Table 1 Summary of themes

1) Adolescents describe the background to self-harm

In-school

i. Powerlessness related to age and gender

▪ Lack of power among young people and girls to take personal decisions and to contribute to or influence decisions and roles in the family.

ii. Parental modelling and parent-child incongruent expectations

▪ Conflicting role expectations between parents and their adolescent children.

iii. Parental criticism

▪ Criticism of adolescents by their parents.

iv. Perceived unfair application of the rule of punishment

▪ Perception that the rules governing punishment of deviant behaviours were unfairly or inconsistently applied by significant other adults (e.g., parents, older siblings etc.), leading to feeling unloved and uncared for.

v. Perceived family mistrust and betrayal

▪ False accusations and rumours where adolescents did not receive support and defence from their family.

vi. Early adultification

▪ The practice of making a child act as a primary caregiver providing emotional, material or instrumental support to adult relatives, younger siblings or to self, before the child is emotionally prepared to do so.

vii. Diabolical control

▪ Manipulations by unseen evil forces.

Street-connected

i. Self-harm as a response to adultification in family of origin

▪ The practice of making a child act as a primary caregiver providing emotional, material or instrumental support to adult relatives, younger siblings or to self, before the child is emotionally prepared to do so.

ii. Self-harm as a response to acculturative stress of street living

▪ For newcomers to street living, self-harm was a response to the mental strain experienced in adapting to the harsh realities of street living.

iii. Self-harm as a response to conflict of conduct norms in charity facility

▪ For newcomers to charity facilities, self-harm was in response to the behavioural difficulty experienced in adapting to the controlled culture of charity facilities.

2) Adolescents explain their self-harm

In-school: meaning-making

i. Enactment of tabooed emotions and contestations

▪ A means of contesting or protesting unbearable scolding, criticism, and (perceived) abuse by their parents.

ii. Avenge excessive control and punishment by parents

▪ A means of avenging and ending the excessive control and punishment by their parents, particularly, fathers.

iii. Responding to and management of negative emotions and circumstances

▪ A way of managing acute negative emotions or as a response to emotional disturbance or negative (interpersonal) circumstances.

In-school: consequences and influence on recovery

i. Self-harm as selfish act and social injury

▪ Self-harm was personally helpful but socially injurious to significant others; this motivated stopping self-harm.

ii. Self-harm improves social relations

▪ Self-harm led to improvement in social relationships with significant other adults; this motivated stopping self-harm.

iii. Self-harm worsens abuse

▪ Harsh punishment or abuse linked to self-harm worsened, particularly, where the self-harm was discovered because it resulted in hospitalisation.

iv. Self-harm as religious transgression

▪ A breach of religious tenets; this motivated stopping self-harm.

Street-connected: explanatory accounts

i. Reliance on peer and surrogate family support

▪ Adolescents relied on surrogate families and friends for financial and emotional support and protection; this motivated stopping self-harm.

ii. Reliance on charity support

▪ Support obtained from attending charity facility helped street-connected adolescents in stopping or avoiding self-harm

iii. Early adultification in the streets

▪ Taking on the role of an adult to care and provide for one’s own needs motivated stopping self-harm.

iv. Use of substitutes

▪ Adolescents pursued (usually, harmful) alternative acts to distract themselves from self-harm (e.g., substance use).