FINALDissertationProposalMAY2015

ADDRESSING NON-SUICIDAL SELF-INJURY
Ph.D. Educational Studies with a Specialization
in Educational Leadership
The Perceptions of Middle School Principals Regarding Their Role in Addressing
Non-Suicidal Self-Injury (NSSI) Among Adolescent Females Ages 10 to 14 Years
Old.
A Dissertation Proposal Presented
By
Tara M. Kfoury
Submitted to the Graduate School of Lesley University
in partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
March 2014
School of Education
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The Perceptions of Middle School Principal Regarding Their Role in Addressing
Non-Suicidal Self-Injury (NSSI) Among Adolescent Females Ages 10 to 14 Years
Old
A Dissertation Proposal Presented
By
Tara M. Kfoury
Approved as to content and style by:
------------------------------------------------- ---------------
Dr. Judith Conley, Ph.D., Senior Advisor Date
------------------------------------------------ ---------------
Dr. Sidney Trantham, Ph.D., Member Date
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Dr. William O’Flanagan, Ph.D., Member Date
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Table of Contents
Dedication i
Acknowledgements ii
Abstract iii
CHAPTER ONE: INTRODUCTION 1
Personal Interest Statement 6
Statement of the Problem 9
Purpose of the Study 18
Significance of the Study 19
Delimitations of the Study 20
Design of the Study 20
Selection of subjects 21
Instrumentation 21
Data Collection Process 22
Pilot Study 27
Data Analysis 30
Chapter Outline of the Dissertation 33
CHAPTER TWO: LITERATURE REVIEW
CHAPTER THREE: RESEARCH DESIGN AND METHODS
CHAPTER FOUR: FINDINGS AND ANALYSIS
CHAPTER FIVE: SUMMARY AND IMPLICATIONS
Summary of Findings
RQ1
RQ2
RQ3
Implications for Practice and Future Research
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Conclusion
REFERENCES 36
APPENDICES
Appendix A – Definition of Terms 44
Appendix B - Participant Letter 46
Appendix C – Follow-up Email 47
Appendix D – Letter of Consent 48
Appendix E - Institutional Review Board Approval 51
Appendix F – Survey Instrument 52
Appendix G – Interview Questions 56
Appendix H – Data 57
Table 3.1 Participant Demographics, Professional History, and
Educational Training
Table 3.2 Participant’s Perception of Middle School Principals
regarding their role in addressing NSSI.
Table 3.3 Participants perceptions of NSSI, NSSI behaviors, &
females engaging in NSSI
Table 3.4 Factors and conditions that are believed to inhibit and
support efforts to address NSSI.
Diagram 4.1. Comparison of Demographic Information of
Participants
Diagram 4.2 A Comparison of Race among Participating Middle
School Principals.
Table 4.3 Comparison of School Community Demographics
Table 4.4 Comparison of Schools
Table 4.5 Student Population Demographics
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Table 4.6 Grade-level demographics
Diagram 4.7 Comparison of answers to the statement: NSSI
is an abnormal developmental stage in a
pre-adolescent’s and/or early adolescents life.
Chart 4.8a & 4.8b. Comparison of the perceptions of NSSI
as an abnormal developmental stage in pre- and early
adolescent development with gender.
Diagram 4.9 Comparison of Principal perceptions in response
to “I think the principal plays a role in addressing NSSI
behaviors within the student population of his/her school.”
Diagram 4.10 Comparison of Male Principal perceptions in response
to “I think the principal plays a role in addressing NSSI
behaviors within the student population of his/her school.”
Table 4.11 A comparison of the perceptions of NSSI as an abnormal
developmental stage in pre- and/or early adolescent’s life
with years of administration.
Table 4.12 Principal plays a role in addressing NSSI
Diagram 4.13: Comparison of Highest level of education attained
Table 4.14. Comparison of the perceptions of NSSI as an abnormal
developmental stage in pre- and/or early adolescent’s life with
level of education.
Table 4.15 Comparison of the level of education and the role of
principal in addressing NSSI
Table 4.16 Correlations of years served as current administrator, years
of career administrator, gender, ethnicity, education level,
years in 6-8 education
Table 4.17a Principal perceptions of female students who engage in
NSSI behaviors.
Table 4.17b Principal perceptions of female students who engage in
NSSI behaviors.
Table 4.17c Principal perceptions of female students who engage in
NSSI behaviors.
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Table 4.17d Principal perceptions of female students who engage in
NSSI behaviors.
Diagram 4.18 Principal perception that a student who engages in
NSSI behaviors is attempting Suicide
Diagram 4.19 Years Served in Administration during Career
Diagram 4.20 Years Served at Current Administrator Position.
Diagram 4.21 Comparison of Principals aware of the number of
incidents of NSSI among the female adolescent population
in school
Table 4.22 Comparison of perceptions of received NSSI training in
Administrative/Graduate programs.
Table 4.23a Comparison of Gender and Range of Perception in regards
to receiving On the Job Training
Table 4.23b Comparison of Years in Administration and Range of
Perception in regards to Receiving On-the-Job Training
Table 4.23c Comparison of Level of Education and Range of
Perception in regards to On-the-Job Training in NSSI
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DEDICATION
To Rich, Elizabeth & Ava, all my love forever.
Mommy, thank you.
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ADDRESSING NON-SUICIDAL SELF-INJURY 8

ACKNOWLEDGEMENTS
To my daughters, Elizabeth and Ava, and my husband Rich, my world starts and
ends with the pride, joy, and deep love I have for all of you. I look forward to our next
steps in life together. Thank you all for your support, patience, sacrifice, and love
throughout this entire process.
Kathy, Ron, and Nicole, your unending words of encouragement motivated me
every step of the way.
To those who guided and supported my work, especially Mary McMackin, Judy
Conley, Sidney Trantham, Steve Gould, and Bill O’Flanagan. You guided my journey
through the peaks and valleys. You each challenged me, encouraged me, and ultimately
guided me towards this dissertation completion. I am forever grateful for the growth I
experienced along this journey besides such great professionals.
I would also like to acknowledge a few friends who continuously encouraged me
when I felt like giving up. Sharon, Tara, and Kate you will never know the true impact
your words of compassion, support, and direction had on my progression towards this
degree. To the O’Brien, Boucher, and Griffin families, your endless effort to provide
childcare so I could finish my degree will never be forgotten.
Finally, I cannot express how fortunate I am to have experienced this program
with my fellow 2010 cohort members. We shared love, support, tears, and laughter.
With their words of encouragement and friendships, I have not only finished my doctoral
program, but also built a vibrant network of educator peers. I would like to mention a
few colleagues who shall forever remain friends in my heart: Jen Fay-Beers, Ayesha
Farag-Davis, Linda Croteau, and Joan McQuade. I can never repay the dedication,
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enthusiasm, guidance, and friendship you gave me throughout the program and through
the completion of my study.
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ABSTRACT
Non-Suicidal Self-Injury (NSSI) continues to be a growing concern among adolescent
females between the ages of 10 to 14 years old within Massachusetts middle schools.
Although Massachusetts middle school principals encounter pre- and early adolescents
who self-injure, their perceptions regarding their role in addressing NSSI among
adolescent females ages 10 to 14 years old remains unknown. This study explored the
degree to which middle school principals consider addressing NSSI to be an important
part of their leadership role. It examined the various ways middle school principals
report they are currently addressing NSSI among adolescent females ages 10 to 14 years
old, and identified the factors and conditions that middle school principals believe inhibit
and support their efforts to address NSSI among the adolescent female population.
Present-day middle school principals participated in a 46 question survey (n=52) and a
one-to-one phone interview (n=15). Results demonstrated an urgent need for principals
to 1) increase their involvement regarding issues associated with NSSI in their individual
school, 2) learn the etiology of NSSI, 3) examine the factors that catalyze NSSI behaviors
within the adolescent female population, 4) be provided training through federal and/or
state education and administrative programs in order to develop a safety protocol for
students who have been identified with self-injurious behaviors, 5) apply for
federal/state/local funding for individual and staff training, 6) implement prevention
programs while minimizing social contagion.
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The Perceptions of Middle School Principals Regarding Their Role in Addressing Non-
Suicidal Self-Injury (NSSI) Among Adolescent Females Aged 10 to 14 Years Old
Nixon, Cloutier, and Jansson (2008) discussed the increase in non-suicidal self-
injuries (NSSI), or the “purposeful direct destruction of body tissue without conscious
suicidal intent” such as the cutting, burning, scratching or minor self-overdosing among
adolescent females (p. 3). Many pre-teen and teenage girls have a greater risk for non-
suicidal self-injury than boys the same age (American Psychological Association, 2012;
ISSI, 2012; Mayo Clinic, 2012; Sax, 2010). At a rate of 24.3%, adolescent females are
three times more likely to engage in NSSI behavior than adolescent boys the same age at
8.4% (Sax, 2010). Contemporary experts in the field of psychology believe the research
on NSSI does not adequately address the reasons why so many adolescent females (10-14
years of age) are physically damaging their bodies. This lack of research has spawned
my interest as an educator to analyze the role a middle school principal plays in
addressing NSSI among adolescent female students ages 10-14. Although there is little
research on the differences in behavior between adolescent males and females in NSSI
behavior, this particular paper will focus on adolescent females given that the data
indicates that this is a primarily a female-associated behavior (Sax, 2010).
Administrators are challenged to limit self-injury, create safe environments, and
prevent antisocial behavior among the student population. Ultimately, this study will
contribute to the body of information that is needed by middle school staff and their
principals in order to prevent or limit NSSI among their student population. Therefore,
this dissertation study will examine how middle school principals can address non-
suicidal self-injury among female students. The primary focus of this dissertation is to
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examine the role of the principal in middle schools in addressing self-injury. This
research may contribute to the development of an educational policy that may bring about
safer, healthier, adolescent girls.
Personal Interest Statement
I am a thirty-six year old, white, middle-class female. I am the middle child of a
second marriage. I am a Catholic. I am a wife, mother, daughter, and sister, friend. I am
a teacher of middle and high school Spanish as well as a student earning my Doctorate in
Educational Leadership.
As a teenager I attended an award winning, all-girls private Catholic high school
located in a quaint suburb of New Jersey. I was surprised to discover that many of my
classmates were from middle-class families like mine, while other girls ranged from
lower class to upper class families. My classmates were daughters of physicians,
lawyers, and professional athletes. Others were daughters of waitresses, teachers, and
construction workers. All parents wanted a better life for their children through a private,
formal education.
We wore uniforms, so fashion was never an indication of a family’s financial
status. Our school prided itself on its reputation for excellence and its dedication to
community service. It was not uncommon for a group of students to volunteer at a
shelter or soup kitchen after they finished a track meet. Personally, I took advantage of
what my school had to offer and invested myself it the experience. I was a member of
Model United Nations, Student Government Association, Students Against Drunk
Driving, the National Honor Society, the Spanish National Honor Society, Big Sister-
Little Sister program and a four-year member of the varsity soccer team. I considered
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myself to be the “well rounded” student colleges were looking for.
Yet, I was not as emotionally adjusted as I feel my classmates were. Despite the
appearance of a perfect family, I had emotional and mental scars that have not healed
fully even today. I never felt my voice was heard in family discussions, so it created a
feeling of being invisible. The overwhelming need to find love anywhere I could get it,
contributed to my need to continually nurse feelings of inadequacy and un-acceptance. I
never felt that my family approved of my personal growth, academic performance, or my
athletic prowess. No matter how good I was in school, how many awards, and how many
soccer games I played, it never felt enough for my family. From these developing
emotional scars, I have lasting psychological insecurities that even today, have led me to
move quicker to my fight rather than flight response of human survival. As methods of
perseverance and survival, I relied on humor, intelligence, and audacity to overcome
personal obstacles. I developed an absolute self-dependence and learned to rely only on a
core group of friends, mostly those with whom I attended grammar school and high
school.
When I began my teaching career, I was aware of girls like myself - those who
suffered quietly, who were emotionally self-deprecating, and who chose self-destruction
over self-love. Over the years, I have made a conscientious effort to connect to these
young women; to be a voice that reinforces their worth and appreciate their contribution
to this world. This has led me to examine the study of the role a middle school principal
plays in addressing NSSI among young female adolescents. Although I never engaged in
acts of NSSI as a maladaptive coping strategy, I would be lying to say I did not think of
actions of self-harm.
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My life experiences and a fourteen-year career in education has provided the
foundation for my belief that educators have to adopt a sense of urgency in addressing the
possible epidemic of NSSI among pre- and early adolescent female students. As a
mother, a teacher, a future administrator, and a student at Lesley University, I feel it is
part of an educator’s duty to protect all children from harm, self-inflicted and other. The
need to identify the role of a middle school principal in addressing NSSI among
adolescent females is pertinent to the successful treatment of the young women who are
engaging in NSSI behaviors. It is through a partnership with teachers, guidance, and
administration that we may be able to lead the necessary efforts to remedy this growing
epidemic among our pre- and early- adolescent female students.
Lesley University has reinforced my knowledge that educators, such as myself,
must build the connections with our students beyond the classroom in ways that
positively affect their lives. Responsibilities that reach beyond the curriculum must be
performed in order to meet the growing social, emotional, and mental needs of our female
students. I have observed that when students identify with me, when we build
connections relevant to both our lives, student participation and health will be more
prosperous, performance scores will increase, and overall learning will be more
successful. When I realize that there is a student in need, I am propelled to help this
student as best I can – whether it means seeking out help or talking it through with her.
As a teacher and future administrator, I feel personally responsible for the
education provided to the students. I will remain vigilant in sharing my knowledge of
NSSI with staff members and colleagues. This will inform other educators of the latest
research in this possibly growing epidemic amongst pre- and early adolescent females in
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our educational systems. My intellectual curiosity will be complimented by the use of
academic journals stemming from the interdisciplinary fields of education, psychology,
and other human sciences. Although I know my efforts will not be able to assuage all
societal ills such as poverty, homelessness, and cultural differences for all students, I do
hope my efforts will make a difference in the psychological, emotional, and physical
education of my female students.
Statement of the Problem
It is estimated that non-suicidal self-injury (NSSI) occurs at an alarming rate
among young adolescents (10 to 14 years). Yet, this phenomenon remains fairly
undocumented across many fields of study. Seventy-seven percent of the participants
who reported self-injury were female (Nixon et al., 2008).
NSSI is direct and deliberate since the intent is to injure oneself, although the
physical harm may vary significantly (Nock & Favazza, 2009). Non-suicidal self-injury
is distinguished from the act of suicide due to the lack of intent to end one’s own life
(International Society for the Study of Self-Injury [ISSI], 2012). Examples of NSSI
include more private, often hidden examples of body tissue mutilation such as cutting,
burning, scratching, biting, self-bruising, and breaking of bones (American Psychological
Association [APA], 2012; ISSI, 2012). Such injuries are committed to induce bleeding,
bruising, or pain on a minor to severe scale (APA, 2012; ISSI, 2012). Other methods may
include eating disorders, excessive laxative use, hair pulling, head banging, and branding
(Adler & Adler, 2007). Although there are other methods of NSSI not mentioned, the
objective of each method is the intent to injure oneself as a means of coping with
emotional pain, anger, and frustration, escaping personal issues, attaining a high, or
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providing self-discipline, not to end the victim’s life (APA, 2012; ISSI, 2012; Mayo
Clinic, 2012).
The APA (2012) has noted that acts of self-mutilation are not common behaviors
like nail biting or picking of scabs. Instead, acts of NSSI are intentional self-inflicted
wounds on the surface of their bodies, most commonly on inner thighs, arms, and
stomachs (Sax, 2010). Unlike suicide attempts, a large percent of self-injury does not
come to the attention of medical, psychiatric, and educational staff members (Adler &
Adler, 2007). Acts of NSSI are generally completed in a secretive manner (Adler &
Adler, 2007). NSSI wounds are mild to moderately superficial on the skin and can be
easily treated by the victim herself (APA, 2012; ISSI, 2012). More severe injuries may
need medical attention with resistance from the victim (Adler & Adler, 2007; Heath,
Baxter, Toste, & McLouth, 2010). Reasons for medical avoidance can range from fear of
discovery leading to public judgment to forced psychiatric attention (Adler & Adler,
2007; Heath et al., 2010).
NSSI is described as the “purposeful, direct destruction of body tissue without
conscious suicidal intent” (American Psychiatric Association, 2012). During the early
1980s, psychiatrists and pediatricians identified a phenomenon of young girls purposely
destroying the top layers of skin on their bodies (Sax, 2010). Originally diagnosed as
“deliberate self-harm syndrome (DSHS)”, (Sax, 2010, p. 93) estimates of the prevalence
of this behavior were under 1% of the population. Sax notes that cutting has become so
common the estimated number hovers above 20%. However, that number may
statistically be higher. A study conducted at Yale University revealed that 56% of the 10
to 14 year old girls they interviewed reported engaging in NSSI at one point in their
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lifetimes (Sax, 2010). Thirty-six percent of those interviewed admitted to committing
acts of NSSI within the last year (Sax, 2010).
Nixon et al. (2008) pinpoints the typical onset of NSSI between 14 and 24 years
of age with the possibility of principal engagement as young as 10 years old. Current
explanations of NSSI among young populations point to the appearance of more volatile
and unstable emotional behavior in pre-teenagers (Adler & Adler, 2007; Mayo Clinic,
2012; Sax, 2010). Hormonal alterations, peer pressures, and desires for independence
from parents and other authorities may also activate non-suicidal self-injury in young
adolescents (Mayo Clinic, 2012; Sax, 2010).
Experts in NSSI have predicted an increase of NSSI among pre-teen and teenage
girls in recent years (Adler and Adler, 2007; Adrian, Zeman, Erdley, Lisa, and Sim, 2010;
Crowell, Beauchaine, and Linehan, 2009). A reason for this prediction may stem from an
increased awareness among community populations of the possible identifiable behaviors
exhibited by those students who engage in NSSI. In addition, peer influence, increased
adolescent stress factors, and increased exposure to media sources are also thought to
contribute to the predicted increase of NSSI behaviors (Adler & Adler, 2007; Junke,
Granello, & Granello, 2011; Linehan, 1993; Muehlenkamp, Walsh, & McDade, 2010).
Educational leaders must become aware of the total emotional, social, psychological, and
developmental impact NSSI may have on their middle school female population. With
this current prediction, it becomes urgent for educational leaders to gain knowledge about
non-suicidal self-injury. First and foremost, non-suicidal self-injury should be clearly
defined to provide all members of the school with an operational definition of NSSI.
Secondly, school staff should become familiar with the various methods and intensity of
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self-injury. This familiarization should include the examination of the methods of
engaging in NSSI, the frequency and intensity of NSSI behavior, as well as the catalysts
for NSSI behaviors. Once possible reasons for self-harm are examined, attempts to relate
the research to individual schools may be made.
Experts have attempted to define NSSI and determine the factors that may
contribute to it. For example, Linehan (1993) proposed a new biopsychosocial model in
an attempt to explain the phenomenon of NSSI. This model linked the etiological
mechanisms, or the causes and origins, associated with the development of emotional
dysregulation and borderline personality disorder to the biological vulnerability of
puberty. When combined with the adolescent inability to manage and process emotion,
Linehan (1993) believed this combination of factors prompted an individual with intense
emotional buildup to seek a release by self-mutilation. This theory was later reinforced
by the findings of biological vulnerability and self-mutilation completed by Crowell et al.
(2009).
Junke, Granello, and Granello (2011) list risk factors such as neglect, abuse,
family violence, emotional deregulation, low self-esteem, exposure to peer NSSI models,
and co-occurring psychological disorders as contributing factors related to NSSI
adolescents (pg. 90). According to Junke et al. (2011), adolescents who experience one
or several of the listed risk factors may develop negative self-image, feelings of intense
anger or frustration, and engage in self-defeating patterns of behavior (p. 93). Such
damaging behaviors perpetuate feelings of depression or discouragement, although not as
low as adolescent suicide attempters (Junke et al., 2011). However, these feelings of
diminished self-worth and self-criticism can lead a youth to self-punishment or escape
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through NSSI.
A student who engages in NSSI behaviors may neglect her schoolwork,
extracurricular activities, even relationships (Nock & Prinstein, 2005; Sax, 2010). A
student may begin to withdraw from her social network, avoid collective gatherings, and
spend more time alone in her room at home (Hooley & St. Germain, 2013). Her attire
may change, wearing long sleeves and pants to hide her injuries even in the summertime
weather. This prohibition of clothing can make it difficult for the student to follow
current fashion trends like her peers in turn perpetuating any self-critical thoughts and
beliefs as well as preventing typical social development (Hooley & St. Germain, 2013).
Current researchers continue to explore the motives for adolescent engagement in
NSSI behavior. Junke et al. (2011) point to biological, psychological, and social
variables that may or may not combine with certain risk factors like neglect; physical,
emotional, or sexual abuse; and co-morbid psychological disorders, among other risk
factors that may contribute to the adoption of NSSI behaviors. Additionally, individual
motives may change over a life span.
Bowman and Randall (2004) identified negative coping techniques such as
alcohol, drugs, eating disorders, smoking, sex, gambling, and self-injury. Data published
by Hilt, Cha, and Nolen-Hoeksema (2008) support a likelihood that cigarette, drugs, and
alcohol abuse connect with the engagement in NSSI behaviors among young female
adolescents as health-risk behaviors tend to cluster together. Such factors as an
awareness of self-harm in peers and family members, drug misuse, depression, anxiety,
impulsivity, disruptive disorders, and low self-esteem (Nixon et al., 2008) may also
contribute to NSSI behaviors among pre-adolescent and adolescent females. Widespread
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media exposure of NSSI, whether from celebrity admissions of NSSI, movies, television
programs, or websites designed to encourage and discourage NSSI behaviors have
brought such behavior to the forefront of everyday teenage life (Bowman & Randall,
2004; Whitlock, Purington, & Gershkovich, 2009).
Pre-teen and teenage girls may commit NSSI in order to feel a sense of control
over their bodies (Mayo Clinic, 2012). Some females engage in NSSI behaviors to cope
with intense negative feelings (Junke et al., 2011). When a pre-teen or teenage girl is
emotionally empty, or unable to express her emotions, she may engage in NSSI in order
to feel something, even if it is pain (Mayo Clinic, 2012). Another perspective can be
understood as a young female seeking relief from a state of extreme anxiety or hyper-
arousal through self-injury. The creation of a disassociated state of being is more
desirable to the female than that of hyper-arousal (Nock & Mendes, 2008). This
“automatic positive” is described as the self-harming injuries committed by the student in
order to awaken a preferred stimulus - “to feel something, even if it was pain” (Nock &
Prinstein, 2004, p. 886). Considering the desired stimulus, pre-adolescent and adolescent
females may use NSSI to manage anxiety and frustration- to inflict pain instead of other
intense stimuli (Mayo Clinic, 2012; Nixon et al., 2008; Sax, 2010). Additionally,
participants may use NSSI as a means to punish themselves for being self-proclaimed
socially, physically, and/or developmentally inept as compared to others in their
environment (Nock & Mendes, 2008).
Developing research has identified a possible link between hormonal
overstimulation and high levels of arousal with incidents of self-injury. Nock and
Mendes (2008) suggest that people engage in NSSI because they experience a heightened
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physiological arousal following a stressful event. The use of NSSI allows the individual
to regulate hyper-arousal and escape the distressful experience (Nock & Mendes, 2008).
It is believed that self-injurers experience extreme and intolerable arousal following
stressful events. In order to decrease or eradicate this arousal, the individuals engage in
NSSI in order to distract themselves from the events, release endorphins, or for other
unknown reasons. According to Nock and Mendes, this lack of distress tolerance is
assumed to be an important explanatory factor in the development and sustainment of the
NSSI.
The study conducted by Bresin and Gordon (2013) supports Nock and Mendes
(2008) in reference to the use of NSSI to regulate personal affect, described within the
studies in terms of the personal expressions of emotions, moods, attitudes, and behaviors
of the participants. Adolescent females may engage in NSSI behaviors to avoid stress,
manage affect, or alleviate anxiety. The simple image of engaging in NSSI automatically
begins to decrease physiological arousal among self-injurers (Bresin & Gordon, 2013;
Nock & Mendes, 2008). Although the study performed by Bresin and Gordon (2013) did
not identify the exact mechanisms that cause NSSI to lead to reduced feelings of negative
affect, it did propose the endrogenous opioid system as a mediator of the affect regulation
effects of NSSI. Due to the endrogenous opioid systems involvement in the regulation of
pain and emotion Bresin and Gordon (2013) proposed that (1) individuals who engage in
NSSI have lower baseline levels of endogenous opioids, (2) NSSI releases endogenous
opioids, and (3) opioids released during NSSI regulate affect.
Adrian et al. (2010) tested the associations between the occurrence of NSSI and
the social contexts of parental and peer relations with the hypothesis that perhaps with a
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developmentally supportive social context, the occurrence of NSSI would diminish.
Nock and Prinstein (2004) categorized the interpersonal reasons for NSSI as “social
positive,” (p. 886) actions done to get attention from others, and “negative
reinforcement”, actions completed in order to avoid punishment from others. It has been
suggested that perhaps with a fully formed web of interpersonal support systems, the
individual would cease to commit self-injury (Adrian et al., 2010; Hilt et al., 2008; Nock
& Prinstein, 2004). In a similar study, Nock and Mendes (2008) suggest the use of NSSI
is more apparent in those individuals that have deficits in their social problem-solving
skills that, in turn, interfere with the performance of more adaptive social responses.
Such individuals use NSSI for social communication – to gain the attention of
others or to influence their behavior in some way (Nock & Mendes, 2008). A desire to
somehow influence and change an environment motivates some self-injurers to engage in
harmful behaviors. (Nock & Mendes, 2008). Experimental research suggests that social
reinforcement may be a primary motivator for the cessation of NSSI. This factor may
hold an even greater importance for individuals who do not possess good social problem-
solving skills in addition to lacking adequate support systems at home and in the
community. There remains a strong need for further research into the etiology of NSSI
and the reasons for the engagement in such harmful behaviors especially among children
ages 10-14 years old.
Contrary to past psychological theories of the cause of NSSI, many contemporary
experts believe that methods of NSSI do not serve as means for a cry for help (Adrien et
al., 2010; Hilt et al., 2008; Klonsky, 2007; Muehlenkamp et al., 2010; Nock & Prinstein,
2004; Sax, 2010). Sax (2010) states that NSSI is a secretive illness; one in which its
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victims do not seek out help and do not wish to gain widespread attention; he notes also
that unlike suicide, NSSI may be carried out to release emotional overstimulation or
hyper-arousal not as an attempt to end a life. This secretive behavior allows self-injurers
to remain hidden from school administration. Secondly, the intimate locations of the
self-inflicted injuries (upper thigh area, inner arm, and stomach) make it difficult for
educational leaders to detect this affliction in early adolescents without notification from
a friend or family member (Sax, 2010).
Unlike NSSI, an adolescent who attempts suicide wants to end her own life. The
methods of NSSI are not the same as those used by adolescents who attempt suicide
(Junke, Granello, & Granello, 2011). The methods that are used by adolescents who
attempt suicide involve a greater lethality than those employed by adolescents who
engage in NSSI (Junke et al., 2011). Attempts at suicide by firearms, poisoning, or
suffocation are most often used by adolescents who wish to end their life (Junke et al.,
2011). According to the American Psychiatric Association (2012) the causes of suicide
are most often a result of depression or other mental illness, substance-abuse disorders, or
a combination of more than one of these factors. “The risk for suicide frequently occurs
in combination with external circumstances that seem to overwhelm at-risk teens who are
unable to cope with the challenges of adolescence because of predisposing vulnerabilities
such as mental disorders” (American Psychiatric Association, 2012, para. 2).
Disciplinary, familial, and interpersonal problems, sexual orientation confusion, physical
and sexual abuse and being the victim of bullying are possible stressors that may render a
student overwhelmed leading to a feeling of hopelessness and desire to end their lives.
In contradiction to the American Psychiatric Association, Jacobson and Gould
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(2007) revealed that 55% to 85% of self-injurers have made at least one attempt at
suicide. The results of that study were reinforced by further research conducted by
Dougherty, Mathias, Marsh-Richard, Prevette, Dawes, Hatzis, Palmes, and Nouvion
(2009). Data gathered by Dougherty et al. (2009) demonstrated higher levels of
impulsivity, depression, and hopelessness among adolescents that engage in NSSI and
have had at least one suicide attempt. Therefore it is urgent for educational practitioners
to evaluate a female adolescent who exhibits NSSI behaviors for past suicide attempts
coexisting mental health disorders, which may increase the risk of suicide (Junke et al.,
2011).
Purpose of the Study
The purpose of this study is to define the role of the middle school principal in
addressing non-suicidal self-injury in female students, aged 10-14 years old. It is vital for
school leaders to remain informed on the types of NSSI and the means of prevention that
exist specifically for middle school-aged girls, since adolescent girls are predominately at
risk for NSSI (Hilt et al., 2008). Knowledge of the etiology of NSSI, whether complex or
rudimentary in form, may aid principals in seeking out possible victims of NSSI and
finding the necessary medical assistance. It is urgent for school leaders to work closely
with guidance counselors, psychologists, and social workers within the school and in the
community in order to raise awareness and collaboratively address NSSI behaviors
among the pre-adolescent and adolescent female population. This study will examine the
contemporary role of the middle school principal in the identification, intervention, and
prevention of NSSI among female adolescents. It will explore the actions principals take
in order to address NSSI among their female students ages 10-14. It will analyze the
25

perceptions held by principals about NSSI and the female student population who engage
in its behavior. Lastly, this study will determine whether there are significant differences
in the perceptions of middle school principals in regard to the role he or she plays in
preventing NSSI among the female student population.
Significance of the Study
Research has shown that NSSI behaviors have become more commonplace and
widespread among early adolescents females in middle school in recent years. In fact,
the number of reported female students ages 10 to 14 who commit non-suicidal self-
injury has increased each passing year with percentages that range from 9% (Barrocas,
Hankin, Young, & Abela, 2012). One may wonder what the causes are for an increase in
this behavior. Additionally, one may question how principals can play an active and
productive role regarding the well being of the students. This study has the potential to
provide information to reduce non-suicidal self-injury among adolescent females 10 to 14
years old by identifying the factors that may cause students to engage in NSSI behaviors.
This study will address the role of the middle school principal in the identification,
intervention, and prevention of NSSI among pre-adolescent and early adolescent females
students. The data gathered for this study will impact the field of leadership in middle
schools by highlighting the components necessary to address physically mutilating
behaviors as private as NSSI. Through the identification of possible factors that
contribute to NSSI among young female adolescents, academic curriculum may be
written to create widespread awareness of NSSI among the staff and student populations.
Finally, potential prevention and intervention plans may be developed using the results of
this study.
26

Delimitations of the Study
This study will focus on the role of the middle school principal in addressing non-
suicidal self-injury among female adolescents ages 10 to 14 years of age. It will
purposely be limited to middle school administrators currently employed in the state of
Massachusetts. This study is delimited in its design to collect self-reporting beliefs of
middle school principals.
This study is designed to intentionally limit the scope to non-suicidal self-injury
(NSSI) as it pertains to the middle school education. While components of prevention
plans will be identified, this study will not propose a “model” for preventions of NSSI.
Instead, this study will attempt to define the role of a principal in addressing non-suicidal
self-injury among female students ages 10 to 14. This study will not include interviews
with any members of the school community other than principals.
Design of the Study
This research design is a phenomenological study. The primary focus of a
phenomenology is “to reduce individual experiences with a phenomenon to a description
of the universal essence” (Creswell, 2007, pg. 58). In this phenomenological study, the
researcher will focus on describing the role of the middle school principal in addressing
non-suicidal self-injury among adolescent females ages 10 to 14.
Selection of Subjects
Since the focus of the study is to identify the role of the middle school principle in
addressing NSSI among female pre-adolescent and adolescent students, the researcher
27

will solicit the participation of 150 middle school principals throughout Massachusetts.
This may provide the researcher with 45-100 participants, a sample size large enough to
provide statistical power to the survey results and be representative of the larger
population of all Massachusetts middle school principals.
There will be no limitation on the type of middle school of a principal in respect
to urban, rural, or suburban nor private, neighborhood public, regional public, charter, or
other. The researcher will access the database of the Department of Elementary and
Secondary Education (DESE) for the initial contact information of the 150 middle school
principals. All principals will be randomly selected and recruited via email.
For the follow-up interview process, a minimal sample size of 8-10 principals will
be sought. Within the initial contact email, consent is sought for both stages of the study,
the survey and the interview. Principals who wish to participate in the interview stage
provide their signature of consent and their contact information. The researcher will
contact those principals who are willing to volunteer for the interview stage of the study.
Instrumentation
The online electronic survey, which utilizes a Likert attitude inventory, will be the
quantitative instrumentation used in this research. Typically, a Likert type attitude scale
is used in research to indicate a “level of agreement or disagreement with each of several
statements by selecting one of four or five options” (Huck, 2008, p. 479). A Likert scale
does not weigh one question as more important than another. Instead, Huck (2008)
believes that a Likert scale produces ordinal data regardless of the positively or
negatively leaning responses.
The Likert attitude inventory will be developed using a Google document survey
28

tool. The use of an online survey will ensure confidentiality and provide a uniform
survey designed to gather information in an efficient manner. It will be designed for
middle school principals to illicit responses used to measure five areas of focus:
principal-held perceptions of NSSI, principal-held perceptions of students who engage in
NSSI, perceptions of the role of a principal in addressing NSSI, the role of principal in
the identification, intervention, and prevention of NSSI among their female students ages
10 to 14, perceptions of which components of prevention plans are most valuable for
students who suffer from NSSI.
The second phase of data collection will be qualitative in the form of face-to-face
live interviews. The researcher will use a designated script and previously designed
interview questions for the interviews.
Data Collection Process
This will be a study that uses Sequential/Concurrent mixed methods, using both
qualitative and quantitative data collection tools. The quantitative research method
utilizing a Likert scale inventory survey will be the primary data collection method and
the qualitative research method of face-to-face interviews will be secondary. This study
combines two research strategies within data collection to examine the role of the middle
school principal in addressing NSSI among female adolescents ages 10 to 14 years old.
Through the use of a mixed-methods approach, greater confidence in the accuracy of the
research findings may be achieved since two research strategies will be used to analyze
the same topic (Denscombe, 2011). Due to the combined use of two strategies, a mixed-
methods approach will provide a well-developed perspective on the role of the principal
in addressing NSSI based on self-reported perceptions.
29

The invitation to participate in the study will sent electronically to 150 middle
school principals throughout Massachusetts. The electronic letter will identify the
researcher, state the purpose of the study, discuss the anonymity of the participants, the
time required for the completion of the online questionnaire, and how subject responses
will be maintained in terms of confidentiality. A requested date of return to the
researcher will be printed within the participation letter. Additionally, in order to
encourage greater participation, the letter will also discuss the possible outcomes the
study may yield upon its completion.
The survey will be a non-probability purposive sampling attempting to produce a
representative sample of principals with a predicted confidence interval of 95%
(Creswell, 2007). A non-probable purposive sampling is one that allows for contact with
potential participants who can best inform the researcher specific to the study (Creswell,
2007). The confidence level is considered to be an estimate of the range of a population
value given the sample value (Salkind, 2011). For the purpose of achieving a significant
sampling, the researcher will contact 150 middle school principals throughout
Massachusetts randomly, introducing the study, requesting participation in the study, and
linking the online survey tool to the initial email.
The Likert inventory is collection information on the extent to which middle
school principals have received training on NSSI received during the participants’
administrative education or in-service training. It will also illuminate any possible lack
of training on NSSI during the same administrator’s educational experience. Secondly,
the Likert scale will attempt to compare the perceptions of NSSI held by current
principals across Massachusetts. Third, it will attempt to reveal principal-held
30

perceptions of female students that engage in NSSI behaviors. Such perceptions of NSSI
and those students who engage in NSSI may highlight whether or not a middle school
principal considers NSSI to be a threat of high priority or one that deserves little attention
in respect to the day-to-day responsibilities of their job. Fourth, the questions posed
within the survey instrument will examine any actions taken by current middle school
principals in reaction to the discovery of students who engage in NSSI behaviors. If this
is the case, the survey results may reveal under-reported cases of NSSI behavior
committed by adolescent females within middle schools across Massachusetts. Lastly,
the results of the study will determine what role middle school principals currently
believe they play in regards to the identification, intervention, and prevention of NSSI
among their female students ages 10 to 14.
The five research questions listed below will frame the study in order to examine
the role of the middle school principal in addressing NSSI among female students ages 10
to 14. These questions will guide the study to determine the similarities and differences
between the perceptions held by current principals about NSSI, the students who engage
in NSSI behaviors, the role of a principal in addressing NSSI, and what actions are
needed in order to address NSSI once it is known in the school.
1. To what degree do middle school principals consider non-suicidal self-injury
(NSSI) among pre-adolescent and early adolescent females to be an important
leadership role?
2. What are the various ways middle school principals report they are addressing
NSSI among pre- and early adolescent females?
3. What are the factors and conditions that middle school principals believe inhibit
31

and support their efforts to address NSSI among pre- and early adolescent
females?
The researcher will not investigate the reasons for the responses given by the
middle school principals’ who participate in the study. The researcher will simply
identify their perceptions and examine those responses for themes and patterns.
Additionally, the Likert attitude inventory will provide questions for the interview
process that will be formed based on the collective responses from the survey.
The online survey instrument will begin with questions geared toward school
demographics and move toward questions that address professional history and any
completed educational training on NSSI. Participant will then begin to answer survey
questions using a five point Likert scale. It will seek to measure the participant’s
perceptions of the principal’s role in addressing NSSI as well as the principal’s
perceptions of the female adolescents who engage in NSSI behaviors. Additionally, the
Likert inventory will also identify the frequency and nature of administrative reactions
once a student or students who engage in NSSI are identified in the school.
Once all surveys have been returned, the researcher will assign a numeric code to
each participant to ensure anonymity during the coding process. From that point, only
numeric codes will be used when analyzing the data from the survey. All codes will
remain in a locked cabinet within the home of the researcher to ensure confidentiality.
Then, the researcher will identify which participants have elected to continue to the
interview stage. The interviews will attempt to provide a cross-section of the population
in order to draw valid conclusions about the overall research population (Denscombe,
2011). The letter of consent for the interview process will be placed at the end of the
32

online survey tool. Once the survey is completed, the participants can provide consent
for the interview process by providing the necessary contact information on the
designated lines at the end of the survey instrument. All participants willing to engage in
the follow-up interview process will be contacted within two weeks following the online
questionnaires.
The interviews will be conducted face-to-face using a scripted introduction to
ensure continuity when providing participants with the context of the follow-up
interview. The researcher will also provide brief descriptions of any key terms or
definitions necessary for accurate understanding of the interview questions. All
interviews will be recorded which will allow greater accuracy by the researcher when
analyzing responses. Confidentiality of participants will be honored. The same numeric
code that was provided for each participant during the survey stage will be used to
identify the participating principals during the interview stage as well. Only the
researcher will possess the numeric translation to the participants, which will be stored in
a locked cabinet within the home of the researcher.
Unlike the Likert type attitude inventory, the face-to-face interview process will
record lived experiences in an attempt to determine what may have led to the perceptions
of the role a principal plays in addressing NSSI. It will examine three specific areas: 1)
the training that is received by principals in addressing NSSI, 2) any perceptions held by
current principals about the female student population who engage in this behavior and,
3) any actions taken by the principal post-discovery of a student who engages in NSSI.
At the end of the interview, the researcher will ask the participant if he or she
would like to add anything further, whether it is in regards to an area of NSSI, principal
33

perceptions of NSSI, principal perceptions of the females who engage in NSSI, or the
role of the middle school principal not addressed during the interview process.
In order for the study to have statistical significance and statistical power a
minimum of 45 surveys will need to be completed. If less than 45 surveys are collected
at the time designated in the original letter, the researcher will send a follow-up email
with the online survey link (see Appendix C). If participation is still low, this factor will
be addressed in the analysis of the study in the dissertation.
A minimum of eight participants will be interviewed in order to provide
evidentiary strength. Due to the small number of interviewees, the researcher will select
principles from urban or suburban public schools with similar grade configurations.
Consideration of participant availability, access, and willingness will also impact the
interview selection process. However, if less than 8 principals are willing to participate
in the interview process, the researcher will send a letter to those principals who
completed the survey to reconsider their decision not to participate in the interview
stage. If participation remains low, the researcher will note this factor in the analysis
section.
Pilot Study
An initial pilot study was conducted using current middle school principals
enrolled at Lesley University. Some bias was expected from the Lesley University
participants due to the established relationship with the researcher and prior knowledge of
the material being researched.
The researcher field-tested both the Likert attitude inventory and interview
questions on several doctoral candidates currently enrolled in the Lesley University
34

Educational Leadership Program. Each participant was sent the introductory email with
the consent to participate in the study. Additionally, the participation email provided the
link to the survey instrument. As part of the pilot study, the researcher requested each
survey to be returned by the participants within a two-week period with any
recommendations and feedback on the survey instrument and letter.
The pilot study had a rate of return of 40% (4 of 10) completion for the survey
instrument and the interview portion of the study. The participants live throughout the
state of Massachusetts covering the north, south, east, and west of the state. Participants
varied in age, gender, years of overall administrative experience, years in the current
administrative experience, and school type and size.
Common trends and themes were identified once the participants returned the
Likert attitude 5-point scale, which ranges from Strongly Agree to Strongly Disagree.
There was little deviation in participant choices for principal perceptions in overall
knowledge of NSSI and NSSI behaviors. Three of the four participants indicated overall
knowledge of how NSSI and NSSI behaviors are defined. This may demonstrate a
somewhat-universal yet informal definition of NSSI used within administrative
education.
The survey instrument results revealed a low rate of received administrative
training in NSSI by the participant. Upon completing the follow up interview, it was
revealed that most principals have gained a working knowledge of NSSI through
everyday administrative experiences. Due to possible increase in NSSI identification
during their current administrative years, all participants realized a growth of this
phenomenon among pre-adolescent and adolescent females. The researcher predicts a
35

similar outcome in the formal study.
Questions that addressed principal perceptions of pre-adolescent and adolescent
females who engage in NSSI produced a greater variety of results than questions that
addressed the role of the principal and administrative training in NSSI. In particular, the
questions about familial background influence and parental and peer involvement tended
to produce the most disparity of responses. Identifying common personality traits of
potential self-injurers also produced a greater variation of results, leading the researcher
to believe the results from the formal study will further identify a need for training in the
identification of students who may self-harm, for without being able to accurately
identify a self-injurer, a principal will not be able to intervene or prevent NSSI from
occurring.
The Survey Instrument and Interview process alike demonstrated a basic lack of
knowledge and training in maladaptive behaviors on the part of the middle school
principals, specifically NSSI-related training. Due to this lack of training, most
principals currently allow guidance counselors to address NSSI with the identified
students - this would include filing the proper district, state, and federal paperwork.
Again through a lack of education, a high percentage of participants felt unable to address
the needs of those females suspected of engaging in NSSI. However, 99% of participants
felt intervention to be a part of the role of principal.
After reviewing the results both data collection instruments, it remains unclear to
the researcher what general role a principal may play in the identification, intervention,
and prevention of NSSI among pre-adolescent and adolescent females currently and in
the future. The researcher may need to ask for further clarification from the participants
36

in response to the interview question addressing any actions taken by a principal in order
to address NSSI behaviors among pre-adolescent and adolescent female populations in
the school. Additionally, clarification may needed about the perceived role of a principal
in regards to the identification, intervention, prevention and reporting of NSSI.
Based on the results of the pilot study, the researcher deleted one question that
was duplicated within the survey instrument. The interview questions were clarified in
order to avoid ambiguity and directions were clarified to avoid confusion. Those
principals that participated in the pilot study will be excluded from the study mailing.
Plan for Data Analysis
Analysis of the collected data will be ongoing. The researcher will code and analyze
the quantitative results given from the online questionnaires using a data research
computer program as soon as the completed surveys are available. Since this is an
emerging subject area, attempts at designing codes will be made using a combination of
codes that were generated through recent studies of NSSI within education, psychology,
and other behavioral sciences.
The researcher will record each interview using Evernote, an online application, to
record the interviews. This will ensure greater accuracy of results gathered from each
interview. Once all interviews have been completed, the researcher alone will review the
responses specifically for patterns and themes that emerge from participants’ answers.
Similar to quantitative data analysis, a computer program will aid in the analysis of the
qualitative information in order to identify emerging patterns, trends, or themes. Such
patterns will generally be abstract and will attempt to highlight the perceptions held by
principals in regards to NSSI, females who engage in NSSI behaviors, the role a principal
37

plays in addressing NSSI among the female pre-adolescent and early adolescent
population, as well as the actions principals take in order to address NSSI in the schools.
Once all interviews have been performed and analyzed, the researcher will burn all
interviews onto a disc and store it within a locked cabinet in an office in the researcher’s
home.
The joint analysis of demographic information with the Likert scale inventory will
explore any possible similarities or differences between rural, suburban, and urban
middle schools concerning the occurrence of NSSI and the reporting of NSSI. The
analysis will examine the role of the principal in the identification, intervention, and
prevention of NSSI, help to compare education levels, and career experiences. Matrices
will be constructed from the data and will be used to further define patterns, themes, or
concepts gathered from the data collected. The researcher will perform periodic reviews
of the data collected and any further questions or inquiries will be noted for later review.
In addition, the researcher will confer with a Lesley University professor to summarize
any research findings as to discuss identified themes, patterns, and trends stemming from
the survey instrument and the interviews.
Once all data collection has been completed, the researcher will review the
interviews for a second time with the objective of collecting threads of information that
seem to emerge throughout the various interviews. These threads will serve as a basis for
the qualitative data collection codes. Using the same online data analysis program used
for quantitative data, the researcher will enter the codified information to identify any
patterns and trends.
Throughout data collection and analysis processes all information will be
38

confidential, properly stored in a locked cabinet drawer, and disposed of once the study
has been completed. An Executive Summary of the results from the study will be mailed
to those who have participated in the study once the dissertation is approved by Lesley
University.
39

Chapter Outline
This dissertation will be organized into five chapters in the
following manner.
Chapter 1 will introduce the dissertation, beginning with a personal interest
statement and correlating with background information on non-suicidal self-injury. After
the introduction, the chapter will explain the problem that prompts the purpose of this
study. Chapter 1will also layout the research questions, the research design, the
limitations and delimitations of the study, as well as express any assumptions. Finally,
Chapter 1 will define key terms, outline the significance of the study, and provide an
overview of the literature.
Chapter 2 will provide a review of the literature that investigates the role of a
principal in addressing non-suicidal self-injury. The chapter will be subdivided into six
sections. Section one will review literature that illustrates the historical to present-day
role of the middle school principal. Section two will review literature that defines NSSI
and highlights common NSSI behaviors among pre-adolescent and early adolescent age
groups. Section three will examine the literature on the role of a middle school principal
in response to addressing non-suicidal self-injury, including reports of actions taken as
the principal of a school to eliminate self-injury among the student population. Section
four will highlight the perceptions currently held by middle school principals of the role a
principal plays in the identification, intervention, and prevention of NSSI in the schools.
Section five will analyze the perceptions held by middle school principals of those
students who engage in behaviors of NSSI. Section six will review the literature on
identification, intervention, and prevention methods designed to address NSSI in middle
40

schools. This literature review will provide a conceptual base for this research.
Chapter 3 will summarize the research methodology, describe the role of the
researcher, and list the research questions guiding this study. Chapter 3 will
also provide a description of the design of the study, the selection of subjects, and the
instrumentation to be used will be provided in chapter 3. The descriptions of the data
collection sites as well the data collection process will follow. Additionally, Chapter 3
will outline the procedure for data analysis. Within the description of data analysis,
references to validity, reliability, and data management will also be made.
Chapter 4 will present the analysis of data collected. The research questions will
provide a framework for the study. Tables and charts will be used to demonstrate data
results in a simplified manner.
Chapter 5 will summarize the study, the results of the study, and draw conclusions
from the analyzed data. In this chapter the purpose of the study will be reiterated and
recommendations for further research will be provided. The last section of Chapter 5 will
summarize the research study, and its significance will conclude the dissertation.
Time Table
41

March Dissertation Proposal approved
March Electronic email including participation letter, consent
form, and questionnaire distributed
March 1st
Electronic reminder sent
2nd
Electronic Reminder sent
April-May Questionnaire data collected and organized
April-May Interview portion of data collection
May-July Analyze Data
Winter 2014-2015 Chapter 4 & 5
Spring 2015 Defend Dissertation
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50

Appendix A
Definition of Terms
For the purpose of the current study, the researcher is defining relevant terms and
concepts as follows:
 Suicide is defined as “death caused by self-directed injurious behavior with any intent to
die as a result of the behavior” (Crosby, Ortega, & Melanson, 2011, p. 11).
 Non-suicidal self-harm is described as the “purposeful, direct destruction of body tissue
without conscious suicidal intent” (American Psychiatric Association, 2012). Also
entitled non-suicidal self-injury (NSSI), deliberate, self-inflicted destruction of body
tissue without suicidal intent and for purposes not socially sanctioned (ISSS, 2007).
 Violence is defined as “the intentional use of physical force or power, against another
person, group, or community, with the behavior likely to cause physical or psychological
harm” (Center for Disease Control, 2012).
 School-associated violence is defined as the antisocial behaviors that occur on school
grounds, while traveling to and from school, or during school sponsored events (Furlong
& Morrison, 2000). For the purpose of this paper school-based violence and school-
associated violence will be used interchangeably.
 Types of violence difficult to detect like bullying can be covert and acts of bullying are
subtle which make them difficult to detect and monitor.
 Aggressive behaviors are those which include targeted verbal, physical, or gestural
behavior that is intended to cause minor physical harm, psychological distress,
intimidation, or to induce fear are currently considered less serious forms of violence by
governmental agencies (Loeber & Stouthamer-Loeber, 1998). An aggressive act may be
51

demonstrated through the spreading of rumors, use of profanity, gestures of bodily harm,
even online harassment.
 Severe violence is defined as the violence that includes a range of antisocial behaviors,
from assault with a deadly weapon to homicide (Office of Juvenile Justice &
Delinquency Prevention, 2001). Severe, or direct violence occurs when one or more
individuals make intentional threats, attempts at, or engage in physical harm toward
another individual or group (FBI, 2012; Greene, 2012; NCES, 2011). This type of
violence can also be exemplified in physical altercations, threats of bodily harm, forcible
robbery, even rape (Greene, 2012).
 Safe learning environment for the purpose of this study is defined as a learning
environment that has freedom from potential physical and psychological harm, absence
of violence, and the presence of nurturing, caring, and protective staff (Sprague &
Walker, 2005).
 Middle school grades are those grades between primary and secondary school level,
ranging from the 5th
to 8th
grade (Department of Elementary and Secondary Education,
2012).
52

Appendix B
25 Cowing Street
West Roxbury, MA 02132
617-390-5149, tmcclosky@hotmail.com
March 14, 2014
Dear Sir or Madame,
My name is Tara Kfoury and I am a doctoral candidate at Lesley University in the
Educational Leadership Program. Currently, I am completing my dissertation research
entitled “The Role of the Middle School Principal in Addressing Non-Suicidal Self-
Injury (NSSI) Among Adolescent Females ages 10 to 14 years old.” In this study I will
examine the role of the middle school principal in addressing NSSI and discover how the
middle school principal may impact the creation and implementation of an effective NSSI
prevention program.
You were randomly selected for this study and your participation is voluntary. However,
I strongly hope you consider participating in this study and complete this brief survey.
Your participation in this study is essential and will afford administrators of all academic
levels the opportunity to examine their role in current NSSI prevention practices in their
school.
This survey should take 15 minutes to complete online at
http://www.surveygizmo.com/s3/1393595/The-Role-of-the-Principal-in-Addressing-Non-
Suicidal-Self-Injury
Please know that your responses will remain completely confidential with results being
viewed only by the practitioner. Individual names of middle school principals and
schools will not be used.
Please complete the survey by Tuesday, March 25, 2014. Should you have any questions
or concerns, please feel free to contact me at tmcclosky@hotmail.com, or my dissertation
chair, Dr. Judith Conley, at jconley@lesley.edu.
Thank you in advance for your participation in this study.
Sincerely,
Tara M. Kfoury
Doctoral Candidate
Lesley University
53

Appendix C: Follow-up Email
March 26th, 2014
Good Morning/Afternoon Principal __________________,
My name is Tara Kfoury and I am a candidate at Lesley University in the Educational
Leadership Doctoral Program. Currently, I am completing my dissertation research
entitled “The Role of the Middle School Principal in Addressing Non-Suicidal Self-
Injury Among Adolescent Females ages 10 to 14 years old.” I will examine the role of
the middle school principal in addressing NSSI, and discover how the middle school
principal may impact the creation and implementation of an effective NSSI prevention
program.
This is a friendly reminder to ask for your participation in this research study by
completing the Non-Suicidal Self-Injury Survey that was emailed to you on March 14th,
2014. The information gathered in this survey is being used to complete my doctoral
dissertation through Lesley University in Cambridge, Massachusetts. Your participation
in this study is essential and will afford administrators of all academic levels the
opportunity to examine their role in current NSSI prevention practices in their school.
This survey should take 15 minutes to complete online at
http://www.surveygizmo.com/s3/1393595/The-Role-of-the-Principal-in-Addressing-Non-
Suicidal-Self-Injury.
Please know that your responses will remain completely anonymous with results being
viewed only by the practitioner. Individual names of middle school principals and
schools will not be used.
Please complete the survey by March 31st, 2014. Should you have any questions or
concerns, please feel free to contact me at tmcclosky@hotmail.com, or my dissertation
chair, Dr. Judith Conley, at jconley@lesley.edu.
If you have already completed the survey, I would like to extend my sincere thanks and
appreciation for taking the time to participate in this study. In closing, I would like to
wish you and your school a wonderful spring and a successful ending to the school year.
Sincerely,
Tara Kfoury
Doctoral Candidate
Lesley University
54

Appendix D – Letter of Consent
Title: The Role of the Middle School Principal in Addressing Non-Suicidal Self-Injury
Among Adolescent Females ages 10 to 14 years old.
Lead Researcher
Tara Kfoury
25 Cowing Street
617-390-5149
tkfoury@arlington.k12.ma.us
Faculty Supervisor
Judith Conley
Lesley University Graduate School of Education
University Hall Rm. 2-047
800-999-1959 ext. 8144; 617-349-8144
jconley@lesley.edu
Lesley University Institutional Review Board (IRB) contacts
Robyn Cruz (rcruz@lesley.edu) or Terry Keeney (tkeeney@lesley.edu)
Purpose: I am conducting a study to define the role of the middle school principal in
addressing non-suicidal self-injury (NSSI) in female students ages 10 to 14 years old.
First, it will examine the contemporary role of the middle school principal in the
identification, intervention, and prevention of NSSI among female adolescents. It will
explore the actions principals take in order to address NSSI among their female students
ages 10 to 14. It will analyze the perceptions held by principals about NSSI and the
female student population who engage in its behavior. Lastly, this study will determine
whether there are significant differences in the perceptions of middle school principals in
regards to the role he or she plays in preventing NSSI among the female student
population. The study will be conducted under the supervision of my senior advisor,
Judith Conley.
I invite you to participate in this study as a middle school principal in Massachusetts.
There are two phases in this study. Phase I involves an online survey which should take
about 15 minutes to complete. At the end of the survey, you may choose to participate in
Phase II, a thirty-minute interview process, by indicating your interest in the designated
area at the end of the survey. By design, the overall collection of middle school
principals will provide a sample size of approximately ten-fifteen principals from
different schools and districts throughout Massachusetts.
Procedures: This study will use a mixed method design of quantitative and qualitative
research methods. Phase I will consist of an online quantitative survey designed to illicit
results concerning professional demographics, professional training in NSSI, perceptions
55

of the role of principal in addressing NSSI, and perceptions of adolescent females who
engage in NSSI behaviors. The online survey will also seek to examine what actions are
taken by principals once a student who engages in NSSI is identified. The scope of the
survey is designed to encompass a wide range of demographics, principal age groups,
experience, and professional training. Phase II, the interview process, will be qualitative.
It will continue to examine the role of the middle school principal in addressing non-
suicidal self-injury among pre-adolescents and early adolescent females ages 10-14.
With a sample size of ten-fifteen middle school principals from different schools and
districts, it will seek to further clarify the perceptions of the role of the principal in
addressing NSSI, the perceptions of students who engage in NSSI, and the actions
principals feel they currently take in addressing NSSI in their schools. The results of
Phase I and II will be combined during the analysis portion of the study.
The timeframe of the study will be from late winter 2014 to early spring 2014.
Risks: There are no known risks and/or discomforts within this study. Since
participation is voluntary, participants may identify possible risks or discomfort factors.
Freedom to withdraw: Participation is voluntary. Therefore, any principal who is
contacted by the researcher has the right to decline participation. Furthermore, at any
point in the research, the participant has the right to withdraw from the study.
Confidentiality, Privacy, and Anonymity: All participants have the right to remain
anonymous. If you elect to remain anonymous, all of your records will be kept
confidential and private to the fullest extent of the law. Coding of responses will protect
your anonymity. For those participants who choose to identify themselves to the
researcher but wish to have their information remain confidential, coding will also serve
to protect your confidentiality. Any identifying private information will not be used in
the published manuscript. If you do not choose to be anonymous, you may authorize the
researcher to use material that may identify you as a subject in the study.
Compensation: You will not receive monetary compensation for your participation in
this study. Upon request, you may receive a summary of results for your use after the
study is complete and approved.
Opportunity to ask Questions: Should you have any questions or concerns prior,
during, or following this study, please contact me at 617-390-5149 or
tkfoury@arlington.k12.ma.us.
If you wish to contact the Senior Advisor, Judith Conley, you may do so at
1-800-999-1959 ext. 8144; 617-349-8144, or jconely@lesley.edu.
If you have any questions concerning your participation rights, the Lesley University
Institutional Review Board (IRB) may be contacted at irb@Lesley.edu.
Consent: Your signature below signifies that you have read and understood the
56

information that was presented to you. By signing on the line below, you are consenting
to participate in this study.
Signature and Names:
1. Phase I (Online Survey):
Name _________________________________
Signature: _____________________________
2. Phase II (Interview):
Name _______________________________
Signature: ____________________________
Contact Information:
Phone Number__________________________________________________________
Email:
_______________________________________________________________________
There is a standing committee for human subjects research at Lesley University, if ethical
problems should arise. Please contact Lesley University at irb@Lesley.edu to report
concerns.
57

Appendix E. Institutional Review Board Approval
58

Appendix F: Survey Instrument
The Role of the Middle School Principal in Addressing Non-Suicidal Self-Injury
(NSSI) Among Adolescent Females ages 10 to 14 years old.
Place an “x” besides the statement that best describes you and the school you
administer.
Which classification best describes your school’s community?
______ Urban (50,000+ people) ______ Suburban (2,00-50,000 people)
________ Rural (0-2,500 people)
How many students are currently enrolled in your school?
_______0-500 ______ 501-1000 ______1001-1500 ______ 1501-2500
other (please define) _____________
How would you describe your school?
_______ private _______ charter ________ regional public
_______ neighborhood public other (please
define)_______________________
What is the grade configuration of the school you administer?
_______ K-8 _______5-8 _______ 6-8 other (please define)
_______________________
How would you describe yourself?
_______ male ________ female _________ transgender (mtf)
________transgender (ftm)
How many years have you served in your current administrative position?
_______ 0-2 ________ 3-5 ________6-10 ________10-15 ________ 16+
59

How many years have you served as an administrator in your career?
_______ 0-2 ________ 3-5 ________6-10 ________10-15 ________ 16+
How many years have you served in 6-8 education?
______ 0-4 ________ 5-10 _______ 11-15 ________ 16-
20
________ 21-34 _________ 35+
What is the highest level of education you have attained?
_____Bachelors ________ Masters ________ C.A.G.S
________Ed. D.
_______ Ph.D. other (please define)
___________________________________
Non-suicidal self-harm, or NSSI, is described as the “purposeful, direct destruction of
body tissue without conscious suicidal intent” (American Psychiatric Association, 2012).
Acts of NSSI are intentional self-inflicted wounds on the surface of the body, most
commonly on inner thighs, arms, and stomachs. Such injuries are committed to induce
bleeding, bruising, or pain on a minor or moderate scale (APA, 2012).
Mark the number that best reflects your opinion on the following statements.
1. Strongly Agree 2. Mostly Agree 3. Agree
4. Mostly Disagree 5. Strongly Disagree
STATEMENTS
RATING
1. NSSI is an abnormal developmental stage in a pre-adolescents life.
2. Female students who engage in NSSI are violent.
3. Female students who engage in NSSI are usually low performers in school.
4. NSSI primarily affects female students with other problems like drugs,
smoking and
other negative behaviors.
60

5. Female students who engage in behaviors of NSSI learn such behaviors from
their friends
or other family members.
6. Female students are more likely to engage in behaviors of NSSI in order to fit
in with
their friends.
7. Female students are more likely than male students the same age to engage in
behaviors
of NSSI.
8. I am currently responsible for reporting the necessary information which
highlights the
status of students who engage in behaviors of NSSI to the Massachusetts
Department of
Elementary and Secondary Education (DESE) and other state agencies.
9. I believe I am unable to thoroughly address the needs of female students
suspected of
engaging in behaviors of NSSI.
10. Female students who engage in NSSI behaviors will stop on their own
without receiving
any therapeutic help.
11. Female students who have been physically or sexually abused are more
likely to engage
in NSSI.
12. Female students who engage in behaviors of NSSI are dramatic, often
exaggerating life
issues.
61

STATEMENT RATING
13. Injuries stemming from NSSI are not severe enough to warrant immediate
attention
from school administration.
14. NSSI is a family issue and should not to be addressed by school
administration.
15. There are no effective treatments for a student with NSSI.
16. A female student who wants help for her NSSI behaviors would seek out her
administrator or guidance counselor.
17. Teachers feel comfortable approaching me with a potential case of NSSI
among the
student population.
18. I am aware of the number of incidents of NSSI among the female pre-
adolescent
population of my school.
19. Female students who engage in NSSI are non-athletes and do not engage in
extra-
curricular activities.
20. Female students who are not necessarily considered pretty or popular by
peers, or
active in school are more likely to engage in NSSI.
21. Female students engage in NSSI as a cry for help.
22. Parental involvement is an essential part of the NSSI intervention and
prevention
process.
23. Grade-level presentations on NSSI, the behaviors of NSSI, and the signs to
look for NSSI
in others should be provided to the students.
24. It should be mandatory for staff to learn about NSSI, NSSI behaviors, how to
identify a
student who engages in NSSI.
STATEMENT RATING
62

25. Female students that engage in NSSI will attempt suicide.
26. Female students who engage in behaviors of NSSI suffer from moderate to
severe
mental illness.
27. It is a role of the principal to prevent NSSI behaviors within the student
population.
28. It is part of the role of principal to create prevention protocols for students
who engage
in NSSI.
29. Female students who feel shame, anger, or sadness engage in behaviors of
NSSI.
30. Female students of divorced, separated, or single parent homes are more
likely to
engage in behaviors of NSSI
31. I act as the leader of a crisis or intervention team once a female student is
identified as
engaging in behaviors of NSSI.
32. I act more as a facilitator in the NSSI intervention process for students.
33. In my administrative program and/or graduate studies, I have received
training that is
necessary to handle student distress like student engagement in behaviors of
NSSI.
34. I have received on-the-job training in NSSI as a principal.
35. There are programs available to administrators providing updated training on
NSSI.
36. During my experience as principal, I have continued to update my
knowledge of NSSI on
my own.
STATEMENT RATING
37. Outplacement of students who engage in NSSI behaviors is the solution.
38. Students who engage in NSSI must be isolated from their peers immediately.
39. Students who engage in NSSI are to be enrolled in a prevention program.
40. Students who engage in NSSI should have a mandatory psychological
evaluation.
41. Staff should be aware of the protocol for alerting administration and/or
guidance if a
student is suspected of engaging in NSSI behaviors.
42. I am aware of the number of incidents of NSSI among the female pre-
adolescent
63

43. I am knowledgeable of the signs of NSSI behavior.
44. It is part of the role of principal to identify students who engage in NSSI
behaviors.
45. It is part of the role of principal to intervene when I believe a student is
engaging in
NSSI behaviors.
46. I allow guidance to address NSSI among female students while maintaining
communication with me abut the students.
Thank you for your time and effort in completing this survey.
After completing this survey, use the self-addressed envelope provided and mail to:
Tara Kfoury
25 Cowing Street
or email
tmcclosky@hotmail.com or tkfoury@arlington.k12.ma.us
Appendix G: Interview Questions
Open ended questions.
What actions have you taken as a principal in order to address NSSI behaviors among the
pre-adolescent female population in your school?
(Please specify your role in the identification, intervention, prevention, and reporting
64

of NSSI among the female student population)
What type of training have you received in regards to the identification, prevention, and
reporting of NSSI among female adolescents ages 10 to 14 years old?
What type of training do you feel middle-school principals should have in order to
effectively address NSSI among female adolescents ages 10 to14 years old?
What role do you feel a principal plays in the identification, intervention, prevention, and
reporting of NSSI among the female student population in middle school?
65

Appendix H: Data Tables
Table 3.1 Participant Demographics, Professional History, and Educational Training
1. Which classification best describes your school’s community?
2. How many students are currently enrolled in your school?
3. How would you describe your school?
4. What is the grade configuration of the school you administer?
5. How would you describe yourself? (gender)
6. How many years have you served in your current administrative position?
7. How many years have you served as an administrator in your career?
8. How many years have you served in 6-8 education?
9. What is the highest level of education you have attained?
Table 3.2 Participant’s Perception of Middle School Principals regarding their role in addressing NSSI.
1. Injuries stemming from NSSI are not severe enough to warrant immediate attention
from school administration.
2. NSSI is a family issue and should not be addressed by school administration.
3. Teachers feel comfortable approaching me with a potential case of NSSI among the
4. Parental involvement is an essential part of the NSSI intervention and prevention
process.
5. Grade-level presentations on NSSI, the behaviors of NSSI, and the signs to look for
NSSI in others should be provided to the students.
6. It should be mandatory for staff to learn about NSSI, NSSI behaviors, and how to
identify a student who engages in NSSI.
7. It is a role of the principal to prevent NSSI behaviors within the student population.
8. It is part of the role of the principal to create prevention protocols for students who
engage in NSSI.
9. I act as the leader of a crisis or intervention team once a female student is identified
as engaging in behaviors of NSSI.
10
.
I act more as a facilitator in the NSSI intervention process for students.
11
.
Staff should be aware of the protocol for alerting administration and/or guidance if a
student is suspected of engaging in NSSI behaviors.
12
.
It is part of the role of principal to identify students who engage in NSSI behaviors.
13
.
It is part of the role of the principal to intervene when I believe a student is engaging
in NSSI behaviors.
14
.
I allow guidance to address NSSI among female students while maintaining
communication with me about the students.
Note: The order the questions are in the table above does not correspond to the survey instrument. Instead,
the questions are grouped to reflect the Research question addressed.
66

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