Parenting behaviors,parenting styles,and non-suicidal self-injury in young people: a systematic review

Abstract

Non-suicidal self-injury (NSSI) is a worrying phenomenon that is prevalent among young people. Prior theorizing and empirical evidence suggest that parenting may play a role in the etiology of NSSI. Thus, we conducted a systematic review to examine the association between parenting behaviors and parenting styles with NSSI in young people. Methods: The following databases were searched for relevant articles in July 2020: PubMed, EMBASE, CINAHL Plus, and PsycINFO. Studies were included if they sampled young persons aged 10–25 years old with a history of NSSI, assessed parenting behavior or style, and tested associations between parenting and NSSI outcomes. Results: A total of 26 studies were included in this review. Among parenting behaviors, low parental support, high psychological control, and high reactive control were more consistently associated with NSSI. Conversely, the evidence for behavioral control is equivocal. There is some evidence that invalidating parenting is also associated with NSSI. Conclusion: Consistent with the wider adolescent psychopathology literature, parenting that is perceived to be supportive, less psychologically controlling and reactive/punitive were less likely to be associated with NSSI. However, these results were largely based on child reports of parenting. Limitations and directions for future research are discussed.

Keywords

non-suicidal self-injury self-injurious behavior self-harm adolescent parents parenting

Introduction

Non-suicidal self-injury (NSSI) is the “deliberate, self-inflicted damage of body tissue without suicidal intent and for purposes not socially or culturally sanctioned” (International Society for the Study of Self-Injury, 2018), using methods such as cutting, scratching, or banging/punching (Sornberger et al., 2012; Whitlock et al., 2006). Although NSSI is hitherto considered as a symptom of borderline personality disorder (BPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2013), accumulating evidence suggests that NSSI is a distinct entity for several reasons, including that not all individuals with NSSI meet the criteria for BPD and that NSSI tends to be comorbid with other psychiatric disorders including mood and anxiety disorders (Glenn & Klonsky, 2013; In-Albon et al., 2013), prompting the American Psychiatric Association to recognize it in the fifth edition of the DSM as a condition for further study. Adolescence appears to be a crucial period in the etiology of NSSI. NSSI is most prevalent among adolescents, with an estimated lifetime prevalence of 17.2% in this population compared to 5.5% among adults (Swannell et al., 2014). The onset of NSSI also tends to occur during early adolescence (Cipriano et al., 2017). Of further concern is that engaging in NSSI can have severe sequelae, being associated with an increased acquired capability for suicide (Willoughby et al., 2015) and future suicidal behaviors (Hamza et al., 2012; Whitlock et al., 2013; Wilkinson et al., 2011). Given the prevalence and dire consequences of NSSI, a better understanding of the risk factors for NSSI is crucial to develop effective interventions for this condition.

Earlier reviews of risk factors for deliberate self-harm in general and NSSI have identified parenting as a potential variable of interest (Arbuthnott & Lewis, 2015; Buckmaster et al., 2019; Fortune et al., 2016). Some theories have also been postulated about the role of parenting in the development and maintenance of NSSI. One prominent theory, Linehan’s biosocial theory, posits that the emotional dysregulation characteristic of BPD and NSSI (Wolff et al., 2019) arises as a result of interactions between a biologically vulnerable individual who has i) heightened sensitivity to emotional stimuli, ii) difficulty regulating intense emotions, and iii) slow return to emotional baseline, with an invalidating caregiving environment characterized by intolerance towards the expression of private experiences and emotions (Linehan, 1993). Parallel lines of research support the notion that parenting practices (e.g., psychologically controlling or permissive parenting) can contribute to the development of emotional dysregulation in adolescents (Morris et al., 2017). From another perspective, Nock and Prinstein (2004) proposed a functional model of NSSI which suggests that intra- (automatic) and interpersonal (social) contingencies reinforce and maintain NSSI. For one, NSSI may be a way of communicating distress, engaged to elicit “caregiving behaviors” from others such as parents that can positively (e.g., by giving attention) or negatively (e.g., withdrawing punishment) reinforce NSSI (Nock, 2008). Nock (2008) suggests that this escalation to more dire distress signals arises due to a caregiving environment that is unresponsive to the child’s milder signals of distress, among other reasons. In some way, it seems, a child’s NSSI can be said to be a result of, or reinforced by, maladaptive or unresponsive parenting.

When it comes to studying parenting, researchers have employed either a dimensional or typological approach to conceptualize parenting behaviors. Parenting dimensions describe specific parenting behaviors in which parents appear to stably differ from each other and that are associated with differences in child outcomes, of which three core dimensions have been repeatedly identified in the literature, namely, support, psychological control, and behavioral control (Barber et al., 2005; Maccoby & Martin, 1983). Parental support consists of behaviors that express love, appreciation, warmth, acceptance, nurturance, emotional availability, or support autonomy and independence (Schaefer, 1965; Skinner et al., 2005). Psychological control refers to “control that constrains, invalidates, or manipulates children’s psychological and emotional experience and expression” through behaviors such as guilt induction or criticisms (Barber, 1996). While psychological control used to be conceptualized as lying on a continuum with autonomy support on the opposite end, recent research has instead argued that they represent distinct constructs (Silk et al., 2003; Soenens et al., 2009). In keeping with these developments, we distinguished autonomy support, defined as behaviors that encourage independence and individual expression (Silk et al., 2003), from psychological control. Another form of control is behavioral control, which are attempts to regulate children’s behavior by setting consistent expectations and structure such as by setting rules or monitoring (Barber, 1996; Smetana, 2017). Unlike how behavioral control was conventionally broadly defined to also include negative behaviors such as the use of harsh punishment, possibly contributing to inconsistencies with regard to child outcomes, we differentiated behavioral control from reactive control, that is, the use of punitive practices such as yelling, scolding, and physical punishment in response to misbehavior (Janssens et al., 2015; Pinquart, 2017; Spithoven et al., 2016).

In contrast to the dimensional approach which views parenting dimensions as discrete entities, the typological approach organizes multiple parenting dimensions into parenting types. For example, Baumrind (1991), as elaborated by Maccoby and Martin (1983), notably identified four parenting styles that fall along the dimensions of demandingness and responsiveness (parallel to the concepts of control and warmth, respectively): authoritative (high demanding, high responsive), authoritarian (high demanding, low responsive), permissive (low demanding, high responsive), and neglectful (low demanding, low responsive).

With theory and observational data linking parenting with NSSI, the present review aims to consolidate the evidence on the association between parenting behaviors and styles on NSSI in young people.

Methods

Search strategy

A systematic search of bibliographic databases including PubMed, EMBASE (Elsevier), CINAHL Plus (EBSCO), and PsycINFO (Ovid) was conducted on July 27, 2020, to identify articles for this review. Articles were searched from database inception up to July 27, 2020. The following combination of search terms were used, with reference to an earlier review (Arbuthnott & Lewis, 2015): (parent* OR upbringing OR childrearing OR caregiv*) AND (self-harm* OR self-injur* OR self-mutilati* OR NSSI) AND (child* OR youth OR adolescen* OR teen OR student OR young). Deduplication was done on Endnote using the method described by Bramer et al. (2016).

Study selection

Records were screened using Rayyan (Ouzzani et al., 2016). Studies were included if they met the following criteria:

(i) Population: Young persons aged 10–25¹ with a history of NSSI, as identified through self-report or clinical interview.

(ii) Exposure: Parenting behavior or parenting style, reported by parent, child, or independent assessor.

(iii) Comparator: Young persons without history of NSSI (if there is a comparison group).

(iv) Outcome: Incidence, frequency, or severity of NSSI.

The exclusion criteria were i) not distinguishing suicidal from non-suicidal self-injury; ii) self-injury associated with developmental disorders; iii) assessed family functioning rather than parenting specifically; iv) assessed parent–child relationship (e.g., attachment); and v) not full-text research articles (e.g., conference abstracts, case reports, or reviews) or not published in English. Studies that only assessed family functioning or parent–child relationship were excluded because these are proxies for or outcomes of parenting behavior and styles rather than direct measures of them.

Data extraction

The following information was extracted from the included studies: authors, year of publication, country, population sampled, NSSI versus overall sample size, sample age (mean, standard deviation, range), NSSI measure, parenting measure used and informant, and results. We also coded the parenting factors studied based on the measures used.

Results

The database search yielded 1525 unique records, of which 132 were screened in full text. A final tally of 26 studies met the inclusion criteria (see Figure 1 for PRISMA flow diagram (Moher et al., 2009)).

Figure 1.

PRISMA flow diagram.

Characteristics of included studies

Table 1 presents the characteristics of included studies. The studies were published between 2009 and 2019. Of the 26 studies, there were seven longitudinal, 15 cross-sectional, and four case-control studies. Studies were mainly conducted in Belgium, Canada, the United States of America (n = 6 each), and Hong Kong (n = 2). The remaining studies were from Australia, Croatia, Germany, Ireland, the Netherlands, Singapore, South Korea, and Switzerland. Two studies sampled from different countries (Claes et al., 2015; Tschan et al., 2015).

Table 1.

Study Characteristics.

Author (Year)	Country	Population	NSSI/Overall sample size	Age M	Age SD	Age range	NSSI measure
Longitudinal
Baetens, Claes, Onghena, et al. (2014)	Belgium	Community cohort	T1: 72/1397	T1: 12	—	—	1 item: Have you ever intentionally hurt yourself (e.g., cut, burn, scratch), without intent to die?
			T2: 23/827	T2: 13
			T3: 40/754	T3: 14–15
Baetens, Claes, Onghena, et al. (2015)			T3: 40/754	T3: 14–15
Daly & Willoughby (2019)	Canada	University students	T1: 441/1132	T1: 19.06	T1: 0.93	?	Inventory of statements about self-injury
Daly & Willoughby (2019)	Canada	University students	T2: 359/816	T1: 19.06	T1: 0.93	?	Inventory of statements about self-injury
Keenan et al. (2014)	USA	Community girls cohort	131/2180	?	?	13–14	1 item: In the past year, did you hurt yourself on purpose, like cutting or burning, even if you did not mean to die?
Victor et al. (2019)	USA	Community girls cohort	T1: 0/2127	T1: 13	—	—	1 item: Have you ever tried to hurt yourself even if you were not trying to kill yourself, like burning or cutting yourself?
			T2: 44/2127	T2: 14
			T3: 88/2127	T3: 15
			T4: 117/2127	T4: 16
			T5: 137/2127	T5: 17
Wang et al. (2017)	Hong Kong	High school student cohort	T1: 620/3381	T1: 14.50	T1: 1.09	13–17	Behavior checklist: In the past 6 months, have you engaged in the following behaviors to deliberately injure yourself but without suicidal intent?
			T2: 424/3381
			T3: 296/3381
You et al. (2017)	Hong Kong	High school student cohort	T1: 981/5423	T1: 14.63	T1: 1.25	12–18	Behavior checklist: In the past 6 months, have you engaged in the following behaviors to deliberately injure yourself but without suicidal intent?
			T2: 488/3999
			T3: 299/3600
Cross-sectional
Ammerman & Brown (2018)	USA	High school and university students	40/291	High school sample: 15.97	High school sample: 1.22	14–20	Deliberate Self-Harm Inventory (Gratz, 2001)
Ammerman & Brown (2018)	USA	High school and university students	40/291	University sample: 18.47	University sample: 0.67	14–20	Deliberate Self-Harm Inventory (Gratz, 2001)
Baetens, Claes, Martin, et al. (2014)	Belgium	Community cohort	72/1397	12	—	—	1 item: Have you ever intentionally hurt yourself (e.g., cut, burn, scratch), without intent to die?
Baetens, Claes, Hasking, et al. (2015)	Belgium	Secondary school students	48/358	16.07	1.12	12–20	Brief NSSI Assessment Tool
Benau et al. (2017)	USA	University students	172/1352	21.10	3.50	?	Form and Function of Self-Injury Scale
Boričević Maršanić et al. (2015)	Croatia	Adolescent psychiatric outpatients, with PTSD veteran father	252/478	15.23	1.41	12–18	Deliberate Self-Harm Inventory (Gratz, 2001)
Brausch & Gutierrez (2010)	USA	High school students	79/373	15.04	1.05	?Grades 9–12	Self-harm Behavior Questionnaire
Claes et al. (2015)	Belgium & Netherlands	High school students	158/785	15.56	1.32	12–19	Self-Harm Inventory
Depestele et al. (2017)	Belgium	Inpatients of eating disorders unit	32/53	17.98	2.45	14–25	Self-Injury Questionnaire-Treatment Related
Emery et al. (2017)	Canada	High school students	116/639	13.38	0.51	?	How I Deal with Stress Questionnaire
Flett et al. (2012)	Canada	University students	94/319	18.89	2.30	?	Self-Harm Inventory (items from Gratz, 2001 and Sansone et al., 1998)
Hay & Meldrum (2010)	USA	Middle & high school students	75/426	14.99	2.18	10–21	1 item: How often “you purposely hurt yourself without wanting to die” for example, cutting or burning
Kim & Yu (2017)	South Korea	Middle school students	63/717	?	?	?Grades 1–3	Deliberate Self-Harm Inventory (Gratz, 2001)
Mahtani et al. (2019)	Australia	?Mainly tertiary students	220/573	20.72	2.20	18–25	Inventory of Statements About Self-Injury
Martin et al. (2011)	Canada	University students	90/1296	19.29	1.40	17–25	Ottawa Self-Injury Inventory
McLafferty et al. (2019)	Ireland	University students	?/716	20.69	5.31	18–?	Self-Injurious Thoughts and Behaviors Interview
Case-control
Heath et al. (2009)	Canada	University students	23/46	NSSI: 20.22	NSSI: 1.76	N–SI: 18-24	How I Deal with Stress Questionnaire; then items from DSHI (Gratz, 2001)
Martin et al. (2016)	Canada	University students	264/528	NSSI: 19.37	NSSI: 1.53	?17-25	Ottawa Self-Injury Inventory
Martin et al. (2016)	Canada	University students	264/528	No-NSSI: 19.27	No-NSSI: 1.33	?17-25	Ottawa Self-Injury Inventory
Tan et al. (2014)	Singapore	Adolescent psychiatric outpatients	30/60	NSSI: 16.30	NSSI: 1.70	13–19	Assessment by attending psychiatrist
Tan et al. (2014)	Singapore	Adolescent psychiatric outpatients	30/60	Control: 15.97	Control: 1.69	13–19	Assessment by attending psychiatrist
Tschan et al. (2015)	Switzerland & Germany	Inpatient child & adolescent psychiatric units; schools	45/116	16.01	1.64	13–20	Structured interview based on DSM-5 criteria

Note. ? = Unclear.

Sample

Of the seven longitudinal studies, two studies used data from the JOnG! cohort in Belgium (Baetens, Claes, Onghena, et al., 2014, 2015), two studies from the Pittsburgh Girls study (Keenan et al., 2014; Victor et al., 2019), and another two from the same high school student cohort in Hong Kong (Wang et al., 2017; You et al., 2017). While most of the cross-sectional studies sampled from schools (middle school to university), two studies sampled from inpatient or outpatient psychiatric population (Boričević Maršanić et al., 2015; Depestele et al., 2017) and another used cross-sectional data from the JOnG! cohort (Baetens, Claes, Martin, et al., 2014). Among the four case-control studies, cases were recruited from universities (Heath et al., 2009; Martin et al., 2016) and adolescent psychiatric population (Tan et al., 2014; Tschan et al., 2015), while controls were sampled from universities (Heath et al., 2009; Martin et al., 2016), schools (Tschan et al., 2015), and adolescent psychiatric outpatients (Tan et al., 2014). Overall, only four studies recruited NSSI participants from clinical settings while the rest of the NSSI participants were identified from the community.

NSSI measure

To assess for NSSI, the majority (n = 24) relied on participants’ self-report, of which six used a single-item measure (Baetens, Claes, Martin, et al., 2014; Baetens, Claes, Onghena, et al., 2014; 2015; Hay & Meldrum, 2010; Keenan et al., 2014; Victor et al., 2019), four used the Deliberate Self-Harm Inventory (Ammerman & Brown, 2018; Boričević Maršanić et al., 2015; Flett et al., 2012; Gratz, 2001; Kim & Yu, 2017), while the Inventory of Statements About Self-Injury (Daly & Willoughby, 2019; Klonsky & Glenn, 2009; Mahtani et al., 2019) and Ottawa Self-Injury Inventory (Cloutier & Nixon, 2003; Martin et al., 2011, 2016) were each used twice. Additionally, NSSI was assessed in one study by the participant’s attending psychiatrist (Tan et al., 2014) and in another using a structured interview based on DSM-5’s criteria (Tschan et al., 2015).

Parenting measure

Table 2 summarizes the parenting measures used and results of the included studies. The commonly used measures of parenting behaviors were: Psychological Control Scale (n = 4) (Barber, 1996), Parental Behavior Scale (n = 3) (Van Leeuwen & Vermulst, 2004), Parental Bonding Instrument (n = 3) (Parker et al., 1979), Child and Adolescent Social Support Scale (n = 2) (Malecki & Demaray, 2002), Conflict Tactics Scale—Parent/Child Version (n = 2) (Straus et al., 1998), Invalidating Childhood Environment Scale (n = 2) (Mountford et al., 2007), Levels of Expressed Emotion Scale (n = 2) (Cole & Kazarian, 1988; Gerlsma et al., 1992), Parent Behavior Inventory—Hostile/Coercive subscale (n = 2) (Lovejoy et al., 1999), and Perceptions of Parents Scale—Autonomy support subscale (n = 2) (Grolnick et al., 1991). Two studies constructed their own measure (Hay & Meldrum, 2010; McLafferty et al., 2019). Most of the studies relied only on child reports of parenting behavior (n = 22), while three studies used both parent and child report and one study by the parent only.

Table 2.

Parenting Measures and Study Outcomes.

Author (Year)	Parenting measure	Informant	Parenting factor	Results
Longitudinal
Baetens, Claes, Onghena, et al. (2014)	Parental Behavior Scale	C	Positive parenting: Positive behaviors, rules setting (S, BC)	Positive parenting and controlling behavior at T1 not predictive of NSSI at T2 or T3.
Baetens, Claes, Onghena, et al. (2014)	Psychological Control Scale	C	Controlling behavior: Psychological control, harsh punishment (PC, RC)
Baetens, Claes, Onghena, et al. (2015)	Parental Behavior Scale	P	Positive parenting (S)	Positive parenting, rule setting, and punishment (but not harsh punishment) at T1 each positively associated with presence of NSSI at T2
			Rules setting (BC)
			Punishment (RC)
			Harsh punishment (RC)
Daly & Willoughby (2019)	Items from Psychological Control Scale	C	Criticism (PC)	Maternal and paternal criticism not associated with NSSI frequency 1 year later.
Keenan et al. (2014)	Conflict Tactics Scale—parent/Child version: Items on Psychological Aggression subscale and 1 item on spanking	C	Harsh punishment (PC, RC)	Harsh parenting measured initially (age 8), but not change over time (ages 8–12), associated with self-harm at ages 13–14, although OR confidence interval included 1.
Victor et al. (2019)	Conflict Tactics Scale—parent/Child version: Items on Psychological Aggression subscale and 1 item on spanking	C	Nonviolent discipline (BC)	Harsh punishment and low monitoring each associated with increased odds of NSSI onset in the following year, while positive parenting predicted decreased odds. Results only significant in individual univariate analysis but not combined multivariate model.
		C	Harsh punishment (PC, RC)
	Positive Parenting Scale	C	Positive parenting (S)
	Supervision Involvement Scale	C	Monitoring (BC)
Wang et al. (2016)	Parent Behavior Inventory—hostile/coercive subscale	C	“Criticism” (PC, RC)	Higher “criticism” associated with increased odds of being NSSI. “Criticism” did not distinguish NSSI subgroups with different engagement patterns.
You et al. (2017)	Parent Behavior Inventory—hostile/coercive subscale	C	Control (PC, RC)	NSSI higher control than no-NSSI at all 3 timepoints. Control at T1 predicted NSSI at T2 (6 m later), but control at T2 did not predict NSSI 12 m later.
Cross-sectional
Ammerman & Brown (2018)	Levels of Expressed Emotion Scale	C	Emotional support (S)	NSSI lower perceived support, higher irritation, intrusion, criticism, and expressed emotions overall.
			Intrusiveness/control (PC)
			Irritation (PC)
			Criticism (PC)
Baetens, Claes, Martin, et al. (2014)	Parental Behavior Scale	C, P	“Support”: Autonomy, positive parenting, material rewards, rules (S, BC)	Higher child-reported “behavioral control” and psychological control in NSSI than no-NSSI, but no difference in “support.” No difference in parent-reported parenting behaviors. However, parent-reported high “behavioral control” and low “support” (affectionless control) increases probability for NSSI in logistic regression.
	Parental Behavior Scale	C, P	“Behavioral control”: Punishing, harsh punishing, neglect (RC)
	Psychological Control Scale	C, P	Psychological control
Baetens, Claes, Hasking, et al. (2015)	Levels of Expressed Emotion Scale	C	Emotional support (S)	Lack of emotional support directly associated with NSSI frequency and indirectly through depressive symptoms. Criticism only indirectly associated through self-criticism.
Baetens, Claes, Hasking, et al. (2015)	Levels of Expressed Emotion Scale	C	Criticism (PC)
Benau et al. (2017)	Parental Monitoring Scale (modified)	C	Monitoring: Knowledge, solicitation, control, disapproval (BC)	Parental involvement directly associated with increased lifetime NSSI acts, while parental knowledge and solicitation associated with decreased lifetime NSSI acts. Knowledge, control, disapproval, and punishment interacted with child’s sexual orientation to predict lifetime NSSI acts.
			Monitoring: Punishment (RC)
			Monitoring: Involvement (S)
Boričević Maršanić et al. (2015)	Parental Bonding Instrument	C	Care (S)	Low maternal and paternal care and high paternal control associated with increased likelihood of NSSI.
Boričević Maršanić et al. (2015)	Parental Bonding Instrument	C	Control/overprotection (S, PC, BC)
Brausch & Gutierrez (2010)	Child and Adolescent Social Support Scale—parent subscale	C	Support	Higher support in no self-harm group than NSSI-only or NSSI + suicide attempt group. Higher support in NSSI-only than NSSI + suicide attempt group.
Claes et al. (2015)	Relational Support Inventory	C	Support	NSSI reported lower support than no-NSSI group. Associations between bullying and victimization with NSSI, and between depressive mood and NSSI, decreased for adolescents that perceive parents as more supportive.
Depestele et al. (2017)	Psychological Control Scale	C, P	Psychological control	No association found between maternal or paternal psychological control and autonomy support with NSSI.
Depestele et al. (2017)	Perceptions of Parents Scale—autonomy support subscale	C, P	Autonomy support (S)
Emery et al. (2017)	Perceptions of Parents Scale—autonomy support subscale	C	Autonomy support (S)	Low autonomy support directly predicted NSSI engagement and partially mediated by difficulties in emotion regulation.
Flett et al. (2012)	Frost Multidimensional Perfectionism Scale	C	Criticism (PC)	Criticism correlated with increased self-harm in women but not men.
Flett et al. (2012)	Frost Multidimensional Perfectionism Scale	C	Expectations (PC, BC)
Hay & Meldrum (2010)	Study-specific scale	C	Authoritative parenting	Authoritative parenting negatively predicted self-harm and moderated the relationship between traditional bullying and self-harm.
Kim & Yu (2017)	Parenting Attitude II of Korean Children & Youth Panel Survey (2015)	C	Neglect (uninvolved) parenting	Higher uninvolved and abusive parenting in NSSI than no-NSSI group. Only abusive parenting predictive of NSSI in logistic regression.
Kim & Yu (2017)		C	Abusive parenting
Mahtani et al. (2019)	Invalidating Childhood Environment Scale	C	Invalidation	Higher maternal and paternal invalidation in NSSI than no-NSSI group. Both maternal and paternal invalidation associated with increased odds of recent NSSI.
Martin et al. (2011)	Parental Bonding Instrument	C	Care (S)	Lower maternal and paternal care and higher maternal control in NSSI than no-NSSI group. No difference for paternal control. Results for females mirrored overall sample; no difference in paternal care for males.
Martin et al. (2011)	Parental Bonding Instrument	C	Control/overprotection (S, PC, BC)
McLafferty et al. (2019)	Study-specific scale	C	Overcontrol (BC)	Overcontrol, but not overprotection or overindulgence, interacted with current stress to predict increased odds of self-harm.
			Overprotection (S)
			Overindulgence (S, BC)
Case-control
Heath et al. (2009)	Child and Adolescent Social Support Scale—Parent subscale	C	Support	No difference between NSSI and comparison group on support. No correlation between support and lifetime frequency of NSSI.
Martin et al. (2016)	Parental Bonding Instrument	C	Care (S)	Self-injurers in 2 latent class profiles characterized by negative parent-child relational patterns reported lower maternal and paternal care and higher maternal control than non-self-injurers. In one of the profiles, self-injurers also reported higher paternal control. A smaller profile of self-injurers reported extremely positive perceptions: Higher parental care and lower control that non-self-injurers.
Martin et al. (2016)	Parental Bonding Instrument	C	Control/overprotection (S, PC, BC)
Tan et al. (2014)	Invalidating Childhood Environment Scale	C	Invalidation	Higher maternal and paternal invalidation in NSSI than control.
Tschan et al. (2015)	Zurich Short Questionnaire on Parental Behavior	C, P	Warmth and support (S)	Lower child-reported maternal warmth and support in NSSI than non-clinical controls, but not different from clinical controls. No significant difference in child-reported paternal warmth and support and both maternal and paternal psychological control and behavioral control.
			Psychological control
			Behavioral control

Note. C = Child; P = Parent; BC = Behavioral Control; PC = Psychological Control; RC = Reactive Control; S = Support.

Parental support

Of the 13 cross-sectional and case-control studies that examined parental support, nine (69%) found an association between low parental support and NSSI (Ammerman & Brown, 2018; Baetens, Claes, Hasking, et al., 2015; Boričević Maršanić et al., 2015; Brausch & Gutierrez, 2010; Claes et al., 2015; Emery et al., 2017; Martin et al., 2011; Martin et al., 2016; Tschan et al., 2015). In particular, low parental support was associated with increased likelihood of NSSI (Boričević Maršanić et al., 2015) and increased NSSI frequency (Baetens, Claes, Hasking, et al., 2015). Further, one of the studies found this significant difference on parental support only between NSSI and non-clinical controls, but not between NSSI and clinical controls with other mental disorders (Tschan et al., 2015), and in another, further analysis by gender revealed that the overall negative association did not hold for paternal support and male participants, suggesting a gender difference (Martin et al., 2011). It was also noted that in one study that used latent class analysis to classify NSSI participants, although participants in the largest profile did report lower parental support than comparison non-self-injurers, a relatively smaller profile (termed “positive-idealistic”) demonstrated the opposite trend: participants reported significantly higher parental support compared to comparison (Martin et al., 2016). In a similar vein, one study reported that increased parental support (in terms of parental involvement in the child’s life) is associated with increased lifetime NSSI (Benau et al., 2017). In contrast, three studies reported no difference between NSSI and control group on parental support (Depestele et al., 2017; Heath et al., 2009; McLafferty et al., 2019).

With regard to longitudinal evidence, one study similarly reported that support decreased the likelihood of NSSI onset (Victor et al., 2019). However, another study found that parent-reported support was positively associated with presence of NSSI 1 year later (Baetens, Claes, Onghena, et al., 2015).

Psychological control

Four of the seven studies (57%) that looked at psychological control reported a significant association with NSSI (Ammerman & Brown, 2018; Baetens, Claes, Hasking, et al., 2015; Baetens, Claes, Martin, et al., 2014; Flett et al., 2012). In particular, higher parental criticism was directly associated with NSSI (Ammerman & Brown, 2018) and indirectly through self-criticism (Baetens, Claes, Hasking, et al., 2015). However, one study found the association between NSSI and criticism only in women, but not men (Flett et al., 2012). Other than criticism, high intrusiveness and irritation (Ammerman & Brown, 2018) were also reported to be associated with NSSI. In contrast, one longitudinal study reported that parental criticism was not associated with NSSI frequency (Daly & Willoughby, 2019), while one cross-sectional and one case-control study did not find any significant association between psychological control and NSSI (Depestele et al., 2017; Tschan et al., 2015).

Behavioral control

Of the five studies that examined behavioral control, two found support of a negative association between behavioral control and NSSI (Benau et al., 2017; Victor et al., 2019), two reported a positive association (Baetens, Claes, Onghena, et al., 2015; McLafferty et al., 2019), and one reported null results (Tschan et al., 2015). Specifically, low monitoring was prospectively associated with increased odds of NSSI onset in the following year in one study (Victor et al., 2019). In another study, parental knowledge and solicitation of child’s daily activities (both aspects of monitoring) were associated with decreased number of lifetime NSSI acts (Benau et al., 2017). In contrast, one study reported that perceiving parents as overcontrolling interacted with current stress to predict increased odds of NSSI (McLafferty et al., 2019). Further, one longitudinal study found that parent-reported rule setting was positively associated with NSSI 1 year later (Baetens, Claes, Onghena, et al., 2015). This result could possibly be attributed to social desirability bias on the part of the parent or, as the authors argued, a negative cognitive bias when parenting behaviors are reported by NSSI youths (Baetens, Claes, Onghena, et al., 2015).

Reactive control

Two of the three studies that examined reactive control found significant associations with NSSI (Baetens, Claes, Martin, et al., 2014; Baetens, Claes, Onghena, et al., 2015). In one study, punishment, but not harsh punishment, reported by the parent was positively associated with the presence of NSSI 1 year later (Baetens, Claes, Onghena, et al., 2015). In another study, the NSSI group reported higher reactive control than the control group, although this difference was not found for parent-reported reactive control (Baetens, Claes, Martin, et al., 2014). For the remaining study, although parental punishment did not directly predict the number of lifetime NSSI acts, it interacted with child’s sexual orientation such that at high parental punishment, the number of lifetime NSSI acts increased as sexual orientation moved from gay to heterosexual (Benau et al., 2017).

Combination constructs

Eleven studies employed measures that assessed constructs that straddled across parenting dimensions. Three studies used the Parental Bonding Instrument that assessed a construct labeled “control/overprotection,” encompassing autonomy support, psychological control, and behavioral control. These studies found that a high level of this construct (i.e., low autonomy support coupled with high psychological and behavioral control) from the father (Boričević Maršanić et al., 2015; Martin et al., 2016) and the mother (Martin et al., 2011, 2016) were associated with NSSI. Apart from these, Martin et al. (2016) also found that a minority of self-injurers perceived significantly lower control/overprotection than their non-self-injuring counterpart, a counterintuitive result that remains to be explored. Five longitudinal studies examined controlling behaviors that included psychological and reactive control, four of which found that such behaviors were associated with NSSI: such control was associated with increased odds of NSSI (Victor et al., 2019; Wang et al., 2017) and predicted NSSI 6 months (You et al., 2017) and 5 years later (Keenan et al., 2014). The remaining study did not find such controlling behaviors to be predictive of NSSI 1 or 2 years later (Baetens, Claes, Onghena, et al., 2014). In addition, three studies examined a construct that covered both support and behavioral control, none of which found any significant association with NSSI (Baetens, Claes, Martin, et al., 2014; Baetens, Claes, Onghena, et al., 2014; McLafferty et al., 2019). Last, one study that examined a construct that encompassed both psychological and behavioral control did not find any significant association with NSSI (Flett et al., 2012).

Parenting styles

Five studies reported how different parenting styles are associated with NSSI (Baetens, Claes, Martin, et al., 2014; Hay & Meldrum, 2010; Kim & Yu, 2017; Mahtani et al., 2019; Tan et al., 2014). Among them, two examined invalidating parenting using the Invalidating Childhood Environment Scale (Mountford et al., 2007). Both studies reported higher maternal and paternal invalidation in the NSSI group compared to the no-NSSI group (Mahtani et al., 2019; Tan et al., 2014). Further, invalidation was associated with increased odds of recent NSSI engagement (Mahtani et al., 2019). Other than invalidation, NSSI participants also reported higher uninvolved and abusive parenting (Kim & Yu, 2017), while authoritative parenting was found to negatively predict NSSI (Hay & Meldrum, 2010). In another study, parent-reported “affectionless control,” a combination of high reactive control and low support and behavioral control, increases the probability of NSSI in a binary logistic regression (Baetens, Claes, Martin, et al., 2014).

Discussion

The aim of the present study was to review whether various parenting behaviors and styles are associated with NSSI in young persons. Overall, there is evidence to suggest that low parental support, high psychological control, and high reactive control are each associated with NSSI. In comparison, the evidence for behavioral control remains equivocal. Previous reviews on family factors for self-harm in general have similarly identified a negative association between parental support and self-harm (Buckmaster et al., 2019; Fortune et al., 2016). Our findings are also consistent with those reported in the wider adolescent psychopathology literature. For example, low parental support (Gorostiaga et al., 2019; Pinquart, 2017; Yap et al., 2014), high psychological control (Gorostiaga et al., 2019; Pinquart, 2017), and high reactive control (Gorostiaga et al., 2019; Pinquart, 2017) have likewise been linked with internalizing and externalizing disorders in adolescents.

Unlike parenting behaviors, we did not find many studies that examined parenting styles and are thus unable to comment on the association between parenting styles and NSSI. The lack of studies on parenting styles was unexpected, given the influence that parenting typologies such as that by Baumrind have in the wider parenting literature. Future research could fill this gap by delving into how different parenting behaviors interact to affect the association between parenting and NSSI. There was similarly a stark absence of studies that examined invalidating caregiving environments and how it relates with NSSI, in contrast to the authority Linehan’s biosocial theory wields in the wider BPD and suicidal behavior research. Of the two studies that did, both found support that invalidating parenting is associated with NSSI. Although some included studies framed their discussion in terms of Linehan’s invalidating environment, the measures used (e.g., Parent Bonding Instrument) poorly map to the components of an invalidating environment described by Linehan (Musser et al., 2018) and were thus listed under specific parenting dimensions instead. More research on the association between invalidation and NSSI, using measures that are aligned with Linehan’s description of invalidation, is needed.

It was observed that the majority of the included studies recruited from Western samples, whereas just four studies were based in Asia. This can be problematic because parenting behaviors are very much influenced by social mores and variations exist in what is considered normative between cultures (Bornstein, 2013). Perception of normativeness of parenting behaviors by the child can also potentially moderate the relationship between the parenting behavior and child mental health outcomes like NSSI (Bornstein, 2013). Rather than generalizing observed associations between parenting behaviors and NSSI in Western cultures as universals, it is imperative to conduct more cross-cultural research involving non-Western samples to better understand the universality of these associations and how culture might potentially moderate these relations.

Our review also revealed that most of the included studies assessed parenting behavior only from the child’s perspective, with just four studies collecting parent reports. The limited evidence available suggests that results based on parent-reported parenting behaviors can be diametrically different from results using child reports. For example, Baetens, Claes, Martin, et al. (2014) found that although the NSSI group reported higher parental reactive control and psychological control, this difference was not found for parent reports. In Baetens, Claes, Onghena, et al. (2015), it was even reported that parental support and rules setting were positively associated with NSSI, a result that ran counter to other studies. The authors suggested that child reports can be problematic because of “negative cognitive biases of adolescents in distress” that can skew their responses (Baetens, Claes, Onghena, et al., 2015). Discrepancies in parent-child reports are unsurprising as it has been widely reported in the literature (Korelitz & Garber, 2016). However, what remains unclear is how to make sense of this discrepancy. Are child reports unreliable or are parents oblivious? Which would be a better predictor of NSSI? Some researchers have further argued that it may be the discrepancy itself that is indicative of family dysfunction and better predictive of child outcomes (Gaylord et al., 2003; Guion et al., 2009). Regardless, it is generally agreed that obtaining data from multiple informants (e.g., both parent and child) is better than relying on a single source (Gonzales et al., 1996; Taber, 2010), something that is lacking in most of these studies. Moving forward, more studies using a multi-informant approach is needed to clarify how such discrepancies in parent and child reports may relate with NSSI.

It is implicitly assumed both in the body of cross-sectional studies and in our discussion that parenting behaviors are independent from the child’s NSSI behavior. However, emerging data from longitudinal studies (including some in this review) reveal a reciprocal relationship: knowledge of child’s NSSI engagement can modify parenting behaviors, for example, by eliciting more parental control (Baetens, Claes, Onghena, et al., 2014; 2015; You et al., 2017) and parental support (Baetens, Claes, Onghena, et al., 2015). Such findings question the validity of interpreting results from cross-sectional studies, as it is unclear if the reported parenting behavior existed long before or after the NSSI onset. Furthermore, as discussed by Baetens and colleagues (Baetens, Claes, Onghena, et al., 2015), it remains to be seen whether an increase in conventionally positive parenting behaviors (e.g., parental support) in response to the child’s NSSI would turn out to be beneficial or detrimental to the child, in light of functional theories of NSSI such as that by Nock and Prinstein that suggests that NSSI can be socially reinforced (Nock & Prinstein, 2004). To address this, future research could consider utilizing a longitudinal study design and collecting data from the pre-adolescence period way before NSSI tends to occur to better establish the temporal association for parenting and NSSI.

Our findings suggest that the psychological treatment of youths with NSSI needs to expand beyond just helping the individual to regulate emotions or cope using more adaptive behaviors. Rather, a systemic approach that also involves parents or caregivers would be beneficial to treatment. For example, psychoeducation may be conducted to help parents understand the potential role of parenting behaviors on the development of NSSI, while parenting workshops may be introduced to help them acquire more adaptive parenting skills. For youths whose families are unable or unwilling to participate in treatment, individual psychological interventions could then target their interpersonal effectiveness skills in the management of highly conflictual or emotional family situations or improving their capability to self-validate and recover from an invalidating environment.

Strengths and limitations

This systematic review was not without limitations. First, due to the plethora of terms used in the parenting literature as well as some inconsistent use of those terms, we organized the various parenting measures under higher-order parenting dimensions it appears to be measuring (i.e., support, psychological control, behavioral control, reactive control). While such an approach is in line with what has been done in earlier reviews and may help bring clarity to the extensive parenting literature, it may also have inadvertently misrepresented some of the concepts that the authors intended. Second, the wide variety of parenting measures and NSSI assessment tool used precluded a quantitative synthesis of the results.

Conclusion

In this review of parenting behaviors and styles, parenting that is low on support and high on psychological and reactive control was independently associated with NSSI in young people. The limited evidence on invalidating parenting also suggests an association with NSSI. As it stands, interventions involving parents of youths with NSSI could focus on psychoeducation about the potential role of parenting behaviors on the development of NSSI and helping them to acquire more adaptive parenting skills.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by grants from the National University of Singapore’s Mind Science Centre.

ORCID iD

Zhi Hui Fong

Note

Author biographies

Zhi Hui Fong was a research assistant at the Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore. He received his Bachelor’s degree in psychology from the National University of Singapore.

Wan Ning Charisse Loh is a Medical Officer currently rotating through the National University Healthcare System.

Ying Jie Fong is a research assistant in the Yong Loo Lin School of Medicine at the National University of Singapore. Her current research focuses on prevention strategies for dementia.

Hui Ling Michelle Neo is a Senior Clinical Psychologist from the National University Hospital, Singapore. Her clinical interest is in the treatment of clients with borderline personality disorder, and post-traumatic stress disorder.

Tji Tjian Chee is a Child and Adolescent Consultant Psychiatrist, in the Department of Psychological Medicine, National University Hospital Singapore. He obtained his General Psychiatry training from the South London and Maudsley NHS Trust, and specialised in Child and Adolescent Mental Health at the Tavistock and Portman NHS Trust. He further obtained Masters in Psychiatric Research and a Diploma in Family Systemic Therapy, during these residency training in London.

Chee has a broad range of clinical, teaching and research interest in youth and young adults, including (i) Family Systemic Therapy; (ii) Behavioural and Addiction Psychiatry; (iii) Clinical Liaison Psychiatry; (iv) Cultural Psychiatry; (v) Global Systems Mental Health. He is keen for clinical and research collaborations, both locally and internationally.

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