Response to the Reviewers
Dear Prof. Paola Gremigni,
I wish to resubmit an original article for publication in PLOS ONE, titled “Development
and validation of the Self-Harm Screening Inventory (SHSI) for Adolescents.” The manuscript
ID is PONE-D-21-17797.
The manuscript has been rechecked and the appropriate changes have been made in accordance
with the reviewers’ suggestions. The responses to their comments have also been drafted
and attached.
I thank the editor and the reviewers for their thoughtful suggestions and insights,
which have enriched the manuscript, and helped in producing a better and more balanced account
of the study. I hope that the revised manuscript is now suitable for publication in
your journal.
I have also attached the certificate of English editing below.
I thank you for your consideration, and am looking forward to hearing from you.
Sincerely,
Jong-Sun Lee
Department of Psychology, Kangwon National University
Chuncheon-si 24341, Korea
jongsunlee@kangwon.ac.kr
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Response: We have checked the PLOS ONE’s style requirements and have used the templates
to format the manuscript’s title page and main body.
2. Please improve statistical reporting and refer to p-values as "p<.001" instead
of "p=.000". Our statistical reporting guidelines are available at https://journals.plos.org/plosone/s/submission-guidelines#loc-statistical-reporting.
Response: As per your recommendation, we have improved the statistical reporting and
referred to p values as “p < .001”.
3. Please provide additional details regarding participant consent. In the ethics
statement in the Methods and online submission information, please ensure that you
have specified what type you obtained (for instance, written or verbal, and if verbal,
how it was documented and witnessed). If your study included minors, state whether
you obtained consent from parents or guardians. If the need for consent or parental
consent was waived by the ethics committee, please include this information.
Response: We thank you for your meticulous review. We have included the details regarding
the consent form and informed parental consent under the subsections on “Participants”
and “Procedures.” Please find the details below.
After:
Participants (Page 6, Line 126-Page 7 Line 129)
We recruited participants on a nationwide scale from multiple elementary and middle
schools in South Korea. Participants were either introduced to this study during their
classes or were provided with the information on the bulletin board at school.
Procedures (Page 10, Line 211-223)
All the participants voluntarily participated in the study. Participants and their
parents were informed about the purpose of the study and its procedures. The research
assistants provided additional information about the study on the request of the participants
or their parents. Written informed consent was obtained from the participants and
their parents prior to participation. A URL of the online survey webpage was sent
to the participants’ smartphones. Participants logged into a secure webpage and completed
a set of self-report measures containing the preliminary versions of the SHSI, K-SHI,
CDI, RCMAS, and RSES. It took them approximately 20 minutes to complete all the questionnaires,
and they received a monetary reward after submitting the measures. To estimate the
temporal stability of the preliminary SHSI, the same tool was administered to 97 participants,
four weeks after the first administration. Participants received a gift card worth
5,000 won (approximately 5 dollars) for their participation in the first administration
and an additional 3,000 won (approximately 3 dollars) worth gift card after the second
administration.
4. Please include your full ethics statement in the ‘Methods’ section of your manuscript
file. In your statement, please include the full name of the IRB or ethics committee
who approved or waived your study, as well as whether or not you obtained informed
written or verbal consent. If consent was waived for your study, please include this
information in your statement as well.
Response: We have added the full statement in the Method section, including the full
name of the IRB and have provided information on the IRB approval, as stated below.
Before
All research procedures were approved by the Institutional Review Board of the authors’
university (IRB NO. KWNUIRB-2019-05-007-002).
After (Page 10, Line 223-Page 11, Line 225)
All research procedures were approved by the Institutional Review Board of the Kangwon
National University in Chuncheon, South Korea (IRB NO. KWNUIRB-2019-05-007-002).
5. We note that you have referenced (Walsh B, Frost A Unpublished study. 2005.which
has currently not yet been accepted for publication. Please remove this from your
References and amend this to state in the body of your manuscript: (Walsh B, Frost
A Unpublished study. 2005Unpublished study. 2005.as detailed online in our guide for
authors http://journals.plos.org/plosone/s/submission-guidelines#loc-reference-style
Response: We appreciate your recommendation. We have removed the reference and updated
the body of our manuscript as well.
Discussion
Before
Considering the purpose of a screening measure, the SHSI should reduce false-positive
errors in selecting adolescents with self-harming behaviors. The excluded four items
are not rare but less lethal and, interestingly, were not as popular as more serious
forms of self-harm (such as cutting with a knife, carving, hitting head, and burning)
in a clinical adolescent sample. (52) These results may be related to the fact that
our sample was recruited from a community population in early adolescence.
After (Page 26, Line 475-478)
Considering that the previous findings suggest that serious self-harm methods are
used among adolescents in clinical setting [55], the SHSI—which considered factor
loading as the criteria and not the frequency—might have decreased the false-positive
errors in selecting the adolescents with self-harming behaviors.
Reviewer #1: I would like to express my sincere gratitude for the opportunity given
to review this manuscript on the development and the validation of the Self-Harm Screening
Inventory.The study’s aim is clearly defined in terms of developing a tool that can
help assess or screen non-suicidal self-injury (NSSI) among adolescents in South Korea.
The study’s originality is unquestionable, as it varies from other scales or tools
developed to screen for NSSI. In addition, the study demonstrates adequate knowledge
and understanding of relevant studies on NSSI. However, there are a few aspects of
the manuscript that need clarifications.
1. In statements numbered 124 and 125 (pp 6), the authors state that existing measures
developed in Western countries have not been validated in Asian countries. This seems
to contradict the adaptation study by Kim et al. (2019) (statements 156 &157, pp7).
Response: Thank you for your comment. We meant that there is a lack of validated measures
that include culturally sensitive items for self-harm in Asia. To clarify the meaning
of the text, we have included additional information on self-harm measures in Asian
countries as depicted below.
Before (Page 5, Line 123-Page 6 Line 125)
Finally, existing measures were developed in Western countries, and culturally sensitive
items have not been developed or validated in Asian countries.
After (Page 6, Line 107 )
Finally, the existing measures have primarily been developed in the Western countries,
and culturally sensitive items have been seldom developed or validated for use in
the Asian countries. In Korea, researchers have translated and validated several measures
of self-harm [28-30]. However, no Korean measure has been developed to assess the
self-harm behaviors in the Korean population. Likewise, the Japanese version of the
DSHI had been validated [31]. However, originally developed Japanese measures to assess
self-harm behaviors in Japan, are hard to seek. Although Chinese research has reported
a few self-harm measures developed in China, the validation of the measures is rare
[32-34]. Considering the potential gap between self-harm behaviors in the Asian and
Western cultures, and the lack of reliable tools for assessing specific self-harm
behaviors in Asia, it seems necessary to develop items reflecting self-harm behaviors
in the Eastern countries.
2. I stand to be corrected but to the best of my knowledge, 1st grade to 3rd grade
students are classified as elementary school pupils, not middle school (statements
136-138, pp 6)
Response: In South Korea, the grade system is different from that of Western countries.
It consists of 1st–6th grade in elementary school, 1st–3rd grade in middle school,
and 1st–3rd grade in high school. Therefore, the 1st–3rd grade in middle school in
South Korea is comparable to 7th–9th grade in Western countries. We have added the
information in the manuscript to improve readers’ understanding as below.
After (Page 7, Line 132-133)
Grade 1-3 in middle school in South Korea is comparable to the grade 7-9 in middle
school in Western countries.
3. In the procedure section, little information is given as to how students got to
know about the study. Please provide further details on that. In addition, the authors
state that monetary reward was given to the participants. Can the authors be specific
as to how much was given to each participant to be certain that participants were
not enticed to partake in the study but did volunteer.
Response: We thank you for your invaluable advice and have improved on the Method
section by incorporating the suggested changes. In the Procedures section, we have
added details on advertisement and recruitment, as mentioned below. We have also included
the specific amounts for the monetary rewards received by the participants
Participants
Before
We recruited participants on a nationwide scale in South Korea.
After (Page 6, Line 127-Page 7, Line 129)
We recruited participants on a nationwide scale from multiple elementary and middle
schools in South Korea. Participants were either introduced to this study during their
classes or were provided with the information on the bulletin board at school.
Procedures
After (Page 10, Line 211-223)
All the participants voluntarily participated in the study. Participants and their
parents were informed about the purpose of the study and its procedures. The research
assistants provided additional information about the study on the request of the participants
or their parents. Written informed consent was obtained from the participants and
their parents prior to participation. A URL of the online survey webpage was sent
to the participants’ smartphones. Participants logged into a secure webpage and completed
a set of self-report measures containing the preliminary versions of the SHSI, K-SHI,
CDI, RCMAS, and RSES. It took them approximately 20 minutes to complete all the questionnaires,
and they received a monetary reward after submitting the measures. To estimate the
temporal stability of the preliminary SHSI, the same tool was administered to 97 participants,
four weeks after the first administration. Participants received a gift card worth
5,000 won (approximately 5 dollars) for their participation in the first administration
and an additional 3,000 won (approximately 3 dollars) worth gift card after the second
administration.
4. At the reference section, there are a few “invalid citations” stated. Please review
the section and provide the appropriate reference.
Response: We thank you for your comment. We have checked the invalid citations and
accordingly modified the manuscript as well.
Nonetheless, sentences are clearly expressed and readable.Again, I appreciate the
opportunity given to review this manuscript and hope to see it in print.
Reviewer #2: The autor does an adequate job elucidating the methodology procedures
and data analysis in the manuscript. Overall, the paper is scientifically sound and
articulates the content well. However, there are a few questions / elements that need
to be addressed. Moreover, there are some mayor edits that are suggested to enhance
the text. Comments are provided below, in paragraphs.1. The title is quite in line
with the objective of the research paper; in this regard, perhaps I would highlight
the population since the validation wants to be sensitive to it.
Response: We thank you for your suggestion. We have included “for adolescents” in
the title, to highlight the population under study.
Before
Development and validation of the Self-Harm Screening Inventory (SHSI)
After
Development and validation of the Self-Harm Screening Inventory (SHSI) for Adolescents
2. The abstract, lacks the hook and the literature gap that you are aiming to contribute
to through your paper. For example, it does not highlight the validation goal. It
is argued that there is dearth of psychological measures for non-suicidal self-injury
(NSSI) screening, but recent literature indicates that there are many and most are
for adolescents. In this respect I am not sure that SHI is the most widely used instrument,
it would need referencing. I suggest reviewing the current NSSI instrument reviews.
Recommend re-visiting it.
Response: We thank you for your meticulous review. We have highlighted the validation
goal in the abstract, as mentioned below. Furthermore, we have reworded the text highlighting
the lack of culturally appropriate tools for assessing NSSI among Asian adolescents.
We also revisited recent literature on self-harm measures and deleted the phrase ‘the
most’ (for the use of SHI) from the manuscript.
Abstract
Before
Despite the rapidly increasing rate of non-suicidal self-injury (NSSI) among adolescents,
there is a dearth of psychological measures for NSSI screening. This study aimed to
develop the Self-Harm Screening Inventory (SHSI), a scale for screening NSSI among
adolescents.
After (Page 2, Line 7-Line 9)
Despite the rapidly increasing rate of non-suicidal self-injury (NSSI) among adolescents,
there is a dearth of culturally appropriate psychological measures screening for NSSI
among the adolescents in the Asian countries. This study aimed to develop and validate
the Self-Harm Screening Inventory (SHSI), a culturally sensitive and suitable scale
for screening adolescents for NSSI.
Page 5, line.
Before
Among the validated self-report measures, the Self-Harm Inventory (23) is the first
and the most widely used measure for assessing self-harming behaviors.
After (Page 5, Line 83-34)
One of the valid self-report measures is the Self-Harm Inventory (SHI) [23]; it is
the first and widely used measure for assessing self-harm behaviors.
3. NSSI has been clearly defined, however it refers to self-injury as NSSI, self-harm,
and other terms. The literature has differentiated NSSI from deliberate self-harm
and suicide. If the objective is to screen for NSSI, the instrument should be sensitive
to non-suicidal self-injury, but it does not show to be so. I suggest clarifying the
terminology and how the instrument is suitable for NSSI screening.
Response: We appreciate your thoughtful comment. As the SHSI was developed for screening
NSSI, which refers to self-injury without intent to die, instructions were clearly
given to the participants. We have added the instructions in the Method section, as
stated below.
Before
The Self-Harm Screening Inventory (SHSI) is a brief self-report measure for assessing
self-harm behaviors among adolescents. The SHSI consists of 10 binary items (yes/no)
which ask about self-harm behaviors within the past year. Cronbach’s alpha of the
SHSI in this sample was .795.
After (Page 7, Line 138-147)
The Self-Harm Screening Inventory (SHSI)
The Self-Harm Screening Inventory (SHSI) is a brief self-report measure for assessing
self-harm behaviors among adolescents. The SHSI consists of 10 binary items (yes/no)
which inquire about one’s engagement in self-harm behaviors within the past year.
For the purpose of assessing NSSI among adolescents, the definition of NSSI was provided
at the end of the instructions as, “Non-suicidal self-injury refers to deliberate
self-harm behavior without the intention to die.” The participants were instructed
to choose “yes” if they had engaged in self-harm at least once in their lifetime,
and to choose “no” if they had not. The Cronbach’s alpha of the SHSI for this sample
was .795. The final version of the SHSI is presented in Supplementary Material S1.
4. Overall, the introduction flows well and provides an overview on the remarkable
literature. However, I would consider revisiting the introduction and provide a stronger
principled argument explaining how your research question will be able to address
the gap. Especially regarding the existence of culturally sensitive items and instruments
have not been developed or validated in Asian countries.
Response: We thank you for your suggestion, and have reviewed sufficient literature
to enhance the contents related to the existing culturally sensitive items and instruments,
in the Asian countries. Please find the changes below.
Before
Finally, existing measures were developed in western countries, and culturally sensitive
items have been developed or validated in Asian countries.
After (page 6, Line 107-118 )
Finally, the existing measures have primarily been developed in the Western countries,
and culturally sensitive items have been seldom developed or validated for use in
the Asian countries. In Korea, researchers have translated and validated several measures
of self-harm [28-30]. However, no Korean measure has been developed to assess the
self-harm behaviors in the Korean population. Likewise, the Japanese version of the
DSHI had been validated [31]. However, originally developed Japanese measures to assess
self-harm behaviors in Japan, are hard to seek. Although Chinese research has reported
a few self-harm measures developed in China, the validation of the measures is rare
[32-34]. Considering the potential gap between self-harm behaviors in the Asian and
Western cultures, and the lack of reliable tools for assessing specific self-harm
behaviors in Asia, it seems necessary to develop items reflecting self-harm behaviors
in the Eastern countries.
5. Methods are generally clearly described and the instruments used seem mostly suitable
for their purpose. The statistical approach is adjusted to the development and validation
of psychological instruments. However, items have been eliminated in most of the measures
for this study. Different measures of NSSI and others have been correlated. If items
are removed from an already validated instrument, the data will not be able to be
compared between this study and others. Have they been removed because the instrument
was not validated for the age group or population of this study? About validation,
it would help to justify why it has been validated with the variables with which it
has been validated.
Response: We thank you for your thoughtful comment. Please find below, the response
for both your questions.
1) Have they been removed because the instrument was not validated for the age group
or population of this study?
Response: No, this study aimed to develop a brief screening measure for self-harming
behaviors among adolescents. Thus, we selected the most relevant and informative items
among the original items to screen the participants for NSSI.
2) About validation, it would help to justify why it has been validated with the
variables with which it has been validated.
-----Messick (1989) recommended five criteria for validation, as under content, construct,
responses, criterion, and consequence evidence. To validate the scale, the criterion
evidence was used. It is "validated with the variables with which it has been validated"
If the developed scale is correlated with the scale which it has been validated, the
developed scale can be validated.
Reference
Messick, S. (1989). Validity. In R. Linn (Ed.). Educational Measurement (3rd edition)
(pp.13-100). Washington, DC: American Council on Education.
6. The discussion is according to the objectives and results. The selection criteria
based on expert has clearly delimited the items that are more serious, this could
make the SHSI measure less prevalence of NSSI than many of the commonly used instruments.
It would be necessary to demonstrate through literature the need to agree on this
criterion. On the other hand, it also seems necessary to make explicit in the text
that the instrument measures the most serious methods. Furthermore, it should be discussed
and also included in a more extended discussion of how SHSI improves NSSI screening.
Response: We thank you for your thoughtful comment. For the development of a quick
screening tool, we adopted two methods: qualitative investigation and quantitative
investigation. In the qualitative investigation, we asked the experts in the field
of self-harm and suicide, to rate the appropriateness, sensitivity and prevalence
of each of the NSSI behaviors. Their ratings were not based on the severity or lethality
of the behavior. After selecting 20 items based on the expert’s ratings, we used exploratory
factor analysis to determine the final 10 items. In the quantitative investigation,
we used factor loadings and not the frequency of each item, as the selecting criteria.
To clarify the procedures and the meaning, we have modified the manuscript as well,
as stated below.
Procedures (Page 9, Line 179-
For the development of the preliminary SHSI, multiple sources of information were
reviewed. Previous research findings (academic sources), news, and social media (such
as Twitter, Instagram, Facebook, and Tumblr), describing self-harm behaviors and related
clinical observations, were investigated. The comments of experts on self-harm and
suicide attempts (non-academic sources) were also considered. Further, the items assessing
self-harm behaviors in the pre-existing self-harm measures, such as the SHI, DSHI,
and FASM, were collected. The focus of the literature review was to generate a list
of specific and observable NSSI behaviors. Thereafter, the overlapping items and dimensions
in the list were either combined or reorganized.
A total of 28 items were developed for the first version of the preliminary measure
(Supplemental Material S2) and sent to 11 Korean experts—four clinical psychologists,
five psychiatrists, and two school counselors —in the areas of self-harm and suicide.
The experts rated individual items for their appropriateness (in assessing self-harm
among adolescents), sensitivity (to distinguish the adolescents engaging in serious
self-harm), and prevalence (of the behavior among Korean adolescents). They rated
each item on a seven-point Likert scale (1 = very unlikely; 7 = very likely) for appropriateness
and sensitivity, and a three-point Likert scale (1 = low prevalence; 3 = high prevalence)
for prevalence. They also provided additional comments on the utility of the items.
Thereafter, the mean rating scores for each item were calculated. First, items with
scores lower than 5 for appropriateness and sensitivity, and scores lower than 2 for
prevalence, were identified. Of the 28 items, eight items below the aforementioned
scores were identified under all three dimensions, one item under two of the dimensions,
and six items under only one dimension. Items identified in more than two of the dimensions
were excluded. Second, the informative value of the excluded items was reconsidered
in the ensuing discussion among the authors. Of the nine items identified under more
than two dimensions, the item on “overdose” was considered a distinctive and comparatively
common method of self-harm. It was, thus, re-included among the preliminary items.
Consequently, eight items with low scores on more than two of the dimensions (appropriateness,
sensitivity, and prevalence) were discarded before administration (e.g., items on
Drank excessively, Engaged in unhealthy sexual relationships (e.g., having multiple
partners), Had unsafe sex, Starved to the point of harming your body (for a few days
at least), Took laxatives, diuretics, etc. to the point of harming your body, Rubbed
skin on rough surfaces, Swallowed dangerous substances (bleach, hand sanitizer, detergent, etc.),
Got a tattoo). Twenty items with higher scores and utility were retained as preliminary
items for the SHSI and administered to the participants along with other self-report
measures.
Results (Page 16, Line 305-309)
The final structure showed a good model fit: χ² (119) = 207.189, p < .001, RMSEA =
.038, CFI = .964, TLI = .959, WRMR = 1.154. Factor loadings for the total items ranged
between .555 and .985. Among the 17 items, 10 items (preliminary items 1, 2, 3, 4,
6, 7, 15, 17, 19, and 20), which showed high factor loadings (greater than 0.7), were
examined by two authors for content validity, and were selected for the final version
of the SHSI.
Discussion
Before (Page 27, Line )
Considering the purpose of a screening measure, the SHSI should reduce false-positive
errors in selecting adolescents with self-harming behaviors. The excluded four items
are not rare but less lethal and, interestingly, were not as popular as more serious
forms of self-harm (such as cutting with a knife, carving, hitting head, and burning)
in a clinical adolescent sample. (52) These results may be related to the fact that
our sample was recruited from a community population in early adolescence.
After (Page 26, Line 475-478)
Considering that the previous findings suggest that serious self-harm methods are
used among adolescents in clinical setting [55], the SHSI—which considered factor
loading as the criteria and not the frequency—might have decreased the false-positive
errors in selecting the adolescents with self-harming behaviors.
7. Finally, a few minor comments:Line 285: “scree plot”Response: We are unsure as
to what you are suggesting for the “scree plot”. Please let us know what your recommendation
is.
Line 314 and 320-322: The data is already in the table, perhaps it would help the
reader if it were evaluated instead of repeating the data.
Response: We thank you for your suggestion and have modified the manuscript accordingly.
Line 314
Before
The item-total correlations for each item ranged between .310 and .670, and Cronbach’s
alpha was .795.
After (Page 21, Line 352-353)
The item-total correlations for each item were acceptable, ranging between .310 and
.670. The Cronbach’s alpha was good (α = .795).
Line 320-322
Before
The SHSI had high correlations with the SHI (r = .775, p < .01), and showed moderate
correlations with the CDI (r = .489, p < .01) and RCMAS (r = .433, p < .01). The SHSI
negatively correlated with the RSES (r = -.399, p < .01; Table 7).
After (Page 21, Line 359-363)
The SHSI had high correlations with the SHI (r = .775, p < .01), and moderate correlations
with the CDI (r = .489, p < .01) and RCMAS (r = .433, p < .01). The SHSI was negatively
correlated with the RSES (r = -.399, p < .01; Table 7). The results indicate that
SHSI is a reliable and valid measure for NSSI, and it is distinct from the other psychological
measures assessing depression, anxiety, and self-esteem.
Line 342: The FASM items selection process was described in in the author's doctoral
thesis.
Response: We thank you for your comment. We have looked up the doctoral thesis of
the author (Lloyd, 1998) and found that the author “established a list of self-mutilative
behaviors based upon review of previous research (Ross & McKay, 1979; Walsh & Rosen,
1988), as well as the authors’ clinical experience.” However, detailed information
on the process of selecting the items was not presented in the doctoral thesis either.
Reviewer #3: This is very interesting paper regarding NSSI issues and wih this new
itmes, clinicinas can assess NSSI patients more systematically and effectively. However,
I have several concerns.1. Please check reference 8 which is inapporpiriate.
Response: We had cited the estimates of prevalence among clinical inpatient adolescents
in the reference 8 (Hamza et al., 2008). The cited part was as below.
“Estimates of prevalence suggest that among clinical inpatient samples, as many as
21% of adults (Briere & Gil, 1998) and 30 to 40% of adolescents engage in NSSI (Darche,
1990, Jacobson et al., 2008). NSSI is not only a clinical health concern, however,
as recent estimates based on community samples indicate that as many as 13 to 29%
of adolescents (Baetens et al., 2011, Brausch and Gutierrez, 2010, Heath et al., 2007, Ross
and Heath, 2002) and 4–6% adults engage in NSSI (Briere and Gil, 1998, Klonsky, 2011).”
Also, the authors should correct or replace the references regarding korean newspapers
which is only written in Korean and which is not found with using even internet adress
such as ref. 14, 19, 20, and etc. The authors should support their ideas with more
evidenced and English-written publications, since this journal is internationally
read.
Response: We thank you for your thoughtful comment. Since the SHSI was developed as
a culturally sensitive measure for the adolescent population, we have not only cited
references written in English but also those written in Korean. Due to the limited
academic evidences on the novel phenomena related to NSSI (e.g., engaged in bloodletting)
among adolescents in Korea, especially those different from Western findings, we have
included Korean newspapers. We have checked the online address of the articles once
again and modified the reference as below.
Before
16. Lee JH, Choe, Y. Y., Jeon, J. Y. . "self-harm experience" in 70,000 middle school
and high school students 2018. November, 11th. [Available from: http://www.hani.co.kr/arti/society/ society_general/869668.html.
19. W. YJ. Adolescents cousulted with self-harm has been tripled. Yonhap News. 2019.
05. 29.
21. Edujin. Is your 'friend' safe, now? Nachimban. 2018. 11. 09.
22. Song HS. Warning for upsurge of self-harming adolescents. Shindonga. 2019. April
7th.
After
16. Lee JH, Choe YY, Jeon JY. "Self-harm experience" in 70,000 middle school and high
school students. The Hankyoreh. 2018 Nov 11 [Cited 2021 Oct 15]. Available from: https://www.hani.co.kr/arti/society/society_general/869668.html
19. Yang, JW. Adolescents consulted with self-harm have been tripled. The Yonhap News.
2019 May 29 [Cited 2021 Oct 15]. Available from: https://www.yna.co.kr/view/AKR20190529078500005.
21. Moon YH, Is your ‘friend’ safe, now?. The Edujin Nachimban. 2018 Nov 9 [Cited
2021 Oct 15]. Available from: http://www.edujin.co.kr/news/articleView.html?idxno=20216
22. Song HS. Warning for upsurge of self-harming adolescents. The Shindonga. 2019
Apr 7 [Cited 2021 Oct 15]. Available from: https://shindonga.donga.com/3/all/13/1686942/1.
2. In the introduction, I cannot understand what the authors mean by the difference
between self-injury and self-harm in page 3, line 64. Please clarify the meaning or
delete the sentence.
Response: Thank you for your valuable comment. We have removed “self-harm” and clarified
the meaning of the sentence as below.
Before
Girls are known to show NSSI earlier than boys are at higher risk of developing self-harm
during adolescence. NSSI declines over time, but approximately 20% of adolescents
who start NSSI maintain the behavior for more than five years, and it often develops
into a chronic and malignant practice
After (Page 3, Line 38-42)
Girls are known to show NSSI earlier than boys and are at a higher risk of developing
self-harm behaviors during adolescence [5,9,10]. NSSI declines over the course of
its development from adolescence to early adulthood. However, approximately 20% of
adolescents maintain the behavior for more than five years, and it often develops
into a chronic and malignant practice that lasts until adulthood [4].
3. In the method section, I recommand the authors should show the readers how 28 items
were selected from the scales the authors utilized, more clearly. For this purpose,
the authors can use the supplemental enlisting materials.
Response: We thank you for your thoughtful suggestion. We have added the preliminary
28 items under the Supplemental Material S2.
Before
For the development of the preliminary SHSI, multiple sources of information were
reviewed. Previous research findings (academic sources), news and social media contents
describing self-harm behaviors, and clinical observations and comments of experts
in self-harm and suicidal attempts (non-academic sources) were investigated. Further,
items from pre-existing self-harm measures, such as SHI, DSHI, and FASM, were collected.
Overlapping items and areas were combined or reorganized. A total of 28 items were
developed for the first version of the preliminary measure, and sent to 11 Korean
experts in self-harm and suicide: four clinical psychologists, five psychiatrists,
and two school counselors.
After (Page 9, Line 179-192)
For the development of the preliminary SHSI, multiple sources of information were
reviewed. Previous research findings (academic sources), news, and social media (such
as Twitter, Instagram, Facebook, and Tumblr), describing self-harm behaviors and related
clinical observations, were investigated. The comments of experts on self-harm and
suicide attempts (non-academic sources) were also considered. Further, the items assessing
self-harm behaviors in the pre-existing self-harm measures, such as the SHI, DSHI,
and FASM, were collected. The focus of the literature review was to generate a list
of specific and observable NSSI behaviors. Thereafter, the overlapping items and dimensions
in the list were either combined or reorganized.
A total of 28 items were developed for the first version of the preliminary measure
(Supplemental Material S2) and sent to 11 Korean experts—four clinical psychologists,
five psychiatrists, and two school counselors —in the areas of self-harm and suicide.
Furthermore, to ease comprehension among the readers, we have added the preliminary
28 items under the Supplemental Materials.
[Supplemental Material_ S2 Table 2]
S2 Table 2. The Preliminary 28 items of the self-harm behaviors among adolescents
No.
Item
1
Overdosed on drugs.
2
Cut my body with sharp objects.
3
Hit my body (e.g. hitting my body, such as the head, hard with my hands).
4
Banged my head against a wall, desk, etc.
5
Hit things hard with my fist.
6
Drank excessively.
7
Scratched my body.
8
Engaged in unhealthy sexual relationships (e.g., having multiple partners).
9
Had unsafe sex.
10
Starved to the point of harming my body (for a few days at least).
11
Took laxatives, diuretics, etc. to the point of harming my body.
12
Cut or carved something onto skin using a knife.
13
Pulled my hair out.
14
Picked or pinched my wound.
15
Burnt my skin with fire (using a cigarette, match, or other hot objects).
16
Stuck objects underneath my fingernails or into my skin.
17
Bit parts of my body (e.g., mouth and lips)
18
Scratched my skin until it left scars.
19
Picked or peeled off my skin.
20
Stabbed my body with sharp or pointed objects.
21
Cut holes in my body (e.g. not ear piercings or body piercings that are meant to enhance
beauty, but to make holes to harm myself)
22
Slit or cut my body with sharp objects
23
Carved words or symbols onto my body.
24
Rubbed my skin on rough surfaces.
25
Swallowed dangerous substances (bleach, hand sanitizer, detergent, etc.).
26
Strangled my neck.
27
Engaged in bloodletting (drained blood from my body).
28
Got a tattoo.
4. In the method section, the authors describled the exclusion and inclusion processes
they made. However, it is hard to read and understand full process clerarly. With
using addtional figure, the readers are able to understand your process more clearly.
Response: We thank you for your recommendation, and have added a figure which depicts
the research flow, as shown below.
Fig 1. Flow of the research
5. I also wonder what was first 20 items in detail.
Response: We thank you for your question. Please find preliminary 20 items in Table
1 of the manuscript.
- Attachments
- Attachment
Submitted filename: Response to the Reviewers-final.docx
https://orcid.org/0000-0002-5747-1052
