Research paperDigital media use and subsequent self-harm during a 1-year follow-up of Chinese adolescents
Introduction
Self-harm refers to intentional self-poisoning or self-injury, irrespective of type of motive or the extent of suicidal intent (Hawton et al., 2003), including suicide attempt and non-suicidal self-injury (NSSI). Self-harm among youth is prevalent, with 2–15% of adolescents having attempted suicide or afflicted self-harm (Hawton et al, 2012; Kann et al., 2016; Liu et al., 2019a). Although most self-harms are low in lethality, they are associated with clinical and functional impairments and are significant predictors of future self-harm and suicide (Gould et al., 2003; Hawton et al., 2012). It is therefore essential to identify modifiable risk factors to develop effective intervention programs for youth self-harm prevention.
In the modern society, digital media transmitted over the internet, computer network, mobile/smart phone, tablet, and/or television (TV) has become an essential source for communication, socialization and education. Internet use in the world has increased considerably over the past few decades, especially among youth (Kaess et al., 2014). According to Per Research Center, 92% of teens in the U.S. report going online daily - including 24% who say they go online “almost constantly” (Lenhart et al., 2010). Digital media use has a mixed effect on pediatric population's well-being, with evidence of increased self-esteem and perceived social support alongside harmful effects such as increased exposure to graphic content, cyber-bullying, and risk of developing online addictive behaviors (Best et al., 2014; Kaess et al., 2014; Tonioni et al., 2012). Excessive digital media use may have a detrimental impact on adolescents’ psychosocial development and mental health (Kaess et al., 2014; Liu et al., 2019b), school performance (Liu et al., 2020), sleep disturbances, and multiple risk-taking behaviors such as disordered eating and substance abuse (Levenson et al., 2016; Park et al., 2018). High profile cases of cyber-bullying and suicide over the past decade (Lester et al., 2013) and reports of suicide clusters facilitated by social media (Robertson et al., 2012) have caused an increased attention to better understand the association between internet use and self-harm/suicide.
Recent studies have demonstrated significant associations between pathological internet use or internet addition and self-injury (Lam et al., 2009) and suicidal behaviors (Kaess et al., 2014; Lin et al., 2014; Marchant et al., 2017). It has also been reported that rates of internet use were higher among adolescents who self-harm than their peers who do not use the internet as much (Daine et al., 2013). A study examined the social dynamics surrounding media reporting on suicide in a suicide-prone community (Poplar Grove, USA) with an enduring adolescent suicide problem and found that suicide deaths that were covered by digital media triggered significant cognitive dissonance, which may generate opportunities for peer role modeling of suicide (Mueller, 2017). Celebrity suicides that generate a large reaction from users on Twitter can also increase suicide risk (Ueda, 2017).
A recent review of the association between social media, internet use, and suicide attempts in adolescent includes nine cross-sectional studies published between 2012 and 2018, and concludes an independent association between problematic use of social media/internet and suicide attempts in young people (Sedgwick et al., 2019). However, to our best knowledge, most previous studies are cross-sectional so that the direction of causality, if any, remains unclear, as such further evaluation through longitudinal studies is warranted; and they have been focused on pathological internet use or internet addiction (Lam et al., 2009; Liu et al., 2017a; Park et al., 2013), and their findings are not consistent. To address these limitations, we conducted a longitudinal study with a large community sample of adolescents in China (n = 7,072) to examine the prospective association between digital media use (television watching, internet use, and mobile phone use) and subsequent self-harm, including suicide attempt and NSSI over a 1-year follow-up.
Section snippets
Participants and procedure
Shandong Adolescent Behavior & Health Cohort (SABHC) is a longitudinal study of adolescent behavior and health in Shandong, China. A total of 11,831 adolescent students participated in SABHC baseline survey. Detailed sampling and data collection have been published elsewhere (Liu et al., 2018, 2019a,b). In brief, participants were sampled from 5 middle and 3 high schools in 3 counties of Shandong province, with considerations of representativeness of the schools across the counties, prior study
Sample characteristics
Of the 8,629 7th-8th graders and 10th graders who participated in the baseline survey, 7,072 (82.0%) were resurveyed at the 1-year follow-up and were included for the analysis. The primary reason for loss to follow-up was that some participants went to different classes/schools. However, baseline adolescent and family demographic characteristics (including age, gender, smoking, drinking, family history of suicide, father's education and occupation, and family economic status) were similar
Discussion
To our knowledge, this is the first study to prospectively examine the association between digital media use and subsequent self-harm in a large sample of Chinese adolescents. Our major findings are 1) internet use ≥ 2 h/day on weekdays and ≥ 3 h at the weekend were associated with an increased risk of recurrent self-harm at 1-year follow-up after adjusting for adolescent and family covariates; 2) mobile phone use ≥ 2 h/day on weekends were associated with increased risk of recurrent self-harm;
Contributors
Liang Wang drafted the manuscript and helped to conceive the research questions and data analyses. Xianchen Liu conceived of the idea and research questions and contributed to data analyses and the manuscript writing. Zhen-Zhen Liu contributed to data collection, data management, and data analyses. Cun-Xian Jia supervised data collection and data management and contributed to developing research questions and drafting the manuscript. All authors approved the final article.
Financial Support
This work was supported in part for data collection by the National Natural Science Foundation of China (grant number 81573233), and Shandong University School of Public Health Third Level Discipline Infrastructure Project Fund (grant number 2017-08).
Availability of Data and Materials
Please contact Dr. Cun-Xian Jia at [email protected] for data supporting the findings of the study.
Conflicts of Interest
None.
Acknowledgment
The authors would like to thank staffs at Yanggu County Center for Disease Control and Prevention, Lijin County Center for Disease Control and Prevention, and Zoucheng City Center for Disease Control and Prevention, Shandong Province, China and all participating school teachers for their help with data collection and all students for their voluntarily participating in the study.
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