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Nursing and Health Sciences (2015), 17, 119–125

Research Article

Suicidal ideation in adolescents: A structural equation modeling approach Jung-hyun Choi, PhD,1 Mi Yu, PhD1 and Kyoung-eun Kim, PhD2 Departments of 1Nursing and 2Child Welfare, Namseoul University, Cheonan, Republic of Korea

Abstract

The purpose of this study is to test a model linking adolescents’ experience of violence and peer support to their happiness and suicidal ideation. The participants were high school students in Seoul, and in Kyungi, and Chungnam Provinces in Korea. The Conflict Tactics Scale, School Violence Scale, Oxford Happiness Inventory, and Suicidal Ideation Questionnaire were administered to just over 1000 adolescents. The model was tested using a path analysis technique within structural equation modeling. The model fit indices suggest that the revised model is a better fit for the data than the original hypothesized model. The experience of violence had a significant negative direct effect and peer support had a significant positive direct effect on their happiness. Happiness had a significant negative effect and the experience of violence had a significant positive effect on suicidal ideation. These findings demonstrate the fundamental importance of reducing exposure of violence to adolescents, and that increasing peer support and their happiness may be the key to adolescent suicidal ideation prevention.

Key words

happiness, Korean adolescents, parental violence, peer support, school violence, suicidal ideation.

INTRODUCTION Suicide is a serious health concern in adolescents.An increase in the incidence of youth suicide has emerged as a major public health and social issue. This has led to an in-depth study and the need for urgent action in Korea (National Evidence-based Healthcare Collaboration Agency, 2012). Korea’s suicide rate is 5.7 persons per 100 000 population. The suicide rate for high-school students aged 15–18 years in Korea is higher than the average suicide rate reported in Organization for Economic Co-operation and Development (OECD) countries (National Evidence-based Healthcare Collaboration Agency, 2012): 8.2 persons per 100 000 and 6.8 per 100 000, respectively. Furthermore, the annual rate of suicidal ideation in high-school students in Korea has increased progressively from 18.9% in 2009 to 19.1% in 2010, and then to 19.6% in 2011 (Korea Centers for Disease Control and Prevention, 2011). Suicidal ideation is a self-destructive thought of planning to end one’s life and is the most powerful predictor of suicide attempts and suicide (Nock et al., 2009). The experience of being emotionally and physically abused by a parent has significant effects on an adolescent’s development process and has been shown to affect adolescent suicide behavior both directly and indirectly (Park, 2010). The experience of Correspondence address: Mi Yu, College of Nursing, Gyeongsang National University, 815-16 Jinju-daero, Gyeongsang National University, Jinju, Gyeongnam, 660751,South Korea, Email: [email protected] Received 15 May 2013; revision received 15 February 2014; accepted 6 March 2014 [Correction added on 2 October 2014, after first online publication: Corresponding author’s address and email address have been updated.]

© 2014 Wiley Publishing Asia Pty Ltd.

school violence by peers has also been shown to lead to adolescent suicide (Zwierzynska et al., 2013) and is recognized as a serious societal problem. In one study, adolescents who experienced traditional bullying or cyber bullying had more suicidal thoughts and were more likely to attempt suicide than those who had not experienced such forms of peer aggression (Hinduja & Patchin, 2010). A second factor that may be influencing the suicide rate of Korean youth is low subjective happiness. Happiness consists of three components: the frequency and degree of positive affects or joy, the average level of satisfaction over a period, and the absence of negative feelings such as depression and anxiety (National Evidence-based Healthcare Collaboration Agency, 2012). Happiness implies the feeling that life is going well. Happy people have an advantage in that they feel that they can take the time to build new resources and work actively towards new goals (Carver, 2003). Happiness is a positive emotion, and positive emotions lead to a widerthan-usual range of perceptions, thoughts, and actions, and thereby promote cognitive and behavioral flexibility and the ability to identify a wider range of available opportunities (Fredrickson et al., 2008). Most importantly, the broadened thought–action repertoires help to build enduring physical, psychological, intellectual, and social resources. These personal resources, in turn, increase the experience of positive emotions and well-being over time (Cohn et al., 2009). Thus, early psychological intervention aimed at instilling optimistic thinking and acting decreases the risks of depression in adolescents (Seligman et al., 2006). The Subjective Well-being Index (SWI) for Korean students between the ages of 10 and 18 years was 65.98, which was comparatively lower than the doi: 10.1111/nhs.12142

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OECD average of 100. The index also showed that 26.5% of children and adolescents in Korea subjectively felt that they were unhealthy, while 18.3% felt alienated. Almost 17% of Korean children and adolescents reported that they felt lonely, which has put the country second to Japan (29.8%). Korean youngsters scored 65.1 points on the Subjective Happiness Index, which combines points scored from six different categories that include satisfaction with life and happiness (National Evidence-based Healthcare Collaboration Agency, 2012). In addition, adolescents with higher levels of depression are more likely to commit suicide, and happiness is considered to be effective in preventing suicide.Adolescents who are happy find their own lives interesting and rewarding, and generally do not engage in high-risk behaviors (Hoyt et al., 2012). Improving the sense of happiness in Korean youth may be considered a measure to prevent suicide in this population. Therefore, in this study, we examined the integrated relationships among adolescents’ past experience of violence, perceived peer support, happiness, and suicidal ideation.

Literature review Previous studies have identified the risk factors and dynamics of adolescent suicidal behavior (Winfree & Jiang, 2010; National Evidence-based Healthcare Collaboration Agency, 2012), and the highest risk factor for suicide is depression (Kumar et al., 2012; National Evidence-based Healthcare Collaboration Agency, 2012). Depression in adolescents is associated with an increased risk of illness and interpersonal and psychosocial difficulties, along with an increased risk of substance abuse and suicidal behaviors. Previous studies have reported a negative relationship between depression and happiness (Seligman et al., 2006); thus, the relationship between happiness and suicidal behavior needs to be examined. Other risk factors for the suicidal behavior of adolescents include health-risk behaviors such as drinking, smoking, and habitual substance use (Pena et al., 2012); family arguments and family abuse (Pillai et al., 2009); school violence or bullying (Bauman et al., 2013); peer relationships, school grades, and learning disabilities (National Evidence-based Healthcare Collaboration Agency, 2012); and stress (Hong & Jeon, 2005; Pillai et al., 2009). These factors can be categorized from the theoretical point of view of the ecological system into factors affecting the organism (individual factors) and factors originating from a microsystem that may act on the organism (environmental factors). Hong and Jeon (2005) reported that the cause of suicidal ideation and attempts in adolescents involves psychological instability that is influenced by negative relationships and interactions with parents, peers, and teachers in an adolescent’s environment. For example, teenagers who have been abused as children are more likely to experience depression and other internalizing problems (Moylan et al., 2010); they are also more likely to exhibit externalizing behavior problems, such as delinquency and violence perpetration (Zwierzynska et al., 2013). Adolescents who have been exposed to abuse in their childhood are more likely to expe© 2014 Wiley Publishing Asia Pty Ltd.

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rience a wide range of adverse psychosocial and behavioral outcomes, including depression, delinquency, suicidal ideation, and suicide attempts. Increasing defense or protective factors, such as a sense of fellowship at home, a positive outlook on life, and the promotion of good social and personal relations and communication (National Evidence-based Healthcare Collaboration Agency, 2012) are important for preventing suicidal ideation and behavior. Protective mechanisms such as a strong character or a personal perception of psychological well-being are positive adaptations to harsh circumstances, rather than a natural progression of character development from the challenges faced in life (Mohamadian et al., 2011). Adolescents possessing personal strength and a sense of well-being are less likely to engage in negative behaviors according to Schwartz et al. (2011), who suggested that a sense of personal strength and well-being may help prevent or reduce risktaking behaviors, such as unhealthy sexual behavior, drinking, and suicidal ideation. During the developmental stage of adolescence, peer-group relationships are very important.Adolescents who experience low intimacy and high rejection from peers can be prone to serious thoughts of suicide. Peer relationships may have indirect effects on the suicidal ideation of adolescents, as a sense of alienation and low self-esteem can stem from a lack of the sense of belonging to a peer group (Kerr et al., 2006). Furthermore, peer support has been considered the most influential factor in promoting happiness in youth (Kim & Jo, 2006). Positive support from peers is likely to increase adolescent happiness and decrease or prevent suicidal ideation. Based on these findings and our theoretical framework, it can be considered that a past experience of violence and the perceptions of peer support will have a direct effect on the sense/level of happiness and the frequency/occurrence/ admission/report of suicidal ideation; furthermore, the experience of violence and the perceptions of peer support will have an indirect effect on suicidal ideation via the sense/level of happiness (Fig. 1). However, few studies have examined integrated relations among variables, which is an important gap in the literature given current appreciation of the essential interaction between suicidal ideation and other factors. Thus, the aim of this study was to test a model linking the adolescent experience of child abuse, school violence, and perceptions of peer support to adolescent happiness and suicidal ideation

METHODS Design This study utilized a cross-sectional research design that investigated the linking of adolescents’ experience of domestic and school violence and the perceptions of peer support to the sense of happiness and suicidal ideation.

Sampling and data collection Our sample comprised high-school students aged 15–18 years, attending two high schools in Seoul and three in

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Parental violence

School violence

Experience of violence

Happiness

Suicidal ideation

Peer support

Figure 1.

Hypothesized path model.

Kyungi and Chungnam Provinces, Korea. Participants were selected by convenience sampling; and two classes from each grade (7th–9th grade) were randomly chosen from the selected schools.The survey was administered in a classroomsetting during a regularly scheduled class period with standardized instructions. After a research assistant explained the purpose of the study, data confidentiality, and possibility of withdrawal to participants, the written informed consent from adolescents was obtained. It required approximately 15–20 min to complete the questionnaires. Originally, 1100 students were invited; and 1003 (8.8% attrition) students finished the questionnaires.

Measurement The experience of violence includes both the experience of parental and school violence. Parental abuse was measured by the use of the Conflict Tactics Scale (CTS) (Straus & Gelles, 2009), which measures the use of reasoning, verbal aggression, and physical aggression between a parent and child. Adolescents responded to a list of questions on the frequency of mistreatment from the parents during the previous 12 months. Eight questions are scored on a scale from 1 (strongly disagree) to 4 (strongly agree). The Cronbach’s alpha for the CTS in this study was 0.91. The School Violence Scale (SVS) (Lim, 1998) was developed and validated to measure the level of exposure to school violence. Adolescents were asked to report the experience of assault, mistreatment, bullying, and violence during the previous 12 months in school. The scale consisted of six items, which were based on a 4-point Likert scale (range = 1 [strongly disagree] to 4 [strongly agree]). A High score indicates that they frequently experienced school violence. The Cronbach’s alpha for the SVS in this study was 0.90. The Peer Support Scale (PSC) was developed and validated by Lee and Shin (1997) and was used to measure the adolescent’s perceived support from peers. Adolescents were asked to report perceived emotional support and encouragement from their friends.The scale consisted of five items, which were based on a 5-point Likert scale (range = 1 [strongly disagree]

to 5 [strongly agree]).A high score indicates high support.The Cronbach’s alpha for this scale in this study was 0.84. The Oxford Happiness Inventory (OHI) was developed and validated by Hills and Argyle (2002) and was used to measure the adolescent’s sense of happiness. Adolescents were asked to report perceived positive affect, sense of control, and self-efficacy. This scale consisted of 29 items, which were based on a 5-point Likert scale (range = 1 [strongly disagree] to 5 [strongly agree]). A high score indicates that they feel happy. Cronbach’s alpha for OHI in this study was 0.92. The Suicidal Ideation Questionnaire (SIQ), developed by Reynolds (1998), was used to assess the participant’s current thoughts about suicide. Adolescents were asked to report a specific suicidal cognition over the past month (e.g.“I thought if had the chance, I would kill myself,” “I thought about how I would kill myself”). This scale consisted of 15 items, which were based on a 5-point Likert scale (range = 1 [strongly disagree] to 5 [strongly agree]). A high score indicates high suicidal ideation. The Cronbach’s alpha for SIQ was 0.96.

Ethical consideration Ethical approval for this study was received from the Institutional Review Board of the Namseoul University (IRB No. NSU-522), Cheonan, Korea. Prior to collecting the data, each student received the information on this study including the purpose, potential risks and benefits of this study, and data collection procedures. Adolescents who were distressed by questionnaire or do not want to participate in this study could refuse at at any time. To ensure the confidentiality of participants individual demographic data were translated into a four-digit numerical code. The final decision regarding consent for participation was made by guardians before data collection and by individual students during the process of data collection.

Data management and analysis Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) (Version 17.0) and the Analysis of © 2014 Wiley Publishing Asia Pty Ltd.

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tion (RMSEA) was used and evaluated using the criteria that a low value (between 0 and 0.06) is indicative of a goodfitting model.

Moment Structures (AMOS) statistical software programs (Version 17.0). Descriptive statistics for all study variables, as well as the reliability assessment of the study instruments, were computed. The hypothesized model in this study was analyzed using structural equation modeling (SEM) techniques. All observed variables exhibited multivariate normality. Missing data were estimated using the full information maximum likelihood (FIML) method. For the SEM, a goodness of fit as well as χ2 were assessed. These included omnibus fit indices such as χ2 and incremental fit indices such as Comparative Fit Index (CFI) and Tucker–Lewis Index (TLI). The χ2 is interpreted as the test of the difference between the hypothesized model and the revised model resulting from this study. Low non-significant values are desired (Kline, 2005). However, χ2 is very sensitive to the sample size, and thus, in a model with a relatively large sample size, the null hypothesis is expected to be rejected almost all of the time. Because of this limitation, the incremental fit indices were also used. The fit indices indicate the proportion of the improvement of the hypothesized model relative to a null model, typically one assuming no correlation among the observed variables. The generally agreed-upon critical value for the CFI and TLI is 0.90 or higher (Kline, 2005). In addition, the root mean square error of approxima-

Table 1.

Characteristics of the participants The demographic profile of the sample is presented in Table 1. Regarding the gender of the participants, 58.12% were female and 41.88% were male. The average age was 17.80 (SD = 0.99) years of age. The socioeconomic status (SES) of the participants is as follows: 12.06% of participants were high, 79.64% were middle, and 8.30% were low SES.

Descriptive statistics and correlations Table 2 presents the means (M), standard deviations, and intercorrelations among the major study variables. The overall mean frequency of the parental and school violence exposure was low (CTS, M = 1.24; SVS, M = 1.11). The adolescents perceived they were supported by peers (M = 3.65 on a 5-point scale); somewhat happy with their current life (3.30 on a 5-point scale); and not likely to think of suicide (2.03 on a 5-point scale). Parental violence was significantly correlated with all major study variables; and most strongly with school violence (r = 0.42) and suicidal ideation (r = 0.29). School violence was negatively associated with happiness (r = −0.14) and peer support (r = −0.07), but positively associated with suicidal ideation (r = 0.21). Peer support was positively related to happiness (r = 0.52), but negatively related to suicidal ideation (r = −0.21). Happiness was strongly related to suicidal ideation (r = −0.48).

Participants’ demographic variables (n = 1003)

Demographics Gender

Female Male 1st 2nd 3rd High Middle Low Elementary school Middle school High school University graduate Elementary school Middle school High school University graduate

Grade

Socioeconomic status

Father’s educational level

Mother’s educational level

Table 2.

RESULTS

N

%

583 420 375 357 271 119 786 82 13 30 421 518 17 37 533 399

58.12 41.88 37.39 35.59 27.02 12.06 79.64 8.30 1.32 3.05 42.87 52.75 1.72 3.75 54.06 40.47

Results of the model testing The initial analysis of the hypothesized model revealed adequate fit to the data (χ2 = 2.72, d.f. = 2, P = 0.26, CFI = 0.99, TLI = 0.99, RMSEA = 0.02). All specified paths were significant, except the path from the perceived peer support to suicidal ideation, and in the expected direction, providing initial support for the model (see Table 3). To improve model fit, we tested a competitive model to find out whether adolescent’s happiness fully mediated the relationship between peer support and suicidal ideation. A competitive model (revised model), based on theoretical reasoning and previous

Means (M), standard deviations (SD), range, and correlation coefficients for the major study variables

Variable Parental violence School violence Peer support Happiness Suicidal ideation

M

SD

Range

1

2

3

4

5

1.24 1.11 3.65 3.30 2.03

0.40 0.32 0.75 0.45 0.96

1–4 1–5 1–5 1–5 1–5

1

0.42*** 1

−0.03 −0.07* 1

−0.16*** −0.14*** 0.52*** 1

0.29*** 0.21*** −0.21*** −0.48*** 1

*P < 0.05, ***P < 0.001. 1 = parental violence, 2 = school violence, 3 = peer support, 4 = happiness, 5 = suicidal ideation.

© 2014 Wiley Publishing Asia Pty Ltd.

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suggested that a happier sense of life may appreciably contribute to the ability to recover from adverse events, including domestic violence and school bullying. Furthermore, Seligman et al. (2006) suggested the importance of positive psychology, where people are taught to focus on the positive side of life, building and engaging in meaningful relationships to develop a sense of happiness, rather than focusing on the trauma or depression that may be rooted in domestic violence and school bullying. Happiness has a protective role against self-destructive thoughts, suggesting that happiness serves as an important asset when considering suicidal behavior among high-school students who have experienced violence (Seligman et al., 2006). A recent study measured average happiness in 130 nations, on a rating scale of 0–10 (0 = low level of happiness; 10 = high level of happiness) and revealed scores ranging from 3.24 in Togo to 8.00 in Denmark. The average happiness score of South Korea was 5.68, which was much lower than the scores from other developed nations (Ott, 2011). In Korea, suicide is the second leading cause of death among adolescents aged 15–19 years (Korea National Statistical Office, 2007). A sense of unhappiness may play a role in the higher incidence of suicidal ideation in Korea. The present findings demonstrate the importance of considering risk factors and protective factors in assessing suicidal ideation among Korean adolescents (Lee, 2009). Indeed, eliminating risk factors is not always possible when intervening with suicidal individuals. It may be more practical to help increase protective factors, such as happiness and the sense of well-being (Lee, 2009). Moreover, while screening for suicidal behavior with high sensitivity and specificity is not always possible with any scale, happiness can be a proxy umbrella-like measure for suicidal risk (Honkanen et al., 2003). Also, this study revealed that the experience of violence directly and indirectly affects an adolescent’s suicidal ideation. Previous studies have shown that childhood physical and emotional abuse are risk factors for youth suicide attempts (Pillai et al., 2009). Adolescents who have reported physical punishment by parents during the previous year are at high risk for suicide attempts (Zwierzynska et al., 2013). Our study adds further evidence that physical or emotional abuse experienced as parental or peer violence affects the rate of suicide attempts among Korean adolescents. Prevention of adolescent abuse could significantly reduce suicidal behavior in adolescents by increasing the frequency of

research suggesting a non-significant relationship between peer support and suicidal ideation (Kim & Jo, 2006), did not have a direct path from the peer support to suicidal ideation within the hypothesized model (Table 4, Fig. 2). The revised model resulted in a substantially better fit to the data (χ2 = 3.75, d.f. = 3, P = 0.29, CFI = 1.00, TLI = 1.00, RMSEA = 0.02). Comparing the hypothesized model with the revised model (Δχ2d.f.=1 = 1.03, P > 0.05), the former is more limited. These results indicated that the revised model is a superior fit to hypothesized model.

DISCUSSION This study revealed the mitigating effect of happiness related to the experience of violence, peer support, and suicidal ideation of adolescents. Happiness is a positive concept vital to the maintenance of health. Yet, few studies of its potential usefulness have been published in the nursing literature (Bekhet et al., 2008). We have found that a higher experience of violence is associated with less happiness and, consequently, greater suicidal ideation. The outcomes of this study are partly consistent with those of previous studies that addressed the sense of happiness by focusing on suicidal ideation (Honkanen et al., 2003). Baumeister et al. (2003)

Table 3. Pathways of the hypothesized and final model Structural paths Hypothesized model Experience of violence → happiness Peer support → happiness Happiness → suicidal ideation Experience of violence → suicidal ideation Peer support → suicidal ideation Final model Experience of violence → happiness Peer support → happiness Happiness → suicidal ideation Experience of violence → suicidal ideation

B

β

SE

P

−0.29 0.31 −0.92 0.91

−0.20 0.51 −0.43 0.29

0.06 0.02 0.07 0.15

< 0.001 < 0.001 < 0.001 < 0.001

0.04

0.03

0.04

0.24

−0.29 0.31 −0.89 0.92

−0.20 0.51 −0.41 0.29

0.06 0.02 0.06 0.15

< 0.001 < 0.001 < 0.001 < 0.001

B: unstandardized effect; β: standardized direct effect; SE: standard error.

Table 4.

Direct and indirect standardized coefficient for the final model structure

Structural paths Experience of violence → happiness Peer support → happiness Happiness → suicidal ideation Experience of violence → suicidal ideation Peer support → suicidal ideation

Standardized direct effect (β)

Standardized indirect effect (β)

SMC

−0.20 0.51 −0.41 0.29

NA NA NA 0.08* −0.21***

0.35 0.35 0.33 0.33 0.33

NA: not applicable; *P < 0.05, ***P < 0.001.

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0.57 Parental violence

0.30 School violence 0.55

0.76 Experience of violence

0.29*** 0.31

0.31

–0.20***

–0.05

Happiness 0.51***

Suicidal ideation –0.41***

Figure 2. Final study model: χ2 = 3.75, d.f. = 3, P = 0.29, CFI = 1.00, TLI = 1.00, RMSEA = 0.02. ***P < 0.001.

Peer support

positive emotions. It is common for adolescents experiencing family and school violence to contemplate or attempt suicide, highlighting the importance of considering environmental factors when assessing suicide risks. Another interesting result of this study was that peer support indirectly influenced suicidal ideation through happiness. This finding was somewhat unexpected, as we assumed that peer support would have both an indirect and a direct effect on suicidal ideation. The present results demonstrate that the influence of peer support on suicidal ideation is channeled through the sense of happiness and that the effects of peer support on suicidal ideation are amplified in happier adolescents. These results are consistent with the findings of a previous study that addressed happiness by focusing on peer support (Natvig et al., 2003). Furthermore, Cui et al. (2010) reported that the lack of peer association was significantly related to suicidal ideation. Social relationships, including peer support, are probably the greatest single source of happiness. When peers feel more connected to and interdependent with their peers, they feel happier and more satisfied in life, fostering an environment that copes better with emerging crises in life (Walker et al., 2009). The present study has some limitations that need to be taken into consideration while interpreting the findings. First, the suicidal ideation questionnaires were collected using selfreport measures in school classes.This may have led to biases, such as socially desirable responses. Second, because this study is cross-sectional in nature, causal inferences cannot be drawn from the results. Any generalizations based on the present findings should be made with caution.

CONCLUSION The aim of this study was to test a model linking the adolescent experience of child abuse and school violence, and the perceptions of peer support to adolescent happiness and suicidal ideation. A reduction of parental and school violence and the promotion of peer support are likely to foster positive emotions and may ultimately decrease the likelihood of adolescent suicide ideation and attempts. © 2014 Wiley Publishing Asia Pty Ltd.

The findings have certain implications for practice. Lyubomirsky et al. (2005) suggested that the key to happiness lies in our thoughts to live a fulfilling life. Interventions to change the way adolescents think of their happiness can successfully be used with victimized adolescents and parents of these adolescents. Cooperation between school nurses and teachers is necessary to assist adolescents who have experienced domestic violence and school bullying to build a sense of happiness. Moreover, further research is required to explore and examine the associations among adolescents’ sense of happiness, experience of violence, and incidence of suicidal ideation more thoroughly.

ACKNOWLEDGMENTS All authors would like to acknowledge the assistance and cooperation of the school administration supervisors of all the participating middle and high schools for their sincerity and keenness to provide us with the adolescents’ evaluations. This research was supported financially by Namseoul University in 2014.

CONTRIBUTIONS Study design: JHC, MY, KEK. Data collection and analysis: JHC, MY, KEK. Manuscript writing: JHC, MY, KEK.

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