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2020, Volume 11, Issue 2, Sup.1, pages: 37-47 | https://doi.org/10.18662/brain/11.2Sup1/92

Self-Harm in
Adolescence as
Maladaptive Coping

Slavka DEMUTHOVA¹,
Andrej DEMUTH

1 Assoc. prof., University of Ss. Cyril and
Methodius, Trnava, Slovakia,
slavka.demuthova@ucm.sk

2 Prof., Comenius University, Bratislava,
Slovakia, andrej.demuth@uniba.sk

Abstract: Psychologists, psychiatrists, doctors, and other associated
professions, as well as the public from all over Europe have noticed the
negative impact of the COVID-19 pandemic on mental health. In this
regard, adolescents appear to be a highly vulnerable group, which is more
affected than adults and children in many aspects. This study focuses on a
specific and extremely maladaptive way of coping with mental stress and
problems – deliberate self-harm. It offers an epidemiological study of the
prevalence of self-harm among Slovak youths, its forms and related
variables, carried out on a sample of 2,280 adolescents aged 11 – 19
using the SHI questionnaire. The results reveal that within the overall
prevalence of 45.2%, the most vulnerable group are girls from non-
traditional families who began to self-harm at an early age. The most
frequent forms of self-harm among adolescents were torturing with self-
defeating thoughts, followed by both direct and indirect forms of physical
self-harm. An analysis of the willingness to disclose self-harming
behaviour shows that the need to raise awareness of this behaviour should
be mostly oriented towards adolescents.

Keywords: self-harm; adolescence; prevalence; forms.

How to cite: Demuthova, S., & Demuth, A. (2020). Self-
Harm in Adolescence as Maladaptive Coping. BRAIN. Broad
Research in Artificial Intelligence and Neuroscience, 11(2Sup1), 37-
47. https://doi.org/10.18662/brain/11.2Sup1/92

https://doi.org/10.18662/brain/11.2Sup1/92
mailto:slavka.demuthova@ucm.sk
mailto:andrej.demuth@uniba.sk
https://doi.org/10.18662/brain/11.2Sup1/92

BRAIN. Broad Research in August, 2020
Artificial Intelligence and Neuroscience Volume 11, Issue 2, Supplementary 1

1. Introduction

The COVID-19 pandemic has brought intense feelings of insecurity
and a radical change in our way of life which has had an impact on the
mental health of young people. Adolescents worry about their health as well
as the health of those close to them, they feel isolated from their peer
contacts that are important to them and the restrictions on their mobility
have an immense effect, their daily routine is greatly disturbed, they have lost
access to leisure activities... all of which limits the possibilities they have to
meet their crucial needs. In more serious cases, they are the witnesses or
victims of unfavourable domestic circumstances or violence and they lack
access to psychological help. Yet, young people must live through these
complications whilst also experiencing the challenging transition from
childhood to adulthood (Casey et al., 2010), including the search for their
own identity (Pfeifer & Berkman, 2018), sexual, emotional, and moral
maturation (Bonnie & Backes, 2019), loosening of ties with the nuclear
family and the formation of their first intimate relationships (Jager et al.
2015), the choice of a future profession... At the same time, it is a period of
emotional instability (Larson et al., 2002), of inner uncertainty and the
absence of verified and functional coping strategies, which only makes the
situation even more complicated.

As is it difficult to cope with all of these developmental needs, with
the radical changes in life and a lack of maturity in the areas that could
potentially help to deal with these problems, adolescents tend to opt for
maladaptive coping strategies. A very serious form is that of self-harm
usually in order to reduce the impact or distract attention away from
negative emotions, to punish oneself, and/or to reduce feelings of numbness
or dissociation (Klonsky, 2007). Through such behaviour, individuals feel
that they have control over their lives (Petermann & Nitkowski, 2015),
which compensates for the absence of control over the current events and
experiences. The danger of this type of behaviour not only lies in the health
risks it poses (often associated with suicide), but also in its addictive nature
(Victor et al., 2012); and in the fact that it does not resolve problems, quite
the contrary – it worsens them. In order to improve the mental health care
for adolescents and to effectively prevent such behaviour, it is crucial to be
aware of the prevalence of self-harm and its associated circumstances.

Self-Harm in Adolescence as Maladaptive Coping
Slavka DEMUTHOVA & Andrej DEMUTH

2. Objectives

The main aim of the study is to obtain the fundamental data relating
to self-harming behaviour in adolescents. The secondary objectives include:

• discovering the prevalence of self-harming behaviour in a sample
of adolescents;

• describing the forms of self-harming behaviour and their
prevalence;

• determining the average age when self-harm began and the average
age of self-harming individuals;

• revealing possible differences across genders, age groups and types
of family backgrounds in the prevalence of self-harm;

• describing the willingness to disclose self-harming behaviour
among self-harming adolescents;

• making essential recommendations for the most effective
intervention strategies in the context of the current challenging situation.

3. Method

3.1. Participants and Procedure

The study sample consisted of 2,280 Slovak adolescents (the WHO
defines adolescents as the age group 11 – 19 – Aarø, 2007) attending
primary or secondary schools. The anonymous collection of data included
participants who (or their guardians) gave their informed consent for
participation. The questionnaire was administered in a standard manner by
trained administrators. Of the total number of 2,280 questionnaires, 61
(0.27%) were excluded due to incorrect data. 2,219 participants were
included in the research (63.1% female; mean age of all participants=15.34;
st. dev.=1.58 years;), however, considering the sensitive nature of the topic
of the research, the participants did not always respond to all questions. For
this reason, each analysis was based on the available number of answers in
the questionnaires.

3.2. Measures and Statistical Analysis

The data was collected using a modified Self-Harm Inventory (SHI)
(Sansone & Sansone, 2010); the aim of the additional questions was to
obtain basic demographic data as well as other data (family background,
willingness to disclose the self-harm etc.). The SHI is a self-assessment
questionnaire that consists of 20 items that reveal the presence of a relatively
wide range of forms of self-harming behaviour. The items are preceded by
the phrase, “Have you ever intentionally, deliberately to cause yourself

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harm…” followed by several forms of self-harming behaviour (see Table 1).
The participants were also asked to report how many times the behaviour
has occurred as well as the frequency of the occurrence (0=never, 1=rarely,
2=sometimes, 3=often). It is also possible to observe the intensity of
prevalence and to measure, using the whole SHI questionnaire, the overall
extent (level) of self-harming behaviour. Previous studies (see e.g.
Démuthová & Doktorová, 2018) have confirmed the relatively high internal
consistency of this method (Cronbach’s α=0.809). In order to classify a
participant as a member of the group of self-harming individuals, it was
necessary to admit to one form of self-harming behaviour with the
frequency of 2 or 3 (sometimes or often). Or to admit to several forms of
self-harming behaviour with a frequency of 1 or above.

The data analysis was conducted using the IBM SPSS 22 statistical
software. The statistical significance threshold (α) in each data analysis was
set to 0.05.

4. Results

4.1. Prevalence of Self-Harm

More than half of those in the research sample (56%) have
intentionally harmed themselves at least once in their lives. After using the
criterion for the classification of an individual as a member of the group of
self-harming adolescents (recurrent self-harming behaviour), it may be stated
that the prevalence of this phenomenon in the study sample is 45.2%.

The prevalence of self-harming among those of female gender is
significantly higher (Pearson Chi-Square=23.114; p=0.000); while the
prevalence of self-harming reaches 39% among males, in the case of
females, the prevalence reaches up to 49%. This tendency for a higher level
of self-harming in those of female gender is also demonstrated in the
analyses of the overall extent of self-harm for the group of self-harming
individuals – using the SHI questionnaire, females reached an average score
of 8.9, whereas men only reached 6.6. The application of Student’s t-test
showed that the difference is statistically significant (t=4.512; sig.=0.000).
An even more striking difference appeared in the analysis of a connection
between family backgrounds and self-harm. While the prevalence of self-
harming individuals in traditional families reaches 41%, in non-traditional
families, the prevalence increases to 57% (Pearson Chi-Square=42.64;
p=0.000).

Self-Harm in Adolescence as Maladaptive Coping
Slavka DEMUTHOVA & Andrej DEMUTH

4.2. Forms of Self-Harm

Table 1 clearly shows that all the forms of self-harm studied through
the modified SHI questionnaire occurred in the research sample.
Participants could list several forms of self-harming behaviour, which
happens rather frequently – almost three quarters of the self-harming
adolescents used more than one form. The most frequent form of self-harm
was torturing with self-defeating thoughts, with a prevalence of 26.8%.

Table 1. The prevalence of the individual forms of self-harm in the adolescent
population

Have you ever intentionally, or on purpose,

done any of the following:
% N*

Tortured yourself with self-defeating thoughts 26.8 2,056

Scratched yourself on purpose 25.2 2,012

Hit yourself 24.6 2,025

Cut yourself on purpose 21.6 2,046

Exercised an injury on purpose 20.1 2.057

Banged your head on purpose 18.3 2,040

Abused alcohol to hurt yourself 17.6 2,062

Not slept enough to hurt yourself 14.7 1,992

Starved yourself to hurt yourself 13.8 2,060

Over-exercised to hurt yourself 11.5 2,060

Engaged in emotionally abusive relationships 9.9 2,038

Made medical situations worse on purpose 9.2 2,063

Prevented wounds from healing 8.8 2,051

Burned yourself on purpose 8.1 2,065

Attempted suicide 8.1 2,053

Distanced yourself from God as a punishment 6.8 2,038

Overdosed 3.9 2,064

Abused prescription medication 3.8 2,064

Set yourself up in a relationship to be rejected 3.8 2,061

Abused laxatives to hurt yourself 2.2 2,055

*Note: The percentage was calculated from valid cases (N)

4.3. Age of Self-Harmers

Student’s t-test did not reveal any age differences between the group
of self-harmers and non-self-harmers (t=0.886; sig.=0.376). A further
analysis showed that the prevalence of self-harming behaviour in the group
of self-harmers does not relate to the actual age of the subject – a Pearson

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Artificial Intelligence and Neuroscience Volume 11, Issue 2, Supplementary 1

test focused on the correlation between age and the SHI score did not show
any relationship (correl. coefficient=0.002; sig.=0.948). On the other hand, it
seems that such a relationship exists between the amount of self-harming
behaviour (SHI score) and the age of the onset of self-harm (correl.
coefficient=-0.121; sig.=0.005) – the earlier the individual starts to self-harm,
the more massive the degree of self-harm in adolescence.

4.4. Disclosure of Self-Harm

An important point in the process of helping self-harming
adolescents is the moment of disclosure. It is crucial to know to what extent
they are willing to communicate their hardships and to whom they disclose
this information. Of 1,002 self-harming adolescents only 553 (55.2%) were
willing to answer the question of whether they had confided in someone and
if they had who they disclosed the information to. The results reveal that
most self-harming adolescents try to hide their behaviour from others –
26.7% of the 553 adolescents indicated that they had not told anyone about
their self-harming. Figure 1 presents the results for those (N=285) who have
told someone about their self-harming behaviour.

Figure 1. Persons in whom adolescents confide with their self-harming (N=285)

Girls are statistically more prone to disclosure than boys (Chi-

Square=13.728; sig.=0.000); 55.9% of them (compared to 37.4% in boys)
revealed their self-harming behaviour to someone. It appears that age is not
linked to the willingness to disclose – there was no statistically significant
difference in age found between the individuals who revealed their
behaviour to someone and those who did not (t-value=1.712; sig.=0.088).

164

0 20 40 60 80 100 120 140 160 180

peers

somebody (did not want to specify)

parent/s

psychologist/psychiatrist

sibling/s

other adult/s

Self-Harm in Adolescence as Maladaptive Coping
Slavka DEMUTHOVA & Andrej DEMUTH

5. Discussion

The analysis of the data shows that the prevalence of self-harming
behaviour in the study sample is 45.2%. In contrast with the majority of
countries, (4.7% in Belgium (Madge et al., 2008), 8% in Australia (Moran et
al., 2012), 9.3% in Norway (Tormoen et al., 2013), 10% in England (Hawton
et al., 2012) or 20.3% in the United States (Swahn et al., 2012) and 25.6% in
Germany (Plener et al., 2009)) it is a rather high level of prevalence. Only a
few studies (see e.g. Lundh et al., 2007) have reported similar figures. In
addition to the situational and social specificities, this difference may be a
consequence of inconsistent methodologies or different understandings of
self-harm. In this regard, it may be advisable to promote some scientific
activity towards the unification of the definition of this negative
phenomenon.

From the perspective of the forms of self-harm the most frequent
form was “torturing with self-defeating thoughts”; this belongs among the
mental forms of self-harming behaviour (see e.g. St Germain & Hooley,
2012). Although it is indirect and hidden, its effect is just as devastating and
strong; however, it targets the mental health of an individual, not their body.
This finding leads us to reconsider the concept of self-harm, since there are
certain tendencies to limit it to only the direct physical forms (e.g. the
concept of non-suicidal self-injury, as proposed by DSM-5, 2013). The need
for a broader understanding of self-harm is reaffirmed by the fact that
various forms and types occurred in the study sample (mental, or direct and
indirect physical forms). Attention must inevitably be paid to the high
occurrence of attempted suicide (8.1%) among self-harmers. Considering the
high risk of mortality and the rapidly growing prevalence of this behaviour
(e.g. Clarke et al., (2019) report a 200% increase in suicides among girls aged
10 – 14 years over the last 15 years), further research and prior intervention
is imperative.

From an age perspective, no significant differences were observed in
terms of self-harm; this type of behaviour can be seen throughout the whole
of adolescence. However, the age of onset of this behaviour plays an
important role in its severity, it has a statistically significant correlation with
the intensity of self-harm. This has also been reported by other studies (Jung
et al., 2018). In this context, it would be appropriate to carry out further
studies and analyses to attempt to define the cut point of high-risk age. The
most vulnerable group is girls; although it is no longer true that self-harm is
an almost exclusively feminine phenomenon, there still are statistics that
indicate a higher prevalence amongst women (Laye-Gindhu & Schonert-

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Reichl, 2005). This trend may be explained from various perspectives –
females are more likely to disclose their problems, whereas males are less
likely to report self-harm and consider it a problem; further on, aggression
may be more socially acceptable for males, therefore they have the
opportunity to turn it outwardly instead of inwardly, which is more typical of
females (Victor et al., 2018). In addition to being more prevalent amongst
women, the risk of severe self-harm is increased if there is an unstable family
background. This highlights the need for broader studies into this issue, for
instance oriented towards the high-risk (and protective) factors of self-
harming behaviour.

The key moment in helping self-harmers is their willingness to
disclose their problems. No intervention can be realised without this step.
The analysis of the data we have obtained clearly shows that self-harmers
keep their behaviour secret. And even if they disclose it, it is most often only
to their peers. Thus, not only is it necessary to inform the high-risk group
(self-harmers) about the need for help and what is available, but also the
whole adolescents population, since they are usually the decisive individuals
in helping self-harmers to reach for help. The overall awareness for the need
of mental health care and the help available should represent one of the
priorities in every society, especially related to the highly vulnerable youth
population. Particularly in the present times, when the COVID-19 pandemic
has made it impossible to have face to face contact with others. Activities
that aim to disseminate this type of information (e.g. through media – Saha
et al. 2019) and make it more accessible should be significantly increased.

6. Conclusions

The issue of self-harming behaviour in adolescence is a highly
relevant present-day phenomenon. The current situation in most countries
has resulted in a deterioration of the state of mental health, and the
population of adolescents is no exception. The options for the
implementation of a more suitable approach are limited and help and
intervention are difficult to access. Now more than ever it is crucial to
intensively promote alternative forms of psychological intervention and to
launch an informational campaign focusing on the high-risk section of the
population, in order to make support available to as many adolescents as
possible. Once the pandemic restrictions are lifted, professionals should be
ready to address an increase in the need for psychological and psychiatric
help and actively offer intervention in cooperation with teachers and parents

Self-Harm in Adolescence as Maladaptive Coping
Slavka DEMUTHOVA & Andrej DEMUTH

as well as with students. Research into the issue of self-harm should also
continue, aiming, in particular, at the study of risk and protective factors.

Acknowledgements

This work was supported by the Slovak Research and Development Agency

under contract No. APVV-17-0123.

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