J Abnorm Child Psychol DOI 10.1007/s10802-013-9822-0
Self-Esteem and Social Support as Moderators of Depression, Body Image, and Disordered Eating for Suicidal Ideation in Adolescents Amy M. Brausch & Kristina M. Decker
# Springer Science+Business Media New York 2013
Abstract The current study investigated risk factors for suicidal ideation in a community sample of 392 adolescents (males 51.9 %; females 48.1 %), while also evaluating selfesteem, perceived parent support, and perceived peer support as protective factors and potential moderators between suicidal ideation and the 3 risk factors. Disordered eating, depression, parent support, and peer support were found to be significant predictors of current suicidal ideation, but body satisfaction was not. The relationship between depression and suicidal ideation was significantly moderated by both selfesteem and parent support, while the relationship between disordered eating and suicidal ideation was significantly moderated by peer support. Results underscore the importance of examining protective factors for suicide risk, as they have the potential to reduce suicidal ideation in adolescents. Keywords Suicidal ideation . Adolescents . Depression . Disordered eating . Social support . Self-esteem The presence of suicidal ideation and behavior has been recognized as an increasing problem among adolescents and young adults. Recent data released from the Centers for Disease Control reported that there were 4,600 completed suicides in the 15–24 year-old age range in 2010 (McIntosh and Drapeau 2012). Suicide continues to be the 3rd ranking cause
A. M. Brausch (*) Department of Psychological Sciences, Western Kentucky University, 1906 College Heights Blvd., Bowling Green, KY 42101, USA e-mail: [email protected] K. M. Decker Department of Psychology, Washington University, 1 Brookings Drive, Campus Box 1125, St. Louis, MO 63130, USA e-mail: [email protected]
of death for young people in the United States, and there are approximately 100–200 suicide attempts per completed suicide in this age group (McIntosh and Drapeau 2012). Due to the consistent rates of suicide among young people, research has focused on risk factors for suicide in adolescent samples. A review of the evidence suggests that it is equally important to investigate protective factors in models of adolescent suicide risk such as self-esteem and perceived social support from peers and family to determine which factors provide a buffering effect against suicide risk (de Man and Gutierrez 2002; Pinto et al. 1998; Rigby and Slee 1999). Depression is one risk factor that has consistently been found to predict suicidal ideation in both psychiatric and community samples and to be one of the strongest predictors of suicide ideation (e.g., Mazza and Reynolds 1998; Reifman and Windle 1995; Rich et al. 1992). More recent research has also examined disordered eating behaviors and poor body image as risk factors for suicidal ideation, with significant relationships found (e.g., Brausch and Gutierrez 2009; Brausch and Muehlenkamp 2007). The goal of the current study was to further investigate these risk factors for suicidal ideation in a community sample of adolescents and to specifically evaluate moderating factors that may serve a protective function. While several theories of suicide risk have been posited and tested for adult populations, (e.g., Escape Theory; Baumeister 1990), a review of the literature suggests that adolescent models of suicide risk tend to focus on evaluating various risk and protective factors without necessarily placing them in the context of an underlying theory of suicide risk. The Interpersonal Theory of Suicide as developed by Joiner (2005) has been studied extensively in adult populations within the past decade. This parsimonious model, which includes the risk factors of thwarted belongingness, perceived burdensomeness, and acquired capability (reduced fear of pain and death), has found great empirical support among many samples of adults (e.g., Joiner 2005).
J Abnorm Child Psychol
However, very few studies have tested this theory in samples of adolescents (Stellrecht et al. 2006), even though the theory is hypothesized to apply across the lifespan. One such study by Timmons et al. (2011) used the framework of this theory and found parental displacement’s impact on suicide attempts to be mediated by low belongingness in adolescents. The current study also recognizes that both belongingness and feelings of being a burden may be reflective of an adolescent’s perception of support received from parents and peers and their integration within a social system. Furthermore, these constructs may be manifested in views of the self as a person of worth who has something to offer, as captured by a global measure of self-esteem. The current study thus included self-esteem and perceived support from parents and peers as protective factors for suicide risk.
Body Image and Disordered Eating Among the most widespread issues of concern that have their onset in adolescence are disordered eating behaviors and poor body image. In a study of both male and female adolescents, Brausch and Muehlenkamp (2007) found that negative body attitudes and feelings were predictive of suicidal ideation beyond the effects of depression, hopelessness, and past suicidal behavior. The authors posited that adolescents with negative attitudes and feelings about their bodies may be more likely to consider suicide because they are less invested in protecting their bodies from harm. Literature has also supported disordered eating’s association with suicidal ideation among adolescents. Brausch and Gutierrez (2009) found a direct relationship between disordered eating and suicidal ideation in a community sample of adolescents while an indirect relationship between low body satisfaction and suicidal ideation was seen through depressive symptoms, indicating that disordered eating behaviors predict suicidal ideation above and beyond depression. Individuals with eating disorders are also noted to have higher suicide attempt and completion rates than the general population; for example, suicide attempt rates for bulimia are 15–40 % vs. 6.5–7 % in the general population, and anorexia nervosa patients are at 23 times greater risk for death by suicide (Corcos et al. 2002; Miotto et al. 2003). Other research has focused on disordered eating behavior such as restricting, purging, and overexercise as contributing to acquired capability for suicide through these repeated painful acts (e.g., Smith et al. 2013). Despite the potential negative impact of body dissatisfaction and disordered eating and their relationship with suicidal ideation, limited research exists exploring these factors.
Self-Esteem One potential protective variable for suicide risk is selfesteem, which is defined as an individual’s global appraisal of his or her own value and competence and has been identified as an important factor in the lives of children and adolescents. Specifically, this study examined explicit self-esteem, which is a person’s conscious feeling of self-worth and acceptance (Rosenberg 1965). Overholser et al. (1995) noted that self-esteem develops in childhood and remains fairly constant throughout adolescence. However, it is believed that selfesteem becomes more salient during adolescence when young people become more aware of the self as an independent person and are better able to evaluate the self. Therefore, when self-esteem is low during adolescence, it is likely to be a stable problem and one that may cause significant emotional distress. Previous studies have identified relationships between low self-esteem and suicidal ideation and suicide attempts in adolescents, as well as depression and hopelessness. Low selfesteem has been implicated in samples of adolescents who have attempted suicide (Kienhorst et al. 1990) and has also been found to be related to increased suicidal tendencies, seriousness of suicidal intent, and medical lethality of attempts in a sample of adolescent psychiatric inpatients (Robbins and Alessi 1985). In both non-clinical and psychiatric samples, low self-esteem has been linked to more previous suicide attempts and suicidal ideation (Overholser et al. 1995). Consistent with these findings, Sharaf et al. (2009) found significant correlations between self-esteem and suicide risk behaviors (e.g., suicide attempts, suicidal ideation) among adolescents. These results confirm the need to include self-esteem as a factor in adolescent suicide risk models, and the importance of looking at the protective value of self-esteem.
Perceived Peer Support and Family Support Research has suggested that perceived social support, often defined as the assistance an individual perceives that he or she receives from his or her environment, is crucial to development during adolescence. Studies have shown that adolescents and young adults who perceive receiving adequate social support fare better than those who do not in many areas of functioning including body satisfaction (Barker and Galambos 2003), depression (Carbonell et al. 1998), suicidal ideation (Crocker and Hakim-Larson 1997), academic performance (Ystgaard 1997), and a variety of emotional and behavioral problems (Garnefski and Diekstra 1996). Perceived social support has been included in a few studies as a socioenvironmental factor in the prediction of suicidal ideation and behavior and has typically been assessed in terms of perceived support received from family and peers. There is conflicting
J Abnorm Child Psychol
evidence over which type of perceived support is most influential in buffering adolescents from increased suicidal ideation. Some studies have found increased perceived support from parents to be a stronger protective factor for suicidal ideation than perceived peer support (e.g., Lewinsohn et al. 1993), and other studies have found that increased perceived peer support has a stronger buffering effect for suicidal ideation than support from parents (e.g., Kandel et al. 1991). WichstrØm (2009) identified attachment to and care from parents as a protective factor for suicide attempts in a 5-year longitudinal study of Norwegian adolescents. The results of these studies provide modest support for the idea that perceived social support may serve a protective function for suicide risk in adolescents. Given that adolescents tend to report varying levels of perceived support from family and friends, it is advantageous to investigate the role of support from these two sources separately. Because teenagers spend the majority of their time with friends and classmates and appreciate that time, it is arguable that adolescents value the support and opinions from friends and classmates more than from their parents.
Rationale and Hypotheses Most adolescent risk models for suicide include depression as a risk factor since it has repeatedly demonstrated itself as a robust and consistent predictor (Mazza and Reynolds 1998), but generally fail to include other possible factors such as body dissatisfaction and disordered eating, even though these factors have been shown to be prevalent in adolescent samples and linked to other risk factors for suicide (e.g., Barker and Galambos 2003; Miotto et al. 2003). These body-related factors are especially important to include for adolescents because this age group reports high levels of body dissatisfaction and disordered eating symptoms, and both factors have been found to be predictive of depression and suicide risk (e.g., Brausch and Gutierrez 2009) as well as potentially contributing to acquired capability for suicide (Smith et al. 2013). Furthermore, it is important to investigate additional factors in models of adolescent suicide risk to determine which may be protective against suicide risk (de Man and Gutierrez 2002; Pinto et al. 1998; Rigby and Slee 1999). While the current study utilized a combined-sex sample, gender differences were not emphasized as previous studies have found similar relationships between the study variables by sex (e.g., Brausch and Gutierrez 2009; Brausch and Muehlenkamp 2007). It was hypothesized that self-esteem, perceived peer support, and perceived parent support would serve as moderators between suicidal ideation and the following variables: disordered eating, body image, and depression. We examined whether the relation between risk factors (i.e., depression,
disordered eating, poor body image) and suicidal ideation depended on various buffering factors (i.e., self-esteem, peer support, parent support). We predicted that these potential buffers would interact with the different risk factors to predict lower levels of suicidal ideation. In particular, we predicted that the combination of high levels of a particular risk factor and high levels of a particular buffering factor would be associated with lower levels of suicidal ideation than other combinations of high and low risk and protective factors. Lastly, it was expected that self-esteem, peer support, and parent support would be significant predictors of current suicidal ideation.
Method Participants Participants for this study were recruited from an urban high school in the Midwestern region of the United States. The data were collected as part of a school mental health screening that had been in place for several years, and a total of 392 students participated in the screening during the 2004–2005 academic year. The mean age was 15.04 (SD =1.05) with a fairly equal gender distribution (males 51.9 %; females 48.1 %). The majority of the participants were freshmen (67.3 %), followed by sophomores (15.8 %), juniors (11 %), and seniors (5.9 %). In terms of racial diversity, 35 % of the participants identified as White; 37.3 % as Black, 15.3 % as Multiethnic, 9.2 % as Hispanic, and 2.3 % as Asian. An “other” category was used for one Native American student and two who identified as “other.” Procedure The screening program was approved by the school principal for school-wide use and received approval from the IRB at Northern Illinois University, with whom the first author was previously affiliated. Students in selected classes (as convenient for the school) were recruited for the study and parents returned consent forms only if they objected to their child’s participation (passive consent). Data collection occurred during regular school hours in classroom settings. A graduate student and at least two research assistants were present at each screening. A standard script was used to describe the survey, and students were given an assent form. Out of the students for whom passive parental consent was obtained, 83.4 % who were present on screening dates gave their assent to participate in the study (16.6 % declined participation). Students were generally able to finish the screening packets within one class period. Packets did not contain identifying information but were marked with unique code numbers that could be linked to students as needed for referral purposes
J Abnorm Child Psychol
only. All assent forms were stored and secured separately from the raw data. As students completed their packets, measures were checked by the research team to ensure complete participation. Packets were later thoroughly checked for pre-determined critical items from several measures that indicate depression or suicide risk. If a student was determined to be at risk on any of the identified measures, he or she was called out of a different class period later in the day and debriefed by a graduate student, which included a brief assessment for depression and suicide risk in a private setting; 4 % of participants were debriefed and referred for further interventions.
alpha) for the total EAT-26 score was 0.78. For this scale, 4.64 % of participants scored above the cutoff for disordered eating symptoms.
Suicidal Ideation Questionnaire (SIQ; Reynolds 1988). The SIQ is a 30-item self-report measure of current suicidal ideation designed for use with older adolescents. Items are rated according to a 7-point scale ranging from 6 (almost every day) to 0 (I never had this thought). Total scores range from 0 to 180 with higher scores indicating a greater level of suicidal ideation. The SIQ has demonstrated good internal consistency (α =0.94 to 0.97), and adequate concurrent and construct validity (Pinto et al. 1997). In the current study, the reliability alpha for the total SIQ score was 0.96. On this scale, 9.14 % of students scored above the clinical cutoff score of 41.
The Multidimensional Body-Self Relations Questionnaire – Appearance Subscales (MBSRQ-AS; Cash 2000). This measure was used to assess body satisfaction and was developed for use with adults and adolescents. The MBSRQ-AS consists of 34 items that make up five subscales: Appearance Evaluation, Appearance Orientation, Overweight Preoccupation, SelfClassified Weight, and the Body Areas Satisfaction Scale (BASS). Only the BASS scores were used in the current study due this scale’s emphasis on body satisfaction. According to Cash, this subscale was modeled on the Body-Esteem Scale (Franzoi and Shields 1984) and assesses satisfaction with different body areas and attributes. For example, the BASS asks individuals to rate their satisfaction with areas such as weight, face, and lower torso. Items on the BASS are presented in a 5point Likert format that range from 1 (very dissatisfied) to 5 (very satisfied). The BASS score is derived by calculating the mean of the subscale items. Internal consistencies for the BASS were 0.73 for females and 0.77 for males in the normative sample (Cash 2000). Test-retest reliability values after one month range were 0.74 for females and 0.86 for males. Norms for males and females on this measure are comparable (Cash 2000). For the current study, the alpha for the BASS was 0.85.
Eating Attitudes Test (EAT-26; Garner and Garfinkel 1979). The EAT-26 was developed, and is mostly used, as a screening measure for identifying symptoms of eating disorders in adolescents and adults. It is comprised of 26 items and sample items include, “Am terrified about being overweight” and “Like my stomach to be empty.” All items are presented in a 6-point Likert scale ranging from 1 (never) to 6 (always). While each item has six response options, only the three responses that are furthest in the “symptomatic direction” are given scores. A score of 3 is assigned to the response that is furthest in the “symptomatic” direction (i.e., never or always, depending on the wording of the item). A score of 2 is given to the immediately adjacent response, and a score of 1 to the next adjacent response. The three response options in the “asymptomatic” direction are given scores of 0. A total score is derived by summing these coded responses so that only symptomatic responses are included in the final score. When the EAT-26 is used as a screening measure, those who score above the cutoff of 20 are referred for a diagnostic interview. For the present study, the total score from the EAT-26 was used to provide an overall index of disordered eating behavior. The EAT-26 has been shown to have good concurrent and criterion validity (Gross et al. 1986; Rosen et al. 1988). In terms of reliability, Garner and Garfinkel (1979) reported an internal consistency coefficient of 0.94 for a group of normal controls. For the current study, the reliability estimate (i.e.,
Reynolds Adolescent Depression Scale – 2nd Edition (RADS-2; Reynolds 2002). The RADS-2 is a 30-item selfreport measure intended for use with adolescents between the ages of 11 and 20 and provides a global picture of the severity of all depressive symptoms. A total score is calculated by summing all items. The RADS-2 is presented in a 4-point Likert format ranging from 1 (almost never) to 4 (most of the time ). Adolescents are asked to respond to each item by indicating how they usually feel and total scores can range from 30 to 120. The RADS-2 also contains six critical items that, when endorsed at certain levels, have been found to discriminate between clinically depressed and non-depressed adolescents. Examples of critical items are “I feel I am no good” and “I feel I am bad.” When at least four of the six critical items are endorsed as “sometimes” or “most of the time,” follow-up with the student is recommended. Students who met the criteria for critical items on the RADS-2 in this study were debriefed by a graduate student, and the appropriate referrals were made. The RADS-2 has demonstrated good internal consistency reliability. Reliability estimates range from 0.80 to 0.93 for the subscale and total scores in adolescent samples. Test-retest reliability coefficients for a 2-week interval were also good, ranging from 0.77 to 0.85 for the total and subscale scores. The RADS-2 has also been found to demonstrate good content, criterion, convergent, and discriminant validity (Reynolds 2002). For the
Measures
J Abnorm Child Psychol
current study, the internal consistency reliability value was 0.92 for the overall total. For this scale, 7.56 % of the participants scored above the clinical cutoff. Rosenberg Self-Esteem Scale (SES; Rosenberg 1965). The SES is a 10-item measure that assesses an individual’s overall evaluation of his or her worth or value. The items are presented in a 4-point Likert format ranging from strongly agree to strongly disagree. Half of the items are positively worded (e.g., I feel that I have a number of good qualities), and the other half are negatively worded (e.g., I certainly feel useless at times). All items are summed to produce a total score, which ranges from 0 to 30. The SES is a widely used measure of self-esteem and has been shown to have good reliability. The test-retest correlations for the scale have ranged from 0.82 to 0.88, and the internal consistency coefficients for the scale have ranged from 0.77 to 0.88 (Blascovich and Tomaka 1993; Rosenberg 1986). For the current study, the internal consistency coefficient was 0.85 for the total score. Child and Adolescent Social Support Scale (CASSS; Malecki et al. 2000). The CASSS is a 60-item scale that assesses perceived social support from five sources: parents, teachers, classmates, close friend, and school. These five sources comprise five separate subscales, with each containing 12 items. Participants respond to each item on two aspects: frequency and importance. For example, adolescents would rate the item “My parent(s) help me make decisions” on both how often it occurs and how important it is to them. Frequency ratings use a 6-point Likert scale from 1 (Never) to 6 (Always). Importance ratings use a 3-point Likert scale that ranges from 1 (Not Important) to 3 (Very Important). Subscale scores are calculated by summing the frequency ratings for each subscale; a total score can be calculated by summing the frequency ratings for all 60 items. For the current study, the frequency scores from the classmates subscale were used as the indicator of perceived peer support. This subscale was chosen to represent peer support rather than the close friend subscale because participants rated perceived support from more than one peer as opposed to only one close friend. This allowed the participant to report on more generalized perceived support from same-age peers and reduced the possibility that an adolescent might rate perceived support from a “close friend” who may or may not reciprocate that label to the participant. Frequency scores from the parent subscale were used as the indicator of perceived family support. The CASSS has been found to have good reliability and validity. Malecki and Demaray (2002) reported that the internal consistency reliability for the CASSS was 0.97 for the Total Frequency scale. Test-retest reliability coefficients were 0.78 for the Total Frequency scale after an 8-week interval. Construct and convergent validity has also been well established. In the current study, reliability was 0.93 for both parent and classmate subscales.
Results Before testing the moderation hypotheses, two MANOVAs were conducted to test for potential differences in the study variables by grade and race, given the variability in age of participants and the racial diversity of the sample. To reduce Type I error due to multiple comparisons, a Bonferroni correction was employed with an adjusted significance level (p < 0.007). The first MANOVA included grade as the independent variable and depression, suicidal ideation, body satisfaction, disordered eating, peer support, family support, and selfesteem as the dependent variables. No significant differences were found for any of the dependent variables, indicating that grade level did not contribute to differences in scores. The second MANOVA included all of the same dependent variables listed above, but included race as the independent variable; the “other” category was not included as its n size was too small to calculate differences (n =3). Significant differences were found for suicidal ideation, F(4, 336)=4.91, p < 0.001, body satisfaction, F(4, 376)=4.88, p
Self-Esteem and Social Support as Moderators of Depression, Body Image, and Disordered Eating for Suicidal Ideation in Adolescents Amy M. Brausch & Kristina M. Decker
# Springer Science+Business Media New York 2013
Abstract The current study investigated risk factors for suicidal ideation in a community sample of 392 adolescents (males 51.9 %; females 48.1 %), while also evaluating selfesteem, perceived parent support, and perceived peer support as protective factors and potential moderators between suicidal ideation and the 3 risk factors. Disordered eating, depression, parent support, and peer support were found to be significant predictors of current suicidal ideation, but body satisfaction was not. The relationship between depression and suicidal ideation was significantly moderated by both selfesteem and parent support, while the relationship between disordered eating and suicidal ideation was significantly moderated by peer support. Results underscore the importance of examining protective factors for suicide risk, as they have the potential to reduce suicidal ideation in adolescents. Keywords Suicidal ideation . Adolescents . Depression . Disordered eating . Social support . Self-esteem The presence of suicidal ideation and behavior has been recognized as an increasing problem among adolescents and young adults. Recent data released from the Centers for Disease Control reported that there were 4,600 completed suicides in the 15–24 year-old age range in 2010 (McIntosh and Drapeau 2012). Suicide continues to be the 3rd ranking cause
A. M. Brausch (*) Department of Psychological Sciences, Western Kentucky University, 1906 College Heights Blvd., Bowling Green, KY 42101, USA e-mail: [email protected] K. M. Decker Department of Psychology, Washington University, 1 Brookings Drive, Campus Box 1125, St. Louis, MO 63130, USA e-mail: [email protected]
of death for young people in the United States, and there are approximately 100–200 suicide attempts per completed suicide in this age group (McIntosh and Drapeau 2012). Due to the consistent rates of suicide among young people, research has focused on risk factors for suicide in adolescent samples. A review of the evidence suggests that it is equally important to investigate protective factors in models of adolescent suicide risk such as self-esteem and perceived social support from peers and family to determine which factors provide a buffering effect against suicide risk (de Man and Gutierrez 2002; Pinto et al. 1998; Rigby and Slee 1999). Depression is one risk factor that has consistently been found to predict suicidal ideation in both psychiatric and community samples and to be one of the strongest predictors of suicide ideation (e.g., Mazza and Reynolds 1998; Reifman and Windle 1995; Rich et al. 1992). More recent research has also examined disordered eating behaviors and poor body image as risk factors for suicidal ideation, with significant relationships found (e.g., Brausch and Gutierrez 2009; Brausch and Muehlenkamp 2007). The goal of the current study was to further investigate these risk factors for suicidal ideation in a community sample of adolescents and to specifically evaluate moderating factors that may serve a protective function. While several theories of suicide risk have been posited and tested for adult populations, (e.g., Escape Theory; Baumeister 1990), a review of the literature suggests that adolescent models of suicide risk tend to focus on evaluating various risk and protective factors without necessarily placing them in the context of an underlying theory of suicide risk. The Interpersonal Theory of Suicide as developed by Joiner (2005) has been studied extensively in adult populations within the past decade. This parsimonious model, which includes the risk factors of thwarted belongingness, perceived burdensomeness, and acquired capability (reduced fear of pain and death), has found great empirical support among many samples of adults (e.g., Joiner 2005).
J Abnorm Child Psychol
However, very few studies have tested this theory in samples of adolescents (Stellrecht et al. 2006), even though the theory is hypothesized to apply across the lifespan. One such study by Timmons et al. (2011) used the framework of this theory and found parental displacement’s impact on suicide attempts to be mediated by low belongingness in adolescents. The current study also recognizes that both belongingness and feelings of being a burden may be reflective of an adolescent’s perception of support received from parents and peers and their integration within a social system. Furthermore, these constructs may be manifested in views of the self as a person of worth who has something to offer, as captured by a global measure of self-esteem. The current study thus included self-esteem and perceived support from parents and peers as protective factors for suicide risk.
Body Image and Disordered Eating Among the most widespread issues of concern that have their onset in adolescence are disordered eating behaviors and poor body image. In a study of both male and female adolescents, Brausch and Muehlenkamp (2007) found that negative body attitudes and feelings were predictive of suicidal ideation beyond the effects of depression, hopelessness, and past suicidal behavior. The authors posited that adolescents with negative attitudes and feelings about their bodies may be more likely to consider suicide because they are less invested in protecting their bodies from harm. Literature has also supported disordered eating’s association with suicidal ideation among adolescents. Brausch and Gutierrez (2009) found a direct relationship between disordered eating and suicidal ideation in a community sample of adolescents while an indirect relationship between low body satisfaction and suicidal ideation was seen through depressive symptoms, indicating that disordered eating behaviors predict suicidal ideation above and beyond depression. Individuals with eating disorders are also noted to have higher suicide attempt and completion rates than the general population; for example, suicide attempt rates for bulimia are 15–40 % vs. 6.5–7 % in the general population, and anorexia nervosa patients are at 23 times greater risk for death by suicide (Corcos et al. 2002; Miotto et al. 2003). Other research has focused on disordered eating behavior such as restricting, purging, and overexercise as contributing to acquired capability for suicide through these repeated painful acts (e.g., Smith et al. 2013). Despite the potential negative impact of body dissatisfaction and disordered eating and their relationship with suicidal ideation, limited research exists exploring these factors.
Self-Esteem One potential protective variable for suicide risk is selfesteem, which is defined as an individual’s global appraisal of his or her own value and competence and has been identified as an important factor in the lives of children and adolescents. Specifically, this study examined explicit self-esteem, which is a person’s conscious feeling of self-worth and acceptance (Rosenberg 1965). Overholser et al. (1995) noted that self-esteem develops in childhood and remains fairly constant throughout adolescence. However, it is believed that selfesteem becomes more salient during adolescence when young people become more aware of the self as an independent person and are better able to evaluate the self. Therefore, when self-esteem is low during adolescence, it is likely to be a stable problem and one that may cause significant emotional distress. Previous studies have identified relationships between low self-esteem and suicidal ideation and suicide attempts in adolescents, as well as depression and hopelessness. Low selfesteem has been implicated in samples of adolescents who have attempted suicide (Kienhorst et al. 1990) and has also been found to be related to increased suicidal tendencies, seriousness of suicidal intent, and medical lethality of attempts in a sample of adolescent psychiatric inpatients (Robbins and Alessi 1985). In both non-clinical and psychiatric samples, low self-esteem has been linked to more previous suicide attempts and suicidal ideation (Overholser et al. 1995). Consistent with these findings, Sharaf et al. (2009) found significant correlations between self-esteem and suicide risk behaviors (e.g., suicide attempts, suicidal ideation) among adolescents. These results confirm the need to include self-esteem as a factor in adolescent suicide risk models, and the importance of looking at the protective value of self-esteem.
Perceived Peer Support and Family Support Research has suggested that perceived social support, often defined as the assistance an individual perceives that he or she receives from his or her environment, is crucial to development during adolescence. Studies have shown that adolescents and young adults who perceive receiving adequate social support fare better than those who do not in many areas of functioning including body satisfaction (Barker and Galambos 2003), depression (Carbonell et al. 1998), suicidal ideation (Crocker and Hakim-Larson 1997), academic performance (Ystgaard 1997), and a variety of emotional and behavioral problems (Garnefski and Diekstra 1996). Perceived social support has been included in a few studies as a socioenvironmental factor in the prediction of suicidal ideation and behavior and has typically been assessed in terms of perceived support received from family and peers. There is conflicting
J Abnorm Child Psychol
evidence over which type of perceived support is most influential in buffering adolescents from increased suicidal ideation. Some studies have found increased perceived support from parents to be a stronger protective factor for suicidal ideation than perceived peer support (e.g., Lewinsohn et al. 1993), and other studies have found that increased perceived peer support has a stronger buffering effect for suicidal ideation than support from parents (e.g., Kandel et al. 1991). WichstrØm (2009) identified attachment to and care from parents as a protective factor for suicide attempts in a 5-year longitudinal study of Norwegian adolescents. The results of these studies provide modest support for the idea that perceived social support may serve a protective function for suicide risk in adolescents. Given that adolescents tend to report varying levels of perceived support from family and friends, it is advantageous to investigate the role of support from these two sources separately. Because teenagers spend the majority of their time with friends and classmates and appreciate that time, it is arguable that adolescents value the support and opinions from friends and classmates more than from their parents.
Rationale and Hypotheses Most adolescent risk models for suicide include depression as a risk factor since it has repeatedly demonstrated itself as a robust and consistent predictor (Mazza and Reynolds 1998), but generally fail to include other possible factors such as body dissatisfaction and disordered eating, even though these factors have been shown to be prevalent in adolescent samples and linked to other risk factors for suicide (e.g., Barker and Galambos 2003; Miotto et al. 2003). These body-related factors are especially important to include for adolescents because this age group reports high levels of body dissatisfaction and disordered eating symptoms, and both factors have been found to be predictive of depression and suicide risk (e.g., Brausch and Gutierrez 2009) as well as potentially contributing to acquired capability for suicide (Smith et al. 2013). Furthermore, it is important to investigate additional factors in models of adolescent suicide risk to determine which may be protective against suicide risk (de Man and Gutierrez 2002; Pinto et al. 1998; Rigby and Slee 1999). While the current study utilized a combined-sex sample, gender differences were not emphasized as previous studies have found similar relationships between the study variables by sex (e.g., Brausch and Gutierrez 2009; Brausch and Muehlenkamp 2007). It was hypothesized that self-esteem, perceived peer support, and perceived parent support would serve as moderators between suicidal ideation and the following variables: disordered eating, body image, and depression. We examined whether the relation between risk factors (i.e., depression,
disordered eating, poor body image) and suicidal ideation depended on various buffering factors (i.e., self-esteem, peer support, parent support). We predicted that these potential buffers would interact with the different risk factors to predict lower levels of suicidal ideation. In particular, we predicted that the combination of high levels of a particular risk factor and high levels of a particular buffering factor would be associated with lower levels of suicidal ideation than other combinations of high and low risk and protective factors. Lastly, it was expected that self-esteem, peer support, and parent support would be significant predictors of current suicidal ideation.
Method Participants Participants for this study were recruited from an urban high school in the Midwestern region of the United States. The data were collected as part of a school mental health screening that had been in place for several years, and a total of 392 students participated in the screening during the 2004–2005 academic year. The mean age was 15.04 (SD =1.05) with a fairly equal gender distribution (males 51.9 %; females 48.1 %). The majority of the participants were freshmen (67.3 %), followed by sophomores (15.8 %), juniors (11 %), and seniors (5.9 %). In terms of racial diversity, 35 % of the participants identified as White; 37.3 % as Black, 15.3 % as Multiethnic, 9.2 % as Hispanic, and 2.3 % as Asian. An “other” category was used for one Native American student and two who identified as “other.” Procedure The screening program was approved by the school principal for school-wide use and received approval from the IRB at Northern Illinois University, with whom the first author was previously affiliated. Students in selected classes (as convenient for the school) were recruited for the study and parents returned consent forms only if they objected to their child’s participation (passive consent). Data collection occurred during regular school hours in classroom settings. A graduate student and at least two research assistants were present at each screening. A standard script was used to describe the survey, and students were given an assent form. Out of the students for whom passive parental consent was obtained, 83.4 % who were present on screening dates gave their assent to participate in the study (16.6 % declined participation). Students were generally able to finish the screening packets within one class period. Packets did not contain identifying information but were marked with unique code numbers that could be linked to students as needed for referral purposes
J Abnorm Child Psychol
only. All assent forms were stored and secured separately from the raw data. As students completed their packets, measures were checked by the research team to ensure complete participation. Packets were later thoroughly checked for pre-determined critical items from several measures that indicate depression or suicide risk. If a student was determined to be at risk on any of the identified measures, he or she was called out of a different class period later in the day and debriefed by a graduate student, which included a brief assessment for depression and suicide risk in a private setting; 4 % of participants were debriefed and referred for further interventions.
alpha) for the total EAT-26 score was 0.78. For this scale, 4.64 % of participants scored above the cutoff for disordered eating symptoms.
Suicidal Ideation Questionnaire (SIQ; Reynolds 1988). The SIQ is a 30-item self-report measure of current suicidal ideation designed for use with older adolescents. Items are rated according to a 7-point scale ranging from 6 (almost every day) to 0 (I never had this thought). Total scores range from 0 to 180 with higher scores indicating a greater level of suicidal ideation. The SIQ has demonstrated good internal consistency (α =0.94 to 0.97), and adequate concurrent and construct validity (Pinto et al. 1997). In the current study, the reliability alpha for the total SIQ score was 0.96. On this scale, 9.14 % of students scored above the clinical cutoff score of 41.
The Multidimensional Body-Self Relations Questionnaire – Appearance Subscales (MBSRQ-AS; Cash 2000). This measure was used to assess body satisfaction and was developed for use with adults and adolescents. The MBSRQ-AS consists of 34 items that make up five subscales: Appearance Evaluation, Appearance Orientation, Overweight Preoccupation, SelfClassified Weight, and the Body Areas Satisfaction Scale (BASS). Only the BASS scores were used in the current study due this scale’s emphasis on body satisfaction. According to Cash, this subscale was modeled on the Body-Esteem Scale (Franzoi and Shields 1984) and assesses satisfaction with different body areas and attributes. For example, the BASS asks individuals to rate their satisfaction with areas such as weight, face, and lower torso. Items on the BASS are presented in a 5point Likert format that range from 1 (very dissatisfied) to 5 (very satisfied). The BASS score is derived by calculating the mean of the subscale items. Internal consistencies for the BASS were 0.73 for females and 0.77 for males in the normative sample (Cash 2000). Test-retest reliability values after one month range were 0.74 for females and 0.86 for males. Norms for males and females on this measure are comparable (Cash 2000). For the current study, the alpha for the BASS was 0.85.
Eating Attitudes Test (EAT-26; Garner and Garfinkel 1979). The EAT-26 was developed, and is mostly used, as a screening measure for identifying symptoms of eating disorders in adolescents and adults. It is comprised of 26 items and sample items include, “Am terrified about being overweight” and “Like my stomach to be empty.” All items are presented in a 6-point Likert scale ranging from 1 (never) to 6 (always). While each item has six response options, only the three responses that are furthest in the “symptomatic direction” are given scores. A score of 3 is assigned to the response that is furthest in the “symptomatic” direction (i.e., never or always, depending on the wording of the item). A score of 2 is given to the immediately adjacent response, and a score of 1 to the next adjacent response. The three response options in the “asymptomatic” direction are given scores of 0. A total score is derived by summing these coded responses so that only symptomatic responses are included in the final score. When the EAT-26 is used as a screening measure, those who score above the cutoff of 20 are referred for a diagnostic interview. For the present study, the total score from the EAT-26 was used to provide an overall index of disordered eating behavior. The EAT-26 has been shown to have good concurrent and criterion validity (Gross et al. 1986; Rosen et al. 1988). In terms of reliability, Garner and Garfinkel (1979) reported an internal consistency coefficient of 0.94 for a group of normal controls. For the current study, the reliability estimate (i.e.,
Reynolds Adolescent Depression Scale – 2nd Edition (RADS-2; Reynolds 2002). The RADS-2 is a 30-item selfreport measure intended for use with adolescents between the ages of 11 and 20 and provides a global picture of the severity of all depressive symptoms. A total score is calculated by summing all items. The RADS-2 is presented in a 4-point Likert format ranging from 1 (almost never) to 4 (most of the time ). Adolescents are asked to respond to each item by indicating how they usually feel and total scores can range from 30 to 120. The RADS-2 also contains six critical items that, when endorsed at certain levels, have been found to discriminate between clinically depressed and non-depressed adolescents. Examples of critical items are “I feel I am no good” and “I feel I am bad.” When at least four of the six critical items are endorsed as “sometimes” or “most of the time,” follow-up with the student is recommended. Students who met the criteria for critical items on the RADS-2 in this study were debriefed by a graduate student, and the appropriate referrals were made. The RADS-2 has demonstrated good internal consistency reliability. Reliability estimates range from 0.80 to 0.93 for the subscale and total scores in adolescent samples. Test-retest reliability coefficients for a 2-week interval were also good, ranging from 0.77 to 0.85 for the total and subscale scores. The RADS-2 has also been found to demonstrate good content, criterion, convergent, and discriminant validity (Reynolds 2002). For the
Measures
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current study, the internal consistency reliability value was 0.92 for the overall total. For this scale, 7.56 % of the participants scored above the clinical cutoff. Rosenberg Self-Esteem Scale (SES; Rosenberg 1965). The SES is a 10-item measure that assesses an individual’s overall evaluation of his or her worth or value. The items are presented in a 4-point Likert format ranging from strongly agree to strongly disagree. Half of the items are positively worded (e.g., I feel that I have a number of good qualities), and the other half are negatively worded (e.g., I certainly feel useless at times). All items are summed to produce a total score, which ranges from 0 to 30. The SES is a widely used measure of self-esteem and has been shown to have good reliability. The test-retest correlations for the scale have ranged from 0.82 to 0.88, and the internal consistency coefficients for the scale have ranged from 0.77 to 0.88 (Blascovich and Tomaka 1993; Rosenberg 1986). For the current study, the internal consistency coefficient was 0.85 for the total score. Child and Adolescent Social Support Scale (CASSS; Malecki et al. 2000). The CASSS is a 60-item scale that assesses perceived social support from five sources: parents, teachers, classmates, close friend, and school. These five sources comprise five separate subscales, with each containing 12 items. Participants respond to each item on two aspects: frequency and importance. For example, adolescents would rate the item “My parent(s) help me make decisions” on both how often it occurs and how important it is to them. Frequency ratings use a 6-point Likert scale from 1 (Never) to 6 (Always). Importance ratings use a 3-point Likert scale that ranges from 1 (Not Important) to 3 (Very Important). Subscale scores are calculated by summing the frequency ratings for each subscale; a total score can be calculated by summing the frequency ratings for all 60 items. For the current study, the frequency scores from the classmates subscale were used as the indicator of perceived peer support. This subscale was chosen to represent peer support rather than the close friend subscale because participants rated perceived support from more than one peer as opposed to only one close friend. This allowed the participant to report on more generalized perceived support from same-age peers and reduced the possibility that an adolescent might rate perceived support from a “close friend” who may or may not reciprocate that label to the participant. Frequency scores from the parent subscale were used as the indicator of perceived family support. The CASSS has been found to have good reliability and validity. Malecki and Demaray (2002) reported that the internal consistency reliability for the CASSS was 0.97 for the Total Frequency scale. Test-retest reliability coefficients were 0.78 for the Total Frequency scale after an 8-week interval. Construct and convergent validity has also been well established. In the current study, reliability was 0.93 for both parent and classmate subscales.
Results Before testing the moderation hypotheses, two MANOVAs were conducted to test for potential differences in the study variables by grade and race, given the variability in age of participants and the racial diversity of the sample. To reduce Type I error due to multiple comparisons, a Bonferroni correction was employed with an adjusted significance level (p < 0.007). The first MANOVA included grade as the independent variable and depression, suicidal ideation, body satisfaction, disordered eating, peer support, family support, and selfesteem as the dependent variables. No significant differences were found for any of the dependent variables, indicating that grade level did not contribute to differences in scores. The second MANOVA included all of the same dependent variables listed above, but included race as the independent variable; the “other” category was not included as its n size was too small to calculate differences (n =3). Significant differences were found for suicidal ideation, F(4, 336)=4.91, p < 0.001, body satisfaction, F(4, 376)=4.88, p
