Liu et al. BMC Pediatrics(2024) 24:524
https://doi.org/10.1186/s12887-024-04986-7

BMC Pediatrics

RESEARCH

Open Access

The mediating effects of school bullying
victimization in the relationship between
childhood trauma and NSSI among
adolescents with mood disorders
Yue Liu1,2,3 , Xueqian Xu1,3, Xiaodan Huang1,3, Qingxiao Hong1,2,3, Longhui Li1,2,3, Xiaohu Xie1,2,3, Weisheng Chen1,2,3,
Wenwen Shen1,2,3, Huifen Liu1,2,3* and Zhenyu Hu1,3*
Abstract
Background Nonsuicidal self-injury (NSSI) is a serious problem in the adolescent population worldwide. Childhood
trauma and bullying have been identified as risk factors for NSSI. We explored the relationships among Childhood
trauma, Bullying victimization and the severity of NSSI behaviours, and test the effect of Bullying victimization inmediating the association between Childhood trauma and the NSSI behaviours.
Methods A total of 123 adolescents were recruited. They were diagnosed with depression or depressive episodesof bipolar disorder and had experienced NSSI in the last year. They were assessed using the Chinese version of theChildhood Trauma Questionnaire (CTQ-C), the Revised Olweus Bullying Victimization Questionnaire (OBVQ-R), and theAdolescent Self-Harm Questionnaire (ASHQ).
Results Females presented a significantly greater prevalence of sexual abuse and relationship bullying than boys.
Individuals in the younger age group (10–14 years) presented a greater incidence of emotional neglect, verbal
bullying, relationship bullying, and total bullying, and their NSSI score was also higher than that of those in the older
age group (15–19 years). Only children show a greater prevalence of sexual abuse than nononly children. Singleparent families scored higher on emotional abuse, emotional neglect, physical neglect and physical bullying than
two-parent families. There was a significant positive correlation between each dimension of childhood trauma and all
the dimensions of bullying, between childhood trauma and NSSI, and between bullying and NSSI. Childhood trauma
can not only directly affect the severity of NSSI but also indirectly aggravate the severity of NSSI through bullying
victimization. The mediating effects of bullying victimization on emotional abuse, physical abuse, emotional neglect
and physical neglect were 14%, 21%, 20%, 13% and 20%, respectively.
Conclusion There was a significant positive correlation between childhood trauma and bullying, between childhood
trauma and NSSI, and between bullying and NSSI. Childhood trauma can not only directly affect the severity of NSSI*Correspondence:
Huifen Liu
lihufen@163.com
Zhenyu Hu
hzy86690952@163.com
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://
creativecommons.org/licenses/by-nc-nd/4.0/.

Liu et al. BMC Pediatrics(2024) 24:524

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but also indirectly aggravate the severity of NSSI through bullying victimization. Bullying victimization played thepartial mediating effects between Childhood trauma and NSSI.
Keywords Childhood trauma, Bullying victimization, Nonsuicidal self-injury, Mediating effect, Depression

Background
NSSI is deliberate damage to the surface of the skin (e.g.,
cutting, scratching, or burning) without suicidal intent[1]. Furthermore, NSSI has been identified as a risk factor for suicide in several studies [2]. Because young people’s physiological and psychological development is notcomplete, adolescents who experience higher levels of
subjective psychological distress in response to adverseor stressful situations and who are less capable of tolerating distress are at increased risk of engaging in NSSI
[3]. Studies have found that NSSI is very common among
adolescents, with international lifetime prevalence rates
of approximately 17.2% [4]. An epidemiological survey inChina also revealed that the self-harm rate among young
people in rural areas was 13.5% in 2015–2016 [5].And
another study in China showed that its prevalence has
been to 15.9% among adolescents in urban areas [6].
NSSI is associated with a variety of psychiatric diagnoses and behavioural concerns. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5),
has identified a independent code to be applied as a
specifier to any nosographic diagnosis.The pathogenesis
of NSSI is still unclear. The risk factors leading to NSSI
behaviours in adolescents involve many factors, such associety, family and individuals [7].School bullying andchildhood trauma seem to be the most common factors
experienced by those engaging in NSSI .
Bullying is defined by Olweus [8] as an “intentional,
repeated, negative (unpleasant or hurtful) behaviour by
one or more persons directed against a person who has
difficulty defending himself or herself ”. Multiple studies support a positive association between bullying victimization and NSSI [9, 10]. The greater the frequencyof bullying is, the greater the risk of NSSI [11]. A large
sample meta-analysis [12] showed that the probabilityof NSSI among bullied adolescents was 2.1 times higher
than that of the general population.
Childhood trauma has five forms: physical abuse,emotional abuse, sexual abuse, emotional neglect, andphysical neglect. To date, most evidence has shown thatemotional abuse and neglect are related to engagement
in NSSI [13].The experience of at least one type of childhood trauma was reported by approximately 30% of thegeneral population of Germany in two independent studies [14, 15]. In another study, among participants with alifetime history of NSSI, approximately 65% reported atleast one type of trauma. Approximately 50% of patients
reported multiple types of trauma, while this was true forapproximately only 12% of the general population [16].

A large body of research [17–20] has shown that childhood trauma can not only directly affect the occurrence of adolescent NSSI but also indirectly affect NSSI
through mediating factors. In turn, several potential
mediators of the relationship between trauma and NSSI
have been identified, including dissociation, self-esteem,
depression, alexithymia, shame, self-criticism, pessimism[21, 22]. However, studies on the mediating role of bullying in the relationship between childhood trauma and
NSSI in adolescents are still scarce.
In addition, it is worth noting that individuals withmental disorders have a high prevalence of NSSI. According to one study, 87.6% of adolescents with NSSI are firstdiagnosed with psychiatric diseases [23]. A meta-analysis
revealed a 17.2% prevalence of NSSI in nonclinical samples of community adolescents [4] and 35–80% among
clinical adolescents [24]. It is believed that NSSI might beoverrepresented in clinical samples such as those adolescents with mental disorders. Therefore, the current study
included patients with depression or depressive episodesof bipolar disorder as our research objects. We aimed to
explore the relationships among childhood trauma, bullying victimization and the severity of NSSI behaviours,
and test the effect of bullying victimization in mediating
the association between childhood trauma and the NSSI
behaviours.

Methods
ParticipantsThis study was approved by the ethics committee ofthe Affiliated Kangning Hospital of Ningbo University in accordance with the Declaration of Helsinki,
and all participants and/or their guardians provided
written informed consent. The ethics trial number is
NBKNYY-2020-LC-52.
Participants were recruited from the outpatient or
inpatient department of the Affiliated Kangning Hospital of Ningbo University from January 2022 to December
2023. These individuals had been diagnosed as depression or depressive episodes of bipolar disorder according
to the International Classification of Diseases 11th Revision( ICD-11) Diagnostic Criteria and had experienced
NSSI behaviour in the last year. The inclusion criteria
were as follows: (1) aged between 12 and 19 years withNSSI behaviour in the last year; (2) met the diagnostic
criteria for NSSI in the DSM-5; (3) were diagnosed withdepression or depressive episodes of bipolar disorder by
an attending psychiatrist or above; and (4) did not haveverbal communication barriers. The exclusion criteria

Liu et al. BMC Pediatrics(2024) 24:524

were as follows: (1) had psychotic symptoms or severe
mental disorders; (2) had a history of suicide attempts; (3)had serious physical illness; and (4) had a history of substance abuse. A total of 130 subjects were recruited, and123 participants provided valid questionnaires. 3 participants data were removed due to data coding errors.4 participants Questionnaires were excluded due to obvious
logic errors or omissions of more than 15%.
Measurements

All information was collected using the General Demographic Information Questionnaire (GDIQ), Chinese
Version of Childhood Trauma Questionnaire (CTQ-C),
Revised Olweus Bullying Victimization Questionnaire(OBVQ-R) and Adolescent Self-Harm Questionnaire(ASHQ) conducted by qualified psychologists.
General Demographic Information Questionnaire (GDIQ)We used open questions in the GDIQ to explore demographic information and the disease type currently
diagnosed (depression or depressive episodes of bipolar
disorder). The GDIQ is actually a record of an interview
between a doctor and a subject. We set up numerous
related questions. The data collected included gender,
age, academic performance, basic information on thefamily and current disease type, etc.
Chinese version of the Childhood Trauma Questionnaire(CTQ-C)The CTQ is a screening tool developed by Bernstein forassessing childhood trauma [25]. The CTQ-C was translated and revised by Zhao Xingfu in China and shows
good reliability and validity, meaning it can be used toassess the severity of childhood trauma in Chinese adolescents [26]. The CTQ-C has 28 items and a five-factor
superstructure. It contains five subscales, each assessedby five items, including physical abuse, emotional abuse,sexual abuse, physical neglect and emotional neglect.
Each participant was asked to answer questions thatmeasured the severity of childhood trauma. They werealso asked to rate the extent of the stated questions. Each
item is answered on a 5-point scale. “Never” is assigned ascore of 1, “occasionally” is assigned a score of 2, “sometimes” is assigned a score of 3, “often” is assigned a scoreof 4, and “always” is assigned a score of 5. Individuals witha physical abuse score ≥ 10, an emotional abuse score ≥ 13,
a sexual abuse score ≥ 8, a physical neglect score ≥ 10, or
an emotional neglect score ≥ 15 (i.e., if any of the subscalescores meet the above criteria) can be regarded as having experienced moderate to severe childhood trauma.
Higher scores indicate greater childhood trauma. In thepresent sample, the Cronbach’s α coefficient of internalconsistency of this scale was 0.853.

Page 3 of 11

Revised Olweus Bullying Victimization Questionnaire(OBVQ-R)

The Olweus Bully/Victim Questionnaire is one of themost widely used instruments to measure adolescents’bullying perfusion/victimization [27]. It was revised byZhang Wenxin et al. in China. The scale has demonstrated good reliability and validity among Chinese adolescents [28]. The scale included two subscales: bullying
perpetration and bullying victimization. We used the latter (OBVQ-R) in the current study. The “bullying” mentioned in the remainder of this article refers to “bullying
victimization”. Bullying victimization was assessed with
six items in total, covering three types: physical bullying(questions 3 and 5), verbal bullying (questions 1 and 6),
and relationship bullying (questions 2 and 4).
Participants were asked how often they had experienced different types of bullying in the past year, and the
response options included the following: 0 = never in thepast year, 1 = only once or twice; 2 = two or three times amonth; 3 = approximately once a week; 4 indicates how
many times per week 2 = happened a year ago, 3 = a few
times within a year, and 4 = a few times a week. If an individual scored ≥ 2 points on any one of the six questions,they were classified as having been victims of bullying.
Higher total scores indicate more severe bullying. The
Cronbach’s α in the sample for the bullying victimization
subscale was 0.807.
Adolescent Self-Harm Questionnaire (ASHQ)

The ASHQ is a self-reported measure developed byZheng Ying and then revised by Feng Yu [29] for assessing NSSI behaviour in the past year. The ASHQ has good
reliability and validity [30]. It assess the prevalence of
18 types of NSSI behaviour. Each participant was asked
to answer questions that measured the frequency andextent of harm to the body or NSSI behaviour separately. According to the frequency of NSSI, 0 points arerecorded for 0 times, 1 point for 1 time, 2 points for 2 to
4 times, and 3 points for 5 times or more. The extent ofharm to the body was divided into 5 levels, namely, none,
mild, moderate, severe and extremely severe, which wererecorded as 0, 1, 2, 3 and 4 points, respectively. The sumof all the products (frequency multiplied by harm extent)
represents the participant’s NSSI score. If the score is
not 0, self-injury behaviour is determined, with higher
numbers indicating higher levels of NSSI. In the present
study, the Cronbach’s α coefficient for the internal consistency of this scale was 0.940.
Statistical analyses

We performed statistical analyses using SPSS version
26.0. The Cronbach’s alpha coefficient was utilized toassess the internal consistency among the items of eachscale. Descriptive statistical analysis was performed toLiu et al. BMC Pediatrics(2024) 24:524

determine the prevalence rates of childhood trauma,
school bullying and NSSI.
The Kolmogorov-Smirnov test is used to evaluate thenormality of the data distribution. In cases of non-normal distribution, non-parametric tests were employed.
To examine the differences in childhood trauma, school
bullying and NSSI across demographic variables, we used
the Mann-Whitney U test for two-group comparisonsand the Kruskal-Wallis H test for multi-group comparisons. For the academic performance variable, significancevalues were adjusted by using Bonferroni correction toaccount for multiple comparisons.
Pearson correlation was conducted to analyse the relationships among childhood trauma, school bullying andthe severity of NSSI. Additionally, Five path analysis
models were used to examine the influence of five typesof childhood trauma as independent variables on NSSI,
with school bullying serving as a mediating variable.
These models were constructed using stepwise linear
regression and validated through. the bootstrap method,respectively.

Results
Demographics

A total of 130 participants and the effective response
rate of the questionnaires was 94.62%. The participants
ranged in age from 12 to 19 years, The mean ± standard
deviation of age was 15.37 ± 1.72. A detailed descriptionof the participants’ general demographic information canbe found in Table 1.
Characteristics of childhood trauma, bullying and NSSI

According to the criteria mentioned above, 93 participants (75.6%) reported having experienced at least one
type of childhood trauma. Concerning bullying victimization, 83 participants (67.5%)were classified as victims of bullying. And all 123 participants in this study
reported engagement in NSSI in the past year. A detailed
description of the participants’ childhood trauma, bullying and NSSI information can be found in Table 2.
Differences in the demographic variables associated withchildhood trauma, school bullying and NSSIDemographic variables such as gender, age, academic
performance, and without siblings were taken as independent variables, and all dimensions of childhood
trauma, school bullying and NSSI were taken as dependent variables. Differences between each demographic
variable were tested by Mann-Whitney U test or KruskalWallis H test.
Overall, Females presented a significantly greater
prevalence of emotional abuse, sexual abuse, emotional
neglect and childhood trauma than males. Individuals
without siblings had a greater prevalence of sexual abuse

Page 4 of 11

than individuals having siblings. The single-parent families or left-behind children had greater scores for emotional abuse, physical abuse, sexual abuse and childhood
trauma than the both-parents present families. For NSSI,
compared to individuals with good and excellent academic performance, individuals with poor and ordinary
academic performance had greater scores. For relationship bullying, compared to individuals with good andordinary academic performance, individuals with poor
academic performance had greater scores. Further details
on all the demographic variables can be found in the
Table 1.
Correlations among childhood trauma, school bullying and
NSSI

There was a significant positive correlation between typesof childhood trauma and the severity of NSSI (r = 0.494
for emotional abuse, r = 0.421 for physical abuse, and soon). Types of bullying were positively correlated with
NSSI. There was also a significant positive correlation
between each dimension of childhood trauma and all thedimensions of bullying. Further details can be found in
Table 3.
Mediating effects of school bullying
The mediating role of bullying in the relationship between
emotional abuse and NSSIIn the first step (Model 1), emotional abuse had a significant influence on NSSI (B = 3.328, p < 0.001), whichmeans that there was a total effect. In the second step
(Model 2), emotional abuse had a significant influenceon bullying (B = 0.413, p < 0.01). In Model 3, emotional
abuse and bullying both had significant effects on NSSI(B = 2.852, p < 0.001; B = 1.225, p < 0.05). Therefore, theeffect of emotional abuse on NSSI was partially mediatedby bullying (for details, see Table 4; Fig. 1.)
The bootstrap method was used to test the mediating role of bullying in the model. The indirect effect was
0.476, and the 95% CI [0.032–1.086] did not contain
0. This indicates an indirect effect. Therefore, bullying
plays a significant mediating role in the model. The direct
effect value was 2.852, and the 95% CI [1.708, 3.997] did
not contain 0, which indicates a direct effect. According to the effect proportion calculation results, the effectproportion of bullying between emotional abuse and
NSSI was 14%. (for details see Table 5).
The mediating role of bullying in the relationshipbetween physical abuse and NSSI, between sexual abuse
and NSSI, between emotional neglect and NSSI, between
physical neglect and NSSI.
As shown in Tables 4 and 5; Fig. 1, the mediating roleof school bullying in the relationship between physicalabuse and NSSI is clear, and the effect of physical abuseon NSSI was partially mediated by bullying. In the same

P = 0.276
12(7, 17.75)
12(10, 18)

56 (45.5%)67(54.5%)33(26.8%)50(40.7%)
29(23.6%)
11(8.9%)103(83.7%)20(16.3%)

Academic performance
Poor (1)Ordinary (2)Good (3)Excellent (4)Diagnosis of disease type
Depression (1)Depressive episodes of Bipolar
disorder(2)96 (78.0%)27(22.0%)45 (36.6%)78(63.4%)

P = 0.221
12(8, 18)
14.5(10,19.75)

P = 0.114
14(11, 20.5)
12(8, 18)
12(8.5, 16)10(6, 19)

P = 0.012
10.5(6, 12)
13(10, 19)
P = 0.720
12(8, 18.5)
12(9, 18)
P = 0.397
12(8, 15.5)
12(10, 18.25)
P = 0.045
12(8, 16.75)
16(11, 19)

28 (22.8%)
95 (77.2%)

GenderMale (1)Female (2)Age
10–14 years (1)
15–19 years (2)Without siblings
Yes (1)
No (1)
Absence of parents
Both parents present (1)Single-parent or Left-behindchildren (2)Home location
Countryside (1)City or town (2)45(36.6%)
78 (63.4%)

N(percentage) Emotional
abuse

Items

Table 1 General information of the participants

P = 0.610
6(5, 10)7.5(5, 10)

P = 0.953
6(5, 11.5)
6(5, 10)
6(5, 9)7(5, 12)

P = 0.487
6(5, 9)6(5, 10)

P = 0.058
5(5, 7.5)
7(5, 10)
P = 0.120
8(5, 11)6(5, 9)P = 0.197
7(5, 10.5)
5.5(5, 10)
P = 0.048
6(5, 9)8(5, 12)

Physicalabuse

P = 0.595
5(5, 7)5(5, 5.75)

P = 0.209
5(5,5)
5(5,7.25)
5(5, 5)5(5, 9)P = 0.531
5(5, 7)5(5, 6)

P = 0.033
5(5,5)
5(5, 8)P = 0.605
5(5, 8)5(5, 6)
P = 0.000183
6(5, 10)5(5 ,5)
P = 0.008
5(5, 6)
5(5, 10)Sexualabuse

P = 0.766
11(7.5, 13)9.5(7.75, 12)9(7.5, 11.5)
10(6, 12)

P = 0.281
10(6.25, 12)10(8, 12)

P = 0.254
9.5(6.5, 11)10(8, 13)
P = 0.077
10(8.5, 13)
9(6, 12)
P = 0.553
10(8, 13)10(6.75, 12)
P = 0.375
10(8, 12)
11(7, 12)

Physicalneglect

P = 0.267
P = 0.111
16(12, 21)
10(8, 12)15(12.25, 17.75) 9(5, 11)

P = 0.577
16(12.5, 20.5)
14.5(11.75, 20)
18(11.5. 21.5)
15(14, 22)

P = 0.432
16(14, 20)
15(11, 20)

P = 0.027
13(11,18.25)
17(14, 20)
P = 0.412
15(12, 20)
16.5(12.75, 20)
P = 0.699
16(12, 20)
16(12.75, 20)
P = 0.332
15.5(12, 20)
16(13, 22)

Emotional
neglect

P = 0.967
58(50, 66)
58(47, 67.75)

P = 0.506
56.5(50.25,
64.75)
59(49, 68)
P = 0.184
60(57, 66)
56.5,(48, 67.25)
54(48, 64.5)
52(47, 68)

P = 0.00017
48.5(44.25,57.75)
59(52, 68)
P = 0.225
59(50.5, 69)
57(48.75, 66)
P = 0.757
56(49, 67)
59(50, 66.25)
P = 0.003
55.5(49, 64.75)
65(59, 73)

ChildhoodtraumaP = 0.8100(0, 1)0(0,1)

P = 0.8260(0,1)
0(0, 1.5)0(0, 0.5)0(0, 1)

P = 0.3540(0, 1)0(0, 1)

P = 0.6660(0, 0.75)
0(0, 1)
P = 0.8420(0,1)
0(0,1)
P = 0.317
0(0, 0.75)
0(0, 1)
P = 0.750
0(0, 1)0(0, 1.25)

Physicalbullying

P = 0.009
2(1, 5)0.5(0, 4)1(0, 2.5)
3(2, 4)
P = 0.033 P = 0.885
1(0, 3)1(0, 4)2(1, 3.75) 1.5(0, 5)

P = 0.095
2(1, 4.50)
1(0, 2)1(0, 3)1(0, 2)

P = 0.497 P = 0.811
2(0, 2)1(0, 4.75)
1(0, 3)2(0, 4)

VerbalRelationbullying shipbullying
P = 0.484 P = 0.5462(0, 3)2(0, 5)1(0, 3)1(0, 4)
P = 0.685 P = 0.136
1(0,2.5) 1(0, 3.5)
1(0, 3)2(0, 5)
P = 0.805 P = 0.827
2(0, 2.5) 1(0, 3.5)
1(0, 3)2(0, 4.25)
P = 0.418 P = 0.179
1(0, 3)2(0, 4)0(0, 3)1(0,3)

P = 0.469
4(1, 8)3.5(2,
10.75)

P = 0.090
5(2, 11.5)
3.5(0, 8)3(0, 6)4(2, 10)

P = 0.824
4(1, 8)3(1,8)

P = 0.669
4(0, 8.75)
3(1, 8)P = 0.4483(0.5, 8)4(1, 8)P = 0.410
3(0.5, 8)4(1, 8)P = 0.347
4(1,8)
2(0, 10)

P = 0.133
27.5(9.5, 41)
30(12, 66)
P = 0.478
27(11, 57)
32(12, 62.5)
P = 0.112
33(19, 59)
26(10, 61)
P = 0.496
27.5(13.25,
60.75)
29(9, 60)
P = 0.232
33(12.25,
65.5)
27(12, 55)
P = 0.000004
17(9, 29.5)
26(10, 48)
55(27.5,
91.5)
61(45, 112)
P = 0.371
27(12, 60)
35.5(17.25,
61.5)

Bullying NSSI

Liu et al. BMC Pediatrics(2024) 24:524
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Liu et al. BMC Pediatrics(2024) 24:524

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Table 2 Descriptive statistics of Childhood trauma, bullying and
NSSIChildhoodtraumaEmotional
abuse
Physical abuse
Sexual abuse
Emotional
neglect
Physicalneglect
Bullying
Physicalbullying
Verbalbullying
Relationshipbullying
NSSI

Yes
Number(%)
93(75.6%)

No
Number(%)
30(24.4%)

Minimum
Score
38

Maxi- Mean ± SD
mum
Score
101
54.06 ± 16.22

62(50.4%) 61(49.6%)

524

13.11 ± 5.56

28(22.8%) 95(77.2%)
23(18.7%) 100(81.3%)
79(64.2%) 44(35.8%)

6
5
5

16
19
25

8.13 ± 4.16
6.59 ± 3.17
16.24 ± 4.95

60(48.8%) 63(51.2%)

520

9.98 ± 3.62

83(67.5%) 40(32.5%)21(17.1%) 102(82.9%)

0
0

21
6

4.95 ± 5.23
0.91 ± 1.75

58(47.2%) 65(52.8%)

08

1.72 ± 1.87

57(46.3%) 66(53.7%)

08

2.32 ± 2.52

123

1

202

39.81 ± 37.45

0clinical population than in the general population [24,32]. The results of our current study are basically consistent with the literature reports. Our study focusedon adolescents with depression or depressive episodesof bipolar disorder; 77.2% of NSSI patients were female,which was significantly more than male adolescents.
However, it is worth noting that the test for differencesin NSSI scores according to gender showed no difference
between females and males in our study. The reasons
may be as follows: the prevalence of NSSI was greaterin female adolescents with depression or depressive episodes of bipolar disorder than in male adolescents, butthere was no difference in the severity of NSSI. On theother hand, our sample size may be small, and the resultsof our study did not reveal a difference in NSSI severity
between males and females.
A total of 83.7% of the participants in our study werediagnosed with depression, which was much higher thanthe percentage of participants diagnosed with bipolar
depressive episodes. This finding corroborates the findings of past studies in which depression was the main
diagnostic factor in clinical NSSI patients [33]. Our study
revealed no significant difference in the severity of NSSI
between adolescents with depression and those withdepressive episodes of bipolar disorder. The reasons may
be that emotional regulation is one of the main purposesof NSSI behaviour [34], and patients with depression andbipolar disorder are characterized by significant emotional dysregulation.
In addition, for the differences of childhood trauma inthe demographic variables such as gender, without siblings, single-parents and so on, our findings are basicallyconsistent with previous literature reports [35–38]. But,in terms of bullying, there was little difference in otherdemographic variables except academic achievementin current study.And this is different from the previous

Note: childhood trauma: at least moderate to severe levelway, the effect of sexual abuse, emotional neglect andphysical neglect on NSSI was also partially mediated bybullying. The effect proportion of bullying victimization
on physical abuse, sexual abuse, emotional neglect andphysical neglect were 21%, 20%, 13% and 20%, respectively.(for details see Tables 4 and 5; Fig. 1).

Discussion
Differences in the demographic variables associated with
NSSI, childhood trauma and school bullying victimization

According to literature reports, among sociodemographic factors, gender is one of the most powerful predictors of NSSI [7, 31]. Females are more likely to develop
NSSI than males are, and this difference is greater in the

Table 3 Correlation analysis of childhood trauma, campus bullying and NSSI
1. Emotional abuse
2.Physical abuse
3. Sexual abuse
4. Emotional neglect
5. Physical neglect
6. Childhood trauma
7. Physical bullying
8. Verbal bullying
9. Relationship bullying
10. Bullying
11.NSSI
Mean
SD
Note: *p < 0.05, **p < 0.01;

110.620**
0.365**
0.613**
0.591**
0.891**
0.366**
0.364**
0.333**
0.413**
0.494**
13.11
5.56

2

3

4

5

6

7

8

9

10

11

1
0.312**
0.318**
0.406**
0.717**
0.507**
0.400**
0.317**
0.465**
0.421**
8.13
4.16

1
0.213*
0.283**
0.528**
0.304**
0.121
0.210*
0.246**
0.341**
6.59
3.16

1
0.610**
0.774**
0.288**
0.247**
0.260**
0.310**
0.494**
16.24
4.95

1
0.771**
0.319**
0.277**
0.235**
0.319**
0.393**
9.98
3.61

1
0.474**
0.388**
0.368**
0.475**
0.582**
54.06
16.22

1
0.525**
0.537**
0.781**
0.349**
0.91
1.75

1
0.664**
0.853**
0.256**
1.72
1.87

1
0.899**
0.285**
2.32
2.52

1
0.346**
4.95
5.23

1
39.81
37.45

Liu et al. BMC Pediatrics(2024) 24:524

Page 7 of 11

Table 4 The mediating role of bullying in the relationship between various dimensions of childhood trauma and NSSI
Model
Dependent variable
Indicator
Emotional abuse
Bullying
R2
F
Physical abuse
Bullying
R2
F
Sexual abuse
Bullying
R2
F
Emotional neglect
Bullying
R2
F
Physical neglect
Bullying
R2
F

Model 1
NSSI
B
3.328
0.244
39.025***
3.786
0.177
26.007***
4.042
0.116
15.92***
3.739
0.244
39.118***4.07

t
6.247***

Model 2
Bullying
B0.413

t4.991**

5.1***

0.171
24.911***
0.585

5.786***

3.99***

0.217
33.472***0.407

2.792**

6.254***

0.061
7.797**
0.327

3.587***

4.695***

0.096
7.797**
0.462

3.704***

0.154
22.044***0.102
13.718***Model 3
NSSI
B
2.852
1.225
0.268
21.978***t4.935***
1.993*

2.983
1.372
0.206
21.978***
3.229
1.998
0.206
21.978***
3.239
1.527
0.285
23.956***
3.257
1.759
0.208
15.782***3.606***
2.083*

3.212**
3.287**

5.276***
2.625*

3.666***
2.865***p < 0.05; **p < 0.01; ***p < 0.001

literature reports [39].Maybe it has something to do with
our insufficiently large sample size.
Associations between childhood trauma, bullying
victimization and NSSIAssociations between childhood trauma and NSSI

Previous research has shown that all types of childhood
trauma lead to greater vulnerability to NSSI [16, 40]. Adolescents who experience adverse childhood experiences
are at increased risk of developing cognitive distortions
that can lead to the endorsement of NSSI behaviours. [17,41, 42].The results concerning the correlation between
childhood trauma and NSSI in the present study arebasically consistent with those studies mentioned above.
For adolescents with depression or depressive episodesof bipolar disorder, there was also a significant positive
correlation between all dimensions of childhood trauma
and NSSI; that is, the more severe the childhood trauma
was, the more severe the NSSI behaviour. This is in linewith theories such as the Developmental Psychopathology Network [43] or the Biopsychosocial Model of Marsha Linehan [44], both of which link adverse childhood
experiences with the development of dysfunctional emotion regulation and thus the development of dysfunctional coping skills such as NSSI. Individuals reduce theiremotional distress and decrease their memories of abuse
through self-injurious behaviour [45].

Association between bullying experiences and NSSI

Previous studies have shown that bullying is a risk factor
for NSSI [7], and our study further confirms this finding. The relevant analysis results of our study showedthat bullying and all of its dimensions, including physical bullying, relational bullying, and verbal bullying, weresignificantly positively correlated with NSSI in adolescents with depression or depressive episodes of bipolar
disorder.
The reasons are as follows. First, bullying can be a
stressor. Bullied individuals are likely to be at risk forpoor adjustment compared to noninvolved adolescents.
The difficulty of adapting and the decline in quality of life
caused by stress can lead to the accumulation of negative
emotions [21], which leads to self-injury behaviour for
their relief. Second, adolescents who suffer from school
bullying may also use self-harm as a form of recourse or
self-punishment [12]. In this way, they try to obtain interpersonal support and convey emotional distress [46], andthen negative emotions can be effectively alleviated.
Association between childhood trauma and bullying
experiences

In our study, there was a significant positive correlation
between childhood trauma and school bullying. This
result corresponds well to findings from Canada that victims of child sexual abuse were more likely to experiencebullying, and females who had experienced sexual abuse
were cyberbullied at twice the rate of those who had notLiu et al. BMC Pediatrics(2024) 24:524

Page 8 of 11

Fig. 1 Path analysis model of various dimensions of childhood trauma related to NSSI with campus bullying as a mediating factor. B1: Analysis of themediating effect of bullying on the relationship between emotional abuse and NSSI: in Model 3, the mediating effect of bullying on NSSI, B1 = 1.225*. B2:
Analysis of the mediating effect of bullying on the relationship between physical abuse and NSSs, B2 = 1.372*. B3: Analysis of the mediating effect of bullying on the relationship between sexual abuse and NSS, B3 = 3.229**. B4: Analysis of the mediating effect of bullying on the relationship between emotional neglect and NSS, B4 = 3.239**. B5: Analysis of the mediating effect of bullying on the relationship between physical neglect and NSS, B5 = 3.257***.
*p < 0.05; **p < 0.01; ***p < 0.001[47].All of these findings can be explained by parent–child attachment theory. That is, adolescents who havesuffered childhood trauma are more likely to develop
insecure attachments, and they are more likely to become
involved in bullying because they do not have appropriate coping styles when facing new situations [48, 49].
Mediating effects of bullying victimization on therelationship between childhood trauma and NSSIAs we mentioned in the previous section of this article,
some research has shown bullying to be a risk factor for
NSSI [7], but bullying is also known to occur as a consequence of childhood trauma [48, 49]. According toprevious studies, some factors, such as dissociation,
self-esteem, depression, or alexithymia, might mediate
the relationship between the experience of childhood
trauma and engaging in NSSI [21, 22]. These factors
were not assessed in the current study. In our study, we
focused on the mediating role of school bullying in therelationship between childhood trauma and NSSI. We
found that childhood trauma can impact NSSI not only
directly but also through the mediating role of bullying
in the adolescent population with depression or depressive episodes of bipolar disorder. Bullying partially mediates the relationships between various types of childhood
trauma (including emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect) and
NSSI behaviour.
According to the above our findings, we analyze thereasons as follows, childhood trauma, especially repeatedtrauma, can disrupt children’s emotional regulation andacquisition of interpersonal skills [50]. Bullying as a negative experience can also lead to deficits in emotion regulation [9]. These deficits may result from individuals’
own psychological experiences but may also result fromneurophysiological dysregulation caused by trauma [51,52], which can then in turn lead to engaging in maladaptive coping strategies, such as NSSI. The fact that NSSI isLiu et al. BMC Pediatrics(2024) 24:524

Page 9 of 11

Table 5 Test results of the bootstrap mediating effect of campus
bullying between various dimensions of childhood trauma and
NSSI

Emotional abuse

Physical abuse

Sexual abuse

Emotional neglect

Physical neglect

Effect type

Effectvalue

Total effectDirect effectIndirect effectTotal effectDirect effectIndirect effectTotal effectDirect effectIndirect effectTotal effectDirect effectIndirect effectTotal effectDirect effectTndirect effect

3.328
2.852
0.476
3.786
2.983
0.802
4.042
3.229
0.813
3.739
3.239
0.5
4.07
3.257
0.812

LL 95% UL
CI
95%
CI
2.273
4.383
1.708
3.997
0.032
1.086
2.316
5.255
1.345
4.622
0.008
1.744
2.036
6.047
1.239
5.219
0.156
2.343
2.555
4.922
2.024
4.455
0.077
1.035
2.354
5.786
1.498
5.017
0.173
1.673

Effect
ratio
86%
14%
79%
21%
80%
20%
87%
13%

relationship between childhood trauma and NSSI in thisdepressed population, which will be helpful for families,
schools and society to pay more attention to childhood
trauma and school bullying. The results of this study also
have implications for preventative and therapeutic interventions for NSSI.

Conclusion
There was a significant positive correlation between
childhood trauma and bullying, between childhood
trauma and NSSI, and between bullying and NSSI. Childhood trauma can not only directly affect the severity of
NSSI but also indirectly aggravate the severity of NSSI
through bullying victimization. Bullying victimization
played the partial mediating role in the relationshipbetween Childhood trauma and NSSI.
Limitations

80%
20%

most often engaged in as a dysfunctional emotion regulation strategy might explain why childhood trauma andschool bullying are both associated with NSSI, as they
can all affect a person’s ability to regulate emotions. Adolescents with childhood trauma are more likely to exhibit
NSSI behaviours after experiencing adverse events suchas school bullying.
On the one hand, adolescents who experience childhood trauma can directly adopt NSSI as a maladaptive
adjustment strategy. On the other hand, due to emotional
dysregulation and a decrease in interpersonal skills, therisk of suffering from bullying increases. In turn, bullying leads individuals to adopt NSSI to regulate theiremotions. Namely, bullying played mediating role in therelationship between childhood trauma and NSSI. Thisis consistent with the principle elaborated in the empirical avoidance model proposed by Chapman [53]. That is,
stimuli cause individuals to produce certain emotional
responses. Under the interaction of many other factors,
individuals choose to avoid through NSSI, which temporarily alleviates their negative emotional experiences. Inturn, the relief of this negative emotion further strengthens NSSI and promotes the maintenance of NSSI [54].
Childhood and adolescence are important periods inhuman development during which harmful experiences
can significantly influence the course of life in the longterm. It is the common responsibility of the whole society to create a healthy and good growth environment
for young people. In particular, adolescents with depression and bipolar disorder need more attention. The
current research explored the correlations among childhood trauma, school bullying victimization and NSSI
and the mediating effect of bullying victimization on theThis study has some limitations that should be consideredwhen interpreting the findings. First, participants wereasked to report on only NSSI that occurred within thepast year. The lifetime data are unknown, which may have
impacted the results. Second, as this was a retrospective
and self-reported cross-sectional study, the possibility ofmemory bias regarding NSSI, childhood trauma and bullying must be considered when interpreting the results.
Self-reported data may also be subject to bias. Third, in
this study, we used the bullied subscale, and only bullying victimization was studied. Future studies should be
conducted to assess bullying perpetration. Furthermore,
the sample size of this study was small, which may haveinfluenced the results. We will expand the sample size infuture studies to further verify the results.
Author contributions
Each author substantially contributed to the paper.ZH and HL carried out themethodological search on the research topic and supervised the writing of
the manuscript; YL performed data analysis, conceived and wrote the firstdraft of the paper; XQX contributed with data analysis and draft preparation;
XH and QH participated in all the questionnaire survey , data collection; LL
and XHX contributed to the statistics of all the data in this study; WC and WS
provided help in reviewing the literature.All authors read and approved thefinal manuscript.
Funding
This research was supported by the Zhejiang Medical and Health Science andTechnology Planning Program (NO. 2021452728) and the Ningbo Medical and
Health Brand Discipline (NO. PPXK 2018-08).
Data availability
All data generated or analysed during this study are included in this publishedarticle.

Declarations
Ethical approval and consent to participate
This study was approved by the ethics committee of Affiliated Kangning
Hospital of Ningbo University in accordance with the Declaration of Helsinki.
The ethics trial no. is NBKNYY-2020-LC-52. Informed consent was obtained
from all subjects and/or their legal guardian(s).

Liu et al. BMC Pediatrics(2024) 24:524

Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Psychiatry, Affiliated Kangning Hospital of Ningbo
University, Ningbo, Zhejiang 315201, China
2
Key Laboratory of Addiction Research of Zhejiang Province, Ningbo,
Zhejiang 315201, China
3
Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, Zhejiang,
China
Received: 1 April 2024 / Accepted: 30 July 2024

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