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Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents ab
a
cd
Sun Mi Kim , Doug Hyun Han , George H. Trksak Lee
& Young Sik
a
a
Department of Psychiatry, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu 156-755, Seoul, Korea
Click for updates
b
Brain Institute, University of Utah, 383 Colorow Drive, Salt Lake City, UT, USA c
Behavioral Psychopharmacological Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA d
Sleep Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA Accepted author version posted online: 17 Dec 2013.Published online: 21 Jan 2014.
To cite this article: Sun Mi Kim, Doug Hyun Han, George H. Trksak & Young Sik Lee (2014) Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents, Anxiety, Stress, & Coping: An International Journal, 27:4, 439-454, DOI: 10.1080/10615806.2013.876010 To link to this article: http://dx.doi.org/10.1080/10615806.2013.876010
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources
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Anxiety, Stress, & Coping, 2014 Vol. 27, No. 4, 439–454, http://dx.doi.org/10.1080/10615806.2013.876010
Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents
Downloaded by [Northeastern University] at 14:14 20 February 2015
Sun Mi Kima,b, Doug Hyun Hana, George H. Trksakc,d and Young Sik Leea* a Department of Psychiatry, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu 156-755, Seoul, Korea; bBrain Institute, University of Utah, 383 Colorow Drive, Salt Lake City, UT, USA; cBehavioral Psychopharmacological Research Laboratory, McLean Hospital/ Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA; dSleep Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA
(Received 7 October 2013; accepted 12 December 2013) Suicide among adolescents is an emerging global public health problem as well as a socioeconomic problem. Stress-coping strategies have been shown to be associated with suicidal ideation. We examined coping behaviors related to suicidal ideation and gender differences in adolescents using the data from the 2010 Korea Youth Risk Behavior Survey (ages 12–19 years; N = 73,238). Logistic regression analysis was used to evaluate associations between suicidal ideation and specific coping behaviors while controlling for potentially confounding variables. In both male and female groups, the coping behavior “drinking alcoholic beverages” and “smoking cigarettes” were positively associated with suicidal ideation. “Watching TV,” “playing online/ mobile games,” and “sleeping” were negatively associated with suicidal ideation in both groups. In males, “engaging in sports” was negatively related to suicidal ideation. In females, “venting by talking to others” and “eating” were negatively related to suicidal ideation. The results indicate that there are gender differences in the effects of coping behaviors on adolescent suicidal ideation, and that developing adaptive coping strategies may function to reduce suicidality. Future studies are needed to examine whether improving coping skills can reduce suicidal ideation in a gender-specific manner. Keywords: coping strategy; suicidal ideation; adolescent; stress; gender difference
Introduction Suicidal ideation and behavior among adolescents are an emerging global public health problem as well as a socioeconomic problem. In South Korea, the overall rate of suicidal ideation for youth between 19 and 29 years of age was 15% in 2009 (Korean Ministry of Health and Welfare [KMHW] & Korea Centers for Disease Control and Prevention [KCDCP], 2010), and the one-year prevalence of suicidal ideation was 2.6% in males and 6.3% in females for youth between 18 and 29 years of age in 2011 (KMHW, 2011). The suicide rate among adolescents between 10 and 19 years of age is 5.2 of 100,000 people in South Korea, and this is the leading cause of death for adolescents in this country. Although the adolescent suicide rate was stabile during the 1990s in some countries, suicide is the fourth leading cause of death globally among adolescents aged 15–19 years
*Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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(Wasserman, Cheng, & Jiang, 2005), and it continues to be a major burden on social healthcare systems for many countries (Cantor, 2008; Peltzer & Pengpid, 2012). Various risk factors for adolescent suicidal ideation have been extensively researched, including psychiatric illnesses, biological factors, and psychosocial distress (Bridge, Goldstein, & Brent, 2006; Peltzer & Pengpid, 2012). Psychiatric illnesses such as mood disorders, substance use disorders, and delinquency (Cash & Bridge, 2009; Gould, Greenberg, Velting, & Shaffer, 2003), as well as biological factors such as sex and ethnicity (Eaton et al., 2008), are well-known major risk factors for adolescent suicidal ideation around the globe. Adolescent suicidal ideation is also reported to have an association with psychosocial distress related to familial environment, social relationships, and other personal problems (Bridge et al., 2006; Kokkevi, Rotsika, Arapaki, & Richardson, 2012). In studies conducted in Korea, family-related problems including low socioeconomic status, parental divorce, and poor parent–child relationships have been shown to be positively associated with adolescent suicidal ideation (Kim, 2008; Park, Schepp, Jang, & Koo, 2006). In Korean middle school students, being involved in school bullying is significantly related to higher risk of suicidal ideation (Kim, Koh, & Leventhal, 2005; Kim, Leventhal, Koh, & Boyce, 2009). Other personal problems such as high levels of stress regarding academic achievement (Juon, Nam, & Ensminger, 1994), dissatisfaction with one’s health (An, Ahn, & Bhang, 2010), and body image dissatisfaction (Kim & Kim, 2009; Kim & Lee, 2010) are also known to be positively related to suicidal ideation in Korea adolescents. Among these various factors, defining the sources of major psychosocial stress and identifying techniques to successfully deal with stress have received increasing attention because the factors are relatively variable, especially in adolescents. In an attempt to manage psychological stress and adaptation to the environment, individuals use certain styles of cognitive or behavioral strategies, which are referred to as coping strategies (Lazarus, 1993). Previous studies investigating coping strategies and their associations with suicidal ideation have used either broad categories of coping strategies or specific coping behaviors for analyzing and interpreting data. Although the categorizations of coping strategies used in various studies have been inconsistent, one widely used, broad categorization uses three categories of problem-solving, emotion distraction, and avoidance coping strategies (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Nagase et al., 2009; Wilson, Pritchard, & Revalee, 2005). A problem-solving coping strategy is defined as an individual’s active planning and efforts to change the environment of psychological stress. An emotional distraction strategy refers to an individual’s attempt to reduce the negative emotion caused by stressful events. This emotional distraction strategy includes specific coping behaviors such as talking to a friend, physical activity, watching TV, eating, shopping, drinking alcohol, and gambling. An avoidance strategy is described as an individual’s attempts to separate from the source of stress, such as by withdrawal, denial, and inactivity. In previous studies that investigated gender differences in coping strategies, males were shown to be more likely to use problem-solving strategies, whereas females preferred to use emotional distraction strategies (Baker & Berenbaum, 2007; Brems & Johnson, 1989). In a previous study about coping behaviors related to anger among youths in the USA (Goodwin, 2006), males were more likely to use physical activity, alcoholic beverages, and drug use, whereas females were more likely to engage in conversation. A previous study that analyzed data from 22-year-old young adults in
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Finland (Hanninen & Aro, 1996) reported that venting emotion on others was more prevalent in females than males, whereas social drinking was more prevalent in males than females. According to previous studies about the relationship between suicidal ideation and coping behaviors, the use of a problem-solving strategy seems to be negatively related to depression (Li, DiGiuseppe, & Froh, 2006); conversely, the use of emotional distraction or avoidance strategies is associated with higher levels of depression and suicidal ideation in both adults (Lam, Schuck, Smith, Farmer, & Checkley, 2003; Marusic & Goodwin, 2006; Tamres, Janicki, & Helgeson, 2002) and adolescents (Horwitz, Hill, & King, 2011; Rafnsson, Jonsson, & Windle, 2006; Seiffge-Krenke, 2004). In a study conducted with 334 middle school students in Korea, the emotional-distraction strategy had a positive relationship with suicidal ideation, whereas there was no significant association between the problem-focused strategy and the suicidal ideation (Kim & Cho, 2011). Another study conducted with 1196 high school students living in the central part of Korea demonstrated that social support seems to have a negative association with suicidal ideation, whereas using an avoidance strategy seems to be positively related to suicidal ideation (Lee, 2013). Compared to previous studies’ use of broad categorizations of coping strategies, an accurate comparison of specific coping behaviors might be difficult because the coping behaviors examined in previous studies were inconsistent. Indeed, although numerous studies have identified coping behaviors associated with adolescent suicide, they have been conducted in various countries over an extended duration of time. Moreover, previous studies have not included newly developed and widely used coping behaviors, especially in adolescents, such as online activities including mobile gaming or online chatting. Accordingly, the objective of this study was to investigate specific coping behaviors related to adolescent suicidal ideation frequently employed in recent years, using data obtained from the 2010 Korea Youth Risk Behavior Web-based Survey. We hypothesized that there would be gender differences in the prevalence of specific coping behaviors. Based on the results of previous studies, we predicted that males would be more likely to drink alcoholic beverages and smoke cigarettes than females. We also hypothesized that healthy and active coping behaviors, such as engaging in sports, would be negatively related to suicidal ideation, whereas unhealthy and illegal coping behaviors for adolescents, such as drinking alcoholic beverages and smoking cigarettes, would be positively related to suicidal ideation. We predicted that the positive association between substance use for coping and suicidal ideation would be stronger in males than females.
Methods Participants The Korea Youth Risk Behavior Web-based Survey data used in the current study were collected in 2010 from a nationally representative sample of 74,980 Korean adolescents, aged 12–19 years. A proportional allocation and a two-stage cluster sampling design were used to obtain a nationally representative sample. That is, 400 middle schools and 400 high schools were selected, and then data were obtained from the students of one class from each school. All steps of the survey study were conducted in computer classrooms of individual schools. Students were randomly and anonymously assigned to a computer,
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where they entered their responses to 128 online survey questions about basic sociodemographic factors, physical- and mental health-related behaviors, and familial environment. The questionnaires were written in Korean, and all students who participated in this survey were fluent in Korean. During the web-based survey, the initial nonresponse rates were zero because every question of the survey was required to be completed. After the survey, through post-censorship using cross-tabulation among questionnaires, logical fallacies (e.g. a participant’s responses to two different questions were mutually contradictory) and extreme values (e.g. values exceeding 3 SDs from mean weight, height, and body mass index) were found, and these items were treated as missing data. As a result, the overall response rate to this survey in 2010 was 97.7%. We analyzed information about the participants’ suicidal behaviors, coping behaviors, stress-related factors, substance use, and other characteristics related to adolescent suicidal ideation (N = 73,238; 38,391 males and 34,847 females). The institutional review board of Chung-Ang University Medical Center permitted data analyses without informed consent because the survey data were collected from a nationally representative sample and was analyzed anonymously.
Study procedures Coping behaviors Coping behaviors were assessed using the following question: “What do you do most often to relax when you feel stressed?” Each participant was instructed to choose 1 of 14 items regarding specific coping behaviors that are most frequently used among Korean adolescents. The items regarding coping behaviors were as follows: (i) “watching TV,” (ii) “listening to music,” (iii) “reading a book,” (iv) “engaging in sports,” (v) “venting emotion by talking to others,” (vi) “online chatting,” (vii) “playing online or mobile games,” (viii) “eating,” (xi) “singing,” (x) “drinking alcoholic beverages,” (xi) “smoking cigarettes,” (xii) “sleeping,” (xiii) “absence of specific coping behavior,” and (xiv) “using coping behavior that is not listed above.” In this study, data for the participants who chose 14th item (N = 4939; 7% of total participants) were excluded from further analyses specifically regarding coping behaviors. In the current study, we decided to categorize responses based on a classification method used in prior studies, as mentioned in the introduction (Compas et al., 2001; Nagase et al., 2009; Wilson et al., 2005): a problemsolving coping strategy refers to an individual’s active planning and striving to change the environment of stress; an emotional distraction strategy refers to an individual’s attempt to reduce the negative emotion caused by stressful events; an avoidance strategy refers to an individual’s attempts to separate from the source of stress. We decided to further divide emotional distraction strategy into two categories, healthy or unhealthy, to distinguish substance use from other coping behaviors. For a consensus of classification of coping strategies, participant responses were categorized by two independent coders as belonging to one of the following categories: a problem-solving coping strategy, a healthy emotional distraction strategy, an unhealthy emotional strategy, or an avoidant strategy. To evaluate intercoder reliability, Cohen’s kappa (Cohen, 1960) statistics were calculated. As a result, Cohen’s kappa for classification of coping strategies was 1.00. Because items regarding a problem-focused strategy, such as “making an effort to solve the problem actively” and “making plans to take time off,” were not included in the survey questionnaire,
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participant responses were categorized as a healthy emotional distraction strategy (1–9), an unhealthy emotional distraction strategy (10–11), or an avoidance strategy (12–13).
Suicidal ideation Suicidal ideation was assessed by the following yes or no question: “During the past 12 months, have you ever seriously wanted to commit suicide?” Suicidal attempt was assessed by the following yes or no question: “During the past 12 months, have you ever attempted suicide?”
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High stress levels and primary stress factors Participant stress levels were assessed by the following question: “Do you often feel stressed?” using a five-point Likert-type scale (1: “not at all” to 5: “very often”). High stress levels were defined as responses of “very often” or “often.” Primary stress factors were assessed using the following question: “What is your primary stressor?” Each participant was instructed to select one of seven specific stress factors: (i) conflict with parents, (ii) familial environment, (iii) conflict with a teacher, (iv) peer relationships, (v) academic performance, (vi) health problems, and (vii) physical appearance. We categorized stressors as those related to family (1–2), social relationships (3–4), or personal problems (5–7) based on previously used categorization methods in studies regarding adolescent stressors (Greenberger, Chen, Tally, & Qi, 2000).
Demographic and clinical characteristics The analysis included participants’ demographic and clinical characteristics, such as age, perception of sadness/hopelessness levels, perceptions of health status, academic performance, and current substance use. Perception of sadness/hopelessness levels was assessed by the following yes or no question: “Have you experienced sadness or hopelessness that has affected your ordinary activities for two weeks or more in the last year?” Perception of poor health status was characterized as responses of “very unhealthy” or “unhealthy” to the following question using a five-point Likert-type scale (1: “very healthy” to 5: “very unhealthy”): “How would you rate your overall health?” Current cigarette smoking was defined as having smoked in the previous 30 days. Current alcohol drinking was defined as having consumed alcohol in the previous 30 days. Current drug use was characterized as having used butane gas, adhesives, stimulant, philopon, amphetamines, cough medicine, or sedatives with the purpose of mood change, hallucination, or excessive weight loss in the previous 30 days.
Familial characteristics We analyzed the factors associated with family environment, such as family structure and socioeconomic status. Family structure was assessed and categorized as living with both parents, living in a mother-only family, living in a father-only family, or living with others. Socioeconomic status was categorized as high, middle, or low according to Family Affluence Scale score (Boyce, Torsheim, Currie, & Zambon, 2006).
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Statistical analyses We conducted all analyses using the Complex Samples module of PASW statistics software package, version 18 (SPSS Inc., Chicago, IL, USA), to account for the stratified cluster sampling design that was used to collect the data. We typically separately analyzed the data obtained from males and females. We analyzed the participant characteristics and distributions of all variables using the chi-square test to assess the associations between participant characteristics and suicidal ideation. We also analyzed the weighted prevalence of coping behaviors and their gender differences using the chi-square method. We used multivariate logistic regression to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for suicidal behavior according to coping behavior, controlling for possible confounding variables such as age, socioeconomic status, perception of health status, academic achievement, current drug use, perception of stress levels, categories of stress factors, and family structure. We set statistical significance at α = .05 (two-sided). We excluded current alcohol drinking and current cigarette smoking from covariates of the multivariate logistic regression analyses to avoid double counting because they coincided with the unhealthy emotional distraction category. We also excluded the sadness/hopelessness level from covariates of the multivariate logistic regression analyses to avoid problems associated with multicollinearity because the variable was highly correlated with suicidal ideation. There were no missing values in the data we analyzed for this study. We excluded data for the participants who chose the item “using coping behavior that is not listed above” from the chi-square analyses regarding prevalence of coping behaviors and the multivariate logistic regression analyses.
Results General characteristics of the study population Table 1 presents the general characteristics of the total study population and the gender differences observed in all variables. In the current study, 19.1% of total participants reported having had suicidal thoughts, and 4.9% reported having made at least one suicidal attempt within the previous year. Prevalences of suicidal ideation and suicidal attempt were both significantly higher in females than in males (p < .001). Females were significantly more likely than males to report perceptions of high sadness/hopelessness levels, high stress levels, and perception of poor health status (p < .001). In contrast, males were significantly more likely than females to report current alcohol drinking, current cigarette smoking, and current drug use (p < .001). Regarding the categories of coping strategies, a healthy emotional distraction strategy was reported most frequently in both groups, followed by an avoidance strategy, and an unhealthy emotional distraction strategy. Males were significantly more likely than females to use an emotional distraction strategy (p < .001). In contrast, females were significantly more likely than males to use an avoidance strategy (p < .001). Prevalence of suicidal ideation and factors associated with suicidal ideation Table 2 shows the prevalence of suicidal ideation within the previous year according to participant characteristics. The prevalence of suicidal ideation was higher among adolescents aged 12–15 years than those aged 16–19 years in both groups (p < .05).
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Table 1. General demographic and clinical characteristics of study populations (total N = 73,238; 38,391 males and 34,847 females). Total
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Characteristic Sex Male Female Age 12–15 16–19 Socioeconomic status High Middle Low Perception of poor health status (yes) Academic achievement High Middle Low High sadness/hopelessness level (yes) Suicidal ideation (yes) Suicidal attempt (yes) High stress level (yes) Current alcohol drinking (yes) Current cigarette smoking (yes) Current drug use (yes) Categories of stress factors Social relationship problems Familial problems Personal problems Categories of coping strategies Healthy emotional distraction Unhealthy emotional distraction Avoidant Family structure Live with both parents Live with a single-parent Live with others
Males
Females
Wt %
SE
Wt %
SE
Wt %
SE
52.8 47.2
1.6 1.6
– –
– –
– –
– –
61.4 38.6
1.0 1.0
61.4 38.6
1.6 1.6
61.4 38.6
1.8 1.8
35.5 52.9 11.6 8.1
0.4 0.3 0.2 0.2
35.9 52.3 11.8 6.7
0.5 0.4 0.3 0.2
35.0 53.6 11.4 9.6
0.6 0.5 0.3 0.2
11.4 51.1 37.5 37.4
0.2 0.2 0.3 0.3
12.9 50.2 36.8 32.7
0.3 0.3 0.4 0.3
9.7 52.0 38.3 42.6
0.2 0.4 0.4 0.4
19.3 5.8 43.8 21.1 12.1 0.4
0.2 0.2 0.3 0.3 0.3 0.0
15.6 4.3 37.7 23.5 16.6 0.5
0.3 0.2 0.4 0.5 0.5 0.1
23.5 7.6 50.7 18.3 7.1 0.2
0.3 0.3 0.4 0.4 0.3 0.0
11.6 21.8 66.6
0.2 0.3 0.3
12.4 22.7 64.9
0.3 0.4 0.5
10.6 20.9 68.4
0.3 0.4 0.5
76.1 5.5 18.3
0.2 0.2 0.3
78.3 7.8 13.9
0.3 0.3 0.3
73.8 3.0 23.2
0.3 0.2 0.3
83.6 13.0 3.4
0.3 0.2 0.1
83.5 12.9 3.6
0.4 0.3 0.2
83.8 13.1 3.1
0.4 0.3 0.1
Adj Wald χ2
p Value
0.001
0.98
2.77
0.23
122.86
Anxiety, Stress, & Coping: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gasc20
Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents ab
a
cd
Sun Mi Kim , Doug Hyun Han , George H. Trksak Lee
& Young Sik
a
a
Department of Psychiatry, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu 156-755, Seoul, Korea
Click for updates
b
Brain Institute, University of Utah, 383 Colorow Drive, Salt Lake City, UT, USA c
Behavioral Psychopharmacological Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA d
Sleep Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA Accepted author version posted online: 17 Dec 2013.Published online: 21 Jan 2014.
To cite this article: Sun Mi Kim, Doug Hyun Han, George H. Trksak & Young Sik Lee (2014) Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents, Anxiety, Stress, & Coping: An International Journal, 27:4, 439-454, DOI: 10.1080/10615806.2013.876010 To link to this article: http://dx.doi.org/10.1080/10615806.2013.876010
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Anxiety, Stress, & Coping, 2014 Vol. 27, No. 4, 439–454, http://dx.doi.org/10.1080/10615806.2013.876010
Gender differences in adolescent coping behaviors and suicidal ideation: findings from a sample of 73,238 adolescents
Downloaded by [Northeastern University] at 14:14 20 February 2015
Sun Mi Kima,b, Doug Hyun Hana, George H. Trksakc,d and Young Sik Leea* a Department of Psychiatry, College of Medicine, Chung-Ang University, 102 Heukseok-ro, Dongjak-gu 156-755, Seoul, Korea; bBrain Institute, University of Utah, 383 Colorow Drive, Salt Lake City, UT, USA; cBehavioral Psychopharmacological Research Laboratory, McLean Hospital/ Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA; dSleep Research Laboratory, McLean Hospital/Harvard Medical School, 115 Mill Street, Belmont, MA 02478, USA
(Received 7 October 2013; accepted 12 December 2013) Suicide among adolescents is an emerging global public health problem as well as a socioeconomic problem. Stress-coping strategies have been shown to be associated with suicidal ideation. We examined coping behaviors related to suicidal ideation and gender differences in adolescents using the data from the 2010 Korea Youth Risk Behavior Survey (ages 12–19 years; N = 73,238). Logistic regression analysis was used to evaluate associations between suicidal ideation and specific coping behaviors while controlling for potentially confounding variables. In both male and female groups, the coping behavior “drinking alcoholic beverages” and “smoking cigarettes” were positively associated with suicidal ideation. “Watching TV,” “playing online/ mobile games,” and “sleeping” were negatively associated with suicidal ideation in both groups. In males, “engaging in sports” was negatively related to suicidal ideation. In females, “venting by talking to others” and “eating” were negatively related to suicidal ideation. The results indicate that there are gender differences in the effects of coping behaviors on adolescent suicidal ideation, and that developing adaptive coping strategies may function to reduce suicidality. Future studies are needed to examine whether improving coping skills can reduce suicidal ideation in a gender-specific manner. Keywords: coping strategy; suicidal ideation; adolescent; stress; gender difference
Introduction Suicidal ideation and behavior among adolescents are an emerging global public health problem as well as a socioeconomic problem. In South Korea, the overall rate of suicidal ideation for youth between 19 and 29 years of age was 15% in 2009 (Korean Ministry of Health and Welfare [KMHW] & Korea Centers for Disease Control and Prevention [KCDCP], 2010), and the one-year prevalence of suicidal ideation was 2.6% in males and 6.3% in females for youth between 18 and 29 years of age in 2011 (KMHW, 2011). The suicide rate among adolescents between 10 and 19 years of age is 5.2 of 100,000 people in South Korea, and this is the leading cause of death for adolescents in this country. Although the adolescent suicide rate was stabile during the 1990s in some countries, suicide is the fourth leading cause of death globally among adolescents aged 15–19 years
*Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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(Wasserman, Cheng, & Jiang, 2005), and it continues to be a major burden on social healthcare systems for many countries (Cantor, 2008; Peltzer & Pengpid, 2012). Various risk factors for adolescent suicidal ideation have been extensively researched, including psychiatric illnesses, biological factors, and psychosocial distress (Bridge, Goldstein, & Brent, 2006; Peltzer & Pengpid, 2012). Psychiatric illnesses such as mood disorders, substance use disorders, and delinquency (Cash & Bridge, 2009; Gould, Greenberg, Velting, & Shaffer, 2003), as well as biological factors such as sex and ethnicity (Eaton et al., 2008), are well-known major risk factors for adolescent suicidal ideation around the globe. Adolescent suicidal ideation is also reported to have an association with psychosocial distress related to familial environment, social relationships, and other personal problems (Bridge et al., 2006; Kokkevi, Rotsika, Arapaki, & Richardson, 2012). In studies conducted in Korea, family-related problems including low socioeconomic status, parental divorce, and poor parent–child relationships have been shown to be positively associated with adolescent suicidal ideation (Kim, 2008; Park, Schepp, Jang, & Koo, 2006). In Korean middle school students, being involved in school bullying is significantly related to higher risk of suicidal ideation (Kim, Koh, & Leventhal, 2005; Kim, Leventhal, Koh, & Boyce, 2009). Other personal problems such as high levels of stress regarding academic achievement (Juon, Nam, & Ensminger, 1994), dissatisfaction with one’s health (An, Ahn, & Bhang, 2010), and body image dissatisfaction (Kim & Kim, 2009; Kim & Lee, 2010) are also known to be positively related to suicidal ideation in Korea adolescents. Among these various factors, defining the sources of major psychosocial stress and identifying techniques to successfully deal with stress have received increasing attention because the factors are relatively variable, especially in adolescents. In an attempt to manage psychological stress and adaptation to the environment, individuals use certain styles of cognitive or behavioral strategies, which are referred to as coping strategies (Lazarus, 1993). Previous studies investigating coping strategies and their associations with suicidal ideation have used either broad categories of coping strategies or specific coping behaviors for analyzing and interpreting data. Although the categorizations of coping strategies used in various studies have been inconsistent, one widely used, broad categorization uses three categories of problem-solving, emotion distraction, and avoidance coping strategies (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Nagase et al., 2009; Wilson, Pritchard, & Revalee, 2005). A problem-solving coping strategy is defined as an individual’s active planning and efforts to change the environment of psychological stress. An emotional distraction strategy refers to an individual’s attempt to reduce the negative emotion caused by stressful events. This emotional distraction strategy includes specific coping behaviors such as talking to a friend, physical activity, watching TV, eating, shopping, drinking alcohol, and gambling. An avoidance strategy is described as an individual’s attempts to separate from the source of stress, such as by withdrawal, denial, and inactivity. In previous studies that investigated gender differences in coping strategies, males were shown to be more likely to use problem-solving strategies, whereas females preferred to use emotional distraction strategies (Baker & Berenbaum, 2007; Brems & Johnson, 1989). In a previous study about coping behaviors related to anger among youths in the USA (Goodwin, 2006), males were more likely to use physical activity, alcoholic beverages, and drug use, whereas females were more likely to engage in conversation. A previous study that analyzed data from 22-year-old young adults in
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Finland (Hanninen & Aro, 1996) reported that venting emotion on others was more prevalent in females than males, whereas social drinking was more prevalent in males than females. According to previous studies about the relationship between suicidal ideation and coping behaviors, the use of a problem-solving strategy seems to be negatively related to depression (Li, DiGiuseppe, & Froh, 2006); conversely, the use of emotional distraction or avoidance strategies is associated with higher levels of depression and suicidal ideation in both adults (Lam, Schuck, Smith, Farmer, & Checkley, 2003; Marusic & Goodwin, 2006; Tamres, Janicki, & Helgeson, 2002) and adolescents (Horwitz, Hill, & King, 2011; Rafnsson, Jonsson, & Windle, 2006; Seiffge-Krenke, 2004). In a study conducted with 334 middle school students in Korea, the emotional-distraction strategy had a positive relationship with suicidal ideation, whereas there was no significant association between the problem-focused strategy and the suicidal ideation (Kim & Cho, 2011). Another study conducted with 1196 high school students living in the central part of Korea demonstrated that social support seems to have a negative association with suicidal ideation, whereas using an avoidance strategy seems to be positively related to suicidal ideation (Lee, 2013). Compared to previous studies’ use of broad categorizations of coping strategies, an accurate comparison of specific coping behaviors might be difficult because the coping behaviors examined in previous studies were inconsistent. Indeed, although numerous studies have identified coping behaviors associated with adolescent suicide, they have been conducted in various countries over an extended duration of time. Moreover, previous studies have not included newly developed and widely used coping behaviors, especially in adolescents, such as online activities including mobile gaming or online chatting. Accordingly, the objective of this study was to investigate specific coping behaviors related to adolescent suicidal ideation frequently employed in recent years, using data obtained from the 2010 Korea Youth Risk Behavior Web-based Survey. We hypothesized that there would be gender differences in the prevalence of specific coping behaviors. Based on the results of previous studies, we predicted that males would be more likely to drink alcoholic beverages and smoke cigarettes than females. We also hypothesized that healthy and active coping behaviors, such as engaging in sports, would be negatively related to suicidal ideation, whereas unhealthy and illegal coping behaviors for adolescents, such as drinking alcoholic beverages and smoking cigarettes, would be positively related to suicidal ideation. We predicted that the positive association between substance use for coping and suicidal ideation would be stronger in males than females.
Methods Participants The Korea Youth Risk Behavior Web-based Survey data used in the current study were collected in 2010 from a nationally representative sample of 74,980 Korean adolescents, aged 12–19 years. A proportional allocation and a two-stage cluster sampling design were used to obtain a nationally representative sample. That is, 400 middle schools and 400 high schools were selected, and then data were obtained from the students of one class from each school. All steps of the survey study were conducted in computer classrooms of individual schools. Students were randomly and anonymously assigned to a computer,
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where they entered their responses to 128 online survey questions about basic sociodemographic factors, physical- and mental health-related behaviors, and familial environment. The questionnaires were written in Korean, and all students who participated in this survey were fluent in Korean. During the web-based survey, the initial nonresponse rates were zero because every question of the survey was required to be completed. After the survey, through post-censorship using cross-tabulation among questionnaires, logical fallacies (e.g. a participant’s responses to two different questions were mutually contradictory) and extreme values (e.g. values exceeding 3 SDs from mean weight, height, and body mass index) were found, and these items were treated as missing data. As a result, the overall response rate to this survey in 2010 was 97.7%. We analyzed information about the participants’ suicidal behaviors, coping behaviors, stress-related factors, substance use, and other characteristics related to adolescent suicidal ideation (N = 73,238; 38,391 males and 34,847 females). The institutional review board of Chung-Ang University Medical Center permitted data analyses without informed consent because the survey data were collected from a nationally representative sample and was analyzed anonymously.
Study procedures Coping behaviors Coping behaviors were assessed using the following question: “What do you do most often to relax when you feel stressed?” Each participant was instructed to choose 1 of 14 items regarding specific coping behaviors that are most frequently used among Korean adolescents. The items regarding coping behaviors were as follows: (i) “watching TV,” (ii) “listening to music,” (iii) “reading a book,” (iv) “engaging in sports,” (v) “venting emotion by talking to others,” (vi) “online chatting,” (vii) “playing online or mobile games,” (viii) “eating,” (xi) “singing,” (x) “drinking alcoholic beverages,” (xi) “smoking cigarettes,” (xii) “sleeping,” (xiii) “absence of specific coping behavior,” and (xiv) “using coping behavior that is not listed above.” In this study, data for the participants who chose 14th item (N = 4939; 7% of total participants) were excluded from further analyses specifically regarding coping behaviors. In the current study, we decided to categorize responses based on a classification method used in prior studies, as mentioned in the introduction (Compas et al., 2001; Nagase et al., 2009; Wilson et al., 2005): a problemsolving coping strategy refers to an individual’s active planning and striving to change the environment of stress; an emotional distraction strategy refers to an individual’s attempt to reduce the negative emotion caused by stressful events; an avoidance strategy refers to an individual’s attempts to separate from the source of stress. We decided to further divide emotional distraction strategy into two categories, healthy or unhealthy, to distinguish substance use from other coping behaviors. For a consensus of classification of coping strategies, participant responses were categorized by two independent coders as belonging to one of the following categories: a problem-solving coping strategy, a healthy emotional distraction strategy, an unhealthy emotional strategy, or an avoidant strategy. To evaluate intercoder reliability, Cohen’s kappa (Cohen, 1960) statistics were calculated. As a result, Cohen’s kappa for classification of coping strategies was 1.00. Because items regarding a problem-focused strategy, such as “making an effort to solve the problem actively” and “making plans to take time off,” were not included in the survey questionnaire,
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participant responses were categorized as a healthy emotional distraction strategy (1–9), an unhealthy emotional distraction strategy (10–11), or an avoidance strategy (12–13).
Suicidal ideation Suicidal ideation was assessed by the following yes or no question: “During the past 12 months, have you ever seriously wanted to commit suicide?” Suicidal attempt was assessed by the following yes or no question: “During the past 12 months, have you ever attempted suicide?”
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High stress levels and primary stress factors Participant stress levels were assessed by the following question: “Do you often feel stressed?” using a five-point Likert-type scale (1: “not at all” to 5: “very often”). High stress levels were defined as responses of “very often” or “often.” Primary stress factors were assessed using the following question: “What is your primary stressor?” Each participant was instructed to select one of seven specific stress factors: (i) conflict with parents, (ii) familial environment, (iii) conflict with a teacher, (iv) peer relationships, (v) academic performance, (vi) health problems, and (vii) physical appearance. We categorized stressors as those related to family (1–2), social relationships (3–4), or personal problems (5–7) based on previously used categorization methods in studies regarding adolescent stressors (Greenberger, Chen, Tally, & Qi, 2000).
Demographic and clinical characteristics The analysis included participants’ demographic and clinical characteristics, such as age, perception of sadness/hopelessness levels, perceptions of health status, academic performance, and current substance use. Perception of sadness/hopelessness levels was assessed by the following yes or no question: “Have you experienced sadness or hopelessness that has affected your ordinary activities for two weeks or more in the last year?” Perception of poor health status was characterized as responses of “very unhealthy” or “unhealthy” to the following question using a five-point Likert-type scale (1: “very healthy” to 5: “very unhealthy”): “How would you rate your overall health?” Current cigarette smoking was defined as having smoked in the previous 30 days. Current alcohol drinking was defined as having consumed alcohol in the previous 30 days. Current drug use was characterized as having used butane gas, adhesives, stimulant, philopon, amphetamines, cough medicine, or sedatives with the purpose of mood change, hallucination, or excessive weight loss in the previous 30 days.
Familial characteristics We analyzed the factors associated with family environment, such as family structure and socioeconomic status. Family structure was assessed and categorized as living with both parents, living in a mother-only family, living in a father-only family, or living with others. Socioeconomic status was categorized as high, middle, or low according to Family Affluence Scale score (Boyce, Torsheim, Currie, & Zambon, 2006).
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Statistical analyses We conducted all analyses using the Complex Samples module of PASW statistics software package, version 18 (SPSS Inc., Chicago, IL, USA), to account for the stratified cluster sampling design that was used to collect the data. We typically separately analyzed the data obtained from males and females. We analyzed the participant characteristics and distributions of all variables using the chi-square test to assess the associations between participant characteristics and suicidal ideation. We also analyzed the weighted prevalence of coping behaviors and their gender differences using the chi-square method. We used multivariate logistic regression to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI) for suicidal behavior according to coping behavior, controlling for possible confounding variables such as age, socioeconomic status, perception of health status, academic achievement, current drug use, perception of stress levels, categories of stress factors, and family structure. We set statistical significance at α = .05 (two-sided). We excluded current alcohol drinking and current cigarette smoking from covariates of the multivariate logistic regression analyses to avoid double counting because they coincided with the unhealthy emotional distraction category. We also excluded the sadness/hopelessness level from covariates of the multivariate logistic regression analyses to avoid problems associated with multicollinearity because the variable was highly correlated with suicidal ideation. There were no missing values in the data we analyzed for this study. We excluded data for the participants who chose the item “using coping behavior that is not listed above” from the chi-square analyses regarding prevalence of coping behaviors and the multivariate logistic regression analyses.
Results General characteristics of the study population Table 1 presents the general characteristics of the total study population and the gender differences observed in all variables. In the current study, 19.1% of total participants reported having had suicidal thoughts, and 4.9% reported having made at least one suicidal attempt within the previous year. Prevalences of suicidal ideation and suicidal attempt were both significantly higher in females than in males (p < .001). Females were significantly more likely than males to report perceptions of high sadness/hopelessness levels, high stress levels, and perception of poor health status (p < .001). In contrast, males were significantly more likely than females to report current alcohol drinking, current cigarette smoking, and current drug use (p < .001). Regarding the categories of coping strategies, a healthy emotional distraction strategy was reported most frequently in both groups, followed by an avoidance strategy, and an unhealthy emotional distraction strategy. Males were significantly more likely than females to use an emotional distraction strategy (p < .001). In contrast, females were significantly more likely than males to use an avoidance strategy (p < .001). Prevalence of suicidal ideation and factors associated with suicidal ideation Table 2 shows the prevalence of suicidal ideation within the previous year according to participant characteristics. The prevalence of suicidal ideation was higher among adolescents aged 12–15 years than those aged 16–19 years in both groups (p < .05).
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Table 1. General demographic and clinical characteristics of study populations (total N = 73,238; 38,391 males and 34,847 females). Total
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Characteristic Sex Male Female Age 12–15 16–19 Socioeconomic status High Middle Low Perception of poor health status (yes) Academic achievement High Middle Low High sadness/hopelessness level (yes) Suicidal ideation (yes) Suicidal attempt (yes) High stress level (yes) Current alcohol drinking (yes) Current cigarette smoking (yes) Current drug use (yes) Categories of stress factors Social relationship problems Familial problems Personal problems Categories of coping strategies Healthy emotional distraction Unhealthy emotional distraction Avoidant Family structure Live with both parents Live with a single-parent Live with others
Males
Females
Wt %
SE
Wt %
SE
Wt %
SE
52.8 47.2
1.6 1.6
– –
– –
– –
– –
61.4 38.6
1.0 1.0
61.4 38.6
1.6 1.6
61.4 38.6
1.8 1.8
35.5 52.9 11.6 8.1
0.4 0.3 0.2 0.2
35.9 52.3 11.8 6.7
0.5 0.4 0.3 0.2
35.0 53.6 11.4 9.6
0.6 0.5 0.3 0.2
11.4 51.1 37.5 37.4
0.2 0.2 0.3 0.3
12.9 50.2 36.8 32.7
0.3 0.3 0.4 0.3
9.7 52.0 38.3 42.6
0.2 0.4 0.4 0.4
19.3 5.8 43.8 21.1 12.1 0.4
0.2 0.2 0.3 0.3 0.3 0.0
15.6 4.3 37.7 23.5 16.6 0.5
0.3 0.2 0.4 0.5 0.5 0.1
23.5 7.6 50.7 18.3 7.1 0.2
0.3 0.3 0.4 0.4 0.3 0.0
11.6 21.8 66.6
0.2 0.3 0.3
12.4 22.7 64.9
0.3 0.4 0.5
10.6 20.9 68.4
0.3 0.4 0.5
76.1 5.5 18.3
0.2 0.2 0.3
78.3 7.8 13.9
0.3 0.3 0.3
73.8 3.0 23.2
0.3 0.2 0.3
83.6 13.0 3.4
0.3 0.2 0.1
83.5 12.9 3.6
0.4 0.3 0.2
83.8 13.1 3.1
0.4 0.3 0.1
Adj Wald χ2
p Value
0.001
0.98
2.77
0.23
122.86
