Association of School, Family, and Mental Health Characteristics With Suicidal Ideation among Korean Adolescents Gyu-Young Lee, Yun-Jung Choi
Correspondence to Yun-Jung Choi E-mail: [email protected] Gyu-Young Lee Associate Professor Red Cross College of Nursing Chung-Ang University Seoul, Korea Yun-Jung Choi Assistant Professor Red Cross College of Nursing Chung-Ang University 221 Heukseok-Dong Dongjak-Gu Seoul 156-756, Korea
Abstract: In a cross-sectional research design, we investigated factors related to suicidal ideation in adolescents using data from the 2013 Online Survey of Youth Health Behavior in Korea. This self-report questionnaire was administered to 72,435 adolescents aged 13–18 years in middle and high school. School characteristics, family characteristics, and mental health variables were analyzed using descriptive statistics, x2 tests, and logistic regression. Both suicidal ideation and behavior were more common in girls. Suicidal ideation was most common in 11th grade for boys and 8th grade for girls. Across the sample, in logistic regression, suicidal ideation was predicted by low socioeconomic status, high stress, inadequate sleep, substance use, alcohol use, and smoking. Living apart from family predicted suicidal ideation in boys but not in girls. Gender- and school-gradespecific intervention programs may be useful for reducing suicidal ideation in students. ß 2015 Wiley Periodicals, Inc. Keywords: substance abuse; adolescent; stress; sleep; mental health; smoking; suicide Research in Nursing & Health, 2015, 38, 301–310 Accepted 31 March 2015 DOI: 10.1002/nur.21661 Published online 27 April 2015 in Wiley Online Library (wileyonlinelibrary.com).
In Korea, suicide has been reported to be the leading cause of adolescent death. Between 2010 and 2013, over 11% of all Korean youth experienced suicidal ideation at least once during the year prior to a suicide attempt (Statistics Korea, 2013). Approximately 20% of all children and adolescents suffer from psychiatric illnesses, and 50% of all adults who suffer from psychiatric illnesses were diagnosed before they reached 14 years of age (World Health Organization, 2007). Among 1,600 adolescents in Paris, 23% of girls and 14% of boys reported suicidal thoughts, and 5–10% of the adolescents reported frequent suicidal ideation (Choquet & Menke, 2007). Despite these statistics, little is known regarding the factors associated with adolescent suicidal ideation, which can threaten healthy development and lead to fatal behaviors. The aim of this study was to identify factors associated with adolescent suicidal ideation, using data from the 2013 Online Survey of Youth Health Behavior in Korea (Statistics Korea, 2013).
Stress and Suicidal Ideation Mental health factors related to adolescent suicidal ideation include academic stress, interpersonal stresses, and risk behaviors. Statistics Korea (2013) suggested that the most frequent causal factors in Korean adolescent suicidal ideation are stress regarding academic records, transitioning to higher education, and family discord. Adolescent academic stress is related to the “education fever” phenomenon in Korea (Suh, 2008). The roots of this phenomenon are found in Confucianism, which emphasizes hard work and success in school and in life. During the hardships of the Japanese occupation (1910–1945) and the Korean War (1950–1953), the application of this principle to education intensified, along with an increased cultural desire for private and national economic growth (Suh). This “education fever” affected parenting style and parental expectations for their children's educational success. Korean parents generally have great expectations for the academic
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achievements and social success of their children. This is more so for sons than daughters, especially first-borns, because one of the traditions of Confucianism is that the eldest son is expected to succeed in the family business and look after his parents (Hur, Namkoong, & Zhang, 2008). Parental expectations in turn apparently have increased children's academic stress and decreased their feelings of academic self-efficacy (Baek, 2011). Academic stress has been linked to youth suicidal behavior across several Asian countries that share a cultural history of Confucianism. Students' academic stress and the rate of suicidal ideation have been related to academic achievement, school grade, and urban or rural location of the school (Che, 2011). Stress is thought to be due to study pressure, heavy school workload, and stress regarding gaining acceptance to a good secondary school (Baek, 2011; Yao et al., 2014). Additionally, although suicidal ideation has not been associated with school location, Korean students living in rural areas have been found to be more likely to attempt suicide than those living in urban areas (Che, 2011; Park, 2009). Suicidal behavior has been significantly associated with the severity of interpersonal stress experienced by adolescents (Rew, Thomas, Horner, Resnick, & Beuhring, 2001). Dawes, Mathias, Richard, Hill-Kapturczak, & Dougherty (2008) found that interpersonal stressors related to one's family or peers were the most important risk factors for adolescent suicidal behavior. These included parental separation, social isolation, poor family communication, family dysfunction, conflicts with peers or parents, victimization by peers, low social support, relationship strain due to parental substance abuse, and other parental psychopathology. School violence, bullying, substance use, and game addictions also have been associated with mental health problems (Che, 2011).
Mental Health, Substance Use, and Suicidal Ideation Youths' mental health problems, such as mood and substance-use disorders, have been linked to increased risk of self-harm and suicidal ideation in Western countries (Barnes, Eisenberg, & Resnick, 2010; Goldstein, Frosch, Davarya, & Leaf, 2008; Gould, Shaffer, & Greenberg, 2003). In particular, depressed mood has consistently been found to be a primary factor in suicidal ideation. Depressed mood is associated with dysregulation of the serotonin system (related to chronic stress or genetic loading) and is characterized by behavioral changes in adequacy of sleep, eating patterns, and interpersonal relationships (McManama O'Brien, Becker, Spirito, Simon, & Prinstein, 2014; Rew et al., 2001; Taliaferro & Muehlenkamp, 2014). The frequency of marijuana use and suicide attempts based on the Youth Risk Behavior Survey (YRBS) increased from 2009 to 2011 in students in the US (CDC,
Research in Nursing & Health
2012). Adolescent substance users have more than a 2.5-fold increase in risk for suicidal behaviors compared to adolescents who do not use drugs, and the progression of substance-use severity has been related to a corresponding increase in the severity of suicidal behaviors (Dawes et al., 2008; McManama O'Brien et al., 2014; Miranda, Ortin, Scott, & Shaffer, 2014; Park, 2005).
Demographic Influences on Suicidal Ideation Other factors affecting adolescent suicidal behavior include gender and living arrangements. Girls are significantly more likely than boys to experience suicidal ideation, whereas boys are more likely to attempt suicide (Taliaferro & Muehlenkamp, 2014; Yao et al., 2014). While differences in suicidal behavior between male and female adolescents have been reported across cultures (Barnes et al., 2010), in Korea this may be augmented by Confucianism, which has emphasized traditional gender roles. Women with more traditional gender role attitudes have manifested a greater risk for depression and suicidal behavior (Han & Hong, 2011). Among substance users, boys are more likely than girls to report suicidal ideation (Taliaferro & Muehlenkamp, 2014). Living apart from both parents and perceiving a low level of parental connectedness are also risk factors for youth suicidal behavior, and this effect seems to be stronger among girls than boys (Han & Hong, 2011).
Suicide Prevention Researchers in Western countries have designed and tested a variety of interventions to help adolescents at risk of suicide. These interventions have primarily addressed mental health issues and have included psychodynamic individual therapy, supportive psychotherapy, group psychotherapy, cognitive behavioral therapy, and dialectical behavior therapy (e.g., Deykin, Hsieh, Joshi, & McNamara, 1986; Donaldson, Spirito, & Esposito-Smythers, 2005; Harrington et al., 1998; Katz, Cox, Gunasekara, & Miller, 2004; Spirito, Boergers, Donaldson, Bishop, & Lewander, 2002; Wood, Trainor, Rothwell, Moore, & Harrington, 2001). Interventions have been effective in reducing rates of self-harm behavior. Harrington et al. (1998) provided a brief homebased problem-focused family intervention, and Spirito et al. (2002) conducted a compliance-enhancement intervention using a problem-solving approach. Deykin et al. (1986) increased help-seeking and compliance using community education and direct service. The Youth Support Team, a social network intervention in hospitalized youth, reduced suicidal ideation in girls (YST; King et al., 2006). In Korea, a national policy to prevent youth suicide (Korean Ministry of Health & Welfare, 2004) included school-based mental health services, but they are not systematically provided, despite evidence that students may
SUICIDAL IDEATION IN KOREAN ADOLESCENTS/ LEE AND CHOI
benefit from the inclusion of such services in the regular curriculum as well as in crisis intervention programs (Lee & Oh, 2014), and have not been systematically evaluated (Korean Educational Development Institute, 2012). No reports of effective interventions for at-risk youth in a school setting were found from other nations. Because most adolescents spend the majority of their time at school, and characteristics of the school setting are related to youth suicide (Korean Educational Development Institute, 2012), there may be a need for further developing and providing school-based mental health interventions. The microsystem of Bronfenbrenner's (1979) ecological systems model framed the research questions and content of the study. The microsystem includes those with which the adolescent has direct contact, including family, school, peers, health services, and church. Not measured in this study were the mesosystem, connecting the structures within the microsystem, the exosystem, including formal and informal support systems and structures that affect children indirectly, or the macrosystem, representing broad influences, such as cultural values, attitudes, laws, and resources (Berk, 2007). In this study, the microsystem was represented by mental health variables, including perceived stress, perceived adequacy of sleep, smoking, alcohol use, depressive mood, and suicidal behaviors, and by gender, school location, academic achievement, parents' education levels, socioeconomic status, and living situation. The purpose of this study was to identify factors associated with adolescent suicidal ideation to determine evidence of a need to provide more effective school-based services, as well as to identify at-risk populations, with the eventual goal to offer early intervention, improve overall mental health, and reduce the number of adolescent suicides. The research questions were whether, within the microsystem, there were associations between Korean adolescents' suicidal ideation and (a) gender, suicide plans, and suicide attempts; (b) school characteristics (school location, grade-level, and academic achievement); (c) mental health variables (perceived stress, perceived adequacy of sleep, smoking, alcohol use, and depressive mood); and (d) family characteristics (parent education, socio-economic status, and student's living situation with parents or away).
Method Data Source The primary data were obtained from the 2013 Online Survey of Youth Health Behavior in Korea. The survey has been conducted every year since 2005 by the Korean Ministry of Education, the Korean Ministry of Health and Welfare, and the Korea Centers for Disease Control and Prevention (KCDC) as required by the National Health Promotion Law, which mandates basic resources for planning and evaluating youth health promotion services and the submission of data on Korean youth health behavior to the
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WHO. The first survey, conducted in 2005, included 11 domains (including smoking, alcohol use, substance use, obesity, eating behavior, physical activities, safety, hygiene, and mental health). The domains of health equity, asthma, internet addiction, and violence were added in 2006, 2007, 2008, and 2012, respectively. The reliability and validity of the survey were assessed in 2009. The test-retest reliability analysis showed that 87.3% of responses had a moderate-level kappa value, which was similar to findings for the Youth Risk Behavior Survey in the USA (Brener, Collins, Kann, Warren, & Williams, 1995; Park, Jeong, Kim, Bae, & Kwun, 2009). The validity of the survey was examined by comparing students' responses to questions regarding smoking tobacco, height, and weight with actual measurements of the urine cotinine level, height, and weight of the students. The results showed a high level of validity (k ¼ .80; Park et al., 2009).
Sample Selection To reduce sampling error, the sampling process for the primary data of this study involved three steps: (a) population stratification, (b) sample allocation, and (c) sampling. For population stratification, seven area clusters (metropolitan, medium or small city, or rural area; geographical accessibility; number of schools; population size; living environment; rate of alcohol use; and smoking rate) and three school clusters (middle school, academic high school, and vocational high school) were used to divide the population into 129 strata. In the sample allocation step, the sample size was set to 400 middle schools and 400 high schools; 5 schools were allocated by proportion according to the school's location (metropolitan city, medium or small city, or rural area) and type (middle school, academic high school, or vocational high school). Then, in stratified cluster sampling, the list of schools was systematically sampled according to the determined sampling interval. In the final step, sample classes were randomly selected from each grade from the sample schools. All students in a sample class who agreed to participate by signing a consent form were included in the survey. Students who were not able to respond to the questionnaire due to dyslexia, autism, ADHD, or long-term absence were excluded. Of the 75,149 students who were identified for the sample, 96.4% had fully completed to the self-report questionnaire, and data related to study variables from 72,435 students were used. The study was approved by the Institutional Review Board (IRB) for the protection of research subjects at Chung-Ang University, Seoul, Korea.
Instrument Instruments for the 2013 Online Survey of Youth Health Behavior were developed by scientific experts on the survey committee. Based on a literature review, they devised
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initial indicators, categories, and questionnaires and revised them based on advice from specialists on youth health. The final survey contained 126 questions in 15 categories: oral health, personal hygiene, physical activity, eating behavior, obesity and weight-control behavior, atopic dermatitis or asthma, perceived adequacy of sleep, perceived stress, smoking, alcohol use, sexual behavior, depressive mood, suicidal behaviors, safety consciousness, and health equity. For the present study, we extracted and analyzed school characteristics, family characteristics, and mental health variables (perceived stress, perceived adequacy of sleep, smoking, alcohol use, and depressive mood). School characteristics. School characteristics included school location (metropolitan cities,medium and small cities, or rural areas), grade (middle school 7th grade, middle school 8th grade, middle school 9th grade, high school 10th grade, high school 11th grade, or high school 12th grade), and academic achievement (high, medium, or low). Family characteristics. Family characteristics included parents' education (high school or less, college or more, or not sure), socioeconomic status (high, medium, or low), and living situation (living with family, living in dormitory/boarding house, or living in orphanage/shelter).
Mental health variables Perceived stress. Perceived stress was measured by the question “Usually, how much do you experience stress?” The available responses were a lot, very much, a little, very little, or never, which were collapsed into three categories: very much, a little, or very little. Perceived adequacy of sleep. Perceived adequacy of sleep was measured by the question “During the last week, have you had enough sleep to eliminate your fatigue?” The responses available were more than enough, enough, medium, not enough, or never enough, which were collapsed into three categories: enough, medium, or not enough. Smoking. Smoking was measured by the question “Have you ever smoked tobacco?” (yes or no). Alcohol use. Alcohol use was measured by the question “Have you ever drunk any alcohol?” (yes or no). Substance use. Substance use was measured by the question “Have you ever used any drugs, butane gas, bond (adhesives), or others intentionally or habitually?” (yes or no). Depressive mood. Depressive mood was measured by the question “During the last year, have you had feelings of sadness or despair that interrupted daily activities?” (yes or no). Suicidal behaviors. Suicidal behaviors included suicidal ideation, suicide planning, suicide attempts, and medical treatment for self-harm, which were measured by the questions “During the last year, have you had any thoughts of suicide?”; “During the last year, have you had a suicide plan?”; “During the last year, have you attempted suicide?”; “During the last year, have you had medical
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treatment after a suicide attempt?” Each question was answered as yes or no.
Data Collection The Korean Online Survey of Youth Health Behavior is mandated by the National Health Promotion Law, and does not require guardian permission for students to participate. Teachers in charge of the survey were assigned and trained to collect the data. The teacher in charge explained the survey's purpose and process to the participants. After school, the participants entered a computer room, randomly sat at computers alone, accessed the online survey system, and responded to the self-report questionnaire. Completion time was approximately 45–50 minutes. Homeroom teachers were not allowed to enter the computer room during the survey in order to avoid undue pressure on the participants. After the survey, small gifts were given to the participants. The teachers in charge reported the number of students who did and did not participate in the survey, as well as the reason for not participating.
Data Analysis Selected data were analyzed using Statistical Package for Social Sciences (SPSS) version 21 (SPSS Inc., Chicago, IL). Cell percentages were calculated for weighted percentages, using survey sample weights. Descriptive statistics were calculated for school characteristics, family characteristics, and mental health variables. Differences between boys and girls for school characteristics, family characteristics, mental health variables, and factors related to suicidal ideation, including suicidal planning and attempts, were calculated using x2 tests. Potential factors predicting suicidal ideation were assessed using logistic regression.
Results Sample Characteristics There were 72,435 participants (36,655 boys and 35,780 girls; Table 1). More than 90% were from urban areas; about half were at middle schools, 43% at academic high schools, and 9% were at vocational high schools. Perceived academic achievement was fairly evenly distributed in high, medium, and low categories. About 48% of their fathers and 39% of their mothers had graduated from college or university. Almost half of the participants perceived their socioeconomic status as medium, and the vast majority were living with their families.
Gender and Suicidal Behavior When analyzed by gender, 13% of boys and 20% of girls reported suicidal ideation (Table 2), a significant difference
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Table 1. School and Family Characteristics of Korean Adolescents for Total Sample and by Gender Variables
Classification
Total (n ¼ 72,435)
%a
Boys (n ¼ 36,655)
%a
Girls (n ¼ 35,780)
%a
32,540 31,037 8,858 12,199 12,113 12,218 12,028 11,865 12,012 24,995 20,148 27,292 26,686 31,362 11,124 32,700 25,775 10,851 22,747 34,494 15,194 69,006 3,026 403
44.0 49.1 6.9 16.2 16.0 16.5 17.1 16.9 17.2 34.5 27.8 37.7 36.8 47.8 15.4 46.2 38.8 15.0 32.3 47.4 20.3 96.1 3.4 .5
16,573 15,312 4,770 6,411 6,261 6,249 6,098 5,595 6,041 12,884 9,897 13,874 13,119 15,880 6,027 15,356 13,278 6,235 12,764 16,377 7,514 34,759 1,640 256
44.1 48.7 7.3 16.2 16.0 16.5 17.0 17.0 17.3 35.4 27.4 37.2 35.9 47.8 16.2 43.5 39.6 16.8 35.5 44.7 19.8 95.7 3.6 .7
15,967 15,725 4,088 5,788 5,852 5,969 5,930 6,270 5,971 12,111 10,251 13,418 13,567 15,482 5,097 17,344 12,497 4,616 9,983 18,117 7,680 34,247 1,386 147
43.9 49.6 6.5 16.2 16.1 16.5 17.3 16.9 17.0 33.8 28.8 37.4 37.7 47.8 14.5 49.1 38.0 12.9 28.8 50.4 20.8 96.5 3.2 .4
Location
Metropolitan cities Medium and small cities Rural areas School grade Middle school 7th grade Middle school 8th grade Middle school 9th grade High school 10th grade High school 11th grade High school 12th grade Academic achievement High Medium Low Father’s education High school College Not sure Mother’s education High school College Not sure Socio-economic status High Medium Low Living situation Living with family Living in dormitory/boarding house Living in shelter/orphanage a
weighted percentage.
(p < .001). The percentage of boys who had made suicide plans was 5%, compared to 7% of girls, and 3% of boys had made suicide attempts, compared to 6% of girls. Both plans and attempts were significantly more frequent in girls. Of those who reported suicide attempts, 22.8% of boys and 10.4% of girls required medical treatment.
Suicidal Ideation and School Characteristics As shown in Table 3, suicidal ideation was more common in schools in large metropolitan areas for boys, but not for girls. There was a significant association between school grade and suicidal ideation in both boys and girls, with higher frequency in grades 8, 9, and 11 for boys and in grades 7–9 for girls. Poor academic achievement was strongly associated with suicidal ideation in both boys and girls (Table 3).
Suicidal Ideation and Family Characteristics The percentage of boys who reported suicidal ideation was higher in those with low socioeconomic status and high parental education (Table 4), whereas in girls, only socioeconomic status was linked to suicidal ideation. The percentage of participants reporting suicidal ideation was approximately double for boys and girls living in orphanages or shelters, compared to those living with family.
Suicidal Ideation and Mental Health Variables All mental health variables measured had statistically significant associations with suicidal ideation (Table 5). The percentage of boys and girls reporting suicidal ideation was almost nine times higher in those who reported “a lot” of
Table 2. Gender Differences in Korean Adolescents’ Suicidal Ideation and Behavior (n ¼ 72,435) Boys (n ¼ 36,655)
Total Variable Suicidal ideation Made a suicide plan Attempted suicide
Girls (n ¼ 35,780)
n
%a
n
%a
n
%a
X2
12,070 4,168 3,021
16.6 5.7 4.1
4,770 1,755 1,065
13.1 4.7 2.8
7,300 2,413 1,956
20.4 6.7 5.5
711.914 127.752 297.191
Note: All differences p < .001. a weighted percentage.
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Table 3. Relationship of School Characteristics to Suicidal Ideation in Korean Boys and Girls Boys With Suicidal Ideation Variables Location Metropolitan Medium and small cities Rural areas School grade Middle school 7th grade Middle school 8th grade Middle school 9th grade Middle school 10th grade Middle school 11th grade Middle school 12th grade Academic achievement High Medium Low
n
%a
x2
2,238 1,935 597
13.6 12.6 13.0
6.481
745 849 841 759 815 761
12.0 13.9 14.0 11.9 14.5 12.3
1,498 1,194 2,078
11.8 12.1 15.1
Girls With Suicidal Ideation n
%a
x2
.04
3,297 3,170 833
20.6 20.2 20.4
1.173
.56
28.309
Correspondence to Yun-Jung Choi E-mail: [email protected] Gyu-Young Lee Associate Professor Red Cross College of Nursing Chung-Ang University Seoul, Korea Yun-Jung Choi Assistant Professor Red Cross College of Nursing Chung-Ang University 221 Heukseok-Dong Dongjak-Gu Seoul 156-756, Korea
Abstract: In a cross-sectional research design, we investigated factors related to suicidal ideation in adolescents using data from the 2013 Online Survey of Youth Health Behavior in Korea. This self-report questionnaire was administered to 72,435 adolescents aged 13–18 years in middle and high school. School characteristics, family characteristics, and mental health variables were analyzed using descriptive statistics, x2 tests, and logistic regression. Both suicidal ideation and behavior were more common in girls. Suicidal ideation was most common in 11th grade for boys and 8th grade for girls. Across the sample, in logistic regression, suicidal ideation was predicted by low socioeconomic status, high stress, inadequate sleep, substance use, alcohol use, and smoking. Living apart from family predicted suicidal ideation in boys but not in girls. Gender- and school-gradespecific intervention programs may be useful for reducing suicidal ideation in students. ß 2015 Wiley Periodicals, Inc. Keywords: substance abuse; adolescent; stress; sleep; mental health; smoking; suicide Research in Nursing & Health, 2015, 38, 301–310 Accepted 31 March 2015 DOI: 10.1002/nur.21661 Published online 27 April 2015 in Wiley Online Library (wileyonlinelibrary.com).
In Korea, suicide has been reported to be the leading cause of adolescent death. Between 2010 and 2013, over 11% of all Korean youth experienced suicidal ideation at least once during the year prior to a suicide attempt (Statistics Korea, 2013). Approximately 20% of all children and adolescents suffer from psychiatric illnesses, and 50% of all adults who suffer from psychiatric illnesses were diagnosed before they reached 14 years of age (World Health Organization, 2007). Among 1,600 adolescents in Paris, 23% of girls and 14% of boys reported suicidal thoughts, and 5–10% of the adolescents reported frequent suicidal ideation (Choquet & Menke, 2007). Despite these statistics, little is known regarding the factors associated with adolescent suicidal ideation, which can threaten healthy development and lead to fatal behaviors. The aim of this study was to identify factors associated with adolescent suicidal ideation, using data from the 2013 Online Survey of Youth Health Behavior in Korea (Statistics Korea, 2013).
Stress and Suicidal Ideation Mental health factors related to adolescent suicidal ideation include academic stress, interpersonal stresses, and risk behaviors. Statistics Korea (2013) suggested that the most frequent causal factors in Korean adolescent suicidal ideation are stress regarding academic records, transitioning to higher education, and family discord. Adolescent academic stress is related to the “education fever” phenomenon in Korea (Suh, 2008). The roots of this phenomenon are found in Confucianism, which emphasizes hard work and success in school and in life. During the hardships of the Japanese occupation (1910–1945) and the Korean War (1950–1953), the application of this principle to education intensified, along with an increased cultural desire for private and national economic growth (Suh). This “education fever” affected parenting style and parental expectations for their children's educational success. Korean parents generally have great expectations for the academic
C
2015 Wiley Periodicals, Inc.
302
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achievements and social success of their children. This is more so for sons than daughters, especially first-borns, because one of the traditions of Confucianism is that the eldest son is expected to succeed in the family business and look after his parents (Hur, Namkoong, & Zhang, 2008). Parental expectations in turn apparently have increased children's academic stress and decreased their feelings of academic self-efficacy (Baek, 2011). Academic stress has been linked to youth suicidal behavior across several Asian countries that share a cultural history of Confucianism. Students' academic stress and the rate of suicidal ideation have been related to academic achievement, school grade, and urban or rural location of the school (Che, 2011). Stress is thought to be due to study pressure, heavy school workload, and stress regarding gaining acceptance to a good secondary school (Baek, 2011; Yao et al., 2014). Additionally, although suicidal ideation has not been associated with school location, Korean students living in rural areas have been found to be more likely to attempt suicide than those living in urban areas (Che, 2011; Park, 2009). Suicidal behavior has been significantly associated with the severity of interpersonal stress experienced by adolescents (Rew, Thomas, Horner, Resnick, & Beuhring, 2001). Dawes, Mathias, Richard, Hill-Kapturczak, & Dougherty (2008) found that interpersonal stressors related to one's family or peers were the most important risk factors for adolescent suicidal behavior. These included parental separation, social isolation, poor family communication, family dysfunction, conflicts with peers or parents, victimization by peers, low social support, relationship strain due to parental substance abuse, and other parental psychopathology. School violence, bullying, substance use, and game addictions also have been associated with mental health problems (Che, 2011).
Mental Health, Substance Use, and Suicidal Ideation Youths' mental health problems, such as mood and substance-use disorders, have been linked to increased risk of self-harm and suicidal ideation in Western countries (Barnes, Eisenberg, & Resnick, 2010; Goldstein, Frosch, Davarya, & Leaf, 2008; Gould, Shaffer, & Greenberg, 2003). In particular, depressed mood has consistently been found to be a primary factor in suicidal ideation. Depressed mood is associated with dysregulation of the serotonin system (related to chronic stress or genetic loading) and is characterized by behavioral changes in adequacy of sleep, eating patterns, and interpersonal relationships (McManama O'Brien, Becker, Spirito, Simon, & Prinstein, 2014; Rew et al., 2001; Taliaferro & Muehlenkamp, 2014). The frequency of marijuana use and suicide attempts based on the Youth Risk Behavior Survey (YRBS) increased from 2009 to 2011 in students in the US (CDC,
Research in Nursing & Health
2012). Adolescent substance users have more than a 2.5-fold increase in risk for suicidal behaviors compared to adolescents who do not use drugs, and the progression of substance-use severity has been related to a corresponding increase in the severity of suicidal behaviors (Dawes et al., 2008; McManama O'Brien et al., 2014; Miranda, Ortin, Scott, & Shaffer, 2014; Park, 2005).
Demographic Influences on Suicidal Ideation Other factors affecting adolescent suicidal behavior include gender and living arrangements. Girls are significantly more likely than boys to experience suicidal ideation, whereas boys are more likely to attempt suicide (Taliaferro & Muehlenkamp, 2014; Yao et al., 2014). While differences in suicidal behavior between male and female adolescents have been reported across cultures (Barnes et al., 2010), in Korea this may be augmented by Confucianism, which has emphasized traditional gender roles. Women with more traditional gender role attitudes have manifested a greater risk for depression and suicidal behavior (Han & Hong, 2011). Among substance users, boys are more likely than girls to report suicidal ideation (Taliaferro & Muehlenkamp, 2014). Living apart from both parents and perceiving a low level of parental connectedness are also risk factors for youth suicidal behavior, and this effect seems to be stronger among girls than boys (Han & Hong, 2011).
Suicide Prevention Researchers in Western countries have designed and tested a variety of interventions to help adolescents at risk of suicide. These interventions have primarily addressed mental health issues and have included psychodynamic individual therapy, supportive psychotherapy, group psychotherapy, cognitive behavioral therapy, and dialectical behavior therapy (e.g., Deykin, Hsieh, Joshi, & McNamara, 1986; Donaldson, Spirito, & Esposito-Smythers, 2005; Harrington et al., 1998; Katz, Cox, Gunasekara, & Miller, 2004; Spirito, Boergers, Donaldson, Bishop, & Lewander, 2002; Wood, Trainor, Rothwell, Moore, & Harrington, 2001). Interventions have been effective in reducing rates of self-harm behavior. Harrington et al. (1998) provided a brief homebased problem-focused family intervention, and Spirito et al. (2002) conducted a compliance-enhancement intervention using a problem-solving approach. Deykin et al. (1986) increased help-seeking and compliance using community education and direct service. The Youth Support Team, a social network intervention in hospitalized youth, reduced suicidal ideation in girls (YST; King et al., 2006). In Korea, a national policy to prevent youth suicide (Korean Ministry of Health & Welfare, 2004) included school-based mental health services, but they are not systematically provided, despite evidence that students may
SUICIDAL IDEATION IN KOREAN ADOLESCENTS/ LEE AND CHOI
benefit from the inclusion of such services in the regular curriculum as well as in crisis intervention programs (Lee & Oh, 2014), and have not been systematically evaluated (Korean Educational Development Institute, 2012). No reports of effective interventions for at-risk youth in a school setting were found from other nations. Because most adolescents spend the majority of their time at school, and characteristics of the school setting are related to youth suicide (Korean Educational Development Institute, 2012), there may be a need for further developing and providing school-based mental health interventions. The microsystem of Bronfenbrenner's (1979) ecological systems model framed the research questions and content of the study. The microsystem includes those with which the adolescent has direct contact, including family, school, peers, health services, and church. Not measured in this study were the mesosystem, connecting the structures within the microsystem, the exosystem, including formal and informal support systems and structures that affect children indirectly, or the macrosystem, representing broad influences, such as cultural values, attitudes, laws, and resources (Berk, 2007). In this study, the microsystem was represented by mental health variables, including perceived stress, perceived adequacy of sleep, smoking, alcohol use, depressive mood, and suicidal behaviors, and by gender, school location, academic achievement, parents' education levels, socioeconomic status, and living situation. The purpose of this study was to identify factors associated with adolescent suicidal ideation to determine evidence of a need to provide more effective school-based services, as well as to identify at-risk populations, with the eventual goal to offer early intervention, improve overall mental health, and reduce the number of adolescent suicides. The research questions were whether, within the microsystem, there were associations between Korean adolescents' suicidal ideation and (a) gender, suicide plans, and suicide attempts; (b) school characteristics (school location, grade-level, and academic achievement); (c) mental health variables (perceived stress, perceived adequacy of sleep, smoking, alcohol use, and depressive mood); and (d) family characteristics (parent education, socio-economic status, and student's living situation with parents or away).
Method Data Source The primary data were obtained from the 2013 Online Survey of Youth Health Behavior in Korea. The survey has been conducted every year since 2005 by the Korean Ministry of Education, the Korean Ministry of Health and Welfare, and the Korea Centers for Disease Control and Prevention (KCDC) as required by the National Health Promotion Law, which mandates basic resources for planning and evaluating youth health promotion services and the submission of data on Korean youth health behavior to the
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WHO. The first survey, conducted in 2005, included 11 domains (including smoking, alcohol use, substance use, obesity, eating behavior, physical activities, safety, hygiene, and mental health). The domains of health equity, asthma, internet addiction, and violence were added in 2006, 2007, 2008, and 2012, respectively. The reliability and validity of the survey were assessed in 2009. The test-retest reliability analysis showed that 87.3% of responses had a moderate-level kappa value, which was similar to findings for the Youth Risk Behavior Survey in the USA (Brener, Collins, Kann, Warren, & Williams, 1995; Park, Jeong, Kim, Bae, & Kwun, 2009). The validity of the survey was examined by comparing students' responses to questions regarding smoking tobacco, height, and weight with actual measurements of the urine cotinine level, height, and weight of the students. The results showed a high level of validity (k ¼ .80; Park et al., 2009).
Sample Selection To reduce sampling error, the sampling process for the primary data of this study involved three steps: (a) population stratification, (b) sample allocation, and (c) sampling. For population stratification, seven area clusters (metropolitan, medium or small city, or rural area; geographical accessibility; number of schools; population size; living environment; rate of alcohol use; and smoking rate) and three school clusters (middle school, academic high school, and vocational high school) were used to divide the population into 129 strata. In the sample allocation step, the sample size was set to 400 middle schools and 400 high schools; 5 schools were allocated by proportion according to the school's location (metropolitan city, medium or small city, or rural area) and type (middle school, academic high school, or vocational high school). Then, in stratified cluster sampling, the list of schools was systematically sampled according to the determined sampling interval. In the final step, sample classes were randomly selected from each grade from the sample schools. All students in a sample class who agreed to participate by signing a consent form were included in the survey. Students who were not able to respond to the questionnaire due to dyslexia, autism, ADHD, or long-term absence were excluded. Of the 75,149 students who were identified for the sample, 96.4% had fully completed to the self-report questionnaire, and data related to study variables from 72,435 students were used. The study was approved by the Institutional Review Board (IRB) for the protection of research subjects at Chung-Ang University, Seoul, Korea.
Instrument Instruments for the 2013 Online Survey of Youth Health Behavior were developed by scientific experts on the survey committee. Based on a literature review, they devised
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initial indicators, categories, and questionnaires and revised them based on advice from specialists on youth health. The final survey contained 126 questions in 15 categories: oral health, personal hygiene, physical activity, eating behavior, obesity and weight-control behavior, atopic dermatitis or asthma, perceived adequacy of sleep, perceived stress, smoking, alcohol use, sexual behavior, depressive mood, suicidal behaviors, safety consciousness, and health equity. For the present study, we extracted and analyzed school characteristics, family characteristics, and mental health variables (perceived stress, perceived adequacy of sleep, smoking, alcohol use, and depressive mood). School characteristics. School characteristics included school location (metropolitan cities,medium and small cities, or rural areas), grade (middle school 7th grade, middle school 8th grade, middle school 9th grade, high school 10th grade, high school 11th grade, or high school 12th grade), and academic achievement (high, medium, or low). Family characteristics. Family characteristics included parents' education (high school or less, college or more, or not sure), socioeconomic status (high, medium, or low), and living situation (living with family, living in dormitory/boarding house, or living in orphanage/shelter).
Mental health variables Perceived stress. Perceived stress was measured by the question “Usually, how much do you experience stress?” The available responses were a lot, very much, a little, very little, or never, which were collapsed into three categories: very much, a little, or very little. Perceived adequacy of sleep. Perceived adequacy of sleep was measured by the question “During the last week, have you had enough sleep to eliminate your fatigue?” The responses available were more than enough, enough, medium, not enough, or never enough, which were collapsed into three categories: enough, medium, or not enough. Smoking. Smoking was measured by the question “Have you ever smoked tobacco?” (yes or no). Alcohol use. Alcohol use was measured by the question “Have you ever drunk any alcohol?” (yes or no). Substance use. Substance use was measured by the question “Have you ever used any drugs, butane gas, bond (adhesives), or others intentionally or habitually?” (yes or no). Depressive mood. Depressive mood was measured by the question “During the last year, have you had feelings of sadness or despair that interrupted daily activities?” (yes or no). Suicidal behaviors. Suicidal behaviors included suicidal ideation, suicide planning, suicide attempts, and medical treatment for self-harm, which were measured by the questions “During the last year, have you had any thoughts of suicide?”; “During the last year, have you had a suicide plan?”; “During the last year, have you attempted suicide?”; “During the last year, have you had medical
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treatment after a suicide attempt?” Each question was answered as yes or no.
Data Collection The Korean Online Survey of Youth Health Behavior is mandated by the National Health Promotion Law, and does not require guardian permission for students to participate. Teachers in charge of the survey were assigned and trained to collect the data. The teacher in charge explained the survey's purpose and process to the participants. After school, the participants entered a computer room, randomly sat at computers alone, accessed the online survey system, and responded to the self-report questionnaire. Completion time was approximately 45–50 minutes. Homeroom teachers were not allowed to enter the computer room during the survey in order to avoid undue pressure on the participants. After the survey, small gifts were given to the participants. The teachers in charge reported the number of students who did and did not participate in the survey, as well as the reason for not participating.
Data Analysis Selected data were analyzed using Statistical Package for Social Sciences (SPSS) version 21 (SPSS Inc., Chicago, IL). Cell percentages were calculated for weighted percentages, using survey sample weights. Descriptive statistics were calculated for school characteristics, family characteristics, and mental health variables. Differences between boys and girls for school characteristics, family characteristics, mental health variables, and factors related to suicidal ideation, including suicidal planning and attempts, were calculated using x2 tests. Potential factors predicting suicidal ideation were assessed using logistic regression.
Results Sample Characteristics There were 72,435 participants (36,655 boys and 35,780 girls; Table 1). More than 90% were from urban areas; about half were at middle schools, 43% at academic high schools, and 9% were at vocational high schools. Perceived academic achievement was fairly evenly distributed in high, medium, and low categories. About 48% of their fathers and 39% of their mothers had graduated from college or university. Almost half of the participants perceived their socioeconomic status as medium, and the vast majority were living with their families.
Gender and Suicidal Behavior When analyzed by gender, 13% of boys and 20% of girls reported suicidal ideation (Table 2), a significant difference
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Table 1. School and Family Characteristics of Korean Adolescents for Total Sample and by Gender Variables
Classification
Total (n ¼ 72,435)
%a
Boys (n ¼ 36,655)
%a
Girls (n ¼ 35,780)
%a
32,540 31,037 8,858 12,199 12,113 12,218 12,028 11,865 12,012 24,995 20,148 27,292 26,686 31,362 11,124 32,700 25,775 10,851 22,747 34,494 15,194 69,006 3,026 403
44.0 49.1 6.9 16.2 16.0 16.5 17.1 16.9 17.2 34.5 27.8 37.7 36.8 47.8 15.4 46.2 38.8 15.0 32.3 47.4 20.3 96.1 3.4 .5
16,573 15,312 4,770 6,411 6,261 6,249 6,098 5,595 6,041 12,884 9,897 13,874 13,119 15,880 6,027 15,356 13,278 6,235 12,764 16,377 7,514 34,759 1,640 256
44.1 48.7 7.3 16.2 16.0 16.5 17.0 17.0 17.3 35.4 27.4 37.2 35.9 47.8 16.2 43.5 39.6 16.8 35.5 44.7 19.8 95.7 3.6 .7
15,967 15,725 4,088 5,788 5,852 5,969 5,930 6,270 5,971 12,111 10,251 13,418 13,567 15,482 5,097 17,344 12,497 4,616 9,983 18,117 7,680 34,247 1,386 147
43.9 49.6 6.5 16.2 16.1 16.5 17.3 16.9 17.0 33.8 28.8 37.4 37.7 47.8 14.5 49.1 38.0 12.9 28.8 50.4 20.8 96.5 3.2 .4
Location
Metropolitan cities Medium and small cities Rural areas School grade Middle school 7th grade Middle school 8th grade Middle school 9th grade High school 10th grade High school 11th grade High school 12th grade Academic achievement High Medium Low Father’s education High school College Not sure Mother’s education High school College Not sure Socio-economic status High Medium Low Living situation Living with family Living in dormitory/boarding house Living in shelter/orphanage a
weighted percentage.
(p < .001). The percentage of boys who had made suicide plans was 5%, compared to 7% of girls, and 3% of boys had made suicide attempts, compared to 6% of girls. Both plans and attempts were significantly more frequent in girls. Of those who reported suicide attempts, 22.8% of boys and 10.4% of girls required medical treatment.
Suicidal Ideation and School Characteristics As shown in Table 3, suicidal ideation was more common in schools in large metropolitan areas for boys, but not for girls. There was a significant association between school grade and suicidal ideation in both boys and girls, with higher frequency in grades 8, 9, and 11 for boys and in grades 7–9 for girls. Poor academic achievement was strongly associated with suicidal ideation in both boys and girls (Table 3).
Suicidal Ideation and Family Characteristics The percentage of boys who reported suicidal ideation was higher in those with low socioeconomic status and high parental education (Table 4), whereas in girls, only socioeconomic status was linked to suicidal ideation. The percentage of participants reporting suicidal ideation was approximately double for boys and girls living in orphanages or shelters, compared to those living with family.
Suicidal Ideation and Mental Health Variables All mental health variables measured had statistically significant associations with suicidal ideation (Table 5). The percentage of boys and girls reporting suicidal ideation was almost nine times higher in those who reported “a lot” of
Table 2. Gender Differences in Korean Adolescents’ Suicidal Ideation and Behavior (n ¼ 72,435) Boys (n ¼ 36,655)
Total Variable Suicidal ideation Made a suicide plan Attempted suicide
Girls (n ¼ 35,780)
n
%a
n
%a
n
%a
X2
12,070 4,168 3,021
16.6 5.7 4.1
4,770 1,755 1,065
13.1 4.7 2.8
7,300 2,413 1,956
20.4 6.7 5.5
711.914 127.752 297.191
Note: All differences p < .001. a weighted percentage.
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Table 3. Relationship of School Characteristics to Suicidal Ideation in Korean Boys and Girls Boys With Suicidal Ideation Variables Location Metropolitan Medium and small cities Rural areas School grade Middle school 7th grade Middle school 8th grade Middle school 9th grade Middle school 10th grade Middle school 11th grade Middle school 12th grade Academic achievement High Medium Low
n
%a
x2
2,238 1,935 597
13.6 12.6 13.0
6.481
745 849 841 759 815 761
12.0 13.9 14.0 11.9 14.5 12.3
1,498 1,194 2,078
11.8 12.1 15.1
Girls With Suicidal Ideation n
%a
x2
.04
3,297 3,170 833
20.6 20.2 20.4
1.173
.56
28.309
