The relationship between parental marital status and suicidal ideation and attempts by gender in adolescents: Results from a nationally representative Korean sample Kounseok Lee, Kee Namkoong, Won-Jung Choi, Jin Young Park PII: DOI: Reference:
S0010-440X(14)00065-0 doi: 10.1016/j.comppsych.2014.03.010 YCOMP 51267
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
24 June 2013 21 March 2014 21 March 2014
Please cite this article as: Lee Kounseok, Namkoong Kee, Choi Won-Jung, Park Jin Young, The relationship between parental marital status and suicidal ideation and attempts by gender in adolescents: Results from a nationally representative Korean sample, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.03.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The relationship between parental marital status and suicidal ideation
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and attempts by gender in adolescents: Results from a nationally
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representative Korean sample
Kounseok Lee 1, Kee Namkoong 2, 3, Won-Jung Choi3, 4, and Jin Young Park 3, 5,* 1
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Department of Psychiatry, Samsung Medical Center, Sungkyungkwan University School of Medicine, Republic of
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Korea 2
Department of Psychiatry, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
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Institute of Behavioral Science in Medicine, Yonsei University, College of Medicine, Seoul, Republic of Korea
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Department of Psychiatry, National Health Insurance Service, Ilsan Hospital, Goyang, Republic of Korea
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Korea
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Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of
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Corresponding author: Jin Young Park, M.D., Ph.D.
Department of Psychiatry, Yonsei University, College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea Tel.: 82-2-2019-3341, Fax: 82-2-3462-4304, Email: [email protected] Abbreviated title: Parental status and suicidal behaviors in Korean adolescents 1
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Abstract
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Objective: Suicide in adolescents is a major problem worldwide. The purpose of this study was
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to identify differences in suicidal behaviors with respect to parental marital status.
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Methods: The data used in this study were obtained from the Korea Youth Risk Behavior Webbased Survey (KYRBWS) of middle and high school students in 2010. Using a national
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representative sample, this study analyzed data from 73,238 subjects. With respect to gender,
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the odds ratios of suicidal behavior were calculated based on the parental marital status, living situation, and family affluence scale (FAS).
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Results: After adjusting for age, achievement, sadness, and substance use, the prevalence of
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suicidal ideation in adolescents with a remarried parent significantly increased among boys to
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1.364 [95% confidence interval (CI)=1.027–1.813] and among girls to 1.511 (95% CI=1.215– 1.879). The odds ratio of suicide attempts increased to 1.808 (95% CI=1.119–2.923) for
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adolescent boys and to 1.947 (95% CI=1.609–2.356) for adolescent girls. However, having a single parent did not affect the prevalence of suicidal ideation in either gender. In girls, as family affluence decreased, the odds ratio of suicidal ideation notably increased. For girls whose families were in a low tier of the FAS, the odds ratio of both suicidal ideation and suicide attempts increased. Conclusions: Both boys and girls were more likely to report suicidal ideation and attempts after a parent’s remarriage, whereas family affluence was inversely related to suicidal ideation and attempts in girls. 2
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Keywords: suicide, adolescent, family structure, family affluence
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Introduction
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In South Korea, one person commits suicide every 34 minutes. The rate of suicide in
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Korea is ranked second in the world and first among countries in the Organization for Economic
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Co-operation and Development [1]. The suicide rate in adolescents was 3.5 suicides per 100,000 adolescents in 2006 but rapidly increased to 5.2 suicides per 100,000 in 2010. In the past,
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suicide was the second leading cause of death after motor vehicle accidents, but it recently
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became the highest cause of death and, as a consequence, developed into a major social issue among adolescents [2].
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The family unit is one of the most important factors contributing to the mental well-
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being of adolescents. Adolescents who have a dysfunctional family structure or who do not receive emotional support from their families are more likely to experience social
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maladjustment (e.g., problems at school, conflicts in relationships, and delinquent behaviors)
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and self-destructive behaviors, such as suicide [3]. Furthermore, adolescents in one-parent or step-parent families are more likely to exhibit depressed moods, have more suicidal thoughts, and attempt suicide more often than their peers [4]. Both socioeconomic status (SES) and family structure affect deviant behaviors in adolescents [5]. An adolescent’s family structure even influences his or her academic performance [6]. For example, having a single mother or no parents adversely influences the academic performance of adolescents [7]. Furthermore, family dysfunction influences emotional difficulties, such as depression, and therefore has an indirect effect on behaviors such as suicide [8]. Other factors, such as experiencing the death of a
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parent, also increase the risk of suicide in adolescents [9], and a family’s SES has been found to
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affect adolescent suicidal ideation and attempts [10].
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Adolescence is a period during which gender differences caused by secondary sexual
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characteristics are evident [11]. It has been found that whereas the greatest cause of death in all Korean adolescents is suicide, among boys, suicide is the second leading cause of death [2].
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Furthermore, it has been found that early onset of puberty is a risk factor among girls, because
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it influences future suicide attempts [12]. The impact of the parents’ marital status on suicidal behavior differs between teenage boys and girls [13]. Gender-specific effects of parental
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divorce on their children's suicidal ideation appear to differ, and gender-specific analyses have revealed conflicting results [14-17]. Such differences might be explained by childhood stressors,
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adverse childhood experiences, etc. [17], but the conclusions are not yet clear.
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Accordingly, it is crucial to identify risk factors for adolescent suicide. Existing studies
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have revealed that family structure has a significant influence on adolescent suicidal behavior, but most of these studies used small samples of adolescents [13, 18, 19]. It is also necessary to specify the previous definition of family structure into possible subcategories, such as parental marital status, the existence of siblings, and the existence of living grandparents, to achieve a more detailed and accurate analysis. To increase objectivity, the SES index, which is often used when comparing adolescents of different nations, was used as a more objective measure than self-reporting.
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Therefore, this study examined the effects of family relationships and SES on adolescent
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suicidal behaviors after adjusting for major factors of suicide, such as depression (sadness) and
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substance use (especially alcohol use) by gender.
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Methods
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Study subjects This study used data from the 2010 Korea Youth Risk Behavior Web-based Survey
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(KYRBWS) that was conducted by the Korea Centers for Disease Control and Prevention (KCDC). The KYRBWS was approved by Statistics Korea (approval No. 11758) and has been conducted
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annually as an anonymous, online, self-reporting survey. The survey consisted of 128 questions
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assessing demographic characteristics and 14 areas of health-related behaviors, including cigarette smoking, alcohol drinking, obesity, physical activity, eating habits, injury prevention,
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sexual behaviors, mental health, oral health, allergic disorders, personal hygiene, internet
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addiction, drug abuse, and health equity.
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The survey’s target population was students in grades 7 through 12 in South Korea. From each grade level, one sample class was chosen, and all students from the six sample
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classes from each school were chosen as sample students. During the survey, participants were assigned identification (ID) numbers and guaranteed anonymity. A total of 73,238 out of 74,980 students completed the survey for a 97.7% participation rate. The test-retest reliability of the KYRBWS questionnaire has been reported to be stable [20]. As this study used public data from an anonymous KCDC sample pool, it did not require approval from any institutional review board.
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Variable measurements
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Suicidal behaviors Answering “Yes” to the sadness question “In the last 12 months, feelings of sadness or
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despair have interrupted my daily activities for at least two weeks” was considered a sign of depression. Answering “Yes” to the question “In the last 12 months, have you seriously
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considered suicide?” indicated suicidal ideation. In addition, answering “Yes” to the question
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“In the last 12 months, have you attempted suicide?” indicated suicidal attempt(s).
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Family factors
Family structure was based on answers to questions regarding the existence of family
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members (father, stepfather, mother, and stepmother). Having both a father and a mother was
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categorized as having both parents, and having either a father or a mother was categorized as only having one parent. Having a father and a stepmother, or a mother and a stepfather, was
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categorized as having step-parents. The category about siblings was separated into questions about having either older siblings or younger siblings. Having either a grandfather or a grandmother was categorized as having a grandparent. To measure the material wealth of a family, the Family Affluence Scale II (FAS-2) was used. Scores from each item were added, and total scores ranged from 0 to 9. A low FAS (score=0–2) indicated low affluence, a medium FAS (score=3–5) indicated middle affluence, and a high FAS (score=6–9) indicated high affluence.
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Statistical analysis A χ2 test was used to evaluate the baseline characteristics of the target sample. To
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examine the relationships among variables that affect suicide and suicide attempts, a logistic regression was used. The association between suicidal behavior and family factors appears to
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vary by gender. In model 1, the dependent variable was either suicidal ideation or attempted
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suicide. Analyses regarding the relationship between suicidal behavior and independent factors, including the FAS, family factors (e.g., family structure, siblings, grandparents, and live with
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family), academic achievement, and age were performed separately for each gender. In model
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2, the presence of sadness and substance use were included as five additional independent variables. Before performing this analysis, multicollinearity among the independent variables
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was examined and did not suggest any presence of multicollinearity. We tested whether
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associations existed by adding sadness × family structure, sadness × FAS, substance abuse × family structure, and substance abuse × FAS interaction terms into the multivariate logistic regression models. As no significant associations were seen, these variables were excluded from the independent variables. PASW statistics 18.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis, and the level of significance was set at 0.05. To control for multiple comparisons, a Bonferroni-corrected alpha was adopted for family factors (0.05/5=0.01).
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Results
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Basic characteristics of study participants Data from a total of 73,238 participants were used in the analysis of 38,391 teenage
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boys and 34,847 teenage girls. There were significant differences by gender in terms of FAS, family structure, academic achievement, sadness, suicidal thoughts, and suicide attempts
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(Table 1).
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Prevalence rates of suicidal ideation and suicide attempts
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Suicidal ideation
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A significant disparity was found in the suicide prevalence rates of both genders with respect to family affluence. This disparity was especially relevant for girls, as they reported
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more suicide incidents as family affluence decreased. Examination of the suicide prevalence rates with respect to family structure indicated that having a single father, compared to having a single mother, significantly increased suicidal behaviors in both genders, and female students with step-parents had considerably more suicide ideation than those with a single parent or with no parent (Table 2). Suicide attempts
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In girls, suicide attempts varied with age, whereas in boys, a significant difference was
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found in family affluence between the high and low groups. Both boys and girls showed
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differences in suicide attempts with respect to family structure. The prevalence of suicide attempts was greatest when boys had a father or a mother with a new spouse, and when girls
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had only a father. Having a sibling or grandparent did not reveal a statistically significant
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difference for either gender. Boys had a significantly lower rate of suicide attempts when they
high suicide attempt rates (Table 2).
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Odds ratio: Suicidal ideation
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lived with their families. Both genders in the substance abuse and sadness groups exhibited
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The odds ratios were high for certain family structures, such as father only and father or mother with a new spouse. However, when sadness and substance use were adjusted, having a
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father or a mother with a new spouse drastically increased suicide ideation in boys to 1.364 (95%
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CI=1.027–1.813) and in girls to 1.511 (95% CI=1.215–1.879). The odds ratio with respect to the existence of siblings or grandparents increased in both genders when factors were unadjusted, but when sadness and substance use were adjusted, the two variables did not have any meaningful effect on suicidal ideation in either gender. While family affluence had no influence on suicidal ideation in boys for all SES groups, in girls, the odds ratio of the low FAS tier increased to 1.217 (95% CI=1.102–1.344), which indicated that as SES decreased, the likelihood of suicidal ideation increased (Table 3). Odds ratio: Suicide attempts 11
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When boys had a step-parent, the odds ratio showed an increase in suicide attempts to
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1.808 (95% CI=1.119–2.923), whereas family affluence for the middle FAS group increased
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attempts to 0.801 (95% CI=0.688–0.932), demonstrating a notably lower odds ratio.
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In girls, the odds ratio of suicide attempts increased to 1.363 (95% CI=1.133–1.639) when they had only a father; when they had a step-parent, the odds ratio increased to 1.947
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(95% CI=1.609–2.356). The odds ratio of suicide attempts significantly increased in the
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following cases: having no older sibling (1.079; 95% CI=1.012–1.150), having no younger sibling (1.077; 95% CI=1.010–1.149), and having no grandparent (1.073; 95% CI=1.014–1.134). The
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odds ratio for the low FAS tier increased to 1.231 (95% CI=1.128–1.344) (Table 4).
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Discussion
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This study intended to examine the gender effects of family relationships and SES on
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adolescent suicide-related behaviors.
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We found that reported suicide attempts among adolescent boys and reported suicidal ideation among adolescent girls were more likely to be classified as a reconstituted family, and
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suicidal attempts in girls was associated with a low SES. The strengths of this study are that its
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data were collected from many more students than found in existing studies, and it carefully examined the effects of family members, such as siblings and grandparents, rather than just
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focusing on the effects of parents.
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Based on the results of previous studies, children with a single father were predicted to
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experience less emotional bonding and have problematic emotional and behavioral issues [7, 11]. Consequently, one may expect that suicidal ideation may also increase in such a situation.
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After adjusting for risk factors, having a single father was not found to have any effect on adolescent suicide attempts in boys. This finding is consistent with empirical findings from a post-mortem study of suicide deaths of those under the age of 20 years, which found that parental separation or divorce does not affect adolescent suicide rates [21]. However, another study showed that the number of suicide attempts doubled in single-parent families [22]. Two previous studies have limitations that were not studied separately by gender. According to the results of the present study, the odds ratio of suicide attempts increased when an adolescent’s parents remarried, increasing for boys to 1.808 (95% CI=1.119– 13
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2.923) and for girls to 1.947 (95% CI=1.609–2.356). This finding is consistent with previous
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research findings that girls, unlike boys, are more likely to attempt suicide when their parents
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remarry or when they live with a single parent [4].
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In this study, girls who attempted suicide were more likely to live with a single father (1.363 [95% CI=1.133–1.639]). A previous study that analyzed family structure, mother-child
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communication, father-child communication, and adolescent life satisfaction, reported that
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emotional bonding with a mother is especially crucial for girls, whereas not living with both parents had an effect on life satisfaction in boys [11]. Furthermore, a study on the relationships
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between family functioning and adolescent suicidal ideation and suicide attempts revealed that the suicide group experienced more distress and greater family dysfunction [23]. This finding
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supports the conclusion that the rate of suicide attempts considerably increases in girls living
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with a single father. Moreover, a survey conducted with 2,707 students in Belgium discovered that boys from a single-parent family exhibited more suicidal ideations and self-harming
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behaviors. The same study also reported that girls from a remarried family demonstrated more suicidal ideations and self-harming behaviors [13]. This Belgian study, however, only examined participants with a deceased parent, whereas the present study did not distinguish between a single parent resulting from divorce or from death. Thus, there are many limitations to comparing the results of this study with those of the Belgian study. Nevertheless, this study’s finding that girls with a single father have a significantly higher odds ratio of suicide attempts confirms that the absence of a mother, rather than parental divorce or death, is an influential factor. 14
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In addition, this study revealed that parental remarriage significantly increases suicidal
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ideation and suicide attempts, which is consistent with the existing empirical finding that a
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parent’s remarriage has a more dramatic effect on an adolescent’s distress and depression than a parent’s separation or divorce [24]. The stability of family relationships lowered feelings of
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depression [18]. This observation may be attributed to the fact that presence of a new family
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member causes changes in the quality of the relationship with the biological parent, and these changes consequently affect the quality of the relationship with the original parent. A previous
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study on adolescents who attempted suicide argued that family cohesion is a crucial treatment target [25]. A parent’s remarriage can manifest as a bigger life event than either divorce or
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death of a parent in the parent-child relationship, and may have a more significant impact on
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an adolescent’s suicidal behavior. The surviving parent may substitute for the lost parent, but in
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the case of remarriage, a parent has changed his or her interest in or affection toward his or her new partner, thus providing less emotional support to the child.
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The current study also examined the effects of having siblings and grandparents, a factor that distinguishes this study from previous studies that only assessed parental influences [21, 22]. It was found that for boys, the existence of family members other than parents did not have an effect on suicidal behaviors. For girls, however, not having a sibling or a grandparent slightly increased the risk for attempted suicide. Empirical findings of a previous study found that social isolation increased suicidal thoughts in girls [26]. Having more family members reduces that sense of isolation, whereas having fewer family members results in less social support, ultimately leading to a heightened feeling of isolation. Therefore, social relationships 15
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with other family members other than just parents are thought to play a role in decreasing the
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rate of suicide among girls.
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Living with family did not have a significant impact on either gender’s suicide-related
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behaviors, although it did appear to have relevance when sadness and substance use were not adjusted.
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The next point of discussion is the relationship between SES and suicide-related
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behaviors. The results of this study showed that when family affluence decreased, the odds ratio of suicidal ideation in girls substantially increased. However, the FAS score did not have an
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effect on suicidal ideation. Girls are more influenced by their family’s SES than are boys. This is
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consistent with a research finding that a family’s economic stress impacts adolescent girls’ social adjustment [27]. In the current study, similar results were observed even after controlling
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for stressors such as sadness and academic achievement. In contrast, socioeconomic factors do
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not affect suicide-related behaviors in boys, which may be because there are other morepertinent factors that influence emotional problems in adolescent boys. However, the absence of a mother, SES, and parent remarriage all have effects on suicide-related behaviors in adolescent girls. During the investigations of suicides of adolescent girls, it is necessary to place an emphasis on attachment and intimacy. Finally, one of the limitations of this study is that the quality of relationships was not measured in assessments of parent-child relationships. It has been reported that the frequency of feelings of depression and suicidal thoughts decreases as the relationship with a parent 16
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stabilizes [18]. However, we posit that this study overcame this limitation, to some extent, by
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controlling for sadness.
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Another limitation of this study is that it did not consider racial differences, because it
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targeted a specific country and race. Korean society has experienced a drastic increase in divorce recently. Although based on insufficient sample sizes, there have been empirical
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findings that demonstrate racial differences in the effects of income and family structure on
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adolescent risk behaviors [28]. Hence, a larger research design is needed to compare various racial groups.
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Despite these limitations, this research has targeted many more adolescent participants
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than did previous studies. In addition, the strength of this study is that the analysis was based on national representative data of students in South Korea. Not only did it consider parental
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factors, but it also considered both gender differences and the roles that siblings and
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grandparents may play in adolescent suicide behaviors.
Conclusion The study revealed that parent remarriage increases suicidal behaviors in both adolescent boys and girls. Furthermore, family affluence was found to be of greater importance for adolescent girls than for boys. These distinctive findings will hopefully serve as a foundation for decreasing suicidal behaviors in adolescents.
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Conflict of interest
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The authors declare that they have no conflicts of interest.
Acknowledgments
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This work was supported by grants from the Korean Association for Suicide Prevention (7-2012-
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0110).
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%
Girls n=34,847
%
Total N=73,238
%
22,188 15,824
58.4 41.6
19,856 14,755
57.4 42.6
42,044 30,579
57.9 42.1
13,313 20,426 4,652
34.7 53.2 12.1
11,480 19,074 4,293
32.9 54.7 12.3
24,793 39,500 8,945
33.9 53.9 12.2
30,461 857 826 369
91.9 2.6 2.5 1.1
29,777 573 760 468
93.3 1.8 2.4 1.5
60,238 1,430 1,586 837
92.6 2.2 2.4 1.3
17,758 19,035 12,345 33,183
51.0 54.6 35.4 95.2
38,531 35,414 26,275 69,342
52.6 48.4
11,975 9,457 13,415 15,007 8,156 2,225 6,515
34.4 27.1 38.5 43.1 23.4 6.4 18.7
25,951 19,651 27,636 27,373 14,011 3,616 15,555
35.4 26.8 37.7 37.4 19.1 4.9 21.2
54.1 42.7 36.3 94.2
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20,773 16,379 13,930 36,159
36.4 26.6 37.0 32.2 15.3 3.6 23.5
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Analyses performed using χ2 tests.
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13,976 10,194 14,221 12,366 5,855 1,391 9,040
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Boys n=38,391
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Variables Age (years) 12–15 16–18 Family affluence scale High (6~9) Middle (3~5) Low (0~2) Family structure Both biological parents Father only Mother only Father or mother with new spouse Sibling(s) Older sibling Younger sibling Grandparents Live with family (yes) Academic achievement High Middle Low Sadness Suicidal ideation (yes) Suicidal attempt (yes) Substance use (yes)
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Table 1. Baseline characteristics of the subjects p 0.006
S0010-440X(14)00065-0 doi: 10.1016/j.comppsych.2014.03.010 YCOMP 51267
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
24 June 2013 21 March 2014 21 March 2014
Please cite this article as: Lee Kounseok, Namkoong Kee, Choi Won-Jung, Park Jin Young, The relationship between parental marital status and suicidal ideation and attempts by gender in adolescents: Results from a nationally representative Korean sample, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.03.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The relationship between parental marital status and suicidal ideation
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and attempts by gender in adolescents: Results from a nationally
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representative Korean sample
Kounseok Lee 1, Kee Namkoong 2, 3, Won-Jung Choi3, 4, and Jin Young Park 3, 5,* 1
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Department of Psychiatry, Samsung Medical Center, Sungkyungkwan University School of Medicine, Republic of
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Korea 2
Department of Psychiatry, Yonsei University College of Medicine, Severance Hospital, Seoul, Republic of Korea
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Institute of Behavioral Science in Medicine, Yonsei University, College of Medicine, Seoul, Republic of Korea
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Department of Psychiatry, National Health Insurance Service, Ilsan Hospital, Goyang, Republic of Korea
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Korea
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Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of
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Corresponding author: Jin Young Park, M.D., Ph.D.
Department of Psychiatry, Yonsei University, College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea Tel.: 82-2-2019-3341, Fax: 82-2-3462-4304, Email: [email protected] Abbreviated title: Parental status and suicidal behaviors in Korean adolescents 1
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Abstract
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Objective: Suicide in adolescents is a major problem worldwide. The purpose of this study was
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to identify differences in suicidal behaviors with respect to parental marital status.
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Methods: The data used in this study were obtained from the Korea Youth Risk Behavior Webbased Survey (KYRBWS) of middle and high school students in 2010. Using a national
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representative sample, this study analyzed data from 73,238 subjects. With respect to gender,
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the odds ratios of suicidal behavior were calculated based on the parental marital status, living situation, and family affluence scale (FAS).
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Results: After adjusting for age, achievement, sadness, and substance use, the prevalence of
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suicidal ideation in adolescents with a remarried parent significantly increased among boys to
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1.364 [95% confidence interval (CI)=1.027–1.813] and among girls to 1.511 (95% CI=1.215– 1.879). The odds ratio of suicide attempts increased to 1.808 (95% CI=1.119–2.923) for
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adolescent boys and to 1.947 (95% CI=1.609–2.356) for adolescent girls. However, having a single parent did not affect the prevalence of suicidal ideation in either gender. In girls, as family affluence decreased, the odds ratio of suicidal ideation notably increased. For girls whose families were in a low tier of the FAS, the odds ratio of both suicidal ideation and suicide attempts increased. Conclusions: Both boys and girls were more likely to report suicidal ideation and attempts after a parent’s remarriage, whereas family affluence was inversely related to suicidal ideation and attempts in girls. 2
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Keywords: suicide, adolescent, family structure, family affluence
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Introduction
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In South Korea, one person commits suicide every 34 minutes. The rate of suicide in
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Korea is ranked second in the world and first among countries in the Organization for Economic
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Co-operation and Development [1]. The suicide rate in adolescents was 3.5 suicides per 100,000 adolescents in 2006 but rapidly increased to 5.2 suicides per 100,000 in 2010. In the past,
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suicide was the second leading cause of death after motor vehicle accidents, but it recently
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became the highest cause of death and, as a consequence, developed into a major social issue among adolescents [2].
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The family unit is one of the most important factors contributing to the mental well-
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being of adolescents. Adolescents who have a dysfunctional family structure or who do not receive emotional support from their families are more likely to experience social
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maladjustment (e.g., problems at school, conflicts in relationships, and delinquent behaviors)
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and self-destructive behaviors, such as suicide [3]. Furthermore, adolescents in one-parent or step-parent families are more likely to exhibit depressed moods, have more suicidal thoughts, and attempt suicide more often than their peers [4]. Both socioeconomic status (SES) and family structure affect deviant behaviors in adolescents [5]. An adolescent’s family structure even influences his or her academic performance [6]. For example, having a single mother or no parents adversely influences the academic performance of adolescents [7]. Furthermore, family dysfunction influences emotional difficulties, such as depression, and therefore has an indirect effect on behaviors such as suicide [8]. Other factors, such as experiencing the death of a
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parent, also increase the risk of suicide in adolescents [9], and a family’s SES has been found to
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affect adolescent suicidal ideation and attempts [10].
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Adolescence is a period during which gender differences caused by secondary sexual
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characteristics are evident [11]. It has been found that whereas the greatest cause of death in all Korean adolescents is suicide, among boys, suicide is the second leading cause of death [2].
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Furthermore, it has been found that early onset of puberty is a risk factor among girls, because
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it influences future suicide attempts [12]. The impact of the parents’ marital status on suicidal behavior differs between teenage boys and girls [13]. Gender-specific effects of parental
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divorce on their children's suicidal ideation appear to differ, and gender-specific analyses have revealed conflicting results [14-17]. Such differences might be explained by childhood stressors,
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adverse childhood experiences, etc. [17], but the conclusions are not yet clear.
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Accordingly, it is crucial to identify risk factors for adolescent suicide. Existing studies
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have revealed that family structure has a significant influence on adolescent suicidal behavior, but most of these studies used small samples of adolescents [13, 18, 19]. It is also necessary to specify the previous definition of family structure into possible subcategories, such as parental marital status, the existence of siblings, and the existence of living grandparents, to achieve a more detailed and accurate analysis. To increase objectivity, the SES index, which is often used when comparing adolescents of different nations, was used as a more objective measure than self-reporting.
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Therefore, this study examined the effects of family relationships and SES on adolescent
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suicidal behaviors after adjusting for major factors of suicide, such as depression (sadness) and
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substance use (especially alcohol use) by gender.
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Methods
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Study subjects This study used data from the 2010 Korea Youth Risk Behavior Web-based Survey
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(KYRBWS) that was conducted by the Korea Centers for Disease Control and Prevention (KCDC). The KYRBWS was approved by Statistics Korea (approval No. 11758) and has been conducted
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annually as an anonymous, online, self-reporting survey. The survey consisted of 128 questions
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assessing demographic characteristics and 14 areas of health-related behaviors, including cigarette smoking, alcohol drinking, obesity, physical activity, eating habits, injury prevention,
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sexual behaviors, mental health, oral health, allergic disorders, personal hygiene, internet
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addiction, drug abuse, and health equity.
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The survey’s target population was students in grades 7 through 12 in South Korea. From each grade level, one sample class was chosen, and all students from the six sample
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classes from each school were chosen as sample students. During the survey, participants were assigned identification (ID) numbers and guaranteed anonymity. A total of 73,238 out of 74,980 students completed the survey for a 97.7% participation rate. The test-retest reliability of the KYRBWS questionnaire has been reported to be stable [20]. As this study used public data from an anonymous KCDC sample pool, it did not require approval from any institutional review board.
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Variable measurements
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Suicidal behaviors Answering “Yes” to the sadness question “In the last 12 months, feelings of sadness or
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despair have interrupted my daily activities for at least two weeks” was considered a sign of depression. Answering “Yes” to the question “In the last 12 months, have you seriously
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considered suicide?” indicated suicidal ideation. In addition, answering “Yes” to the question
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“In the last 12 months, have you attempted suicide?” indicated suicidal attempt(s).
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Family factors
Family structure was based on answers to questions regarding the existence of family
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members (father, stepfather, mother, and stepmother). Having both a father and a mother was
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categorized as having both parents, and having either a father or a mother was categorized as only having one parent. Having a father and a stepmother, or a mother and a stepfather, was
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categorized as having step-parents. The category about siblings was separated into questions about having either older siblings or younger siblings. Having either a grandfather or a grandmother was categorized as having a grandparent. To measure the material wealth of a family, the Family Affluence Scale II (FAS-2) was used. Scores from each item were added, and total scores ranged from 0 to 9. A low FAS (score=0–2) indicated low affluence, a medium FAS (score=3–5) indicated middle affluence, and a high FAS (score=6–9) indicated high affluence.
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Statistical analysis A χ2 test was used to evaluate the baseline characteristics of the target sample. To
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examine the relationships among variables that affect suicide and suicide attempts, a logistic regression was used. The association between suicidal behavior and family factors appears to
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vary by gender. In model 1, the dependent variable was either suicidal ideation or attempted
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suicide. Analyses regarding the relationship between suicidal behavior and independent factors, including the FAS, family factors (e.g., family structure, siblings, grandparents, and live with
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family), academic achievement, and age were performed separately for each gender. In model
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2, the presence of sadness and substance use were included as five additional independent variables. Before performing this analysis, multicollinearity among the independent variables
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was examined and did not suggest any presence of multicollinearity. We tested whether
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associations existed by adding sadness × family structure, sadness × FAS, substance abuse × family structure, and substance abuse × FAS interaction terms into the multivariate logistic regression models. As no significant associations were seen, these variables were excluded from the independent variables. PASW statistics 18.0 (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis, and the level of significance was set at 0.05. To control for multiple comparisons, a Bonferroni-corrected alpha was adopted for family factors (0.05/5=0.01).
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Results
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Basic characteristics of study participants Data from a total of 73,238 participants were used in the analysis of 38,391 teenage
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boys and 34,847 teenage girls. There were significant differences by gender in terms of FAS, family structure, academic achievement, sadness, suicidal thoughts, and suicide attempts
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(Table 1).
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Prevalence rates of suicidal ideation and suicide attempts
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Suicidal ideation
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A significant disparity was found in the suicide prevalence rates of both genders with respect to family affluence. This disparity was especially relevant for girls, as they reported
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more suicide incidents as family affluence decreased. Examination of the suicide prevalence rates with respect to family structure indicated that having a single father, compared to having a single mother, significantly increased suicidal behaviors in both genders, and female students with step-parents had considerably more suicide ideation than those with a single parent or with no parent (Table 2). Suicide attempts
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In girls, suicide attempts varied with age, whereas in boys, a significant difference was
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found in family affluence between the high and low groups. Both boys and girls showed
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differences in suicide attempts with respect to family structure. The prevalence of suicide attempts was greatest when boys had a father or a mother with a new spouse, and when girls
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had only a father. Having a sibling or grandparent did not reveal a statistically significant
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difference for either gender. Boys had a significantly lower rate of suicide attempts when they
high suicide attempt rates (Table 2).
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Odds ratio: Suicidal ideation
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lived with their families. Both genders in the substance abuse and sadness groups exhibited
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The odds ratios were high for certain family structures, such as father only and father or mother with a new spouse. However, when sadness and substance use were adjusted, having a
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father or a mother with a new spouse drastically increased suicide ideation in boys to 1.364 (95%
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CI=1.027–1.813) and in girls to 1.511 (95% CI=1.215–1.879). The odds ratio with respect to the existence of siblings or grandparents increased in both genders when factors were unadjusted, but when sadness and substance use were adjusted, the two variables did not have any meaningful effect on suicidal ideation in either gender. While family affluence had no influence on suicidal ideation in boys for all SES groups, in girls, the odds ratio of the low FAS tier increased to 1.217 (95% CI=1.102–1.344), which indicated that as SES decreased, the likelihood of suicidal ideation increased (Table 3). Odds ratio: Suicide attempts 11
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When boys had a step-parent, the odds ratio showed an increase in suicide attempts to
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1.808 (95% CI=1.119–2.923), whereas family affluence for the middle FAS group increased
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attempts to 0.801 (95% CI=0.688–0.932), demonstrating a notably lower odds ratio.
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In girls, the odds ratio of suicide attempts increased to 1.363 (95% CI=1.133–1.639) when they had only a father; when they had a step-parent, the odds ratio increased to 1.947
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(95% CI=1.609–2.356). The odds ratio of suicide attempts significantly increased in the
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following cases: having no older sibling (1.079; 95% CI=1.012–1.150), having no younger sibling (1.077; 95% CI=1.010–1.149), and having no grandparent (1.073; 95% CI=1.014–1.134). The
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odds ratio for the low FAS tier increased to 1.231 (95% CI=1.128–1.344) (Table 4).
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Discussion
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This study intended to examine the gender effects of family relationships and SES on
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adolescent suicide-related behaviors.
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We found that reported suicide attempts among adolescent boys and reported suicidal ideation among adolescent girls were more likely to be classified as a reconstituted family, and
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suicidal attempts in girls was associated with a low SES. The strengths of this study are that its
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data were collected from many more students than found in existing studies, and it carefully examined the effects of family members, such as siblings and grandparents, rather than just
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focusing on the effects of parents.
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Based on the results of previous studies, children with a single father were predicted to
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experience less emotional bonding and have problematic emotional and behavioral issues [7, 11]. Consequently, one may expect that suicidal ideation may also increase in such a situation.
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After adjusting for risk factors, having a single father was not found to have any effect on adolescent suicide attempts in boys. This finding is consistent with empirical findings from a post-mortem study of suicide deaths of those under the age of 20 years, which found that parental separation or divorce does not affect adolescent suicide rates [21]. However, another study showed that the number of suicide attempts doubled in single-parent families [22]. Two previous studies have limitations that were not studied separately by gender. According to the results of the present study, the odds ratio of suicide attempts increased when an adolescent’s parents remarried, increasing for boys to 1.808 (95% CI=1.119– 13
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2.923) and for girls to 1.947 (95% CI=1.609–2.356). This finding is consistent with previous
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research findings that girls, unlike boys, are more likely to attempt suicide when their parents
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remarry or when they live with a single parent [4].
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In this study, girls who attempted suicide were more likely to live with a single father (1.363 [95% CI=1.133–1.639]). A previous study that analyzed family structure, mother-child
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communication, father-child communication, and adolescent life satisfaction, reported that
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emotional bonding with a mother is especially crucial for girls, whereas not living with both parents had an effect on life satisfaction in boys [11]. Furthermore, a study on the relationships
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between family functioning and adolescent suicidal ideation and suicide attempts revealed that the suicide group experienced more distress and greater family dysfunction [23]. This finding
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supports the conclusion that the rate of suicide attempts considerably increases in girls living
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with a single father. Moreover, a survey conducted with 2,707 students in Belgium discovered that boys from a single-parent family exhibited more suicidal ideations and self-harming
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behaviors. The same study also reported that girls from a remarried family demonstrated more suicidal ideations and self-harming behaviors [13]. This Belgian study, however, only examined participants with a deceased parent, whereas the present study did not distinguish between a single parent resulting from divorce or from death. Thus, there are many limitations to comparing the results of this study with those of the Belgian study. Nevertheless, this study’s finding that girls with a single father have a significantly higher odds ratio of suicide attempts confirms that the absence of a mother, rather than parental divorce or death, is an influential factor. 14
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In addition, this study revealed that parental remarriage significantly increases suicidal
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ideation and suicide attempts, which is consistent with the existing empirical finding that a
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parent’s remarriage has a more dramatic effect on an adolescent’s distress and depression than a parent’s separation or divorce [24]. The stability of family relationships lowered feelings of
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depression [18]. This observation may be attributed to the fact that presence of a new family
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member causes changes in the quality of the relationship with the biological parent, and these changes consequently affect the quality of the relationship with the original parent. A previous
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study on adolescents who attempted suicide argued that family cohesion is a crucial treatment target [25]. A parent’s remarriage can manifest as a bigger life event than either divorce or
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death of a parent in the parent-child relationship, and may have a more significant impact on
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an adolescent’s suicidal behavior. The surviving parent may substitute for the lost parent, but in
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the case of remarriage, a parent has changed his or her interest in or affection toward his or her new partner, thus providing less emotional support to the child.
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The current study also examined the effects of having siblings and grandparents, a factor that distinguishes this study from previous studies that only assessed parental influences [21, 22]. It was found that for boys, the existence of family members other than parents did not have an effect on suicidal behaviors. For girls, however, not having a sibling or a grandparent slightly increased the risk for attempted suicide. Empirical findings of a previous study found that social isolation increased suicidal thoughts in girls [26]. Having more family members reduces that sense of isolation, whereas having fewer family members results in less social support, ultimately leading to a heightened feeling of isolation. Therefore, social relationships 15
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with other family members other than just parents are thought to play a role in decreasing the
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rate of suicide among girls.
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Living with family did not have a significant impact on either gender’s suicide-related
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behaviors, although it did appear to have relevance when sadness and substance use were not adjusted.
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The next point of discussion is the relationship between SES and suicide-related
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behaviors. The results of this study showed that when family affluence decreased, the odds ratio of suicidal ideation in girls substantially increased. However, the FAS score did not have an
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effect on suicidal ideation. Girls are more influenced by their family’s SES than are boys. This is
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consistent with a research finding that a family’s economic stress impacts adolescent girls’ social adjustment [27]. In the current study, similar results were observed even after controlling
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for stressors such as sadness and academic achievement. In contrast, socioeconomic factors do
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not affect suicide-related behaviors in boys, which may be because there are other morepertinent factors that influence emotional problems in adolescent boys. However, the absence of a mother, SES, and parent remarriage all have effects on suicide-related behaviors in adolescent girls. During the investigations of suicides of adolescent girls, it is necessary to place an emphasis on attachment and intimacy. Finally, one of the limitations of this study is that the quality of relationships was not measured in assessments of parent-child relationships. It has been reported that the frequency of feelings of depression and suicidal thoughts decreases as the relationship with a parent 16
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stabilizes [18]. However, we posit that this study overcame this limitation, to some extent, by
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controlling for sadness.
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Another limitation of this study is that it did not consider racial differences, because it
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targeted a specific country and race. Korean society has experienced a drastic increase in divorce recently. Although based on insufficient sample sizes, there have been empirical
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findings that demonstrate racial differences in the effects of income and family structure on
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adolescent risk behaviors [28]. Hence, a larger research design is needed to compare various racial groups.
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Despite these limitations, this research has targeted many more adolescent participants
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than did previous studies. In addition, the strength of this study is that the analysis was based on national representative data of students in South Korea. Not only did it consider parental
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factors, but it also considered both gender differences and the roles that siblings and
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grandparents may play in adolescent suicide behaviors.
Conclusion The study revealed that parent remarriage increases suicidal behaviors in both adolescent boys and girls. Furthermore, family affluence was found to be of greater importance for adolescent girls than for boys. These distinctive findings will hopefully serve as a foundation for decreasing suicidal behaviors in adolescents.
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Conflict of interest
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The authors declare that they have no conflicts of interest.
Acknowledgments
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This work was supported by grants from the Korean Association for Suicide Prevention (7-2012-
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0110).
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%
Girls n=34,847
%
Total N=73,238
%
22,188 15,824
58.4 41.6
19,856 14,755
57.4 42.6
42,044 30,579
57.9 42.1
13,313 20,426 4,652
34.7 53.2 12.1
11,480 19,074 4,293
32.9 54.7 12.3
24,793 39,500 8,945
33.9 53.9 12.2
30,461 857 826 369
91.9 2.6 2.5 1.1
29,777 573 760 468
93.3 1.8 2.4 1.5
60,238 1,430 1,586 837
92.6 2.2 2.4 1.3
17,758 19,035 12,345 33,183
51.0 54.6 35.4 95.2
38,531 35,414 26,275 69,342
52.6 48.4
11,975 9,457 13,415 15,007 8,156 2,225 6,515
34.4 27.1 38.5 43.1 23.4 6.4 18.7
25,951 19,651 27,636 27,373 14,011 3,616 15,555
35.4 26.8 37.7 37.4 19.1 4.9 21.2
54.1 42.7 36.3 94.2
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20,773 16,379 13,930 36,159
36.4 26.6 37.0 32.2 15.3 3.6 23.5
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Analyses performed using χ2 tests.
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13,976 10,194 14,221 12,366 5,855 1,391 9,040
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Boys n=38,391
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Variables Age (years) 12–15 16–18 Family affluence scale High (6~9) Middle (3~5) Low (0~2) Family structure Both biological parents Father only Mother only Father or mother with new spouse Sibling(s) Older sibling Younger sibling Grandparents Live with family (yes) Academic achievement High Middle Low Sadness Suicidal ideation (yes) Suicidal attempt (yes) Substance use (yes)
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Table 1. Baseline characteristics of the subjects p 0.006
