harming behaviors at wave
6; and (b) suicidal behaviors at wave 6. In the first step of
each regression, covariates that included gender, family
nonintactness, and economic disadvantage measured at
wave 1 or wave 4 were entered correspondingly to control
their effects on the outcome. Next, we added the 7 pre-
dictors to determine their effects.
Missing data are inevitable in longitudinal studies. In the
current study, approximately 72.9% of the participants
(n 5 1475) had complete data in all study variables, and
approximately 17.3% had missing data in 1 variable. The rest
of the participants had missing data in 2 or more variables.
No participants had missing data in all variables. Instead
of using pairwise or listwise deletion, we used full infor-
mation maximum likelihood estimation, which produces
relatively unbiased results, to handle missing data.55 For
multiple regressions, we used listwise deletion.
Results
Participants' Profiles on Demographic Variables, Self-Harm, and
Suicidal Behaviors
Table 1 shows the descriptive statistics of the participants.
The mean age of the participants at wave 1 was 12.53 years
(SD 5 0.66), ranging from 10 to 16 years of age. Approxi-
mately 52% were female, 88.7% were from intact families,
and 7.3% were categorized as economically disadvantaged.
Tables 2 and 3 show the descriptive profiles on self-harm
and suicidal behaviors of the participants at wave 6. In
general, 15.3% of Hong Kong adolescents engage in self-
harming behaviors, and 1.6% had suicidal attempts at wave 6.
 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48 S41

Positive Youth Development:

Demographic Predictors: Family Functioning:
Cognitive-behavioral Competency
Gender Mutuality
Prosocial Attributes
Family Nonintactness Conflicts
General Positive Youth Development Qualities
Economics Disadvantages Communications
Positive Identity

Self-Harm Self-Harm
Self-Harm
Behaviors Behaviors
Behaviors
Linear Quadratic
Intercept 0 Slope 0 Slope
1 5
1 1
1 1 4 4 25
1 1 2 3 16
1 9

Self-Harm Self-Harm Self-Harm Self-Harm Self-Harm Self-Harm

Behaviors Behaviors Behaviors Behaviors Behaviors Behaviors
W1 W2 W3 W4 W5 W6

1 2 3 4 5 6

Fig. 1. Proposed latent growth model of self-harm behaviors with the 3 latent growth factors regressed on demographic predictors, positive youth development, and family
functioning. W, wave.

Trajectories of Self-harm and Suicidal Behaviors (Unconditional Model)
As the first step of LGM, an unconditional model was run
to determine the shape of the trajectory of self-harm and
suicidal behaviors. Linear and quadratic models were esti-
mated using full information maximum likelihood. Bayesian
information criterion (BIC) was used to help compare the 2
models.56 A small value on BIC suggests better models in
terms of model fit and parsimony.57
The BIC value for the linear model for self-harm was
37,519.89 and that for the quadratic model was 37,432.37.
The quadratic model had a small BIC value and fit the data
well (c2 [12] 5 20.651, P 5 .06; RMSEA 5 0.019 [90% CI,
0.000-0.032], Cfit P 5 1.00; CFI 5 0.966; SRMR 5 0.030).
Similarly, the BIC value for the linear model for suicidal
behaviors was 15,182.81 and that for the quadratic model
was 15,115.78. The quadratic model again had a small BIC
value and fit the data well (c2 [12] 5 35.982, P ! .001;
RMSEA 5 0.031 [90% CI, 0.020-0.044], Cfit P 5 .995;
CFI 5 0.970; SRMR 5 0.031]). In both cases, we used the
quadratic models in the subsequent analyses.
As shown in Tables 4 and 5, the models for self-harm or
suicidal behaviors exhibit a significant negatively linear (self-
harm: b 5
0.10, P ! .001; suicide: b 5
0.03, P ! .001) and
positive quadratic growth (self-harm: b 5 0.01, P ! .05;
suicide: b 5 0.04, P ! .05). This finding indicates that self-
harm or suicidal behaviors on average decline over time,
but the rate of decline is positive (ie, with a smaller decrease
over time). Therefore, hypothesis 1 was supported.
Contribution of Positive Youth Development and Family Functioning
to the Change in Self-harm and Suicidal Behaviors
After the unconditional model in LGM was run and the
shape of the trajectory of self-harm and suicidal behaviors
was determined, 3 demographic variables (gender, economic
disadvantage, and family nonintactness), 4 variables of pos-
itive youth development, and 3 variables of family func-
tioning were added to predict the effects on the intercept
factor and growth factors. The model fit statistics indicated
a relatively good fit for self-harm (c2 [42] 5 66.578, P ! .01;
RMSEA 5 0.021 [90% CI, 0.010-0.030], Cfit P 5 1.00; CFI
5 0.968; SRMR 5 0.024) and also a good fit for suicidal be-
haviors (c2 [42] 5 67.006, P ! .01; RMSEA 5 0.021 [90% CI,
0.011-0.030]; Cfit P 5 1.00; CFI 5 0.977; SRMR 5 0.017).
The unstandardized coefficients of the quadratic models
of self-harm and suicidal behaviors are shown in Tables 4
and 5, respectively. Both models yielded similar findings
for the regression of the intercept factor (wave 1): female
(self-harm: b 5 0.35, P ! .001; suicide: b 5 0.13, P ! .001),
lower CBC (self-harm: b 5
0.16, P ! .05; suicide: b 5
0.11,
P ! .05), lower GPYDQ (self-harm: b 5
0.45, P ! .001;
suicide: b 5
0.19, P ! .001), and higher conflicts (self-
harm: b 5 0.11, P ! .05; suicide: b 5 0.07, P ! .05) indicated
S42 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48

Positive Youth Development:

Demographic Predictors: Family Functioning:
Cognitive-behavioral Competency
Gender Mutuality
Prosocial Attributes
Family Nonintactness Conflicts
General Positive Youth Development Qualities
Economics Disadvantages Communications
Positive Identity

Suicidal Suicidal
Suicidal
Behaviors Behaviors
Behaviors
Linear Quadratic
Intercept 0 Slope 0 Slope
1 5
1 1
1 1 4 4 25
1 1 2 3 16
1 9

Suicidal Suicidal Suicidal Suicidal Suicidal Suicidal

Behaviors Behaviors Behaviors Behaviors Behaviors Behaviors
W1 W2 W3 W4 W5 W6

1 2 3 4 5 6

Fig. 2. Proposed latent growth model of suicidal behaviors with the three latent growth factors regressed on demographic predictors, positive youth development, and family
functioning. W, wave.

greater likelihood to exhibit higher self-harm or suicidal
behaviors at the baseline (wave 1).
Gender was negatively associated with linear growth for
self-harm only (b 5
0.08, P ! .05), but it had no significant
effect on quadratic growth. In other words, the decline of
self-harming behaviors was faster among adolescent boys
on average.
Among the positive youth development variables, PA
affected self-harm and suicidal behaviors. PA at the baseline
was positively associated with linear growth (self-harm:
associated with the quadratic slope growth (self-harm:
b 5
0.02, P ! .01; suicide: b 5
0.01, P ! .01). In other
words, whereas students in general experienced a decline in
self-harm and/or suicidal behaviors with a positive acceler-
ation (ie, reducing rate of decline), this typical trajectory was
less pronounced among those who scored higher PA than
those with lower PA at the baseline. Figures 3 and 4 show
Table 2
Self-harm Behaviors at Wave 6 According to Gender (n 5 2023)

b 5 0.10, P ! .05; suicide: b 5 0.05, P ! .05) and negatively Types of Self-harm Male, n (%) Female, n (%) Total n (%) c2
Wrist-cutting 24 (2.5) 37 (3.6) 61 (3.1) 1.95
Burn with cigarette 7 (0.8) 3 (0.3) 10 (0.5) 1.93
Table 1 Burn with fire 9 (0.9) 2 (0.2) 11 (0.6) 5.04*
Descriptive Statistics of the Participants Carving word on body 13 (1.4) 19 (1.8) 32 (1.6) 0.73
Carving marks on body 11 (1.1) 17 (1.6) 28 (1.4) 0.90
Characteristic Mean (SD) or %
Self-scratching 34 (3.5) 66 (6.3) 101 (5.2) 8.48y
Gender, % Biting 39 (4.1) 45 (4.3) 84 (4.3) 0.11
Male 48.0 Rubbing sandpaper 7 (0.7) 3 (0.3) 10 (0.5) 1.92
Female 52.0 Acid dripping 4 (0.4) 2 (0.2) 6 (0.3) 0.83
Age at wave 1, years Bleach scrubbing 6 (0.6) 2 (0.2) 8 (0.4) 2.32
Mean age 12.53 (0.66) Sharp objects into body 11 (1.1) 9 (0.9) 21 (1.1) 0.38
Age range 10-16 Rub glass into skin 7 (0.7) 2 (0.2) 9 (0.5) 3.18
Family nonintactness (wave 1/wave 4), % Break bones 8 (0.8) 1 (0.1) 9 (0.5) 6.01*
Nonintact family 11.3%/14.5% Head banging 15 (1.6) 15 (1.4) 30 (1.5) 0.04
Intact family 88.7%/85.5% Self-punching 20 (2.1) 32 (3.1) 53 (2.7) 2.00
Economic disadvantage (wave 1/wave 4), % Prevent wound from healing 73 (7.6) 77 (7.4) 152 (7.8) 0.20
Not receiving CSSA 92.7%/94.7% Other forms of self-harm 28 (2.9) 24 (2.3) 52 (2.7) 0.69
Receiving CSSA 7.3%/5.3% Any harm 130 (13.9) 166 (16.5) 296 (15.3) 2.50

CSSA, Comprehensive Social Security Assistance * P ! .05.

y
Valid percentages were reported. P ! .01.
 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48 S43

Table 3 Table 5
Suicidal Signs at Wave 6 According to Gender (n 5 2023) Quadratic Model of Suicidal Behaviors

Types of Suicidal Behaviors Male, n (%) Female, n (%) Total, n (%) c2 Variable Unstandardized Estimates

Suicidal thoughts 78 (8.1) 106 (10.2) 186 (9.2) 2.72 Intercept Linear Quadratic
Suicidal plans 30 (3.1) 28 (2.7) 59 (3.0) 0.32 Slope Slope
Suicidal attempts 15 (1.6) 15 (1.4) 31 (1.6) 0.43
Unconditional model
Mean 0.204* -0.03* 0.004y
Variances 0.19* 0.06* 0.00*
the trend of the change. Note that the differences among Conditional model
Mean 10.26* -0.34z 0.05y
specific time points might not be statistically significant, but Variances 0.16* 0.04* 0.00*
the overall slopes were more critical. For example, Figure 3 Gender 0.13*
0.02 0.00
shows that those with higher PA scores (2 SD above the Family non-intactness
0.06 0.06
0.01
Economic disadvantage
0.06
0.07 0.02
mean) initially decreased slower in self-harm than those Cognitive-behavioral competencies -0.11y
0.03 0.00
with lower PA scores (2 SD below the mean), but the related Prosocial attributes
0.03 0.05y -0.01y
decrease was relatively faster at later time points. The effect General positive youth development qualities -0.19z 0.04
0.00
Positive identity
0.03 0.01
0.00
size for the effect of PA on the differences in self-harm at Mutuality
0.06 0.02
0.00
wave 1 and wave 6, Cohen d, was 0.27, and the same effect Conflicts 0.07z 0.03
0.01
size for suicidal behaviors was 0.10. The difference implies Communications 0.04 -0.04y 0.01y

the significance of PA on the self-harm and suicidal behavior
trajectory.
In addition to PA, GPYDQ affected the self-harm behavior
only. Although it had no effect on the linear slope growth, it
was positively associated with the quadratic slope growth
(b 5 0.03, P ! .05). That is, all students on average expe-
rienced some decline in self-harm behaviors with a gradual
decrease. This typical trajectory was more pronounced
among those who scored higher in the general positive
youth development at the baseline but was less pronounced
among those with lower scores. Figure 5 shows the trend of
the change. The effect size for the effect of GPYDQ on the
differences of self-harm at wave 1 and wave 6, Cohen d, was
small at 0.33. GPYDQ had a small effect on the self-harm
behaviors.
Among the family functioning variables, only communi-
cation had an effect on suicidal behaviors. It was negatively
associated with linear growth (b 5
0.04, P ! .05) but was
positively associated with quadratic growth (b 5 0.01,
Table 4
Quadratic Model of Self-Harm Behaviors
CSSA, Comprehensive Social Security Assistance
Gender (0 5 male; 1 5 female); economic disadvantage (0 5 not receiving CSSA;
1 5 receiving financial aid); family nonintactness (0 5 nonintact family; 1 5 intact
family).
* P ! .001.
y
P ! .05.
z
P ! .01.
P ! .05). This result indicated that although all students
generally experienced decline in suicidal behaviors, this
typical trajectory was less pronounced among those with
effective communication at the baseline but was more pro-
nounced among those with poor communication. Figure 6
shows the trend of the change. The effect size for the effect
of communication on the differences in self-harm at wave
1 and wave 6, Cohen d, was small at 0.06.
Prediction of Wave 6 Self-harm and Suicidal Behaviors from Wave 1
and Wave 4 Variables
Hierarchical multiple regressions for wave 1 and wave 4
variables to wave 6 self-harm (Table 6) and suicidal be-
haviors (Table 7) were performed. After step 1, the variances

Variable Unstandardized Estimates

Intercept Linear Quadratic

slope slope

Unconditional model
Mean 0.59*
0.10* 0.01*
Variances 1.53* 0.42* 0.01*
Conditional model
Mean 3.12*
0.51z 0.02
Variances 1.20* 0.25* 0.01z
Gender 0.35*
0.08z 0.00
Family nonintactness
0.01
0.08 0.01
Economic disadvantage
0.11
0.08 0.02
Cognitive-behavioral competencies
0.16z
0.01
0.00
Prosocial attributes
0.05 0.10z
0.02y
General positive youth development qualities
0.45*
0.04 0.03z
Positive identity 0.00 0.02
0.01
Mutuality
0.10 0.05
0.01
Conflicts 0.11z 0.03
0.00
Communications
0.06
0.01 0.00
Fig. 3. Predicted trajectories of self-harm behaviors related to prosocial attributes.
CSSA, Comprehensive Social Security Assistance Intercept, linear growth coefficient, and quadratic growth coefficients were predicted
Gender (0 5 male; 1 5 female); economic disadvantage (0 5 not receiving CSSA; by using the averages of predictors, and the 3 demographic variables were set as
1 5 receiving CSSA); family nonintactness (0 5 nonintact family; 1 5 intact family). female (code as 1), family nonintactness (code as 0), and economically disadvantaged
* P ! .001. (code as 1). Gray short dashed line is the mean of prosocial attributes, the solid line
y
P ! .01. is 2 SD below mean, and the long dashed line is 2 SD above mean. The differences
z
P ! .05. between specific time points might not be statistically significant.
S44 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48

Fig. 4. Predicted trajectories of suicidal behaviors related to prosocial attributes.

Intercept, linear growth coefficient, and quadratic growth coefficients were predicted
by using the averages of predictors, and the 3 demographic variables were set as fe-
male (code as 1), family nonintactness (code as 0), and economically disadvantaged
(code as 1). The gray short dashed line is the mean of prosocial attributes, the solid line
is 2 SD below the mean, and the long dashed line is 2 SD above the mean. The dif-
ferences between specific time points might not be statistically significant.
Fig. 6. Predicted trajectories of suicidal behaviors related to communications. Inter-
cept, linear growth coefficient, and quadratic growth coefficients were predicted by
using the averages of predictors, and the 3 demographic variables were set as female
(code as 1), family nonintactness (code as 0), and economically disadvantaged (code as
1). The gray short dashed line is the mean of communications, the solid line is 2 SD
below the mean, and the long dashed line is 2 SD above the mean. The differences
between specific time points might not be statistically significant.

explained were 0.01 (self-harm from wave 1), 0.00 (self-
harm from wave 4), 0.01 (suicide from wave 1), and 0.02
(suicide from wave 4), with gender, family non-intactness,
and economic disadvantage as predictors. The regressions
for self-harm were not significant, whereas those for suicide
were significant. Adolescents in nonintact families either
at wave 1 or at wave 4 were more likely to harm themselves
or perform more suicidal behaviors.
With the addition of the 4 variables of positive youth
development and the 3 variables of family functioning in
step 2, the variance did not increase from wave 1 predictors
to wave 6 self-harm. The regression was again not signifi-
cant. However, the variances increased to 0.02 (wave 4
predictors to wave 6 self-harm), 0.04 (wave 1 predictors to
wave 6 suicide), and 0.05 (wave 4 predictors to wave 6
suicide). The regressions for these 3 predictors were sig-
nificant. The wave 1 predictor for wave 6 self-harm was
nonintact family. The wave 4 predictors for wave 6 self-
harm were nonintact family and lower GPYDQ. Conversely,
the wave 1 predictors for wave 6 suicidal behaviors were
nonintact family, lower PI, and higher conflict. Wave 4
predictors for wave 6 suicidal behaviors were nonintact
family, economically disadvantaged, lower CBC, and lower
GPYDQ. Overall, the effect size involved in the significant
predictors was not high.
Discussion
This study aimed at exploring the trend of self-harm and
suicidal behaviors among Chinese adolescents in Hong
Kong on the basis of a 6-year longitudinal study. To our
knowledge, this work is the first known scientific study on
the changes in self-harm and suicidal behaviors in adoles-
cents in their high school years.
Trajectory of Self-harm and Suicidal Behaviors
The first groundbreaking finding was that for Chinese in-
dividuals, the trajectory of self-harm and suicidal behaviors
gradually decreased from grade 7 to grade 12. In the West,
suicidal ideation increases from early adolescence to
midadolescence and then decreases in late adolescence.16
However, this study showed that the peak risk period for
self-harm and suicidal behaviors for Chinese adolescents is
Table 6
Hierarchical Multiple Regression Analysis Predicting Self-Harm Behaviors at Wave 6

Independent Variables Predictors at Wave 1 Predictors at Wave 4

Step 1 Step 2 Step 1 Step 2

Gender 0.02 0.02
0.00
0.00

Family nonintactness
0.06*
0.05*
0.07*
0.06*
Economic disadvantage 0.02 0.01
0.00
0.00
Cognitive-behavioral competencies 0.00 0.01
Prosocial attributes
0.01 0.02
General positive youth 0.01
0.16y
development qualities
Positive identity
0.04 0.03
Mutuality
0.06 0.02
Conflict
0.03
0.06
Communication 0.01 0.01
2
R 0.01 0.01 0.00 0.02
DR2 0.01 0.01 0.00 0.02z
Fig. 5. Predicted trajectories of self-harm behaviors related to general positive youth
F for R2 change 2.25 (ns) 1.90 (ns) 2.24 (ns) 3.70z
development qualities. Intercept, linear growth coefficient, and quadratic growth co-
n 1309 1551
efficients were predicted by using the averages of predictors, and the 3 demographic
variables were set as female (code as 1), family nonintactness (code as 0), and ns, not statistically significant
economically disadvantaged (code as 1). The gray short dashed line is the mean of Standardized coefficients are listed.
general positive youth development qualities, the solid line is 2 SD below the mean, * P ! .05.
y
and the long dashed line is 2 SD above the mean. The differences between specific time P ! .01.
z
points might not be statistically significant. P ! .001.
 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48 S45

Table 7 Gender and Self-harm or Suicidal Behavior

Hierarchical Multiple Regression Analysis Predicting Suicidal Behaviors at Wave 6

Independent Variables Predictors at Wave 1 Predictors at Wave 4
Step 1 Step 2
Gender 0.01 0.02
Family nonintactness
0.07*
0.06*
Economic disadvantage 0.04 0.02
Cognitive-behavioral competencies 0.05
Prosocial attributes
0.03
General positive youth
0.07
development qualities
Positive identity
0.10*
Mutuality 0.01
Conflict 0.09*
Communication
0.01
R2 0.01 0.05
DR2 0.01z 0.04y
2
F for R change 3.87* 6.67y
n 1308 1551
Standardized coefficients are listed.
* P ! .05.
y
P ! .001.
z
P ! .01.
early adolescence (grade 7 and grade 8) instead of mid-
adolescence. Early adolescence is the period of school
adjustment from primary school to secondary school. In
general, adolescents experience a decline in motivation and
academic performance when they move to secondary
schools.58 A shift toward a more performance-oriented style
of instruction and evaluation is observed from primary
school to secondary school. Primary schools stress mastering
the materials. Secondary schools place more emphasis on
achieving high grades, which are associated with future
schooling and careers. This school adjustment induces stress,
which might cause self-harm and suicidal behaviors. The
present findings suggest that self-harm and suicidal behavior
might peak earlier than adolescence in Hong Kong.
Several reasons account for the decline of self-harm and
suicidal behaviors in the present study. First, adolescents'
sense of autonomy is enhanced, and they are less suscep-
tible to use internalized means to harm themselves.59 Sec-
ond, as they develop their cognitive abstract thinking and
reasoning when they grow older, their problem-solving
abilities are enhanced. Moreover, with physical, social, and
cognitive maturation, adolescents become more resourceful
to deal with problems in life. Therefore, they tend not to
adopt self-harm or suicide as a problem-solving means.60
Third, staying in the same school environment longer
helps them better cope with the academic strain.61 Finally,
self-harm and suicidal behaviors might peak earlier in the
Hong Kong context. Because the education system in Hong
Kong is highly competitive, primary school students have to
take many tests in their senior primary schooling for the
purpose of secondary school allocation. If this conjecture is
correct, we have to collect data from senior primary school
students in the future. Although the first 3 factors might be
universal across the Chinese and Western contexts, the
morbid emphasis on education is a unique cultural char-
acteristic of the Chinese culture. Studies should be further
conducted to understand the relationship between aca-
demic stress and issues and risk behavior indexed according
to self-harm and suicidal behavior in the future.
Results of the current study supplement missing infor-
Step 1 Step 2 mation about the relationship between gender and self-harm
0.01 0.03 or suicidal behavior. For the baseline, (ie, wave 1), adolescent

0.10y
0.07z girls showed a higher prevalence of self-harm and suicidal
0.05* 0.06* behaviors. In addition, the results indicated that girls in

0.16y
0.02 general have higher self-harm and suicidal behaviors than

0.24y boys at other waves. This finding is in accordance with the
existing literature on gender difference in self-harm and

0.05

0.05 suicidal behavior.4 Law and Shek explained that pubertal

0.05 changes and school transition bring high levels of stress to

0.01 adolescent girls.7 Young adolescent girls engage in self-harm
0.02 0.07
0.02y 0.05y and suicidal behaviors to release the overwhelming emo-
8.15y 11.04y tions. Therefore, hypothesis 2 was supported.
Another groundbreaking finding was that the self-harm
decline rate for boys was more pronounced than that for
girls. A possible explanation for this phenomenon is that
boys are more prone to pain aversion.62 Many self-injury
activities involve pain infliction, and therefore more
adolescent boys are deterred from such acts. Furthermore,
boys are more prone to using externalizing behavior
(distraction, aggression, and drug use) instead of internal-
izing behavior or rumination to deal with life stressors.63
Therefore, the frequency of using internalized behavior
decreases more drastically. Because this finding is novel,
further work is needed to replicate the findings and
examine the related mechanisms.
Nonintact Family and Self-harm or Suicidal Behavior
This study also explored how family can affect adolescent
self-harm or suicidal behaviors in a more in-depth manner.
Multiple regression results showed that adolescents from
nonintact families at wave 1 or wave 4 were more likely
to have self-harm or suicidal behaviors at wave 6. The
present findings were consistent with those of the existing
literature.29,34 Therefore, the present findings supported
hypothesis 3. One potential problem of nonintact families is
that they involve many changes in family situations. Adoles-
cent mental health suffers each time for each change.64
Therefore, adolescents from nonintact families are more
prone to stress and engage in self-harm or suicidal behav-
iors to regulate negative emotions than those from intact
families. The cultural factor is pertinent. For Chinese, family
is the core of all social institutions. Chinese families require
children to respect the elders of the family. Care, obedience,
and vigilance are important virtues in Chinese culture. The
parent-child relationship is formed on the basis of respect
and conformity. However, when the family is not intact,
adolescent children do not know how to respect their par-
ents, and they might be confused and frustrated.
Economic Disadvantage and Self-harm or Suicidal Behavior
Multiple regression analyses showed that economic
disadvantage at wave 4 (but not wave 1) led to a higher rate
of suicidal behavior but not self-harm at wave 6. This
finding partially supports hypothesis 4. The main effect of
financial stress is transmitted to adolescents through the
S46 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48
negative effect that they have on parents' mental health and
marital relations.64 Adolescents from an economically
disadvantaged background suffer from lack of resources
that results in isolation.37,40 In Hong Kong, joining addi-
tional tuition classes is common. Many adolescent students
attend private tuition classes after school to prepare for the
public examination at the end of grade 12. Parents are
willing to spend more money in buying drilling exercises for
their children to practice. When an adolescent at wave 4
becomes economically disadvantaged, he or she might not
be able to join the tuition classes and buy additional drilling
exercises. With the already escalating academic strain, he or
she will be highly stressed. The present finding suggests
that the effect of economic disadvantage on adolescent
development might be more pronounced in late adoles-
cence. With the development of the social self and social
circle in late adolescence, economic disadvantage might
have a greater effect in late adolescence. These findings also
explain why economic disadvantage at wave 1 does not
affect wave 6 suicidal behavior.
Positive Youth Development and Self-harm or Suicidal Behaviors
The relationship between positive youth development
and self-harm or suicidal behaviors is more complicated
than expected. CBC, PA, GPYDQ, and PI play different roles
in influencing self-harm or suicidal behaviors at different
time points.
Adolescents with higher CBC at the baseline showed a
lower level of self-harm and suicidal behavior at wave 6,
and thus hypothesis 5 was supported. CBC at wave 4 also
indicated decreased suicidal behavior at wave 6. CBC con-
sists of 3 components, namely, self-determination, behav-
ioral competence, and cognitive competence. The empirical
finding highlights that if an adolescent solves problems
with more constructive thinking and behaviors at grade
7, then he or she will not engage in self-harm or suicidal
behaviors in the same year. An empirical finding showed
that only wave 4 CBC but not wave 1 CBC can predict wave 6
suicidal behavior. One possible reason for this finding is that
adolescents' information processing has increased remark-
ably between early and middle adolescence with the growth
of formal operational thinking and abstract thinking.60
Wave 4 CBC is more advanced than wave 1 CBC. There-
fore, only wave 4 CBC can reduce suicidal behavior.
In addition to the unconditional model, PA also exerted a
small but significant effect on the difference between the
wave 1 and wave 6 self-harm rate. The self-harm decline
rate for the higher PA group was slower. Adolescents from
grade 8 to grade 11 (wave 2 to wave 5) enter the mid-
adolescence stage, and they are more susceptible to peer
influence in this period. PA include prosocial involvement
and prosocial norms. These 2 domains are heavily inter-
personally related. This fact explains why adolescents
with higher PA tend to be influenced more by peers. They
might easily become upset by peer comments. With their
imaginary audience and self-conscious thinking in mid-
adolescence,64 adolescents with higher PA are more stressed
than their counterparts with lower PA. This finding also
explains the slower decline rate in self-harm.
Consistent with hypothesis 5, adolescents with higher
GPYDQ at the baseline displayed a lower rate of self-harm
and suicidal behavior. The self-harm decline rate for ado-
lescents with higher GPYDQ was faster. A higher GPYDQ at
wave 4 was the most significant predictor of a lower rate of
self-harm or lower rate of suicidal behaviors. GPYDQ con-
sists of resilience, social competence, self-efficacy, moral
competence, bonding, recognition for positive behavior,
spirituality, and emotional competence.41 Because of adoles-
cent development, these qualities at wave 4 are more
mature and advanced than at wave 1. These developed
qualities can help protect against self-harm and suicidal
behavior.
PI at wave 1 was associated with decreased suicidal
behavior at wave 6. According to Erikson,65 the establish-
ment of a coherent sense of identity is the main psychoso-
cial crisis during adolescence. Adolescents' identity results
from the mutual recognition between them and the soci-
ety. The key to resolution lies in social interactions. There-
fore, having a clear identity acts as a shield against stresses
for early adolescents, and it can be particularly beneficial
for their positive development. The formed identity affects
the adolescent development and helps shield against sui-
cidal behaviors.
Family Functioning and Self-harm or Suicidal Behavior
As far as family functioning is concerned, adolescents
with more family conflicts are prone to having higher self-
harm and suicidal behaviors at the baseline. Therefore,
hypothesis 6 was supported. Multiple regression analyses
also showed that a lower rate of family conflict at wave 1
was associated with a lower level of suicidal behavior at
wave 6. Early adolescents are more easily affected by fam-
ilies. Family conflicts are linked to adolescent self-harm and
suicidal behaviors, and the effect can be long-lasting.45
In addition to conflicts, family communication also
contributed to the difference between wave 1 and wave 6
suicidal behavior. However, the decline rate for suicidal
behavior among adolescents with weaker family commu-
nication was faster. As adolescents grow up, they relate to
nonfamily members more, such as their peers.66 Weaker
family communication might even paradoxically push ad-
olescents to look for nonfamilial support. Moreover, greater
communication with parents during early adolescence
might also create stress for adolescents.
This study is a pioneer attempt to delineate the trajectory of
self-harm and suicidal behaviors among adolescents in Hong
Kong from a 6-year, 6-wave longitudinal study. Using general
linear modeling and multiple regressions, we found that
gender (being female), nonintact family status, and economic
disadvantage can be regarded as risk factors for self-harm and
suicidal behaviors. Conversely, positive youth development
and family functioning are protective factors that play
different roles in affecting self-harm and suicidal behaviors.
Although this work is a pioneer longitudinal study in
suicidal and self-harm behavior of adolescents and it pre-
sents some novel observations, it still has several limita-
tions. First, the findings were derived from self-reported
data. The assessment of some measures, such as family
 B.M.F. Law, D.T.L. Shek / J Pediatr Adolesc Gynecol 29 (2016) S38eS48
functioning, by multiple informants is suggested. However,
the methodology adopted can be counter-argued to be
consistent with the best practice in mainstream research.
Second, because only Chinese adolescents in Hong Kong
were involved, future studies are recommended to recruit
Chinese adolescents from other communities. Third, to
strengthen the assessment of suicidal behavior, more items
should be included. Finally, other measures of internaliza-
tion behavior should be added to provide a more complete
picture of the problem.
Acknowledgments
The preparation for this article and the Project Positive
Adolescent Training through Holistic Social Programs were
financially supported by The Hong Kong Jockey Club Char-
ities Trust.
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