FINALDISSERTATION

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 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
August 2015
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 Presented
By
Tara M. Kfoury
Approved as to content and style by:
_________________________________ __________
Dr. Stephen Gould, Ph.D., Senior Advisor Date
------------------------------------------------ ---------------
Dr. Sidney Trantham, Ph.D., Member Date
------------------------------------------------ ---------------
Dr. William O’Flanagan, Ph.D., Member Date
2

TABLE OF CONTENTS
Dedication 5
Acknowledgements 6
Abstract 7
CHAPTER ONE: INTRODUCTION 8
Statement of the Problem 12
Purpose of the Study 21
Definition of Terms 23
Significance of the Study 23
Delimitations of the Study 24
Design of the Study 25
Pilot Study 28
Data Analysis 28
Chapter Outline of the Dissertation 31
CHAPTER TWO: LITERATURE REVIEW 33
Introduction 34
History of Non-Suicidal Self-Injury 35
Pathology of Self-Injury 36
Treatment & Prevention Approaches 40
Program Evaluations 43
Other Pathological Concerns
47
Social Contagion 48
Historical Perspective of the Principalship 52
Role of the Principal 52
Failure to Include Psychological Indicators in Principal 54
Responsibilities
Training with Principals at the Helm 55
Lack of Course Offerings 57
Obstacles in Addressing NSSI in Middle School
59 Lack of Evidence-Based Programs
60 Specific Training for Principals
62
Student Engagement in NSSI 64
The Failure to Realize the Severity of NSSI 66
Factors that Impede a Principal’s Role in Addressing NSSI 67
Conclusion
68
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CHAPTER THREE: RESEARCH DESIGN AND METHODS 71
Introduction 71
Selection of Participants 71
Design Strategy 73
Instrumentation 74
Role of the Researcher 75
Methods and Procedures
77 Confidentiality Efforts
88 Chapter Summary
89
CHAPTER FOUR: FINDINGS AND ANALYSIS 91
Introduction 91
Research Question One: To what degree do middle school
Principals consider non-suicidal self –injury among
adolescent females ages 10 to 14 years old. 93
Research Question Two: What are the various ways middle
school principals report they are addressing non-suicidal
self-injury among adolescent females? 120
Research Question Three: What are the factors and conditions
that middle school principals believe inhibit and support their
efforts to address NSSI among pre- and early adolescent females? 138
Chapter Summary 161
CHAPTER FIVE: SUMMARY AND IMPLICATIONS 163
Introduction 163
Overview of the Study 163
Key Findings
166
Implications for Principals and Other School Leaders 173
Future Research
179
Final Reflections 184
REFERENCES 190
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APPENDICES
Appendix A - Participant Letter 198
Appendix B – Follow-up Email 199
Appendix C – Letter of Consent 200
Appendix D – Survey Instrument 203
Appendix E– Interview Questions
208
Appendix F – Data 209
DEDICATION
To Rich, Elizabeth & Ava, all my love forever.
Thank you Mommy.
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ADDRESSING NON-SUICIDAL SELF-INJURY 6

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, Stephen Gould, and William 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. 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, 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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CHAPTER ONE: INTRODUCTION
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-
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suicidal self-injury among female students. The primary focus of this dissertation is to
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.
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). Non-suicidal self-injury is described as the
“purposeful, direct destruction of body tissue without conscious suicidal intent”
(American Psychiatric Association, 2012). NSSI is deliberate, self-inflicted destruction
of body tissue without suicidal intent and for purposes not socially sanctioned (ISSS,
2007). Seventy-seven percent of the participants who reported self-injury were female
(Nixon et al., 2008). Unfortunately, this phenomenon remains fairly undocumented
across many fields of study.
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). Crosby, Ortega, and
Melanson (2011) define suicide as “death caused by self-directed injurious behavior with
any intent to die as a result of the behavior” (p. 11).
Examples of NSSI include more private, often hidden examples of body tissue
mutilation such as cutting, burning, scratching, biting, self-bruising, and breaking of
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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 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
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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
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).
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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
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
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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
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
17

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
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,
18

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
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
19

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
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
20

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
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
21

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
(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 was 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
existed 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
22

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 examined the
contemporary role of the middle school principal in the identification, intervention, and
prevention of NSSI among female adolescents. It explored the actions principals take in
order to address NSSI among their female students ages 10-14. It analyzed the
perceptions held by principals about NSSI and the female student population who engage
in its behavior. Lastly, this study determined whether there were significant differences
in the perceptions of middle school principals in regard to the role he or she played in
preventing NSSI among the female student population.
Three research questions framed the study in order to examine the perceived role
of the middle school principal in addressing NSSI among female students ages 10 to 14.
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
or support their efforts to address NSSI among pre- and early adolescent
females?
Definition of Terms
For the purpose of the current study, the researcher is defining relevant terms and
concepts as follows:
23

 Perception is defined as the way of regarding, understanding, or interpreting something;
a mental impression. (google.com)
 Middle School Principal is defined as the head or director of a school that includes
grades 5 to 8 (dictionary.reference.com).
 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).
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-years-old 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. Data will be significant to
24

practitioners, researchers, policymakers, and educational organizations. 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.
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-old. 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. It does not include elementary or high 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 was a phenomenological study with a 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
The researcher solicited the participation of 150 middle school principals
25

throughout Massachusetts. This number was calculated in order to 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. The follow-up interview process included a minimal sample size of 8
principals. There was 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.
Instrumentation
The online electronic survey, which utilizes a Likert attitude inventory, was the
quantitative instrumentation used in this research. The Likert attitude inventory was
developed using a Google document survey tool in order to ensure confidentiality and
provide a uniform survey designed to gather information in an efficient manner. It was 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 was qualitative in the form of phone
interviews. The researcher used a designated script and previously designed interview
questions for the interviews.
Data Collection Process
This study used a Sequential/Concurrent mixed methods approach, using both
qualitative and quantitative data collection tools. The quantitative research method
26

utilizing a Likert scale inventory survey was the primary data collection method and the
qualitative research method of phone interviews was secondary. Through the use of a
mixed-methods approach, greater confidence in the accuracy of the research findings was
achieved since two research strategies were used to analyze the same topic (Denscombe,
2011). Due to the combined use of two strategies, a mixed-methods approach provided a
well-developed perspective on the role of the principal in addressing NSSI based on self-
reported perceptions.
The invitation to participate in the study was sent electronically to 150 middle
school principals throughout Massachusetts. The electronic letter identified the
researcher, stated the purpose of the study, discussed the anonymity of the participants,
the time required for the completion of the online questionnaire, and how subject
responses were maintained in terms of confidentiality. Additionally, in order to
encourage greater participation, the letter also discussed the possible outcomes the study
may yield upon its completion.
The Likert inventory collected 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 illuminated a lack of training on NSSI during the
same administrator’s educational experience. Secondly, the Likert scale compared the
perceptions of NSSI held by current principals across Massachusetts. Third, it revealed
principal-held perceptions of female students that engage in NSSI behaviors. Fourth, the
survey instrument examined any actions taken by current middle school principals in
reaction to the discovery of students who engage in NSSI behaviors. Lastly, the study
determined what role middle school principals currently believe they play in regards to
27

the identification, intervention, and prevention of NSSI among their female students ages
10 to 14.
The researcher did not investigate the reasons for the responses given by the
middle school principals’ who participated in the study. The researcher simply identified
their perceptions and examined those responses for themes and patterns. Additionally,
the Likert attitude inventory provided questions for the interview process.
The interviews were conducted over the phone, with one face-to-face interview,
using a scripted introduction to ensure continuity when providing participants with the
context of the follow-up interview. All interviews were recorded which allowed greater
accuracy by the researcher when analyzing responses. The recorded experiences
attempted to determine what may have led to the perceptions of the role a principal plays
in addressing NSSI.
28

Pilot Study
An initial pilot study was conducted using both the Likert attitude inventory and
interview questions on current middle school principals currently enrolled in the
Educational Leadership Program 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 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.
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. 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. The Pilot Study will be discussed in greater detail in
Chapter Three.
Data Analysis
Analysis of the collected data was ongoing. The researcher coded and analyzed
the quantitative results given from the online questionnaires using a data research
computer program as soon as the completed surveys were available. Since this is an
emerging subject area, attempts at designing codes were made using a combination of
codes that were generated through recent studies of NSSI within education, psychology,
29

and other behavioral sciences.
The researcher recorded each interview using Evernote, an online application, to
record the interviews. This ensured greater accuracy of results gathered from each
interview. Once all interviews were completed, the researcher alone reviewed the
responses specifically for patterns and themes that emerge from participants’ answers.
Similar to quantitative data analysis, a computer program was used in the analysis of the
qualitative information in order to identify emerging patterns, trends, or themes. Such
patterns were abstract and attempted to highlight the perceptions held by principals in
regards to NSSI, females who engage in NSSI behaviors, the role a principal 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.
The joint analysis of demographic information with the Likert scale inventory
explored any possible similarities or differences between rural, suburban, and urban
middle schools concerning the occurrence of NSSI and the reporting of NSSI. The
analysis examined the role of the principal in the identification, intervention, and
prevention of NSSI, compared education levels, and career experiences. Matrices were
constructed from the data and were used to further define patterns, themes, or concepts
gathered from the data collected. The researcher performed periodic reviews of the data
collected and any further questions or inquiries were noted for later review. In addition,
the researcher conferred 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. Data Analysis will be discussed in greater detail in
Chapter Four.
30

Throughout data collection and analysis processes all information was
confidential, properly stored in a locked cabinet drawer, and will be 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.
31

Chapter Outline
This dissertation is 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 present the research questions, the significance of the study, 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
schools. This literature review will provide a conceptual base for this research.
32

Chapter 3 will summarize the research method and procedures, 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, a rationale for the design type
chosen, 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 an organizational 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, reinforce its significance, and conclude with final
reflections.
33

CHAPTER TWO: REVIEW OF THE LITERATURE
A nice deep gash
To change my pain.
My heart hurts no more,
Solid as rock
Scars lining my skin
To forget my emotions
My pain inside
Shows on the outside
No tears in my eyes
Blood drops streak my sin
Those trusty scissors
Make me alive again
-Anonymous (Nixon & Heath, 2009)
34

Chapter Two presents a literature review regarding: a) Non-Suicidal Self-Injury
and b) the development of the role of Principal in education. This chapter is divided into
subheadings that provide a foundation of Non-Suicidal Self-Injury as well as a historical
timeline of the role of Principal. The subheadings for self-injury include: a) History of
NSSI, b) Pathology of NSSI, c) Treatment and Prevention Approaches, d) Program
Evaluations, e) Other Pathological Concerns, and f) Social Contagion. The subheadings
for the development of the role of Principal are: a) The Historical Perspective of the
Principalship, b) Role of the Principal, c) Failure to Include Psychological Indicators in
Principal Responsibilities, d) Training with Principals at the Helm, e) Lack of Course
Offerings, f) Obstacles in Addressing NSSI in Middle School, g) Lack of Evidence-Based
Programs, h) Specific Training for Principals, i) Student engagement in NSSI, j) Failure
of Principals to Realize the Severity of NSSI, and k) Factors that Impede the Principal’s
Role in Addressing NSSI. The Conclusion will summarize the literature presented
regarding the development of the principalship in education. It will present a brief
overview of the information regarding NSSI and the factors that contribute to the success
or failure of principals when addressing NSSI in school. Lastly, it will reinforce the vital
need of principals to stay informed on the factors and behaviors of NSSI during the pre-
and early adolescent years.
Data collected in recent years shows an increase in the cases of non-suicidal self-
injury (NSSI) in schools (Nixon & Heath, 2009). Briere and Gil (1998) estimated that
four percent of the general population engaged in self-injury. Sax (2010) found the rate
of self-injury among female adolescents attending middle through high school to be at a
rate of 23.4 percent, almost twenty percentage points higher than the general population
35

twelve years prior. Yet, knowledge of what NSSI is, what it means to engage in NSSI
behaviors, how to react to a student who engages in NSSI, and when and how to
intervene are questions that remain challenging. As Nixon and Heath (2009) state:
“Working with youth who self-injure often means that clinicians, mental health
professionals, school counselors, teachers, and youth workers alike are faced with the
challenge of how best to understand the behavior and intervene” (p. 2). Since many
researchers have shown that students who engage in NSSI are among the most difficult to
reach (Adler & Adler, 2007; Nixon & Heath, 2009; Sax, 2010), there remains a great
need for education and guidance in dealing with self-injury in school.
History of Non-Suicidal Self-injury
Self-mutilation has been documented throughout history. Whether performed
during cultural ceremonies or rituals of passage, self-injury has served a purpose for
multiple cultures worldwide. Body modification rituals, as described by Favazza (1989),
occurred as far back as the Olmec, Aztec, and Mayan civilizations. Depictions of self-
mutilation can be seen in Greek, Roman, and Japanese artifacts and writings (Favazza,
1989). Passages in the Koran and the Bible tell of sinners who were forced to punish
themselves with the removal of limbs, tongues, or eyes (Favazza, 1989). Ancient
illustrations demonstrate the willingness of many Christians to self-punish through
whippings, starvation, even the cutting of their veins in order to eradicate “evil” from
their bloodstream (Milia, 2000, p.17). Indigenous funeral rites from Australia to North
America included acts of self-mutilation in order to provide blood for the mystic life-
union (Milia, 2000).
The practice of self-injury can be seen in modern day rituals of various cultures
36

around the world as well. Ritual self-injury is viewed as part of ritual of becoming and
belonging to a larger community (Korn, 2013). In shamanic societies, those men and
women who desire to become leaders of the community would have to endure great pain
and self-injury to demonstrate their worthiness for the communal position (Milia, 2000).
Christian, Jewish, and Muslim men are willingly circumcised for their faith (Korn, 2013).
Although females in Africa have their genitalia cut against their will, it is culturally
endorsed (Korn, 2013). Members of the Lakota community continue to engage in the
practice of self-injury during the Sundance ceremony, ranging from piercings of the skin
to the insertion of sharpened sticks through the flesh (Milia, 2000). Such acts of self-
mutilation hold reverence and meaning for the cultures that commit the behaviors. They
are considered to be acts of bravery and courage. The ceremony itself is considered a
religious and purifying rite of passage in the Lakota Indian Community, one that
represents the giving of one’s body to the sun (Korn, 2000). This is a very different
phenomenon than the NSSI behaviors identified in middle schools today.
Pathology of Self-Injury
Milia (2000) considers self-injury to be pathological when the actions become
individualized and lack aesthetic, ritualistic, or cultural meaning for a community.
Favazza (1998) classified self-mutilation into two categories: culturally sanctioned acts of
self-mutilation, and deviant-pathological self-mutilation (p. 20). The initiation of the
shaman is believed to help maintain order within a society (Favazza, 1998). The Lakota
Sundance and the Aztec rites of purification are considered culturally sanctioned acts of
self-mutilation. In contrast, many contemporary means of self-injury Favazza (1998)
defines as pathological self-mutilation. This is the deliberate alteration or destruction of
37

body tissue without conscious suicidal intent (Favazza, 1998). The motivation for self-
injury determines if the actions are culturally sanctioned or maladaptive coping strategies.
Unlike culturally sanctioned acts of self-mutilation, non-culturally sanctioned acts of self-
mutilation are completed in secrecy, often hidden from medical, clinical, and academic
persons. Such acts are motivated by a need for security, escape, enhanced sexuality,
euphoria, emotional release, and impassivity, among others (Favazza, 1998). This form
of self-injury is intentional with low-lethality bodily harm performed to reduce and/or
communicate psychological distress (Walsh, 2012).
The evolution of the language used to refer to such behaviors like cutting,
burning, hitting, scratching, and other self-injurious behaviors has changed over time.
What was once referred to as “self-mutilation” (Favazza, 1998; Milia, 2000; Walsh,
2012), is now termed “self-harm,” “self-injury, ” or “non-suicidal self-injury” (Walsh,
2012, p. 3).
According to the International Society for the Study of Self-Injury (ISSS, 2013)
non-suicidal self-injury (NSSI) is described as the “purposeful, direct destruction of body
tissue without conscious suicidal intent” (para. 2). It is the deliberate, self-inflicted
destruction of the body without suicidal intent and for purposes not socially sanctioned
(ISSS, 2013). NSSI can be demonstrated as cutting, burning, branding, scratching, or
biting of the flesh (ISSS, 2013; Nixon & Heath, 2009; Sax, 2010). Head banging,
breaking of bones, and other methods of self-mutilation can also be practiced by
individuals (ISSS, 2013; Nixon & Heath, 2009; Sax, 2010). Although the physical harm
may vary significantly, the intent is to commit bodily harm (Knock & Favazza, 2009).
Favazza (1998) distinguished “superficial/moderate self-mutilation” to involve injury to
38

the skin surface such as cutting or branding. More severe self-mutilation, such as
castration or puncturing, goes below the top layer of the skin and may require medical
attention with the resistance from the victim (Adler & Adler, 2007; Favazza, 1998; Heath
et al., 2010).
Individual desires to avoid medical treatment may stem from multiple areas of
concern. A pre-adolescent or adolescent female may feel a sense of shame after
committing self-injuries (Milia, 2000). This shame may manifest itself as a result of
engaging in behavior that is considered deviant by society (Milia, 2000). Most pre-
adolescent and adolescent females desire to remain anonymous out of fear of how others
will perceive them and their injuries (Nixon & Heath, 2009).
Moderate to superficial injuries stemming from self-injury may be the result of
impulsive behaviors in response to bodily or cognitive urges (Nixon & Heath, 2009).
Such behaviors tend to be repetitive and compulsive in nature, often using the same
method of self-harm each time (Nixon & Heath, 2009). Some authors posit that acts of
self-injury serve as a form of emotional release or a relief from tension or anxiety (Nock
& Prinstein 2005; Juhnke, Granello & Granello, 2011; Nixon & Heath, 2009; Sax, 2010).
Some students satisfy sexual urges through the use of self-harm. Milia (2000) compares
the function of fetish with a body part to that of the function a wound may play on an
adolescent’s body. Milia (2000) believes that a wound may become the concentrated
object of erotic fascination and fixation, causing the individual to sustain the injury
through further mutilation. Even still, some engage in NSSI to attain a euphoric high.
Scaer (2007) stated: “The brain/biochemistry link in this behavior is quite analogous to
the brain biochemistry of narcotic addition that simply substitutes synthetic morphine
39

derivatives for the brain’s natural endorphins” (p. 133). All four identified reasons for
engaging in behaviors of NSSI also serve to explain why NSSI may be addictive to some
individuals (Nixon & Heath, 2009; Nock & Prinstein, 2005; Milia, 2000; Sax, 2010;
Scaer, 2007).
Prior to 1990, little was known about pathological self-injury outside of clinical
patients. Most literature involved in-patients who self-injured as an expression of a
comorbid disorders like bipolar disorder or schizophrenia (Adler & Adler, 2007).
However, Favazza and DeRosear (1989) suggested that since the dawning of Internet
websites and portrayals of NSSI in books, movies, television shows, awareness of NSSI
among the general populations has increased. Research has shown that NSSI behaviors
manifest in early adolescence (Favazza & DeRosear, 1989; Heath, Schaub, Holly, &
Nixon, 2009; Sax, 2010). As awareness of NSSI grows, more cases of female
adolescents who engage in NSSI are recognized, creating a greater need for
identification, intervention, and prevention protocols to be established, implemented, and
supported by the middle school.
Self-injury is difficult to treat clinically since most of the behavior is done in
secret with little to no intent for anyone to see but the self-injurer (Favazza, 1998; Nock
& Favazza, 2009; Milia, 2000; Sax, 2010). It becomes even more difficult when there is
little to no evidence-based information that directly deals with how to identify, intervene,
and prevent NSSI among pre-adolescent and adolescent females (Nixon & Heath, 2009).
Presently, there are no evaluated prevention initiatives specific to NSSI in a school
setting (Adler & Adler, 2007; Nixon & Heath, 2009). Much of the literature on self-
injury stems from clinical, psychiatric, and medical perspectives, creating a vacuum of
40

knowledge on victims not currently under medical care (Adler & Adler, 2007). NSSI is
listed by the DSM-IV-TR as a symptom of borderline personality disorder (Bowman &
Randall, 2012). However, Bowman and Randall highlighted that other adolescents with
NSSI may suffer from anxiety, depression, substance abuse, eating disorders, and post-
traumatic stress among others. Many of the adolescents who experience these illnesses
do not seek medical attention, proliferating the vacuum of knowledge on NSSI.
Treatment & Prevention Approaches
To remedy the current situation, researchers have been examining prevention
programs aimed at curbing other maladaptive behaviors. The effectiveness of suicide
prevention programs in schools is being examined in an attempt to design a preventative
program that specifically addresses NSSI behaviors (Bowman & Randall, 2012). A
major concern for educators when implementing a prevention program in school,
especially one that lacks program specificity like NSSI, is the need for containment of the
harmful behavior. Copycat behavior is common in middle school children since
adolescents look to peers for guidance on what constitutes socially acceptable behaviors
(Juhnke et al., 2011; Nixon & Heath, 2009). A student self-injurer has the potential to
encourage NSSI behaviors as a means of passage into a group or a close friendship
(Juhnke et al., 2011; Nixon & Heath, 2009). Students who self-injure may discuss NSSI
behaviors with other students, possibly triggering further self-injury in each other (Walsh,
2012). Juhnke et al. (2011) stress that although adults are hesitant to engage students in
conversations around NSSI, it is important to create awareness and connectedness of the
faculty to the student body. When implementing such prevention programs,
administrators, teachers, and staff members must be vigilant in preventing the spread of
41

copycat behaviors. Juhnke et al. (2011) provide several suggestions for strategies that
may be helpful when attempting to keep copycat behaviors to a minimum:
1) Working with NSSI to limit their communications with peers about their behavior
2) Making sure teachers or other school staff do not comment on any individual’s NSSI
behavior in front of groups of students
3) Refraining from group treatment or support group interventions for NSSI youth
4) Developing school policies on the use of Facebook or other social media (Juhnke et
al., 2011, p. 96).
Intervention and prevention programs can be designed as “universal,” “selective,”
and “targeted” (Juhnke et al., 2011, p. 97; Whitlock & Knox, 2009, pp 183-184).
Although there are no current prevention programs designed specifically for NSSI, such
behaviors are detailed under the prevention programs of other anti-social behaviors and
suicide prevention (Nixon & Heath, 2009). A universal prevention program is directed at
the entire school population and focuses on the development of healthy coping skills,
stress management, emotional regulation skills, relaxation skills, emotional
communication skills, and problem solving skills as a school community (Juhnke et al.,
2011). This approach targets an entire population regardless of the level of risk for
negative behaviors within the population, although some may be at risk due to their
individual circumstances (Nixon & Heath, 2009). Universal prevention programs are
designed to create awareness of harmful behaviors and aim to change group norms,
policies, or practices that may unwittingly cultivate such negative behaviors (Nixon &
Heath, 2009).
Throughout the year, schools often try to expose students to healthy media
42

literacy, provide coping skills training within the common curriculum, and encourage
open communication between faculty and students (Nixon & Heath, 2009). Health
education lessons can reinforce essential coping skills presented in the universal program
as well as raise student awareness of NSSI behaviors. Prevention programs provide
opportunities to increase student knowledge of mental illness and self-harm, external
environments and self-harm, external and internal factors that may influence acts of self-
harm, neurobiological abnormalities and self-harm, and family and/or peer history and
self-harm (Carlson, 2013). Additionally, such programs may address personal social
skills, academic accountability, failure to attend school, depression, and other
psychological behaviors that can impact students who self-harm (Fennig, Carlson, &
Fennig, 2013). Through education, students can gather important resources that may be
needed to seek help for herself or another student (Fennig et al., 2013).
Peers often know about classmates’ self-injuries before staff members do
(Marachi, Astor, & Benbenishty, 2007; Muehlenkamp et al., 2010). Raising awareness
and encouraging open and safe communication with adults is essential for the success of
prevention programs. Similar to public education campaigns aimed at recognizing
suicidal risk, students may benefit from understanding the causes and risk factors for
NSSI (Mann, Apter, Bertolote, & Beautrais, 2005). In order for universal programs to be
successful, a school must address the issue of NSSI multiple times throughout the school
year (Junke et al., 2011). There are limited evidence-based studies connecting the
exposure to prevention programs to a large decrease in harmful behaviors (Fennig et al.,
2013). However, the exposure to prevention programs may communicate to the students
that engagement of NSSI does not solve the underlying problems that exist (Fennig et al.,
43

2013).
Juhnke et al. (2009) do not believe this type of exposure would be effective in
preventing NSSI among large proportions of adolescents. Prevention research in the
mental health arena has struggled to ensure that interventions are theoretically and
empirically tied to known risks in order to maximize healthy outcomes and minimize
negative outcomes (Mann et al., 2005; Nixon & Heath, 2009). A systematic review
performed of studies published from 1990-2002 found that curriculum-based programs
increased knowledge and attitude toward mental illness yet found little impact on the
prevention of self-harming behaviors (Mann et al., 2005). Research by Mann et al.
(2005) and Nixon and Heath (2009) found that improving problem solving, coping skills,
and help-seeking behaviors enhance possible protective factors however the authors note
that the reduction of NSSI among youths remains unevaluated.
Program Evaluations
Models like Levine and Smolak’s (2006) non-specific vulnerability-stressor
model (NSVS) combine empirical and theoretical knowledge about adolescent
development and social/emotional/environmental causes of antisocial behaviors. Unlike
other universal prevention programs, NSVS alters the arrangement of information
depending on age group, behaviors being addressed, and essential life skills in which the
audience can grasp and practice after the program is finished (Juhnke et al., 2011).
NSVS uses empirical studies to teach families, students, groups, and staff members’
essential life skills for coping for stress, creating opportunities for success (both at home
and in school), nurturing feelings of competence, and increasing social connectedness to
the school environment (Juhnke et al., 2011).
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Mann et al. (2005) evaluated the appropriateness of the Gatekeeper program for
the prevention of suicide and other maladaptive behaviors, including NSSI, among
adolescent audiences. Gatekeeper programs are designed to increase identification of at-
risk individuals and refer them to appropriate assessment and treatment (Mann et al.,
2005; Wyman, Brown, Inman & Cross, 2008). Whitlock and Knox (2009) explain the
possibility of using “gatekeepers” (p. 185) from the U.S. Air Force (USAF) Suicide
Prevention Program within schools. To Whitlock and Knox (2009) school staff receive
specific Gatekeeper training in the identification of self-harming behaviors and potential
risk factors. In turn, educational leaders can begin the process of initiating the school-
sanctioned protocol for NSSI (Mann et al., 2005; Whitlock & Knox, 2009). With
training, gatekeepers may be able to create policy changes to encourage help-seeking
behaviors, create a resource database for students, reduce the perceptions a school
community may have toward those that self-harm, and reach out to those individuals in
need. According to Mann et al. (2005) the aspect of a universal program such as the
gatekeeper program may be implemented in the middle schools since students and
teachers are aware of those who self-injure often before administration or guidance.
USAF and other clinical institutions have also instituted a buddy system, if a
Gatekeeper program is not ideal for a particular middle school setting. In this system, all
students, staff, and administrators would be trained to recognize the early warning signs
and symptoms of a student who may be harming herself. This program has raised
awareness of self-harm and self-harm in others. To Whitlock and Knox (2009) the
universal training has provided opportunities for connectedness with peers as well as
creating a sense of community, a sense of unity. Although Whitlock and Knox (2009)
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reported that the USAF has seen an increase in help-seeking and lower risks of self-harm
since the introduction of the buddy system, to date, there have been few buddy systems
initiated in school settings. This provides limited knowledge on the success rates of its
design for early adolescent and adolescents (Mann et al., 2005).
In recent years many schools have initiated programs like Signs of Self-Injury
(SOSI), which employs the acronym ACT “Acknowledge the signs, demonstrate Care
and a desire to help, and Tell a trusted adult” in its lessons (Lieberman, Toste, & Heath,
2008, p. 198). This program is designed to provide adolescents with the knowledge,
skills and confidence to reach out to peers, guidance counselors, teachers, administrators,
and family members. Through video demonstrations, students learn to recognize the
warning signs of NSSI, understand increased risk factors, diminish stigmas associated
with NSSI, and increase reporting and help-seeking techniques (Muehlenkamp, Walsh, &
McDade, 2009; Whitlock & Knox, 2009). Unlike other universal programs, SOSI is a
program designed to encourage students to be the main defenders of other student lives.
The Screening for Mental Health, Inc (2013) uses the same model as the Signs of Suicide
(SOS) program for the SOSI program where “modeling” (para. 2) is used to teach young
adolescents to recognize the signs of self-injury among their peers. Through modeling,
the SOSI program attempts to educate students to recognize the signs and symptoms of
self-injury, provides examples of proactive peer responses to NSSI, and stresses the
urgent need to seek help from an adult (SMH, 2013, para. 2). Overall, the goals of the
SOSI program tailored to middle school students is to increase knowledge of NSSI
including warning signs and symptoms, improve attitudes and perceived capability to
respond and help refer students or peers who engage in NSSI, increase help-seeking
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behaviors for NSSI for peers or self, and decrease acts of NSSI among adolescents
(Muehlenkamp et al., 2009, p. 307).
Muehlenkamp et al. (2010) studied five schools that implemented the SOSI
program. The study consisted predominantly of Caucasian adolescents with a median
age of 16. Slightly more than half of the adolescents studied were female. Muehlenkamp
et al. (2010) performed pre- and post-evaluation surveys of the SOSI program in
combination with several interviews of school personnel. The data collected from this
study demonstrated an improved awareness of accurate knowledge of NSSI and
improved help-seeking attitudes among students (Muehlenkamp et al., 2010).
Additionally, there was no evidence of negative effects stemming from the content of the
SOSI after it was implemented into the classrooms of the five schools (Muehlenkamp, et
al., 2010). Yet, the individual self-seeking help data collected did not demonstrate any
significant changes since the program implementation.
Whitlock and Knox (2009) reported the SOSI program as the only one available
that has empirical evidence of success. Muehlenkamp et al. (2010) describe the SOSI
program as comprehensive in nature – one that has the potential to be effective among
adolescents – but needs to have this effectiveness continuously assessed. Although little
data has been published about the fidelity of these other programs, the SOSI program
does not appear to increase self-injury among middle to high school students who have
participated in the program (Screening for Mental Health, 2013).
Another preventative approach toward NSSI involves a more selective, or
targeted population. Selective prevention programs are aimed to interact with those
students who are deemed by administrators, teachers, or guidance to be at risk for
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engaging or developing self-harming behaviors (Whitlock & Knox, 2009). Such children
may have increased negative factors outside of school that may induce stress, such as
childhood trauma, familial difficulties, a history of emotional or personality disorders,
anorexia or bulimia nervosa, drug or alcohol abuse, struggle with sexual orientation, self-
depreciating cognitive appraisal style, and negative emotionality (Whitlock & Knox,
2009). With NSSI training, administrators and school staff members will become
knowledgeable that for some individuals, self-injury is a way of coping with negative
emotions or a bad life situation (Fennig et al., 2013). Fennig et al. (2013) notes that
cutting, burning, or self-hitting may co-occur with depression, obsessive thinking, and
other mental disorders, which may or may not have developed as a result of one or
several of the negative factors.
Other Pathological Concerns
Other pathological concerns for administrators stem from those children who
somaticize, or internalize, pain thereby potentially resulting in sleep disorders and
increased health issues (Strong, 1999; Whitlock & Knox, 2009). Somatization is the
conversion of emotional stress into physical symptoms like headaches, stomachaches,
shortness of breath, and other pain symptoms (Strong, 1999). The unexplainable
symptoms may be a result of the dysregulation of the body’s biological stress responses
(Juhnke et al., 2011; Strong, 1999; Whitlock & Knox, 2009; Yates, 2009). According to
Yates (2009), environmental and internal maltreatment influence the function of the
neurobiological stress response systems. This dysregulation may lead female pre-
adolescents and early adolescents to engage in NSSI behaviors. This allows a pathway
for adolescents to process any internalized emotional eruptions, to alleviate anxiety or
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depression, and to reconnect by self-harming (Conterio, Lader, & Bloom, 1998; Whitlock
& Knox, 2009; Yates, 2009).
Social Contagion
Whitlock and Knox (2009) write about how belonging to a social group where
one or several students have been identified as self-injurers may be a warning sign for
school administrators. To Bjärehed, Pettersson, Wangby-Lundh, and Lundh (2013),
NSSI is like many other types of behaviors; it is socially patterned, and social
mechanisms can contribute to the spread of NSSI. “It is possible that attention given to an
individual’s NSSI could inadvertently reinforce the behavior, for example, if the behavior
is perceived as a functional method to gain sought after social support and care”
(Bjärehed et al., 2013, p. 226). Within a short period of time, multiple students within the
group begin engaging in self-injury (Walsh, 2012). The students may be discussing
methods of self-harm, frequency of self-harm, and other topics involved with NSSI. This
open communication within a group may lead to the triggering of further self-harm in
each other. Walsh (2012) states that in some situations, the “contagion” (p. 280) may
even lead to students harming themselves in front of each other or harming each other
using the same tools, designs, and locations of the body. Contagion episodes arise in
schools because the maladaptive behaviors of peers create a group cohesiveness – a
special connection to each other when they self-injury (Bjärehed et al., 2012; Hilt, Cha, &
Nolen-Hoeksema, 2008; Juhnke et al., 2009; Walsh, 2012). Through NSSI, members of
a group can communicate the levels of sadness, hurt, or pain each one feels. The
engagement in self-harm may be seen as provocative or courageous – an action that
another friend may be curious to try.
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In instances of self-harm, the creation of positive relationships can ultimately
serve as a protective factor for the students (Bjärehed et al., 2012; Carlson, 2013;
Conterio, Lader, & Bloom, 1998; Strong, 1999; Walsh, 2013). Other protective factors
can counteract students who engage in NSSI (Walsh, 2013; Whitlock & Knox, 2009).
These factors include: the development appropriate forms of expressing negative
emotions and reducing communication about self-injury within a group while expanding
social network support. According to authors Juhnke et al. (2009) and Nixon and Heath
(2009), an open and caring environment can have preventative effects for NSSI.
Selective, or targeted, efforts should aim to enhance the emotional, social, mental,
and physical well-being of students who may currently engage in NSSI or may be
thinking of engaging in self-harm (Whitlock & Knox, 2009). Whitlock and Knox (2009)
believe that unlike the universal approach to prevention, a targeted approach helps to
control many of the negative affects of NSSI that may result from education, like
endorsing negative norms and increase NSSI behavior among female adolescent social
groups. Strong (1998), Conterio, Lader, and Bloom (1998), and Walsh (2013), endorse a
targeted approach to prevention and intervention. A targeted approach addresses the
behavior individually using various counseling methods specifically aligned to the
personality and emotional needs of a particular student. The targeted approach may
provide a better platform for creating long lasting impacts and changes for the students.
Collaboration with individual students will allow school personnel to work on
enhancing interpersonal, intrapersonal, and environmental relationships. Preliminary
research has shown that creating a web of protective factors for the student at risk may
diminish the risk for committing acts of self-harm (Center for Disease Control and
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Prevention, 2009; Nixon & Heath, 2004; Sax, 2010; Whitlock & Knox, 2009). To
Lieberman et al. (2009), Walsh (2012), and Bjärehed et al. (2012), self-injury prevention
programs consistently emphasize the forming of an open and validating relationship.
Safe and caring relationships will enable the disclosure of information about self-injury
(Bjärehed et al., 2012; Lieberman et al., 2009; Walsh, 2012).
The CDC (2009), describes protective factors as “individual or environmental
characteristics, conditions, or behaviors that reduce the effectiveness of stressful life
events; increase an individual’s ability to avoid risks or hazards; and promote social and
emotional competence to thrive in all aspects of life now and in the future” (p. 3). These
protective factors include:
1. A positive view of one’s future
2. Commitment to education
3. Parental presence in the home at key times of the day (breakfast, after school,
weekends)
4. And active participation in school activities (CDC, 2013).
Juhnke, et al. (2011) suggest teaching adolescents how to appropriately express negative
emotions, supportive social network, and access to competent care for emotional and
mental disorders to the list of protective factors.
Programs such as SOSI and SAFE-Alternative can train principals and school
personnel in order to offer individual students positive coping techniques, emotion
regulation skills, and cognitive self-affirmation training (Conterio, Lader, & Bloom,
1998; Strong, 1999; Walsh, 2013; Whitlock & Knox, 2009). These skills, when
combined with improved relationships, may strengthen the ability for schools to identify,
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intervene, and prevent acts of self-harm among the middle school female student
population. Whitlock and Knox (2009) have echoed prior research (Conterio, Lader, &
Bloom, 1998) when demonstrating selective prevention efforts. These efforts focus on
the formation and implementation of school-wide protocols for detecting, addressing, and
preventing NSSI behaviors and intervening those groups whose norms endorse and
promote acts of self-harm. Such protocols guide group norms toward socially acceptable
behaviors and avoid reinforcing negative behaviors, including the engagement of NSSI
(Whitlock & Knox, 2009).
According to Whitlock and Knox (2009) the indicated, or the targeted prevention
approach, places the focus on those individuals who are diagnosed with a personality
disorder or behave in such a manner to pose a diagnosis of a personality disorder. This
approach is also used to address individuals with bipolar disorder and those students who
experience episodes of disassociation. It appears less frequently in schools due to the
aggressive efforts of medical professionals who try to diagnose such disorders as soon as
symptoms appear in a student (Fennig et al., 2013; Whitlock & Knox, 2009). To
Whitlock and Knox (2009) this approach involves close contact between in-school
personnel and external professionals, demanding time and detailed mental health
assessments to be shared and specific-to-the-individual protocols to be implemented. For
these reasons, there are no generalized prevention programs designed for this category of
student self-injurers to date.
Historical Perspective of the Principalship
In the days of a one-roomed schoolhouse, the teacher was the administrator,
disciplinarian, maintenance person, and community outreach liaison. Schools in the
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United States grew into multi-roomed buildings. The need for a central leader became
evident; this centralized teacher would inevitably change the face of education. As the
country grew and more importance was placed on having an education, the role of the
lead teacher morphed into that of a principal.
This centralized role of principal is one that continues to change. Since the
invention of a principal, the definition has changed from a lead teacher still active in the
classroom to a more administrative role set in a front office overseeing the daily activities
and maintenance of the school building. The principal is an employer, supervisor, agent
of change, and inspirational figure. The role has many definitions bound to a single
person. To demonstrate the complexity of the principalship, Rousmaniere (2009) wrote
“The principal is both the administrative director of educational policy and a building
manager, both an advocate for school change and the protector of bureaucratic stability”
(p. 215).
The Role of the Principal
Authors such as Riehl (2000) and Rousmaniere (2009) have identified 5 areas to
describe the role of principal. These include:
1) To implement central educational policies into the classrooms
2) To promote inclusive school cultures and instructional programs
3) To manage the day to day events of the school
4) To foster the growth of teachers and staff members and
5) To build relationships between schools and communities.
According to the Interstate School Leaders Licensure Consortium (ISLLC, 2012) a
principal should meet six federal standards. The standards define strong school
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leadership and promote student success. The standards include:
1) Setting a widely shared vision for learning
2) Developing a strong school culture and instructional program conducive to student
learning and staff professional growth
3) Ensuring effective management of the organization, operation, and resources for a
safe, efficient, and effective learning environment
4) Collaborating with faculty and community members, responding to diverse
community interests and needs, mobilizing community resources
5) Acting with integrity, fairness, and in an ethical manner
6) And understanding, responding to, and influencing the political, social, legal, and
cultural contexts.
Apart from Riehl (2000), Rousmaniere (2009), and the ISLLC (2012), the state of
Massachusetts created four professional standards that collectively demonstrate effective
administrative leadership:
1) Instructional Leadership: Promotes the learning and growth of all students and
the success of all staff by cultivating a shared vision that makes effective teaching
and learning the central focus of schooling.
2) Management and Operations: Promotes the learning and growth of all students
and the success of all staff by ensuring a safe, efficient, and effective learning
environment, using resources to implement appropriate curriculum, staffing
and scheduling.
3) Family and Community Engagement: Promotes the learning and growth of all
students and the success of all staff through effective partnerships with families,
community organizations, and other stakeholders that support the mission of the
school and district.
4) Professional Culture: Promotes success for all students by nurturing and
sustaining a school culture of reflective practice, high expectations, and
continuous learning for staff (Massachusetts Department of Elementary and
Secondary Education, 2012).
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The four state standards were developed to evaluate the overall performance of
Massachusetts’ administrative leaders.
Failure to Include Psychological Indicators in Principal Responsibilities
The qualities outlined by Riehl (2000), Rousmaniere (2009), ISLLC (2013) and
Massachusetts DESE (2012) fail to address the psychological, behavioral, and socio-
emotional health of the students. The lists of standards and qualifications did not identify
the role a principal may play in addressing maladaptive behaviors like NSSI. A failure to
include a measure of the effectiveness of a principal in addressing the psychological
needs of a child pinpoints a gap in leadership expectations.
State and federal standards fail to address the need for administrators to be current
on issues regarding mental and emotional health of the student body. Therapeutic
training is not mentioned in either contemporary document. Inevitably, a lack of a
defined role for principals creates a vacuum in reference to the identification,
intervention, and prevention of NSSI among female adolescents in middle schools.
These documents are essential in the evaluation of a state and federal administrator yet
the role in addressing such behaviors as NSSI is not included. It can then be perceived by
many in the principal position that issues of mental and emotional health do not fall in the
realm of the job. As a result, many principals may not seek out professional training in
these areas, remaining ill prepared to deal with NSSI in the schools.
Failure to include the responsibility of caring for the social, emotional, and mental
health of students in the job description of principal within the federal and state standards
creates a lack of innovation and understanding by policy makers. A principal is the
primary leader of a school community, to whom the students, staff, and parents look for
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leadership (Oakes, 2000; Rousmaniere, 2009). According to Oakes (2000), the creation
of the modern middle school did include consideration for the mental, social, and
emotional health of the students. However, current state and federal standards have
failed to mention the role a principal plays in the education of the whole child beyond
academics and behavior. Parents, teachers, and staff alike may believe a principal is
familiar with the needs of the students – whether academically, emotionally, physically,
mentally, or socially. However, since these leadership indicators are not specifically
addressed within the ISSLC or DESE standards many principals may be uncertain of the
role he or she plays in addressing non-suicidal self-injury in school. Therefore, it leads
many to question how important the mental and emotional health of the students is to
public policy makers? How far off the educational radar is NSSI? If the media, books,
movies, and television programs are including such issues in their content, and students,
parents, teachers, and communities are talking about it in their inner circles, why do
current federal and state policy makers fail to address the subject within the creation of
federally or state mandated indicators?
Training with Principals at the Helm
Principal’s have the responsibility to balance a school’s budget, track all
expenditures, hire and dismiss teachers and staff, as well as maintain order in the school
every day (Robbins & Alvy, 2004). The role involves constantly updating the knowledge
of special education law, common core curriculum, and ensuring that the school is
meeting the requirements of the annual yearly report (AYP) and proficient MCAS scores
(Ruggere, 2014). A principal is charged with creating, implementing, and sustaining
safety protocols (U.S. Department of Education, 2013). Once trained, principals are
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expected to share their knowledge with all teachers and staff members. These aspects
define the principalship. Each leader is then expected to provide every staff member with
the skills necessary to protect the students and themselves (Robbins & Alvy, 2004).
Principals receive this training in formalized collegiate programs, administrative
programs, and professional development, while other aspects are learned through
experience on the job.
A leader must maintain an awareness of non-socially accepted behaviors
exhibited by students (Juhnke et al., 2011; Nixon & Heath, 2009; U.S. Department of
Education, 2013; Walsh, 2012). Awareness brings identification and intervention.
Intervention brings further awareness and ultimately produces prevention among staff
and students (Robbins & Alvy, 2004). A principal should work closely with the guidance
counselors and support staff. He or she can assist when necessary in cases of personal
and school-wide safety evaluations, educational plans, and behavioral concerns exhibited
by a particular student or group (Nelson, 1996; Nock, 2009; O’Connell, 2012; Robbins &
Alvy, 2004; U.S. Department of Education, 2013). However, literature that encourages
principals to take a proactive role in the identification of students who exhibit anti-social
or non-socially accepted behaviors is limited.
Cornell and Sheras (1998) stress that leadership is equally important as having
any prevention plan in place for school officials. It is more effective in meeting the needs
of the students if the relationship with school staff (especially guidance) looks more like a
partnership. To Nixon and Heath (2009), this partnership is one in which both parties are
actively seeking out students who are in need of help. This may be especially important
in some districts across Massachusetts, as guidance positions are being eliminated
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thereby creating the expectation that the principal must act as a guidance counselor as
well (Boston Teachers Union, 2011; Marion, 2011). Qualities of leadership,
responsibility, and accountability are just as essential to having prevention plans set in
place to respond to a crisis or a student in need (Cornell & Sheras, 1998; U.S.
Department of Education, 2013).
Lack of Course Offerings
This study reviewed administrative programs offered at half a dozen well-
regarded Massachusetts institutions. It revealed that many fail to include courses that
address mental, emotional, and social health concerns of students. This further obscures
the role a principal plays when addressing students who need mental, social, and
emotional interventions, like NSSI. Administrators receive training in best business
practices, leadership fundamentals, and public policy. An awareness of socio-emotional
issues like NSSI and the evidence-based programs that address NSSI behaviors are not
provided in the program or course design. The administrative programs offered through
the colleges and universities in Massachusetts, the Massachusetts Commonwealth
Academy, and the National Institute for School Leaders (NISL) are not geared to educate
principals in addressing issues of socio-emotional concern, like NSSI. There are little to
no scholarly educational journals about NSSI and the role of middle school principals in
addressing socio-emotional health of students. Federal, state, and local agencies fail to
place urgency on training in the mental and emotional health of the student body.
This gap in leadership instruction forces a principal to define his or her individual
role (Nixon & Heath, 2009). Principals may assume their role in addressing the
therapeutic health of students is not under the umbrella of principal (Walsh, 2012).
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Instead, it is placed solely on the guidance department. O’Connell (2012) wrote:
“Naturally, school principals expect to be informed about situations involving the health
and safety of the school” (pg. 1) in reference to a school’s guidance department.
Nixon and Heath (2009) argue that a principal must take responsibility for the
whole child - including the mental, social, and emotional health. Authors Reeves, Kanan,
and Plog (2010) and Walsh (2012) encourage a staff-wide shared goal of helping students
reaching their full potential academically, socially, and emotionally. According to Oakes
(2000), the purpose of structuring middle schools into cluster or small grouping was to
better meet student needs. When middle school principals, teachers, and staff members
educate and care for the whole child, they encourage a child’s growth feeling of
belonging to a community. This sense of community and investment by the students is a
natural preventative of harmful behaviors (Moorman & Haller, 2007; Nixon & Heath,
2009). Without policy changes to include the responsibility of caring for the whole child,
principals may continue to step back from the situation and allow guidance to handle the
student in need, instead of taking part in the identification, intervention, and prevention of
harmful behaviors.
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Obstacles in Addressing NSSI in Middle School
Current research lacks a unified definition of NSSI. Literature on NSSI may
include attempts at suicide, puncture wounds, ingesting of toxic substances, or more
lethal methods of self-harm such as ingesting potent amounts of medications despite a
desire to take one’s own life (CDC, 2013; Juhnke, et al., 2011; Milia, 2000; Nock &
Favazza, 2009; Walsh, 2012). Without a clear definition of NSSI it is hard for
administrators to recognize an increase or decrease in self-harm behaviors in comparison
to other districts, states, and the APA annual report (Juhnke, et al., 2011; Nock and
Favazza, 2009).
There is limited exposure to information on NSSI for professional development.
Although NSSI is not a new topic to education, existing professional development
workshops may be limited on the information they have to offer to educators. NSSI
literature stems from clinical and medical studies and often accompanies other co-morbid
disorders such as personality disorder, Bipolar disorder, or Schizophrenia (Adler &
Adler, 2007; Nixon & Heath, 2009; Nock & Favazza, 2009). This literature limits the
knowledge of empirically-proven prevention programs for those who are not clinical
inpatients (Lieberman, 2004; Lukomski & Folmer, 2004). Principals have a limited
knowledge base to design safety protocols for students identified as engaging in NSSI or
having contributing factors that increase the possibility of self-harm (Nixon & Heath,
2009). According to Walsh (2013), staff members are to be aware of NSSI behavior,
detect the behavior, and react appropriately so as not to further isolate the student.
However, with the current lack of training on the school administrative level, principals
are left feeling ill-equipped (Cornell & Sheras, 1998; Junke et al., 2011; Lukomski &
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Folmer, 2004; Walsh, 2013). The responsibility for the identification, intervention, and
prevention of NSSI falls on guidance counselors and school psychologists. However,
they may have only received rudimentary training on NSSI when it was accompanied
with training on suicide and other maladaptive behaviors (Whitlock & Knox, 2009).
Lack of Evidence-Based Programs
There are only a few evidence-based programs that have demonstrated efficacy in
identifying, intervening, and preventing NSSI among adolescents (Nock, 2010).
Programs such as SOSI and SAFE-alternatives have recorded positive changes in the
reporting and self-help requests with little to no negative outcomes (Klonsky et al., 2011).
However, since 2009 there has been a shortage of new evidence-based programs
introduced in the schools beyond the SOSI and Safe-alternatives programs (Klonsky et
al., 2011). This shortage of programs limits schools that may be in need of different
alternatives than those offered through SOSI and SAFE-alternatives (Klonsky et al.,
2011; Lieberman et al. 2009; Nock, 2010; Whitlock & Knox, 2009).
Lieberman (2004) argues that “Principals can help preserve the physical and
psychological welfare of students who self-mutilate by improving awareness about the
cause and signs of the behavior and establishing procedures for response.” Yet currently,
principals face a shortage of professional training in regards to NSSI, even within state
and private administrative training programs. At the university and college level,
programs designed to create administrative leaders fail to include mental, emotional, and
social training within the coursework requirements. Programs designed for
administrators at the state and federal levels do not broach the topic of social-emotional
health of students. Although there are professional development offerings in suicide
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prevention, programs are not specifically offered or inclusive of school administrators
(Juhnke, et al., 2011). Furthermore, most suicide training programs have a limited
exposure to the prevention of self-harm, and such information is presented more in terms
of a possible indicator to commit suicide (Nixon & Heath, 2009; Nock & Prinstein,
2006).
Preventive programs are primarily aimed at equipping guidance counselors or
school psychologists with the necessary information to address a student who is thinking
or has tried to attempt suicide (Juhnke, et al., 2011). Bowman and Randall (2012) are not
inclusive of school administration when addressing the creative strategies for helping
students who engage in NSSI. Therefore, this leaves a void in leadership training.
Principals may seek interdisciplinary coursework to be able to identify, intervene, and
prevent NSSI among the student body. Others may experience difficulty in finding
appropriate training and do not complete this realm of educating the whole child. This
leads to a percentage of administrators with little to no training in the identification,
intervention, and prevention of self-injury among the student population. They will not
develop the capacity for an initial intervention with at-risk students or the ability to
respond to these maladaptive coping strategies.
Limited administrative training in self-harm may also stunt the possibility of
implementing a successful prevention program. With limited exposure to instruction,
principals may remain ignorant of the ways and means of effectively addressing NSSI
among the female adolescents (Juhnke et al., 2009; Nock, 2010). The inability to
recognize a student who exhibits behaviors of NSSI will prevent any effort to respond
(Cornell & Sheras, 1998). To Nixon & Heath (2009), protocols needed for another type
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of school crisis are not the same for NSSI. This limitation can be seen in a case study
conducted by Cornell and Sheras (1998) within Randolph Middle School, Virginia. The
study revealed a lack of strong leadership and knowledge of self-injury by the middle
school principal. The principal’s response to the identified female student who was
cutting during lunch was not protective of the student’s overall emotional and mental
health. Additionally, the principal’s lack of communication following the events within
the school community also perpetuated the large-scale outcry among students and parents
(Cornell & Sheras, 1998). The principal’s behavior multiplied the fear and anger felt
among students, staff, and parents (Cornell & Sheras, 1998). Had the principal been
educated on NSSI protocols, he may have acted differently. According to Cornell and
Sheras (1998), established NSSI protocols would have minimized student turmoil and
parental outcry at Randolph Middle School. This case demonstrated the drastic need and
urgency of middle school principals to be educated on NSSI and the warning signs,
symptoms, and prevention steps needed to prevent a possible school-wide contagion.
Specific Training for Principals
Researchers recommend providing formalized training in crisis intervention
(Lieberman et al., 2004; Nock, 2009; Reeves et al., 2010; Shapiro, 2008; Whitlock &
Knox, 2009). This includes training in assessment and treatment of NSSI for principals,
nurses, psychologists, teachers, and guidance counselors. To Walsh (2012) teachers are
the most likely candidates to identify a student who engages in NSSI while the U.S.
Department of Education (2013) state that other members of the school community help
to protect the safety of all students and staff. In a crisis, teachers and staff look toward
the principal for guidance and leadership. This is especially true since many principals in
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Massachusetts are responsible for the finalization of intervention and prevention plans for
students in need of health services (Ruggere, 2013). It is hard to grapple with a
leadership role on a subject matter that he or she knows little about. Often, principals
who have little training in NSSI may parlay the concerns to the guidance counselors
(Ruggere, 2013).
It is urgent for principals to receive concentrated training on NSSI.
Understanding NSSI will inform student outcome decisions (Sax, 2010; U.S. Department
of Education, 2013; Whitlock & Knox, 2009). Liebermann (2004) recommends NSSI
training during professional development and crisis intervention team training. Currently
there are few offerings for NSSI instruction alone. However, a principal may wish to
consider interdisciplinary courses offered by Massachusetts’ colleges and universities and
professional development offerings. The Gatekeeper program is one example for
administrative training. In a randomized trial of a gatekeeper program for suicide
prevention (which included NSSI), Wyman et al. (2008) published increased results from
the one-year impact on the staff in the areas of self-reported knowledge.
Protocols that are created and implemented by the administration in collaboration
with the teachers and staff may alleviate anxiety, provide direction, and attempt to
prevent unconsciously rewarding and reinforcing the negative behaviors of NSSI
(Bowman & Randall, 2004; Juhnke et al., 2011; Reeves et al., 2010; U.S. Department of
Education, 2013; Whitlock & Knox, 2009). A school-wide disbursement of knowledge
may intrinsically encourage a community-wide endorsement of the developed protocols
for NSSI and peer education of the assessment and intervention tools (Nixon & Heath,
2009; Nock, 2009; Reeves et al., 2010; Whitlock & Knox, 2009).
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According to Whitlock and Knox (2009), schools are most successful in
preventing NSSI behaviors when all three prevention approaches (universal, selected, and
indicated) occur simultaneously. Yet, many schools are unable to spend the essential
time, staff, and money on prevention programs (Nixon & Heath, 2009). The search to
find external professionals willing to train the school community in NSSI may also
present a challenge (Reeves et al., 2010). A principal may also struggle to recruit reliable
teachers and staff members due to the graphic nature of NSSI injuries. To Nixon and
Heath (2009), NSSI prevention training may prove to be a difficult task since human
reactions to possible grotesque bodily mutilation may create a sense of horror within that
adult. Time must also be invested to fully ingest the knowledge of assessment and
intervention (Whitlock & Knox, 2009). However, schools may not be able to justify the
use of time for adequate training when confronted with ever-changing state and federal
mandates on schools’ academic measurements. Additionally, a school may lack much-
needed external community support for the students if the community fails to recognize
or chooses to ignore a possible growing epidemic of NSSI (Juhnke, et al., 2011; Milia,
2000; Walsh, 2012).
Student Engagement in Non-Suicidal Self-Injury
Students engage in NSSI in an attempt to cope with stressors, to punish
themselves, or to seek a euphoric state (Bowman & Randall, 2012; Walsh, 2012). It may
stem from abandonment or neglect from a parent or peers, physical or sexual abuse, low
self-esteem, breakdown of emotional communication, and other reasons associated with
early adolescent development (Adler & Adler, 2007; Bowman & Randall, 2012; Juhnke,
et al., 2011; Nixon & Heath, 2007; Reeves, et al., 2010; Walsh, 2013; Whitlock & Knox,
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2009). Most pre- and early adolescents commit self-harm in the privacy of their homes.
Injuries occur in places on the body most often covered by clothing (Adler & Adler,
2007; Bowman & Randall, 2012; Juhnke, et al., 2011; Nixon & Heath, 2007; Whitlock &
Knox, 2009). This conscious prevention of injuries may inhibit a principal or other staff
member from identifying a student who commits NSSI. This becomes especially true in
highly populated schools where one-on-one student/teacher interactions may be scarce
and guidance caseloads are larger. Highly populated schools diminish the ability for a
principal to be actively involved in the identification, intervention, and prevention of
NSSI since the principal is more ingrained in the day-to-day schedule of the school
(Stone, Astor, & Benbenishty, 2009).
The prevention of health services may be prolonged if the family of the student
does not realize the severity of the students’ actions (Bowman & Randall, 2012; Juhnke
et al., 2011; Shapiro, 2008). To authors Bowman and Randall (2012), the way in which
parents respond to NSSI may make a difference in the resolution of the student behavior.
Families may fail to realize the severity of NSSI by their children, rationalizing the self-
injurious behaviors or excusing them as being dramatic or in desperate need for parental
attention (Bowman & Randall, 2012; Juhnke et al., 2011; Shapiro, 2008). This places the
school in a difficult position. A principal may wish to reinforce the messages published
by researchers on NSSI. These include: families are not alone in the struggle with NSSI,
they are not “bad parents”, and their child is not a “bad child” (Bowman & Randall,
2012).
Armed with NSSI literature, external support contacts, and the help of the
guidance department, a principal may wish to explain NSSI and the reasons why students
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engage in NSSI behaviors (Juhnke et al., 2011; Shapiro, 2008; U.S. Department of
Education, 2013). Recommendations of external family counseling with a therapist or
other medical healthcare provider who has experience with NSSI may also be provided to
the family (Bowman & Randall, 2012; Shapiro, 2008; U.S. Department of Education,
2013). However, some families may not feel comfortable with the recommendation to
see a medical professional for such a private matter. This can be especially challenging
for the principal, who is then placed in a position where medical help is necessary but
parental cooperation is not achieved. It may then become part of the principal’s role in
NSSI-established protocol to file a report on the student if the parents fail to cooperate
with the school (U.S. Department of Education, 2013).
The Failure to Realize the Severity of NSSI
To Robbins and Alvy (2004), school policy and safety regulations may prohibit a
principal from helping students in need. Principals are overburdened with responsibilities
that prohibit the role of identifying and intervening a student who engages in behaviors of
NSSI (Robbins & Alvy, 2004). The role of identifying, intervening, and preventing acts
of NSSI is placed on guidance and/or a school psychologist. This limited contact with
students in need may alter a principal’s perspective in regards to the intervention and
prevention of maladaptive behaviors like NSSI (Juhnke et al, 2011). Without a
heightened sense of awareness within a principal, the need for immediate attention to
educate students on NSSI may not be perceived. This isolates guidance counselors and
school psychologists in the concern for the socio-emotional health of female adolescents.
A lack of involvement may define the role a principal perceives he or she plays in the
education of the students on NSSI and the methods and means of preventing NSSI
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behaviors in the schools.
Factors that Impede a Principal’s Role in Addressing NSSI
A breakdown in communication between school personnel and the principal may
lead to a lack of response to NSSI (Stone et al., 2009; Juhnke et al., 2011; Walsh, 2013).
School staff may not be comfortable approaching a principal or may be hesitant to report
the identity of a student they may feel is engaging in NSSI. A failure of urgency by the
principal may not stem from disbelief that NSSI is present among the student population.
Instead, it may be due to the lack of formalized education needed to identify and address
the behaviors and the factors associated with NSSI (Cornell & Sheras, 1998). Without
proper training, a principal may not realize the severity of identifying, intervening,
preventing NSSI behaviors among the student population.
The demands of the principal may impede a principal’s reactions to issues among
the student population. In middle school there are continual hormonal changes that may
contribute to an increase in antisocial behavior (Spear, 2000). Principals may see
engaging in NSSI as a cry for attention (Bowman & Randall, 2012; Sax, 2010) and not as
imminent concern for the emotional and physical safety of the student. A principal may
unconsciously react with a lack of urgency to an issue that remains hidden on the body of
the student. To Sax (2010), a principal may approach his or her role as the administrator
of managerial and behavioral concerns only. Mental health concerns are the
responsibility of the guidance department or school psychologist (Sax, 2010). As a
consequence, principals may not securely embrace the role of identification, intervention,
and prevention of NSSI among pre-adolescent and adolescent females. Instead, a
principal may wish to serve as a facilitator, giving the role of intervention to the guidance
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department or the school psychologist.
Conclusion
NSSI is a secretive illness, one in which the evidence of the harmful behavior can
be hidden from school administration (Adrien, et al. 2010; ISSS, 2007; Juhnke et al.,
2011; Klonsky, 2007; Muehlenkamp, Walsh, & Prinstein, 2008; Sax, 2010; Walsh,
2014). The intimate locations of the self-inflicted injuries (upper thigh area, inner arm, &
stomach) are difficult to detect without notification from a friend or family member
(Bjärehed et al., 2012; Sax, 2010; Walsh, 2012). 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; Bowman &Randall, 2012;
Muehlenkamp, Walsh, & Prinstein, 2008; Sax, 2010). Instead, those students who
engage in NSSI do not seek help and do not wish to gain widespread attention (Sax,
2010; ISSS, 2007; Walsh, 2012). Unlike suicide, NSSI may be carried out to release
emotional buildup, not as an attempt to end a life (Sax, 2010; Walsh, 2012).
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. Adolescent girls
are the predominant group at risk for NSSI (Hilt et al., 2008; Walsh, 2010). 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.
NSSI behaviors may become deeply engrained in an older adolescent (Hilt et al.,
2008). It is imperative for principals to identify the components of NSSI in order to
sufficiently address student self-mutilation during the pre-adolescent stage. Middle
school administrators may not perceive non-suicidal self-injury to be a medical risk
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among their female students.
Several factors may contribute to the ineffectiveness of a principal in the
identification, intervention, and prevention of NSSI among her young female students.
Such factors include: the lack of support from a Superintendent, unavailable funding for
administrative and staff training, and prohibitive district policies Principals may not be
able to closely monitor the female student population in their schools. A lack of urgency
within the mindset of a principal may also prevent any proactive approaches to NSSI
prevention. Principals may believe that NSSI, its prevention, and treatment methods are
beyond the scope of the educator. However, the principal is ultimately the one held
responsible for the safety and well being of the students. It is a part of his or her
responsibility. A principal must ensure that both she and her staff appropriately address
NSSI among her female students. In conjunction with the guidance department and
supporting staff, a principal must facilitate a comprehensive prevention program designed
to address NSSI. Ultimately, as the school’s primary leader, he or she must raise
awareness of NSSI and lead the staff in properly addressing NSSI among the young
female student population. She must aid in the development, implementation, and
facilitation of an effective NSSI prevention program.
Middle school principals must be able to identify, intervene, and prevent NSSI
among adolescent females ages 10-14-years-old. Principals must remain updated on the
ever-changing profile of a typical youth who engages in NSSI behaviors (Heath et al.,
2009). It is their role to relay this information to the school staff and families within the
communities. Most important, principals, guidance departments, and school
psychologists or social workers must work together to break through the walls of secrecy
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and deception many NSSI individuals attempt to conceal.
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CHAPTER THREE: DESIGN OF THE STUDY
This study examines the perceptions of middle school principals regarding their
role in addressing non-suicidal self-injury (NSSI) among pre-adolescent and adolescent
females ages 10- to 14-years-old. The researcher seeks to highlight to what degree
middle school principals consider NSSI to be an important leadership role. It examines
the various ways middle school principals report they are addressing NSSI among
adolescent females. It analyzes the perceptions principals have of NSSI behaviors as well
as what perceptions they have of the female students who engage in NSSI. In addition, it
examines the factors and conditions that middle school principals believe inhibit or
support their efforts to address NSSI among pre- and early adolescent females.
This chapter presents the design of the study, including research methods and
instrumentation. It provides a rationale for the research approach and explains the role of
the researcher. It identifies the sample used in the study, and explains the process of
participant recruitment, data collection, and data analysis.
Selection of Participants
This study employed a purposeful selection of participants to identify individuals
whose career experiences may best address the research questions of the study.
Participants were practicing middle school principals in the state of Massachusetts. For
the purpose of this study, middle school was defined as educating students in grades 6 to
8. However, principals of other grade configurations such as k to 8 or 5 to 8 grades were
included in the data collection process since the school did encompass grades 6 to 8 as
well.
There are currently 365 middle school principals in the state of Massachusetts
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(Massachusetts Department of Elementary and Secondary Education, 2014); of those,
189 are males and 166 are females. The researcher petitioned 150 middle school
principals chosen without a designated choice pattern from the Massachusetts
Department of Elementary and Secondary Education (DESE) website. The researcher
chose various names of schools within a certain alphabet letter continuing without a
pattern through the entire alphabet of schools. The researcher used the DESE database
for the initial contact information.
One hundred fifty middle school principals were recruited through an email
invitation sent by the researcher. This invitation contained a cover letter, consent form, a
statement guaranteeing confidentiality, and the online survey. The study included
general population public schools; as well as charter, vocational, and collaborative
schools, also known as collaboratives. The researcher expected 45 to 50 middle school
principals to complete the online survey instrument. After two weeks from the initial
email, the researcher sent a follow-up email to solicit further participation from principals
who did not partake in the initial sending of the survey. For examples of recruitment
communications, see Appendices A-D.
The researcher expected eight to ten principals to participate in the interview
process. A total of twenty-two Massachusetts middle school principals volunteered; of
those, fourteen were interviewed over the telephone and one principal was interviewed
face-to-face. Interviews via telephone, were conducted in a closed office containing only
the researcher. The single face-to-face interview was conducted in the principal’s office.
All interviews were recorded using a program called Evernote. The remaining seven
volunteers were not interviewed due to personal time constraints and end of the school
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year scheduling. One volunteer was not yet a practicing principal, which eliminated her
responses from the study. It is important to note that participating principals ranged in
age, experience, education level, and gender. The schools in which they serve differed in
size, location, and student population. Their participation provided a diverse spectrum of
leadership for the study.
Design Strategy
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-years old.
This study used a mixed-methods approach. A mixed-method approach has three
distinguishing features: 1) it combines qualitative and quantitative methods to examine an
identified problem which grounds a study, 2) the combined methods allow for a greater
range of perspectives, 3) research instruments are developed through the combined
methods based on previously collected data to gather in-depth information on the subject
matter (Denscombe, 2011). This study combined the three features to create the
framework for data collection by using quantitative and qualitative approaches.
Specific steps were taken to obtain the necessary information to answer the
research questions contained in Chapter One. The use of a mixed methods approach
strove to reduce personal experiences, statements, and meanings to a cohesive and clear
description of the perceived role a principal currently plays in addressing NSSI among
female adolescents ages 10- to 14-years-old. Creswell (2009) explained that the
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connection and the integration of the quantitative and qualitative data within the mixed
methods approach allows for clearer data interpretation.
Denscombe (2011) believed that pragmatism, or the “what works” approach, is
generally regarded as the philosophical partner of the mixed methods approach. He
acknowledged that there is skepticism about the distinction between quantitative and
qualitative research, yet he believed that what guides researchers to use a mixed methods
approach is the attainment of answers to research questions (Denscombe, 2011). The
mixed methods allowed the researcher to gain an authentic understanding of the role a
middle school principal plays in addressing NSSI among females ages 10- to 14-years-
old in a timely, yet concise manner.
Both research strategies enabled the researcher 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 was sought since the two research strategies analyzed the same topic
(Denscombe, 2011). Due to the combined use of two strategies, a mixed-methods
approach provided a well-developed perspective on the role of the principal in addressing
NSSI as well as compensated for the strengths and weaknesses of various research
strategies. An online survey was used to collect qualitative data while interviews
collected qualitative data.
Instrumentation
This was a qualitative and quantitative study used to investigate the perceptions of
middle school principals regarding their role in addressing NSSI among adolescent
females ages 10- to 14-years-old. This was a sequential study in which the collection and
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analysis of quantitative data in a first phase of research was followed by the collection
and analysis of qualitative data in a second phase (Creswell, 2007). The second phase
used the results of the initial quantitative results to construct the qualitative instrument
(Creswell, 2007). Using the sequential mixed method described by Creswell (2009), the
study began with a quantitative survey instrument. Following the quantitative data
collection, interviews were conducted to collect qualitative data for the study. The study
was designed to allow for the interpretation of quantitative data at a deeper and more
meaningful level when combined with qualitative data.
Role of the Researcher
I am a mother of two young girls, a middle school teacher, a full-time doctoral
student, and a coach. Within these roles, I have developed several preconceived ideas of
the role I believe a principal should play in safeguarding the physical, socio-emotional,
and mental well being of female students. As a practicing teacher, I have witnessed
multiple cases of NSSI injuries among my middle and high school students. This has
prompted me to examine the evolution of NSSI among pre- to early adolescent females
and has guided my study on the role of a middle school principal in addressing NSSI in
pre- to early adolescent females.
As the researcher, I conducted the processes of data collection and data analysis.
I identified and recruited middle school principals in the state of Massachusetts. I
designed an original quantitative survey instrument. I analyzed the data from the survey
instrument and used it to inform the development of the qualitative interview questions.
The interview questions I created were designed to elaborate on the perceived role of the
principal in response to NSSI, the perception of NSSI, the perceptions of adolescent
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females that engage in NSSI, and the administrative actions taken in order to address
NSSI when it becomes known in their school. During each research phase, I reviewed
transcripts and recordings, verified coding and identified important themes and concepts
illuminated during the interview stage.
Throughout this process, I attempted to contain my own assumptions, beliefs, and
experiences in order to actively engage in interview sessions with participants. These
actions were taken to bracket my own personal perceptions for the purpose of data
collection and analysis in this study. When I set aside my own personal biases, I was
able to approach each and every participant with a “fresh perspective” (Creswell, 2007,
pg. 59). However, it is pertinent to note that my interpretation and analysis of the data
will inevitably reveal some aspect of my personal biases that may not be evident to the
researcher during the process.
Particular care was given to safeguard against the appearance of my own personal
bias during the data analysis stage. As the researcher I wrote a descriptive account of
participants’ perceptions of the role of a middle school principal in addressing non-
suicidal self-injury among pre- and early adolescent females ages 10- to 14-years-old. A
continual chain of communication was established between my senior advisor and my
committee to accurately analyze survey results and review interview coding and analysis.
My committee members confirmed my interpretations and understandings of interview
responses. Further, conferences with the writing center maintained accuracy and clarity
of the data collection and analysis sections of the study.
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Methods and Procedures
In this study, the researcher investigated the perceptions of middle school
principals regarding their role in addressing NSSI among adolescent females ages 10- to
14-years-old. The researcher sought to identify to what degree do middle school
principals consider NSSI among adolescent females to be an important leadership role.
The study attempted to evaluate principals’ perceptions of NSSI and of those students
who engage in NSSI. Simultaneously, the study evaluated any perceived contributing
factors for NSSI among females aged 10- to 14-years-old within a general school
population setting. The researcher examined the various ways middle school principals
report they are addressing NSSI among pre-adolescent and adolescent females.
Additionally, the researcher highlighted the factors and conditions that middle school
principals believe inhibit or support their efforts to address NSSI in their schools.
Pilot Study
The pilot study collected data from members of the Lesley University Education
Leadership Doctoral Community who were practicing middle school principals. The
research attempted to discover what are the perceptions of middle school principals
regarding their role in addressing NSSI among adolescent females age 10- to 14-years-
old. Each candidate was sent the introductory email with the consent to participate in the
study with the link to the survey instrument. The researcher field-tested the 56–item
survey instrument, which consisted of 10 demographic questions and 46 questions using
a Likert attitude inventory. 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
78

weigh one question more importantly than another. Instead, Huck (2008) believes that a
Likert Scale produces ordinal data regardless of the positively or negatively charged
responses to certain questions held by the participants. This provides an inferred order of
agreement among participants. The researcher requested a return of each survey by the
participants within a two-week period with critical feedback regarding the overall content
of the survey instrument.
Feedback was collected from the initial test of the survey instrument regarding the
survey content and instrument validity. To Creswell (2009), validity is how well a test
measures what it is designed to measure. According to Gay (2003), this can be
determined in two subgroups involving item validity and sampling validity. Item validity
would examine whether the statements posed in the survey instrument are relevant to the
purpose if the study. Sampling validity measures how much of the content area is being
tested by the survey instrument.
For this study, in order to increase validity and assure participants’ understood
NSSI, a definition of self-injury was included within the survey: “NSSI is described as
the purposeful, direct destruction of body tissue without conscious suicidal intent”
(American Psychiatric Association, 2012, para. 1). Injuries of NSSI are considered
intentional self-inflicted wounds on the surface of the body, most commonly on inner
thighs, arms, and stomachs. According to the APA (2012), NSSI injuries are committed
to induce bleeding, bruising, or pain on a minor or moderate scale.
Feedback was collected and analyzed from the pilot study by the researchers and
the committee. Feedback included an eradication of a question written twice within the
survey instrument, a need for rewording or clarification of questions, and the addition of
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a neutral category (somewhat agree) to create a 5-point ranking system (Strongly
Disagree, Disagree, Somewhat Agree, Agree, Strongly Agree). The researcher added the
APA (2012) definition of NSSI along with several examples of NSSI behaviors to the
opening script. The surveys were then placed in a locked cabinet in the researcher’s
office, saved in case any further clarification may be needed as the interviews were
performed.
The pilot study interviews were conducted over the phone with participating
middle school principals from the Lesley University Education Leadership Doctoral
Program. The researcher used a designated script informing candidates of their
confidentiality and their rights to cease the interview if desired. The researcher
anticipated the possibility of bias from the Lesley University participants due to the
relationship established with the researcher and the knowledge of the subject matter of
the study prior to their participation. Interviews lasted ten to fifteen minutes each.
Once any researcher error, question ambiguity, or unclear directions were
remedied, an invitation to participate in the study with the link to the online survey was
emailed to 150 randomly chosen middle school principals in Massachusetts. The
invitation identified the researcher, stated the purpose of the study, discussed the
anonymity of the participants, the time required for the completion of the online
questionnaire, and how subject responses would be maintained in terms of
confidentiality. A requested date of return to the researcher was printed within the
participation letter. Additionally, in order to encourage greater participation, the letter
also discussed the possible outcomes the study may yield upon its completion.
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Phase One: Survey Instrument
The survey instrument was sent via email to one hundred fifty middle school
principals in Massachusetts. The invitation identified the researcher, stated the purpose
of the study, discussed the anonymity of the participants, the time required for the
completion of the online questionnaire, and how subject responses would be maintained
in terms of confidentiality. A requested date of return to the researcher was printed
within the participation letter. Additionally, in order to encourage greater participation,
the letter also discussed the possible outcomes the study may yield upon its completion.
A power analysis was conducted to evaluate if the number of participants solicited
were a large enough sample to correctly reject the null hypothesis. The null hypothesis is
a statement of equality between sets of variables” (Salkind, 2011, p. 434). As the sample
size increases, so does the power of the instrument. A larger sample size provides more
information, which makes it easier to correctly reject the null hypothesis. In this case, the
study measured a need of 45 respondents out of the 150 principals in Massachusetts’
public school districts. This will give a .8 (80%) or greater chance of finding a
significant difference when there is one among the responses.
Phase One gathered quantitative data through an electronic online survey via
Surveygizmo.com (2014) (see Appendix F). The middle school principal-only survey
was distributed to a non-probability purposive sampling with a goal of producing 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
81

value given the sample value (Salkind, 2011).
The researcher introduced the study, requested participation in the study, and
linked the online survey tool to the initial email. Common definitions of NSSI were
provided in the survey instrument in order to provide a general understanding of the
terminology used in describing NSSI and gather comparable data for the study (See
Appendix F).
This was a sequential study in which the quantitative research method preceded
the qualitative research method for data collection. The survey design attempted to
gather data on the perceived role, biases, and current actions taken by middle school
principals to address NSSI among female adolescents ages 10- to 14-years-old. The
researcher did not intend to investigate the determining causes for the responses given by
the middle school principals who participated in the study, but to simply identify their
perceptions and examine those responses for themes and patterns. Additionally, the
Likert attitude inventory collected data that in turn provided questions for the interview
process. Principals who chose to participate in the interview process of the study
completed the survey instrument and provided consent to be interviewed within a two
week timeframe.
The survey gathered principals’ demographic and descriptive data through
quantitative measures (see Appendix F). A Likert type attitude inventory gathered initial
data on principals state-wide and ultimately provided a sampling of principals for the
second phase of research, the interview. 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
82

does not weigh one question more importantly than another. Instead, Huck (2008)
believes that a Likert scale produces ordinal data regardless of the positively or
negatively charged responses to certain questions held by the participants. This provides
an inferred order of agreement among participants.
The Likert attitude inventory began with nominal questions regarding school
demographics, professional history, and any completed educational training on NSSI. A
five point Likert scale was used during the second part of the quantitative survey to
measure the participant’s perceptions of the principal’s role in addressing NSSI. It also
attempted to identify and measure the frequency of administrative actions once a student
or students who engage in NSSI was identified in the school. In addition, the Likert scale
collected data on principal’s perceptions of the female adolescents who engage in NSSI
behaviors.
The survey instrument was designed by the researcher using five types of
questions aligned with the guiding questions of the study. Initial questions collected
demographic information on the participating principals. (See Table 3.1) Research
Question One guided the creation of questions that examined the degree to which
principals consider addressing NSSI as an important leadership role. (see Table 3.2)
Research Question Two guided the creation of the next two types of questions regarding
the various ways in which middle school principals report they are addressing NSSI
among adolescent females. These questions solicited opinions regarding NSSI, NSSI
behaviors, and the pre-adolescent and early adolescent females who engage in NSSI
behaviors. Statements that created an image of a self-injuring female were presented in
order to delve deep into those perceptions. (See Table 3.3).
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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.
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
population of my school.
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.
Research Questions One and Two also prompted the creation of a fourth type of
question in which statements were introduced to describe possible roles current principals
play within their schools. It was hoped that the data gathered from this set of questions
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?
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would help to define a generalized role of the principal in addressing NSSI within
Massachusetts’ schools. This set of questions was designed to categorize the actions
currently taken by middle school principals to address NSSI once a student is identified
as a self-injurer. (See Table 3.2).
Table 3.3 Participants perceptions of NSSI, NSSI behaviors, & Females engaging in NSSI
1. NSSI is an abnormal developmental state 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.
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 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. Female students who engage in NSSI behaviors will sop on their own without receiving any
therapeutic help.
9. Female students who have been physically or sexually abused are more likely to engage in
NSSI.
10. Female students who engage in behaviors of NSSI are dramatic, often exaggerating life issues.
11. There are no effective treatments for a student with NSSI.
12. Female students who engage in NSSI are non-athletes and do not engage in extra-curricular
activities.
13. Female students who are not necessarily considered pretty or popular by peers, or active in
school are more likely to engage in NSSI.
14. Female students engage in NSSI as a cry for help.
15. Female students that engage in NSSI will attempt suicide.
16. Female students who engage in behaviors of NSSI suffer from moderate to severe mental illness.
17. Female students who feel shame, anger, or sadness engage in behaviors of NSSI.
18. Female students of divorced, separated, or single parent homes are more likely to engage in
behaviors of NSSI.
19. Outplacement of students who engage in NSSI behaviors is the solution.
20. Students who engage in NSSI must be isolated from their peers immediately.
21. Students who engage in NSSI are to be enrolled in a prevention program.
22. Students who engage in NSSI should have a mandatory psychological evaluation.
23. A female student who wants help for her NSSI behaviors would seek out her administrator or
guidance counselor.
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.
A fifth type of survey question aimed to collect data in response to Research
Question Three. This set of questions attempted to identify the factors and conditions
that middle school principals believe inhibit or support efforts to address NSSI among
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pre-adolescent and adolescent females in their schools. Level of education, years of
experience in administration, years in current administration, and any NSSI training for
administrators were some of the factors and conditions that were examined through this
line of questioning. (See Table 3.1 & Table 3.4).
Table 3.4 Factors and conditions that are believed to inhibit and support efforts to
address NSSI
6. I believe I am unable to thoroughly address the needs of female students suspected of
10. Injuries stemming from NSSI are not severe enough to warrant immediate attention from
school administration.
11. 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.
12. I have received on-the-job training in NSSI as a principal.
13. There are programs available to administrators providing updated training on NSSI.
14. During my experience as a principal, I have continued to update my knowledge of NSSI
on my own.
15. I am knowledgeable of the signs of NSSI.
17. I am aware of the number of incidents of NSSI among the female pre-adolescent
population in my school.
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.
One specific goal of the survey instrument as a whole was to gather valuable
information on the perceptions of a principal regarding their role in addressing NSSI in
order to cross-reference it with the gender of the principal. The data gathered by the five
types of questions allowed the researcher to examine if gender affected the perception of
the role a principal plays in addressing NSSI and the perception of those students who
86

engage in NSSI behaviors. Gathering this data would make it possible to analyze
whether gender has an affect on the degree to which principals consider NSSI to be an
important leadership role.
Phase Two: Interview
The second phase was qualitative in the form of a semi-structured telephone
interview (see Appendix F) (Denscombe, 2011). The researcher utilized the data
collected from the pilot study and the survey instrument to construct the four interview
questions in an effort to better understand the perceived role of the middle school
principal in addressing NSSI among the female population. The semi-structured design
of the interview provided identical questions to all study participants yet allowed more
flexibility than a structured interview. In terms of the order in which questions were
asked, in a semi-flexible interview a researcher has more of a possibility to alter the order
of the interview questions. This type of interview format also allows participants to
expand on ideas or concepts more freely. All questions are open-ended and provide a
catalyst of the issue of NSSI.
This interview attempted to provide a cross-section of the population in order to
draw valid conclusions about practicing Massachusetts’ middle school principals
(Denscombe, 2011). Based on the goal of a 30% ratio on return, one hundred fifty
principals in Massachusetts were contacted randomly via email using an online survey
tool for the quantitative method. Upon completion of the survey instrument, principals
were prompted to provide contact information needed to conduct a follow-up interview
and a consent form to participate in Phase Two: Interview.
Interviews were conducted over the telephone by the researcher. All interviews
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were recorded using the Evernote application on the researcher’s Apple iPad. Using the
analyzed results from the survey instrument, the researcher developed a set of four
questions to ask each interviewee. Throughout the interview if a response prompted
further investigation or clarity, the researcher continued the questions using one of two
phrases: “Could you explain what you mean?” or “Please tell me more.” The interviews
ranged in duration from fifteen to twenty minutes. The length depended on the
information offered by that particular principal, if clarification was needed while asking
the interview questions, or if the participant added anything further to their initial
responses.
One-to-one phone interviews allowed the researcher to collect data to help
understand the perception of the role a principal plays in addressing NSSI. Open-ended
questions allowed participants to describe NSSI as they see it and provide some
justification or rationale for their perceptions. If additional information or clarification
was needed, the researcher used one of the two phrases: “Could you explain what you
mean?” or “Please tell me more.”
The interview question “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?” attempted to answer Research Question One. A second
interview question, “What actions have you taken as a principal in order to address NSSI
behaviors among the pre-adolescent female population in your school?” gathered data
regarding Research Question Two.
Lastly, two interview questions sought to address Research Question Three:
“What type of training have you received in regards to the identification, prevention, and
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reporting of NSSI among female adolescents ages 10- to 14-years-old?” and “What type
of training do you feel middle school principals should have in order to effectively
address NSSI among female adolescents ages 10- to 14-years-old?” Interviews were
recorded and transcribed by the researcher. Chapter Four will identify themes, patterns,
and concepts that were identified and recorded. Any responses that prompted further
investigation in the subject matter were recorded by the researcher and will be revisited in
Chapter Five under future study recommendations.
Confidentiality Efforts
All participants were informed of the purpose of the study. The researcher also
communicated the steps to be taken to maintain confidentiality. A statement was
included in the initial email sent to potential participants. During the interview process,
principals were read a statement reiterating participant confidentiality, unless given
permission prior to beginning the interview itself. This statement also informed the
participants that no information would be published using the participants’ identity in any
way and that each participant would receive a coded identity in place of their real
identity. Interviews were performed individually and privately. Results were coded and
analyzed by myself alone, and all documents remained in a locked cabinet in the office of
my home.
Within the same script, principals were reminded to answer the interview
questions based on their own personal beliefs and experiences. Despite my best efforts to
gain a clear understanding of the role a principal may play in addressing NSSI, the
perceptions a principal may have of NSSI behaviors and of those females who engage in
NSSI, some ambiguity may still exist. This may impact the overall results of the study.
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Findings from this study are reported in Chapter 4. The use of name coding will
maintain that no identifiable information is presented in this study. Information gathered
during the interview process will be used to test the researcher’s hypotheses and the
results of the data analysis will support or refute those hypotheses.
Chapter Summary
Chapter Three provided an explanation and rationale for the use of the mixed-
methods research approach. It described the methods and procedures employed for the
study, defined essential terms, and outlined limitations and delimitations of the study.
Also included was an explanation of the trustworthiness of the study. Finally, Chapter
Three identified the focus group of the study, the data collection process, and how data
will be analyzed during chapter four.
The mixed method approach to research provided the framework for the data
collection process described within Chapter Three. This study examined the role of the
middle school principal in addressing NSSI among pre- and early adolescent females.
Using the quantitative and qualitative methods of data collection, the researcher was able
to delve deeper into the perceptions Massachusetts Middle School principals in this study
have of their role in addressing NSSI, NSSI behaviors, the perceptions of the students
who engage in NSSI, and the actions principals currently take in addressing NSSI in
schools. Based on the answers given in the survey instrument in phase one of data
collection, interview questions were designed with the intent to clarify ambiguous
statements and gather further information on the perceptions of current principals.
During the interview process, the researcher intended to gain clarification to the role
principals believe they currently play in regards to NSSI and the actions currently taken
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by principals to identify, intervene, and prevent NSSI behaviors in the schools. The
interview process also strived to identify further the perceptions principals have of NSSI
and of the female students who engage in NSSI behaviors.
Through the use of a mixed-methods approach, the researcher was able to gather
pertinent data to analyze the role of a middle school principal in addressing NSSI among
pre- and early adolescent females. Throughout data collection, the researcher used the
guiding questions to frame the study.
The mixed methods approach used within this study shall bring forth a deepened
understanding of the perceived role a principal plays in addressing NSSI within the
schools. Using the qualitative and quantitative analyses gathered in this study, the
researcher is able to present information supported by multiple perspectives from those
who are currently serving in the position in Massachusetts. The data analyzed in this
study shall lay the foundation for further research into the role a principal plays in
response to NSSI within their schools. The data analysis is presented in Chapter Four.
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CHAPTER 4: RESULTS AND ANALYSIS
This study examined 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. The researcher investigated to what degree middle school principals
consider NSSI among adolescent females to be an important leadership role. It assessed
the various ways middle school principals report they are addressing NSSI and
researched factors and conditions that middle school principals believe inhibit and
support their efforts to address NSSI. Understanding the perceived role of the middle
school principals regarding their role in addressing NSSI among adolescent females will
help audiences understand how personal perceptions impact how principals currently act
in their daily role.
In review, this study used sequential mixed methods research strategy consisting
of a quantitative survey instrument followed by a qualitative interview process (Creswell,
2009). Three questions guided the study:
1. To what degree do middle school principals consider non-suicidal self injury
(NSSI) among female adolescents ages 10- to 14-years-old to be an important
leadership role?
2. What are the various ways middle school principals report they are addressing
non- suicidal self-injury (NSSI) among adolescent females ages 10-14-years-old?
3. What are the factors and conditions that middle school principals believe inhibit
and support their efforts to address non-suicidal self-injury (NSSI) among female
adolescents ages 10- to 14-years-old?
Research Question One sought to expose the perceptions of current middle school
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principals when addressing the mental, physical, and emotional health of the female
student body in Massachusetts’ middle schools. It was hypothesized that many principals
do not consider NSSI to be an important part of their role as principal. Therefore,
Question One attempted to highlight the degree to which Massachusetts’ middle school
principals consider the identification, intervention, and prevention of NSSI among pre-
and early adolescent female students to be an important part of their leadership. In
connection to Question One, Question Two investigated whether principals play a
primary role or a secondary role, supporting guidance and other staff members, when
addressing NSSI and the female students who engage in NSSI behaviors. In Question
Two, the researcher anticipated analyzing the various ways middle school principals do,
or do not, address NSSI among female adolescents in their schools. Research Question
Three expected to reveal several factors and conditions that impede principals from
addressing NSSI within their schools. It was hypothesized that a lack of training in NSSI
leads to many cases of NSSI going undetected or mishandled and the creation of
misconceptions as to why students engage in NSSI behaviors. Before the data is
presented, NSSI, Onset of NSSI, and middle school grades will be defined in the context
of the study.
In Chapter 4, the researcher will present data collected according to the three
Guiding Questions of the study. These data were gleaned from the mixed method
strategy used where Phase One was the Survey Instrument and Phase Two was the One-
to-One Interviews. After the introduction, the chapter is organized according to the
following subheadings: (a) Research Question One: Degree of Leadership Role, (b)
Research Two: Addressing NSSI among adolescent females, (c) Research Question
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Three: Reported Factors and Conditions, (d) identified themes from data collection, and
(e) a summary of key findings for each research question. Research Question One, and
Two will each have additional subheadings: (i) gender, (ii) level of education attained,
and (iii) years of administrative experience. Research Question Three does not include
the subsections of gender, level of education, and years of administrative experience
since there was little to no statistical difference demonstrated in the analysis within the
subheadings. Chapter Four mirrors the data collection process, with the analysis of
quantitative data presented first and qualitative data second under the defined
subheadings.
Research Question One: To what degree do middle school principals consider non-
suicidal self-injury (NSSI) among adolescent females ages 10 to 14 years old.
This section will present data collected according to Research Question One.
The information was gleaned from the mixed method strategy used where Phase One was
the Survey Instrument and Phase Two was the One-to-One Interviews. The Quantitative
Method subsections are: a.) Demographic Information Analysis, b.) Gender, c.)
Administrative Experience, d.) Level of Education, and e.) Mancova of combined
variables. Once Data has been presented from the Quantitative Method, the researcher
will present the results from the Qualitative Data Analysis. The Qualitative Method
subheadings are: a) Individual Interviews, b) Themes, c) Quantitative and Qualitative
combined Key Findings. Themes gleaned from the data will be presented in the
following subheadings: i) Lack of Understanding, ii) Job Limitation, iii) School Support
System, and iv) Training in NSSI. The key findings from the mixed methods will
summarize the results.
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Quantitative Data Analysis
The Likert attitude inventory was used to collect quantitative data for Research
Question One. The Survey Instrument recorded participants’ perceptions regarding their
role in addressing NSSI among pre- and early adolescent middle school females. The
data analyzed principal perceptions of NSSI behaviors of the females that engage in
NSSI. The survey instrument highlighted the ways practicing principals are reporting
NSSI and the role they play during the identification, intervention, and prevention
process. In addition, the survey instrument inquired about any education and/or training
participating principals may have received on NSSI during their career.
Data were collected and analyzed a survey instrument sent to 150 Massachusetts
public middle school principals. Fifty-three Massachusetts middle school principals
participated in the survey, for an overall response rate of 35%. One survey was
dismissed out of a lack of experience at the principal level of one of the respondents,
leaving a total of fifty-two participants. Fifty-five percent (55%) of principals whom
answered the survey were females (N=29), forty percent (40%) were males (N=21), and
three percent (3%) were gender undefined (N=2). The majority of principals in the study
were White, non-Hispanic at a rate of 83% (N= 44). Other respondents were Hispanic
(N=1; >1%) or Asian/Pacific Islander (N=3; >1%). There were no participants self-
identified as Black, non-Hispanic (N=0; 0%) or Native American/American Indian (N=0;
0%).
The data collected demonstrates an acceptable representative sample of the
middle school population for the state of Massachusetts. However, the study did have a
representative discrepancy in the category of racial diversity. There was a low
95

participation rate from principals of Asian/Pacific Islander and Hispanic decent and zero
participation from principals of Black/African American and Native American/American
Indian decent.
The researcher used SPSS (2014), predictive analytics software, to analyze the
quantitative data and perform tests of analysis. This program tested the null hypothesis of
the variables of the study to see if there existed a correlation between them. The null
hypothesis acts as a “starting point and a benchmark against which the actual outcomes of
the study can be measured” (Salkind, 2011, p. 129). According to Salkind, the null
hypothesis is considered the starting point because it is “the state of affairs that is
accepted as true in the absence of any other information” (p. 130). The results of the data
either explained or rejected the null hypotheses, or a general statement that there is no
relationship between two measured phenomena (Salkind, 2011).
The initial questions of the quantitative data collection target the demographic
information of middle school principals across the state of Massachusetts. It collected
information on the gender, ethnicity, level of education, years in middle school education,
years of current position, and the cumulative experience as a middle school administrator.
The survey instrument collected quantitative information on school classification, size,
grade configuration, and total enrollment of students. Data was gathered highlighting the
perceptions current principal have of NSSI, of the females that engage in NSSI, the role
of the principal in the identification, intervention, and prevention of NSSI, and the actions
taken by current principals if a student is identified as engaging in NSSI. The following
paragraphs will reveal the results.
Overall analysis demonstrated the most dominant characteristics to be female,
96

white, 0-10 years served in current administrative position, 0-10 years served as
administrator in overall career, 11-35+ years in grades 6-8 education, Master’s degree,
suburban, 501-1000 students enrolled, and school grade configuration of 6-8 (refer to
Appendix F). The following texts and data tables will present the findings of the study
that pertain to Research Question One.
Table 4.1. Participation Data
Total Principals Contacted Principals who completed
the Survey
Principals who participated
in the Interview
150 52 15
Table 4.3. Demographic Information of Participants
Principals
that
partici-
pated in
the Survey
Male Female Transgender
(mtf)
Transgender
(ftm)
Responses
21
42.0%
29
55%
0
0.0%
0
0.0%
50
White Hispanic
or Latino
Black/African
American
Native
American/
American
Indian
Asian/
Pacific
Islander
Other
(please
describe)
Responses
44
83%
1
>1%
0
0.0%
0
0.0%
3
>1%
0
0.0%
48
Note: The (2) Principals who did not declare gender are not listed in chart above. The four (4)
principals who did not declare their ethnicity and are not listed in the chart above.
Diagram 4.4 A Comparison of Race among Participating Middle School Principals.
97

Note: The four (4) principals who did not declare their ethnicity and are not listed in the
chart above.
A frequency and percentage distribution of school communities and student
populations for this study are presented in Table 4.5 and Table 4.6 (see Appendix F for
Table 4.7, and Table 4.8). Suburban school communities (20,000-50,000 people) had the
highest rate of principal participation in the study at 38.8%. The Other category, defined
as regional charter school communities and/or regional suburban or rural school
communities, presented the lowest rate of principal participation with a percentage of
12.2%. Most principals administer in schools with student populations of 1000 or less.
Seventy-two (72.2%) of the principals surveyed work in neighborhood public schools.
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Table 4.5 A Comparison of School Community Demographics
School Community N %
Urban
(50, 000+ People)
7 14.3%
Suburban
(20,000-50,000 People)
19 38.8%
Rural
(0-25,000 People)
17 34.7%
Other
(Regional Suburban/Urban &
Regional Charter)
6 12.2%
Total 49 100%
Note: The (3) Principals who did not declare community category are not listed in chart
above.
Table 4.6 Comparison of Schools
Type of School N %
Charter Public 1 5.6%
Regional Public 3 16.7%
Neighborhood Public 13 72.2%
Other
Regional Charter/All-City Public)
1 5.6%
Total 18 100%
The data collected from the Massachusetts Department of Elementary and
Secondary Education (DESE) website listed more females in the principal role than males
in the state. This demographic factor may or may not correlate to a possible lack of
gender sensitivity to cases of pre- and/or early adolescent females ages 10- to 14-years-
old who engage in NSSI behaviors.
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Gender.
The gender breakdown of participants included 21 males and 29 females (see
Table 4.3). The researcher hypothesized that gender would be a variable of statistical
significance in regards to addressing NSSI in school. It was pondered that male and
female principals report differently the degree of addressing NSSI as an important
leadership role. Whereas, one gender would be more attune to the behaviors of NSSI
among pre- and early adolescents. In addition, the variables of administrative experience
and the level of education would also determine the importance placed on addressing
NSSI by a practicing principal. It was hypothesized that these two additional variables
would affect the perceptions principals have of NSSI, NSSI behaviors, students who
engage in NSSI, and the degree of importance NSSI has as part of the leadership role.
Tables 4.9, 4.10, and 4.11 compare the demographic information with that of question
#12 “NSSI is an abnormal stage of development in pre-adolescent’s and/or early
adolescent lives”.
It was posited that male principals would respond less in agreement that NSSI is
an abnormal stage in adolescent development. It was thought that if a male principal
does not perceive NSSI to be life threatening, less urgency may be given to a female
student who engages in NSSI behaviors. Although literature does not demonstrate one
gender responding to NSSI over the other, the literature does demonstrate a higher
percentage of females engaging in NSSI behaviors than males the same age. For the
purpose of this study, it was hypothesized that female principals would perceive NSSI as
an abnormal stage at a higher percentage than male principals. It was thought that male
principals may not be as comfortable probing into the personal lives of pre-adolescents
100

and early adolescent females or may be unaware of the behaviors demonstrated by a
student who may be self-injuring due to issues of student privacy.
The gender of a principal was compared to survey question #12, if NSSI is an
abnormal stage in adolescent development. Ninety percent of male principals responded
in agreement to the statement that NSSI is an abnormal stage versus the 86% of female
principals. The cross-tabulation measured the nominal scale (1=male, 2=female) with the
likert scale (1= strongly disagree to 5= strongly agree) of the statement “NSSI is an
abnormal developmental stage in a pre-adolescent’s and/or early adolescent’s life”.
Table 4.9 demonstrates the results.
Table 4.9 A comparison of the perceptions of NSSI as an abnormal developmental stage
in pre- and early adolescent development with gender.
NSSI is an abnormal developmental stage in pre- adolescent’s and/or early adolescent’s
life.
How
would you
describe
yourself?
Strongly
disagree
Disagree Agree Mostly
Agree
Strongly
Agree
Total
Male
0
0.0%
2
10.0%
1
5.0%
12
60.0%
5
25.0%
20
100.0%
Female 2
7.1%
2
7.1%
1
3.6%
13
46.4%
10
35.7%
28
99.9%
Transgen-
der (m-f)
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
Transgen-
der (f-m)
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
Note: (4) principals did not respond to question #12. Their missing responses are not listed in the
chart.
A combined eighty-four percent (84%) of participating Massachusetts’ middle
school principals perceive NSSI to be an abnormal developmental stage in a pre- or early
adolescent’s life (see Diagram 4.10). This was a strong finding because it demonstrated a
consistency of principal opinion throughout Massachusetts.
The results of the cross-tabulation 4.9 demonstrated a strong finding that posits
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NSSI to be an abnormal stage in pre- and early adolescents. However, it did not prove
the hypothesis that males are less likely to perceive NSSI as a normal developmental
stage in adolescents. As demonstrated in Table 4.9, four females versus two males
disagreed with the statement that NSSI is an abnormal developmental stage. In the range
of mostly agree to strongly agree, males responded in agreement at a rate of 18 in
comparison to the 24 of female respondents. Taking into consideration that out of the 20
male principals who responded to the survey question, 90% of males believe NSSI is not
a normal stage in adolescent development. However, 82% of females responded in
agreement. Also refer to Diagrams 4.11a and 4.11b.
Diagram 4.10 NSSI is an abnormal developmental stage in a pre-adolescent’s and/or
early adolescents life.
Note: Four (4) principals did not answer the question and are not listed in the diagram above.
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Chart 4.11a & 4.11b. Comparison of the perceptions of NSSI as an abnormal
developmental stage in pre- and early adolescent development with gender.
Note: (4) principals did not respond to question #12. Their missing responses are not
listed in the chart.
103

The null hypothesis challenged the research hypothesis by stating that no
statistical difference existed between the means of the two groups (male and female)
other than by chance (Salkind, 2011). The Chi-Square Analysis provided a Pearson Chi-
Square result of 2.4411 with a p-Value of .09984 (> 0.05). There is not sufficient
evidence to reject the null hypothesis (p> .05%). Gender is likely correlated to the
perception of NSSI as an abnormal stage in pre- adolescent and early adolescent
development.
Gender was also compared to the interview statement “I think the principal plays
a role in addressing NSSI behaviors within the student population of his/her school”.
Although only 7 females answered the survey question, all 7 (100%) answered with
Mostly Agreed. Whereas, 9 males answered the same question, the results were scattered
in four separate categories. Three male principals (30%) answered in the mostly agreed
category, 3 (30%) in the agreed category, 1 (10%) in the mostly disagree category, and 2
(20%) in the strongly disagree category. Although 6 of the 9 male principals answered in
agreement, the 3 in the negative response may be reflective of the difference gender of a
principal may play affects the degree to which they address NSSI among the adolescent
female population. When the researcher performed a chi-square, a score of 7.4667 was
measured and a p-value of .8253. This obtained value is more extreme than .05, so the
null hypothesis cannot be accepted. Both measures point to gender as a variable that
effects correlation to the perception of the role a principal in addressing NSSI. See Table
4.12 below.
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Table 4.12 The Principal plays a role in addressing NSSI behaviors
I think the principal plays a role in addressing NSSI behaviors within the student
population of his/her school.
1 2 3 4 5 Total
Respondents
How would
you describe
yourself?
Male 0
0.0%
3
30.0%
3
30.0%
1
10.0%
2
20.0%
9
Female 0
0.0%
7
100.0%
0
0.0%
0
0.0%
0
0.0%
7
Note: the categories Transgender (mtf) and Transgender (ftm) were excluded from the chart as
there were no participants that had qualified under the two categories.
Administrative Experience.
Administrative experience was another factor proposed as an influence on the
perception of the role of principal in addressing NSSI. Demographic data demonstrated
that fifty-two percent of the participating principals have served in an administrative
position for less than 10 years during their career. Forty-eight percent have served for
more than 10 years. The researcher performed a cross-tabulation of the nominal data
(1=0-2 years, 2=3-5 years, 3=6-10 years, 4=10-15 years, 5=16+ years) with the Likert
scale (1= strongly disagree to 5= strongly agree) of the following statements: “NSSI is
an abnormal developmental stage in a pre-adolescent’s and/or early adolescent’s life” and
“I think the principal plays a role in addressing NSSI behaviors within the student
population of his/her school”. Refer to Table 4.12 above and Diagram 4.13 in Appendix
F.
The researcher hypothesized that principals who have served in administration for
10 or more years would be less likely to perceive NSSI as an abnormal stage of
development. Furthermore, the same principals would not consider addressing NSSI
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directly to be an important part of the role of principal. The researcher posited these two
hypotheses based on the fact that the literature that describes NSSI apart from a mental
health disorder, such as bipolar disorder or multiple personality disorder, had only begun
to emerge within recent years. In addition, it is pondered that the length of time
principals serve, the less likely they are to respond with urgency to behaviors of NSSI.
Table 4.14 demonstrates the greatest difference regarding NSSI as an abnormal
developmental stage to be among those principals who have practiced two or less years in
the position. Twenty percent (n=2) of principals under 10 years strongly disagreed versus
a combined 80% (n=6) in agreement with the statement. The researcher believes this
difference may be due to a lack of exposure by some principals to NSSI in their schools.
Educational training recently offered to new principals on NSSI may explain a high
percentage of principals responding in agreement to the statement.
Table 4.14 A comparison of the perceptions of NSSI as an abnormal developmental
stage in pre- and/or early adolescent’s life with years of administration.
How
many
years
have
you
served
as an
admini
strator
in your
career?
NSSI is an abnormal developmental stage in pre- and/or early
adolescent’s life
Strongly
Disagree
Disagree Agree
Mostly
Agree
Strongly
Agree
0-2 years
1
20.0%
0 0 3
60.0%
1
20.0%
3-5 years
0
0.0%
0
0.0%
0
0.0%
5
100.0%
0
0.0%
6-10 years
1
6.3%
2
12.5%
0
0.0%
8
50.0%
5
31.3%
10-15
years
0
0.0%
2
13.3%
2
13.3%
4
26.7%
7
46.7%
16+ years 0
0.0%
0
0.0%
0
0.0%
5
71.4%
2
28.6%
Note: A total of (48) principals answered question #12. Four (4) principals did not answer
the question. The missing responses are not listed in the chart.
Principals who have 6 to 10 years experience varied greatly in opinions among all
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Likert scale categories. As seen in Table 4.14, 18.8% (n=3) of principals in this category
disagreed with the statement that NSSI is an abnormal stage in development for females
ages 10- to 14-years-old. In contrast, 81.3% (n=13) agreed to the statement. During data
analysis, the researcher posited if this 18.8% perceive NSSI to be a normal
developmental stage in female adolescence. This prompted the need for further
investigation into this perception during the interview phase.
It was hypothesized that the length of time in administration is connected to the
urgency given to address female adolescents identified as engaging in self-harm. Those
principals who have extended time in administration were hypothesized to approach
NSSI with less urgency and less agreement that NSSI is an abnormal developmental
stage in pre- and early adolescent lives. Table 4.14 showed that principals who have
practiced for 16 or more years responded in a combined agreement (100.0%, n=7) in
response to the survey question.
A Chi-Square test was performed with a result of 18.463, a p-Value of 0.2975.
There is not sufficient evidence to accept the null hypothesis providing that equality is
distributed equally throughout years of experience and how they perceive NSSI in
adolescent development. Years of experience as a principal is likely correlated as
contributing to the perception of NSSI. However, the data did not demonstrate research
hypothesis. As seen in Table 4.14, the calculations of principals serving ten or less years
in administration appear to be more diverse in perception of NSSI than those of 10 or
more.
In respect to the survey statement “I think the principal plays a role in addressing
NSSI behaviors within the student population of his/her school”, greater diversity was
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seen in those principals who have served ten or fewer years in administration. Refer to
Table 4.16.
Table 4.16 Principal plays a role in addressing NSSI
I think the principal plays a role in addressing NSSI behaviors
within the student population of his/her school.
How many
years have
you served as
an
administrator
in your
career.
Strongly
Disagree
Agree
Strongly
Agree
0-2 years
0
0.0%
1
10.0%
0
0.0%
0
0.0%
0
0.0%
1
3-5 years
0
0.0%
1
10.0%
1
33.3%
0
0.0%
0
0.0%
2
6-10 years
0
0.0%
1
10.0%
2
66.7%
1
100.0%
1
50.0%
5
10-15 years
0
0.0%
4
40.0%
0
0.0%
0
0.0%
1
50.0%
5
16+ years
0
0.0%
3
30%
0
0.0%
0
0.0%
0
0.0%
3
Total
0
0.0%
10
100%
3
100%
1
100%
2
100%
16
The Pearson Chi-Square produced a result of 9.973 and a p Value of .868. The
null hypothesis is measured at 5%, or p < .05. In this chi-square, the result is greater than
the null hypothesis at .868 or 86%. The calculation accepted the research hypothesis.
Level of Education.
Fifty-seven percent of participating Massachusetts principals possess a Master’s
degree and a combined forty percent possess a Certificate of Advance Graduate Studies
(C.A.G.S.), Doctorate of Education (Ed. D.), Doctor of Philosophy (Ph.D.), or in the
process of earning a C.A.G.S., Ed. D., or Ph.D. (see Diagram 4.17). Using these data, the
hypothesis was tested that a principal’s education level is a factor of influence on the
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perceptions he or she has of NSSI and of the students that engage in NSSI behaviors.
Diagram 4.17: Highest level of education attained
The researcher hypothesized that principals with higher educational degrees my
be more likely to hold NSSI as an important part of their leadership role. To test this
hypothesis, two cross tabulations were performed. The first cross tabulation used NSSI as
an abnormal developmental state and the level of education principals reported. Nominal
categories were designated 1=Master’s degree, 2=C.A.G.S., 3=Ed.D., 4=Ph.D., and
5=Other. Eighty eight percent (N=43) of principals perceived NSSI as an abnormal
behavior (Refer to Table 4.18). Twenty-seven of the total 49 participants were
categorized as Master’s degree recipients. Within this education level bracket, 23
participants responded in agreement to the statement that NSSI is an abnormal behavior.
This provides a 96% result that principals who have achieved a Master’s degree believe
NSSI is an abnormal developmental stage of female adolescent development. With the
exception of 2 principals with Ed.D., the majority of principals with post-bachelor’s
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degrees (91%, n=22) mostly to strongly agree with the statement posed in the survey.
Table 4.18. A comparison of the perceptions of NSSI as an abnormal developmental
stage in pre- and/or early adolescent’s life with level of education.
NSSI is an abnormal developmental stage in pre-adolescent’s and early adolescent’s
development
Strongly
Disagree
Agree
Strongly
Agree
What is
the
highest
level of
education
you have
attained?
Master’s 0 4 2 13 8
C.A.G.S. 0 0 0 3 2
Ed.D. 2 0 0 3 2
Ph.D. 0 0 0 0 2
Other 0 0 0 1
1
Note: A total of 49 principals answered question #12. Two (2) principals did not answer the
question. Their missing responses are not listed in the chart.
A Chi-Square test was performed in addition to the cross tabulation. The Pearson
Chi Square result was 21.7334, with 20 degrees of freedom. The test resulted in a p-
Value of .3552, which is greater than < 0.05. Therefore, there is not significant evidence
to reject the null hypothesis and it can be assumed that the level of education affects the
perception a principal has of NSSI.
The second cross tabulation was performed comparing the highest level of
education attained with the survey statement “I think the principal plays a role in
addressing NSSI behaviors within the student population of his/her school”. With a
Pearson Chi-Square mark of 12.3056 and a p-value of .9052, the second cross tabulation
also failed to provide significant evidence to reject the null hypothesis. It can be assumed
then, that the level of education of a principal and the perception of the role a principal
plays in addressing NSSI are correlated.
Table 4.19 Comparison of the level of education and the role of principal in
addressing NSSI
I think the principal plays a role in addressing NSSI
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behaviors within the student population in his/her
school.
What is the highest
level of education
you have attained?
Strongly
Disagree
Agree
Strongly
Agree
Total
Bachelors
0 0 0 0 0 0
Masters
0 7 2 0 1 10
C.A.G.S.
0 1 1 1 0 3
Ed.D.
0 0 0 0 1 1
Ph.D.
0 1 0 0 0 1
Total
0 9 3 1 2 15
Note: A total of fifteen (15) principals answered the question of education level attained.
Their responses were used in this cross tabulation.
The null hypothesis stated that a relationship of chance existed between the two
variables at a p-Value of >.05. Since the p-value of both cross tabulations was .3552
and .9052, respectively, there is statistical significance between the level of education of
a principal and the perception of the role a principal has in addressing NSSI among pre-
and early adolescent females.
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MANCOVA of the combined variables.
The researcher also performed a MANCOVA analysis. The data demonstrated
that gender, level of education, and years of experience in administration were
statistically strong factors in the development of a perception of NSSI (see Table 4.20 in
Appendix F). The amount of years in the current administration (p=.545) as well as the
overall career administrative role (p=.269) revealed a failure to accept the null hypothesis
since it can be interpreted that a perception is formed not simply by chance but with on-
the-job experience and education. Refer to Table 4.19 (above) and 4.20 in Appendix F.
Based on the significance of these results, it is possible to assume that the results of these
tests can apply to the generalized pool of principals across Massachusetts.
Data analysis from Phase One demonstrated career experience to be a greater
factor than education and administrative programs. Based on the responses, it appeared
that many principals had little to no training in NSSI in their educational programs. Yet,
of those principals, the data demonstrates that almost all of them have learned about
NSSI from previous positions in their careers or during their current role as principal. It
is believed that this experience has shaped the perceptions each principal holds of NSSI
and of the individuals who engage in self-harm.
Qualitative Data Analysis
The interview probed deeper into the degree to which middle school principals
consider addressing NSSI among adolescent females to be an important leadership role
(Research Question One). This section is organized by: (a) Phase Two Individual
interviews, (b) Research Question One key findings.
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Phase Two Individual Interviews
Fifteen Principals (15) participated in Phase Two. One (1) interview was
conducted face-to-face and fourteen (14) interviews were conducted via telephone. The
researcher inquired about the perceptions that principals have on their role in addressing
NSSI. Many of the participants declared their role as a secondary member in support of
guidance counselors or school psychologists. One principal said she believed there is a
“grey area” when it comes to the level of importance principals place on addressing
students who engage in NSSI behaviors. She believed that the degree of leadership role
“depends on what type of support systems a school has, in terms of guidance, role of a
school psychologist, [as theses individuals are] more trained than a principal.” Another
principal echoed the previous participant when she said: “the role a principal plays in
addressing NSSI depends on how much support there is in a building. How deep the role
of a principal depends on how much training a principal has in comparison to other staff
members in the building.” Repeated statements alluded to a lack of a defined importance
addressing NSSI as part of the leadership role of principal.
Unlike the preceding principals who reported the uncertainty of the degree of
importance they should place on addressing NSSI, one principal believed the small size
of his school impacts the level of importance for him.
“I believe a small school has impact. I know all students since this is a small
school of 392 kids, from Pre-kindergarten to 6th
[grade]. I feel the importance of
connecting with the kids, especially the girls that need a male figure to connect
with. It is beneficial, but I work closely with the school nurse since [these] girls
also seek out a female to connect with.”
To him: “If [students are] presenting themselves [with behaviors of NSSI] or hearing
about it electronically, on Instagram or other sites, I’ll connect with people here. I’ll have
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conversations with the teachers of the students and with the parents of the students.” His
responses demonstrated a role opposite of most participants - one of an active participant,
if not leader of a crisis team. The importance of personally connecting with students
suspected of engaging in NSSI was evident.
The lack of understanding of NSSI and the uncertainty as to what role a principal
should play in addressing NSSI was also evident in participant responses. In one
example, a participant responded to the interview question with a sense of frustration:
“I don’t know [what role] I should play. I really am not prepared to answer this
question at the moment.” When prompted to indulge me with the meaning of their
statement, the principal explained: “I have a tough time understanding why girls cut. I
don’t get that. I don’t understand other than they are looking for attention, looking for
some help” and “why are they hurting themselves. That’s my biggest struggle.”
The lack of understanding of why students engage in NSSI appeared be streamed
throughout the interviews. According to some participants, this lack of understanding
appears to add further challenge as they attempt to define the level of importance they
give to addressing NSSI. Participants felt uncertain of the reasons why a student would
engage in self-injury. A number of principals questioned if NSSI is a cry for help or a
cry for attention. One principal believed he may have had a student who was cutting her
forearm for attention from her peers and family members.
“I was unsure if she was hurting herself because certain Hollywood celebrities
admitted to cutting and other self-mutilation. Like it was the ‘cool’ thing to do to
have her peers pay attention to her. The child admitted to using media sites that
demonstrated how to self-harm and she found them interesting. It was hard for
me and my staff to determine if she needed help or attention from her peers,
teachers, and parents. To not understand why a child would hurt herself and then
combine that with not knowing her reasons, it was a tough call.”
Bowman and Randall (2012) and Whitlock, Purington, and Gershkovich (2009) described
the factor of social media as a contributing factor that brought NSSI to the forefront for
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adolescents. Widespread media exposure, whether from celebrity interviews, magazine
articles, online blogs, or websites designed to encourage or discourage NSSI have
flooded the social media formats of adolescent females. Nixon et al. (2008) believe when
media is combined with the factors of low self-esteem, abuse, neglect, and/or disorders, it
may contribute to NSSI behaviors among pre- and early adolescent females.
On the contrary, several participant statements described NSSI as a method of
coping with the stressors in each student’s lives. One principal was quoted: “it [NSSI] is
a maladaptive way of coping with home life, social life, or academic pressures; it is not a
result of a mental illness or desire to kill herself.” Linehan (1993) believed the
combination of external and internal factors prompted an individual with emotional
buildup to seek a release through methods of self-harm. The intent to take one’s life is
not present, yet the desire to remedy pain or suffering is the main purpose of NSSI (Junke
et al., 2011). The Mayo Clinic (2012) alludes to the emotionally empty adolescent
engaging in NSSI in order to feel something, even if it is pain. NSSI behaviors allow a
student to seek relief from a state of extreme anxiety, sadness, anger or hyper-arousal
(Mayo Clinic, 2012; Nock & Prinstein, 2004).
Echoing the literature of NSSI, this principal knows that “having perspective [of
NSSI] is powerful. I am pretty sure my colleagues are clueless on it…and to be able to
see a really damaged kid, and they do have some stuff, but they just need some help.”
One principal resonated the findings of Junke, Granello, and Granello (2011)
when she referred to the combination of biological, psychological, and social factors with
potential risk factors like abuse, neglect, and co-morbid psychological disorders:
“females who experience risk factors, either in school or at home, develop
negative self-images. Some may have anger or frustration and others may act
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out. If we don’t get them the help they need, these destructive behaviors will only
replicate and cause even greater negative self-images and self-harm.”
Her understanding of NSSI provided a perspective different from other colleagues.
However, like other middle school principals in Massachusetts, she is unsure of the
degree to which her job can be consumed in addressing NSSI. Like her colleagues, this
principal does not feel she has adequate time to address students identified as engaging in
NSSI behaviors.
A small group of principals believe or know of Massachusetts’ principals who
believe that NSSI is a result of a mental illness. Statements like: “students that engage in
this type of behavior are begging for some medical attention” or “some of my peers
think: ‘this kid is going completely crazy; this kid is suicidal” were threaded throughout
the interviews. Multiple principals stated a lack of involvement or a passive
involvement, second to guidance, in addressing students identified with NSSI behaviors.
Themes.
The researcher identified several emerging themes gleaned from the interview
statements of the fifteen principals: (a) lack of understanding, (b) job limitation, (c)
school support system, and (c) training in NSSI. This section will describe each theme
identified in the data gathered, analyzed, and recorded.
Lack of Understanding.
In addition, principals questioned the reasons why pre-and early adolescent
females engage in NSSI behaviors and the factors that contribute to NSSI behavior.
Without understanding NSSI, principals find it difficult to quantify the degree of time and
energy spent on addressing NSSI in their schools. One principal stated that despite
round-table discussions with principals throughout Western Massachusetts, these topics
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rarely come up in conversation. “Principals tend to work in isolation from one another,
even though we are doing a lot better in terms of networking in Western Massachusetts
these days. We do host round table discussions about this, that, and the other thing. Yet,
at the principal level, these topics are not addressed formally. And, I don’t believe that is
necessarily a bad thing. In a school the folks who know their stuff are the point people,
in this case, it would be our guidance counselors.”
Job Limitation.
Several participants described a certain level of uncertainty in respect to the
degree of importance they place on addressing NSSI among their female student
populations due to the limit of professional time and the abundance of job
responsibilities. One principal lamented:
“I not do much of anything. Most of the students who need administrative
assistance see one of the vice principals or the guidance [counselors]. I do not
have the opportunity to aide in the intervention of students identified in engaging
in NSSI behavior. I just don’t have the time to spare.”
Many participants stressed the overwhelming number of responsibilities principals have
today. Addressing NSSI behaviors is not an important part of their role. Principals
believed the limitations of their role, in regards to time and content knowledge prevent
them from considering NSSI to be an important part of their role. According to
principals, this can be especially true when they have staff members in their schools that
are either better trained or more familiar with NSSI and NSSI behaviors.
“I am the point person on curriculum, assessment, instruction, and five hundred
other things which includes the safety and well-being of all my kids, but this
[NSSI] is not my area of expertise, so I trust the guidance folks to do their job and
I like to be kept abreast of what’s going on. I don’t believe I should take the lead
in determining the course of action.”
In one participant’s school, the psychologist is contacted by a staff member, who then
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immediately begins the intervention plan singlehandedly.
School Support System.
The type of support system that exists in a school appeared to be a factor in regard
to the degree a middle school principal considers NSSI to be part of the leadership role.
The support system that was referenced throughout the interviews included members of
guidance, psychologists, and behavioral specialists.
Principals that lacked a structured guidance department and/or in-school
psychologist believed the principal played a larger role in addressing NSSI. One
participant explained: “since there are only two guidance members in my school, we tend
to work as a close team when addressing health concerns of our students.” On the
contrary, those principals who were able to rely on other staff members within the
building, declared playing secondary, or supportive roles. “The role of principal becomes
supportive in nature, as others in the school are more trained than myself. The more
support there is in the building, the more shallow the role of the principal is, and vice
versa.” This belief was seen again in a statement collected from a principal in a school
with a large guidance department and an in-house school psychologist: “ [I] allow
guidance to take control of addressing students with social, emotional, and physical
issues.”
Training in NSSI.
A lack of training in NSSI among administrators was identified as a common
thread throughout interviews. Many principals stated they felt unsure of making
decisions in regards to NSSI since they have little knowledge of NSSI as a behavior.
“Girls go through different times than we did. Peers, media influence, family
options for growing up, growing up itself, dealing with outside forces. A girl’s
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stress is not in her head. It manifests in eating disorders, external self-abuse, and
other bad choices that can lead to grave health concerns. This is beyond my scope
of knowledge. And, so far, no one has given principals the tool kit needed to
address the growing societal and family influences pushed on our girls.”
In addition, the same principals felt a lack of comprehension of why students
engage in NSSI behaviors. “I understand that self-mutilation is a symbol of stress that is
placed on the individual, but I cannot understand how these… in essence… little girls can
take a knife or a razor or pen tip to their body and rip the flesh open.”
To other principals who possessed a basic understanding of NSSI, the need for
formalized administrative training in NSSI was a common thread that ran throughout
their interviews.
“During my undergrad, I earned a minor in psychology. I learned about NSSI
during those courses, yet so much has changed since then. So much more is
known about NSSI than 10 or so years ago. It is necessary for school districts to
provide administrators training in NSSI, especially since it appears to be a
growing trend in schools among our pre-teen students.”
Although this principal felt he had knowledge of NSSI, his concern was that the
information was outdated and lacked the concentration of NSSI that usually comes along
with suicide prevention training offered in schools.
Key Findings
Data analysis revealed several key findings in response to Research Question
One. The demands placed on administrative schedules of current Massachusetts’
principals appeared to be a key factor determining to what degree a principal addresses
NSSI among females 10- to 14-years-old. Multiple principals reported feeling as if their
schedules make them unavailable for other ways to address NSSI among adolescent
females beyond a consultation with Guidance or School Psychologists. Although some
principals consider themselves to play a primary role in addressing NSSI, most
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interviewees believe they are secondary members, or a supportive role, of a crisis team.
Another key finding relayed a lack of knowledge of NSSI behaviors, the ways and
means of addressing NSSI, and methods of preventing NSSI behaviors. Participants
reported minimal educational programs, courses, and professional development series
offered to administrators. Upon further investigation, the researcher discovered graduate
schools, administrative programs, and professional development organizations do not
address topics on the emotional, mental, and physical health of students in the middle
school for principals. If a principal would like to become informed on NSSI, he or she
should consider enrolling in a course designed for guidance counselors, psychologists,
and other health care professionals. In addition, most of said courses are not published in
magazines, blogs, or other media forms addressed to administrators.
However, many principals reported gaining knowledge through career
experience. Principals with 6 or more years were hypothesized to address NSSI more
callously than their peers fresh into the field. However, data analysis demonstrated an
opposite effect. Many administrators with more than 6 years in their role as principal
believe they gained their knowledge of NSSI behaviors through yearly exposure to
instances of students engaging in NSSI behaviors. These principals declared a close
working relationship with guidance and health care professional within the building, ones
in which principals allow others to take the lead position on addressing NSSI.
Research Question Two: What Are the Various Ways Middle School Principals
Report They Are Addressing Non-Suicidal Self-Injury Among Adolescent Females?
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This section will present data collected according to Research Question Two.
The information was also gathered from the mixed method strategy used where Phase
One was the Survey Instrument and Phase Two was the One-to-One Interviews. The
subsections of Quantitative Method are: a.) Demographic Information Analysis, b.)
Gender, c.) Administrative Experience, and d.) Gender, Administrative Experience, and
Level of Education Compared. Qualitative Method will consist of Individual Interviews.
Once Data has been presented from the Quantitative Method, the researcher will present
the Themes. Themes will have several subheadings: i) Facilitative Role, ii) Supportive
Role, iii) Knowledge of Cases of NSSI, iv) Approachability, and v) Availability. Key
findings from the mixed methods will summarize the results.
Research Question Two examined the ways in which principals report addressing
NSSI among adolescent females in school. It was hypothesized that gender, education
level, and years of administrative experience influenced the perceptions of NSSI held by
current Massachusetts’ principals. These perceptions were theorized to contribute to the
various ways in which practicing principals address, or fail to address, NSSI among pre-
The data gathered from the Likert scale compared several questions in order to
glean perceptions held by current principals across Massachusetts. It aimed at divulging
principal-held perceptions of female students that engage in NSSI behaviors. The
researcher hypothesized that principal perceptions of NSSI and of those students who
engage in self-harm 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
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day-to-day responsibilities of their job. This decision would dictate what actions a
principal takes in addressing NSSI. In addition, the researcher examined the survey
instrument for the possibility of revealing under-reported cases of NSSI behavior
committed by adolescent females within middle schools across Massachusetts.
Gender.
A total of 90.5 % (n=19) of male principals and 96.4% (n=27) female principals
disagree with the survey statement that pre- and early adolescent females who self-injure
are violent. The majority of principals (n=44) disagree with the statements that those
who commit NSSI behaviors are low performers at school. Of that 44, males constitute
19 (90.5%) and females constitute 25 (89.3%). It was also negated greatly that NSSI is
more prevalent in female students who engage in other maladaptive behaviors (n=43,
M=20, F=23), and are not outgoing, pretty, athletic, intelligent, or involved in school
activities (n=35, M=14, F=21). See Table 4.21 a-d.
Table 4.21a Principal perceptions of female students who engage in NSSI behaviors.
Female
Students who
engage in NSSI
are violent
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 11 8 1 1 0 21
Females 9 18 0 0 1 28
Total 20 26 1 1 1 49
Table 4.21b
Female students who
engage in NSSI are
low performers in
school.
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 8 11 1 1 0 21
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Females 8 17 0 3 0 28
Total 16 18 1 4 0 49
Table 4.21c
NSSI primarily affects
female students who engage
in drugs, smoking, or other
maladaptive behaviors
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 10 10 1 0 0 21
Females 7 16 3 0 0 26
Total 17 26 4 0 0 47
Table 4.21d
Female students who
engage in NSSI are non-
athletes and do not engage
in extra-curricular
activities.
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 6 13 0 2 0 21
Females 3 18 1 3 0 25
Total 9 31 1 5 0 46
According to Favazza (1998), acts of self-harm are motivated by a need for
security, escape, enhanced sexuality, euphoria, emotional release, and impassivity,
among others. It is the “purposeful, direct destruction of body tissue without conscious
suicidal intent” (American Psychiatric Association, 2012). Eighty-Five percent (n=39) of
the 46 principals who answered, agreed that acts of self-harm serve as a cry for help. To
Nixon and Heath (2009), acts of self-mutilation are completed in secrecy, often hidden
from medical, clinical, and academic persons because they serve as a private mode of
coping. This form of self-injury is intentional with low-lethality bodily harm performed
to reduce and/or communicate psychological distress (Walsh, 2012). It is not conducted
to solicit help from others, especially from those in roles of authority.
Literature supports the argument that NSSI serves as a maladaptive coping
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strategy employed by students who suffer from psychological and emotional distress, not
as an outcry for help. According to Nixon and Heath (2009), most pre-adolescent and
adolescent females desire to remain anonymous out of fear of how others will perceive
them and their injuries. For principals, hidden injuries make the discovery process
difficult. It becomes even more difficult to address NSSI when principals do not know
what to look for as possible signs of NSSI. If a principal does not perceive NSSI to be an
urgent matter to address, female students have a potential to maintain this behavior into
adulthood.
Eighty-three percent (n=43) of male and female principals stated that pre- and
early adolescent females who engage in NSSI are not likely to abuse drugs, smoking, and
other negative behaviors. See Table 4.21c. In contrast, according to Bowman and
Randall (2012), some adolescents with NSSI may suffer from substance abuse. An
adolescent’s desire to escape reality or seek refuge from current stress may have
compounding bodily abuses, like substance abuse, in combination with NSSI behaviors.
When compared with the quantitative data on NSSI as an abnormal state of
adolescence, a combined 84% of principals agreed with the statement. In considering the
reasons for NSSI, both genders (90%, n=43) agreed that shame, anger, and sadness
prompt a student to harm herself. A combined 25 (56%) of the participating 45 principals
who answered believe females who were sexually or physically abused are more likely to
engage in NSSI behaviors. Yet, a combined 62% (n=29) negate being a child of a
divorced, separated, or single-parent households as a reason for self-harm.
Literature demonstrates the use of self-harm as a means of expressing strong
negative emotional experiences such as pain, hurt, loss, or anger (Favazza, 1998). This
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type of emotional regulation (Favazza) allows the adolescent female to focus on a
physical pain instead of the emotional pain within them. Kress and Drouhard (2006)
expressed the belief that self-injury may be a chosen method of gaining control over a
personal situation in which the female feels a loss of control. In respect to a divorce,
separation, and/or death of a parent, a female adolescent may seek to engage in NSSI
behaviors in order to relieve overwhelming emotions.
Two of the best predictors of self-harm are childhood sexual abuse and/or family
violence (Kress & Drouhard, 2006). Female victims of physical and/or sexual abuse are
in a constant state of emotional dysregulation and may not develop the capacity needed to
regulate the intense emotions that accompany such trauma. Instead, self-mutilation by
foreign objects, starvation, or extraction may serve to regulate strong emotions (Simeon
& Favazza, 2001).
More male principals (57.2%, n=12) than females (39%, n=11) believed NSSI is a
learned behavior from friends and family members. In contrast, Nixon and Heath (2009)
believed moderate to superficial injuries stemming from self-injury may be the result of
impulsive behaviors in response to bodily or cognitive urges, not from external human
influence. Yet, copycat behaviors are a big concern among middle school-aged children
since adolescents look to peers for guidance on what constitutes socially acceptable and
cool behaviors (Juhnke et al., 2011; Nixon & Heath, 2009). A student self-injurer has the
potential to encourage NSSI behaviors as a means of passage into a group or a close
friendship (Juhnke, et al., 2011; Nixon & Heath, 2009).
Principals were asked if they felt students who self-harm suffer from moderate to
severe mental illness. Sixty-six percent (n=14) of the 21 male participants and 52%
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(n=13) of the 25 female principals disagreed with the statement. However, a combined
41% (n=19) agreed. The disparity between the two subsets of female principals is
minimal, which led to the researcher to conduct a Chi-Square test using the survey
statement “female students who engage in moderate to severe mental illness” with the
gender of the participant. The researcher hypothesized that principals recognize NSSI as
a coping mechanism yet still believe students who engage in NSSI behaviors suffer from
mental illness. The results demonstrated a p=.9958 which does not provide significant
evidence to accept the null hypothesis. Refer to Table 4.22.
Table 4.22 The Comparison of Gender with the perception of females who engage in
NSSI behaviors having a moderate to severe mental illness.
Pearson Chi-Square 2.9646
Degrees of Freedom 12
p-Value .9958
Note: Six (6) principals did not answer this question. Their missing responses are not listed
in the chart.
Most telling was the results to whether or not the majority of principals believe
the individual is attempting suicide when she is engaging in NSSI behaviors. Forty-three
principals (93.48%) did not agree with the Quantitative statement that a student who
engages in NSSI behaviors is attempting suicide. Refer to Diagram 4.23.
In alignment with the literature, participating principals demonstrated the
knowledge that behaviors of NSSI do not reflect a desire to take one’s own life.
According to the APA (2014) the intent of the female who engages in NSSI behaviors is
not of a suicidal nature. Instead, it is considered more to be a coping strategy allowing
for emotional regulation or reset.
Diagram 4.23 Principal perception that a student who engages in NSSI behaviors is
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attempting Suicide
Administrative Experience.
The researcher hypothesized that experience gained as a principal influences the
perception he or she has of a student who engages in NSSI. To test this theory, the
survey instrument asked participating principals about their years serving in
administration, years served in their current administrative position, and various
questions presenting possible perceptions of students who engage in NSSI behaviors.
Diagram 4.24 demonstrates the concentration of years spent during a career as an
administrator at the 6 to 10 and 10 to 15 year marks evenly at 32%. Another 16% have
served for more than 16 years as a principal. This presented a survey heavily completed
by veteran administrators.
Diagram 4.24 Years Served in Administration during Career.
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Diagram 4.25 presents the data gleaned from the survey that illustrated the years
the participants have served in their current administrative position at the time of the
survey. Data revealed a high percentage of principals serving less than 6 years in their
current positions. Fifty-eight (58%) percent of participating principals have served in
their current schools for 5 years or less.
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Diagram 4.25 Years served at current administrator position.
Several Survey Questions highlighted perceptions of principals in regards to how
they currently report addressing NSSI. Survey statement #15 inquired as to whether or
not a principal believes the female adolescent will stop NSSI behaviors on their own
without receiving any therapeutic help. Forty-six principals responded in disagreement,
with the highest concentration ratio (70.8%) in the disagree category. A greater number
of females responded (n=26) in the disagreement categories versus twenty (n=20) males.
Two (n=2) female principles answered in agreement to the survey question.
Gender, Administrative Experience, and Level of Education Compared.
A number of chi-square tests were performed comparing gender, career
experience, and level of education with the ways middle school principals report
addressing NSSI among adolescent females. Multiple tests demonstrated ratings greater
than p = .05, prohibiting the acceptance of the null hypothesis. However, when the
researcher compared the years of experience as an administrator with the survey
statement “A female student who wants help for her NSSI behaviors would seek out her
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administrator or guidance counselor” produced a p-Value .07, greater than p = >0.05, yet
not as great a difference as other chi-test results.
Another question, #32 “Teachers feel comfortable approaching me with a
potential case of NSSI among the student population in my school”, produced a p-Value
of .04. The null hypothesis can be accepted in this question. The researcher noted this
result for further investigation during the interview stage of data collection. It was during
the data analysis phase that the researcher hypothesized the relationship between a
principal and his or her staff may result in successful reporting or a possible
underreporting of NSSI due to a breakdown in communication between the teachers and
principal.
The researcher suggested a subsequent hypothesis: Would participants with 10 or
more years of experience consider NSSI a mental illness and not a maladaptive coping
strategy as suggested by current researchers (Junke et al., 2011; Nock, 2012)? When
analyzed jointly, various questions on the survey demonstrated a collective perception
that principals with 10 or more years of experience have an understanding of NSSI as a
coping strategy and not as an issue of mental illness. However, the survey question
regarding a mandatory psychological evaluation resulted in the greatest difference of
opinion among these veteran administrators. Close to half of the principals (n= 15) that
answered the survey did not believe in the need to have a mandatory psychological
evaluation, where 24 veteran principals agreed to the need for the evaluation. When
questioned about the need to enroll students who were identified as engaging in NSSI
behaviors in prevention programs, 29 principals agreed, while 9 other veteran principals
responded in disagreement. Thirty-seven (n=37) principals believe it is part of the role of
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administration to address NSSI and not solely a family issue. In addition, 37 veteran
principals answered in disagreement to the statement that females who self- injure should
be isolated immediately from their peers.
The level of education a principal has obtained may influence the perception he or
she has in regards to females who engage in self-harm. Several tests were conducted to
compare multiple statements regarding female self-injurers with that of the highest level
of education received by a principal. The results demonstrate a positive effect of
education in regards to the detection and understanding of NSSI among the young female
student population. Those principals who achieved advanced degrees have reported a
higher understanding of the means and ways of identifying a females who engages in
NSSI, means of intervention in a school setting, and methods of preventing individual
NSSI and avoid a contagion effect within the school.
A strong finding was present when participants’ education levels were compared
to the statement “female students who engage in behaviors of NSSI learn such behaviors
from their friends or family members”. The majority of practicing principals spanning all
levels of education disagreed with the statement. Those participants at the Masters level
had the largest subgroup of individuals (42.8%, n=12) who agreed to the statement.
This study attempted to investigate the hypothesis that principals do not perceive
identification, intervention, and prevention of NSSI to be a part of the role as
administrative leader in school. Instead, it was believed that principals relay the
responsibility of the social, emotional, mental, and physical health of students to the
guidance department and school psychologists or social workers. In order to test this
hypothesis, the survey instrument questioned the participants on the role they currently
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play within their everyday position.
One survey question stated that injuries stemming from NSSI warrant immediate
attention from administration. Sixty-eight (n=32) percent of principals responded in
agreement, while 32% (n=15) disagreed. Five principals did not answer the question. A
subsequent survey statement followed that said: “I am aware of the number of incidents
of NSSI among the female pre-and early adolescent population of my school.” In
response to this statement, 77% (n=38) principals responded in agreement stating they are
aware of the number of incidents, while 22% (n=11) principals responded in
disagreement. Refer to Diagram 4.28.
Diagram 4.28 Principals aware of the number of incidents of NSSI among the female
adolescent population in school
Note: Two principals did not respond to this statement.
When responding to the statement #34, “A principal should play an important role
in the identification of students who engage in NSSI behaviors,” 68% (n=32) of
principals responded in agreement. Roughly 39% (n=15) of principals did not agree, and
four principals did not respond to this question. There was no particular marker of
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gender, years in administration, or level of education that distinguished one particular
group to be more in agreement with the statement than others. Statement #35 posits that
principals should play an important role in the identification and intervention of students
who engage in NSSI behaviors. To this, more than half of the 49 principals who
answered the question responded in agreement. Similar to the previous survey statement,
statement #35 did not show any population to be vastly greater than the other.
Question #36 asked if participants believe it is the role of the principal to create
prevention protocols for students who engage in NSSI behaviors. Thirty-six principals
(73.5%) agreed that it is part of the role of principal while 13 (26.5%) principals disagree
with the statement. In line with this question, participants were questioned about the role
a principal plays within a school crisis team. When prompted to respond to the statement
that “I am required to report students who are identified to engage in behaviors of NSSI
to the Massachusetts Department of Elementary and Secondary Education (DESE) and
the Department of Children and Families (DCF) 72% (n= 31) disagreed while 28%
(n=12) were in agreement. The majority of principals (n=33, 68.7%) responded in
agreement to the role as a leader of the crisis or intervention team yet 66%, or 31
principals, responded in agreement to the role of a facilitator in the intervention process.
As well, roughly ninety-one percent of surveyed principals believe they allow guidance
to address NSSI while maintaining communication with them.
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The interview protocol used probed deeper into the various ways middle school
principals report they are addressing NSSI among adolescent females. This section is
organized by: (a) Individual Interviews, (b) Themes, and c) Key Findings.
Individual Interviews. The survey probed into the role of the principal to see if it is one
of a primary or secondary person when addressing NSSI in schools. During the
interviews, Research Question Two attempted to illuminate the various ways principals
report addressing NSSI among their female population. Although the result sought for
Question Two regarded the ways in which a principal reports addressing NSSI, themes
beyond the ways of reporting were uncovered. Below are those themes gleaned from the
interviews.
Themes.
Facilitative Role.
The theme of facilitator appeared throughout the responses of participating
principals. One principal stated that when she and her staff gather each week during
“catch up” meetings, any behaviors executed by the students that appear to peak a staff
members curiosity are discussed. If that particular behavior can appear as a gateway
behavior, the school nurse, the psychologist, and the principal will investigate further. In
the case of NSSI, this principal said: “If we notice a child may be rubbing themselves
with an eraser really hard in class, or drawing lines that may appear as cut marks, this
peaks our curiosity and we investigate immediately.” In this particular case, she is taking
the role of a co-facilitator. In other cases, one principal in a school in Western
Massachusetts calls the students he believes may be harming themselves into his office
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for a lunch date along with some of her friends. In this manner, he can observe the
student thought to be engaging in self-harm without singling her out.
“I watch the young female. I watch to see if she is quick to cover her arms or her
legs- places where students would hide self-injury. I see how she interacts with her
friends, is she outgoing, quite, or disengaged from conversations. This type of
identification process allows me to inspect the suspicions without added to any
stress it may cause the student if done in other ways.”
This principal declared that he liked the role he plays when attempting to identify
potential students of self-harm. Being the head of a crisis team is not what he believes he
is, but more of a team captain – a team in which all members have a facilitative role, not
just himself.
Supportive Role.
In other schools, principals declared themselves secondary members whom serve
to support the guidance counselors or school psychologists when addressing students
identified as engaging in NSSI behaviors. One principal stated: “Honestly, I do not do
much in addressing NSSI. Instead, almost all cases are handled by guidance.” When
further probed, the same principal said: “guidance and teachers are the staff members
who identify and intervene when a student is suspected of engaging in NSSI behaviors…I
am usually approached as details come in on the particular student’s case.” A similar
statement was made by an urban school principal:
“There is a very comprehensive program in place that is run through our guidance
department that is designed to identify students who are cutting themselves. And, a
protocol in place designed to get kids into therapy or other forms deemed necessary.
So, while I don’t run the program myself, I am aware of what is going on and when
we need to put those protocols in place. I am part of the team, but I don’t lead the
team.”
A further participant was quoted: “In my school, all [those] behaviors come to the
guidance counselor, who then deals with the student, who then contacts the family, and
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then I am made aware of the situation.” This principal went on to say: “I prefer the role of
a supporter, an interested party who cares for the health of each student, yet I know my
limitations.”
Knowledge of Cases in NSSI.
Participants were asked if they were knowledgeable of the number of incidents in
their school. The majority of responses believed they were, yet not because they were the
primary person to identify the females who are engaging in self-harm. When the
researcher requested further information on these answers, multiple participants felt they
were not sure they would be able to identify personally the signs of NSSI behaviors in
their students. One principal stated: “I am not sure I would be able to distinguish the
difference between NSSI and suicide attempts. I feel I rely heavily on my staff to
recognize the difference before we begin the intervention process.” Another principal
was recorded: “This is not an area of expertise of mine. Certainly, the more I learn about
this, the better I’d be to deal with it. Until then, I leave this in the hands of others who are
more capable professionals.”
Approachability.
The researcher inquired if participants believe teachers in their schools feel
comfortable approaching them with possible incidents of NSSI. The majority of the
principals (n=12) believe their staff members would approach them with a concern.
However, 3 principals felt the staff members would bring the concern first to the
guidance counselors, who would then bring the concerns to them. One principal stated
that she believes her job as principal is to ensure there is a process in place and monitor
that team regularly. “I am not the candidate to approach in the building since I am not
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the one with the expertise to deal with a student in crisis. I just make sure the process
runs smoothly in the school.”
Availability.
Principals have many roles during the typical school day that fill up their daily
schedule fast. Availability was often quoted as a reason why many principal take a
secondary role to guidance and psychologists during health issues in students.
Participants felt there was not enough available time in their busy schedules to address
suspected cases of NSSI among the student population.
“Due to my busy schedule and my changing location throughout the building, it is
easier for staff members to find the guidance counselors to express their concerns.
Normally, once the guidance counselors have looked into the situation a bit further,
they will approach me to report on the teachers’ concerns. Then, together, we
decide if we should activate the crisis team.”
Due to the time constraints and the constant flow throughout the building of a principal,
this participant felt she played the role of a co-facilitator and one of support to the staff
members acting on the child’s behalf.
Key Findings
The data collected demonstrated an increase in frustration and confusion as to
what ways a principal can engage in the identification, intervention, and prevention
processes of female students in middle school. Survey results and interview responses
revealed a lack of confidence and/or personal competence among principals due to a lack
of knowledge of NSSI and how to best address student self-injurious behaviors.
Although the participating principals recognize the urgency for addressing what they
believe is becoming a more prevalent health concern in their schools, many principals
cited a lack of scheduled availability, mental health resources directed toward
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administration, and the lack of clarity as to the role the state of Massachusetts believes a
principal should play when addressing NSSI in school.
Throughout interviews, participants labeled the role in which they serve in a crisis
team as either a facilitator or a supporter. The individual role appeared to be defined as
to the level of support a principal has on staff. Data demonstrated a school with a fairly
well trained, specified mental health department requires a principal to play a supportive
role; one in which the principal is kept abreast on the information yet not the leader of the
intervention process. On the contrary, schools that tended to be smaller in size with less
staff, tended to require a principal to play more of a facilitative role; one requiring more
decision-making and investment of time on the part of the principal.
Knowledge of self-injury and available resources were factors that limited the role
principals played as well. The mixed methods demonstrated a lack of training options
offered to principals throughout undergraduate, graduate, post graduate and professional
development course offerings. A lack of personal competence needed to best serve the
female population who self-injure was noted multiple times within the interview
responses. Some principals declared an inability to define self-injury. Others were not
able to speculate what correlations or risk factors are associated with NSSI behavior.
Numerous participants have had little, if any, training in managing mental health to be
able to recognize the behaviors of NSSI and how NSSI differs from suicidal intent. With
these boundaries of professional competence, principals feel they are beyond the scope of
their responsibility based on the lack of training, education, and professional experience.
Gender was not a factor in the ways practicing principals address NSSI among
adolescent females ages 10- to 14-years-old as hypothesized by the researcher originally.
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However, a lack of a school-wide self-harm policy was a factor identified within the
interviews. Principals stated the need for their schools to develop a clear and concise, yet
flexible, self-harm policy. Some suggestions included topics like a) when to report
suspected NSSI injuries, b) to which school staff members to report NSSI behaviors, c)
what role do administrators in that particular school policy, and d) how involved with
self-injurious students do principals become.
Research Question Three: What are the factors and conditions that middle school
principals believe inhibit and support their efforts to address NSSI among pre- and
early adolescent females?
This section will present data collected according to Research Question Three.
The information was also gathered from the mixed method strategy used where Phase
One was the Survey Instrument and Phase Two was the One-to-One Interviews. The
subsections of Quantitative Method are: a) Lack of Training among Administration, b)
Lack of Staff Training, c) Lack of Knowledge of Etiology of Non-Suicidal Self-Injury,
and d) Fear of Contagion. Unlike previous questions, the Key Findings for Quantitative
Method is presented immediately after the data. Qualitative Method will consist of
Individual Interviews. Themes will have several subheadings: i) Lack of Training ii)
Suicide versus Non-Suicidal Self-Injury, iii) Lack of Support from Central Office, iv)
Lack of Funding and Time, v) Fear of Contagion, vi) Parental Influence, and vii) Student
Cooperation. Qualitative Method Key findings will summarize the results.
Research Question Three sought to uncover the factors and conditions that middle
school principals in Massachusetts believe inhibit and support their efforts to address
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NSSI among pre- and early adolescent females. It was hypothesized that a lack of
training at the administrative level of principal influenced the perceptions of NSSI.
These perceptions contributed to the various ways in which practicing principals address,
or fail to address, NSSI among pre- and early adolescent females. The data gathered
from the survey instrument compared several questions that gleaned the factors that
inhibit or support actions taken by current principals to address NSSI among the female
student population. Research Question Three aimed at divulging information on the
current training offerings of principals in NSSI, highlight any education in undergraduate
or graduate programs in NSSI, and illuminate individual thoughts on educating students
on the signs and behaviors of NSSI. In addition, it sought to uncover possible inhibitors
like a lack of funding, support staff, and support from upper administration or school
committees.
Themes.
Lack of Training Among Administrators.
Research has shown that NSSI behaviors manifest in early adolescence (Favazza,
1989; Heath, Schaub, Holly, & Nixon, 2009; Sax, 2010). As awareness of NSSI grows,
more cases of female pre- and early adolescents who engage in NSSI are recognized.
This creates a greater need for identification, intervention, and prevention protocols to be
established, implemented, and supported by the middle school administration. The
researcher hypothesized that on-the-job training, professional development, and
administrative programs that instruct principals on adolescent mental health concerns will
allow them to acquire the knowledge for professional competency. Principals that are
properly trained in the etiology of NSSI, recognition of NSSI behaviors, and the methods
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needed to address NSSI in schools, will be able to adequately female students who
engage in NSSI behaviors.
The survey revealed that principals feel a lack of training options offered in
graduate and/or administrative programs compounded with a lack of on-the-job training.
The researcher hypothesized that a lack of training was a factor that inhibits principals
from addressing NSSI within the pre- and early female adolescent populations in school.
It was thought that without training in NSSI, principals would fail to address NSSI
behaviors entirely or fail to impact the female student body in their efforts. To Kress and
Drouhard (2006), students who self injure require skilled educators who are
knowledgeable on the etiology and functions of self-injury, as well as appropriate
interventions. Without such training, principals lack professional competence and skill in
mental health of their female student body.
The survey addressed this area of inquisition in the question: “In my
administrative program and/or graduate studies, I have received training on NSSI, what
behaviors are classified as self-harm, and how to recognize a student who engages in
NSSI behaviors.” Regardless of gender, educational level, and years of experience, 43
principals disagreed with the statement, resulting in a heavy concentration of
Massachusetts’ principals feeling ill-equipped to address behaviors of NSSI. Refer to
Table 4.26 in Appendix F.
The researcher questioned the availability of programs for administrators that
update their training on NSSI throughout their careers. Thirty-one principals answered in
disagreement to the survey question asking if they received training on the job. This
sample of principals believed there is insufficient training during a career. Based on the
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data pertaining to this question, it can be interpreted that there are insufficient course
offerings and/or external programs that offer training in NSSI for administrators.
Without training that provides the knowledge of the etiology of NSSI, a familiarity of
NSSI behaviors, and an established protocol for self-injury, principal actions may hinder,
not help, the female student. To Berger, Hasking, and Reupert (2014) the lack of
knowledge contributes toward a hesitancy to play a crucial role in the intervention of a
student of self-harm. Without confidence and knowledge of the signs and protocols to
address NSSI, a principal is left to play a secondary role when addressing NSSI among
the adolescent female population.
It was also hypothesized that a lack of training leads to a misunderstanding of
NSSI. In the survey statement that asked if principals agree that students who engage in
NSSI as suffering from a mental illness, the majority of participants disagreed with the
statement. To some authors, acts of self-injury serve as a form of emotional release or a
relief from tension or anxiety (Nock & Prinstein 2005; Juhnke, Granello & Granello,
2011; Nixon & Heath, 2009; Sax, 2010). Some students satisfy sexual urges through the
use of self-harm. Milia (2000) compared the function of fetish with a body part to that of
the function a wound may play on an adolescent’s body. Milia (2000) believed that a
wound may become the concentrated object of erotic fascination and fixation, causing the
individual to sustain the injury through further mutilation. Even still, some engage in
NSSI to attain a euphoric high.
Interestingly, participants (n=30) disagreed with the statement that principals are
not familiar enough with NSSI to address the needs of female students in school
suspected of engaging in behaviors of NSSI. This led the researcher to question whether
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principals educated themselves independent of instituted programs on NSSI or received
on-the-job training during their career. A chi-square test was performed comparing on-
the-job training, gender, years of experience, and education. Refer to Tables 4.30a –
4.30c in Appendix F.
Principals who have been in the position for 6 to 10 years (n=15) demonstrated a
greater percentage of agreement to receiving on-the-job training. Due to the ambiguity of
the question it was unclear as to whether the principals receive training on NSSI at the
behest of their district or self-motivation. Seventy percent (n=14) of male principals and
73 (n=19) percent of female principals believe they have updated their knowledge on
their own while on the job.
Lack of Staff Training.
The survey instrument collected data on the opinions of current principals in
regards to the education of staff on NSSI and NSSI behaviors. Principals were asked
whether they believe it should be mandatory for staff to learn about NSSI, NSSI
behaviors, and how to identify a student who engages in NSSI within the school
population. Thirty-nine (n=39) principals expressed the need for training in NSSI for the
staff. Forty-seven (90%) principals believed that staff should be aware of the school’s
protocol for alerting administration and/or guidance if a student is suspected of engaging
in NSSI behaviors. As Nixon and Heath (2009) state: “Working with youth who self-
injure often means that clinicians, mental health professionals, school counselors,
teachers, and youth workers alike are faced with the challenge of how best to understand
the behavior and intervene” (p. 2). Since many researchers have shown that students who
engage in NSSI are among the most difficult to reach (Adler & Adler, 2007; Nixon &
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Heath, 2009; Sax, 2010), there remains a great need for education and guidance in
dealing with self-injury in school. Yet, knowledge of what NSSI is, what it means to
engage in NSSI behaviors, how to react to a student who engages in NSSI, and when and
how to intervene are questions that remain challenging. Despite the urgency for training
specifically designed for addressing NSSI, principals surveyed illustrated a lack of course
offerings and/or professional development. Furthermore, the survey results demonstrated
a lack of knowledge and confidence in recognizing the signs of NSSI behaviors within
the adolescent female population.
Lack of Knowledge of Etiology of NSSI.
With an increase in the reporting of female pre- and early adolescent self-injury, it
is important that principals and school staff recognize the signs and symptoms of NSSI
within their student populations. Each educator should have the knowledge necessary to
intervene when a young female is suspected of engaging in self-harm (Kress & Drouhard,
2006). Yet, only 3 of the 46 principals in this study received training in NSSI in their
graduate and/or administrative programs.
Thirty-nine (n=39) principals believe acts of NSSI are committed as help seeking
actions. Contrary to the hypothesis of the researcher, gender, years of career experience,
and level of education were not deciding factors of this perception. There was no distinct
difference between the categories that would lead the researcher to assume one
categorical group was more likely to perceive NSSI as help-seeking behaviors. Only 12
principals responded to the statement regarding peer-inclusion motivation as a factor for
NSSI. Of the 12, 7 principals disagreed and 5 agreed with the perception that students
engage in NSSI because of motivation to fit in with their peers.
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Despite the perceptions of the participating principals, current researchers have
continued to discredit actions of self-harm as help-seeking and/or attention-seeking
behaviors (Berger et al., 2014; Kress & Drouhard, 2006; Nock & Prinstein, 2005; Ross &
Heath, 2002). Instead, acts of self-harm are viewed as maladaptive means of coping with
strong emotions. To Walsh (2006), self-injury should not be minimized or dismissed as
“attention seeking” (p. 38) when reported. Walsh stated: “when people take the radical
step of harming their bodies, they should be taken seriously and the sources of their stress
addressed” (p. 38).
Considering their own lack of education on the topic, 39 of the 45 principals
agreed to mandatory staff education of NSSI. Kress and Drouhard (2006) encourage staff
members to become aware of what defines self-injury, and the correlating risk factors
associated with self-injury. Forty-seven (n=47) of the 47 principals who responded to the
statement agreed that staff should be aware of the schools protocol for alerting
administration, and/or guidance if a student is suspected of engaging in NSSI behaviors.
Correspondingly, 45 principals feel confident that their staff members feel comfortable
approaching them about a student who may potentially be self-injuring.
Fear of Contagion.
Recent studies have documented a significant rise in the rate of engagement in
NSSI from late childhood to early adolescence (Centers for Disease Control, 2012;
Heilbron, Franklin, Guerry, & Prinstein, 2014). Although considered a factor in the
initiation and continuation of self-harmful behaviors, the influence of peer relationships
has only begun to be studied (Heilbron et al., 2014).
Despite the lack of empirical evidence demonstrating a clear impact of peer
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relationships as a contributing factor of NSSI behaviors, principals demonstrated a fear of
the contagion factor that may have them feeling constricted to take action to address
NSSI within the student population. Twenty-three (23) of the 49 principals agreed that
students who engage in NSSI have learned such behaviors from family members and
friends. Twenty-six (n=26) principals disagreed with this as a catalyst for self-injurious
behaviors. The researcher viewed a percentage size this close to demonstrate how a fear
of social contagion among adolescent females may be a factor that inhibits the actions of
principals to address NSSI.
Programs that are geared toward middle age students that include the accepted
definition of NSSI (Nock & Favazza, 2009; Prinstein, 2008), a description of the
behaviors of NSSI, and the signs to look for in other students are suggested for general
class populations (Hillery, 2008). For this study, there was little return on the statement
suggesting that students should have grade-level presentations on NSSI. Fifteen (15)
principals responded to the statement. Of those 15 principals, 13 principals agreed to
grade level presentations, and 2 principals disagreed. Yet, it remains uncertain as to why
multiple principals did not respond to this survey statement.
Lieberman, Toste, and Heath (2008) have designed intervention protocols within
prevention programs that address NSSI on a whole school as well as one-on-one
intervention model. They suggest for each student to be assessed individually. However,
Lieberman et al. (2008), caution administrative overreaction, which may include isolating
a student from her peers during the identification, intervention, and prevention protocols.
When participating principals were asked to respond to the statement “students who
engage in NSSI must be isolated from their peers immediately”, 45 principals of 46
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responded in disagreement. Thirty-five (n=35) principals out of the 47 responded in
agreement to the survey statement regarding enrolling students who self-harm in
prevention programs. Thirty-seven (n=37) of 49 respondents support a mandatory
psychological evaluation for students who engage in NSSI. Only 15 principals replied to
the statement regarding the outplacement of students who engage in NSSI as a possible
solution. Fourteen (n=14) of principals disagree with outplacement as a possible
solution. One (n=1) principal agreed. It can be assumed that principals realize students
who self-harm should be evaluated individually, but segregating the student from her
peers may only cause further emotional dysregulation.
Key Findings
Overall, four major themes were identified as the most proficient as factors and
conditions that support or inhibit the role of the principal in addressing NSSI among
female pre- and early adolescents. These were A) a lack of training in administration, B)
a lack of staff training, C) a lack of knowledge of the etiology of NSSI, and D) a fear of
contagion.
A lack of training offered in graduate and administrative training programs was
identified as a factor that impacts the knowledge, confidence, and skills of principals. A
majority of principals surveyed did not feel they were educated on self-harm. Despite the
urgency of addressing NSSI in schools today, principals have not currently seen or
participated in professional development geared toward issues of self-harm.
This perceived lack of training extended to school staff. Participating principals
felt as primary points of contact with students, teachers and other staff members should
also be aware of the ways and means to identify, intervene, and prevent NSSI among
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young adolescent females. Teachers and support staff members should participate in one
of several emerging programs like ACT, LifeSIGNS, and the gatekeeper program.
Participants in this study believed their staff members would approach them if a student
is identified as possibly engaging in self-harm. Yet, in response, without staff or
administrative training, many are “working in the dark” (Berger et al., 2014). It is crucial
for administrators, teachers, and other school staff members to develop knowledge of
NSSI in order to approach a possible case of self harm with confidence and respond with
accuracy and skill.
Researchers believe acquiring the knowledge of NSSI before developing a crisis
protocol is essential (Berger et al., 2014; Hillery, 2008; Kress & Drouhard, 2006; Nock &
Prinstein, 2004). According to Berger, et al. (2014), it remains crucial for administrators
and school staff members to become educated on the etiology of NSSI first. Then, as a
school staff, a protocol to address existing NSSI behaviors, and possible methods to
address self-harm can de created. Berger, et al. (2014) and Heath et al. (2011) consider
1.) inaccurate knowledge, as a result of the lack of education, and 2.) negative attitudes,
which include the confidence in assessment and referral of student who self-injure, as
factors that may interfere with administrators’ and school staffs’ ability to identify and
refer students.
In response to the statements concerning the contagion factor in school settings,
the majority of principals recognized the need to efficiently release the stressors of a
student engaging in self-harm, avoid overreactions that may possibly exacerbate the
emotional dysregulation of the student. Principals responded to the statements about
group presentations, student isolation, and mandatory psychological evaluations much
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aligned with current research on addressing NSSI among student populations (Berger et
al., 2014; Hillery, 2008; Kress & Drouhard, 2006). Although it is crucial to address a
student identified as engaging in self-harm, it is urgent for principals and school staff to
remain efficient in their actions, evaluate self-harm actions as individually or socially
motivated, and avoid stressors for the student which may motivate further injury.
The interview process gathered information addressing Research Question #3
perceived factors and conditions Massachusetts’ principals believe inhibit and support
their efforts to address NSSI among pre- and early adolescent females. Many participants
in this study felt the frustration and confusion related to addressing NSSI behaviors
within their schools. Several themes were identified and gleaned from the interviews.
They are: A) a lack of training, B) knowledge of suicide versus non-suicide self-injury,
C) a lack of central office support, D) a lack of funding and time, E) the fear of
contagions, F) Parents, G) student cooperation. The findings below will demonstrate the
major themes as they emerged during the one-to-one interviews.
Themes.
Lack of Training.
According to Yates (2009), environmental and internal maltreatment influence the
function of the neurobiological stress response systems. This dysregulation may lead
female pre-adolescents and early adolescents to engage in NSSI behaviors (Nock &
Favazza, 2009). Self-injury allows a pathway for adolescents to process any internalized
emotional eruptions, to alleviate anxiety or depression, and to reconnect by self-harming
(Conterio & Lader, 1998; Whitlock & Knox, 2009; Yates, 2009). Peer relationships may
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also motivate, reinforce, or prevent self-harm in pre- and early adolescent females
(Heilbron et al., 2014).
Without the knowledge of the factors and conditions that motivate SI behaviors,
principals are left in a therapeutic darkness. Training is essential to addressing NSSI.
However, in response to the researcher asking what type of training he or she may have
received in his career, one principal answered:
“personally, none. It was not a part of principalship 101. I am currently in my
doctoral program at [name of university] and it hasn’t come up. Sadly, it hasn’t
come up at all. What I have learned has been through my very capable guidance
staff who have both been to trainings to stay updated on the phenomenon. What I
have learned, I have learned through them.”
One principal, who expressed grave concern for knowledge of NSSI due to the growing
percentage of students he has in his school stated: “We need knowledge and resources in
NSSI. Our girls suffer from anxiety and other personal health concerns. We have to be
able to treat the girls on a case-by-case basis. It would be better to treat the students in-
house than to ship them out to Westwood Lodge.”
The lack of training theme appeared throughout the interview phase. Another
participant expressed frustration: “There is not enough formalized training on issues like
NSSI. There may be some break-out session on suicide prevention, which includes
NSSI, but administrators need to be offered actual training sessions on NSSI.” She
expressed what she felt was her biggest obstacle in addressing NSSI in her school:
“Principals should also be trained in how to set up support teams, or counseling
supports for a variety of student issues, including NSSI. Principals should know
who and what they need to address a student who is in crisis. Any type of program
where we have better clues on identifying the contagion, and then exploring
beyond what we already know – what treatment options exist and which treatment
options have been successful for kids who resort to this [NSSI].”
Statements gleaned throughout the interview phases demonstrate a willingness to
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learn about NSSI. Many principals felt it urgent for staff and themselves to learn about
the etiology and risk factors contributing to NSSI. Interviewed principals stressed the
need for administrative and staff education on the signs and behaviors of NSSI in order to
follow school protocol. One principal stated:
“at [school] we need to get more and more outside resources and organizations
involved in teaching the staff. Currently, only one staff member is
knowledgeable of how to address a student who is engaging in self-injury. That
is simply unacceptable. As a leader, I know I should be doing more, learning
more. I just don’t know where to start.”
Another principal explained a fear of miscommunication of NSSI:
“I feel I cannot effectively address NSSI since I have no real understanding of
self-injury. I have heard contradictory messages about self-harm. On one hand,
the girls are looking for attention and nothing is actually severe. On the other
hand, I am hearing that it is becoming a crucial issue to address. But, how? Who
has the answers?”
Other statements demonstrated perceptions of a self-injurious student as one who
suffers from an inherent mental illness. More than one principal of this study felt there
was an unidentified element of the students’ mind that was causing them to self-harm,
even if it remained unknown to the family at the time. “I believe when she is a bit older,
some doctor will discover an imbalance of some sort, causing her to cut.” Throughout
the research, the researcher gleaned several responses that highlighted the perception that
NSSI is an attention seeking behavior and not of emotional dysregulation and/or
maladaptive coping strategies. Yet, during the survey instrument, many principals
disagreed with the statement that female adolescents that self-injure are suffering from a
mental disorder. However, a few statements during the interview phase demonstrated the
possibility of another perspective of NSSI. “I don’t understand why girls would cut their
arms and legs, other than wanting to seek attention or suffering from a mental illness.”
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To Berger et al. (2014), inaccurate knowledge and negative attitudes towards
NSSI, including confidence in assessment and referral of students who self-injure, may
interfere with the ability of school staff and administration to efficiently identify and refer
these students. Teaching staff and administration of the etiology and early intervention
and prevention of self-injurious behaviors is central to the timely treatment of NSSI.
Threaded throughout the interviews principals were calling for education resources that
would improve their knowledge of NSSI, demonstrate signs to identify self-harmers, and
build skills crucial to addressing self-injury among the student population. Almost all
participants (n=13) felt it was crucial for administrators to receive training on NSSI,
despite the role the principal may play in a particular school.
Suicide Versus Non-Suicidal Self-Injury.
With little preparation and knowledge of the etiology of NSSI, principals may
find themselves with the task of decoding student intent of suicide or self-harm to
alleviate emotional dysregulation. Without knowledge of the etiology of suicide and the
etiology of self-harm, it is quite understandable for principals to misread the reasons of
self-injurious actions. Although NSSI is associated with completed suicide (Whitlock et
al., 2013), the intent of self-harm is not to take one’s life. Rather, self-injury is a means
of regulating emotional and social situations (Nock, 2009). However, many principals
demonstrated a lack confidence to make a decision. To some participants, without
knowing the difference between suicide and self-injury, led them to possibly overreact.
“It was quite tough for my staff and I to decide if one of our 7th
graders was trying
to harm herself or take her life. She had other scars and cuts on her inner legs, but
these wounds were deep, it hard not to think she was trying to kill herself. She
told us she just wanted to make the pain stop for a while. For us, this statement
could mean she attempted suicide. So, we engaged the crisis team to address an
attempt at suicide.”
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Although the principal does not regret the decisions he made in that particular situation,
he has reflected on the intent of the student. After his personal investigation into NSSI he
felt he may have overreacted to suicide, yet, he felt his actions did help the 7th
grader
begin the process of healing. “Knowing what I know now, her actions may have been
more self-injurious and not suicide. But at the time, without this knowledge, I did what I
felt best for the student.”
Whether the primary or secondary member of a school crisis team, the principal
is a deciding factor on the treatment process for a student identified with self-harming
behaviors. In cases where a principal has not received any training in the graduate and/or
administrative programs, the confidence level of a principal may impede his/her ability to
react to a student with NSSI behaviors.
During the interview phase several participants expressed a fear of decision-
making on the issue of self-harm injuries as a means to take one’s life or as signs of
emotional distress.
“Some of the girls that self-harm in our school are bright, talented girls. But they
do not appear to want to end their lives. And then you see their injuries – injuries
so close to major veins and arteries in their small bodies. Without knowing the
difference, I tend to err on the side of caution and choose our suicide attempt
protocol.”
Another principal stated:
“I could not live with my decision if I underestimated the risk and failed to help
initiate the crisis team’s suicide process. I simply just don’t know the difference
between attempted suicide, suicide ideation, and self-injury as a coping skill.”
Another strand identified within the suicide versus NSSI theme whether actions of self-
harm serve as a precursor to suicide.
“My teachers ask me if cutting is a precursor to suicide. My response is always
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‘possibly’. However, I have no real idea if my answer is accurate. What it boils
down to is a lack of training of staff and administration, which leads to a lack of
competence in the staff, including myself.”
Unlike guidance counselors, social workers, school psychologists, and other
health professionals, suicide and NSSI are not topics covered in general education
classes. To the principals interviewed, there is a systematic disconnect with suicide and
NSSI training and the educational training they received during their careers. One
principal bluntly stated: “I have never received any training for anything health related.
All that I have acquired has come straight from my guidance department. Schooling did
not prepare me at all.”
Some responses from the interviews left the researcher to believe that principals
ponder if students are temporary ill due to external or internal stress factors. One
principal asked the researcher if it was indeed a cry for help. To which the researcher
responded with the abbreviated response from Nock and Prinstein (2004, 2005):
Functional models of NSSI suggest humans engage in NSSI behaviors for primarily
intrapersonal, or the regulation of negative affects, or for interpersonal reasons, or to
communicate with others or influence others in some way. The researcher explained that
the interpersonal means is more of a social or peer influence and not as a potential cry for
help. When a student is attempting suicide, she feels there is no other choice but to take
her life. With NSSI, a student would like to regain control over her emotions through
self-injury.
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Lack of Support from Central Office.
Another common thread identified throughout the response of principals from the
study involved the overall lack of support from a principal’s central office. Several
principals explained that a common factor that inhibits the training in NSSI revolves
around the central administration. If the central administration of a school district does
not seem it necessary for the content of subject matter, or in fulfillment of state and
federal mandates, most often it becomes pushed aside for other topics. Despite one
principal’s fight for staff training in suicide and self-injury, his assistant superintendent
would not sign off on the time spent for professional development. “I understood the
need for us to raise our MCAS scores, but what happened to educating the whole child-
including the social and emotional aspects?” His sentiment was echoed by another
principal who said she was frustrated at seeing an increase in self-injury among her 7th
grade girls, yet when she went to present the introduction of professional development for
the upcoming fall, she was rejected. According to this participant, “Central office should
provide support staff and professional training to best meet the needs of this struggling
population of girls.”
One principal discussed what she believed would support the education of her and
her staff when she said:
“There should be ongoing training where outside trainers return multiple times to
refresh and update the information on NSSI. We don’t have the expertise,
including the nurse and our 2 guidance counselors, to address this major concern.
We need experts from the field to instruct our staff on how to identify the
behaviors, what to look for, and how to establish a good protocol for our school.
Yet, each time we propose this to our central office, we are shot down. What are
we to do?”
Principals in this study felt it was urgent for central office administration to
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support the training needs of building administrators and their staff members. Many of
the interviewed principals felt that if it is possible to provide training for the school staff
members in NSSI, central office should stand behind the building administrations
decisions to request funding and provision of such training by experts in the field of
mental health.
Lack of Funding and Time.
In combination to the lack of central office support, a lack of funding and time
were also major themes to emerge from the interview process. Budgets are a primary
motivating factor for professional development. Therefore, when central administration
and building administration consider what programs to use for professional development,
funding has an impact on the possibility of NSSI training. In addition, depending on a
districts contract, there is only a certain amount of time allowed for staff professional
development. One principal stated: “Additional hours for professional development,
especially those not in a teachers content, require a discussion with the union.” Based on
this and several other statements made by principals throughout the interview process, the
theme of funding and time emerged.
One principal sounded quite deflated when she responded to what factors inhibit
your success at addressing NSSI.
“I harrange the school committee and central administration for funding to send
staff, including myself, to workshops to address mental and emotional health
issues of students. Sadly, more times than not I am told that funding for this type
of PD is not available. Unfortunately for my district, funding and time constraints
limit this training quite a bit.”
Several principals noted that specialized training like those for student mental health are
placed on the budgets of the individual middle schools. Therefore, the principals have to
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determine where and how the buildings budget will allot funding for training. Most of
the principals in this study said they address the training of the staff first, leaving any
leftover monies for their individual professional development. “We are so busy trying to
juggle the professional development money, I believe principals short-change themselves
on their training offerings.” In fact, one principal revealed that his central office
discouraged him from maneuvering the money in this fashion. Yet he, like other
principals, felt it better for him to be more sacrificial with the money and use it for their
training.
Fear of Contagions.
A major concern for educators when implementing a prevention program in
school, especially one that lacks program specificity like NSSI, is the need for
containment of the harmful behavior. Copycat behavior is common in middle school
children since adolescents look to peers for guidance on what constitutes socially
acceptable behaviors (Heilbron et al., 2014; Juhnke et al., 2011; Nixon & Heath, 2009).
A student self-injurer has the potential to encourage NSSI behaviors as a means of
passage into a group or a close friendship (Juhnke et al., 2011; Nixon & Heath, 2009).
Students who self-injure may discuss NSSI behaviors with other students, possibly
triggering further self-injury in each other (Walsh, 2012). To demonstrate such an
opinion, one principal interviewed was quoted as: “If we educate the students on NSSI,
would we be putting ideas in their heads. Even worse, would we be helping them by
providing them with information on how to better harm themselves?”
Juhnke et al. (2011) stress that although adults are hesitant to engage students in
conversations around NSSI, it is important to create awareness and connectedness of the
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faculty to the student body. Knowing the impact of peer relationships, identifying the
impact of social and emotional stressors among students, and how to readdress students
to healthy coping strategies are essential to the prevention of NSSI among adolescent
females.
Whitlock and Knox (2009) write about how belonging to a social group where
one or several students have been identified as self-injurers may be a warning sign for
school administrators. To Bjärehed et al. (2013) NSSI is like many other types of
behaviors; it is socially patterned, and social mechanisms can contribute to the spread of
NSSI. “It is possible that attention given to an individual’s NSSI could inadvertently
reinforce the behavior, for example, if the behavior is perceived as a functional method to
gain sought after social support and care” (Bjärehed et al., 2013, p. 226). Some
participants identify with this theory, that if a school were to recognize self-injury openly,
through class-level presentations and advisory sessions, they may reinforce self-harm and
not prevent it.
Junke et al. (2011) recommend schools to deliver universal programs throughout
the school year. In agreement, several principals in this study feel that order for universal
programs to be successful, their schools must address the issue of NSSI multiple times
throughout the school year. Contagion episodes arise in schools because the maladaptive
behaviors of peers create a group cohesiveness – a special connection to each other when
they self-injury (Bjärehed et al., 2012; Hilt, Cha, & Nolen-Hoeksema, 2008; Juhnke et
al., 2009; Walsh, 2012). If schools can provide ongoing education regarding NSSI,
perhaps schools can minimize the contagion. “We cannot have an introduction to self-
harm without having several less invasive refreshers throughout our school year.
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Otherwise, the program will be inefficient.”
In contrast, some principals felt a program designed solely on self-injury would
not be appropriate for the school population. One principal stated:
“I am not concerned about contagion. Our health program includes lessons on peer
influence, reporting of friends who may potentially attempt suicide, eating
disorders and other life threatening issues. However, I would not structure a course
solely on NSSI.”
Parental Influence.
According to the principals interviewed in this study, the reactions of parents and
their possible reluctance to support school mental health initiatives play a large role in the
factors of a principal addressing NSSI within his or her school.
One suburban principal stated: “The parents of my students can either lift a program in
school or completely kill it.”
In respect to a program designed to address NSSI, multiple participants expressed
parents as a factor that could either support or prevent a prevention program from being
delivered during school. One principal expressed the unknown of parental opinion:
“It can go either way. Parents who are aware of it [self-injury] and wish to be
proactive with the school will support the prevention programs. If they choose to
remain with their heads in the sand, then they will be our biggest road block.”
Throughout the interviews, principals expressed that parents can be a great resource and
body of help for administrators, but they may also limit or prevent programs that want to
be started by current administrators.
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Student Cooperation.
Student cooperation is a factor that many principals believe inhibit their efforts in
addressing NSSI. Those participants who recognize NSSI as a coping strategy and not as
a cry for help, understand the reluctance to seek help is a major obstacle for school staff.
One principal sadly remarked:
“By the time we noticed her, the insides of her arms and legs were all cut up. She
was doing this [NSSI] for over two years before her friend reported her. We just
kept wondering why she didn’t come to us. We could have helped her sooner.”
Unfortunately, the refusal of students to seek help is a factor that appeared to inhibit the
efforts of principals when addressing NSSI. Another principal explained what she feels
are the reasons why her female students refuse to seek help.
“I have found that students are afraid my staff and I will tell their parents. That
we will be talking about her as if she is a freak. This fear of being stigmatized,
labeled, or her confidentiality being broken restricts many of those [girls]
who
need help, to seek out help. We do have an obligation to tell their parents – yet,
we can also provide them with the help and emotional guidance they desperately
need.”
Another principal said:
“One of the students we identified as a cutter came from a highly respected, high-
educated family. Her main concern was embarrassing her family. She cried about
not telling her parents because they would not approve of her anymore. She was
worried they would not love her anymore with her injuries. It was heartbreaking
for the nurse and I to hear. I guess that is why she never sought out her guidance
counselor.”
Students who self injure do not wish to receive attention for their injuries. The students
who self-harm wish to regulate their emotions, to feel control over their own minds and
bodies, as well as to feel emotions even if it be physical pain. Since they are not
attention-seeking individuals, it becomes a major factor in addressing NSSI among pre-
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Key Findings
Several emerging themes were discovered during Research Question #3. These
included a lack of training for principals as well as staff, the knowledge between suicide
and non-suicidal self-injury, the lack of support from central administration, and the lack
of funding and time. Additional themes were parental influence and student cooperation.
Regarding training in topics of mental health, principals in the study felt it is
crucial to have programs that offer training for administrators despite the role they may
play in the schools safety protocols. Having the knowledge of NSSI and the skills
necessary to address NSSI behaviors, breads confidence in a school leader. Many felt it
necessary for central administration to support mental health professional development.
This would require central administrators to create financial budgets to include ample
funding for training. In addition, many participants wish to alter some professional
development days to include staff training on NSSI and other mental issues affecting the
students.
Multiple participants recognize that if training in received, and all staff are aware
of the signs and symptoms of NSSI, the threat of contagion may be minimized. In
addition, by reaching out for parental support and help in a mental health initiative, and
possibly parental training offered as well, many felt parental influence will be more of a
resource and source of support.
Student cooperation will remain the most influential factor in addressing NSSI in
schools. The concern of principals is how to break the walls of silence between a self-
injurious female and the school staff, including themselves. Understanding that students
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who self-harm do not actively seek help encourages principals to establish school
protocols to seek out those students and begin the process of intervention.
Chapter Summary
The aim of this chapter was to investigate and report on the findings for the three
Research Questions guiding this study. Through the use of a mixed method data
collection process, the researcher was able to gather essential information to analyze the
perceived role of the middle school principal regarding his or her role in addressing non-
suicidal self-injury among female adolescents ages 10- to 14-years-old.
Many principals considered NSSI to be an important leadership role. Yet, many
principals recognized the lack of basic knowledge of NSSI needed to address students
with self-injurious behaviors. This leadership deficit allowed many principals to alleviate
responsibility of the mental health of students and instead work cooperatively with the
guidance department and other health care professionals within the school building.
These principals described their role as a facilitator and/or supporter of the main crisis
team members. These principals provide discrepancy to the guidance counselors, school
psychologists, social workers, and school nurses to make decisions for the mental and
physical health of the young female.
In contrast, the participants who claimed to have with limited mental health care
resources within their schools considered NSSI to be a greater degree of their
responsibility as a leader. Such principals play a major role in the activation of the crisis
team so they independently tend to seek out education on their own and update their
knowledge through online and printed media sources.
Throughout the study, common concerns were expressed regarding professional
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development training in NSSI, creating safety protocols adequate to address NSSI,
providing ample funding and time for professional development, access to expert mental
health resources, and the fear of contagion. Parental influence and student cooperation
were other factors that contribute to the success or failure of efforts to address NSSI by
principals.
In summary, current Massachusetts’ middle school principals who participated in
this study acknowledged a severe lack of education on NSSI in Massachusetts institutions
and training programs. The participants were aware of the lack of federal and state
mandates for therapeutic education for administrators. Since many felt ill equipped with
limited resources, funding, and time to effectively address female adolescents with self-
injurious behaviors, it has become crucial to receive training and resources in mental
health. Education will allow current and future administrators to confidently approach
NSSI in school, foster early identification, intervention, and prevention of self-injury, and
develop a safety protocol to support the mental and physical health of pre-and early
adolescent females.
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CHAPTER FIVE: SUMMARY, DISCUSSION, RECOMMENDATIONS FOR
FUTURE RESEARCH, FINAL REFLECTIONS
The final chapter is presented in four sections. The first section presents a brief
overview of the study, including a summary of the research questions. The next section
presents a discussion of the key findings. This section is subdivided into the Key
Findings for Research Question One, Research Question Two, and Research Question
Three. A third section discusses implications for principals and other school leaders as
well as recommendations for future research. Chapter 5 concludes with personal and
final reflections.
With the perceived increase in self-harm among pre- and early adolescent
females, it is urgent for principals to receive training on the etiology, behaviors, and
prevention plans to minimize self-injury. Regardless of the role each individual principal
plays in addressing NSSI, they must be aware of the total emotional, social,
psychological, physical, and developmental impact NSSI may have on the middle school
female population.
Overview of the Study
The study examined the perceptions of middle school principals regarding their
role in addressing non-suicidal self-injury among adolescent females ages 10 to 14 years
old. In Research Question One, this study addressed the degree Massachusetts’ middle
school principals consider NSSI among adolescent females to be an important part of
their leadership role. Research Question Two examined the various ways middle school
principals report they are addressing NSSI among adolescent females, including means of
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identification, intervention, and prevention. The final research question attempted to
discover the factors and conditions middle school principals believe inhibit or support
their efforts to address NSSI.
The review of the literature in Chapter Two defined NSSI and self-mutilating
behaviors among pre- and early adolescent females and provided information necessary
for educators of all grade levels, policy makers, and government educational agencies to
better understand NSSI and the need to prevent NSSI behaviors among young females.
The researcher gathered pertinent information from the areas of psychology,
adolescent development, neuroscience, and psychiatry. The researcher examined the
mental, emotional, physical, and social health of early adolescent females as well as
investigated the etiology of NSSI and behaviors associated with self-injury. Information
was analyzed for possible factors that contribute to the initiation of self-harm, possible
identifiers of self-injurious behaviors, and understanding NSSI as a maladaptive coping
strategy. Experts like Hilt, Nock, Lloyd-Richardson, and Prinstein (2008), Nock (2009,
2010), Nock & Prinstein (2009) were referenced throughout the study. Additional
experts included Berger, Hasking, and Reupert (2014), Favazza (2011), Heath, Baxter,
Toste, and McLouth (2010), and Junke, Granello, and Granello (2011) were referenced to
create the empirical foundation of this study.
The second area of research examined educational leadership. Literature in this
area of expertise provided a foundational definition of a principal, albeit ever evolving
and changing. The historic timeline of a principal was investigated, and historic
responsibilities were compared with those of present day. State, federal, and local
mandates of administrative duties were examined and analyzed and aligned with the
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experiences of principals who participated in the study. The core contents of graduate
and administrative programs were analyzed with the goal to identify the role of the
principal in issues of mental, emotional, and social health of a student. Several sources
of reference included Brown, and Anfara (2002), Juvonen, Le, Kaganoff, Augustine, and
Constant (2004), and Oakes, Quartz, Ryan, and Lipton (2000). Federal resources such as
the United States Department of Education and state resources like Massachusetts
Department of Elementary and Secondary Education (DESE) were also referenced.
The data gathered in Chapter 3 for this study attempted to reveal the perceived
role of current middle school principals when addressing the mental, physical, and
emotional health of the female student body in Massachusetts’ middle schools. The
researcher hypothesized that gender, years of administrative service, and level of
education may impact the perceived role a principal may have when addressing NSSI. In
addition, the researcher hypothesized that current principals do not have specified
training necessary to address mental/emotional/ and physical needs of the students within
their buildings. For this, the researcher explored the level of training principals certified
in Massachusetts received during their graduate and/or administrative programs. Overall,
the study sought to generate information regarding the perceived role current
Massachusetts middle school principals play in addressing the emotional and physical
needs of the adolescent female populations in the communities in which they serve.
In Chapter Four, several key findings were gleaned from the analysis of responses
to the three research questions guiding the study. These are: a) knowledge of NSSI, b)
administrative training, c) time and funding, d) student cooperation, and e) contagion.
The information presented in the following paragraphs will discuss the key findings as
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they were included in the quantitative and qualitative stages of research. The next
section will examine key findings revealed from each of the three Research Questions.
Key Findings
Research Question One: To what degree do middle school principals consider non-
suicidal self-injury (NSSI) among female adolescent females to be an important part
of their leadership role?
The research gathered for Research Question One provided two key findings:
Time and Knowledge of NSSI.
Time. Most principals reported that the demands placed on administrative
schedules of current Massachusetts’ principals appeared to be a key factor determining to
what degree a principal addresses NSSI among females 10- to 14-years old. Multiple
principals reported feeling as if their schedules make them unavailable for other ways to
address NSSI among adolescent females beyond a consultation with Guidance or School
Psychologists. Although some principals consider themselves to play a primary role in
addressing NSSI, most interviewees believe they are secondary members, or in a
supportive role, of a crisis team due to time constraints. A lack of time in their daily
schedules as well as and the continual demands of their job prohibit principals from
dedicating the time necessary to addressing NSSI in school.
Knowledge of NSSI. Data collected through the quantitative and qualitative
stages demonstrated principals’ lack of knowledge of NSSI, methods to address NSSI,
and prevention protocols. Participants reported minimal educational programs, courses,
and professional development opportunities offered to administrators. Participants
reported a crucial need for administrators to receive mental health training, specifically in
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addressing behaviors of self-harm.
Research Question Two: What Are the Various Ways Middle School Principals
Report They Are Addressing Non-Suicidal Self-Injury Among Adolescent Females?
The key findings for Research Question Two are: a) knowledge of NSSI, b)
limited time, c) training, and d) a defined role of principal.
Knowledge of NSSI. To restate the finding from Research Question One, data
collected through the quantitative and qualitative stages demonstrated principals’ lack of
knowledge of NSSI, methods to address NSSI, and prevention protocols. Participants
reported minimal educational programs, courses, and professional development
opportunities offered to administrators. Participants reported a crucial need for
administrators to receive mental health training, specifically in addressing behaviors of
self-harm.
Time. Due to the time constraints and the constant flow throughout the building
principals in this study felt they address NSSI through the lens of a co-facilitator and one
of support to the staff members acting on the child’s behalf. Since principals have many
roles during the typical school day that fill up their daily schedule availability and limited
time were often cited as a reason why many principal take a secondary role to guidance
and psychologists regarding health issues in students. Participants felt there was not
enough available time in their busy schedules to address suspected cases of NSSI among
the student population.
Training. Multiple participants demonstrated uncertainty when it comes to the
ability to identify the signs of NSSI behaviors in their students. Due to a reported lack of
educational training in their undergraduate and/or administrative programs, many felt that
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they are not capable of distinguishing the difference between NSSI and suicide attempts.
Participants felt with considerable training, they could potentially intervene and prevent
self-injury.
Defined Role of Principal. In the quantitative and qualitative measures,
principals labeled the role in which they serve in their school crisis team either as a
facilitator or a supporter. Multiple principals acknowledge a lack of active identification
and intervention of students in their schools. Yet, many believe they serve as a
soundboard in the initiation and implementation of the prevention process within their
schools. Schools must create a clearly defined role of the principal in regards to
addressing NSSI.
There is a vital need for principals to work closely with guidance counselors,
psychologists, and social workers in order to raise awareness and collaboratively address
NSSI behaviors among the pre-adolescent and adolescent female population. Yet,
principals lack a clearly defined role when it comes to addressing NSSI among the
student population. Instead, principals defined the role as he or she felt necessary. Those
principals whose schools have limited guidance counselors and psychologists believe
they take a more defined, active role in addressing NSSI behaviors. In these schools,
principals organically take the lead in initiating the identification and intervention
process. Alongside their staff, principals are in charge of contacting the students’ parents
or guardians, outside services, and initiating a safety plan. In schools where there is
greater support, principals tend to allow guidance, nurses, and school psychologists to
initiate the identification and implementation process. In these schools, the principal
does not ordinarily contact mental health resources, design a plan for the individual
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student, or contact the students’ parents or guardians. Instead, the individual principal
relies on the support staff to complete such responsibilities.
Regardless of the role a principal may take, facilitator or supporter, it is important
for each principal to connect with outside resources, mental health centers, and local
hospitals to remain up-to-date with identified self-harm behaviors and most- efficient
research-based protocols to address each type. Principals may wish to enlist specialists to
present the latest literature and data during professional development opportunities in
order to create a proactive and knowledgeable staff. He or she can build a school crisis
team enlisting teachers and staff members, also with clearly defined roles. As a faculty, a
protocol should be created to address the steps in the identification, intervention, and
prevention of NSSI process within the student population. At the direction of the crisis
team or individual principal, reviews of such protocols should be provided to the staff
throughout the school year. The principal, alongside crisis team members, should work
closely with guidance counselors, nurses, and school psychologists to remain aware of
students who are, may be, or have self-harmed. These defined leaders may wish to enroll
in additional training on maladaptive behaviors, especially NSSI, provided by state and
local health care professionals and local hospitals.
If feasible, principals may wish to reach out to the students directly to discover
the factors that have started the self-harm behaviors and possibly identify ways the school
may intervene. Individual principals may use the school psychiatrists and outside
resources to seek help for the students when at school and at home. In other schools
where direct contact may not be possible, the principal may wish to have guidance or
other staff members keep him or her abreast of the individual student cases. IN both
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scenarios, principals should participate in the reintegration process of the student if time
outside of the school was required. Updates on student health between administration,
guidance, nurses, and school psychologists is another way principals can increase the
degree of participation in the identification, intervention, and prevention process.
Research Question Three: What are the factors and conditions that middle school
principals believe inhibit or support their efforts to address NSSI among pre- and
early adolescent females?
The same two key findings examined in Research Question Two also emerged
when analyzing Research Question Three, Limited Knowledge of NSSI and Training in
Administration. Two other key findings emerged from principals when answering what
factors and conditions do they believe inhibit or support their efforts to address NSSI in
school: Staff Training and Contagion.
Training in Administration. A lack of training offered in graduate and
administrative training programs was identified as a key finding that impacts the
knowledge, confidence, and skills of principals. A majority of principals surveyed did
not feel they were educated on self-harm. Despite the urgency of addressing NSSI in
schools today, principals have not currently seen or participated in professional
development geared toward issues of self-harm.
Staff Training. Participating principals felt that as primary points of contact with
students, teachers and other staff members they should also be aware of the ways and
means to identify, intervene, and prevent NSSI among young adolescent females. The
participants felt it was also crucial for their teachers and other school staff members to
develop their knowledge of NSSI in order to address a potential student promptly,
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skillfully, and with confidence.
Knowledge of NSSI. Principals believe a major factor that inhibits their efforts
to facilitate or lead their staff in addressing NSSI stems from a lack of working
knowledge of self-injury. The participants would like to see professional development
that continues throughout the year addressing mental health, specifically NSSI.
However, in the vacuum of mental health education provided for principals in
graduate programs, those who currently and in the future will serve as leaders of middle
schools in Massachusetts should feel compelled to seek out training in NSSI and other
maladaptive behaviors. Principals can communicate with their staff members,
educational programs for mental and emotional health, and local, state, and federal
organizations to see if there are any offerings provided in the realm of mental and
emotional health. In addition, connecting with the local, state, and federal mental health
resource organizations will provide a substantial amount of information necessary for
principals to design self-directed knowledge base. Conversations between mental and
emotional health experts and principals allow principals to gather current information on
NSSI behaviors and factors that may affect young females in middle school.
As a leader of the school, principals may wish to take responsibility for their own
education on NSSI and read about the etiology of NSSI, the factors that may trigger acts
of self-harm, particular NSSI behaviors, intervention protocols, and prevention programs
proven to be successful. Principals may then feel confident and knowledgeable to
address students when action may be needed. Many libraries carry reading materials that
can educate principals on the topic of NSSI. Reliable online media such as
googlescholar.com, academia.edu, and vitae.com may provide principals current data in
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the educational and mental health fields. Principals may even wish to reach out to
experts in self-harm like Matthew Nock (2012), Leonard Sax (2010), and Armando
Favazza (2011), who have built extensive outreach connections for those working with
youth that engage in NSSI.
Contagion. Many principals are hesitant to present school prevention programs
broadly out of fear of social contagion. Despite the private nature of NSSI emphasized
throughout literature, the majority of principals believed that self-harm in middle school
is more of a social engagement, engaged in part to imitate group leader behavior.
Data revealed several key findings that have developed principals’ perceptions of
their role in addressing NSSI. Deficits in scheduled time, administrative and staff
training, and knowledge of NSSI shaped the role of principal when addressing the female
student population. In addition, the lack of a defined role of principal aided in the
designation of their role in addressing NSSI, leaving principals to decipher the needs of
the school and mold their role accordingly. Lastly, the fear of contagion played a role in
the prevention process principals’ implement in school. This factor also revealed that at
times, principals had guidance and health staff members actually choose and implement
the prevention plans in school due to their limited mental health training. It is urgent for
educational policy makers, institutions, and state-guided administrative programs to
remedy the factors that have limited the role of principals and perpetuated the perceptions
of principals in addressing NSSI. Through the provision of a) social, emotional, and
mental health training in administrative programs, b) mandated federal and state mental
health training and certification requirements for administrators, c) professional
development training offerings in maladaptive behaviors like NSSI, and d) a concise
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defined role of a principal in addressing NSSI in schools, principals will understand the
important role they serve in their schools.
Implications for Principals and Other School Leaders
There is a perceived increase in self-harmful behaviors in middle schools across
Massachusetts (Berger et al., 2014; Heath et al., 2011). Berger et al. (2014) urge
educators to improve their knowledge, confidence and skills to prevent NSSI – emanating
from the principals office to the additional staff aides. Experts recommend designing
professional development around the identification of self-injurious behavior (Berger et
al., 2014; Heath et al., 2011). It is through administrative leadership and a partnership
with the school staff, that Massachusetts’ principals may be able to develop, implement,
and sustain efforts to remedy the growing epidemic of self-injury.
However, data analysis demonstrated the limited training principals receive
during their graduate and/or administrative training programs. According to the
participants, this lack of training on NSSI, from the etiology to the prevention protocols,
creates a void in working knowledge available to help their students who self-harm.
Instead of serving as a primary leader on the crisis team, they feel relegated to serve as a
facilitator supporting the guidance department in the process. To Berger et al. (2014),
without the knowledge of NSSI, principals lack the confidence needed to efficiently
address a student who needs intervention from self-harm. Until training on the response
to NSSI is provided, principals will lack the ability to react effectively and confidently.
Berger et al. (2014) believe that self-injury education programs designed for
administrators will enhance the knowledge and confidence to both detect and respond to
students who self-harm.
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The job description of principal published on the website for the state of
Massachusetts is not inclusive of the role a principal should play when addressing NSSI.
Therefore, the perceived role has emerged based on the level of supports a principal has
on staff. However, mental health experts, alongside educational policy and law makers,
should create defined expectations of Massachusetts middle school principals in regards
to the degree to which their role is responsible for addressing NSSI in schools. Clear,
concise requirements should be developed to provide a framework of actions that
principals must fulfill during their role as the leaders of schools.
In this study, principals reported gaining knowledge through career experience. It
was hypothesized that Principals with six or more years were to address NSSI with less
sympathy than their peers fresh into the field. However, data analysis demonstrated an
opposite effect. Many administrators with more than 6 years in their role as principal
believe they gained their knowledge of NSSI behaviors through yearly exposure to
instances of students engaging in such behaviors. These principals declared a close
working relationship with guidance and health care professional within the building, ones
in which principals allow others to take the lead position on addressing NSSI.
Unfortunately, principals reported two factors that inhibit their ability to
adequately fulfill the needs of students who self-harm. Multiple demands required daily
from principals is the first inhibitive factor, while a scarcity of time is another significant
factor. For those reasons, principals are hesitant to serve as a primary point person in the
identification and intervention process. Qualitative information demonstrated feelings of
frustration in regards to this limited principal involvement. Kress and Drouhard (2006)
encourage principals to create a protocol with built-in flexibility for professional time in
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order to learn the full extent of self-injury for a particular student. During the varied
scheduled time, principals will discover the type of NSSI behavior(s) the individual
students are using, identify the student’s personal and academic needs, and uncover the
underlying dynamics that are motivating her to self-harm.
Quantitative data demonstrated that gender, level of education, and years of
experience in administration were statistically significant in the development of a
perception of NSSI (see Table 4.15 in Appendix F). The amount of years in the current
administration as well as the overall career administrative role demonstrated that a
perception of the role of principal is formed not simply by chance but with on-the-job
experience and education combined. Data analysis in Chapter Four underscored career
experience to be a greater factor than education and administrative programs. Of the 53
participating principals, the data demonstrates that almost all of them have learned about
NSSI from previous positions in their careers or during their current role as principal. It
can therefore, be implied that on-the-job experience has shaped the perceptions each
principal holds of NSSI and of the individuals who engage in self-harm.
Regardless of the degree principals consider NSSI to be an important leadership
role, it is urgent for them to gain knowledge about non-suicidal self-injury. During this
study, the researcher evaluated several recommendations made throughout the literature.
Suggestions include: the development of school-wide staff training in NSSI, the creation
of a school-endorsed definition of NSSI, staff enrollment in cross-disciplinary courses for
mental/emotional/behavioral health of adolescents, the design of a school-wide policy
which would include a defined outline comparing suicide and non-suicide self-injury, the
creation and implementation of a safety protocol, the adoption of a no-harm contract, and
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the recommendation for federal, state, and local agencies to develop a model for
educating middle school principals in NSSI. In the following paragraphs, these
recommendations will be discussed.
According to Berger et al. (2014) principals should continue staff development of
NSSI beyond the adoption of a school-endorsed definition. Once possible reasons for
self-harm are examined, attempts to apply the research to individual schools may be
made. This familiarization should include the examination of the methods of engaging in
NSSI, the various types of NSSI, the frequency and intensity of NSSI behavior, as well as
the catalysts for NSSI behaviors. To Berger et al. (2014), schools, under the leadership
of their principals, should create a unique, concise, user-friendly definition of non-
suicidal self-injury to provide to all members of the school staff. It should include a
research-based operational definition understandable by all. School districts should
encourage principals to provide continual staff professional development on NSSI
throughout the school year for reference and refocus.
Due to a lack of course offerings and professional development courses designed
for administrators, principals should enlist themselves and other staff members in
ongoing cross-disciplinary courses designed to address mental health issues and abnormal
child development. In addition, professional development offerings should be provided
to a) instruct on abnormal child development and abnormal child behavior, b) identify
maladaptive coping strategies and to teach positive coping skills and appropriate
expressions of emotion, and c) methods designed to minimize contagion during
prevention.
Principals should oversee the creation of a school policy that specifically
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addresses NSSI. It should address a) when a staff member should report suspected self-
injurious behaviors by a student, b) to whom a staff member should report the suspected
student, c) a defined role of administration in the process of identification and
intervention for students, d) a defined role of guidance counselors, e) a defined role of
school psychologists/social workers, f) a defined role of a school nurse, g) a defined
policy on parental notification and involvement, and h) a defined point of contact for
external mental health resources.
Once a school policy is established, principals, in conjunction with the staff,
should then design a safety protocol to address NSSI. It should be designed to cover the
topics of a) identification, b) reporting of a suspected self-injurious student,
c) intervention, d) initial in-school prevention, e) out-of-school prevention, and f)
follow-up procedures for the student.
Within this protocol, principals and staff should become familiar with the
relationship between suicide and self-injury. It is recommended that a side-by-side rough
delineation outline be provided to the staff to demonstrate which behaviors may possibly
constitute suicide versus behaviors designed to alleviate pain, frustration, sadness, and
other emotional reactions.
When a school policy and NSSI protocol is adopted by the administration and
staff, a no-harm contract should be created that concisely specifies which behaviors are
acceptable and which behaviors are not acceptable while on school property. The
contracts should also refer students to inside and outside of school resources to seek out
help before a student initiates self-injurious behaviors (Berger et al., 2014).
Based on the findings of this study, the researcher recommends the development
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of a training model for administrators addressing non-suicidal self-injury from the initial
identification of a student to the implementation of school-wide prevention programs. In
addition, federal, state, and local educational organizations should include mental health
courses within existing professional development programs. It is vital that these courses
provide annual training to educators of all levels, including future and current
administrators. Graduate and certification courses should also offer the latest in research
on maladaptive behaviors such as NSSI as well as ways to identify and address possible
students engaging in NSSI behaviors. Syllabi may include knowledge of such topics as
the initial point of harmful engagement, the acceleration of time and intensity of self-
injurious behavior, and the current factors affecting pre-and early adolescent females.
Content covering NSSI should be embedded in the current course offerings of
Massachusetts’ universities, colleges, and administrative programs. Lastly, continuing
educational courses should offer those principals already in the field training on the
etiology of maladaptive behaviors, forms of NSSI, factors that initiate NSSI, and how
students who engage in NSSI can be identified within a school population. Lastly, it is
critical for administrative programs to include a defined role of the principal in
addressing NSSI as well as how to design a crisis plan, a no-harm contract, and a school
protocol for reporting NSSI. As the pinnacle leader of the school, a principal must have
knowledge of the emotional, social, psychological, physical, and mental development of
his or her pre-and early adolescent female student population.
Future Research
Further studies should continue to address the perceived role of an administrator
in addressing NSSI in middle school. Although there are studies regarding elementary
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and high school students who self-injure, there tend to be minimal studies on the
perceived role of the high school and elementary principals in addressing NSSI among
these populations. Both areas of education are important due to the possible onset of
NSSI at elementary ages and a continued pattern during the initial teenage years.
Another topic of future research revolves around factors that enable early
identification of individual student engagement in maladaptive behaviors in elementary
and middle school students. Principals must consider what factors could be identifiable
by staff members and administrators in elementary and middle school. These studies
should evaluate empirically based training programs that have the possibility to instruct
administration and staff to readily identify behaviors of self-harm, know how to respond
to them, and how to quickly obtain help for students so engaged. Additionally, the
training programs would instruct educators a) how to enhance student protective factors,
b) build resilience in students who self-harm through the use of resiliency based
programs, c) develop strategies for more efficient identification and assessment of NSSI,
d) class management when staff is knowledgeable of a student with self-injury, and e)
ethical and privacy responsibilities staff-wide.
Additional studies should be performed to assist the development of federal and
state administrative training programs addressing the identification, intervention, and
prevention of non-suicidal self-injury, specifically within the initial years of adolescence.
Education and administrator preparation programs should seek to compile current
empirically based programs to design effective prevention programs and crisis response
strategies for schools. Additionally, such programs should be designed to instruct
administrators how to create a school policy with the staff, and how to share their
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knowledge of the school prevention programs and crisis protocols with the staff before
launching possible prevention programs. A final consideration for the administrative
mental health training programs is to provide examples of conversations and
presentations to encourage both positive parental influence and student cooperation.
Additional research should be conducted regarding curriculum implementation in
schools. The curriculum should be designed specifically for pre and early adolescent
students. The foundation of this curriculum should avoid instructing students how to
engage in NSSI and attempt to eliminate glorification of the behaviors. Yet, it should
guide students on how to spot the signs and behaviors of NSSI among their friends and
family members. In addition, the discussion of when and how to best deliver the
curriculum to students should be examined in future research. It may reveal frequent
instruction in small groups to be more effective in reducing contagion and diminishing
maladaptive behaviors among student populations.
Similarities and differences between rural, suburban, and urban middle schools
concerning the occurrence of NSSI and the reporting of NSSI should also be examined.
Future studies may reveal that urban middle schools have a higher rate of NSSI behaviors
than rural and suburban schools. Yet, those principals may not perceive NSSI to be a
great health risk to the students due to other life-threatening behaviors such as high
occurrences of drug-use, domestic violence, dating violence, gang involvement, food
scarcity, and homelessness, to name a few. In contrast, a rural or suburban middle school
principal may view NSSI as a severe issue among female students despite low numbers
of student cases. This may be due to a lack of social issues that plague urban schools.
Although food scarcity, domestic violence, dating violence, and drinking or drug use may
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be considerable issues for rural or suburban school communities, NSSI may prove to be
one of the greater issues of concern for principals.
Non-suicidal self-injury is a broad term that encompasses a variety of behaviors.
In recent years, a self-injurious behavior has reemerged in the form of self-asphyxiation
(Walsh, 2012). Students that engage in self-asphyxiation do so with the “desired effect of
dizziness, a ‘head rush,’ and a simulated experience of ‘getting high” (Walsh, 2012).
Self-asphyxial risk-taking behavior (SAB) typically occurs within adolescent groups,
most notably within the middle school years of education (Walsh, 2012). Other
maladaptive behaviors often accompany SAB, though research is still in its initial stages
(Walsh, 2012). The researcher recommends future studies to include SAB.
It is urgent for future researchers to investigate the role of the family in regards to
addressing NSSI among adolescent females. Presently, there is insufficient research
highlighting the role of the family when a student is identified in school. Federal, state,
and local mandates require schools to report harmful and life-threatening behaviors,
leaving schools to question where the lines between family privacy end and the
mandatory role to report begin. In respect to a school’s role of en loco parentis, research
much seek to identify parental privileges to the conversations between the school staff,
and the school staff and outside mental health organizations. This question remains
incredibly challenging for school staff, especially when cases of self-harm may stem
from factors of home life. Future research may attempt to clarify the role of the family
and the school, as well as set boundaries for the transfer of information from one party to
another. In addition, future research should analyze what legal and financial
responsibilities schools have to students identified as self-injurious.
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The data from this study suggests that Massachusetts’ school systems re-evaluate
the everyday demands on a principal as well as consider a possible realignment of
principal’s daily schedule in order to provide a greater ability to address NSSI in school.
In addition, with the provision of increased administrative training within graduate and
administrative programs, principals will be knowledgeable of the etiology of NSSI,
factors that catalyze self-injurious behaviors, and the signs of NSSI among students.
Armed with this knowledge, middle school principals will become confident in
approaching cases of NSSI within their schools. Knowledge will also define the role a
principal may play once a student is identified as engaging in NSSI, perhaps more
principals will consider playing a leadership role versus one of a supporter or facilitator.
Adopting a school policy and enacting a no-harm contract for students engaging in NSSI
will allow principals to have a greater chance at limiting contagion. It may affect change
in the behaviors of those students struggling with maladaptive behaviors, and provide a
safety net within the school for students and families.
This study has outlined possible factors that principals perceive inhibit or support
their ability to address NSSI among the adolescent female population in their schools.
Limited time, schedule flexibility, shortage of training, professional development and
funding are all factors that have been identified which limit the ability of principals to
address NSSI. On the contrary, those factors that inhibit principals can also support
principals in addressing NSSI. With upper administrative support, principal and staff
training, professional development, flexible time and secured funding, principals can
begin to perceive a greater degree of responsibility in their role for addressing NSSI
among adolescent females in school.
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This study also demonstrated a lack of direct involvement with students engaging
in NSSI as a direct result of the shortage of training in NSSI offered to current and future
administrators. Therefore, it is suggested that this study guide graduate and
administrative program requirements at the federal, state, and local levels. Through the
identification of possible factors that contribute to NSSI among young female
adolescents, academic curricula may be written to broaden awareness of NSSI among the
staff and student populations.
Federal, state, and local governing bodies should create educational policies
outlining necessary requirements for current and future principals designed to include
mental, emotional, social, and behavioral health courses as part of their licensure. In
addition, potential prevention and intervention plans should be developed, adapted, and
implemented using the results of this study.
This research yielded a great deal of information that helps us to better under
understand the perceptions current Massachusetts middle school principals have in
addressing NSSI, the various ways middle school principals report they are addressing
NSSI, and the factors and conditions that inhibit or support their efforts to address NSSI.
It is of great importance that researchers continue to investigate the role of the middle
school principal in addressing NSSI among adolescent females. Future research should
be inclusive of SAB and any other types of self-harm that were not discussed within this
study. In respect to educational leadership and addressing NSSI, graduate programs must
remain vigilant to continually update existing mental health course offerings and provide
current research to educators of all levels. With the possibility of an increase in self-harm
within Massachusetts’ middle school populations, it is crucial for research to continue to
184

investigate the etiology, behaviors, and prevention plans to minimize self-injury.
Educational leaders must be aware of the developmental impact NSSI has on their
student body, whether physically, mentally, emotionally, or socially.
Final Reflections
Through this study, I have learned an incredible amount – about NSSI, about the
role of a principal, and about myself. Using the lens of a researcher was difficult,
especially with a topic as emotionally laden as self-injury. It was difficult to place
personal bias aside for the sake of the research. Yet, without doing so, I never would
have learned why principals are hesitant to identify their role when addressing NSSI. As
this study concludes, I have a better understanding of principals’ fears of addressing
NSSI. Without a working knowledge of the etiology of self-harm, the behaviors of NSSI,
the factors that impact student self-harm, and the ways to identify, intervene, and prevent
self-harm, principals remain deficient in the mental, emotional, social, and physical areas
of a child in crisis. Before this study, I was unaware of why principals fail to address
such physically and mentally anguishing behaviors in school. Now, through the lens of a
researcher, I like to think I have a well-rounded understanding of the role of principal in
addressing NSSI.
This educational deficit may inhibit any efforts to prevent self-harm in their
individual schools, especially when combined with insufficient time and increased work
demands on principals. This study has contributed to my awareness of NSSI and how I
can continue to help the administration in my school bring about prevention programs
efficiently and effectively.
The revelations of what drives a student so young to self-harm was astonishing to
185

learn. At times, I feel my heart truly ached for individual students. I found myself
viewing online resources, blogs, and supporting prevention programs like To Write Love
On Her Arm. I have not stopped reading about the factors that catalyze a student to acts
of self-injury, nor do I believe I will stop. I plan on continuing my study beyond the
dissertation on how schools can adequately address this perceivably growing epidemic
among young women.
Throughout the interview process, I enjoyed listening to the principals discuss
their perceptions in regards to the three research questions. Different reactions to the
research questions brought the literature of NSSI and the historical role of the principal to
life. On one hand, it was evident that most participants had an authentic desire to learn
how to understand and help students who engage in self-injury. In contrast, it was hard to
hear from principals who did not prioritize the mental, emotional, and physical health of
the students in their schools. To me, it felt like those principals were throwing away the
children who self-harm. Instead, I felt the strong desire to tell them how they should
become educated enough to reach out to the students who are hurting. However, I
remembered to place my bias aside and collect the data necessary to answer the research
questions of this study.
In the future, I plan on continuing my study on self-injury. One of my career
goals is to provide the knowledge I have learned through this study with professionals in
my field. I will reach out to universities, colleges, professional development
organizations, administrative programs, and school communities, in order to educate
teachers, principals, and parents or guardians on the etiology of NSSI, the behaviors of
NSSI, the factors that initiate NSSI behaviors, and the ways to identify, intervene, and
186

prevent self-injury among students. I will seek to share my research through professional
development offerings and workshops, administrative programs, and courses at
universities and colleges. I will strive to encourage policy makers to include
comprehensive mental, social, emotional, and physical training for administrative leaders
in education as part of their job requirements before obtaining their initial or professional
licenses. In addition, I will encourage policy makers to require mandatory education
courses on issues of self-harm and other maladaptive behaviors in schools within
Massachusetts’ colleges, universities, and state-sponsored administrative programs. .
Three factors surprised me the most during this study: limitations of funding,
parental influence, and a lack of training offered to principals in the mental health field.
When the participants mentioned the limitations of funding, I was fascinated to hear how
much of an effect it has in school policy and professional development. Clearly, I
understood the concept that funding is needed for educational programs, but I could not
believe how much principals have to play with the budgets in order to meet the basic
needs of the students and at times the staff. It was fascinating, yet disheartening, to hear
how devastating school budget limitations effect current principals. Although aware of
parental influence, I was never privy to the extent that this factor has on the success of
health and prevention programs in schools. This study has heightened my awareness of
maintaining a strong and positive parental influence in my school.
The lack of training offered to principals in the field of mental health was one
factor that angered me as an educator. Since the days of Columbine, Virginia Tech, and
Sandy Hook, I would have thought there would have been a greater push to educate our
school leaders in the field of mental health. Yet, throughout the listed course offerings in
187

the universities and colleges of Massachusetts, the administrative programs supported by
the Massachusetts DESE, the professional development programs, and the state endorsed
guidelines provided by the DESE for principal certification, mental health courses were
not evident. It is my belief that without requiring universities, colleges, and
administrative programs to have mandatory courses on student mental, emotional, social,
and physical health, school leaders will not be educated beyond self-directed education.
Throughout data collection, it became clear that in order to meet the needs of
students who self-injure, principals need to seek training on their own since it is not being
provided to them. It is urgent for principals to acquire the knowledge on the etiology of
NSSI, the behaviors of NSSI, the factors of NSSI, and the ways to address NSSI in
middle school. Once principals possess this basis of knowledge, they will be more
confident and proactive in the role they play in addressing NSSI among adolescent
females in their schools. With such knowledge, principals may consider the degree of
importance for their role in the identification and implementation process greater than
perhaps originally thought.
Overall, this study has created a greater lens for me, not only in research, but also
in life. The mixed method taught me a deeper understanding of the research process and
provided me with a more global view of education. Although using both quantitative and
qualitative research measures were challenging in several ways, I felt it provided this
study with a richer, more in-depth view of the perceived role Massachusetts middle
school principals have regarding addressing NSSI. In addition, it has provided the
foundation for future studies I plan to contribute in this field.
This study investigated the perceived role of the middle school principal in the
188

identification, intervention, and prevention of NSSI among pre-adolescent and early
adolescent female students. With a recognized growth in NSSI behaviors, it is urgent for
Massachusetts’ middle school principals to take a more active role in addressing students
who engage in NSSI behaviors. 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. Therefore, principals must demand academic institutions and administrative
programs to provide specific courses in mental health issues for educators. In addition,
policy and law makers should be aware of the need to design educational laws and
policies requiring and providing specialized training for principals. Regardless of the
current provision of training, principals must be trained in the etiology of NSSI in order
to understand it and efficiently address it within their schools. Whether self-directed
study or through cross-disciplinary studies, principals must be able to identify NSSI
behaviors and recognize the factors that influence self-harm. In order to diminish the risk
of NSSI and the possibility of a contagion, principals must gain knowledge of
intervention and prevention methods designed for middle school females. They must be
trained to write student no-harm contracts, design safety protocols for students identified
as self-injurious, and lead crisis teams. Whether they play the role of a facilitator or a
supporter, principals must work collaboratively with school staff and outside mental
health organizations and hospitals to ensure the safety of the students. Most important, it
is imperative for principals to recognize the role they play in addressing NSSI with a
greater degree of importance so that our society can raise healthier, safer, adolescent
girls.
189

REFERENCES
Adler, P.A., & Adler, P. (2007). The demedicalization of self-injury: From
psychopathology to social deviance. Journal of Contemporary Ethnography
36, 537-570.
190

Adrian, M., Zeman, J., Erdley, C., Lisa, L., & Sim, L. (2011). Emotional dysregulation
and interpersonal difficulties as risk factors for nonsuicidal self-injury in
adolescent girls. Abnormal Child Psychology, 39, 389-400.
American Psychiatric Association. (2012) Non-suicidal self-injury. Retrieved
from www.psych.org
American Psychological Association. (2012). Non-suicidal self-injury. Retrieved
from www.apa.org
Barrocas, A.L., Hankin, B.L., PhD, Young, J.F., PhD., Abela, J.R., PhD. (2012) Rates of
nonsuicidal self-injury in youth: Age, sex, and behavioral methods in a
community sample. Pediatrics Digest, 130, 39-45.
Booth, B., PhD., Van Hasselt, V.B., PhD., Vecchi, G. M., PhD. (2011) Addressing school
violence. FBI Law Enforcement Bulletin. Retrieved from
http://www.fbi.gov/stats-
services/publications/lawenforcementbulletin/may_2011/school_violence.
Bowman, S. C., & Randall, K. (2004). See my pain!: Creative strategies and
activities for helping young people who self-injure. YouthLight, Inc.
191

Brausch, A. M., Decker, K. M., & Hadley, A. G. (2011). Risk of suicidal ideation
in adolescents with both self-asphyxial risk-taking behavior and non-
suicidal self-injury. Suicide and Life-Threatening Behavior, 41, 424-
434.
Briere, J. & Gil, E. (1998). Self-mutilation in clinical and general population samples:
Prevalence, correlates and functions. American Journal of Orthopsychiatry, 68
(4), 609-620.
Bresin, K & Gordon, K. (2013). Endrogenous opiods and nonsuicidal self-injury: A
mechanism of affect regulation. Neuroscience & Behavioral Review, 37 (3),
374-383.
Brown, K. M., Anfara, Jr., V.A. (2002). From the desk of the middle school principal:
Leadership responsive to the needs of young adolescents. Lanham, MD:
Scarecrow Press, Inc.
Center for Disease Control. (2012). Self-harm in the United States. Retrieved from
www.cdc.gov
Creswell, J.W. (2007). Qualitative inquiry & research design. Thousand Oaks, CA: Sage
Publications, Inc.
Crosby, A., Ortega, L., Melanson, C. (2011). Self-directed violence surveillance:
Uniform definitions and recommended data elements. Atlanta, GA: National
Center for Injury Prevention and Control (U.S.), Division of Violence Prevention.
Crowell, S.E., Beauchaine, T.P., Linehan, M.M. (2009). A biosocial developmental
model of borderline personality: Elaborating and extending Linehan’s theory.
Journal of Consulting and Clinical Psychology, (76), 15-21.
192

Denscombe, M. (2011). The good research guide: For small-scale social research
projects, 4th
ed. New York, NY: Open University Press.
Department of Elementary and Secondary Education. (2012). Health and risk behaviors
of Massachusetts. Retrieved from www.doe.edu
Dougherty, D.M., Mathais, C.W., Marsh-Richard, D., Prevette, K.N., Dawes, M.A.,
Hatzis, E.S., Palmes, G., & Nouvion, S.O. (2009). Impulsivity and clinical
symptoms among adolescents with non-suicidal self-injury with or without
attempted suicide. Psychiatry Research, 169, 22-27.
Dreikers, R., M.D., Cassel, P., M.Ed., Dreikers Ferguson, E., Ph.D. (2004). Discipline
without tears: How to reduce conflict and establish cooperation in the
classroom, Revised ed. Canada: Wiley & Sons, Ltd.
Favazza, A. (2011). Bodies under siege (3rd
ed.) Baltimore, MD: Johns Hopkins
University Press.
Federal Bureau of Investigation (2012). Retrieved from www.fbi.gov
Furlong, M., & Morrison, G. (2000). The school in school violence: Definitions and
facts. Journal of Emotional and Behavioral disorders, 8, 71-82.
Gay, P. (2003). Educational research: Competencies for analysis and application (7th
ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.
Greene, S.B. (1991). How many subjects does it take to do a regression-analysis.
Multivarite Behavioral Research, 26 (3), 499-510.
Hilt, L., Cha, C., & Nolen-Hoeksema, S. (2008). Nonsuicidal self-injury in young
adolescent girls: Moderators of the distress-function relationship. Journal of
Consulting and Clinical Psychology, 76 (1), 63-71.
193

Heath, N., Baxter, A., Toste, J., McLouth, R. (2010). Adolescents’ willingness to access
school-based support for nonsuicidal self-injury. Canadian Journal of School
Psychology, 25, 260-276.
Hilt, L., Nock, M., Lloyd-Richardson, E., Prinstein, M. (2008). Longitudinal study of
nonsuicidal self-injury among young adolescents: Rates, correlates, and
preliminary test of an interpersonal model. Journal of Early Adolescence 28
(3), 455-469.
Hooley, J. M., & St. Germain, S. A. (2013). Nonsuicidal self-injury, pain, and self-
criticism: Does changing self-worth change pain endurance in people who engage
in self-injury? Clinical Psychological Science. doi:10.1177/2167702613509372.
Huck, S. (2008) Reading statistics and research (5th
ed.). Boston, MA: Pearson.
International Society of Self-Injury. (2012). About self-injury. Retrieved from
http://www.isssweb.org/aboutnssi.php
Jacobson, C. M., & Gould, M. (2007). The epidemiology and phenomenology of non-
suicidal self-injurious behavior among adolescents: A critical review of the
literature. Archives of Suicide Research, 11 (2), 129-147.
Junke, G.A., Granello, P.F., & Granello, D.H. (2011). Suicide, self-injury, and violence
in the school; Assessment, prevention, and intervention strategies. Hoboken, NJ:
John Wiley & Sons, Inc.
Juvonen, J., Le, V-N., Kaganoff, T., Augustine, C., Constant, L. (2004). Focus on the
wonder years: Challenges facing American middle school. Santa Monica, CA:
Rand Co.
194

Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the
evidence. Clinical Psychology Review, 27, 226-239.
Klonsky, E. D., Muehlenkamp, J. J., Lewis, S. P., & Walsh, B. (2011). Nonsuicidal self-
injury: Advances in psychotherapy evidence-based practice. Cambridge, MA:
Hogrefe Publishing.
Knock, M. K., & Favazza, A. R. (2009). Nonsuicidal self-injury: Definition and
classification. Understanding nonsuicidal self-injury: Origins, assessment,
and treatment. Washington, DC: American Psychological Association.
Linehan, M. (1993). Boderline Personality Disorder: Concepts, Controversies, and
Definitions. New York, NY: Guilford Publications.
Loeber, R., & Stouthamer-Loeber, M. (1998) Development of juvenile aggression and
violence: Some common misconceptions. American Psychologist, 53 (2),
242-259.
Marion, J. (2011, March 29). Boston Schools budget slashes $63 million, cuts 250
jobs. World Socialist Web Site. Retrieved from
http://www.wsws.org/en/articles/2011/03/bost-m29.html
Mayo Clinic Staff. (2012). Self-Injury/Cutting. Retrieved from
http://www.mayoclinic.com/health/self-injury/DS00775
Marachi, R., Astor, R. A., & Benbenishty, R. (2007). Effects of teacher avoidance on
school policies on student victimization. School Psychology International, 28
(4), 501-518.
Massachusetts Department of Elementary and Secondary Education. (2012). Retrieved
from http://www.doe.mass.edu
195

Milia, D. (2000). Self-mutilation and art therapy: Violent creation. United Kingdom:
Jessica Kingsley Publishers, Ltd.
Muehlenkamp, J.J., & Walsh, B., McDade, M. (2010). Preventing non-suicidal self-
injury in adolescents: The signs of self-injury program. Journal of Youth
Adolescence 39, 306-314.
National Center for Education Research. (2011). Retrieved from nces.ed.gov/
Nelson, J. R. (1996). Designing schools to meet the needs of students who exhibit
disruptive behavior. Journal of Emotional and Behavioral Disorders, 4 (3),
147-161. doi: 10.1177/106342669600400302
Nixon, M. K., Cloutier, P., Jansson, M. (2008). Nonsuicidal self-harm in youth: A
population-based survey. Canadian Medical Association Journal, 178 (3), 306-
312.
Nixon, M.K., & Heath, N.L. (2009). Self-injury in youth: The essential guide to
assessment and intervention. New York, NY: Routledge.
Nock, M. K. (2012) Future directions for the study of suicide and self-injury. Journal
of Clinical Child & Adolescent Psychology, 41 (2), 255-259:
doi:10.1080/15374416.2012.652001
Nock, M. K., & Mendes, W. B. (2008). Physiological arousal, distress tolerance, and
social problem solving deficits among adolescent self-injurers. Journal of
Consulting and Clinical Psychology, 76 (1), 28-38.
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-
mutilative behavior. Journal of Consulting and Clinical Psychology 72 (5), 885-
890.
196

(2005). Contextual features and behavioral functions of self-mutilation among
adolescents. Journal of Abnormal Psychology, 114 (1), 140.
Oakes, J., Quartz, K.H., Ryan, S., Lipton, M. (2000). Becoming good American schools:
The struggle for civic virtue in education reform. Phi Delta Kappan.
Oates, J. C. (2012). Two or three things I forgot to tell you. New York, NY: Harper
Collins Publishers.
Office of Juvenile Justice and Delinquency Prevention. (2001). Retrieved from
http://www.ojjdp.gov/
Preyde, M., Watkins, H., Csuzdi, N., Carter, J., Lazure, K., White, S., Penney, R.,
Ashbourne, G., Cameron, G., Frensch, K. (2012). Non-suicidal self-injury and
suicidal behaviour in children and adolescents accessing residential or
intensive home-based mental health services. Journal of the Canadian
Academy of Child and Adolescent Psychiatry 21 (4), 270-281.
Ruggere, T. (2013, 2014). Personal communication.
Salkind, N. (2011). Statistics for people who (think they) hate statistics. Thousand Oaks,
CA: Sage.
Sax, L. (2010). Girls on the edge: The four factors driving the new crisis for girls.
New York, NY: Basic Books.
Sax, L. (2010) “Why are so many girls cutting themselves?” Sax on Sex. Psychology
Today. Retrieved from
http://www.psychologytoday.com/blog/sax-sex/201003/why-are-so-many-girls-
cutting-themselves
197

Scaer, R., MD. (2007). The body bears the burden: Trauma, dissociation, and disease
(2nd
ed.). New York, NY: The Hayworth Medical Press, Inc.
Screening for Mental Health (SMH). (2013). Signs of self-injury program. Wellesley
Hills, MA: Screening for Mental Health, Inc. Retrieved from
http://www.mentalhealthscreening.org/programs/youth-prevention-programs/sosi/
Shapiro, S. (2008). Addressing self-injury in the school setting. The journal of school
nursing, 24 (3), 124-130.
Spear, L. P. (2000). The adolescent brain and age-related behavioral manifestations.
Neuroscience and Biobehavioral Reviews 24, 417-463.
Sprague, J. R., & Walker, H. M. (2005). Safe and healthy schools: Practical prevention
strategies. Guilford Press.
Stone, S., Astor, R., Benbenishty, R. (July, 2009). Teacher and principal perceptions
of student victimization and the school’s response to violence: The
contributions of context on staff congruence. International Journal of
Educational Research 48, 194-213.
Whitlock, J., Purington, A., & Gershkovich, M. (2009). Media, the internet, and
nonsuicidal self-injury. Washington, DC: American Psychological Association.
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Appendix A
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
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Appendix B: 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
200

Appendix C – 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
201

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
202

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.
203

Appendix D: 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)
204

How many years have you served in your current administrative position?
_______ 0-2 ________ 3-5 ________6-10 ________10-15 ________ 16+
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.
4. NSSI primarily affects female students with other problems like drugs,
smoking and other negative behaviors.
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
205

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.
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.
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.
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
206

STATEMENT RATING
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.
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
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 population of my school.
43. I am knowledgeable of the signs of NSSI behavior.
207

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
208

Appendix E: 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 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?
209

Appendix F: 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?
Table 3.2 Participant’s Perception of Middle School Principals regarding their role in
addressing NSSI.
3. Teachers feel comfortable approaching me with a potential case of NSSI among the
population of my school.
4. Parental involvement is an essential part of the NSSI intervention and prevention
process.
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
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.
210

Table 3.3 Participants perceptions of NSSI, NSSI behaviors, & females engaging in NSSI
1. NSSI is an abnormal developmental state in a pre-adolescents life.
4. NSSI primarily affects female students with other problems like drugs, smoking, and
other negative behaviors.
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 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. Female students who engage in NSSI behaviors will sop on their own without
receiving any therapeutic help.
9. Female students who have been physically or sexually abused are more likely to
engage in NSSI.
10. Female students who engage in behaviors of NSSI are dramatic, often exaggerating
life issues.
12. Female students who engage in NSSI are non-athletes and do not engage in extra-
curricular activities.
13. Female students who are not necessarily considered pretty or popular by peers, or
active in school are more likely to engage in NSSI.
16. Female students who engage in behaviors of NSSI suffer from moderate to severe
mental illness.
17. Female students who feel shame, anger, or sadness engage in behaviors of NSSI.
18. Female students of divorced, separated, or single parent homes are more likely to
engage in behaviors of NSSI.
22. Students who engage in NSSI should have a mandatory psychological evaluation.
23. A female student who wants help for her NSSI behaviors would seek out her
administrator or guidance counselor.
211

Table 3.4 Factors and conditions that are believed to inhibit and support efforts to
address NSSI.
6. I believe I am unable to thoroughly address the needs of female students suspected of
11. 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.
13. There are programs available to administrators providing updated training on NSSI.
14. During my experience as a principal, I have continued to update my knowledge of
NSSI on my own.
15. I am knowledgeable of the signs of NSSI.
17. I am aware of the number of incidents of NSSI among the female pre-adolescent
population in my school.
Table 4.1. Participation Data
Total Principals Contacted Principals who completed the
Survey
Principals who participated
in the Interview
150 52 15
Diagram 4.2. Comparison of Demographic Information of Participants
212

Note: The (2) Principals who did not declare gender are not listed in chart above.
Table 4.3. Demographic Information of Participants
Principals
that partici-
pated in the
Survey
Male Female Transgender
(mtf)
Transgender
(ftm)
Responses
21
42.0%
29
55%
0
0.0%
0
0.0%
50
White Hispanic
or Latino
Black/African
American
Native
American/
American
Indian
Asian/
Pacific
Islander
Other
(please
describe)
Responses
44
83%
1
>1%
0
0.0%
0
0.0%
3
>1%
0
0.0%
48
Note: The (2) Principals who did not declare gender are not listed in chart above. The four (4)
principals who did not declare their ethnicity and are not listed in the chart above.
213

Diagram 4.4 A Comparison of Race among Participating Middle School Principals.
Note: The four (4) principals who did not declare their ethnicity and are not listed in the
chart above.
Table 4.5 Comparison of School Community Demographics
School Community N %
Urban
(50, 000+ People)
7 14.3%
Suburban
(20,000-50,000 People)
19 38.8%
Rural
(0-25,000 People)
17 34.7%
Other
Regional Charter)
6 12.2%
Total 49 100%
Note: The (3) Principals who did not declare community category are not listed in chart
above.
214

Table 4.6 Comparison of Schools
Type of School N %
Charter Public 1 5.6%
Regional Public 3 16.7%
Neighborhood Public 13 72.2%
Other
Regional Charter/All-City Public)
1 5.6%
Total 18 100%
Table 4.7 Student Population Demographics
Student Population
N %
0-500 12 37.5%
501-1000 19 59.4%
1001-1500 1 3.1%
1501-2500 0 0%
Total 32 100%
Note: Eighteen (18) Principals did not answer the student population question on the
survey. These responses are not listed in the chart above.
215

Table 4.8 Grade-level Demographics
Grade Configuration N %
K-8 7 14.3%
5-8 7 14.3%
6-8 21 42.9%
Other 14 28.6%
Total 49 100%
in pre- and early adolescent development with gender.
NSSI is an abnormal developmental stage in pre- adolescent’s and/or early
adolescent’s life.
How
would
you
describe
yourself?
Strongly
disagree
Agree
Strongly
Agree
Total
Male
0
0.0%
2
10.0%
1
5.0%
12
60.0%
5
25.0%
20
100.0%
Female 2
7.1%
2
7.1%
1
3.6%
13
46.4%
10
35.7%
28
99.9%
Transgen-
der (m-f)
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
Transgen-
der (f-m)
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
Note: (4) principals did not respond to question #12. Their missing responses are not listed in the
chart.
216

Diagram 4.10 Comparison of answers to the statement: NSSI is an abnormal
developmental stage in a pre-adolescent’s and/or early adolescents life.
Note: Four (4) principals did not answer the question and are not listed in the diagram
above.
Chart 4.11a & 4.11b. Comparison of the perceptions of NSSI as an abnormal
developmental stage in pre- and early adolescent development with gender.
217

Note: (4) principals did not respond to question #12. Their missing responses are not
listed in the chart.
Table 4.12 The Principal plays a role in addressing NSSI behaviors
I think the principal plays a role in addressing NSSI behaviors within the
student population of his/her school.
1 2 3 4 5 Total
Respondent
s
How would
you
describe
yourself?
Male 0
0.0%
3
30.0%
3
30.0%
1
10.0%
2
20.0%
9
Female 0
0.0%
7
100.0%
0
0.0%
0
0.0%
0
0.0%
7
Note: the categories Transgender (mtf) and Transgender (ftm) were excluded from the chart as
there were no participants that had qualified under the two categories.
218

Diagram 4.13 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.”
in pre- and/or early adolescent’s life with years of administration.
How many
years have
you served as
an
administrator
in your
career?
NSSI is an abnormal developmental stage in pre- and/or early
adolescent’s life
Strongly
Disagree
Disagree Agree
Mostly
Agree
Strongly
Agree
0-2 years
1
20.0%
0
0.0%
0
0.0%
3
60.0%
1
20.0%
3-5 years
0
0.0%
0
0.0%
0
0.0%
5
100.0%
0
0.0%
6-10 years
1
6.3%
2
12.5%
0
0.0%
8
50.0%
5
31.3%
10-15
years
0
0.0%
2
13.3%
2
13.3%
4
26.7%
7
46.7%
16+ years 0
0.0%
0
0.0%
0
0.0%
5
71.4%
2
28.6%
Note: A total of (48) principals answered question #12. Four (4) principals did not answer
the question. The missing responses are not listed in the chart.
219

Diagram 4.15 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.”
Note: the categories Transgender (mtf) and Transgender (ftm) were excluded from the
chart as there were no participants that had qualified under the two categories.
220

Table 4.16 Principal plays a role in addressing NSSI
I think the principal plays a role in addressing NSSI behaviors
within the student population of his/her school.
How many
years have
you served as
an
administrator
in your
career.
Strongly
Disagree
Agree
Strongly
Agree
0-2 years
0
0.0%
1
10.0%
0
0.0%
0
0.0%
0
0.0%
1
3-5 years
0
0.0%
1
10.0%
1
33.3%
0
0.0%
0
0.0%
2
6-10 years
0
0.0%
1
10.0%
2
66.7%
1
100.0%
1
50.0%
5
10-15 years
0
0.0%
4
40.0%
0
0.0%
0
0.0%
1
50.0%
5
16+ years
0
0.0%
3
30%
0
0.0%
0
0.0%
0
0.0%
3
Total
0
0.0%
10
100%
3
100%
1
100%
2
100%
16
Diagram 4.17: Comparison of Highest level of education attained
221

Table 4.18. Comparison of the perceptions of NSSI as an abnormal developmental stage
in pre- and/or early adolescent’s life with level of education.
NSSI is an abnormal developmental stage in pre-adolescent’s and early adolescent’s
development
Strongly
Disagree
Agree
Strongly
Agree
What is
the highest
level of
education
you have
attained?
Master’s 0 4 2 13 8
C.A.G.S. 0 0 0 3 2
Ed.D. 2 0 0 3 2
Ph.D. 0 0 0 0 2
Other 0 0 0 1
1
Note: A total of 49 principals answered question #12. Two (2) principals did not answer
the question. Their missing responses are not listed in the chart.
Table 4.19 Comparison of the level of education and the role of principal in addressing
NSSI
I think the principal plays a role in addressing NSSI
behaviors within the student population in his/her
school.
What is the
highest level of
education you
have attained?
Strongly
Disagree
Agree
Strongly
Agree
Total
Bachelors
0 0 0 0 0 0
Masters
0 7 2 0 1 10
C.A.G.S.
0 1 1 1 0 3
Ed.D.
0 0 0 0 1 1
Ph.D.
0 1 0 0 0 1
Total
0 9 3 1 2 15
Note: A total of fifteen (15) principals answered the question of education level
attained. Their responses were used in this cross tabulation.
Table 4.20 Correlations of years served as current administrator, years of career
administrator, gender, ethnicity, education level, years in 6-8 education.
222

NSSI is
abnormal
developmt
stage in
pre- or
early
adolescent
life
How
many
years
served
as
Admin
in
career
How
many
years
served
as
currnt
admin
How
would
you
des-
cribe
your-
self
How
many
years
served in
6-8
educatn
How
would
you
identify
your
ethnicty
What is
the
highest
level of
educatn
attained?
NSSI is
abnormal
Developmtl
state in a
pre-adoles
or early
adoles. life
Sig. (2)*
N 48
.269
48
.545
48
.908
48
.701
46
.312
44
.556
47
How many
years
served as
Admin in
Career
PC**
Sig. (2)
N
.163
.269
48
1
50
.377
.007
50
.040
.784
50
.397
.005
48
-.465
.001
46
-.003
.982
49
How many
years
served as
current
Admin
PC
Sig. (2)
N
.090
.545
48
.377
.007
50
1
50
.183
.203
50
.540
.000
48
-.058
.700
46
-.017
.907
49
How would
you
describe
yourself
(gender)
PC
Sig. (2 )
N
-.017
.908
48
.040
.784
50
.183
.203
50
1
50
.053
.720
48
.073
.630
46
.124
.394
49
How many
years
served in
6-8
education
PC
Sig. (2)
N
-.058
.701
46
.397
.005
48
.540
.000
48
.053
.720
48
1
48
-.210
.166
45
-.067
.656
47
How would
you
identify
your
ethnicity
PC
Sig. (2 )
N
-.156
.312
44
-.456
.001
46
-.058
.700
46
.073
.630
46
-.210
.166
45
1
46
-.025
.869
45
What is the
highest
level of
education
attained
PC
Sig. (2)
N
.088
.556
47
-.003
.982
49
-.017
.907
49
.124
.394
49
-.067
.656
47
-.025
.869
45
1
49
* Sig. (2) is a 2 tailed test. **PC is for Pearson Correlation
Table 4.21a Principal perceptions of female students who engage in NSSI behaviors.
Female
223

Students who
engage in
NSSI are
violent
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 11 8 1 1 0 21
Females 9 18 0 0 1 28
Total 20 26 1 1 1 49
Table 4.21b
Female students
who engage in NSSI
are low performers
in school.
Strongly
Disagree
Disagre
e
Agree Mostly
Agree
Strongly
Agree
Total
Males 8 11 1 1 0 21
Females 8 17 0 3 0 28
Total 16 18 1 4 0 49
Table 4.21c
NSSI primarily affects
female students who
engage in drugs, smoking,
or other maladaptive
behaviors
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 10 10 1 0 0 21
Females 7 16 3 0 0 26
Total 17 26 4 0 0 47
Table 4.21d
Female students who
engage in NSSI are
non-athletes and do not
engage in extra-
curricular activities.
Strongly
Disagree
Agree
Strongly
Agree
Total
Males 6 13 0 2 0 21
Females 3 18 1 3 0 25
Total 9 31 1 5 0 46
224

Table 4.22 The Comparison of Gender with the perception of females who engage in
NSSI behaviors having a moderate to severe mental illness.
Pearson Chi-Square 2.9646
Degrees of Freedom 12
p-Value .9958
Note: Six (6) principals did not answer this question. Their missing responses are not listed
in the chart.
225

Diagram 4.23 Principal perception that a student who engages in NSSI behaviors is
attempting Suicide
Diagram 4.24 Years Served in Administration during Career.
226

Diagram 4.25 Years served at current administrator position.
Table 4.26 Principals perceptions on the training received
In my
administr
ative
program/
grad
studies, I
have
received
training
on NSSI,
behaviors
are self-
harm,
how to
recognize
a student
who
engages
in NSSI
behaviors
M F 0-2 3-5 6-10 10-15 16+ Bachlr Mstrs CAGS EdD Ph.D. Otr
1
10
50%
8
30.8%
2
40%
1
25%
7
43.8%
6
46.2%
2
25%
0
0%
10
38.5%
3
33.3%
4
80%
0
0%
1
33.3%
2
10
50%
15
57.7%
3
60%
3
75%
8
50%
5
38.5%
6
75%
0
0%
16
61.5%
5
55.6%
1
20%
2
100%
0
0%
3
0
0.0
%
1
3.8%
0
0%
0
0%
0
0%
1
7.7%
0
0%
0
0%
1
11%
0
0%
0
0%
0
0%
0
0%
4
0
0.0
%
1
3.8%
0
0%
0
0%
0
0%
1
7.7%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
1
33.3%
5
0
0.0
%
1
3.8%
0
0%
0
0%
1
6.3%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
1
33.3%
227

Table 4.27 On the Job Training in NSSI
I have
received
on-the-
job
training
in NSSI
as a
princi-
pal.
M F 0-2 3-5 6-10 10-15 16+ Bhlr Mtrs CAGS EdD Ph.D. Otr
1 4
19%
4
16%
1
20%
1
25%
0
0%
5
35.7%
1
12.5
0
0%
7
25.9%
0
0%
0
0%
0
0%
1
33.3%
2 9
42.9
%
12
48%
1
20%
2
50%
8
50%
7
50%
3
37.5
0
0%
12
44.4%
3
33.3%
3
60%
2
100%
1
33.3%
3 1
4.8%
1
4%
1
20%
0
0%
1
6.7%
0
0%
0
0%
0
0%
0
0%
1
11%
1
20%
0
0%
0
0%
4 7
33.3
7
28%
2
40%
1
25%
6
40%
1
7.7%
4
50%
0
0%
7
25.9%
5
55.6%
1
20%
1
33.3
%
1
33.3%
5 0
0.0%
1
4.0%
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
1
3.7%
0
0%
0
0%
0
0%
0
0%
Note: 6 principals did not respond to the statement.
Diagram 4.28 Principals are aware of the number of incidents of NSSI
among the female adolescent population in school
Note: Two principals did not respond to this statement.
228

Table 4.29 Comparison of perceptions of received NSSI training in
Administrative/Graduate programs
229

Table 4.30a Comparison of Gender and Range of Perception in regards to receiving On
the Job Training
Note: 6 principals did not respond to the statement
230

Table 4.30b Comparison of Years in Administration and Range of Perception in regards
to Receiving On-the-Job Training
Note: Six (6) principals did not respond to the statement
231

Table 4.30c Comparison of Level of Education and Range of Perception in regards to
On-the-Job Training in NSSI
Note: Six (6) principals did not respond to the statement
232

Table 4.31 Comparison of Principals Perceptions on the Training Received during
Administrative Program/Graduate Studies
233

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