Cyberbullying and Non-Suicidal Self-Injury NSSI in

children
Systematic Review
Cyberbullying and Non-Suicidal Self-Injury (NSSI) in Adolescence:
Exploring Moderators and Mediators through a Systematic Review
Elena Predescu 1 , Iulia Calugar 2 and Roxana Sipos 1, *
1 Department of Neuroscience, Psychiatry and Pediatric Psychiatry, “IuliuHatieganu” University of Medicine

and Pharmacy, Republicii Street No. 57, 400489 Cluj-Napoca, Romania; [email protected]
2 Clinic of Pediatric Psychiatry and Addiction, Clinical Emergency Hospital for Children,
400489 Cluj-Napoca, Romania
* Correspondence: [email protected]
Abstract: (1) Objective: This systematic review explores the intricate relationship between cyber-
bullying and non-suicidal self-injury (NSSI) in adolescents, acknowledging the dynamic nature
of these phenomena in the evolving landscape of technology and social norms. (2) Methods:
PubMed/MEDLINE, Web of Science, and EMBASE were searched, and 14 studies were selected
based on the eligibility criteria, focusing on participants aged 10 to 19, cyberbullying roles, and
NSSI as the predictor and outcome variables, respectively. (3) Results: Internalizing symptoms,
specifically depression and anxiety, emerged as the most prominent mediators. However, factors such
as externalizing symptoms, stress, and negative emotional responses (emotion reactivity, negative
emotions) were also identified to play a significant role in the relationship between cyberbullying and
NSSI. On the other hand, protective factors against the negative impact of cyberbullying on NSSI risk,
such as strong peer connections and school engagement, were identified. (4) Discussions: This review
underscores the multidimensional nature of the cyberbullying–NSSI association, emphasizing the
roles of potential risk factors such as internalizing and externalizing symptoms, stress, and negative
emotional response. Internalizing symptoms played a central role as pathways between cyberbul-
lying victimization and NSSI. Additionally, social factors, including peer connections and school
engagement, were found to act as protective elements. (4) Conclusion: Continuous investigation is
crucial in order to adapt interventions to the evolving technological and social landscape. The study
advocates for targeted interventions that prioritize positive social connections to mitigate the impact
Citation: Predescu, E.; Calugar, I.; of cyberbullying on adolescent well-being.
Sipos, R. Cyberbullying and Non-
Suicidal Self-Injury (NSSI) in Keywords: cyberbullying; non-suicidal self-injury; adolescents; internalizing symptoms; protective
Adolescence: Exploring Moderators
factors
and Mediators through a Systematic
Review. Children 2024, 11, 410.
https://doi.org/10.3390/
children11040410
1. Introduction
Received: 29 February 2024 In today’s digital world, technology plays a pivotal role in shaping our daily lives,
Revised: 20 March 2024 including the way we communicate and socialize. However, alongside its numerous
Accepted: 26 March 2024 benefits, it introduces new avenues for negative or harmful conducts, such as cyberbullying.
Published: 29 March 2024
In the last decade, cyberbullying has become a public health issue, especially among
adolescents. It represents one of the less desirable effects of technological evolution with a
negative impact on mental health and the quality of life. It is defined as “an aggressive,
Copyright: © 2024 by the authors.
intentional act carried out by a group or individual using electronic forms of contact,
Licensee MDPI, Basel, Switzerland. repeatedly and over time against a victim who cannot easily defend himself or herself” [1].
This article is an open access article Cyberbullying includes but is not limited to harassment of others through text message,
distributed under the terms and email, or social media, posting or sharing harmful or negative content about others, or
conditions of the Creative Commons even creating fake social media profiles meant to impersonate other people. With the
Attribution (CC BY) license (https:// rapid emergence of different online platforms, social media has become the most common
creativecommons.org/licenses/by/ vehicle for cyberbullying and its perpetration [2]. There are common elements between
4.0/). traditional bullying and cyberbullying, such as repetitiveness, power imbalance between
Children 2024, 11, 410. https://doi.org/10.3390/children11040410 https://www.mdpi.com/journal/children

Children 2024, 11, 410 2 of 20
the aggressor and the victim, intentionality, and aggressiveness [1]. However, contrary
to the classical forms of bullying, cyberbullying is characterized by anonymity, a lack
of need for physical interaction in order to produce harm and, moreover, by a non-stop
availability of access to victims through electronic platforms [3]. Due to the characteristics
of the environments in which cyberbullying occurs, this phenomenon has the potential of
reaching a greater potential audience, as opposed to the classical form of bullying [4], which
magnifies its potential harmful effects on cybervictims. Moreover, it has been shown that
cyberbullies feel less remorse due to the fact that they cannot see their victims’ reactions [5],
which contributes to significant perpetration of cyberbullying and further victimization
through cyberbullying.
Thus, cyberbullying can be more harmful than other classical forms of bullying, as
victims can be reached in their own homes and exposed to a wider audience with little or no
adult supervision or authority entity present. Moreover, due to the aggressors’ anonymity
and lack of fear of being caught [3], as well as a significant state of permanence of words
or images disseminated in the online space [6], cyberbullying represents a public health
problem that requires more resources in terms of prevention and intervention.
Research has identified potential predictors of cyberbullying victimization. A meta-
analysis of predictors for both perpetration and victimization in cyberbullying has shown
that previous experiences of victimization offline and psychological risk factors play sig-
nificant roles in cyberbullying victimization [7]. It has been widely indicated that there is
significant overlap between victims of traditional bullying and cybervictims [8], suggesting
a carryover of traditional schoolyard bullying from the real world to the online world.
Common predictors for both cyberbullying and cyberbullying victimization are in-
creased Internet use, poor family environment [9], low school commitment, and higher
levels of impulsivity, narcissism, hostility, or/and phobic anxiety [2,7].
While boys are more likely to be involved in direct physical confrontation, bullying in
the digital space is equally likely to be employed by girls as it is by boys [8]. Gender is one of
the unique predictors that distinguishes between cybervictims and cyberbullies, with girls
presenting a higher risk of cyberbullying victimization [7]. At an individual level, negative
beliefs about the self, such as low self-esteem or self-concept [10], low agreeableness [11],
high outgoingness and openness to risky behaviors [12], and being a member of the LBGTQ
community [13] were related to being a cybervictim, while aggressors presented a lack of
moral values, empathy, or remorse [5,7]. Social media behaviors such as posting indiscreet
or negative content and a higher number of social media “friends” were also linked to
victimization through cyberbullying [14].
Increased levels of psychological and physical distress have been reported among
victims of cyberbullying. While most research has been focused on the internalizing aspects
of the mental health issues generated by cyberbullying, such as anxiety, negative affect, or
loneliness [15,16], a higher risk of non-suicidal self-injurious acts in cybervictims has been
identified across multiple studies over the last decade [17,18].
An important concern in self-injurious behavior research revolves around the ter-
minology used, with expressions like “non-suicidal self-injury” (NSSI) and “self-harm”
prevailing. NSSI is characterized as the “deliberate, self-inflicted destruction of body tis-
sues, with no intention of suicide and no purpose of being sanctioned by society” [19].
Self-harm represents an encompassing term referring to “an intentional act of self-poisoning
or self-injury, irrespective of the motivation or apparent purpose of the act” [20]. Thus,
NSSI refers to a type of self-harm which involves no suicidal intent, while self-harm en-
compasses all types of non-fatal self-injurious acts, with or without suicidal intent [21,22].
Victimization has been identified as a contributing factor to NSSI in adolescents [23,24].
The conceptual framework of the interpersonal model of NSSI suggests that individuals
facing adverse interpersonal events may adopt NSSI as an adaptive mechanism to cope
with stress, tension, or to seek relief from distressing experiences [19]. Shedding light on
the pathways between stressful life events and NSSI, Zhou et al. (2024) indicates multiple
mechanisms. One indirect pathway involves internalizing symptoms as a mediating factor
Children 2024, 11, 410 3 of 20
of this relationship, while a second, more complex pathway involves co-mediation by

both dysfunctional emotion regulation and internalizing symptoms. Moreover, a direct
association between recent stressful life events and NSSI was also observed [25]. With the
escalating number of Internet users, cyberbullying victimization is increasingly prevalent,
particularly among adolescents [26]. A recent study investigating the relationship between
peer victimization and NSSI in 14.666 high school students indicated that peer victimiza-
tion directly predicts NSSI. Moreover, it has shown that social anxiety and mobile phone
use presented mediating effects between peer victimization and NSSI [27]. Data related
directly to cyberbullying shows that cybervictims exhibit a greater risk of self-harm than
non-victims. Similarly, but to a lesser extent, cyberbullying perpetrators are at a greater
risk of self-harm compared to non-perpetrators [28].
Building on the concept of risk and protective factors, Baker et al. (2023) investigated
how adolescents’ perceptions of socioecological connectedness influence the likelihood of
NSSI. Their finding revealed that stronger family connectedness both directly and indirectly
reduced the risk of NSSI through bullying victimization and depressive symptoms, while
school connectedness showed an indirect protective effect [29].
A comprehensive literature review investigating the global prevalence of cyberbully-
ing revealed an ascending trend in the prevalence rate over a 5-year period of study from
2015 to 2019. The average cyberbullying perpetration rate indicated was 25.03%, while the
average victimization rate was 33.08% [30]. It was observed that these rates showed higher
values when compared to previous similar research, with percentages of cyberbullying
involvement ranging from 15% to 25% [31,32].
Extensive evidence supports the association between cyberbullying and an increased
likelihood of individuals, both victims and perpetrators, engaging in self-injurious be-
haviors like cutting or burning oneself [28]. The prevalence of self-injurious behaviors,
regardless of the cause, has evolved into a public health concern, exerting lasting negative
impacts on the lives of those involved, both in the subsequent years and extending into
adulthood [33]. The lifetime prevalence of self-injurious behaviors both with and without
suicidal intent has been reported at 20% in a meta-analytical study investigating the global
prevalence of self-harming behaviors in adolescents [34]. Farkas et al. (2023) revealed in
their recent systematic review and meta-analysis an overall prevalence of NSSI of 16%
in studies published between 2015 and 2020. Noteworthy gender differences in preva-
lence rates were also reported, with a prevalence rate of approximately 21% for females
and 16.5% for males [35]. A 90% prevalence of internet use has been reported among
adolescents that employ self-injurious acts [36]. Other than being a venue for bullying
perpetration, the digital space can potentially normalize self-harming behaviors and impact
the repetitiveness of these behaviors [28]. These findings emphasize the pressing need for
comprehensive research to explore the intricate dynamics between cyberbullying and NSSI
among adolescents, considering its far-reaching impact on adolescent well-being.
The Present Study

The data presented above suggest a significant association between cyberbullying
involvement and NSSI engagement. This systematic review aims to investigate moderating
and mediating variables between cyberbullying and NSSI, taking into consideration the
status of involvement (victim/aggressor). Previous research conducted by Moore et al. [37]
investigated the relationship between the types of bullying involvement and self-harmful
thoughts and behaviors in young people, revealing significant data heterogeneity and a
noteworthy lack of terminological consistency within the literature. To our current knowl-
edge, no systematic review to date has exclusively addressed the non-suicidal dimension
of self-harming behaviors in adolescents involved in cyberbullying. Consequently, our ob-
jective is to systematically identify the mediator and moderator variables that influence the
relationship between cyberbullying and NSSI occurrence. The current review investigates
the following question: what are the moderating and mediating variables associated with
NSSI in adolescents involved in cyberbullying? This analysis aims to provide a compre-
Children 2024, 11, 410 4 of 20
hensive understanding of the nuanced interplay between cyberbullying and NSSI among
adolescents, contributing valuable insights to the existing body of knowledge.
2. Materials and Methods

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [38–40] (Supplementary Figure S1).
2.1. Information Sources

Comprehensive searches for the relevant literature were conducted across multiple
academic databases: PubMed/MEDLINE, Web of Science, and EMBASE. The search strings
specific to every database employed controlled cyber-related vocabulary terms in order to
ensure a robust and exhaustive retrieval of relevant studies (see Table 1), minimizing the
risk of publication bias and guaranteeing the comprehensiveness of this systematic review.
The strings used for each academic database can be found in Supplementary Table S1.
Table 1. Key terms employed in database search.
Term Category 1: Term Category 2: Term Category 3:

Cyberbullying NSSI Child x Adolescent
Cyber-bull*
Cyber-victim*
Cyberstalk*
Cyber harass*
Online bully*
NSSI Child*
Online victim*
Non-suicidal self-injury Adolescen*
Online stalk*
Self-harm* Youth
Online harass*
Self-injur* School aged
Internet bully*
Automutilat* Student*
Internet stalk*
Internet harass*
Electronic bully*
Electronic stalk*
Electronic harass*
2.2. Eligibility Criteria

A structured approach based on PICOS principles [41] was employed to determine
the study inclusion criteria.
In accordance with the World Health Organization’s definition of adolescence [42],
participants aged 10 to 19 were recruited for this study. The sample populations encom-
passed individuals identified as victims or aggressors in the context of cyberbullying, with
participants identified as bystanders excluded. No eligibility criteria were established based
on other participant characteristics. Studies which examined cyberbullying independently
were included. Studies which investigated cyberbullying and other forms of bullying
were included only if they ensured a clear differentiation between the types of aggression
approached. It was required that studies investigate at least one of the following cyberbul-
lying roles as a predictor variable: victim, aggressor, or aggressor–victim. Additionally,
studies were required to examine NSSI as an outcome variable. Taking into consideration
the significant overlap in definitions, studies investigating self-harm behaviors explicitly
measured and reported as lacking suicidal intent were included. Our analysis relied on full-
text, peer-reviewed articles with original research data, published in English and designed
as observational studies (cross-sectional, case–control, or longitudinal). This excluded
book chapters, case studies, non-peer-reviewed materials, theses, dissertations, systematic
reviews, meta-analyses, research protocols, and opinion pieces.
Children 2024, 11, 410 5 of 20
2.3. Study Selection

The initial search of bibliographic databases yielded 323 records. Upon the removal of
116 duplicates, the titles and abstracts of 207 records were screened. The first and second
author conducted a screening of the titles and abstracts in the Zotero reference management
software v4.0. This initial screening aimed to identify studies that met the predefined
inclusion criteria based on the title and abstract content. Forty-one of the full-text studies
retrieved were evaluated for eligibility by the first and second authors. Discrepancies in
eligibility assessment were resolved through structured discussions involving the third
author until consensus was reached. Following a rigorous selection process based on the
predetermined inclusion criteria, 27 of the 41 retrieved studies were excluded. A detailed
overview for each excluded study, along with the specific criteria that were not met, is
provided in Section 3.1, as well as Supplementary Figure S1: Quality assessment and
inter-rater reliability.
In order to ensure quality control, two researchers independently assessed study qual-
ity using the Newcastle–Ottawa Scale (NOS). The NOS for non-randomized case–control
and cohort studies [43] and the adapted version for cross-sectional studies developed by
Herzog and colleagues were used to establish methodological quality [44]. Quality assess-
ment adhered to a star-based system, with case–control and cohort studies categorized on
a 0–9 scale and cross-sectional studies rated on a 0–10 scale. Discrepancies were resolved
through consensus discussion. Studies scoring ≤5 on the NOS were deemed to have a high
risk of bias, while those scoring ≥6 were categorized as having a low risk of bias. Inter-rater
reliability, measured as the percentage of agreement, was calculated as the number of
agreements divided by the total number of scores.
2.4. Data Extraction and Analysis

To address the research question, data were extracted from the included studies for the
following key categories: author and year of publication, type of design, population (sample
size, mean age, gender distribution, household income, area type), bullying participation
role, measure of cyberbullying, outcome variables, measures of outcomes, moderator
and mediator variables, measure instruments of moderators/mediators, and timespan
of measurement.
Descriptive statistics were computed for key sample characteristics. These characteris-
tics included sample size, mean age, gender distribution, categorized household income
levels, and area type (urban/rural). Data on these characteristics were extracted from the
included studies and compiled into a database using IBM SPSS Statistics software V.17. In
addition, the studies included in this review employed a variety of methodologies (e.g.,
surveys, interviews, validated psychometric instruments) in order to measure NSSI as well
as cyberbullying. This fact, coupled with the relatively limited number of articles identified
through our search strategy, rendered a meta-analysis infeasible.
3. Results
3.1. Overview and Characteristics of Included Studies
Full-text assessment resulted in the exclusion of 27 studies that did not comply with the
predetermined inclusion criteria, as outlined in the methodology section. Seventeen studies
were excluded from analysis due to the outcome variable not aligning with the established
criteria (e.g., unspecified lack of suicidal intent) [45–61]. Four additional studies [62–65]
were excluded because cyberbullying was not measured independently from other types
of bullying or mistreatment. Other four studies were excluded because the predictor and
outcome variables did not meet the inclusion criteria; one study [66] did not investigate
cyberbullying as a predictor variable, while the other three studies [67–69] did not assess
NSSI as an outcome variable. The exclusion of [18,70] was due to study participants
exceeding the upper age limit (19 years old). A final selection of 20 articles was considered
for further analysis. Of the fourteen studies included, twelve were cross-sectional, while
two were longitudinal (see Table 2).
Children 2024, 11, 410 6 of 20
Table 2. Characteristics of the studies included in this systematic review.
Population Bullying
Author, Year, Country Type Population Cyberbullying Measure Outcome Variables NSSI Measure QA
Characteristics Participation Role
Self-report:
Traditional and Self-harm */Suicide
Azami and Taremian School sample: N = 400; E-Victimization scale
Cross-sectional cyberbullying attempts/Substance Single-item question 6
2020 [71], Iran High-school students Mean age = 16.61; (Lam and Li 2013) [72],
victimization use
Cronbach’s alpha 0.85
Self-report: Inventory
Traditional and Self-report: Revised
N = 1011, of Statements
Drubina et al. 2023 [73], School sample: cyberbullying Olweus Bully/Victim
Cross-sectional Mean age = 16.81, NSSI About Self-Injury (ISAS) 5
Hungary high-school students aggression and Questionnaire
SD = 1.41 (Washburn et al.,
victimization (Olweus 1996) [74]
2012) [75],
Self-report: Survey
adapted from Olweus
N = 2166, Traditional and Bully-Victim
M. I. Islam, Khanam, and School Sample: Suicidal
Cross-sectional Mean age = 14.83, cyberbullying Questionnaire and Cyber Single-item question 6
Kabir 2020 [76], Australia high-school students ideation/Self-harm*
SD = 1.70 victimization Friendly Schools Project
(Cross et al., 2016 [77];
Thomas et al., 2017 [78])
N = 2125, Traditional and
M. Islam et al. 2021 [67], Community sample: Suicidality/
Cross-sectional Mean age N.A. cyberbullying Single-item question Single-item question 4
Australia adolescents Self-harm *
(age range 14–17) victimization
Self-report: The
NSSI/Suicide Self-Harm Behavior
Clinical sample: N = 64;
Lanzillo et al. 2023 [79], Cyberbullying Self-report: 3-item attempt/Suicide Questionnaire (SHBQ)
Cross-sectional inpatient and outpatient Mean age = 14.3; SD 5
USA victimization questionnaire threat/Suicidal (Gutierrez et al.,
psychiatric adolescents = 1.44;
ideation 2001 [80])
Cronbach’s alpha 0.89–0.96
Self-report: 18-item
Self-report: selected
cyberbullying
N = 1368. items from Deliberate
School sample: victimization scale
Lin et al. 2023 [81], China Longitudinal Mean age = 15.05, Cybervictimization NSSI Self-Harm Inventory 6
high-school students (Erdur-Baker and Kavsut,
SD = 0.85 at T1 (Gratz 2001 [83])
2007 [82]) Cronbach’s
Cronbach’s alpha = 0.97
alpha = 0.89
Self-report using the
Cyberbullying Self-report: Non-Suicidal
N = 1006,
School sample: Victimization Scale Self-Injury scale (NSSI)
Liu et al. 2023 [84], China Cross-sectional Mean age = 13.16, Cybervictimization NSSI 8
middle-school students (Erdur-Baker and Kavsut, (Yu et al., 2013 [85])
SD = 0.67
2007 [82]) Cronbach’s alpha = 0.71
Children 2024, 11, 410 7 of 20
Table 2. Cont.
Population Bullying
Suicide
attempts/Suicidal
N = 2647, Traditional and
Peng et al. 2019 [86], School sample: middle- Self-report: ideation and
Cross-sectional Mean age = 13.6, cyberbullying Single-item question 7
China and high-school students questionnaire self-harm/Suicidal
SD = 1.1 victimization
ideation/Self-harm
only
Self-report: subscale of
Self-report: The
N = 1324; the Cyberbullying Scale
Y. Wang, Chen, and Ni School sample: middle- Cyberbullying Adolescent Self-Harm
Cross-sectional Mean age = 13.67; (Kwan and Skoric NSSI 6
2021 [87], China and high-school students victimization Scale (Feng 2008 [89])
SD = 1.34 2013 [88])
Kuder-Richardson 0.83
Self-report: adapted
three-item questionnaire Self-report: adapted
(Hinduja and Patchin 3-item questionnaire
N = 464; Cyberbullying
Wiguna et al. 2021 [90], School sample: middle- 2019 [91]; 2010; (Sourander et al.,
Cross-sectional Mean age = 14.61; victimization and NSSI 4
Indonesia and high-school students Sourander et al., 2010 [92]; Wiguna et al.,
SD = 1.65 aggression
2010 [92]; Wiguna et al., 2018 [60])
2018 [60]) CR = 0.953
CR = 0.958
School sample: Self-report: 12-item
Traditional and Self-report: The
adolescents with questionnaire (Wright Health
Wright and Wachs N = 121; cyberbullying Self-Harm Inventory
longitudinal intellectual or and Li 2013 [94]; Wright, complaints/Suicidal 8
2020 [93], USA Mean age = 14.10; victimization and (Sansone, Wiederman,
developmental Wachs, and Harper ideation/NSSI
bystanding and Sansone 1998 [96])
disabilities 2018 [95])
Self-report: the
Cyberbullying Self-report: Non-Suicidal
N = 1006;
School sample: Victimization Scale Self-Injury
Yu et al. 2020 [26], China Cross-sectional Mean age = 13.16, Cybervictimization NSSI 8
middle-school students (Erdur-Baker and Kavsut Scale (You et al., 2013 [85])
SD = 0.67
2007 [82]) Cronbach’s alpha = 0.71
Self-report:
Cyberbullying
Victimization subscale of Self-report: Deliberate
School sample: N = 2523;
Zhao et al. 2022 [66], the second revision of the Self-Harm Inventory
Cross-sectional elementary and Mean age = 13.22, Cybervictimization NSSI 8
China Revised Cyberbullying (Gratz 2001 [83])
middle-school students SD = 1.60
Inventory (Topcu and Cronbach’s alpha = 0.91
Erdur-Baker 2018 [97])
Children 2024, 11, 410 8 of 20
Table 2. Cont.
Population Bullying
Self-report:
Cybervictimization
N = 1987; Mean age subscale in the Electronic
T1 = 12.32, SD = 0.53 Bullying Questionnaire Self-report: 7-item
Zhu et al. 2021 [98], School sample:
Longitudinal Mean age T2 = 12.82, Cybervictimization (EBQ) at T1 (Moore, NSSI questionnaire 7
China middle-school students
SD = 0.53, Mean age Huebner, and Hills Cronbach’s alpha = 0.8
T3 = 13.33, SD = 0.53 2012 [99]; Tian, Yan, and
Huebner 2018 [100])
* Refers to non-suicidal self-harm behaviors.
Children 2024, 11, 410 9 of 20
3.2. Populations
The studies included participants ranging in age from 10 to 19 years old (M = 14.30,
SD = 1.27). Sample sizes varied from 64 to 2647.
Half of the studies (n = 7) included participants from China, whilst others were carried
out on American (n–2), Australian (n = 2), Iranian, Indonesian, and Hungarian populations.
Two studies included in this review used the same participant sample in their respective
analyses [26,84]. Most studies (n = 12) reported gender characteristics. Using the available
data, it was calculated that females comprised 52.29% of the population (Mean = 584.91,
SD = 120.37), whilst males comprised 47.70% (Mean = 581.33, SD = 131.88). Regarding
sociodemographic aspects, only half of the studies reported area characteristics, while only
four reported household income levels. Thus, using the data available, it was revealed
that 67.5% of the participants resided in urban areas (Mean = 917.85, SD = 191.62), while
32.49% resided in suburban or rural areas (Mean = 546.14, SD = 204.87). Low-income
households accounted for 20.27% of the total (Mean = 330.90, SD = 119.17), while medium
and high-income households accounted for 79.63% (Mean = 1164.11, SD = 276.56)
One study focused on a specific population—students with intellectual disabilities [93].
Only one study utilized a clinical sample [79], while the remaining studies recruited
participants from educational settings.
3.3. Predictor Variables

Eight studies solely assessed cyberbullying, whereas six assessed both traditional
bullying and cyberbullying. All joint studies conducted separate analyses for each of the
two types of bullying.
Data on cyberbullying experiences exclusively relied on self-reported measures across
studies, adopting diverse operational definitions and psychometric instruments. These
ranged from basic questionnaires providing definitions or examples of cyberbullying
acts [79,86] to validated psychometric instruments [71,84,98], or even adapted items from
established tools [76,90]. Psychometric properties were reported in eight of the fourteen
studies included.
3.4. Outcome Variables

As shown in Table 2, outcome variables were measured differently across the included
studies. Ten studies utilized the term “NSSI” specifically, whereas others operationalized
the construct by emphasizing the lack of suicidal intent in self-harm behaviors within their
methodologies. Eight studies measured single outcomes (NSSI), whereas six measured
additional outcomes alongside NSSI (e.g., suicidal ideation, suicide attempts, substance
use). Notably, all studies conducted separate analyses for NSSI, regardless of the number
of variables.
Outcome variables were collected exclusively through self-report data across all stud-
ies. Self-report measures included single-item questions, standardized questionnaires,
validated psychometric instruments, or adapted items from a validated tool. Measure
reliability characteristics were mentioned for eight of the included studies.
3.5. Quality Assessment

Quality assessment scores varied significantly, with 10 studies fulfilling the established
criteria for low risk of bias. Detailed explanations of potential bias sources across studies
with lower quality assessment scores are provided in Supplementary Table S2.
3.6. The Association between the Role of Cybervictim and NSSI

Regarding individual factors, several studies investigated internalizing symp-
toms as mediators in the relationship between cyberbullying victimization and
NSSI [73,81,84,98]. Internalizing symptom assessments included various indicators such as
overall internalizing symptom scores [73], measurements of depression [84], anxiety [98],
or self-esteem [81] (see Table 3).
Children 2024, 11, 410 10 of 20
Table 3. Moderators and mediators between cyberbullying role and NSSI.
Cyberbullying Role Author, Year, Country Outcome Timespan * Moderators Mediators Measures
Internalizing problems were a
mediator between the role of online
victim and past NSSI (β = 0.044;
SE = 0.01; p < 0.01), online
bully–victim and past NSSI (β = 0.032;
SE = 0.01; p < 0.01), and online victim
and current NSSI (β = 0.058; SE = 0.04;
Drubina et al., 2023 [73], p < 0.001). Self-report: The Strength and
CV and CA NSSI N.A.
Hungary Externalizing problems were a Difficulties Questionnaire (SDQ) [101]
mediator between the role of online
bully and current NSSI (β = 0.022;
SE = 0.01; p < 0.01), online victim and
current NSSI (β = 0.011; SE = 0.01;
p < 0.05), and online bully–victim and
current NSSI (β = 0.028; SE = 0.01;
p < 0.01).
High peer attachment moderated the
Self-esteem was a mediator between
indirect effect of self-esteem on the Self-report: Self-Esteem Scale (SES) [102]
cybervictimization and NSSI (indirect
CV Lin et al., 2023 [81], China NSSI 12 months relationship between cybervictimization and The Inventory of Peer Attachment
effect = 0.007, SE = 0.002,
and NSSI (β = 0.013, SE = 0.005, Scale [103]
95% CI = 0.003 to 0.011)
95% CI = 0.004 to 0.025)
School connectedness moderated the Depression significantly mediated the Self-report: Depression was evaluated
indirect effect of depression on the relationship between using The Center for Epidemiologic
CV Liu et al., 2023 [84], China NSSI Past 6 months association between cybervictimization cybervictimization and adolescent Studies Depression Scale [104] and the
and NSSI (indirect effect = 0.12, NSSI (indirect effect = 0.09, Emotional Engagement Sub-scale of
SE = 0.03, 95% CI [0.07, 0.18]) SE = 0.02, 95% CI [0.06, 0.14]) the School Engagement Scale [105]
Friendship quality moderated the
Negative emotions were a partial
indirect association between Self-report: Friendship quality
Wang, Chen and Ni, 2021 [87], mediator between cybervictimization
CV NSSI N.A. cybervictimization and NSSI via scale [106] and The Negative Emotion
China and NSSI (β = 0.04, SE = 0.01,
negative emotions (β = −0.04, Scale [107]
95% CI [0.02, 0.06]).
95% CI [−0.09, −0.002])
Stress had a partial mediating effect on
Self-report: adapted items from
Wiguna et al., 2021 [90], cyberbullying victimization and
CV and CA NSSI 6 months the Depression Anxiety Stress Scale-21
Indonesia aggression in the relationship with
(DASS-21) [108]
adolescent NSSI (critical t-value: 5.27)
School engagement mediated the
relationship between cybervictimization
CV Yu et al., 2020 [26], China NSSI Past 6 months - and NSSI in subjects with high levels of Self-report: questionnaire [105]
attention-seeking (indirect effect = 0.018,
SE = 0.008, 95% CI [0.005, 0.036])
Children 2024, 11, 410 11 of 20
Table 3. Cont.
Cyberbullying Role Author, Year, Country Outcome Timespan * Moderators Mediators Measures
Dispositional mindfulness acted as a Emotion reactivity was a mediator Self-report: Child and Adolescent
moderator for the direct effect of between cyberbullying victimization Mindfulness Measure (CAMM) [109]
CV Zhao et al., 2022 [66], China NSSI Past 6 months
cyberbullying on NSSI (β = − 0.15, and NSSI (β = 0.05, and the Emotion Reactivity
SE = 0.07, p < 0.05) 95% CI = [0.031, 0.061]) Scale (ERS) [110]
Anxiety symptoms mediated the
Self-control moderated the association relationship between cyberbullying Self-report: the Self-Control Scale [111]
CV Zhu et al., 2021 [98], China NSSI 12 months between anxiety symptoms and NSSI in and NSSI, but only in adolescents with and the anxiety subscale in Depression
cybervictims (β = −0.11, p < 0.05) low self-control (indirect effect = 0.04, Anxiety Stress Scales [112]
p < 0.05, 95% CI [0.014, 0.083]).
CV = cybervictimization; CA = cyberaggression. * refers to the period of time over which cyberbullying was investigated.
Children 2024, 11, 410 12 of 20
It has been indicated that online victimization indirectly contributes to both past
NSSI (indirect effect = 0.044; SE = 0.01; p < 0.01) and current NSSI (indirect effect = 0.058;
SE = 0.04; p < 0.001) via internalizing problems in a sample of high-school students, with a
slightly larger effect size for current NSSI. Regarding internalization, self-esteem emerged
as a partial mediator in the relationship between cybervictimization and NSSI; specifically,
cybervictimization was associated with lower self-esteem (β = −0.21, p < 0.05), and lower
self-esteem, in turn, was associated with higher NSSI (β = 0.32, p < 0.05) in high-school-aged
participants [81]. The results also indicated that cybervictimization leads to NSSI indirectly
through increased depressive symptoms (indirect effect = 0.09, SE = 0.02, 95% CI [0.06,
0.14]) [84], while anxiety mediated this association in adolescents with low self-control [98]
in samples comprising middle-school students. Similarly, externalizing symptoms were
also shown to mediate the relationship between cyberbullying victimization and NSSI
(β = 0.011; SE = 0.01; p < 0.05). Moreover, additional cross-sectional studies have iden-
tified various mediators involved in the relationship between cyberbullying victimiza-
tion and NSSI such as school engagement [26] but also emotional reactivity (β = 0.05,
95% CI = [0.031, 0.061]) [66], negative emotions (β = 0.04, SE = 0.01, 95% CI [0.02, 0.06]) [105]
and stress [90], thus highlighting the role of negative emotions in adolescent populations.
Social factors. In terms of social support, strong peer connections can buffer against
the negative impact of cyberbullying on self-esteem and NSSI risk, influencing the self-
esteem pathway (β = 0.013, 95% CI [0.004, 0.025]) in high-school-aged samples [81].
Moreover, feelings of school connectedness reduced the influence of depression on me-
diating the link between cybervictimization and NSSI (indirect effect = 0.12, SE = 0.03,
95% CI [0.07, 0.18]) [84], while high-quality friendships buffered the effect of nega-
tive emotions on the relationship between cybervictimization and NSSI (β = − 0.04,
95% CI [−0.09, −0.002]) in middle-school samples [87].
3.7. The Association between the Role of Cyberbully and NSSI

Only two studies [73,90] investigated the relationship between the role of cyberbully
and NSSI. Externalizing problems mediated the association between the role of online
bully and NSSI (β = 0.022; SE = 0.01; p < 0.01), as well as between the role of online
bully–victim and NSSI (β = 0.028; SE = 0.01; p < 0.01) [73]. Stress was also highlighted as a
partial mediator [90].
4. Discussion
The significance of this systematic review is underscored by the dynamic and evolv-
ing nature of both cyberbullying and non-suicidal self-injury among adolescents. With
the earliest study included in this review dating to 2019, the rapid pace of technological
advancement and evolving social norms require continuous investigation on this critical
topic. While there is considerable understanding of the impact of cyberbullying victim-
ization on adolescent NSSI, it is recognized that not all adolescents are uniformly affected
by such victimization [113]. Consequently, potential moderators that either mitigate or
intensify the risk associated with cyberbullying victimization on adolescent NSSI must
exist. By comprehensively synthesizing the current research, this review aims to provide
an up-to-date understanding of the complex interactions between cyberbullying and NSSI
in this vulnerable population via identifying mediating and moderating variables between
cyberbullying participation roles and NSSI in adolescents.
The relationship between cybervictimization and NSSI emerged as the most promi-
nent theme in this systematic review, as it is the focus of most records identified. Notably,
our analysis identified a multitude of mediators and moderators that extend the findings
of previous studies. Research has established a notable link between being subjected to
bullying and increased stress levels among adolescents. This heightened stress, in turn,
appears to correlate with a higher likelihood of engaging in NSSI as a coping mechanism.
The connection between bullying, stress, and NSSI suggests that adolescents may resort
to self-injurious behaviors to manage or alleviate the emotional distress brought about
Children 2024, 11, 410 13 of 20
by the bullying experience [23]. Furthermore, this association intertwines with the con-
cept of internalizing problems, which encompass various emotional and psychological
challenges faced by individuals. Adolescents who experience cyberbullying may inter-
nalize the negative effects of online harassment, leading to heightened stress levels and,
subsequently, an increased propensity for engaging in NSSI [114]. At an individual level,
internalizing symptoms played a central role as pathway between cyberbullying victim-
ization and NSSI in adolescents. Overall, internalizing problems significantly mediated
the relationship between online victimization and both past and current NSSI, suggesting
that experiencing cyberbullying can contribute to NSSI risk through increased internal
distress [73]. Within the spectrum of internalizing symptoms, depression emerged as
playing a role in the interplay of cyberbullying and NSSI, suggesting that cyberbully-
ing victimization can trigger depressive symptoms, which can then increase the risk of
NSSI [84]. This supports existing evidence on the relationship between one’s involvement
in cyberbullying and affective symptoms [15,16,115]. An interesting finding regarding the
internalizing symptomatology is that anxiety symptoms only mediated the relationship
between cyberbullying and NSSI in adolescents with low self-control in a longitudinal
study [98]. Empirical evidence suggests that cybervictimization heightens the risk of anxi-
ety symptoms in adolescents [116,117]. Also, prior research demonstrated a positive link
between anxiety symptoms and NSSI [118–120]. In addition, few studies supported the
role of self-control as a moderator in the proposed mediation model, aligning with general
strain theory (GST) [121]. Higher self-control, according to GST, enables adolescents to
regulate impulsive reactions and negative emotions effectively in response to stress, a no-
tion corroborated by existing evidence demonstrating the interaction between self-control
and environmental risk in predicting adolescent internalizing problems [122]. However,
the scarcity of studies on this specific mediating effect requires cautious interpretation
and highlights the need for further research on the topic. Focusing on another specific
internalizing symptoms, low self-esteem acted as a mediator, indicating that cyberbullying
can lead to decreased self-esteem in victims, which in turn increases their vulnerability
to engaging in NSSI behaviors [81]. Available data investigating the association between
self-esteem and cyberbullying victimization indicate a bidirectional relationship. Cyber-
bullying victimization has been linked to decreased self-esteem, while high self-esteem
has been indicated to be a protective factor against victimization [123,124]. Apart from
internalizing symptoms, it was found that externalizing symptoms are also involved in the
studied association. Although specific externalizing symptoms are not described, previ-
ous studies have indicated that both perpetrators and victims of cyberbullying engage in
substance use or violence-related behaviors [125,126]. Cyberbullying victims may struggle
with managing the intense emotions of anger, frustration, and helplessness brought on by
victimization, which can in turn lead to externalizing these emotions through disruptive
or aggressive behaviors [10]. Moreover, they may engage in externalizing behaviors as a
means of retaliation, to regain a sense of control [127], or due to the normalizing effects
of witnessing online aggression, which can contribute to the adoption of similar tactics
and desensitization to their harmful impact [128]. Furthermore, the key role of negative
emotional response was suggested in three of the studies identified [66,87,90]. Cybervic-
timization correlates with negative emotions in adolescents [129]. Emotional consequences
include decreased self-esteem and increased anger, embarrassment, and grief [130]. Victims
of cyberbullying exhibit higher levels of hostility, depressive symptoms, and persecution-
related anxiety compared to non-victimized peers [114]. Klonsky (2007) notes NSSI is often
seen as a negative emotional coping strategy [131]. In addition, Hughes et al. (2019) found
that negative emotions, including anxiety, strongly predict adolescents’ NSSI [132]. Be-
havioral experiments suggest NSSI is triggered by guilt and shame, which it subsequently
alleviates [59]. These findings were supported by a recent systematic review of risk and
protective factors for self-harm behaviors among the adolescents involved in cyberbullying
which indicated that higher self-control and emotional intelligence represent protective
factors against bullying victimization. Moreover, it emphasized the role of perceived stress
Children 2024, 11, 410 14 of 20
as a risk factor [133], which emerged as a moderator for both the roles of cybervictim
and cyberbully.
Overall, these findings emphasize the multidimensional nature of the cyberbullying–NSSI
association, with both internalizing and externalizing factors playing crucial roles as mediat-
ing and moderating factors in the association between NSSI and cyberbullying victimization
and aggression.
From a social perspective, our findings highlight the importance of social support
as a key component. It has been indicated that in the case of adolescents who exhibit
high levels of attention-seeking behaviors, being engaged in school may act as a buffer
against the negative consequences of cyberbullying, potentially reducing their risk of
engaging in NSSI [26]. Peer connection-related findings have indicated positive peer
relationships can support self-worth and reduce the impact of cybervictimization [81].
Furthermore, it has been indicated that feeling integrated within the school environment
can buffer against the depressive symptoms triggered by cyberbullying experiences [84].
High-quality friendships were found to directly mitigate the effect of negative emotions on
the cybervictimization–NSSI association, further highlighting the important role of positive
social connections [87]. A recent systematic review investigating cyberbullying prevention
strategies underscores the critical role of schools in this initiative. Their findings reveal
that the majority of existing interventions emphasize educational approaches, primarily
targeting schools and families. These strategies often involve enhancing teacher and parent
training, fostering a positive school climate, and integrating social–emotional learning
programs [134]. Furthermore, school-based interventions were proven effective in reducing
cyberbullying victimization and perpetration in another meta-analytical review assessing
cyberbullying intervention and prevention programs [135]. Overall, these findings offer
robust evidence for prioritizing interventions aimed at developing positive and supportive
social connections that could counteract the impact of cyberbullying victimization on
adolescent well-being.
5. Limitations
Although this review strengthens our understanding of the relationship between
cyberbullying and NSSI by focusing on psychological symptoms and social factors, it is
important to acknowledge some limitations. Considering that this is a relatively new field
of research, there is a restricted number of studies meeting our inclusion criteria. This
potentially limits the generalizability of our findings and the ability to comprehensively
assess the existing evidence base. Moreover, existing research investigating the associ-
ation between cyberbullying and self-harm behaviors encompasses a broader spectrum
of self-injurious behaviors, including both NSSI and suicidal behaviors. However, our
review focused solely on NSSI, potentially excluding relevant studies that do not explicitly
distinguish between suicidal and non-suicidal self-harm behaviors.
Most studies included used a cross-sectional design, limiting causal inferences and
understanding of temporality. While these studies provide valuable insights into the asso-
ciation between cyberbullying and NSSI, they cannot definitively demonstrate whether
cyberbullying causes NSSI or vice versa. Further research employing longitudinal designs
is needed to explore the developmental pathways and potential bidirectional influences
involved. Moreover, a cross-sectional design lacks an adequate control for confound-
ing variables, potentially overseeing variables that might influence both cyberbullying
and NSSI. Thus, the exploration of this topic in cohort studies is required to address
this limitation.
Several limitations related to operationalizing definitions and measurement of key
variables were identified. Despite some shared methodological approaches, the studies
employed different conceptualizations and timeframes over which variables were mea-
sured as well as a diverse range of instruments to measure both cyberbullying and NSSI.
This heterogeneity in measurement strategies poses a significant challenge, limiting the
Children 2024, 11, 410 15 of 20
comparability of results. Additionally, not all studies reported the reliability and validity
properties of their chosen instruments, raising concerns about the accuracy of their findings.
Such methodological inconsistencies pose challenges for data comparison, interpreta-
tion, and generalizability of findings across the field. Further research establishing a clearer
distinction between NSSI and other self-harm behaviors as well as standardized measure-
ments of cyberbullying are required. This would contribute to a more comprehensive
understanding of the relationship between cyberbullying and NSSI.
6. Conclusions
This systematic review offers insights into the complexities of the relationship between
cyberbullying and NSSI in adolescents, highlighting diverse factors that mitigate this asso-
ciation. While this review encountered significant heterogeneity in the literature, as well as
a restricted body of literature, it revealed that factors such as internalizing symptoms and
positive social connections play an important role in mediating the relationship between
cyberbullying and NSSI. Although internalizing symptoms (depression, anxiety, decreased
self-esteem) were the most prominent mitigating factors identified, we acknowledge the
potential influence of other factors, such as externalizing symptoms, stress, and negative
emotional responses (emotion reactivity, negative emotions). Thus, adolescents experienc-
ing these symptoms may be more vulnerable to the negative psychological consequences
of cyberbullying, potentially leading to increased NSSI behaviors. On the other hand, this
review highlights the protective role of positive social connections (increased levels of peer
attachment, school connectedness and engagement). Strong and supportive relationships
with friends, family, or mentors can buffer the impact of cyberbullying and offer adolescents
a sense of belonging and emotional security, ultimately reducing the risk of NSSI.
Furthermore, this review acknowledges the unpredictable nature of cyberbullying
compared to traditional forms. Victims are often more exposed, easier to target, and lack
the real-time supervision present in physical settings. This underscores the urgent need for
effective prevention strategies tailored to the specific risks of cyberbullying.
In conclusion, future research could benefit from exploring this relationship using
longitudinal designs while ulteriorly investigating intervention development and effective-
ness. Rigorous studies investigating the effectiveness of interventions specifically tailored
to adolescents are required. Existing research demonstrates the effectiveness of school-
based programs in preventing and intervening against cyberbullying. However, a critical
gap remains in the lack of standardization across these programs. Further research is
needed to establish a more unified approach, ensuring the consistent implementation of
evidence-based strategies across diverse school settings. In this aspect, our findings could
be valuable in the development of prevention strategies towards fostering positive social
connections and equipping young people with effective emotion regulation skills.
Supplementary Materials: The following supporting information can be downloaded at: https://www.
mdpi.com/article/10.3390/children11040410/s1, Figure S1: Identification of studies via databases and
registers; Table S1: Search String; Table S2: Newcastle–Ottawa Scale rating.
Author Contributions: Conceptualization, E.P. and R.S.; methodology, E.P.; software, I.C.; validation,
E.P., R.S. and I.C.; formal analysis, E.P. and I.C.; investigation, R.S.; resources, E.P. and R.S.; data
curation, I.C.; writing—original draft preparation, E.P., I.C. and R.S.; writing—review and editing,
E.P., I.C. and R.S.; visualization, R.S.; supervision, E.P.; project administration, E.P. and R.S.; funding
acquisition, E.P. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflicts of interest.
Children 2024, 11, 410 16 of 20
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children

1 Department of Neuroscience, Psychiatry and Pediatric Psychiatry, “IuliuHatieganu” University of Medicine

Children 2024, 11, 410. https://doi.org/10.3390/children11040410 https://www.mdpi.com/journal/children

of this relationship, while a second, more complex pathway involves co-mediation by

The Present Study

2. Materials and Methods

2.1. Information Sources

Table 1. Key terms employed in database search.

Term Category 1: Term Category 2: Term Category 3:

2.2. Eligibility Criteria

2.3. Study Selection

2.4. Data Extraction and Analysis

Table 2. Characteristics of the studies included in this systematic review.

3.3. Predictor Variables

3.4. Outcome Variables

3.5. Quality Assessment

3.6. The Association between the Role of Cybervictim and NSSI

Table 3. Moderators and mediators between cyberbullying role and NSSI.

3.7. The Association between the Role of Cyberbully and NSSI

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