Int J Adolesc Med Health 2015; 27(4): 415–423
Matthew E. Hirschtritt*, Anna E. Ordóñeza, Yvette C. Rico and Kaja Z. LeWinn
Internal resilience, peer victimization, and suicidal ideation among adolescents Abstract Purpose: Our goal was to examine the association between peer victimization (PV) and suicidal ideation (SI), and the degree to which internal resilience moderates this association. Materials and methods: We examined the independent associations between PV frequency and type (verbal, cyber, physical, and relational), internal resilience, and the risk of SI within the last 12 months among 9th and 11th grade students participating in the California Healthy Kids Survey (CHKS) (n = 42,594; 55.2% female; 72.2% non-white). Results: Odds ratios (OR) of SI associated with very low- (at least 1 PV type 1 time, but none more than 1 time), low- (at least 1 PV type 2–3 times, but none more than 2–3 times), and moderate/high- (at least 1 PV type 4 times or more) frequency PV compared with no PV were 1.30 (95% CI = 1.15–1.45), 1.70 (95% CI = 1.51–1.90) and 2.47 (95% CI = 1.23–2.73), respectively. Any exposure to physical (OR = 1.31; 95% CI = 1.19–1.44), relational (OR = 1.26; 95% CI = 1.15–1.38), verbal (OR = 1.38; 95% CI = 1.27–1.50), or cyber (OR = 1.26; 95% CI = 1.15–1.39) PV was associated with increased odds of SI compared with no PV. Internal resilience was associated with lower odds of SI (OR = 0.98, 95% CI = 0.98–0.99), regardless of PV exposure. The slope between internal resilience and SI was significantly steeper for those subjects who experienced verbal PV (OR interaction = 0.99; 95% CI = 0.98–1.00). Conclusion: Even infrequent PV was found to be associated with increased risk for SI. Internal resilience was associated with reduced SI, particularly for verbal forms of PV. Our results suggested that efforts to decrease SI
Current address: Child Psychiatry Branch, National Institutes of Mental Health, National Institutes Health, Bethesda, MD, USA *Corresponding author: Matthew E. Hirschtritt, MD, MPH, Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, Box 0984-RTP, San Francisco, CA 94143-0984, USA, Phone: +1 415-476-7577, Fax: +1 415-476-7722, E-mail: [email protected] Anna E. Ordóñez: Department of Psychiatry, University of California, San Francisco, CA, USA Yvette C. Rico and Kaja Z. LeWinn: Department of Psychiatry, University of California, San Francisco, CA, USA a
among adolescents should be directed toward both preventing PV and strengthening internal resilience. Keywords: high school; peer victimization; resilience; suicidal ideation. DOI 10.1515/ijamh-2014-0060 Received September 26, 2014; accepted November 22, 2014; previously published online February 10, 2015
Introduction Peer victimization (PV), characterized by being the recipient of either physical or non-physical forms of aggression and harassment by peers, is a common and persistent problem among adolescents. Recent estimates for the percentage of US adolescents who report being victimized range from 10% to 30% (1, 2). Among participants in the 2013 National Youth Risk Behavior Surveillance (YRBS), 19.6% endorsed having been bullied on school property in the past 12 months (3). Furthermore, longitudinal studies suggest a relatively high persistence of PV behavior across childhood and adolescence (4). Previous studies have identified associations between PV and multiple, diverse negative outcomes that include suicidal ideation, which represents a high clinical and public health priority. Suicidal ideation is a common phenomenon among adolescents, with prevalence rates ranging from 15% to 30% (5, 6); 17.0% of participants in the 2013 YRBS endorsed seriously considering suicide in the past 12 months (3). Though estimates vary (7, 8), results from a recent national survey of US adolescents indicate that approximately 30% of adolescents with suicidal ideation go on to make a suicide attempt (9). Furthermore, risk factors for suicidal ideation and suicide attempts show significant overlap (10), emphasizing the importance of addressing suicidal ideation. Both cross-sectional (11–16) and longitudinal studies (17–19) have demonstrated associations between PV and suicidal behaviors, including suicidal ideation. In addition, some studies have suggested that females are more likely than males to engage in suicidal behavior in response to PV (12, 14, 15, 19), whereas others have not found significant sex-related differences (11, 13, 16, 18). - 10.1515/ijamh-2014-0060 Downloaded from De Gruyter Online at 09/13/2016 08:53:47AM via McMaster University
416 Hirschtritt et al.: Suicidal ideation in adolescents In addition to sex, there is evidence that external assets may moderate the adverse effects of PV among adolescents. For instance, school-based research demonstrates that social support from family and friends protects peer-victimized adolescents from experiencing decreased academic performance (20) and suicidal ideation (11). Likewise, the association between PV and suicidal ideation may be mediated by other individual-level characteristics, such as negative self-esteem (21). Taken together, these findings suggest that there may be certain modifiable factors among peer-victimized adolescents that could be targeted to decrease the risk of suicidal ideation. One such factor that has received increased attention in recent years is internal resilience, which is composed of individual-level resources, such as sociability, communication skills, self-esteem, and self-efficacy (22). Internal resilience has been shown to be protective against suicide in multiple studies. For example, a longitudinal study of children who had been victims of abuse found that those who had high-quality interpersonal skills throughout their lifespan were less likely to exhibit suicidality as adults (23). Another longitudinal study of adolescent suicide behavior found that those who attempted suicide were significantly more likely to have lower resilience at baseline controlling for antecedent depression (24). However, despite the fact that internal resilience may moderate the impact of PV on suicidal ideation, to our knowledge, no study has yet to examine how both PV and internal resilience are associated with suicidal ideation among adolescents in a non-clinical setting. This study contributes to the literature by assessing both risks (i.e., PV) and protective factors (i.e., internal resilience) for suicidal ideation in a large sample of adolescents in California. We hypothesize the following: 1) increasing frequency of PV is associated with an increased risk of suicidal ideation, 2) increasing levels of internal resilience are associated with decreased risk of suicidal ideation, and 3) increasing levels of internal resilience are more strongly and negatively associated with suicidal ideation in the context of PV. In other words, we hypothesize that internal resilience moderates the association between PV and suicidal ideation.
Materials and methods Design and participants The California Healthy Kids Survey (CHKS) is an anonymous, crosssectional, self-report survey that measures health-related risk behavior and resilience in students in grades 5 through 12 (25). Administered
and sponsored by the California Department of Education, the survey is designed primarily to provide data for school administrators and policy makers to help them identify and reduce youth risk behaviors. For this study, we used two-year aggregated CHKS data for students in the 9th and 11th grades, spanning 2009 through 2011. Each school district is asked to administer the CHKS every other year, and we used data from two non-consecutive class grades, minimizing the likelihood that individual students are represented more than once in our dataset. Complete survey design and administration details may be found at http://chks.wested.org/about.
Procedure The CHKS was administered to students in the 7th, 9th, and 11th grades by teachers, staff, and administrators in English, health, or history classes. All proctors were trained in survey administration, including delivery of an introductory script that summarized the content and purpose of the CHKS. This introduction also reminded students of the voluntary nature of the survey and that responses would be kept confidential.
Measures The CHKS is composed of a Core Module administered to all schools, as well as supplemental modules, including the Resilience and Youth Development Module (RYDM). For this analysis, we used items from both the Core Module and the RYDM. To measure suicidal ideation, we used a validated single, yes/no item: “During the past 12 months, did you ever seriously consider attempting suicide?” (14, 16, 26). This item was only available for students in the 9th and 11th grades. To measure PV, we used 4 items, each of which began with the prompt: “During the past 12 months, how many times on school property have you…” and included the answer choices “0 times”, “1 time”, “2–3 times”, and “4 or more”. Three of the PV items chosen were consistent with prior literature (27): “…been pushed, shoved, slapped, hit, or kicked by someone who wasn’t just kidding around?” “…had mean rumors or lies spread about you?” and “been made fun of because of your looks or the way you talk?” for physical, relational and verbal PV, respectively. We also included an item to measure cyber PV, which had the same answer choices as the other 3 PV items: “During the past 12 months, how many times did other students spread mean rumors or lies about you on the Internet (i.e., Facebook™, MySpace™, email, instant message)?” To assess the impact of PV type, we dichotomized responses for each type of PV into those who had been victimized at least once and those who had not been victimized. To assess the impact of PV frequency, we used the highest frequency among the four types of PV reported to anchor our categories; thus, we categorized each student as either “none” (i.e., endorsed “0 times” for all 4 types of PV), “very low” (i.e., endorsed “1 time”, but no higher, for at least 1 type of PV), “low” (i.e., endorsed “2–3 times”, but no higher, for at least 1 type of PV), or “moderate/high” (i.e., endorsed “4 or more times” for at least 1 type of PV). On a continuous scale, the “very low” category captured those with a median of 1 (interquartile range [IQR] = 1–2) PV experience, 3.5 (IQR = 2.5–5) PV experiences among students in the “low” category, and 7.5 (IQR = 5–10) PV experiences in the “moderate/high” category. The data did not allow
- 10.1515/ijamh-2014-0060 Downloaded from De Gruyter Online at 09/13/2016 08:53:47AM via McMaster University
Hirschtritt et al.: Suicidal ideation in adolescents 417 for accurate categorization of those who experienced a very high PV frequency (4 or more times) due to ceiling effects of how the PV question was asked. We summed responses from 18 items in the Resilience and Youth Development Module to measure internal resilience (28, 29). Items addressed domains that include cooperation and communication (e.g., “I can work with someone who has different opinions than mine”), self-efficacy (e.g., “I can work out my problems”), empathy (e.g., “I feel bad when someone gets their feelings hurt”), problemsolving (e.g., “When I need help I find someone to talk with”), selfawareness (e.g., “I understand my moods and feelings”), and goals and aspirations (e.g., “I have goals and plans for the future”). Each item began with the prompt “How true do you feel these statements are about you personally?” and was scored on a 4-point scale: “not at all true”, “a little true”, “pretty much true”, and “very much true”. These items demonstrated very good internal consistency in our sample (α = 0.93). In addition, we chose covariates based on established risk and protective factors for suicidal ideation among adolescents. These variables included self-reported sex (6, 30), ethnicity (recoded as Hispanic, white, Asian/Pacific Islander, African American, and multiple/other) (6), grade (9th or 11th) (31), use of alcohol and drugs (for each: never, 1–3 times, 4 or more times) (30, 31), depressive symptoms (14, 30), and external assets (30, 31). Specifically, depressive symptoms were measured with the only question that addressed this construct in the survey, a single yes/no question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more that you stopped doing some usual activities?” External assets were measured on the same scale as internal resilience items, and included 31 questions regarding caring relationships, high expectations, and meaningful participation in school, home, community, and with peers. External asset items demonstrated very good internal consistency in our sample (α = 0.93). The full text of these questions is available at .
Statistical analysis For all analyses, we used a complete-case analysis, i.e., only subjects with complete data for all variables of interest were included. To address each of our aims, we constructed binary logistic regression models with suicidal ideation as the dependent variable. We reported both unadjusted and adjusted models, the latter of which included the covariates listed above. For endorsement of any and specific types of PV (physical, relational, verbal and cyber), frequency of PV, and internal resilience, we reported the independent odds ratios (OR) of suicidal ideation, as well as the interaction of endorsement and frequency of PV with internal resilience. The interaction terms between internal resilience with any PV, with specific types of PV, and with frequency of PV were entered into separate models to avoid collinearity among the PV variables, all of which were derived from the same 4 CHKS items. To further examine the role of gender in the association between PV and internal resilience with suicidal ideation, we tested the interaction of gender with individual types and frequencies of PV and with internal resilience. If the interaction between gender and internal resilience and that between gender and type or frequency of PV was significant, we then tested the three-way interaction of gender, internal resilience, and the type or frequency of PV. We conducted analyses using Stata/SE release
13.0, applying “svy” commands to account for the complex survey design; we included the WestEd-calculated weights for the CHKS dataset at all stages of analysis. This study was exempt from review by the University of California, San Francisco Committee on Human Research because no identifiable information was provided in the CHKS dataset.
Results Sample characteristics Students included in our analytic sample (n = 42,594) were similar overall, but less likely than students with incomplete data (n = 454,243) to be a gang member, to have low academic grades, to be in the 9th grade, to be male, to be Hispanic, and to have never been drunk or sick from alcohol or to have been high from drugs (all p
Matthew E. Hirschtritt*, Anna E. Ordóñeza, Yvette C. Rico and Kaja Z. LeWinn
Internal resilience, peer victimization, and suicidal ideation among adolescents Abstract Purpose: Our goal was to examine the association between peer victimization (PV) and suicidal ideation (SI), and the degree to which internal resilience moderates this association. Materials and methods: We examined the independent associations between PV frequency and type (verbal, cyber, physical, and relational), internal resilience, and the risk of SI within the last 12 months among 9th and 11th grade students participating in the California Healthy Kids Survey (CHKS) (n = 42,594; 55.2% female; 72.2% non-white). Results: Odds ratios (OR) of SI associated with very low- (at least 1 PV type 1 time, but none more than 1 time), low- (at least 1 PV type 2–3 times, but none more than 2–3 times), and moderate/high- (at least 1 PV type 4 times or more) frequency PV compared with no PV were 1.30 (95% CI = 1.15–1.45), 1.70 (95% CI = 1.51–1.90) and 2.47 (95% CI = 1.23–2.73), respectively. Any exposure to physical (OR = 1.31; 95% CI = 1.19–1.44), relational (OR = 1.26; 95% CI = 1.15–1.38), verbal (OR = 1.38; 95% CI = 1.27–1.50), or cyber (OR = 1.26; 95% CI = 1.15–1.39) PV was associated with increased odds of SI compared with no PV. Internal resilience was associated with lower odds of SI (OR = 0.98, 95% CI = 0.98–0.99), regardless of PV exposure. The slope between internal resilience and SI was significantly steeper for those subjects who experienced verbal PV (OR interaction = 0.99; 95% CI = 0.98–1.00). Conclusion: Even infrequent PV was found to be associated with increased risk for SI. Internal resilience was associated with reduced SI, particularly for verbal forms of PV. Our results suggested that efforts to decrease SI
Current address: Child Psychiatry Branch, National Institutes of Mental Health, National Institutes Health, Bethesda, MD, USA *Corresponding author: Matthew E. Hirschtritt, MD, MPH, Department of Psychiatry, University of California, San Francisco, 401 Parnassus Avenue, Box 0984-RTP, San Francisco, CA 94143-0984, USA, Phone: +1 415-476-7577, Fax: +1 415-476-7722, E-mail: [email protected] Anna E. Ordóñez: Department of Psychiatry, University of California, San Francisco, CA, USA Yvette C. Rico and Kaja Z. LeWinn: Department of Psychiatry, University of California, San Francisco, CA, USA a
among adolescents should be directed toward both preventing PV and strengthening internal resilience. Keywords: high school; peer victimization; resilience; suicidal ideation. DOI 10.1515/ijamh-2014-0060 Received September 26, 2014; accepted November 22, 2014; previously published online February 10, 2015
Introduction Peer victimization (PV), characterized by being the recipient of either physical or non-physical forms of aggression and harassment by peers, is a common and persistent problem among adolescents. Recent estimates for the percentage of US adolescents who report being victimized range from 10% to 30% (1, 2). Among participants in the 2013 National Youth Risk Behavior Surveillance (YRBS), 19.6% endorsed having been bullied on school property in the past 12 months (3). Furthermore, longitudinal studies suggest a relatively high persistence of PV behavior across childhood and adolescence (4). Previous studies have identified associations between PV and multiple, diverse negative outcomes that include suicidal ideation, which represents a high clinical and public health priority. Suicidal ideation is a common phenomenon among adolescents, with prevalence rates ranging from 15% to 30% (5, 6); 17.0% of participants in the 2013 YRBS endorsed seriously considering suicide in the past 12 months (3). Though estimates vary (7, 8), results from a recent national survey of US adolescents indicate that approximately 30% of adolescents with suicidal ideation go on to make a suicide attempt (9). Furthermore, risk factors for suicidal ideation and suicide attempts show significant overlap (10), emphasizing the importance of addressing suicidal ideation. Both cross-sectional (11–16) and longitudinal studies (17–19) have demonstrated associations between PV and suicidal behaviors, including suicidal ideation. In addition, some studies have suggested that females are more likely than males to engage in suicidal behavior in response to PV (12, 14, 15, 19), whereas others have not found significant sex-related differences (11, 13, 16, 18). - 10.1515/ijamh-2014-0060 Downloaded from De Gruyter Online at 09/13/2016 08:53:47AM via McMaster University
416 Hirschtritt et al.: Suicidal ideation in adolescents In addition to sex, there is evidence that external assets may moderate the adverse effects of PV among adolescents. For instance, school-based research demonstrates that social support from family and friends protects peer-victimized adolescents from experiencing decreased academic performance (20) and suicidal ideation (11). Likewise, the association between PV and suicidal ideation may be mediated by other individual-level characteristics, such as negative self-esteem (21). Taken together, these findings suggest that there may be certain modifiable factors among peer-victimized adolescents that could be targeted to decrease the risk of suicidal ideation. One such factor that has received increased attention in recent years is internal resilience, which is composed of individual-level resources, such as sociability, communication skills, self-esteem, and self-efficacy (22). Internal resilience has been shown to be protective against suicide in multiple studies. For example, a longitudinal study of children who had been victims of abuse found that those who had high-quality interpersonal skills throughout their lifespan were less likely to exhibit suicidality as adults (23). Another longitudinal study of adolescent suicide behavior found that those who attempted suicide were significantly more likely to have lower resilience at baseline controlling for antecedent depression (24). However, despite the fact that internal resilience may moderate the impact of PV on suicidal ideation, to our knowledge, no study has yet to examine how both PV and internal resilience are associated with suicidal ideation among adolescents in a non-clinical setting. This study contributes to the literature by assessing both risks (i.e., PV) and protective factors (i.e., internal resilience) for suicidal ideation in a large sample of adolescents in California. We hypothesize the following: 1) increasing frequency of PV is associated with an increased risk of suicidal ideation, 2) increasing levels of internal resilience are associated with decreased risk of suicidal ideation, and 3) increasing levels of internal resilience are more strongly and negatively associated with suicidal ideation in the context of PV. In other words, we hypothesize that internal resilience moderates the association between PV and suicidal ideation.
Materials and methods Design and participants The California Healthy Kids Survey (CHKS) is an anonymous, crosssectional, self-report survey that measures health-related risk behavior and resilience in students in grades 5 through 12 (25). Administered
and sponsored by the California Department of Education, the survey is designed primarily to provide data for school administrators and policy makers to help them identify and reduce youth risk behaviors. For this study, we used two-year aggregated CHKS data for students in the 9th and 11th grades, spanning 2009 through 2011. Each school district is asked to administer the CHKS every other year, and we used data from two non-consecutive class grades, minimizing the likelihood that individual students are represented more than once in our dataset. Complete survey design and administration details may be found at http://chks.wested.org/about.
Procedure The CHKS was administered to students in the 7th, 9th, and 11th grades by teachers, staff, and administrators in English, health, or history classes. All proctors were trained in survey administration, including delivery of an introductory script that summarized the content and purpose of the CHKS. This introduction also reminded students of the voluntary nature of the survey and that responses would be kept confidential.
Measures The CHKS is composed of a Core Module administered to all schools, as well as supplemental modules, including the Resilience and Youth Development Module (RYDM). For this analysis, we used items from both the Core Module and the RYDM. To measure suicidal ideation, we used a validated single, yes/no item: “During the past 12 months, did you ever seriously consider attempting suicide?” (14, 16, 26). This item was only available for students in the 9th and 11th grades. To measure PV, we used 4 items, each of which began with the prompt: “During the past 12 months, how many times on school property have you…” and included the answer choices “0 times”, “1 time”, “2–3 times”, and “4 or more”. Three of the PV items chosen were consistent with prior literature (27): “…been pushed, shoved, slapped, hit, or kicked by someone who wasn’t just kidding around?” “…had mean rumors or lies spread about you?” and “been made fun of because of your looks or the way you talk?” for physical, relational and verbal PV, respectively. We also included an item to measure cyber PV, which had the same answer choices as the other 3 PV items: “During the past 12 months, how many times did other students spread mean rumors or lies about you on the Internet (i.e., Facebook™, MySpace™, email, instant message)?” To assess the impact of PV type, we dichotomized responses for each type of PV into those who had been victimized at least once and those who had not been victimized. To assess the impact of PV frequency, we used the highest frequency among the four types of PV reported to anchor our categories; thus, we categorized each student as either “none” (i.e., endorsed “0 times” for all 4 types of PV), “very low” (i.e., endorsed “1 time”, but no higher, for at least 1 type of PV), “low” (i.e., endorsed “2–3 times”, but no higher, for at least 1 type of PV), or “moderate/high” (i.e., endorsed “4 or more times” for at least 1 type of PV). On a continuous scale, the “very low” category captured those with a median of 1 (interquartile range [IQR] = 1–2) PV experience, 3.5 (IQR = 2.5–5) PV experiences among students in the “low” category, and 7.5 (IQR = 5–10) PV experiences in the “moderate/high” category. The data did not allow
- 10.1515/ijamh-2014-0060 Downloaded from De Gruyter Online at 09/13/2016 08:53:47AM via McMaster University
Hirschtritt et al.: Suicidal ideation in adolescents 417 for accurate categorization of those who experienced a very high PV frequency (4 or more times) due to ceiling effects of how the PV question was asked. We summed responses from 18 items in the Resilience and Youth Development Module to measure internal resilience (28, 29). Items addressed domains that include cooperation and communication (e.g., “I can work with someone who has different opinions than mine”), self-efficacy (e.g., “I can work out my problems”), empathy (e.g., “I feel bad when someone gets their feelings hurt”), problemsolving (e.g., “When I need help I find someone to talk with”), selfawareness (e.g., “I understand my moods and feelings”), and goals and aspirations (e.g., “I have goals and plans for the future”). Each item began with the prompt “How true do you feel these statements are about you personally?” and was scored on a 4-point scale: “not at all true”, “a little true”, “pretty much true”, and “very much true”. These items demonstrated very good internal consistency in our sample (α = 0.93). In addition, we chose covariates based on established risk and protective factors for suicidal ideation among adolescents. These variables included self-reported sex (6, 30), ethnicity (recoded as Hispanic, white, Asian/Pacific Islander, African American, and multiple/other) (6), grade (9th or 11th) (31), use of alcohol and drugs (for each: never, 1–3 times, 4 or more times) (30, 31), depressive symptoms (14, 30), and external assets (30, 31). Specifically, depressive symptoms were measured with the only question that addressed this construct in the survey, a single yes/no question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more that you stopped doing some usual activities?” External assets were measured on the same scale as internal resilience items, and included 31 questions regarding caring relationships, high expectations, and meaningful participation in school, home, community, and with peers. External asset items demonstrated very good internal consistency in our sample (α = 0.93). The full text of these questions is available at .
Statistical analysis For all analyses, we used a complete-case analysis, i.e., only subjects with complete data for all variables of interest were included. To address each of our aims, we constructed binary logistic regression models with suicidal ideation as the dependent variable. We reported both unadjusted and adjusted models, the latter of which included the covariates listed above. For endorsement of any and specific types of PV (physical, relational, verbal and cyber), frequency of PV, and internal resilience, we reported the independent odds ratios (OR) of suicidal ideation, as well as the interaction of endorsement and frequency of PV with internal resilience. The interaction terms between internal resilience with any PV, with specific types of PV, and with frequency of PV were entered into separate models to avoid collinearity among the PV variables, all of which were derived from the same 4 CHKS items. To further examine the role of gender in the association between PV and internal resilience with suicidal ideation, we tested the interaction of gender with individual types and frequencies of PV and with internal resilience. If the interaction between gender and internal resilience and that between gender and type or frequency of PV was significant, we then tested the three-way interaction of gender, internal resilience, and the type or frequency of PV. We conducted analyses using Stata/SE release
13.0, applying “svy” commands to account for the complex survey design; we included the WestEd-calculated weights for the CHKS dataset at all stages of analysis. This study was exempt from review by the University of California, San Francisco Committee on Human Research because no identifiable information was provided in the CHKS dataset.
Results Sample characteristics Students included in our analytic sample (n = 42,594) were similar overall, but less likely than students with incomplete data (n = 454,243) to be a gang member, to have low academic grades, to be in the 9th grade, to be male, to be Hispanic, and to have never been drunk or sick from alcohol or to have been high from drugs (all p
