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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.8 Rio de Janeiro Aug. 2019  Epub Aug 05, 2019

https://doi.org/10.1590/1413-81232018248.18502017 

ARTICLE

Assessment tools of non-suicidal self-injury in adolescents 1990-2016: a systematic review

Yolanda Viridiana Chávez-Flores1 
http://orcid.org/0000-0003-0613-167X

Carlos Alejandro Hidalgo-Rasmussen2 
http://orcid.org/0000-0002-5287-2076

Libia Yanelli Yanez-Peñúñuri3 
http://orcid.org/0000-0003-4682-5123

1Escuela de Ciencias de la Salud Valle de las Palmas, Universidad Autónoma de Baja California. Calzada Universidad 14418, Parque Industrial Internacional. 22427 Tijuana B.C. México. carlos.hidalgo@academicos.udg.mx

2Centro de Investigación en Riesgos y Calidad de Vida, Departamento de Promoción, Preservación y Desarrollo de la Salud, Universidad de Guadalajara. Centro de Estudios Avanzados, Universidad de Playa Ancha. Cd. Guzman Jalisco Mexico.

3Departamento de Ciencias Sociales, Unidad Regional Norte, Universidad de Sonora. Caborca Sonora México.


Abstract

The purpose of this systematic review was to identify the instruments created or adapted to assess non-suicidal self-injury (NSSI) among adolescents. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) methodology was used. Two individual reviewers analyzed the psychometric properties of instruments published in English or Spanish from 1990 to 2016 considering standardized quality criteria. The PsycINFO, PubMed, ISI Web of Knowledge, Scopus, SciELO, ScienceDirect, and EBSCO databases were consulted. Eighteen studies that created or adapted 11 instruments were selected. Most were developed in the United States or Canada, and none were developed in Latin America. Several studies presented no evidence of the psychometric properties of their instruments. Seven of the 18 studies obtained at least one positive score. The Alexian Brothers Urge to Self-Injure Scale (ABUSI) and the Impulse, Self-harm, and Suicide Ideation Questionnaire for Adolescents (ISSIQ-A) obtained the highest positive scores. The limitation of this study is that only seven databases were employed for the literature search in English and Spanish. The reporting of the psychometric properties of NSSI instruments among adolescents should be improved, and adaptations to Latin American countries should be developed for international comparisons.

Key words Self-destructive behavior; Adolescent; Surveys and questionnaires; Cross-cultural comparison; Review

Resumen

El propósito de esta revisión sistemática fue identificar los instrumentos creados o adaptados para evaluar la autolesión no suicida en adolescentes. Se utilizó la metodología PRISMA. Dos revisores independientes analizaron las propiedades psicométricas de los instrumentos publicados en inglés o español desde 1990 a 2016 considerando criterios de calidad estandarizados. Las bases utilizadas fueron PsycINFO, PubMed, ISI Web of Knowledge, Scopus, SciELO, ScienceDirect y EBSCO. Se seleccionaron 18 estudios que crearon o adaptaron 11 instrumentos. La mayoría desarrollados en Estados Unidos y Canadá y ninguno en América Latina. Varios estudios no presentan evidencia de las propiedades psicométricas de los instrumentos. Siete de los 18 estudios obtuvieron al menos una puntuación positiva. El ABUSI y el ISSIQ-A obtuvieron la mayor cantidad de puntuaciones positivas. Las limitaciones de este estudio fueron que la búsqueda se realizó solamente en siete bases de datos y en los idiomas inglés y español. Se sugiere mejorar el reporte de las propiedades psicométricas de los instrumentos de autolesión no suicida en adolescentes y desarrollar adaptaciones a países de América Latina que permitan hacer comparaciones internacionales.

Palabras clave Conducta autodestructiva; Adolescente; Encuestas y cuestionarios; Comparación transcultural; Revisión

Non-suicidal self-injury (NSSI) was included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), as a condition that requires greater research1. NSSI is defined as the deliberate self-inflicted destruction of the body or skin tissue without the intention of dying1. NSSI behaviors include self-cutting, burning, skin rubbing, hitting, biting, and others2.

Internationally, the prevalence of NSSI varies based on the studied population, age group, and criteria used to operationally define this construct. The rates of NSSI among adults during the last 6 months were estimated at 4% for the general population and 21% for the clinical population3, whereas those for adolescents over the last 12 months increase to 16.1-18.0% for the general population4 and 60% for the clinical population5. The onset age of NSSI is between 12 and 15 years6,7. The risk of this behavior is higher in adolescents8,9 in both the general and clinical populations, which suggests the need for assessment instruments that are validated and appropriate for this age group.

The comprehensive and precise study of NSSI allows, in clinical practice, to support decision making regarding diagnosis and treatment plans. Furthermore, in research field it supports theoretical development and favors agreement among researchers for the denomination and operationalization of the construct10. Because of the incidence of NSSI behaviors and health risks associated among adolescents and adults, the number of studies and the development of various evaluation tools (including interviews and self-report tools) have increased11 since the 1990s. To ensure that the data provided by these reports are useful for the diagnosis and treatment of NSSI, evaluating the psychometric quality of these instruments is paramount to generate evidence about their validity (content, criteria, and construct) and reliability (internal, consistency, and reproducibility) as well as to ensure that evidence is reported according to standardized criteria12,13. Likewise, the use of exploratory or confirmatory factor analyses is required to understand the nature and quantity of the underlying factors of the variables included in an instrument14 and to provide cross-cultural validity when using instruments from different languages or countries13,15,16. Cross-cultural validity is understood as how the performance of the items in a translated or culturally adapted instrument reflects the performance of the items in the original version of the instrument17.

Systematic reviews attempt to collect all of the empirical evidence that fits previously specified eligibility criteria to answer a specific research question18. Although systematic reviews and studies that analyze the psychometric properties of the instruments that evaluate NSSI have been published10,19,20, they were not specifically performed with regard to adolescents. Data regarding this age group is necessary given that vulnerability to NSSI behaviors is greatest during puberty and adolescence. Therefore, the objective of this research was to execute a systematic review to identify the assessment instruments for to assess NSSI among adolescents, created or adapted from 1990 to 2016 as well as to analyze their psychometric properties.

Method

The systematic review protocol applied was approved and registered by the Research and Postgraduate Coordination of the university in charge of this study.

Search strategies

Using the methodology guidelines of Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA; http://www.prisma-statement.org/), an author of the present study conducted (from October 28 to November 28, 2016) a comprehensive search of studies published in English and Spanish between January 1990 and October 2016 and indexed by the PsycINFO, PubMed, ISI Web of Knowledge, Scopus, SciELO, ScienceDirect, and EBSCO databases.

The search terms were divided into three groups using the Boolean operators “AND” and “OR”. The terms in English were (“self-injury OR self-injurious behavior OR self-mutilation OR non-suicidal self-injury * OR NSSI OR self-poisoning * OR self-harm * OR deliberate self-harm * OR parasuicide OR deliberate self-injury * OR deliberate self-determination OR self-aggression * OR autoaggression * OR autoaggressive “*) AND (“ instrument * OR measure * OR questionnaire * OR scale * OR assessments * OR inventory * OR psychometric * OR validity OR reliability OR psychometric properties OR factor analysis) AND (“Adolescence OR youth OR teenager OR teens OR adolescents”). The terms in Spanish were (“autolesi* OR comportamientos autolesivos OR autoagresión OR lesiones autoprovocadas OR automutilación OR autodaño OR autolesión* OR lesiones autoinflingidas OR autodestructivo OR autoflagelación”) AND (“instrumento* OR cuestionario* OR escala* OR inventario* OR entrevista* OR autoreporte OR pruebas psicométricas OR validación OR confiabilidad OR propiedades psicométricas OR análisis factorial”) AND (“adolescencia OR adolescentes OR pubertad”).

Subsequently, another author performed a directed search to verify that the initial search identified internationally recognized instruments. In addition, both authors independently conducted a manual search based on the reference lists of the identified studies to add those not included to the main search. Additional data were requested from two authors because one published article did not include sufficient data concerning the instrument to evaluate its possible inclusion in this study.

Selection of studies

Based on the outcome of the main, directed and manual searches (which were performed independently), the research team agreed select studies based on the following inclusion and exclusion criteria. Studies that developed, adapted, or evaluated the psychometric properties of instruments or domains of NSSI with regard to adolescents (10 to 19 years of age) were included. Studies that used the term “self-injury” to evaluate suicidal behavior or those in which the evaluation of psychometric properties could not be performed because of insufficient data or the authors' lack of response were excluded. To reduce bias with regard to the search and study selection, the definition of self-injury was reviewed in each article, and its theoretical foundation was identified to ensure that NSSI was evaluated.

Data extraction

Two of the authors of this study separately used an electronic form previously designed and piloted by the research team to collect the data. Data from each study concerning the characteristics of the instrument (i.e., name, author, country, year of publication, dimensions, and number of items), the study characteristics (i.e., population type, sample size, average age, and sex distribution), and reported evidence of the psychometric properties of each instrument (considering the criteria of Terwee et al.12,13) were extracted.

Evaluation of the studies

One of the authors evaluated the quality and bias risk of the selected studies using Downes et al.'s21 AXIS tool. To analyze the psychometric characteristics of the instruments, two authors independently evaluated the selected studies according to the standardized criteria proposed by Terwee et al.12 on a four-point scale (positive, intermediate, poor, or unavailable) and nine psychometric characteristics (content validity, internal consistency, criterion validity, construct validity, agreement, reliability, responsiveness, floor-ceiling effect, and interpretability). Although these criteria exclude the cross-cultural validity of the instruments, it was added in a complementary manner based on the Agreement-based Standards for the Selection of Health Measurement INstruments (COSMIN) tool (www.cosmin.nl) created by Terwee et al.13 that evaluates the evidence presented in cross-cultural validation studies as excellent, good, fair, or poor. Ten psychometric characteristics were evaluated. The rating provided by each reviewer was analyzed; disagreements were discussed by a third party to reach agreement. The evaluation of the psychometric characteristics performed by the two independent reviewers showed an almost perfect agreement (Kappa = .86).

Results

The main search identified 282 studies, and the manual and directed searches identified 29, for a total of 311. A total of 32 duplicate studies were eliminated. Based on the inclusion and exclusion criteria, 207 studies were eliminated, and 72 were selected for a full-text review. Based on the full review, 54 studies were excluded. The main grounds for rejection were the lack of psychometric characteristics for any instrument (71%), the evaluated instruments were created based on a population of adults or young adults (23%), or that the evaluation method included fewer than three items (5.7%). Finally, 18 studies were included in the systematic review to evaluate the psychometric properties (Figure 1).

Figure 1 Description of the search and selection process of the included studies in the systematic review. 

(Table 1 shows the characteristics of the studies selected for evaluation. Of these 18 studies, 11 were instruments for evaluate NSSI in adolescents: the Self-Injurious Thoughts and Behaviors Interview (SITBI)22 with one adaptation23; the Self-Harm Behavior Questionnaire (SHBQ)24; the Functional Assessment of Self-Mutilation (FASM)6 with three adaptations25-27; the Self-Injury Motivation Scale, Adolescent version (SIMS-A)28; the Alexian Brothers Assessment of Self-Injury (ABASI)29; the Alexian Brothers Urge to Self-Injure Scale (ABUSI)30, four adaptations of the instrument Ottawa Self-Injury Inventory (OSI)31-34; the Risk-Taking and Self-Harm Inventory for Adolescents (RTSHIA)35; the Repetitive Non-Suicidal Self-Injury Questionnaire (R-NSSI-Q)36; the 6-item measure of Prinstein37; and the Impulse, Self-harm, and Suicide Ideation Questionnaire for Adolescents (ISSIQ-A)38. With its publication in 2007, the SITBI22 became the first instrument intended to measure NSSI among adolescents. The SITBI is an interview-format instrument with 169 items that was developed in the United States using a general population of adolescents and young adults. Of the 18 included studies, eleven (61.1%) were performed in the United States, and four (22.2%) were performed in Canada. Eight (44.4%) were adapted cross-culturally. No instruments created in or adapted for Latin America were found. Of the total studies, six (33.3%) were performed with clinical populations, ten (55.5%) were performed with students, one (5.6%) was performed with a general population, and one (5.6%) was performed with both patients and students. Regarding the use of a factor analysis, three studies (16.6%) conducted an exploratory factor analysis, eight (44.4%) conducted a confirmatory factor analysis, and seven (38.8%) did not report such an analysis.

Table 1 Description of the NSSI instruments and sample characteristics. 

Instrument Author(s), year Country of creation and/or adaptation n Type of participant Age, M (SD) No. Items Dimensions Factor Analysis
ABASI Washburn et al., 2015 USAc 511 P 17.3 (6.2) 28 Criteria A, B, C and D of the DSM-5 EFA
ABUSI Washburn et al., 2010 USAc 36 P 18.7 (7.5) 5 Unidimensional EFA
FASM Nock & Prinstein, 2004 USAc, USAa 108 P 14.8 (1.4) 22 Methods, frequency and self- injury function CFA
Leong et al., 2014
(C-FASM)
USAc, Cha 825 St 11.4 (1.3) CFA
Calvete et al., 2015 (FASM-E) USAc, Sa 1864 St 15.3 (2.0) CFA
Dahlstrom et al., 2015 (FASM) USAc, Swa 3097 St 15-17* CFA
ISSIQ-A Carvalho et al., 2015 Pc 1722 St 16.7 (1.3) 56 Impulsivity, self-injury, risk behaviors, suicidal ideation CFA
R-NSSI-Q Manca et al., 2014 Ic 383
251
953
St
R
St
23.3 (4.0) 16.4 (1.7) 16.2 (1.5) 38 Frequency and non-suicidal self-injury methods NR
RTSHIA Vrouva et al., 2010 Enc 651 P
St
St
15.3 (2.1)
15.2 (2.2)
15.8 (1.5)
27 Self-injury and risk taking CFA
SHBQ Muehlenkamp et al., 2010 USAc, USAa 1386 St 15.4 (1.4) 22 NSSI behaviors, suicidal ideation, suicide threat and past suicide attempts CFA
SIMS-A Swannell et al., 2008 USAc, Aua 38 P M 15.7 (1.0) H 16.1 (0.9) 22 Emotions Regulation, communicating/influencing others, punishment/excitement and psychosis/emptiness of insight EFA
SITBI Nock et al., 2007 USAc 94 PG 17.1 (1.9) 169 Suicidal ideation, suicidal planning, suicidal gestures, suicidal attempt, and NSSI
Fischer et al., 2014 (SITBI-G) USAc, Ga 111 P 15.4 (1.7)
OSI Plener et al., 2009 Cc, Ga 665 E 14.8 (0.7) 21 Self-injury methods, suicidal behavior, functions, coping strategies, and addiction NR
Csorba et al., 2010 Cc, Hua 427 E 16.7 (NR) 37 Impulse, behaviors, feelings, and behavior climate NR
Rodav et al., 2014 Cc, Isa 275 E 14.8 (1.4) 34 Frequency, methods, and functions of NSSI NR
Nixon et al., 2015 Cc, Ca 94 P 15.7 (1.5) 31 Internal emotional regulation, social influence, external emotional regulation, and search for sensations CFA
6 Item-Measure Prinstein et al., 2008 USAc 148 E 13.5 (0.8) 6 NR NR

Note: ABASI, Alexian Brothers Assessment of Self- Injury; ABUSI, Alexian Brothers Urge to Self-Injure Scale; FASM, Functional Assessment of Self -Mutilation; ISSIQ-A, Impulse, Self-harm and Suicide Ideation Questionnaire for Adolescents; R-NSSI-Q, Repetitive Non-Suicidal Self-Injury Questionnaire; RTSHIA, Risk-taking and self-harm inventory for adolescents; SHBQ, Self-Harm Behavior Questionnaire; SIMS-A, Self-Injury Motivation Scale Adolescent. Au, Australia; Ch, China; S, Spain; USA, United States of America; I, Italy; En, England; P, Portugal; Sw, Sweden. P, Patients; R, Residents in therapeutic community; St, Students; CFA, Confirmatory factor analysis; EFA, Exploratory factor analysis.

*Age range is presented;

cCountry of creation;

aCountry of adaptation.

Regarding the quality and risk of bias of the selected studies, all listed clear objectives. Concerning their methods, all showed appropriate designs and clearly defined samples with a sampling frame representing the researched population as well as risk factors and outcome variables appropriate for their objectives. Only 33% justified their sample sizes, 28% ensured a random selection, 39% took action to address non-respondents, 78% evaluated risk factors and outcome variables using previously tested or published instruments, 78% specified what was applied to determine the significance or precision estimates, and 94% described the methodology to replicate them. Regarding the results, all studies described the basic data and delivered the results of the analyses described in the methods. Although 61% provided information about non-respondents, 44% provided insufficient information about a non-response bias. Approximately 83% of the studies had outcomes that were internally consistent. Limitations were indicated in all of the studies' discussions, and 94% of the results and authors' discussions were justified. No study reported conflicts of interest, and 94% secured ethical approval or the consent of the participants.

Results of the evaluation of the psychometric properties

(Table 2 shows the studies that created instruments that evaluate NSSI among adolescents and their psychometric properties. Of the seven instruments, only the ISSIQ-A38 obtained positive content validity scores, whereas five instruments (71.4%) obtained poor ratings. When evaluating internal consistency, two of the seven instruments (28.5%), the ABUSI30 and ISSIQ-A38, obtained positive scores, and two instruments presented no data (28.5%). Five instruments (71.4%) provided data on criteria validity, but none obtained positive ratings. Regarding construct validity, five instruments (71.4%) obtained a positive score, and two instruments (28.5%) had no available data. Concerning reliability, two instruments (28.5%), the ABUSI30 and SITBI22, obtained positive scores, whereas the ABASI29 (14.2%) obtained poor scores, and the remaining instruments presented no data. Only two instruments (28.5%), the R-NSSI-Q36 and RTSHIA35, presented evidence of responsiveness and obtained a positive score. None of the instruments provided data concerning agreement or of floor or ceiling effects. Five instruments (71.4%) provided data on interpretability, but none obtained a positive score.

Table 2 Analysis of the psychometric properties of studies reporting the creation of instruments to assess NSSI among adolescents considering the criteria of Terwee et al.12

Instrument Content Validity Internal Consistency Criteria Validity Construct Validity Agreement Reliability Responsiveness Floor-Ceiling Effect Interpretability Positive Scores Total
ABASI - - ? 0 0 - 0 0 ? 0
ABUSI - + ? + 0 + 0 0 ? 3
ISSIQ-A + + - + 0 0 0 0 ? 3
R-NSSI-Q ? 0 ? + 0 0 + 0 ? 2
RTSHIA - - ? + 0 0 + 0 ? 2
SITBI - 0 0 + 0 + 0 0 0 2
6-item measure - - 0 0 0 0 0 0 0 0

Note: ABASI, Alexian Brothers Assessment of Self- Injury; ABUSI, Alexian Brothers Urge to Self-Injure Scale; ISSIQ-A, Impulse, Self-harm and Suicide Ideation Questionnaire for Adolescents; R-NSSI-Q, Repetitive Non-Suicidal Self-Injury Questionnaire; RTSHIA, Risk-taking and self-harm inventory for adolescents; SITBI, Injurious Thoughts and Behaviors Interview. Criteria: + positive; ? intermediate; - poor; 0 unavailable.

Of the 11 studies that described an instrument adaptation (Table 3), only the SHBQ24 obtained a positive score for internal consistency. Six instrument adaptations (54.5%) obtained poor scores, and four adaptations (36.3%) presented no data. With regard to criteria validity, only the C-FASM25 provided evidence and obtained an intermediate score. Regarding construct validity, only two instruments (18.1%), the C-FASM25 and SHBQ24, obtained positive scores, and the SITBI-G23 (9.0%) scored poorly. Concerning reliability, only the SITBI-G23 presented evidence and obtained a poor score. None of the instruments adaptations provided evidence of agreement, responsiveness or floor or ceiling effects. Regarding interpretability, five instrument adaptations (45.5%) presented evidence and obtained intermediate scores.

Table 3 Analysis of the psychometric properties of the adaptations of the instruments evaluating NSSI among adolescents considering the criteria of Terwee et al.12

Instrument Content Validity Internal Consistency Criteria Validity Construct Validity Agreement Reliability Responsiveness Floor-Ceiling Effect Interpretability Positive Scores Total
FASM EU - 0 0 0 0 0 0 0 0
C-FASM Ch - ? + 0 0 0 0 ? 1
FASM-E E - 0 0 0 0 0 0 ? 0
FASM S - 0 0 0 0 0 0 0 0
SHBQ EU + 0 + 0 0 0 0 ? 2
SIMS-A Au - 0 0 0 0 0 0 0 0
SITBI-G A 0 0 - 0 - 0 0 0 0
OSI A 0 0 0 0 0 0 0 ? 0
OSI Hu 0 0 0 0 0 0 0 0 0
OSI Is 0 0 0 0 0 0 0 ? 0
OSI C - 0 0 0 0 0 0 0 0

Note: FASM, Functional Assessment of Self-Mutilation; SHBQ, Self-Harm Behavior Questionnaire; SIMS-A, Self-Injury Motivation Scale Adolescent; SITBI, Injurious Thoughts and Behaviors Interview; OSI, Ottawa Self-Injury Inventory. G, Germany; Au, Australia; C, Canada; Ch, China; S, Spain; USA, United States of America; Hu, Hungary; Is, Israel; Sw, Sweden. Criteria: + positive; ? intermediate; - poor; 0 unavailable.

Only the FASM25 adaptation in China obtained a positive evaluation regarding cross-cultural validity, and the remaining adaptations (87.5%) were evaluated as poor. These poor evaluations were for not describing or poorly describing the translator's expertise regarding the tested construct; for not clarifying whether there was more than one translator, whether they worked independently, or how they resolved their differences; or for not clarifying whether the translation was reviewed by a committee involving the researchers or the creators of the original instrument. Some studies did not pilot the translated instrument or perform a confirmatory factor analysis.

Discussion

This systematic review identified the NSSI assessment instruments created or adapted for adolescents between 1990 and 2016 as well as analyzed the outcomes of their psychometric properties. A total of 18 studies were identified; seven created instruments, and 11 adaptations. Seven of the 18 studies obtained at least one positive score. The ABUSI30 and the ISSIQ-A38 obtained the greatest number of positive scores, fulfilling three of the nine evaluation criteria. However, no evidence regarding the psychometric properties of the various instruments was found using Terwee et al.'s12,13 evaluation criteria, and no data were presented regarding agreement or floor or ceiling effects.

Because NSSI is a widespread phenomenon reported across different countries4, it is associated with negative well-being39,40, higher probability of suicide41,43, and a higher prevalence of NSSI has been reported among adolescents compared with adult populations, and that the present review identified 11 instruments, more than half of which were created over the last 7 years (as well as seven of eight adaptations), suggest that this field of study is still incipient. No instruments created for or adapted to Latin America were identified, despite evidence that NSSI is a common phenomenon in these populations44-47. Eleven instruments were created or adapted in the United States; only the FASM6,25-27, the SITBI22,23, and the OSI31-34 were adapted for application among the adolescents of several countries to allow for international comparisons31. Therefore, it is necessary to make progress toward culturally adapting the instruments with the best psychometric properties for several regions of the world.

Regarding the target population of the analyzed instruments, seven were originally designed for adolescents, and four were designed for adults. It is necessary that the instruments applied to adolescents be designed specifically for this age group; if they were created for adults, then a semantic adaptation should be made because adolescents might interpret and answer questions from an instrument in a different way because of developmental differences compared with adults48.

Of the evaluated instruments, those with the greatest evidence of validity and reliability were the ABUSI30 and ISSIQ-A38. These instruments evaluated the different dimensions of the NSSI. The ABUSI30 evaluates criteria A, B, C, and D of the DSM-5, whereas the ISSIQ-A38 is useful for determining impulsivity, NSSI, risky behaviors, and the intrapersonal or interpersonal functions of the NSSI. More dimensions are addressed in other instruments that might be useful in clinical practice given the relevant information they provide; however, it is necessary to provide greater evidence of validity and reliability. Seven of the 18 analyzed studies did not report the use of factor analysis methods. These methods provide evidence of the exploration or confirmation of the dimensions evaluated by an instrument.

Eleven of the 18 analyzed instruments were created for or adapted to general or school populations; therefore, it is important to evaluate the psychometric properties of the instruments across different types of vulnerable populations (e.g., clinical populations), which would enable researchers to establish cut-off points and broaden the analysis of psychometric characteristics such as responsiveness and specificity; however, one possible difficulty would be accessing this population, partially because of the low prevalence of NSSI or the lack of seeking help among those who show these behaviors.

Assessing the psychometric properties of the instruments is important because of its relevance regarding the evaluation and treatment of NSSI. Regarding the internal consistency of the creations, the ABUSI30, the ISSIQ-A38, and the adaptation of the SHBQ24 obtained positive scores. This criterion was met by only three instruments. From our perspective, this finding suggests that difficulties (e.g., those regarding content validity) were present during previous phases of the construction of the instruments or their adaptations. Thus, instruments with internal consistency issues also scored low on content validity. The application of Cronbach's alpha to evaluate the internal consistency of the instruments was criticized because this statistic improves as the number of items in the instrument increases49,50. The evidence for content validity was weak because only one of the seven created instruments, the ISSIQ-A38, obtained positive scores. The participation of experts and the target population in focus groups is critical for the items' final outcomes (and the domains to which they contribute) to be included in the instrument. Although most of the analyzed studies did not report satisfactory evidence with regard to the two evaluated criteria, they contribute to an understanding of how the scales behave.

No instrument obtained positive scores regarding criteria validity because there are few gold standards in psychology. Therefore, the need to create standardized evaluation criteria and updates of the psychometric properties of the instruments is evident because the criteria of Terwee et al.12 were elaborated from a medical context. Regarding construct validity, obtained positive scores the instruments created ISSIQ-A38, ABUSI30, R-NSSI-Q36, RTSHIA35, and SITBI22, and those adapted the C-FASM25 and SHBQ24. Because this type of validity helps prove that a specific construct is being evaluated, it is an essential feature among instruments designed to evaluate the set of indicators that comprise or relate to a specific diagnostic criterion. Based on all of the analyzed studies, it is noteworthy that this value was not reported by more than half. This fact might be related to the shortage of validated instruments that evaluate NSSI among adolescents, through which a convergent validity analysis could be performed.

Only the created instruments the ABUSI30 and SITBI22 obtained positive reliability scores. Terwee et al.12 distinguished between the relative and absolute measurement of reliability, which he called reliability and agreement, respectively. No study reported having calculated this latter condition, which shows that an analysis like the minimum important change (MIC), which describes the certainty that the magnitude of a change is not the result of chance, is not widely used among researchers in this field even though its use has increased, most likely because it requires more dissemination and training for this community of researchers to become familiar with it, compared with traditional analysis Kappa. Although reliability is much less complex to calculate, presents difficulties because of the need for multiple measurements of the same participants, so it was only evaluated by four instruments: the ABASI29, ABUSI30, and SITBI22 as well as the adaptation SITBI-G23. Therefore, we also think that the journals where these studies are published should play a primary role in requiring that certain important analyses are executed by the researchers to guarantee the quality of the creation or adaptation of an instrument.

Positive scores in responsiveness were only reported for the created instruments R-NSS-Q36 and RTSHIA35. Previous systematic reviews such as that concerning self-injury instruments for adults19 have argued that the importance of reporting responsiveness has received little attention. It is necessary to insist on the importance of evaluating these properties for the creation or adaptation of instruments because, rather than being an exclusive failure of the NSSI instruments aimed at adolescents, it is a general weakness of the studies and reviews of the creation or adaptation of instruments.

Our results showed that of the seven studies that culturally adapted an instrument, only one adaptation, the C-FASM25, obtained a good evaluation, and six adaptations obtained poor evaluations. This result occurred because the process of translating the instrument and verifying its adaptation through a review by a committee, pilot study, or confirmatory factor analysis was not described or only briefly described. Thus, the instruments evaluated in this review were not culturally adapted based on established standards. In this regard, Leong et al.25 mentioned that the translation of psychological instruments without empirical validation is common because the psychometric properties are not exhaustively verified or the procedure is not described in detail. It cannot be assumed that a translated version of an instrument has the same psychometric properties as the original version; therefore, the validity of a translated instrument should be evaluated before applying it to another country or culture.

The lack of high scores regarding the evaluation of an instrument does not necessarily denote poor psychometric properties; rather, it represents an absence of evidence because no available data were found for any of the nine evaluated criteria for any of the instruments. One relevant aspect is that several instruments showed evidence of their psychometric characteristics, although they differed from Terwee et al.'s12 criteria. Therefore, the evidence was considered as insufficient. In the case of the RTSHIA34, reliability was evaluated using Pearson's r coefficient, which is not an incorrect procedure51. In the case of the SITBI-G23, inter-rater reliability was evaluated by agreement; although this method delivers excellent Kappa coefficients, it is not possible to evaluate it using standardized criteria. In addition, the considered evaluating criteria were designed for self-report instruments; therefore, because the SITBI22,23 is an interview, it was not possible to evaluate its internal consistency or perform a factor analysis.

Regarding the current review's limitations, this search was conducted using only seven databases and two languages; therefore, subsequent studies might seek to broaden this search. It was not possible to collect data from one study, even after the corresponding author was contacted. Future studies should address important practical aspects when selecting an evaluation instrument, such as the time to respond according to the number of items, the required resources for qualifications, or the training needed for its application52.

One challenge for Ibero-American researchers is to quickly become familiar with the progress toward measuring the properties of instruments and their evaluation techniques to generate knowledge. Likewise, it is important that the knowledge and techniques required to evaluate the properties of instruments in developing countries (e.g., most of Latin America), especially those that are least likely to be reported in scientific articles, be promoted in research and training centers. If the researchers know and value the important role of instrument adaptations, they will achieve intercultural comparability and a greater understanding of the studied phenomenon, in this case the NSSI, even if they are developed and designed in other countries out of necessity.

The use of different nomenclatures to refer to the NSSI, the different ways of managing it, and the lack of adequately standardized and validated assessment instruments might trigger potential biases in the estimates of NSSI4, which limits our knowledge of its incidence and prevalence53. This review found that little or insufficient evidence regarding the psychometric properties of the instruments evaluating NSSI among adolescents is available, which justifies greater research because it is during this developmental stage that higher prevalence of NSSI is observed, in both general and clinical populations. This outcome is consistent with that regarding the NSSI instruments for adults, where a lack of developed instruments and insufficient evidence of psychometric properties is also observed. This lack of data hinders the evaluation of NSSI using standardized methods10.

Acknowledgments

The author expresses gratitude to Dr. Karina Franco Paredes for her orientation and support with regard to the methodological revision of this study.

The main author received grant from the National Council of Science and Technology. The funding source played no role in conducting this study. No conflicts of interest are present.

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Received: May 21, 2017; Accepted: December 18, 2017; Revised: December 20, 2017

Collaborations

YV Chávez-Flores worked on the design, analysis, interpretation, drafting, review and approval of the final version of the article. CA Hidalgo-Rasmussen worked on the conception, design, analysis, interpretation, drafting, review and approval of the final version of the article. LY Yanez-Peñúñuri worked on the analysis of the studies, interpretation, review and approval of the final version of the article.

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