Childhood maltreatment and non-suicidal self-injury: a systematic review and meta-analysis

Abstract

Background: Non-suicidal self-injury is being increasingly recognised as a prominent public health concern. Identification of early and modifiable risk factors is necessary to advance the screening and intervention efforts, particularly early detection of at-risk individuals. We aimed to examine childhood maltreatment, including its specific subtypes, in relation to non-suicidal self-injury.

Methods: We did a comprehensive meta-analysis of childhood maltreatment (overall, sexual abuse, physical abuse and neglect, and emotional abuse and neglect) in association with non-suicidal self-injury. We also provided a qualitative review of mediators and moderators of this association. We identified relevant articles published from inception to Sept 25, 2017, through a systematic search of Embase, MEDLINE, and PsycINFO. We extracted continuous and categorical data and assessed for potential moderators using ten study characteristics. We generated random-effects models for analysis and evaluated for publication bias.

Findings: We identified 71 publications that met eligibility criteria. Overall childhood maltreatment was associated with non-suicidal self-injury (odds ratio 3·42, 95% CI 2·74-4·26), and effect sizes for maltreatment subtypes ranged from 1·84 (1·45-2·34) for childhood emotional neglect to 3·03 (2·56-3·54) for childhood emotional abuse. Publication bias was not evident, except in the case of childhood emotional neglect. Across multiple maltreatment subtypes, we found stronger associations with non-suicidal self-injury in non-clinical samples.

Interpretation: With the exception of childhood emotional neglect, childhood maltreatment and its subtypes are associated with non-suicidal self-injury. Screening of childhood maltreatment history in non-suicidal self-injury risk assessments might hold particular value in community settings, and increased attention to childhood emotional abuse is warranted.

Funding: National Institute of Mental Health.

Figure 1

PRISMA flow chart of literature search

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury

Figure 2

Funnel plot for effect sizes in the meta-analyses. The vertical line indicates the weighted mean effect. Open circles indicate observed effects for actual studies, and closed circles indicate imputed effects for studies believed to be missing due to publication bias. The clear diamond reflects the unadjusted weighted mean effect size, whereas the black diamond reflects the weighted mean effect size after adjusting for publication bias. 2a. Overall childhood maltreatment and non-suicidal self-injury 2b. Childhood sexual abuse and non-suicidal self-injury 2c. Childhood physical abuse and non-suicidal self-injury 2d. Childhood physical neglect and non-suicidal self-injury 2e. Childhood emotional abuse and non-suicidal self-injury 2f. Childhood emotional neglect and non-suicidal self-injury