Abstract

Deliberate self-harm (DSH), which includes nonsuicidal self-injury (NSSI) and suicide

attempt (SA), is of serious psychiatric and public health concern for adolescents in the

United States. Despite increasing rates of DSH behaviors in ethnic minority adolescents,

there is limited understanding of factors that discriminate NSSI from SA, two behaviors

that frequently co-occur. The current study examined group differences between

adolescents with No DSH, NSSI Only, and those with NSSI and SA amongst a sample of

primarily ethnic minority adolescents receiving services at an outpatient psychiatric

clinic. Differences between the three DSH groups were compared on family dysfunction,

parental acceptance and rejection, externalizing and internalizing behaviors, and parent-

adolescent discordance on family and behavioral functioning. It was hypothesized that

higher levels of family dysfunction, behavioral symptoms, and parent-adolescent

discordance would be evidenced for adolescents with NSSI and SA followed by NSSI

Only and No DSH. Results indicated the NSSI Only group perceived more family

dysfunction and significantly less parental acceptance compared to the No DSH group.

Externalizing and internalizing behaviors and parent-adolescent discordance were not

significant predictors of DSH group. However, adolescent suicidal ideation was a

significant predictor of parent-adolescent discordance, such that as suicidal ideation

increased discordance between parent and adolescent reports decreased. Contrary to

hypotheses, the current study variables were not robust predictors of DSH group and

results suggested that these DSH groups may not represent an escalating continuum of
severity. More research is needed to identify predictors that distinguish which adolescents

are at risk for NSSI and SA.

 The Role of Family Functioning and Perceived Parental Support in Suicidal and

Non-suicidal Self-injurious Ethnic Minority Adolescents

by

Valerie J. Ellois

November 2015

Submitted to The New School for Social Research of The New School University
in partial fulfillment of the requirements for the degree of Doctor of Philosophy.

Dissertation Committee:
Lisa Rubin, Ph.D.
Miguelina Germán, Ph.D.
Joan Miller, Ph.D.
Benoit Challand, Ph.D.
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 Table of Contents

CHAPTER 1: REVIEW OF THE LITERATURE

I. Introduction…………………………………………………………………….. 1
a. Deliberate Self-Harm in Adolescents…………………………………….…. 1
b. Family Functioning and DSH among Hispanic and African American
Adolescents…………………………………………………………………. 5
c. Parental Acceptance and Rejection ………………………………………… 7
d. Adolescent Internalizing and Externalizing Behaviors…………………….. 8
e. Parent-Adolescent Agreement on Mental Health Functioning………………9

CHAPTER 2: EMPIRICAL ARTICLE

I. Rationale………………………………………………………………………....12
II. Hypotheses……………………………………………………………………….13
III. Methods…………………………………………………………………………. 14
IV. Results…………………………………………………………………………... 21
V. Discussion………………………………………………………………………. 32
VI. Limitations……………………………………………………………………… 45
VII. Implications…………………..…………………………………………………. 47
VIII. References………………………………………………………………………. 52
IX. List of Tables
a. Table 1. ………………………………………………………………….……16
b. Table 2. ………………………………………………………………….……21
c. Table 3……………………………………………………………………..….22
d. Table 4. ……………………………………………………………………….22
e. Table 5……………………………………………………………………….. 65
f. Table 6……………………………………………………………………….. 66

ii
g. Table 7……………………………………………………………………….. 67
h. Table 8. ……………………………………………………………………….68
i. Table 9……………………………………………………………………….. 69
j. Table 10……………………………………………………………………… 70
k. Table 11…………………………………………………………………….... 71
l. Table 12……………………………………………………………………… 72
m. Table 13………………………………………………………………...……. 73
n. Table 14……………………………………………………………………….74
o. Table 15……………………………………………………………………….75
p. Table 16……………………………………………………………………….76
q. Table 17……………………………………………………………………….77
r. Table 18……………………………………………………………………….78

iii
CHAPTER 1: REVIEW OF THE LITERATURE

I. Introduction

Deliberate Self-Harm in Adolescents

Deliberate self-harm (DSH), which includes nonsuicidal self-injury (NSSI) and

suicide attempts (SA), is of serious psychiatric concern for adolescents in the United

States and presents a significant public health problem. NSSI is widely defined as

deliberate destruction to one's body without intent to die (Favazza, 1989). While a suicide

attempt is also causing deliberate harm to oneself, it is accompanied by the intent to die.

In 2014, 8% of adolescents reported at least one suicide attempt (Centers for Disease

Control [CDC], 2014). Notwithstanding these national statistics, research has

demonstrated that prevalence rates for suicide attempts are increasing and vary based on

ethnicity and race. In 2014, African American adolescents reported higher rates of suicide

attempts than White adolescents, and Latina adolescents had the highest rate of suicide

attempt compared with other ethnic groups (Centers for Disease Control [CDC], 2014).

Across racial groups, increases in prevalence of suicide attempt have been evidenced

with the greatest increase amongst Hispanic adolescents followed by Black and White

adolescents (Centers for Disease Control [CDC], 2014). Regardless of recent increases in

suicide rates among African American and Hispanic adolescents, the focus of most

suicide research to date has been on White adolescents (Spann, Molock, Puri, Matlin, &

Barksdale, 2006). A similar disparity exists for NSSI. In a review article that examined

rates of DSH across multiple studies with predominantly White participants in the US,

1
Muehlenkamp and colleagues (2012) found lifetime prevalence rates of NSSI ranging

from 17-28% (Muehlenkamp, Claes, Havertape, & Plener, 2012). However, it remains

unclear if these rates are similar across different racial and ethnic groups. One exception

is a study that investigated ethnicity and NSSI that found higher rates for ethnic

minorities as compared to Whites (Whitlock, Eckenrode, Silverman, 2006).

NSSI and SA are two behaviors that frequently co-occur (Klonsky &

Muehlenkamp, 2007; Nock, Joiner, Gordon, Lloyd-Richardson, Prinstein, 2006;

Whitlock, Eckenrode, Silverman, 2006) but not always. In clinical settings, there are

subgroups that emerge among adolescents who engage in DSH – adolescents who engage

in NSSI only and adolescents who engage in both NSSI and SA (Jacobson,

Muehlenkamp, Miller & Turner, 2008). Of those adolescents engaging in NSSI 28% to

41% have had suicidal ideation (Favazza, 1996), and approximately 55% to 85% have

attempted suicide once in their lifetime (Stanley et al., 1992). Theoretically, it is

important to understand why NSSI may increase risk for SA for some adolescents but not

others. Three prominent theories have been proposed to eludcidate this important finding:

(1) the “Gateway Theory” posits a continuum of DSH where NSSI and SA are variations

of the same behavior where NSSI precedes SA developmentally, (2) the “Third Variable

Theory” asserts that a third variable accounts for the overlap in NSSI and SA whereby

NSSI and SA co-occur frequently because they are both indicators of extreme

psychological distress, and (3) Joiner’s Theory of Acquired Capability for Suicide which

suggests that NSSI habituates one to self-harm, where the pain and fear associated with

2
self-harm is overcome resulting in an acquired capability for suicide (Hamza, Stewart, &

Willoughby, 2012). Each of these theories offers differing explanations of the

relationship between NSSI and SA, although each is compelling, current research on

NSSI and SA does not adequately support one prevailing theory.

Despite increasing rates of DSH behaviors in adolescents, there is limited

understanding of the factors that discriminate NSSI from SA. Few studies have

investigated the potential differences between adolescents who engage in NSSI only and

those who have attempted suicide. However, Brausch & Gutierrez (2010) have found

significant differences between adolescents who engage in NSSI compared to those with

SA and NSSI in several domains including depressive symptoms, parental support,

suicidal ideation, self-esteem, social support, body satisfaction, and disordered eating.

Conversely, in a study of predictors of NSSI and SA, Wichstrøm (2009) found several

risk and protective factors that were common to NSSI and SA. However, both NSSI and

SA also demonstrated unique risk and protective factors. Therefore, although NSSI and

SA are related and share some factors, this suggests that NSSI and SA may not denote

differing degrees of suicidality.

Nonsuicidal self-injury and suicide attempt share similarities and important

differences (Chapman & Dixon-Gordon, 2007; Muehlenkamp & Gutierrez, 2004; Wester

& Trepal, 2005). However, varied conceptualization and definition of self-injury within

the literature has complicated examination of these differences (Chapman & Dixon-

Gordon, 2007; Nock & Favazza, 2009). Several researchers conceptualize NSSI along a

3
continuum of suicidal intent which is not clearly distinct from suicide attempt (Hawton &

Harris, 2008;Hawton, Harris & Rodman, 2012; Howson, Yates, & Hatcher, 2008). Other

researchers distinguish self-injury and suicide by pointing to the multiple functions of

self-injury, such as emotion regulation, emotion expression, and distraction (Chapman &

Dixon-Gordon, 2007) and by noting differences in intent, frequency, severity, and

methods (Klonsky et al., 2011; Walsh, 2006).

Although an overlap exists between self-injury and suicide whereby those who

self-injure are at a heightened risk for suicide, Toprak et al. (2011) assert that self-injury

remains largely conceptualized as a means of coping that prevents suicide. Research has

shown that NSSI serves as a coping mechanism for difficult emotions, such as

depression, anger, stress, and loss of control. Nock (2009) posits that NSSI can function

as a means of emotional regulation, communication with and influence of others.

Empirical evidence exploring the relationship between NSSI and SA is based almost

entirely on primarily European American samples. Therefore, further investigation to

better understand the relationship of NSSI and SA within a primarily ethnic minority

adolescent population.

In a study by Jacobson and colleagues (2008), which was a predominately

Hispanic and African American sample, approximately 43% of those engaging in NSSI

had a history of at least one suicide attempt. Despite the marked relationship between

NSSI and SA, few studies have investigated factors that distinguish adolescents engaging

in NSSI from those with NSSI and SA (see Brausch & Gutierrez, 2010 for an exception).

4
For Hispanic and African American adolescents, there is some evidence to suggest that

family factors and psychiatric symptoms may be particularly important in the

development of deliberate self-harm. Identifying specific factors for suicide attempts

amongst Hispanic and African American adolescents with and without NSSI is critically

important for accurate risk assessment, prevention, and intervention efforts (Brausch &

Gutierrez, 2010; Muehlenkamp & Gutierrez, 2007). Thus, exploration of the associations

between family variables and psychiatric symptoms among a predominately Hispanic and

African American sample of adolescents engaging in DSH behaviors is warranted.

Family Functioning and DSH among Hispanic and African American Adolescents

Amongst African Americans and Latinos, familial functioning may impact DSH

behaviors in unique ways. Amongst African Americans, family support is considered a

culturally relevant ideal given the history of family connectedness as a coping mechanism

within a discriminatory society (Billingsley, 1992). Amongst Latino teens, there is

evidence that family variables are more frequently cited as a precipitant of DSH

compared to peer variables (Zayas, Lester, Cabassa, & Fortuna, 2005; Turner, Kaplan,

Zayas & Ross, 2002). In a longitudinal survey of low-income urban African American

and Latino adolescents, results indicated that adolescents who reported suicidal ideation

and suicide attempt were more likely to report low levels of perceived family support

(O'Donnell, Stueve, Wardlaw & O’Donnell, 2003). Although this study did not consider

NSSI, it provides evidence that low familial support may function as a risk factor against

5
adolescent suicidal ideation and attempts in Latino and African Americans. In another

study of several risk factors amongst African American and White suicidal adolescents,

racial differences were found only in perceived familial support (Joe, Clarke, Ivey, Kerr,

& King, 2007). Less support from family was associated with more severe suicidal

ideation and higher levels of depression amongst African Americans, but there was no

significant association between familial support, suicidal ideation, or depression in White

adolescents (Joe, Clarke, Ivey, Kerr, & King, 2007). Overall, the research conducted to

date points toward the importance of family functioning among Latino and African

American adolescents who engage in SA. However, very little research has been

conducted on the relation between family functioning variables and African American

and Latino adolescents who only engage in NSSI or who engage in both NSSI and SA.

A dysfunctional family environment, specifically low levels of parental warmth

and affection and high levels of parental hostility and aggression, may impact a family’s

ability to provide a supportive and accepting environment for an adolescent and may

directly impact DSH behaviors. A review of previous studies found that suicide

attempters compared to those with only suicidal ideation reported more chronic family

discord (Kosky, Silburn & Zubrick, 1990; Spirito, Valeri, Boergers & Donaldson, 2003).

In addition, investigated differences between suicide ideators and suicide attempters on

measures of family functioning and parent/child relationships found rates of reported

familial discord were generally higher for the SA group as compared to suicidal ideation

only group (Séguin, Lynch, Labelle & Gagnon, 2004). Despite the findings on suicidal

6
ideation and attempts, very few studies to date have examined African American and

Latino adolescents who only engage in NSSI or who engage in both NSSI and SA.

Further evaluation of family functioning as a distinguishing factor between these high-

risk groups of adolescents with varying severity of DSH specifically as it relates to NSSI

is needed.

Parental Acceptance and Rejection

Amongst African Americans and Latinos, parental acceptance and rejection

demonstrates an influential relationship with DSH behaviors. Perkins and Hartless (2002)

found that amongst African Americans parental acceptance was a significant predictor of

adolescent suicide attempt, although NSSI was not specifically explored. Parental

acceptance has been operationalized by researchers to include warmth and affection,

including physical and verbal manifestation. Parental rejection has been operationalized

as hostility/aggression, indifference/neglect, and undifferentiated rejection (Rohner,

1975). Turner and colleagues (2002) found that Latina adolescents who perceive their

parental relationships as warm and accepting were less likely to make a suicide attempt.

Lyon and associates (2000), in a sample of African American adolescents found that a

history of reported parental neglect differentiated clinical samples of suicide attempters

from nonsuicidal adolescents. Although empirical studies have examined similar

constructs such as parental warmth, neglect, and aggression amongst African American

and Latino adolescents with DSH, no studies have looked at parental acceptance and

7
rejection as outlined by Rohner (1975) with regard to NSSI and NSSI with SA. Further

research should elucidate whether parental acceptance and rejection differentiates

escalating level of suicidality (i.e. NSSI and NSSI + SA) within a sample of ethnic

minority adolescents.

Adolescent Internalizing and Externalizing Behaviors

Research has indicated that African-American and Latino adolescents may

demonstrate externalized displays of suicidal ideation and intent including aggression,

risk-taking behavior, and violence (Kaslow et al., 2004; Olshen, McVeigh, Wunsch-

Hitzig, & Rickert, 2007). Internalizing symptoms such as hopelessness, withdrawal, and

low self-worth have been found to be less predictive of suicide for African Americans as

compared to Whites (Perkins & Hartless, 2002; Walker, Alabi, Roberts, Obasi, 2010;

Willis et al, 2003). Internalizing symptoms (e.g., depression, anxiety, somatic

complaints) are characterized by inner distress and externalizing symptoms (e.g.,

aggression, delinquent behaviors) are characterized by conflicts with others or society

(Achenbach & McConaughy 1996). At present, externalizing disorders, especially when

not comorbid with internalizing disorders, are typically not a focus of attention in

psychiatric assessment for suicide risk (Hills, Cox, McWilliams, Sareen, 2005). Within

the context of variable idioms of distress such as externalizing self-destructive behaviors

amongst ethnic minorities (Joe & Kaplan, 2001; Morrison & Downey, 2000; Rockett et

al., 2006; Willis, Coombs, Drentea, & Cockerman, 2003), examining both externalized as

8
well as internalized idioms of distress is of extreme importance for suicidality risk

assessment.

Limited research has investigated the relation between NSSI and externalizing

and internalizing symptoms. Internalizing disorders are frequently identified in

adolescents engaging in NSSI (Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005). In

a primarily White sample, researchers found that amongst adolescents with a recent

history of NSSI more than half of the adolescents met criteria for an internalizing

disorder (51.7%), most also met criteria for an externalizing disorder (62.9%) (Nock,

Joiner, Gordon, Lloyd-Richardson, Prinstein, 2006). Larsson and Sund (2008), in a study

of Norwegian adolescents with only SA or NSSI, found that the SA group reported

greater internalizing (anxiety, depression), suicidal ideation and externalizing behaviors

(delinquency) than the NSSI only group. Given the variable idioms of distress with

regard to suicidality across racial and ethnic groups, more research is warranted to

investigate whether behavioral symptoms distinguish between adolescents with NSSI and

those with NSSI and SA amongst African American and Latino adolescents.

Parent-Adolescent Agreement on Mental Health Functioning

The impact of parent-adolescent discordance on perceptions of adolescent mental

health and family functioning is largely unknown. Research suggests African American

and Latino parent-adolescent dyads have a higher threshold for recognizing and reporting

mental health and family functioning (Fabrega, Ulrich, & Mezzich, 1993; Wachtel et al.,

9
1994; Youngstrom, Loeber, & Stouthamer-Loeber, 2000). In addition, African American

and Latino parent-adolescent dyads have been shown to have greater discordance on

measures of family and mental health functioning. In an investigation of parent-child

reporting carried out in a multiethnic sample, minority parents were found to underreport

on measures of family dysfunction and mental health problems such that African

American and Latino parent-child reports were likely to be more discordant, as compared

with White parent-child reports (Roberts, Alegria, Roberts & Chen, 2005). Investigations

are needed across African American and Latino families to ascertain if parent-adolescent

discordance on measures of psychiatric symptoms and family functioning distinguish

amongst escalating levels of DSH.

Despite the documented differences in reporting of family and mental health

functioning, only recently have researchers suggested that these discrepancies are

important in their own right (De Los Reyes, Henry, Tolan, & Wakschlag, 2009). Limited

research investigating parent-adolescent discordance on adolescent mental health

functioning has been shown to be predictive of future adverse outcomes. Research

conducted by Breland-Noble and Weller (2012), on African American parent-adolescent

report of emotional concern and behavioral functioning found that discordance amongst

parent-adolescent reporting was predictive of depression. In a longitudinal study of Dutch

parent-adolescent disagreement regarding adolescents’ behavioral and emotional

problems, discrepancy scores predicted deliberate self-harm (Ferdinand, van der Ende,

Verhulst, 2004). To date, no research studies have investigated parent-adolescent

10
concordance on reports of behavioral and emotional difficulties among adolescents with

NSSI only as compared to those with NSSI and SA.

Parents and adolescents demonstrate differential reporting of mental health and

family functioning. Research has indicated greater agreement between parent and child

reporting of externalizing symptoms as measured against internalizing symptoms

(Achenbach, McConaughy, Howell, 1987; Edelbrock, Costello, Dulcan, Conover & Kala,

1986; Kolko & Kazdin, 1993). It has been found that children report more internalizing

and externalizing symptoms as compared to parents (Sourander, Helstela, & Helenius,

1999; Stanger & Lewis, 1993). Additionally, discrepancy between parent and child

reporting of problem severity was found to be more severe for internalizing versus

externalizing problems in a sample of clinically referred adolescents (Yeh and Weisz,

2001). Schwarz, Batron-Henry, & Pruzinsky (1985) suggest that parents typically are

biased towards reporting positively on their family functioning. Researchers have found

that parents consistently describe their families as more cohesive, loving, stress adaptive,

and less conflictual as compared to their adolescent children (Ohannessian, Lerner, &

Von Eye, 1995). Although adolescents and parents possess differing perceptions of

mental health and family functioning, the question of how this discrepancy relates to

escalating adolescent DSH, specifically NSSI amongst African American and Latinos,

remains unanswered.

11
CHAPTER 2: EMPIRICAL ARTICLE

I. Rationale

Ethnic minorities have been underrepresented in research on suicidality and even

more specifically, NSSI. The proposed research will explore specific correlates that may

distinguish between adolescents with NSSI from those with NSSI and SA amongst

primarily ethnic minority adolescents. Although research has examined suicidal ideation

and attempt, NSSI has only recently become a specific focus of research on DSH. It is

difficult to determine which adolescents amongst these high-risk groups are most likely

to engage in SA. Despite the fact that NSSI and SA are behaviors that frequently co-

occur, little empirical research has investigated factors that distinguish between these

escalating levels of suicidality.

Research has identified ethnic group differences in the expression of suicidality

indicating varied idioms of distress. Perceived family functioning and parental support

have been identified as important factors for suicidality with little emphasis placed on

NSSI specifically. The proposed study aims to explore group differences between

adolescents with NSSI only compared to those with NSSI and SA on measures of family

dysfunction, parental acceptance and rejection, externalizing and internalizing behaviors,

and parent-adolescent concordance on measures of perceived family and behavioral

functioning among primarily ethnic minority adolescents. The current study will evaluate

both adolescent and parent report of family functioning and psychiatric symptoms. To

12
date, no studies have investigated parent-adolescent concordance as a distinguishing

factor between adolescents with NSSI and those with NSSI and SA.

Empirical research documents the importance of these specified correlates

amongst African American and Latino adolescents for suicidal ideation and suicide

attempt with significantly less research on NSSI. The current study seeks to explore these

specific factors within a clinical outpatient population of primarily African American and

Latino adolescents as distinguishing factors across escalating levels of suicidality.

II. Hypotheses

Hypothesis 1: The highest level of perceived family dysfunction will be for adolescents

with SA+NSSI, followed by adolescents with NSSI Only, then No DSH by both

adolescent and parent reports of family functioning controlling for ethnicity and gender.

Hypothesis 2: By adolescent report, levels of parental rejection on the dimensions of

hostility/aggression, indifference/neglect and undifferentiated rejection will be highest for

those with SA+NSSI, followed by NSSI Only and No DSH controlling for ethnicity and

gender. Report of parental acceptance on the dimension of warmth/affection will be

highest for those adolescent with No DSH followed by NSSI Only and then SA+NSSI

controlling for ethnicity and gender.

13
Hypothesis 3: Externalizing and internalizing behaviors will be highest for adolescents in

the SA+NSSI group followed by those with NSSI Only and then No DSH by both parent

and adolescent reports controlling for ethnicity and gender.

Hypothesis 4: The degree of concordance for externalizing and internalizing symptoms

and family functioning between parent and adolescent reports will be compared. Ethnic

minority adolescents with SA+NSSI will evidence less concordance on measures of

perceived family functioning and behavioral functioning as compared to adolescents with

NSSI Only and No DSH using both parent and adolescent report. (Although it is expected

that adolescent and parent reports will be positively correlated with one another, some

disagreement is expected.)

III. Methods

Participants

The sample for this study consisted of admitted outpatients to an adolescent

depression and suicide program in an urban hospital in New York that specializes in

treating self-injuring adolescents. The majority of patients presented to the clinic with

suicidal ideation, suicidal behavior and/or NSSI within the preceding 16 weeks.

Adolescents (73.2% female) averaged 14.91 years (SD = 1.49) and ranged in age from

11-18 years old. Almost all of the adolescents in this study were Hispanic (74.2%) most

frequently Puerto Rican or Dominican; African-American adolescents comprised 19.7%,

14
White adolescents were 2.8% and Other were 2.8%. Over half (53.1%) of the adolescents

had major depressive disorder, 9.9% of adolescents were diagnosed with adjustment

disorder, 5.2% were diagnosed with mood disorder not otherwise specified , 4.7% were

diagnosed with posttramatic stress disorder, 4.7% were diagnosed with dysthymic

disorder, 4.2% were diagnosed with oppositional deviant disorder, 3.8% were diagnosed

with bipolar disorder, and the remaining 14.4% were diagnosed with other disorders.

Additionally, approximately 85% of the patients receiving treatment at the clinic received

Medicaid.

Procedure

This study utilized data collected from comprehensive diagnostic intake

evaluations, part of the standard protocol for admission to the outpatient clinic. As part of

the intake procedure, patients were required to complete a battery of self-report

questionnaires in a semi-private room as well as semi-structured diagnostic interviews

administered by doctoral–level clinical trainees who were supervised by licensed

psychologists. The current study utilized these archival data obtained from adolescents'

charts.

The measures used in the current study were obtained from a time range spanning

from 2005-2012. The clinic director added or removed measures from the intake battery

over this time span resulting in a different eligible sample for the proposed analyses in

this study. See Table 1 for more details. To examine the hypotheses proposed in this

15
study, participants were divided into self-harm groups. Specifically, the current study

divided the sample into three groups based on their reported lifetime history of NSSI and

SA: No DSH (n=82), NSSI-Only (n=66), and SA+NSSI (n=65). Adolescents who

endorsed at least one instance of NSSI and denied SA in the intake interview are included

in the NSSI group. Adolescents who endorsed at least one instance of NSSI and at least

one suicide attempt are included in the NSSI and SA group.

Table 1 Eligible Sample

Measure N Years Administered
Brief Family Assessment Measure (BFAM) 117 2005-2007
Parental Acceptance & Rejection Questionnaire (PARQ) 117 2005-2007
Child Behavior Checklist (CBCL) 213 2005-2012
Youth Self-Report (YSR) 213 2005-2012
Suicidal Ideation Questionnaire (SIQ) 213 2005-2012
Beck Depression Inventory (BDI) 213 2005-2012
Brief Reasons for Living (BRFL) 213 2005-2012
Life Problems Inventory (LPI) 213 2005-2012

Measures

Eight measures were utilized in this study. Reliability was calculated using

Cronbach’s alpha and a value of .70 or greater was considered to indicate adequate

reliability (Field, 2005).

Externalizing and Internalizing Behaviors. The Achenbach Youth Self Report

(YSR) was developed by Achenbach (1991) and is a 112 –item scale that assesses

internalizing and externalizing behaviors in 11-18 year olds. It was designed to obtain

16
adolescents’ reports of their own competencies and problems. The current study utilized

raw scores from the Internalizing and Externalizing subscales. The raw scores directly

reflect the actual distributions of problems and are generally preferable to T scores for

statistical analyses of the Achenbach measures (Achenbach & Rescorla, 2001). The

Internalizing subscale was comprised of items assessing symptoms of withdrawal (e.g. “I

would rather be alone than with others”), somatic complaints (e.g. “I feel dizzy or

lightheaded”) and anxiety/depression (e.g. “I am afraid of going to school”). The

Externalizing subscale was comprised of items assessing delinquent (e.g. “I break rules at

home, school, or elsewhere”) and aggressive behavior (e.g. “I destroy things belonging to

others”) symptoms. Each item was answered using a 3-point Likert-type scale ( 0 = Not

true; 2 = Very true or often true). Cronbach’s alphas for the internalizing and

externalizing subscales in the current sample were .73 and .77, respectively.

The Achenbach Child Behavior Checklist (CBCL) parallels the YSR and

provided a standardized measure of the behavior problems as assessed by parent report

(Achenbach, 1991; Achenbach & Edelbrock, 1983; Edelbrock & Achenbach, 1980).

Parent report of Internalizing and Externalizing symptoms were used. Cronbach’s alphas

for the internalizing and externalizing subscales in the current sample were .73 and .77,

respectively.

Family Functioning. The Brief Family Assessment Measure (BFAM) contains 14

items that provide an overview of family functioning. The BFAM consisted of two

different scales to assess general family functioning: the self-rating scale and the dyadic

17
relationship scale. The self-rating scale measured the individual’s functioning within the

family (Adolescent BFAM-Self) and consisted of 14 items. Sample items included “My

family and I usually see our problems the same way” and “I am tired of being blamed for

family problems”. The dyadic relationship scale focused on how members of the family

perceive each other. Both adolescents and parents completed the dyadic relationship

scale. Sample items of both adolescent (Adolescent BFAM Dyadic) and parent (Parent

BFAM Dyadic) versions included, “My parent and I have the same views about who

should do what in our family” and “My daughter/son and I aren’t close to each other.”

Each item was scored on a 3-point Likert scale (0 = Strongly Disagree; 3 = Strongly

Agree). Total scores were calculated by summing the 14 items for each scale with higher

scores indicating more family disturbance. Cronbach’s alphas for the Adolescent BFAM

Self, Adolescent BFAM Dyadic, and Parent BFAM Dyadic in the current sample were

.83, .91, and .81, respectively.

Parental Acceptance and Rejection. The Parental Acceptance-Rejection

Questionnaire (PARQ) contained 60 items that assess children’s perceptions of the

degree of acceptance or rejection they receive from their parent (mother, father, or other

family member). The PARQ had a total of four subscales: (a) Warmth/Affection, (b)

Hostility/Aggression, (c) Indifference/Neglect, and (d) Undifferentiated Rejection.

Examples of scale items are: "My mother makes me feel wanted and needed"

(Warmth/Affection); "My mother goes out of her way to hurt my feelings"

(Hostility/Aggression); "My mother ignores me as long as I do nothing to bother her"

18
(Indifference/Neglect); "My mother does not really love me" (Undifferentiated

Rejection). Each item was scored on a Likert scale ranging from 1-4 (1 = Almost never

true; 4 = Almost always true). Total scores were calculated by summing the scores for

each item, with the entire Warmth/Affection subscale reverse scored. Higher scores were

indicative of a more rejecting parenting style. Cronbach’s alphas for Warmth/Affection,

Hostility/Aggression, Indifference/Neglect, and Undifferentiated Rejection in the current

sample were .96, .89, .85, and .86, respectively.

Suicidal Ideation. The Suicidal Ideation Questionnaire Junior (SIQ-Jr.) contained

15 self-report items that assessed the extent of suicidal ideation of the adolescent within

the preceding month. Sample items included “I thought it would be better if I was not

alive” and “I thought about killing myself”. Items are scored on a 7 point Likert scale

ranging from 0 = “I never had this thought” to 6 = “Almost every day”. Total scores were

calculated by summing the scores for each item. A total score greater than 31 was

indicative of “significant suicidal ideation”. Cronbach’s alpha for the SIQ was .95.

Depression. The Beck Depression Inventory (BDI) contained 21 items that

measure depression. Each item consisted of four statements indicating different levels of

severity of a particular symptom experienced over the past week (e.g. 0 = I do not feel

sad, 1 = I feel sad much of the time, 2 = I am sad all the time, 3 = I am so sad or unhappy

that I can’t stand it). Total scores were calculated by summing all 21 items. Scores

ranging from: 0-9 were considered a “normal range”, 10-15 were indicative of “mild

depression”, 16-19 were indicative of “mild-moderate depression”, 20-29 were indicative

19
of “moderate-severe depression”, and 30-63 were indicative of “severe depression”.

Cronbach’s alpha for the BDI was .92.

Reasons for Living. The Brief Reasons for Living Inventory – Adolescent Version

(BRFL-A) contained 14 items that assessed reasons adolescents give for not killing

themselves. Sample items included “I believe I can find other solutions to my problems”

and “I am afraid of death.” Each item was scored on a 6 point Likert scale (1 = not at all

important, 6 = extremely important). Total scores were calculated by summing the scores

from the 14 items. Higher scores were indicative of greater reasons for living. Cronbach’s

alpha for the BRFL-A was .83.

Life Problems. The Life Problems Inventory (LPI) contained 60 items that

assessed core aspects of borderline personality disorder addressed in four subscales of:

confusion about self, interpersonal difficulties, emotion dysregulation, and impulsivity.

Sample items included “I'm not sure I know who I am or what I want in life” and “I feel

pretty lost and don't know where I'm going in life.” Each item was scored on a 5 point

Likert scale (1 = Not at all like me, 5 = Extremely like me). Total scores were calculated

by summing the scores from the 60 items. Cronbach’s alpha for the LPI was .97.

Demographic variables. Gender and ethnicity were obtained from the

comprehensive diagnostic intake evaluations.

20
 IV. Results

Descriptive Statistics

The means, standard deviations and range for each measure are presented in Table

2. Means and standard deviations by DSH group for all measures are presented in Table

3. Percentages for gender and ethnicity by DSH group are presented in Table 4.

Table 2
Means, Standard Deviations, and Range for Study Variables
Measure N M SD Range
Adolescent BFAM self 76 20.17 6.84 1 - 39
Adolescent BFAM dyadic scale 76 15.71 8.08 0 - 41
Parent BFAM dyadic scale 75 16.04 5.94 3 - 29

PARQ Warmth/Affection 92 58.50 20.10 5 - 80

PARQ Hostility/Aggression 92 24.92 10.82 3 - 54
PARQ Indifference/Neglect 92 24.30 10.17 3 - 46
PARQ Undifferentiated rejection 92 17.13 8.01 2 - 36

CBCL Internalizing 172 20.16 12.65 1 – 93

CBCL Externalizing 172 17.95 14.43 0 – 99
YSR Internalizing 188 22.40 14.70 0 – 84
YSR Externalizing 188 18.54 13.27 0 - 99

Suicidal Ideation Questionnaire 186 19.80 21.13 0 - 88

Beck Depression Inventory 166 18.10 12.39 0 - 49
Brief Reasons for Living 174 49.22 15.01 15 - 80
Life Problems Inventory 170 133.26 48.41 60 - 259
Note. N = Sample Size, M = Mean, SD = Standard Deviation

21
Table 3

Means and Standard Deviations by DSH group for Study Variables

Measure No DSH NSSI-Only SA+NSSI

Adolescent BFAM self 17.13 (7.15) 21.13 (6.83) 21.21 (6.49)
Adolescent BFAM dyadic scale 13.24 (5.94) 14.57 (8.07) 19.38 (9.05)
Parent BFAM dyadic scale 20.35 (5.01) 20.66 (5.39) 19.03 (6.27)

PARQ Warmth/Affection 62.14 (20.01) 55.44 (22.19) 56.91 (18.47)

PARQ Hostility/Aggression 22.51 (9.68) 27.36 (12.01) 25.66 (10.84)
PARQ Indifference/Neglect 22.46 (9.02) 25.80 (11.14) 25.16 (10.57)
PARQ Undiff. rejection 15.74 (7.49) 19.16 (9.37) 17.06 (7.31)

CBCL Internalizing 20.60 (9.55) 20.74 (14.09) 18.94 (14.72)

CBCL Externalizing 16.56 (10.72) 18.69 (16.02) 19.04 (16.95)
YSR Internalizing 18.21 (13.17) 23.36 (12.89) 26.68 (16.78)
YSR Externalizing 16.23 (12.49) 17.98 (10.67) 21.92 (15.73)

Suicidal Ideation Questionnaire 9.83 (13.84) 21.52 (22.40) 31.64 (21.73)

Beck Depression Inventory 13.40 (11.93) 20.62 (12.33) 21.57 (11.36)
Brief Reasons for Living 52.47 (16.65) 49.17 (13.64) 45.61 (13.65)
Life Problems Inventory 113.34 (43.72) 138.63 (44.52) 154.76 (48.52)
Note. Mean (SD). No DSH = no deliberate self-harm group, NSSI-Only = nonsuicidal
self-injury group, SA+NSSI = nonsuicidal self-injury and suicide attempt group

Table 4

Frequencies and Percentages of Gender and Ethnicity by DSH Group

No DSH NSSI Only SA+NSSI
Variable Frequency % Frequency % Frequency %

Gender 82 100.0 66 100.0 65 100.0

Male 39 47.6 9 13.6 8 12.3
Female 42 51.2 57 86.4 57 87.7
Not reported 1 1.2 0 0.0 0 0.0

Ethnicity 82 100.0 66 100.0 65 100.0

African American 20 24.4 13 19.7 9 13.8
Hispanic 54 65.9 52 78.8 52 80.0

22
 White 4 4.9 0 0.0 2 3.1
Other 4 4.9 1 1.5 1 1.5
Not reported 0 0.0 0 0.0 1 1.5

Data Analytic Strategy

A series of multivariate multiple regression analyses were used to address the

hypotheses relating to the study hypotheses. Mplus v7.31 (Muthén & Muthén, 1998-

2012) statistical software was used for inferential analyses. All inferential analyses were

tested at the 95% level of significance. The Mplus software was used instead of SPSS

because it offered the option of performing all inferential tests using full information

maximum likelihood estimation (FIML) of the model parameters. Simulation studies

indicate use of FIML results in more accurate parameter estimates (Enders, 2010). Given

the significant amount of missing data in the current sample which ranged from 13% to

30% on different variables, the method of FIML was used to adjust for the missing values

in the dataset, by using likelihood functions to estimate model parameters with all of the

available data.

Regression Analyses

The Mplus software does not provide specific syntax or procedures for

MANOVA analyses. Therefore, multivariate regression techniques were used instead. A

total of fourteen inferential tests were defined and reported according to each of the four

hypotheses. Significant associations in the overall model were probed by conducting

23
separate multiple group analyses to examine the mean difference on the outcome

variables by group (i.e. gender, DSH, ethnicity). First, a model was estimated that

allowed means to vary freely across groups (e.g. males vs. females). Then, separate

models were estimated that constrained the means to be equal across the groups. Model

comparisons were conducted using chi-square (χ2) difference tests. Evidence of mean

differences is described below when a constrained model resulted in a significant change

in χ2 (p < .05) and fit indices indicated that the unconstrained model fit better than the

constrained model (Kline, 1998).

Family Dysfunction. The first hypothesis was tested by conducting three separate

multivariate multiple regression models on the following outcome variables (a)

adolescent BFAM self, (b) adolescent BFAM dyadic scale, and (c) parent BFAM dyadic

scale. Independent variables included (a) DSH behavior group, with three levels of (1)

No DSH, (2) NSSI-Only, and (3) SA+NSSI; (b) Gender, and (c) Ethnicity, with three

levels of (1) Hispanic, (2) African-American, and (3) Other. The ethnicity of “Other”

was an aggregate of the White (n = 6), Other (n = 6) and not reported (n = 1) participants.

The DSH group of “No DSH” was used as the reference DSH group in the regression

models, male was used as the gender reference group in the regression models, and the

ethnicity group of “Other” was used as the reference group in the regression models.

In the first regression model which included the dependent variable of adolescent

BFAM self, the independent variables as a group predicted approximately 16% of the

variability in the dependent variable of adolescent BFAM self, R2 = .16; F(4,113) = 1.95,

24
p = .05. Gender was a statistically significant predictor of the adolescent BFAM self

variable, B = 3.63, t(113) = 2.20, p < .05. The magnitude and direction of the gender

predictor indicated that females scored about 3.6 points higher on the adolescent BFAM

self scale. Thus, females perceived greater difficulties within their family than males,

holding all of the other variables constant. None of the DSH predictors were statistically

significant at the p < .05 level; however, one notable trend was observed. NSSI Only had

a notable relation to the adolescent BFAM self scale, B = 3.42, t(113) = 1.85, p = .06; the

NSSI Only group scored approximately 3.4 points higher on the adolescent BFAM self

scale when compared to adolescents in the No DSH group. The higher scores on the

adolescent BFAM self scale are indicative of adolescents perceiving more difficulties

between his/her self and his/her family. Ethnicity was not a significant predictor. Neither

Hispanic ethnicity B = 2.17, t(113) = 0.68, p = .50, nor African American ethnicity, B =

2.06, t(113) = 0.57, p = .57 were significant at the p < .05 level.

A second multiple regression model was calculated for the dependent variable of

adolescent BFAM dyadic scale. The predictors as a whole predicted approximately 12%

of the variability in the dependent variable of adolescent BFAM dyadic scale, R2 = .12;

F(4,113) = 1.85, p = .06. Contrary to hypotheses, none of the predictors were statistically

significant at the p < .05 level; however, one notable trend was observed. Gender was a

predictor of the adolescent BFAM dyadic scale, B = 3.67, t(113) = 1.89, p = .06. The

magnitude and direction of the gender predictor indicated that females scored about 3.7

points higher on the adolescent BFAM dyadic scale. Thus, females perceived greater

25
difficulties with their family than males, holding all of the other variables constant.

Ethnicity was not a significant predictor, neither Hispanic ethnicity B = 4.08, t(113) =

1.06, p = .29, nor African American ethnicity, B = 4.97, t(113) = 1.15, p = .25 were

significant at the p < .05 level.

A third multiple regression model was calculated for the dependent variable of

parent BFAM dyadic scale. The predictors as a whole predicted approximately 8% of the

variability in the dependent variable of adolescent BFAM dyadic scale, R2 = .08;

F(4,113) = 1.40, p = .16. Contrary to hypotheses, DSH group membership was not a

significant predictor of parent BFAM dyadic: NSSI Only, B = 1.25, t(113) = 0.73, p = .47

and SA+NSSI Only, B = 2.20, t(113) = 1.24, p = .21. Gender was not a significant

predictor of parent BFAM dyadic, B = -0.26, t(113) = -0.17, p = .86. Ethnicity was not a

significant predictor, neither Hispanic ethnicity B = -1.06, t(113) = -0.36, p = .72, nor

African American ethnicity, B = -2.80, t(113) = -0.86, p = .39 were significant at the p <

.05 level.

Parental Acceptance and Rejection. A multivariate multiple regression was

performed to test the second hypothesis which included conducting four separate

regressions to test the dependent variables of (a) PARQ-Hostility/Aggression, (b) PARQ-

Indifference/Neglect, (c) PARQ-Undifferentiated Rejection, and (d) PARQ-

Warmth/Affection. Independent variables included (a) DSH behavior group, with three

levels of (1) No DSH, (2) NSSI-Only, and (3) SA+NSSI; (b) Gender, and (c) Ethnicity,

with three levels of (1) Hispanic, (2) African-American, and (3) Other. The ethnicity of

26
“Other” was an aggregate of the White (n = 6), Other (n = 6) and not reported (n = 1)

participants. The DSH group of “No DSH” was used as the reference DSH group in the

regression models, male was used as the gender reference group in the regression models,

and the ethnicity group of “Other” was used as the reference group in the regression

models.

The first multiple regression model for the dependent variable of PARQ-

Warmth/Affection was conducted. The predictors as a whole predicted approximately

17% of the variability in the dependent variable of PARQ-Warmth/Affection, R2 = .17

F(4,113) = 2.29, p = .02. Two predictors were significant for the outcome of PARQ-

Warmth/Affection: NSSI-Only and Ethnicity = African American. As predicted, results

showed that NSSI-Only was a statistically significant predictor of the PARQ-

Warmth/Affection outcome, B = -10.63, t(113) = -2.07, p = .04. The magnitude and

direction of the NSSI-Only predictor indicated that adolescents in the NSSI-Only group

scored about 11 points lower on the outcome of PARQ-Warmth/Affection than

adolescents in the No DSH group. The greatest perceived parental acceptance on the

PARQ-Warmth/Affection outcome was for the SA+NSSI group, followed by the No

DSH group, with the least perceived parental acceptance for the NSSI-Only group.

African-American adolescents also scored significantly lower on the PARQ-

Warmth/Affection outcome than adolescents who were classified as “Other” ethnicity, B

= -19.81, t(113) = -2.06, p = .04. The size and direction of the coefficient indicates that

African-American adolescents scored about 20 points lower on the PARQ-

27
Warmth/Affection outcome than adolescents who were classified as “Other” ethnicity.

Gender was not a significant predictor of PARQ-Warmth/Affection, B = -0.15, t(113) = -

1.46, p = .15.

Separate regression models were estimated for the dependent variables of PARQ-

Hostility/Aggression, PARQ-Indifference/Neglect, and PARQ-Undifferentiated Rejection

However, none of the predictors were statistically significant at the p < .05 level.

Contrary to stated hypotheses, there was not sufficient evidence to indicate that by

adolescent report, levels of parental rejection on the dimensions of hostility/aggression,

indifference/neglect and undifferentiated rejection were highest for those with SA+NSSI,

followed by NSSI-Only, and then No DSH.

Externalizing and Internalizing Symptoms. Four multivariate multiple regression

were performed to test the outcomes of (a) CBCL-Internalizing, (b) CBCL-

Externalizing, (c) YSR-Internalizing, and (d) YSR-Externalizing. Independent variables

included (a) DSH behavior group, with three levels of (1) No DSH, (2) NSSI-Only, and

(3) SA+NSSI; (b) Gender, and (c) Ethnicity, with three levels of (1) Hispanic, (2)

African-American, and (3) Other. The ethnicity of “Other” was an aggregate of the

White (n = 6), Other (n = 6) and not reported (n = 1) participants. The DSH group of “No

DSH” was used as the reference DSH group in the regression models, male was used as

the gender reference group in the regression models, and the ethnicity group of “Other”

was used as the reference group in the regression models.

28
 For the dependent variable of CBCL-Internalizing, the predictors as a whole

predicted approximately 1% of the variability, R2 = .01; F(4,209) = 0.54, p = .59. For the

dependent variable of CBCL-Externalizing, the predictors as a whole predicted

approximately 2% of the variability, R2 = .02; F(4,209) = 0.90, p = .37. For the dependent

variable of YSR-Internalizing, the predictors as a whole predicted approximately 7% of

the variability, R2 = .07; F(4,209) = 1.99, p = .05. For the dependent variable of YSR-

Externalizing, the predictors as a whole predicted approximately 3% of the variability, R2

= .03; F(4,209) = 1.33, p = .18. However, none of the predictors were statistically

significant at the p < .05 level. Contrary to hypotheses, results did not demonstrate

sufficient evidence to indicate that externalizing and internalizing behaviors were highest

for NSSI with SA adolescents followed by those with NSSI-Only by both parent and

adolescent reports. Additionally, there is not sufficient evidence to indicate that

regardless of adolescent DSH group, adolescents will report more internalizing symptoms

as compared to parents.

Concordance rates between parents and adolescents. In order to calculate

concordance values between parent and adolescent reports of internalizing and

externalizing symptoms and family functioning, the difference scores between adolescent

and parent reports were calculated (adolescent minus parent). Three new outcome

variables were created: Discordance-Internalizing (YSR-Internalizing minus CBCL-

Internalizing), Discordance-Externalizing (YSR-Externalizing minus CBCL-

Externalizing), and Discordance-BFAM (Adolescent BFAM dyadic minus Parent BFAM

29
dyadic). The following variables were used as predictors in separate regression analyses

for the newly created outcome variables to examine their associations with the

concordance scores: Suicidal Ideation Questionnaire (SIQ), Beck Depression Inventory

(BDI), Brief Reasons for Living (BRFL), Life Problems Inventory ((LPI). Independent

variables also included (a) DSH behavior group, with three levels of (1) No DSH, (2)

NSSI-Only, and (3) SA+NSSI; (e) Gender, and (f) Ethnicity, with three levels of (1)

Hispanic, (2) African-American, and (3) Other. The ethnicity of “Other” was an

aggregate of the White (n = 6), Other (n = 6) and not reported (n = 1) participants. The

DSH group of “No DSH” was used as the reference DSH group in the regression models,

male was used as the gender reference group in the regression models, and the ethnicity

group of “Other” was used as the reference group in the regression models.

The predictors as a whole predicted approximately 37% of the variability in the

dependent variable of Difference-Internalizing, R2 = .37 F(4,209) = 4.70, p < .001. DSH

group membership was a nonsignificant predictor of discordance, however other findings

are worth highlighting. The SIQ was a statistically significant predictor of the

Discordance-Internalizing outcome, B = 0.26, t(209) = 2.18, p = .03. SIQ was a

significant, positive predictor of internalizing discordance such that each standard

deviation increase in SIQ (SD = 21.13) resulted in a predicted increase in discordance of

5.71. Adolescents who reported high SIQ scores (1 SD above the sample mean) had a

discordance score of 0.72 as compared to youth who reported low SIQ scores (1 SD

below the sample mean) and had a predicted discordance of -10.32. Positive discordance

30
scores indicate that adolescents endorsed more symptoms and negative discordance

scores are indicative of parents reporting more symptoms. Scores were computed using

the average on all other predictors in the model. For categorical variables,

ethnicity=Hispanic, gender=female, and DSH category=NSSI only. Therefore, as SIQ

scores decrease there is increased discordance between parent and adolescent reports with

parents endorsing more internalizing behaviors.

For the dependent variable of Discordance-Externalizing, the predictors as a

whole predicted approximately 26% of the variability in the dependent variable of

Discordance-Externalizing, R2 = .26 F(4,209) = 3.27, p = .001. DSH behavior group was

not significant predictor of Discordance-Externalizing. None of the predictors were

significant at the p < .05 level. However, the SIQ demonstrated a notable trend, B = 0.24,

t(209) = 1.93, p = .05. Each standard deviation increase in SIQ (SD = 21.13) resulted in a

predicted increase in externalizing discordance of 4.50. Adolescents who reported high

SIQ scores (1 SD above the sample mean) had an externalizing discordance score of 3.40

as compared to youth who reported low SIQ scores (1 SD below the sample mean) and

had a predicted discordance of -4.71. Positive discordance scores indicate that

adolescents endorsed more symptoms and negative discordance scores are indicative of

parents reporting more symptoms. Scores were computed using the average on all other

predictors in the model. Therefore, as SIQ scores decrease there is increased discordance

between parent and adolescent reports with parents endorsing more externalizing

behaviors.

31
 The result of the multiple regression model for the dependent variable of

Discordance-BFAM indicated that none of the predictors were statistically significant at

the p < .05 level. In contrast to the other discordance scores, SIQ was not a statistically

significant predictor.

V. Discussion

The main goal of this study was to examine risk factors associated with deliberate

self-harm (DSH), specifically nonsuicidal self-injury (NSSI) and suicide attempt (SA)

within a sample of primarily African American and Latino adolescents receiving services

at an outpatient psychiatric clinic. Because so few studies have investigated group

differences between adolescents with No DSH, NSSI Only, and those with SA+NSSI

amongst a sample of primarily African American and Latino adolescents, this study

offers important information about adolescents who engage in different types of

deliberate self-harm behaviors. The first goal of the current study was to examine

perceived family dysfunction across the three escalating DSH groups by adolescent

perception of their functioning within the family, adolescent assessment of the parent-

adolescent relationship, and parent assessment of the parent-adolescent relationship. The

second goal was to examine parental acceptance and rejection across the three escalating

DSH groups. Specifically, subscales of parental acceptance and rejection

(warmth/affection, hostility/aggression, indifference/neglect, & undifferentiated

rejection) were examined as possibly differentiating between escalating groups of DSH

behavior. The third goal was to examine the relationship between DSH group

32
membership and report of externalizing and internalizing behaviors by both parent and

adolescent report. Lastly, analyses were performed in order to examine the relationship

between parent-adolescent discordance on measures of family functioning and

externalizing and internalizing behaviors as related to DSH behavior group (No DSH,

NSSI only, and SA+NSSI).

Research examining differences between groups of adolescents with self-injurious

behaviors, differentiated on the basis of suicide intent, is still in its initial stages. It is

increasingly important to be able to distinguish self-harming adolescents from those who

are at risk for suicide attempt. The study contributes important information regarding

differences between adolescents with varying levels of self-harm.

DSH and Family Functioning

This study explored the relationship between escalating DSH behaviors and

family functioning as reported by both parent and adolescent. This was achieved by

analyzing the result from three Brief Family Assessment Measure (BFAM) scales

(Adolescent BFAM Self, Adolescent BFAM Dyadic, and Parent BFAM Dyadic). It was

hypothesized that there would be significant differences between the three DSH groups

and that the SA+NSSI group would demonstrate the highest level of perceived family

dysfunction followed by adolescents with NSSI-Only and then No DSH across BFAM

measures. Contrary to hypotheses, across BFAM measures, statistically significant

differences between DSH groups by severity was not evidenced.

33
 However, a notable trend in the result from the Adolescent BFAM Self revealed

that adolescents in the NSSI-Only group perceived greater difficulties in their functioning

within the family as compared to the No DSH group. This finding lends support to the

theory that there may be fundamental differences in adolescents who engage in self-harm

and those who do not with regard to family functioning and parent-adolescent

relationships (O’Donnell et al., 2003; Séquin, Lynch, Labelle & Gagnon, 2004).

However, the findings of the regression model for the Adolescent BFAM Self did not

follow the hypothesized ranking order. For the Adolescent BFAM Self, the DSH group

by ranking of highest to lowest perceived dysfunction was: NSSI-Only, No DSH, and

SA+NSSI. Therefore, when adolescents are reporting on their own functioning within the

family, those in the NSSI-Only group reported the highest level of dysfunction. This

finding is somewhat contrary to research linking negative self-evaluation and lower

parental support to suicide attempters as compared to those who engage in NSSI only

(Brausch & Gutierrez, 2010). Additionally, Asarnow et al. (2011) found greater

perceived family conflict amongst adolescents engaging in SA+NSSI as compared to

NSSI only and SA only groups. Given the established relational functions of NSSI, such

as interpersonal influence, and interpersonal communication (Turner, Chapman, &

Layden, 2012), those engaging in NSSI Only may perceive more conflict associated with

efforts to influence others or communicate distress to family members through self-harm.

Further research to investigate adolescent perceived functioning within the family as a

distinguishing factor amongst DSH groups is warranted.

34
 Notably, results showed that for the Adolescent BFAM Self, females perceived

significantly greater difficulties within their families as compared to males. This finding

was also a notable trend for the Adolescent BFAM Dyadic scale. These results may

suggest that family functioning differentially impacts females and males. Additionally,

these findings support previous research asserting that adolescent gender affects the

relationship between perceived parent-adolescent relationship and suicidal behavior

(Ponnet et al., 2005). By investigating the effects of not only gender, but also ethnicity,

the possibility exists for understanding and distinguishing DSH behaviors amongst this

high-risk population. Given the majority adolescent Latina sample of the current study, it

is important to highlight the importance of familism, the normative value whereby

emphasis is placed on the economic and emotional needs of the family over the

individual amongst Latino families (Sabogal et al., 1987). Radzin et al. 1991 found that

adolescent Latinas with suicide attempt often blame themselves for problems within the

family, although this study did not investigate NSSI specifically. Research has

demonstrated that familial cumulative stress and family conflict, especially with parents

is often an antecedent to Latina suicide attempt (Berne, 1983, Marttunen et al., 1994;

Moscicki, 1999; Wagner, 1997). Despite these previous research findings, the current

study did not suggest ethnicity as a significant predictor of adolescent or parent perceived

family functioning. Although suicide attempt has been investigated within the literature,

NSSI, particularly amongst ethnic minority adolescents, warrants further investigation to

better understand the sociocultural factors that impact DSH behaviors. Therefore, due to

35
the paucity of research on African American and Latino adolescents who engage in

NSSI-Only or who engage in SA+NSSI, the current study suggests family functioning,

particularly looking at how adolescents view their functioning within the family, as an

important factor when examining DSH amongst these high-risk groups.

DSH and Parental Acceptance and Rejection

Another primary goal of this study was to investigate the associations between

parental acceptance and rejection and DSH across groups of adolescents with varying

severity of self-harm. In this study we investigated parental acceptance and rejection by

examining the specific subscales of the PARQ which include: Warmth/Affection,

Hostility/Aggression, Indifference/Neglect, and Undifferentiated Rejection. It was

hypothesized that there would be statistically significant differences between the three

escalating DSH groups on report of parental acceptance and that the No DSH group

would report the highest levels of Warmth/Affection followed by NSSI-Only and then

SA+NSSI. This hypothesis was partially supported whereby adolescents in the NSSI

Only group reported significantly less Warmth/Affection as compared to the No DSH

group. However, the result did not follow the hypothesized ranking with adolescents in

the SA+NSSI group reporting the most Warmth/Affection. The current study finding that

adolescents in the NSSI Only group reported significantly less warmth/affection

highlights the fact that this group may be distinct as compared to those with No DSH or

SA+NSSI. The current study finding supports research by Baetens et al. (2014) who

found a significant association between parental warmth and behavioral support in

36
relation to NSSI. However, few studies have investigated the association between NSSI

and perceived parental warmth/ affection specifically, though hypotheses exist in the

literature on the development of NSSI. Notably, Linehan (1993) theorized that

invalidating parental relationships, characterized as poor parenting and family

functioning, might influence the likelihood of adolescents engaging in NSSI as well as

difficulty with emotional regulation. Research has documented emotional regulation as

one of the most frequently cited functions of NSSI to manage negative emotions

(Klonsky & Muehlenkamp, 2007; Turner et al., 2012). Feeling generation has also been

cited as another function of NSSI whereby self-injury aids in coping with numbness.

Klonsky and Olino (2008), in a study of adolescents with DSH, linked greater severity of

NSSI with intrapersonal/automatic functions (e.g. to reduce bad feelings, to relax) and

lesser severity of NSSI with more social functions. Additionally, Klonsky and Olino

(2008) found that adolescents with the greatest severity of NSSI also endorsed the highest

rates of suicidal ideation and attempt. Taken together, one possible explanation of the

current study findings is that those with NSSI-Only are indeed a distinct group of

adolescents where the social function of NSSI may predominate and thus perceived

parental warmth/affection is differentially affected as compared to SA+ NSSI adolescents

who endorse more intrapersonal/automatic functions. Therefore, the current finding

supports the concept that adolescents engaging in NSSI Only would report less

warmth/affection.

37
 Additionally, African American adolescents reported significantly less parental

Warmth/Affection as compared to adolescents in the “other” category. This finding

supports previous research by Summerville, Kaslow, Abbate, & Cronan (1994) who

found that a majority of adolescent African American suicide attempters classified their

families as maladaptive with regard to level of warmth and adaptability. Further research

has shown that amongst African American adolescents, as compared to their White

counterparts, perception of parental warmth was significant in explaining variation in

psychological adjustment. Therefore, the findings of the current study underscore the

importance of examining perceived parental warmth amongst African American

adolescents.

Contrary to the hypotheses, significant differences between DSH behavior groups

on parental rejection dimensions of hostility/aggression, indifference/neglect and

undifferentiated rejection were not evidenced. This finding suggests that perceived

parental rejection may not be a good predictor of DSH behavior amongst this population.

DSH and Adolescent Internalizing and Externalizing Behaviors

The current study aimed to investigate the relationship between internalizing and

externalizing symptomatology and DSH behavior amongst a primarily ethnic minority

population. It was hypothesized that reports of internalizing and externalizing behaviors

would be highest for the SA+NSSI group followed by those with NSSI-Only an then No

DSH by both parents and adolescent report. Contrary to expectations, the hypothesized

associations were not observed in this study and none of the predictors were statistically

38
significant. Research investigating NSSI along a continuum of suicidality is in its nascent

stages and evidence has been mixed when investigating externalizing and internalizing

symptoms (Larson and Sund, 2008; Nock et al., 2006). This is particularly the case with

investigation of internalizing and externalizing symptoms amongst ethnic minority

adolescents. Previous research on suicidality has focused on internalizing disorders and

demonstrated that internalizing symptoms contribute to the occurrence of NSSI (Guerry

& Prinstein, 2010; Hankin & Abela, 2011). The relationship between NSSI and

externalizing symptoms has not been extensively studied within the field; however,

recent research suggests externalizing behavior as a significant predictor of NSSI as well

(Wilcox et al., 2012; Baetens et al., 2014). Therefore, either by parent or adolescent

report, internalizing and externalizing behaviors may not be adequate in distinguishing

amongst escalating DSH behavior groups. Current study findings also revealed that

parents reported more symptoms than adolescents across both externalizing and

internalizing behaviors. This finding is contrary to Roberts et al. (2005), who found that

amongst African American and Latino parent-adolescent dyads, parents reported fewer

adolescent mental health problems as compared to their White counterparts. Roberts et al.

(2005) posited a differential threshold effect for parents reporting on adolescent mental

health, whereby despite adolescents across ethnic groups reporting equivalent levels of

problems, African American and Latino parents endorsed fewer symptoms. Additionally,

when parents in this study were asked about their own mental health functioning, a

differential threshold effect was not found. One important distinction is the Roberts et al.

39
(2005) study was conducted on a community sample, whereas the current findings are

from a psychiatric outpatient clinic. Therefore, one possible explanation is parents in the

current study were more willing and or likely to endorse symptoms since adolescents

were utilizing mental health services. This might highlight the more complex association

between DSH, internalizing and externalizing behaviors, and variable idioms of distress

amongst African American and Latino adolescents and their parents.

Thus far, inconsistent findings characterize research examining ethnic differences

in adolescent psychopathology and prevalence of internalizing and externalizing

symptoms. Some studies have evidenced significant ethnic group differences across

internalizing and externalizing symptoms (Roberts & Chen, 1995; Austin and Chorpita,

2004) and others found no significant difference in symptoms across groups (Cole et al.,

1998). This hypothesis deserves more attention in future work designed to test these

potential relations amongst African American and Latino adolescents.

DSH and Parent-Adolescent Concordance on Family Functioning

The current study hypothesized that adolescents in the SA+NSSI group would

evidence statistically less concordance on perceived family functioning as compared to

adolescents in the NSSI-Only and No DSH groups. These data revealed no significant

association between DSH group membership and parent-adolescent concordance on

functioning within the adolescent-parent dyad. Although not statistically significant,

these data did follow the hypothesized pattern of discordance, whereby those in the

SA+NSSI group had the highest level of discordance followed by those in the NSSI only

40
group and then the No DSH group with parents reporting more dyadic dysfunction than

adolescents. This trend is opposite to research that has found that parents are biased

toward reporting positively on their family functioning (Ohannessian, Lerner, & Voneye,

1995). However, findings from studies that have examined family relationships as

possibly influencing parent-child agreement on mental health functioning have been

inconsistent (Treutler and Epkins, 2003). Also, of the studies that have investigated

discordance and family functioning, the focus has been almost exclusively on White

populations (Kazdin et al., 1983; Kiss et al., 2007). The findings of the current study may

be specific to this population who were outpatients at a depression and suicide prevention

clinic, with base rates of symptoms and prevalence of comorbidities higher than the

general population but lower than inpatient groups used in adolescent research.

Additionally, because the self-report measures were completed within the context of an

intake evaluation, parents may have demonstrated heightened sensitivity to and reporting

of family dysfunction and behavioral symptoms. Moreover, it may be that other factors

are a stronger predictor of parent-adolescent disagreement. Research suggests that

increased parental or familial stress is associated with decreased levels of agreement

between parent and adolescents about adolescent pathology (Kolko & Kazdin, 1993).

DSH and Parent-Adolescent Concordance on Internalizing and Externalizing

Behaviors

41
 This study investigated the extent to which DSH group membership predicted

parent-adolescent dyadic agreement on a widely used behavior checklist focusing on

internalizing and externalizing behaviors. It was hypothesized that adolescents in the

SA+NSSI group would evidence the least concordance as compared to those in the NSSI

Only group followed by those in the No DSH group on both internalizing and

externalizing measures. Present findings did not indicate DSH group membership as a

significant predictor of discordance between adolescent-parent dyads on either

internalizing or externalizing behaviors. However, previous research has shown that

measures of depression, suicidal ideation, and attitudes toward life have predicted DSH

group membership (Muehlenkamp & Gutierrez, 2004). Therefore, the current study

included these factors as possible predictors of discordance amongst this population and

found that adolescent suicidal ideation (SIQ) was a significant predictor of internalizing

discordance. Results from the SIQ reveals a pattern whereby adolescents with higher SIQ

scores reported more symptoms than their parents but also evidenced less discordance.

This finding supports previous research where parent-adolescent concordance differed by

severity level of depressive symptoms (Williams, Lindsey, & Joe, 2011; Yeh & Weisz,

2001). It is encouraging that the current study evidenced greater agreement on

internalizing symptoms as severity of adolescent reported depression and suicidal

ideation increased. Therefore, adolescents with more severe emotional symptoms are

more concordant with parents. This is important because parents have been identified as

gatekeepers to adolescent utilization of mental health services. Additionally, research has

42
shown that parent-adolescent disagreement on emotional and behavioral problems results

in a higher risk for poor outcomes (Ferdinand, Ende, & Verhulst, 2006).

The current study supports previous research that has found greater agreement on

externalizing problems as compared to internalizing problems (Breland-Noble & Weller,

2012). In the current sample there was greater parent-adolescent concordance for

externalizing behaviors as compared to internalizing behaviors. Again, DSH group

membership was not a significant predictor of externalizing concordance. However,

adolescent reported suicidal ideation (SIQ) was a notable predictor of parent-adolescent

discordance on externalizing behaviors. Results from the SIQ evidenced similar patterns

whereby adolescents with higher scores on suicidal ideation had less discordance as

compared to adolescents endorsing fewer symptoms on these measures.

The current study did not support previous research that found African-American

and Latino parent-adolescent dyads were likely to be more discordant on measures of

family and mental health functioning as compared to White parent-adolescent dyads

(Roberts, Alegria, Roberts & Chen, 2005). In the current study, ethnicity was not a

significant predictor of internalizing or externalizing discordance. Additionally, previous

research on gender as a predictor of parent-adolescent concordance on measures of

emotional problems, behavioral problems, and self-harm have been mixed (Sourander,

Helstela, & Helenius, 1999; Weissman et al., 1987). In the current study, gender was not

a significant predictor of internalizing or externalizing discordance. Given the

43
inconsistencies in findings, future research is warranted for investigating parent-

adolescent agreement on behavioral and emotional symptoms for minority adolescents.

Overall, the findings of the current study contribute to a growing body of

literature investigating DSH and more specifically the relationship between NSSI and SA

amongst a primarily African American and Hispanic adolescent population. Current

study findings support aspects of family functioning and parental acceptance as

distinguishing adolescents with NSSI from those with No DSH or SA+NSSI. This may

suggest the importance of familial interpersonal factors in conjunction with interpersonal

and communication functions of NSSI as key characteristics for further investigation.

Additionally, the current study highlighted female adolescents as experiencing increased

family dysfunction as compared to males. Given the primarily Latina population of the

current study, understanding the larger sociocultural constructs as well as cultural and

familial factors that shape DSH behavior is of paramount importance. Moreover, the

current study highlighted the importance of perceived parental warmth/affection amongst

African American adolescents. This current study continues to highlight the importance

of developing theoretical frameworks of DSH behavior that take into account

psychosocial, cultural, and familial factors as well as adolescent’s emotional

vulnerabilities.

The current study also emphasized the complexity of adolescent versus parent

reporting of symptoms in this high risk primarily African American and Hispanic

population. A threshold effect for parental reporting of adolescent symptoms was not

44
supported in this study, although documented in community samples. Therefore, this

theory may not hold for parents and adolescents in psychiatric outpatient settings.

Community-based and familial interventions may aid in bringing ethnic minority

adolescents with DSH behavior to treatment faster. The current study also underscored

suicidal ideation as a significant predictor of parent-adolescent concordance across both

internalizing and externalizing behaviors with greater suicidal ideation associated with

increased concordance. Therefore, the adolescents in the current study are poised for

positive outcomes since parents often serve as gatekeepers to adolescents receiving

treatment and ethnic minority parents have been found to access mental health services at

a lower rate than other groups (Angold et al., 2002). Continued exploration of DSH,

most specifically NSSI, with incorporation of impactful sociocultural contexts is needed

amongst high risk adolescents.

VI. Limitations

The results of the current study have important theoretical and clinical

implications for understanding varying levels of deliberate self-harm amongst African

American and Latino adolescents. However, there are several limitations that should be

considered when interpreting the meaning and utility of these findings. One limitation of

the current study is related to the fact that it was a chart review study and the instruments

included were not chosen for this study specifically. In particular, the current study used

45
the Brief Family Assessment Measure (BFAM), which provides an overview of family

functioning and it is typically used as a screening measure or for preliminary evaluation.

Use of the Family Assessment Measure III (FAM-III) would offer a more comprehensive

assessment of family functioning (Skinner et al., 1995) and may impact the findings of

the current study. Additionally, several instruments used in the current study were self-

report measures where responses may be affected by social desirability.

Moreover, the current study is cross-sectional and therefore prevents the

identification of causal relationships. Longitudinal, prospective studies of self-harm

behavior that explore the relation of NSSI to suicide attempt, as well as other

psychosocial variables such as ethnicity, age, socioeconomic status, and psychiatric

diagnoses are warranted. A strength of the current study is its investigation of under

researched populations, whereas a majority of research on deliberate self-harm and

specifically NSSI has been conducted among primarily Caucasian samples (Jacobson,

Muehlenkamp, Miller & Turner, 2008). However, the ethnic and gender makeup of this

study, largely Hispanic females, limits the generalizability of these findings to different

ethnic groups and/or male persons.

The current study examined the role of ethnicity on deliberate self-harm and in

doing so considered the African-American and Latino adolescents sampled for this study

as homogenous groups, though ethnicity is quite complex. The population sampled for

this study comes from ethnically rich and diverse setting where the Hispanic population

is largely Dominican and Puerto Rican and the African American population includes

46
peoples from the West Indies. Research examining aspects of ethnicity, race, and culture

would be enhanced by measures of ethnic identity and cultural beliefs about mental

illness and treatment (Roberts, Alegria, Roberta, & Chen, 2005; Cuellar and Paniagua,

2000).

Despite these limitations, this study contributes to the scholarly literature on

deliberate self-harm amongst African American and Latino adolescents. With limited

literature on the correlates of deliberate self-harm within this population, this current

study and our findings have significant clinical relevance.

VII. Implications

The results of the current study contribute to a growing body of literature on

deliberate self-harm, specifically on adolescents who engage in NSSI and those who

engage in NSSI and have also made a suicide attempt. In sum, the results of the current

study may have important theoretical and clinical implications for the understanding and

treatment of adolescents who engage in acts of deliberate self-harm, particularly ethnic

minority adolescents.

Contrary to hypotheses, No DSH, NSSI Only, and SA+NSSI may not reflect an

escalating continuum of underlying distress and conflict, such that SA+NSSI inherently

reflects the most significant level of distress. The current study results do lend support

for adolescents with NSSI as distinct from those with No DSH or SA+NSSI, at least in

particular domains. The current study highlights the need for detailed risk assessment

47
amongst adolescents and their families, with particular attention paid to family

functioning, perceived parental acceptance and psychiatric symptom concordance

amongst African American and Latino teens and their parents. Clinicians who work with

adolescents who engage in NSSI must assess for suicide risk as these behaviors

frequently co-occur. This can at times be difficult and identifying differentiating factors

between DSH groups may aid in more accurate estimations of risk for suicide attempt.

Understanding NSSI by providing new information about the overall family

functioning, parental acceptance and rejection, behavioral symptoms, and parent-

adolescent concordance relative to individuals with No DSH and SA+NSSI can help to

develop better methods for both identifying and treating NSSI and SA. In the current

study, those with NSSI-Only perceived more dysfunction within their family as compared

to the other DSH groups which may suggest an interpersonal function for those in the

NSSI-Only group. This finding, taken together with recent research suggests that careful

understanding of the meaning and function of NSSI for adolescents is essential for

comprehensive risk assessment for suicide attempt. Gaining a better understanding of

circumstances leading to adolescents’ DSH behavior will also give rise to more informed

intervention protocols. When interpersonal functions are more prominent, therapy may

focus on developing adaptive and effective interpersonal skills and ways of handling

interpersonal situations without self-injury. Therapeutic interventions focused on

emotional regulation skills may be most relevant when self-injury is primarily used to

cope with negative emotions.

48
 The current study also highlights the importance of assessing suicidal ideation

severity and its relationship to more severe DSH behavior including suicide attempt.

Findings from this study support distinguishing between parent-adolescents dyads with

high and low levels of concordance on behavioral symptoms based on suicidal ideation

severity. Adolescents in the current study with high endorsement of suicidal ideation also

had high levels of concordance with parents which research suggests results in better

overall outcomes (Yeh and Weisz, 2001). Therefore, at-risk adolescents with mild to

moderate suicidal ideation and less concordance with parents may require more

intervention to increase effective communication and understanding and to promote

timely and appropriate intervention. Additionally, the current sample consisted of help-

seeking adolescents in a psychiatric outpatient clinic, whereas research investigating

concordance in community and non-help seeking samples is important and may produce

different results.

The development of risk assessment measures that account for and incorporate

cultural and sociocultural factors into risk management will aid clinicians efforts.

Specifically amongst African American adolescents, interventions targeting perceived

parental warmth/affection would support adolescents’ psychological and social

development and possibly prevent or mitigate the severity of NSSI. More research is

needed to identify the specific family functioning factors affecting adolescent NSSI and

SA risk and most effective ways to support families. Developing evidence-based family

interventions targeted at decreasing family dysfunction and increasing parental warmth

49
and affection may have a positive impact on treatment for this high risk African

American and Latino population. Maintaining a culturally attuned approach to

prevention, risk assessment, and intervention is justified and may provide an organizing

framework to contextualize these DSH behaviors.

Future studies should continue to explore whether the relation of NSSI to other

DSH groups vary by other psychosocial variables (e.g. ethnicity, age, socioeconomic

status, psychiatric diagnoses). Specifically, given the significant findings related to

female gender and family functioning, comparisons between males and females with

regard to family correlates and DSH are warranted in future research. Additionally, since

the family functioning and behavioral symptoms explored in this study were not robust

predictors of DSH group membership, other factors should be explored as potential

moderators of this relationship. One potential interpersonal factor influencing DSH is

peer influence. Some research has suggested that among adolescent females, NSSI may

be influenced by social processes including peer socialization (Prinstein et al, 2010).

These social processes might include peer reinforcement of behaviors, social modeling,

and response to perceived norms within the peer group. Discovering factors that

distinguish DSH group membership will help to develop prevention, risk assessment, and

interventions applicable to Latino and African American adolescents with DSH

behaviors.

Future longitudinal and prospective studies are desperately needed to gain better

understanding between NSSI and risk for SA amongst ethnic minority adolescents. In

50
addition, continuing to explore the sociocultural, economic, and historical contexts in

which DSH occurs amongst African American and Latino adolescents will enhance our

research design, interpretation, and clinical awareness.

51
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Table 5
Multivariate Regression Results for Adolescent BFAM Self Regressed on Independent
Variables of Study (Hypothesis 1)

Variable B SE B β t p

NSSI-Only 3.42 1.85 0.25 1.85 .06

SA+NSSI -0.60 1.81 0.13 -0.33 .74

Gender = Female 3.63 1.65 0.11 2.20 .03

Ethnicity = Hispanic 2.17 3.21 0.19 0.68 .50

Ethnicity = African American 2.06 3.62 0.20 0.57 .57

Constant 13.44 3.34 --- --- ---

Note. Brief FAM = Brief Family Assessment Measure; B = Unstandardized Regression
Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient; β = Beta
Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 6
Multivariate Regression Results for Adolescent BFAM Dyadic Scale Regressed on
Independent Variables of Study (Hypothesis 1)

Variable B SE B β t p

NSSI-Only 0.09 2.16 0.02 0.04 .98

SA+NSSI 3.67 2.15 0.21 1.70 .09

Gender = Female 3.67 1.94 0.20 1.89 .06

Ethnicity = Hispanic 4.08 3.86 0.20 1.06 .29

Ethnicity = African American 4.97 4.34 0.22 1.15 .25

Constant 7.98 3.98 --- --- ---

Note. Brief FAM = Brief Family Assessment Measure; B = Unstandardized Regression
Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient; β = Beta
Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 7
Multivariate Regression Results for Parent BFAM Dyadic Scale Regressed on
Independent Variables of Study (Hypothesis 1)

Variable B SE B β t p

NSSI-Only 1.25 1.72 0.10 0.73 .47

SA+NSSI 2.20 1.77 0.17 1.24 .21

Gender = Female -0.26 1.53 -0.02 -0.17 .86

Ethnicity = Hispanic -1.06 2.98 -0.07 -0.36 .72

Ethnicity = African American -2.80 3.26 -0.17 -0.86 .39

Constant 16.18 3.18 --- --- ---

Note. Brief FAM = Brief Family Assessment Measure; B = Unstandardized Regression
Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient; β = Beta
Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 8
Multivariate Regression Results for PARQ-Hostility/Aggression Regressed on
Independent Variables of Study (Hypothesis 2)

Variable B SE B β t p

NSSI-Only 5.02 2.95 0.23 1.70 .09

SA+NSSI -1.61 2.88 -0.07 -0.56 .58

Gender = Female -0.98 2.63 -0.04 -0.37 .71

Ethnicity = Hispanic -1.76 4.98 -0.07 -0.35 .72

Ethnicity = African American -2.14 5.52 -0.07 -0.39 .70

Constant 24.82 5.16 --- --- ---

Note. PARQ = Parental Acceptance-Rejection Questionnaire; B = Unstandardized
Regression Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient;
β = Beta Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 9
Multivariate Regression Results for PARQ-Indifference/Neglect Regressed on
Independent Variables of Study (Hypothesis 2)

Variable B SE B β t p

NSSI-Only 2.11 2.77 0.10 0.76 .45

SA+NSSI -0.28 2.70 -0.01 -0.10 .92

Gender = Female 0.56 2.47 0.02 0.23 .82

Ethnicity = Hispanic 4.99 4.67 0.20 1.07 .29

Ethnicity = African American 2.00 5.18 0.07 0.39 .70

Constant 18.42 4.84 --- --- ---

Note. PARQ = Parental Acceptance-Rejection Questionnaire; B = Unstandardized
Regression Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient;
β = Beta Coefficient; t = t-test statistic; p = probability value (2-sided test).

69
Table 10
Multivariate Regression Results for PARQ-Undifferentiated Rejection Regressed on
Independent Variables of Study (Hypothesis 2)

Variable B SE B β t p

NSSI-Only 3.73 2.18 0.23 1.71 .09

SA+NSSI -1.78 2.13 -0.10 -0.84 .40

Gender = Female -2.09 1.94 -0.12 -1.07 .28

Ethnicity = Hispanic -1.35 3.67 -0.07 -0.37 .71

Ethnicity = African American -1.56 4.08 -0.07 -0.38 .70

Constant 18.29 3.81 --- --- ---

Note. PARQ = Parental Acceptance-Rejection Questionnaire; DSH = Deliberate self-
harm; B = Unstandardized Regression Coefficient; SE B = Standard Error of
Unstandardized Regression Coefficient; β = Beta Coefficient; t = t-test statistic; p =
probability value (2-sided test).

70
Table 11
Multivariate Regression Results for PARQ-Warmth/Affection Regressed on Independent
Variables of Study (Hypothesis 2)

Variable B SE B β t p

NSSI-Only -10.63 5.14 -0.26 -2.07 .04

SA+NSSI 3.71 5.02 0.09 0.74 .46

Gender = Female -6.59 4.58 -0.15 -1.44 .15

Ethnicity = Hispanic -0.45 8.66 -0.01 -0.05 .96

Ethnicity = African American -19.81 9.61 -0.36 -2.06 .04

Constant 72.04 8.97 --- --- ---

Note. PARQ = Parental Acceptance-Rejection Questionnaire; B = Unstandardized
Regression Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient;
β = Beta Coefficient; t = t-test statistic; p = probability value (2-sided test).

71
Table 12
Multivariate Regression Results for CBCL-External Regressed on Independent Variables
of Study (Hypothesis 3)

Variable B SE B β t p

NSSI-Only 3.37 2.77 0.11 1.22 0.22

SA+NSSI 0.81 2.79 0.03 0.29 0.77

Gender = Female -3.32 2.65 -0.10 -1.26 0.21

Ethnicity = Hispanic -3.41 4.93 -0.10 -0.69 0.49

Ethnicity = African American -2.22 5.26 0.15 -0.42 0.67

Constant 20.87 5.03 --- --- ---

Note. CBCL = Achenbach Child Behavior Checklist; DSH = Deliberate self-harm;
B = Unstandardized Regression Coefficient; SE B = Standard Error of Unstandardized
Regression Coefficient; β = Beta Coefficient; t = t-test statistic; p = probability value (2-
sided test).

72
Table 13
Multivariate Regression Results for CBCL-Internal Regressed on Independent Variables
of Study (Hypothesis 3)

Variable B SE B β t p

NSSI-Only 0.29 2.45 0.10 0.12 0.91

SA+NSSI -2.02 2.48 -0.07 -0.82 0.42

Gender = Female -0.27 2.35 -0.01 -0.12 0.91

Ethnicity = Hispanic -0.87 4.43 -0.03 -0.20 0.84

Ethnicity = African American -2.16 4.71 -0.07 -0.46 0.65

Constant 21.92 4.53 --- --- ---

Note. CBCL = Achenbach Child Behavior Checklist; DSH = Deliberate self-harm;
B = Unstandardized Regression Coefficient; SE B = Standard Error of Unstandardized
Regression Coefficient; β = Beta Coefficient; t = t-test statistic; p = probability value (2-
sided test).

73
Table 14
Multivariate Regression Results for YSR-Internal Regressed on Independent Variables of
Study (Hypothesis 3)

Variable B SE B β t p

NSSI-Only 3.78 2.68 0.13 1.41 0.16

SA+NSSI 3.14 2.63 0.01 1.19 0.23

Gender = Female 4.00 2.53 0.12 1.58 0.12

Ethnicity = Hispanic -0.69 4.74 -0.02 -0.15 0.88

Ethnicity = African American -2.27 5.13 -0.06 -0.44 0.66

Constant 17.10 4.69 --- --- ---

Note. YSR = Achenbach Youth Self-Report; B = Unstandardized Regression Coefficient;
SE B = Standard Error of Unstandardized Regression Coefficient; β = Beta Coefficient; t
= t-test statistic; p = probability value (2-sided test).

74
Table 15
Multivariate Regression Results for YSR-External Regressed on Independent Variables of
Study (Hypothesis 3)

Variable B SE B β t p

NSSI-Only 2.00 2.47 0.07 0.81 0.42

SA+NSSI 4.02 2.43 0.14 1.65 0.10

Gender = Female -0.57 2.34 -0.02 -0.24 0.81

Ethnicity = Hispanic 0.23 4.16 0.01 0.05 0.96

Ethnicity = African American 1.61 4.51 0.05 0.36 0.72

Constant 15.99 4.16 --- --- ---

Model Summary
F = 1.33, p = .18
R2 = .03, SE R2 = .03
Note. YSR = Achenbach Youth Self-Report; DSH = Deliberate self-harm; B =
Unstandardized Regression Coefficient; SE B = Standard Error of Unstandardized
Regression Coefficient; β = Beta Coefficient; t = t-test statistic; p = probability value (2-
sided test).

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Table 16

Multivariate Regression Results for Achenbach Discordance-Internalizing Regressed on

Independent Variables of Study (Hypothesis 4)

Variable B SE B β t p

SIQ 0.26 0.12 0.27 2.18 0.03

BDI 0.28 0.22 0.18 1.26 0.21

BRFL 0.02 0.10 0.02 0.19 0.85

LPI 0.07 0.06 0.16 1.15 0.25

Gender 4.08 3.81 0.10 1.07 0.29

Ethnicity = Hispanic -2.39 7.43 -0.05 -0.32 0.75

Ethnicity = African American 0.26 7.98 0.01 0.03 0.97

NSSI-Only -1.07 4.11 -0.03 -0.26 0.79

SA+NSSI 4.86 4.68 0.12 1.04 0.30

Constant -19.88 9.66 --- --- ---

Model Summary
F = 4.70, p = .00
R2 = .37, SE R2 = .08
Note. SIQ = Suicidal Ideation Questionnaire; BDI = Beck Depression Inventory; BRFL =
Brief Reasons for Living; LPI = Life Problems Questionnaire; B = Unstandardized
Regression Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient;
β = Beta Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 17

Multivariate Regression Results for Achenbach Discordance-Externalizing Regressed on

Independent Variables of Study (Hypothesis 4)

Variable B SE B β t p

SIQ 0.24 0.12 0.27 1.93 0.05

BDI 0.23 0.23 0.18 1.00 0.32

BRFL 0.14 0.11 0.02 1.32 0.19

LPI 0.05 0.06 0.16 0.77 0.44

Gender 0.47 3.97 0.10 0.12 0.91

Ethnicity = Hispanic 2.32 7.73 -0.05 0.30 0.76

Ethnicity = African American 2.64 8.31 0.01 0.32 0.75

NSSI-Only -4.33 4.28 -0.03 -1.01 0.31

SA+NSSI 4.97 4.87 0.12 1.02 0.31

Constant -20.89 10.05 --- --- ---

Model Summary
F = 3.27, p = .001
R2 = .26, SE R2 = .08
Note. SIQ = Suicidal Ideation Questionnaire; BDI = Beck Depression Inventory; BRFL =
Brief Reasons for Living; LPI = Life Problems Questionnaire; B = Unstandardized
Regression Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient;
β = Beta Coefficient; t = t-test statistic; p = probability value (2-sided test).

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Table 18
Multivariate Regression Results for Discordance-BFAM Regressed on Independent
Variables of Study (Hypothesis 4)

Variable B SE B β t p

SIQ 0.13 0.12 0.35 1.11 0.27

BDI 0.16 0.17 0.24 0.90 0.37

BRFL 0.08 0.08 0.15 0.99 0.32

LPI -0.03 0.05 -0.18 -0.56 0.58

Gender 4.33 2.69 0.26 1.61 0.11

Ethnicity = Hispanic 4.18 7.31 0.22 0.57 0.57

Ethnicity = African American 3.58 7.53 0.17 0.48 0.64

NSSI-Only -1.52 3.20 -0.10 -0.47 0.64

SA+NSSI -1.75 4.49 -0.11 -0.39 0.70

Constant -10.38 10.01 --- --- ---

Model Summary
F = 1.56, p = .12
R2 = .23, SE R2 = .15
Note. SIQ = Suicidal Ideation Questionnaire; BDI = Beck Depression Inventory; BRFL =
Brief Reasons for Living; DSH = Deliberate self-harm; B = Unstandardized Regression
Coefficient; SE B = Standard Error of Unstandardized Regression Coefficient; β = Beta
Coefficient; t = t-test statistic; p = probability value (2-sided test).

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