150225_risk and protective factors for suicidal ideation among taiwanese adolescents

Nursing Research November/December 2011 Vol 60, No 6, 413421

Risk and Protective Factors for SuicidalIdeation Among Taiwanese Adolescents

Ruey-Hsia Wang 4 Hsiao-Jung Lai 4 Hsiu-Yueh Hsu 4 Min-Tao Hsu

b Background: Suicide is the ninth leading cause of death inadolescents aged 15Y19 years in Taiwan. Suicidal ideationis an important predictor of committing suicide among

adolescents.

b Objectives: The aim of this study was to examine theimportant risk factors, the protective factors, and the role

of protective factors on the relationship of risk factors to

suicidal ideation among Taiwanese adolescents aged

15Y19 years.b Methods: By adopting a cross-sectional study, senior high

school students (n = 577) aged 15Y19 years in southernTaiwan were recruited for this study. An anonymous self-

reported questionnaire was used to collect demographic

characteristics, risk factors, protective factors, and suicidal

ideation of the sample. Hierarchical logistic regression was

used to identify the important risk and protective factors

and the interaction between risk and protective factors on

suicidal ideation.

b Results: Nearly 18% (n = 101) of the participants reportedhaving suicidal ideation during the past 12 months. Gender

(female; odds ratio [OR] = 4.23), life stress (OR = 1.03),

depression (OR = 3.44), peer suicidal ideation (OR = 4.15),

and bullying victimization (OR = 1.81) were important risk

factors of suicidal ideation among the targeted sample. In

addition, self-esteem (OR = 0.92) and emotional adapta-

tion (OR = 0.88) were important protective factors of

suicidal ideation. Self-esteem and emotional adaptation

were not used to moderate the negative effects of life

stress, depression, perceived peer suicidal ideation, and

bullying victimization on suicidal ideation. The final model

explained 40.6% of the total variance in suicidal ideation

and correctly predicted 86.1% of participants with suicidal

ideation.

b Discussion: Suicidal ideation prevention programs should betargeted to female adolescents. School-based efforts that

provide adolescents with self-esteem enhancement, emo-

tional regulation skills training, positive peer norms for life,

coping skills for managing stress and depression, and

antibullying programs might help reduce the suicidal

ideation of adolescents.

b Key Words: adolescent & protective factor & risk factor &suicidal ideation

Suicide is the third leading cause of death in adolescentsaged 15Y24 years in the United States (Centers forDisease Control and Prevention, 2011). In Taiwan, suicideis the ninth leading cause of death in adolescents aged15Y19 years (Department of Health, Executive Yuan,Taiwan, 2011). Adolescence is a special stage of humandevelopment that bridges childhood to adulthood. In thiscrucial period, adolescents experience drastic changes innot only physical body growth but also cognition, so-cial relations, and emotions that can arouse many pres-sures in such a transition stage of human life. If adaptationsare not successful in allowing adolescents to pass throughstages of development, many of them may become de-termined to commit suicide (Manor, Vincent, & Tyano,2004).

Suicidal ideation is an important predictor of commit-ting suicide; it can be an indicator for suicidal prevention(Chamberlain, Goldney, Delfabbro, Gill, & Dal Grande,2009). Suicidal ideation is defined as wishes, thoughts, or de-sires to take ones own life violently (OCarroll et al., 1996).Approximately one third of adolescents have reported hav-ing suicidal ideation at some time (Evans, Hawton, Rodham,& Deeks, 2005).

The factors that influence adolescents at risk for sui-cidal ideation are complex. Many demographic factorsare related to adolescent suicidal ideation. Cheng et al.(2009) found that female adolescents are at greater riskfor suicidal ideation than are male adolescents. In addi-tion, adolescents living in single-parent families experiencesignificantly more suicidal ideation than those from two-parent families (Bearman & Moody, 2004). Furthermore,lower socioeconomic status is associated with higher levelsof suicidal ideation in Taiwanese and American adolescents(Chan et al., 2009; Yoder & Hoyt, 2005).

Several risk factors are crucial for predicting adoles-cent suicidal ideation. Stress is a response of the human

Nursing Research November/December 2011 Vol 60, No 6 413

Ruey-Hsia Wang, PhD, RN, is Professor, College of Nursing,Kaohsiung Medical University, Kaohsiung, Taiwan.Hsiao-Jung Lai, MSN, RN, is Instructor, College of Nursing,Fooyin University, Kaohsiung, Taiwan.Hsiu-Yueh Hsu, PhD, RN, is Associate Professor, Department ofNursing, Meiho University, Pingtung, Taiwan.Min-Tao Hsu, PhD, RN, is Professor, College of Nursing,Kaohsiung Medical University, Kaohsiung, Taiwan.DOI: 10.1097/NNR.0b013e3182337d83

Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.1

body to any stimulus that disrupts theindividuals homeostasis and has beenfound to relate to emotional and psy-chological problems. Previous studieshave supported that high perceived lifestress significantly increases the risk forsuicidal ideation among Taiwanese andAmerican adolescents (Chang, Yang, Lin,Ku, & Lee, 2008; Portzky, Audenaert,& van Heeringen, 2009). Depression hasbeen identified as the most significantrisk for suicidal ideation in Eastern andWestern countries (Bearman & Moody,2004; Chan et al., 2009). More than50% of adolescents who commit suicidewere diagnosed with depression (Chiou,Chen, & Lee, 2006).

An ecological model emphasizes theinfluence of environmental context such as family and peerson adolescent risk behaviors (Bronfenbrenner & Morris,1998). Peer and parental suicidal ideation are correlated sig-nificantly to suicidal ideation among adolescents (Bearman& Moody, 2004). Peer bullying is a specific form of ag-gression that occurs commonly among adolescents, espe-cially in school settings (Smith-Khuri et al., 2004). Bullyingvictimization has been found to be associated positively withsuicidal ideation (Hinduja & Patchin, 2010).

However, not all adolescents with risk factors havesuicidal ideation. Protective factors can minimize the threatof risk factors on suicidal behaviors and play an essentialrole in preventing suicide (Benard, 2002). Self-esteem re-flects a persons overall evaluation or appraisal of his orher own worth, and it is a powerful protective factor forsuicidal ideation (Kidd & Shahar, 2008; Wilburn & Smith,2005). In addition, emotional adaptation involves effectiveresponses to stress (Greenberg, 2006) and was proven to berelated to suicidal ideation (Cha & Nock, 2009). More-over, adolescents having high levels of family communica-tion with their parents will cope successfully with lifechanges because they can turn to their families for support(Davalos, Chavez, & Guardiola, 2005). These high levelsof family communication with parents reduce the risk ofsuicidal ideation (Garcia, Skay, Sieving, Naughton, &Bearinger, 2008). Future aspirations are positive views fortheir future and can be a protective factor of suicidal ide-ation. However, previous studies have focused on how fu-ture aspirations reduce sexual risk behaviors and tobaccouse (Atkins, Oman, Vesely, Aspy, & McLeroy, 2002; Veselyet al., 2004). Not much is known about the relationshipbetween future aspirations and adolescent suicidal ideation.

Conceptually, risk factors increase the probability ofengaging in risky behaviors, whereas protective factorsdecrease the likelihood of engaging in risky behaviors. How-ever, protective factors play a different role in influencingthe relationship of risk factors to risky behaviors (Fergus &Zimmerman, 2005). The compensatory model assumes thatthe effect of protective factors is independent of the effect ofrisk factors on risky behaviors. The protective factor modelassumes that protective factors moderate the negative effectsof risk factors on risky behaviors. Previous studies foundthat protective factors are not only related directly but also

moderate the effect of risk factors onproblem behaviors in Taiwanese andAmerican adolescents (Jessor et al.,2003; Wang, Hsu, Lin, Cheng, & Lee,2010). Until now, little research hasaddressed the relationship between riskfactors and protective factors on thesuicidal ideation of Asian adolescents.

The purpose of this study was toidentify the important risk and protec-tive factors and the role of protectivefactors on the relationship of risk fac-tors on suicidal ideation of Taiwaneseadolescents aged 15Y19 years. Riskand protective factors were hypothe-sized to relate directly to suicidal ide-ation; furthermore, protective factorsmoderate the negative effects of risk

factors on suicidal ideation. The hypothesized conceptualframework is shown in Figure 1.

Methods

SampleThis study was a cross-sectional study. The sample size waspredetermined using power analysis based on the smalleffect size (, = 0.20) in a bivariate correlation situation,with the alpha level being .05 and the power being .80.Four hundred participants were determined as adequate foranalysis (Polit & Hungler, 2004). With the use of con-venience sampling, three senior high schools were selectedfrom Pingtung County and Kaohsiung City in southernTaiwan. Two classes were selected randomly from eachincluded school, and students in the selected classes wereinvited to participate in the study. Of the 653 studentsinvited to participate in this study, 577 (88.4%) providedcomplete data for the variables of interest in this study andwere included in the final analysis. Data were collectedfrom October 2006 to March 2007.

More than 50% of

adolescents who commit

suicide were diagnosed

with depression

(Chiou et al., 2006).

qqq

FIGURE 1. Hypothesized conceptual framework outlining the role ofrisk and protective factors on suicidal ideation.

414 Suicidal Ideation Factors Nursing Research November/December 2011 Vol 60, No 6


InstrumentationAn anonymous questionnaire was used to collect the fol-lowing data.

Demographic Characteristics Information on the partici-pants age, gender, socioeconomic status, and family struc-ture (living in a family with or without both parents) wascollected. Socioeconomic status was determined based onthe highest levels of education and the occupation of bothparents.

Suicidal Ideation The suicidal ideation of participantswas measured using a single item adopted from the ques-tionnaire of the Youth Risk Behavior Surveillance System(National Center for Chronic Disease Prevention and HealthPromotion, n.d.). This item has been used in periodic U.S.national surveillance. The item is During the past 12months, did you ever seriously consider attempting suicide?This item was scored as no (0 points) or yes (1 point).

Risk Factors Risk factors included individual and environ-mental risk factors. Individual risk factors were measuredin two dimensions: life stress and depression. Life stressduring the past 6 months was measured using a 35-itemscale developed by Harn (1999). An example item is I ampunished by my parents. Responses ranged from doesntbother me (0 points) to bothers me very much (4 points).Higher scores indicate higher perceived life stress.

Depression was measured using a single item adoptedfrom the questionnaire of the Youth Risk Behavior Sur-veillance System (National Center for Chronic Disease Pre-vention and Health Promotion, n.d.). This item also hasbeen used in periodic U.S. national surveillance. The item isDuring the past 12 months, did you ever feel sad orhopeless almost every day for at least 2 weeks in a row thatyou stopped doing some usual activities? Responses wereyes or no.

Environmental risk factors were measured using fourdimensions: suicidal ideation of the father, mother, andpeers and bullying victimization at school. The suicidalideation of the father, mother, and peers was measuredfrom the adolescents subjective perception. A single itemwas used: Did your father/mother/good friends have sui-cidal thoughts or attempt suicide in the past 12 months?Each item was scored with a yes or no response.

Bulling victimization was assessed via three experiencesin the past 12 months: being threatened by a weapon, per-sonal property being deliberately stolen or damaged, orbeing deliberately harmed by others. Each item was scoredwith a yes (1 point) or no (0 points) response. The scores ofthese three items were combined into a single score, withhigher total scores indicating greater bullying victimization.

Protective Factors Protective factors were measured usingfour multi-item scales assessing self-esteem, future aspiration,emotional adaptation, and family communication. The self-esteem scale was developed by Lin (1996), adopted from theself-esteem scale developed by Rosenberg (1965). Althoughit was originally a 10-item scale, one item was deleted after

explanatory factor analysis in this study. An example item isIn general, I am satisfied with myself. Future aspirationand emotional adaptation were measured using three itemsdeveloped by the authors. An example item of future as-piration is I think I will have a great future. An exampleitem of emotional adaptation is My behavior is easilyinfluenced by my emotions.

The family communication scale included three itemsmodified from the Youth Asset Survey scale (Oman et al.,2002). An example item is How often does your motheror father discuss your worries with you? Responses ofself-esteem, future aspiration, and emotional adaptationwere scored from strongly disagree (0 points) to stronglyagree (3 points). Reversed items were coded oppositely.Responses on the family communication scale were scoredfrom almost never (0 points) to almost always (3 points).The scores of individual items were combined into totalscores for each scale. Higher total scores indicated better self-esteem, future aspiration, emotional adaptation, or familycommunication.

Validity and Reliability of MeasuresFive experts in nursing and adolescent health confirmed thecontent validity of the scales used in this study. Theseexperts rated the relevance of each item in each scale from1 (irrelevant) to 4 (very relevant). The items rated with arelevance of 3Y4 by the experts were divided by the totalnumbers of items in each scale to produce the contentvalidity index of each scale. The content validity index forall the scales ranged from .90 to 1.00, indicating that allscales had acceptable content validity (Waltz, Strickland, &Lenz, 1991). Some items were revised based on the expertssuggestions. Revised questionnaires were given to fourjunior high students to test item clarity. They respondedthat the items of the questionnaire were adequate for ad-olescents to understand.

Cronbachs alpha was calculated to test internal con-sistency using data for all participants in the study. Aconvenience sample of 36 adolescents who satisfied theresearch criteria were recruited from another school. Theycompleted the revised questionnaire to determine thetestYretest reliability of the scales over a 2-week interval.Cohens kappa (one-item scale) or intraclass correlationcoefficient (multi-item scale) was used to examine thetestYretest reliability. Principal axis factor analysis withPromax rotation was performed to examine the constructvalidity of each multi-item scale using data for all par-ticipants in the study. As shown in Table 1, Cronbachsalpha, testYretest reliability, and construct validity of eachscale are acceptable in this study.

Ethical ConsiderationsThis study was approved by the institutional review boardof Kaohsiung Medical University. In this study, passiveparental consent was used rather than active consent.Parents or guardians were provided with consent forms,and they informed the researchers only if they did not wanttheir child to participate in the study. The students whoseparents or guardians consented were asked to sign con-sent forms.

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ProceduresPermission and support for this study were obtained fromeach selected school. An anonymous questionnaire with acover page to ensure confidentiality was distributed to eachstudent during a regular class period. After teachers leftthe classroom, questionnaires were administered to partic-

ipants under the direction of a trained assistant. Studentswere assured of the confidentiality and anonymity of thedata provided and were informed of their right to with-draw from the study at any stage without penalty or prej-udice. After completing the questionnaire, the studentsreceived a gift for their participation.

qTABLE 1. Internal Consistency, TestRetest Reliability, ICC, and Factor Analysis of Scales

Cronbachs ! ICC

Factor analysis

No. of factors Explained variance (%)

Protective factors

Future aspirations .69 0.81 1 61.93

Emotional adaptation .62 0.67 1 57.33

Family communication .80 0.76 1 71.95

Self-esteem .84 0.75 2a 59.56

Risk factors

Life stress .92 0.90 5b 53.83

Depression NA 1.0c NA NA

Bullying victimization NA 0.78 NA NA

Fathers suicidal ideation NA 1.0c NA NA

Mothers suicidal ideation NA 1.0c NA NA

Peers suicidal ideation NA 0.8c NA NA

Note. ICC = intraclass correlation coefficient for testYretest reliability; NA = not applicable.aTwo factors were termed positive evaluation and negative evaluation. One item was discarded because of low factor loading (G.30).bFive factors were termed family stress, environmental stress, school stress, peer stress, and academic stress.cCohens kappa.

qTABLE 2. Distribution and Comparison of Demographic Data to Suicidal Ideation (n = 577)

Variables

Suicidal ideation

#2 pTotal, n (%) No, n (%) Yes, n (%)

Age 2.57 0.277

15Y16 years 323 (56.0) 261 (80.8) 62 (19.2)

16Y17 years 211 (36.6) 181 (85.8) 30 (14.2)

917 years 43 (7.5) 34 (79.1) 9 (20.9)

Gender 18.33 G.001

Male 283 (49.0) 253 (89.4) 30 (10.6)

Female 294 (51.0) 223 (75.9) 71 (24.1)

Family structure 4.19 .041

Living with both parents 465 (80.6) 391 (84.1) 74 (15.9)

Living without both parents 112 (19.4) 85 (75.9) 27 (24.1)

Socioeconomic status (n = 531)a 1.35 0.507

Low 362 (62.7) 294 (81.2) 68 (18.8)

Middle 139 (24.1) 119 (85.6) 20 (14.4)

High 30 (5.2) 25 (83.3) 5 (16.7)

aForty-six missing cases.



Data AnalysisData analysis was done using SPSS Version 16.0 forWindows. Chi-squared tests and t tests were performed toanalyze the relationships between demographic character-istics, risk factors, protective factors, and suicidal ideation.Hierarchical logistic regression was used to analyze theimportant explanatory variables of suicidal ideation. Eachstep reported j2 log likelihood; Nagelkerke R2, indicatingproportion of explained variance; and the chi-square valueassociated with the change in j2 log likelihood measuringimproved model fit. The HosmerYLemeshow goodness-of-fittest measured whether the data fit the model. In all tests,p values of less than .05 were interpreted as statisticallysignificant.

Results

Of the participants, 17.5% (n = 101) reported havingsuicidal ideation. Participants who were female, who wereliving without both parents, who had depression, or whosemother or peers had suicidal ideation had a significantlyhigher proportion of suicidal ideation than others did. Ad-olescents who had suicidal ideation had significantly higherscores of life stress, higher scores of bullying victimization,lower scores of self-esteem, lower scores of future aspira-

tion, and lower scores of emotional adaptation than didthose without suicidal ideation (Tables 2 and 3).

Before hierarchical logistic regression, the correlationmatrix and collinearity diagnostics were carried out to ex-amine the collinearity among independent variables. Allvalues of tolerance were larger than 0.67, variance inflationfactors were smaller than 1.53, and condition indexes weresmaller than 21.18. The results indicated that there was nocollinearity among the independent variables. Then, hier-archical logistic regression was used to identify the mostimportant explanatory variables of suicidal ideation. Partic-ipants of middle and high socioeconomic status were com-bined into a single group. Age was coded into three groups:15 years, 16 years, and 17 years or older. Age of 15 years,male gender, living with both parents, and having a middleor high socioeconomic status were used as reference groups.

Demographic characteristics were entered in Step 1 ofthe hierarchical logistic regression analysis. As shown inTable 4, demographic variables accounted for 6.7% of thevariance in suicidal ideation (#2 = 22.10, df = 5, p = .001).Female gender (odds ratio [OR] = 2.50) and not living in afamily with both parents (OR = 1.78) were statisticallysignificant explanatory variables to suicidal ideation inStep 1. The model correctly identified 82.5% of the par-ticipants with suicidal ideation.

qTABLE 3. Distribution and Comparison of Risk Factors and Protective Factors to SuicidalIdeation (n = 577)

Total, n (%) No, n (%) Yes, n (%) #2 p

Risk factors

Depression 48.96 G.001

Yes 60 (10.4) 30 (50.0) 30 (50.0)

No 517 (89.6) 446 (86.3) 71 (13.7)

Mothers suicidal ideation 17.04 G.001

Yes 28 (4.9) 15 (53.6) 13 (46.4)

No 549 (95.1) 461 (84.0) 88 (16.0)

Fathers suicidal ideation 0.31 .57

Yes 8 (1.4) 6 (75.0) 2 (25.0)

No 569 (98.6) 470 (82.6) 99 (17.4)

Peers suicidal ideation 63.86 G.001

Yes 114 (19.8) 65 (57.0) 49 (43.0)

No 463 (80.2) 411 (88.8) 52 (11.2)

M T SD M T SD M T SD t

Life stress 40.21 T 21.03 37.04 T 20.01 55.14 T 18.81 j8.35 G.001

Bullying victimization 0.27 T 0.58 0.22 T 0.52 0.48 T 0.78 j3.19 .002

Protective factors

Self-esteem 15.77 T 4.49 16.27 T 4.36 13.39 T 4.33 6.05 G.001

Future aspirations 5.88 T 1.66 5.97 T 1.65 5.47 T 1.66 2.78 .006

Emotional adaptation 7.37 T 2.40 7.61 T 2.36 6.29 T 2.31 5.14 G.001

Family communication 3.26 T 2.21 3.33 T 2.25 2.95 T 2.01 1.55 .121



The six risk factors were added in Step 2. The modelexplained that the total variance of suicidal ideation signif-icantly increased to 37.5% (#2 = 114.56, df = 6, p G .001).Female gender (OR = 4.67), life stress (OR = 1.03),depression (OR = 4.13), peers suicidal ideation (OR =3.71), and victimization (OR = 1.76) were significant riskfactors of suicidal ideation. The model correctly identified84.7% of the participants with suicidal ideation.

The four protective factors were added in Step 3. Themodel explained that the total variance of suicidal idea-tion significantly increased to 40.6% (#2 = 13.11, df = 4,p = .011). Female gender (OR = 4.23), life stress (OR =1.03), depression (OR = 3.41), peers suicidal ideation(OR = 4.15), and bullying victimization (OR = 1.80) weresignificant risk factors of suicidal ideation. Self-esteem(OR = 0.92) and emotional adaptation (OR = 0.88) weresignificant protective factors of suicidal ideation. The modelcorrectly identified 86.1% of the participants with suicidalideation.

The interaction effects of the protective factors and therisk factors of suicidal ideation were tested in Step 4. Sig-nificant risk factors (life stress, depression, peers suicidalideation, and victimization) and significant protective

factors (self-esteem and emotional adaptation) of suicidalideation were selected in Step 3 analyses to produce riskfactors and protective factors cross-products. The eightinteraction terms were added in Step 4. Compared withStep 3, the explained variance (42.1%) did not increasesignificantly (#2 = 6.23, df = 8, p = .622). The protectivefactors were unable to moderate the negative effect of therisk factors on suicidal ideation. The HosmerYLemeshowtest for goodness of fit from Steps 1 to 3 were 2.95 withdf = 7 (p = .890), 8.39 with df = 8 (p = .397), and 5.60 withdf = 8 (p = .693), respectively, indicating a good model fitfor these three steps of analysis.

A post hoc power analysis of multiple linear regressionindicated a power of 1.0 for the study. The sample size wasjudged to be adequate.

Discussion

Results showed that 17.5% of adolescents reported havingsuicidal ideation in the previous year. This prevalence issimilar to that of a previous systematic review showingthat 19.3% (95% confidence interval = 11.7Y27.0) ofadolescents had suicidal thoughts in the previous year

qTABLE 4. Hierarchical Logistic Regression of Suicidal Ideation (n = 577)

Variables

Step 1 Step 2 Step 3

OR 95% CI OR 95% CI OR 95% CI

Demographics

Age (16Y17 years)a 0.69 0.42Y1.13 0.90 0.50Y1.60 0.99 0.54Y1.80

Age (917 years)a 1.07 0.46Y2.50 1.16 0.41Y3.24 1.10 0.39Y3.16

Gender (female)b 2.50*** 1.53Y4.05 4.67*** 2.46Y8.86 4.23*** 2.20Y8.14

Family structure (living without both parents)c 1.78* 1.04Y3.06 1.47 0.77Y2.81 1.40 0.72Y2.73

Socioeconomic status (low)d 1.35 0.81Y2.26 1.26 0.70Y2.26 1.45 0.79Y2.67

Risk factors

Life stress 1.03*** 1.02Y1.05 1.03*** 1.01Y1.04

Depression 4.13*** 2.06Y8.28 3.41*** 1.66Y7.01

Fathers suicidal ideation 2.62 0.41Y16.74 2.86 0.43Y19.11

Mothers suicidal ideation 1.62 0.59Y4.39 1.28 0.44Y3.70

Peers suicidal ideation 3.71*** 2.10Y6.57 4.15*** 2.29Y7.51

Bullying victimization 1.76** 1.16Y2.68 1.80** 1.16Y2.81

Protective factors

Self-esteem 0.92* 0.85Y0.99

Future aspirations 1.03 0.86Y1.24

Emotional adaptation 0.88* 0.78Y1.00

Family communication 1.00 0.88Y1.14

Note. R2 = 40.6%. The results of Step 4 are not shown because all statistics were not significant. OR = odds ratio; CI = confidence interval.aReference group: age of 15 years.bReference group: male.cReference group: living with parents.dReference group: middle and high socioeconomic status.

*p G .05.

**p G .01.

***p G .001.



(Evans et al., 2005). The results showed that the risk ofsuicidal ideation in female adolescents increased from 2.50to 4.23 times that of male adolescents after controlling forthe risk and protective factors. Some factors related to thefemale gender may explain the increasing risk of suicidalideation in female adolescents that need to be exploredfurther. Family structure was not a statistically significantexplanatory variable of suicidal ideation after controllingfor the effects of risk and protective factors. This findingis similar to that of a previous study (Reinherz, Tanner,Berger, Beardslee, & Fitzmaurice, 2006).

Results show that life stress and depression areimportant risk factors for adolescent suicidal ideation aftercontrolling for demographics and protective factors. Inter-vention programs aimed at preventing suicidal ideation inadolescents should include stress management skills. Fur-thermore, screening for depression may help identify ado-lescents at risk for suicidal ideation.

Suicidal ideation of participants mothers was related toadolescent suicidal ideation, but their fathers suicidalideation was not. This result is similar to that of the studyof An, Ahn, and Bhang (2010) in Korea. This might bebecause mothers take more responsibility in the direct careof their children in Taiwan; consequently, children aremore influenced by their mothers suicidal ideation than bytheir fathers. Peer identity is important to adolescentpsychosocial development (Smetana, Campione-Barr, &Metzger, 2006). The developmental characteristics ofadolescents might cause them to be more influenced bytheir peers suicidal ideation than by their mothers suicidalideation. School-based programs focused on buildingadolescent peer norms of appropriate attitudes for lifeand help-seeking strategies that might help reduce suicidalideation in adolescents.

Bullying is recognized as a serious problem in highschools in the United States (Spriggs, Iannotti, Nansel, &Haynie, 2007). However, it is a new phenomenon thatdoes not get much attention in Taiwan. Bullying victim-ization was found in this study to be an important riskfactor of suicidal ideation. Victims of bullying in the schoolsetting are relatively easy to identify, and antibullyingprograms in schools can also help in detecting bulliedadolescents (Mytton, DiGuiseppi, Gough, Taylor, &Logan, 2006). Hopefully, consciousness can be raisedabout implementing antibullying programs in high schoolto reduce youth suicidal ideation. Of note, bullying victim-ization was based solely on reports of physical bullyingvictimization in this study. However, adolescent bullyingmay take other forms, such as verbal, relational, or social(Wang, Iannotti, & Nansel, 2009). To understand therelationships of different types of bullying victimization tosuicidal ideation more fully, future research should includeforms of bullying victimization.

Self-esteem and emotional adaptation were found to beimportant protective factors for suicidal ideation. Self-esteem has been linked to better psychological functionand adjustment. Moreover, adolescents with good emo-tional adaptation may cope well with stress. The resultssuggest that interventions to decrease suicidal ideationshould include content to enhance self-esteem and improvethe emotional adaptation skills of adolescents.

Self-esteem and emotional adaptation compensate forbut do not moderate the negative effect of risk factors onsuicidal ideation in this study. The role of self-esteem onsuicidal ideation in this study is consistent with that ofWilburn and Smith (2005). However, by using differentprotective factors, emotional intelligence and problem-solving skills were found to moderate the negative effectof stress on adolescent suicidal ideation (Cha & Nock,2009; Grover et al., 2009). Different protective factorsmight have different roles in influencing the relationship ofrisk factors on suicidal ideation. Other protective factorsshould be explored, such as emotional intelligence andproblem-solving skills in adolescent suicidal ideation in thefuture.

Cognitive and situational factors such as privacy andconfidentiality can influence the validity of self-reportedrisk behaviors in adolescents (Brener, Billy, & Grady,2003). However, such effects were minimized because greatcare was taken when designing the questionnaire andcollecting data. The final model explained 40.6% of thetotal variance in suicidal ideation and correctly predicted86.1% of the participants with suicidal ideation. Thismodel is appropriate to explain suicidal ideation inTaiwanese adolescents.

The low reliability coefficients for scales of futureaspiration (.69) and emotional adaptation (.62) indicatethat these scales require further revision. Efforts such asadding items should be made to increase the reliability ofthese scales. Some data collected in the study relied on asingle item. Although the testYretest reliability in this studyis acceptable, to measure the concept more comprehen-sively, multiple items should be used in the future. Thesample was selected by convenience from southern Taiwan,which limits the generalizability of the results to otherareas. Conducting further studies in more heterogeneousand national adolescent populations is needed to confirmthese results. A cross-sectional design was used in thisstudy, precluding an exploration of the causal associationsbetween risk and protective factors and suicidal ideation.Prospective longitudinal studies examining the causalrelationships between risk and protective factors and theirinteraction on suicidal ideation of adolescents are suggestedfor the future.

ConclusionsThe findings of this study highlight that risk and protectivefactors independently influence the suicidal ideation ofadolescents. Results from this study make a uniquecontribution to existing knowledge about the role of riskand protective factors on suicidal ideation in Asianadolescents. Because adolescents spend most of their timein school, a whole-school approach is ideal to provideinterventions to reduce the suicidal ideation of adolescents.On the basis of the results of this study, nurses, especiallyschool nurses, working with teachers and other healthcareproviders to provide intervention programs in schools mayhelp to reduce suicidal ideation. Some interventions can beclass based, such as self-esteem enhancement, emotionaladaptation and stress management skills training, andantibullying programs. Others can change the ethos of theschool, such as positive peer norms for life. q



Accepted for publication August 1, 2011.We thank R.F. Oman, P.C. Harn, and P.C. Lin for providing per-mission to use their scale.This research was supported by funding from the National ScienceCouncil of Taiwan under Grant NSC-95-2314-B-037-054.The authors have no conflicts of interest to disclose.Corresponding author: Ruey-Hsia Wang, PhD, RN, College of Nursing,Kaohsiung Medical University, 100 Shih-Chuan 1st Road, San-MingDistrict, Kaohsiung City 807, Taiwan (e-mail: [email protected]).

ReferencesAn, H., Ahn, J. H., & Bhang, S. Y. (2010). The association of

psychosocial and familial factors with adolescent suicidalideation: A population-based study. Psychiatry Research, 177,318Y322.

Atkins, L. A., Oman, R. F., Vesely, S. K., Aspy, C. B., &McLeroy, K. (2002). Adolescent tobacco use: The protectiveeffects of developmental assets. American Journal of HealthPromotion, 16(4), 198Y205.

Bearman, P. S., & Moody, J. (2004). Suicide and friendships amongAmerican adolescents. American Journal of Public Health, 94,89Y95.

Benard, B. (2002). Fostering resiliency in kids: Protective factorsin the family, school, and community. San Francisco, CA: FarWest Laboratory.

Brener, N. D., Billy, J. O., & Grady, W. R. (2003). Assessmentof factors affecting the validity of self-reported health-risk be-havior among adolescents: Evidence from the scientific litera-ture. Journal of Adolescent Health, 33, 436Y457.

Bronfenbrenner, U., & Morris, P. A. (1998). The ecology of devel-opment process. In W. Damon, & R. M. Lerner. Handbook ofchild psychology, theoretical models of human development(5th ed., pp. 993Y1028). New York, NY: Wiley.

Centers for Disease Control and Prevention. (2011). Deaths: Pre-liminary data for 2009. Retrieved July 22, 2011, from http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf

Cha, C. B., & Nock, M. K. (2009). Emotional intelligence is aprotective factor for suicidal behavior. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 48(4), 422Y430.

Chamberlain, P., Goldney, R., Delfabbro, P., Gill, T., & DalGrande, L. (2009). Suicidal ideation. The clinical utility of theK10. Crisis, 30(1), 39Y42.

Chan, W. S. C., Law, C. K., Liu, K. Y., Wong, P. W. C., Law,Y. W., & Yip, P. S. F. (2009). Suicidality in Chinese adolescentsin Hong Kong: The role of family and cultural influences. SocialPsychiatry and Psychiatric Epidemiology, 44, 278Y284.

Chang, H. J., Yang, C. Y., Lin, C. R., Ku, Y. L., & Lee, M. B.(2008). Determinants of suicidal ideation in Taiwanese urbanadolescents. Journal of Formosan Medical Association, 107(2),156Y164.

Cheng, Y., Tao, M., Riley, L., Kann, L., Ye, L., Tian, X., I Chen,D. (2009). Protective factors relating to decreased risks ofadolescent suicidal behaviour. Child: Care, Health and Devel-opment, 35, 313Y322.

Chiou, P. N., Chen, Y. S., & Lee, Y. C. (2006). Characteristics ofadolescent suicide attempters admitted to an acute psychiatricward in Taiwan. Journal of the Chinese Medical Association,69, 428Y435.

Davalos, D. B., Chavez, E. L., & Guardiola, R. J. (2005).Effects of perceived parental school support and family com-munication on delinquent behaviors in Latinos and White non-Latinos. Cultural Diversity & Ethnic Minority Psychology, 11,57Y68.

Department of Health, Executive Yuan, Taiwan. (2011). Taiwanarea main causes of death, 2009. Retrieved June 30, 2011, from

http://www. doh.gov.tw/CHT2006/DisplayStatisticFile.aspx?d=71700&s=1

Evans, E., Hawton, K., Rodham, K., & Deeks, J. (2005). Theprevalence of suicidal phenomena in adolescents: A systematicreview of population-based studies. Suicide & Life-ThreateningBehavior, 35, 239Y250.

Fergus, S., & Zimmerman, M. A. (2005). Adolescent resilience: Aframework for understanding healthy development in the faceof risk. Annual Review of Public Health, 26, 399Y419.

Garcia, C., Skay, C., Sieving, R., Naughton, S., & Bearinger, L. H.(2008). Family and racial factors associated with suicide andemotional distress among Latino students. Journal of SchoolHealth, 78, 487Y495.

Greenberg, M. T. (2006). Promoting resilience in children andyouth: Preventive interventions and their interface with neu-roscience. Annals of the New York Academy of Sciences, 1094,139Y150.

Grover, K. E., Green, K. L., Pettit, J. W., Monteith, L. L.,Garza, M. J., & Venta, A. (2009). Problem solving moderatesthe effects of life event stress and chronic stress on suicidalbehaviors in adolescence. Journal of Clinical Psychology, 65,1281Y1290.

Harn, P. C. (1999). The impact of Internet users characteristics,behaviors, and psychological traits on Internet addiction forTaiwanese high school students. Unpublished doctoral disser-tation, National Taiwan Normal University, Taiwan.

Hinduja, S., & Patchin, J. W. (2010). Bullying, cyberbullying, andsuicide. Archives of Suicide Research, 14, 206Y221.

Jessor, R., Turbin, M. S., Costa, F. M., Dong, Q., Zhang, H., &Wang, C. (2003). Adolescent problem behavior in China andthe United States: A cross-national study of psychosocialprotective factors. Journal of Research on Adolescence, 13,329Y360.

Kidd, S., & Shahar, G. (2008). Resilience in homeless youth: Thekey role of self-esteem. American Journal of Orthopsychiatry,78, 163Y172.

Lin, P. C. (1996). Weight-control behaviors and related factorsamong obese junior high school students. Unpublished mastersthesis, Kaohsiung Medical University, Taiwan.

Manor, I., Vincent, M., & Tyano, S. (2004). The wish to die andthe wish to commit suicide in the adolescent: Two differentmatters? Adolescence, 39, 279Y293.

Mytton, J., DiGuiseppi, C., Gough, D., Taylor, R., & Logan, S.(2006). School-based secondary prevention programmes forpreventing violence. Cochrane Database of Systematic Reviews,19, CD004606.

National Center for Chronic Disease Prevention and HealthPromotion. (n.d.). Youth Risk Behavior Surveillance System.Retrieved June 31, 2006, from http://www.cdc.gov/HealthyYouth/yrbs/index.htm

OCarroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K.,Tanney, B. L., & Silverman, M. M. (1996). Beyond the Towerof Babel: A nomenclature for suicidology. Suicide & Life-Threatening Behavior, 26(3), 237Y252.

Oman, R. F., Vesely, S. K., McLeroy, K. R., Harris-Wyatt, V.,Aspy, C. B., Rodine, S., & Marshall, L. (2002). Reliability andvalidity of the youth asset survey (YAS). Journal of AdolescentHealth, 31(3), 247Y255.

Polit, D. F., & Hungler, B. P. (2004). Nursing research: Principlesand methods (7th ed.). Philadelphia: Lippincott Press.

Portzky, G., Audenaert, K., & van Heeringen, K. (2009).Psychosocial and psychiatric factors associated with adolescentsuicide: A case-control psychological autopsy study. Journal ofAdolescence, 32, 849Y862.

Reinherz, H. Z., Tanner, J. L., Berger, S. R., Beardslee, W. R., &Fitzmaurice, G. M. (2006). Adolescent suicidal ideation as



predictive of psychopathology, suicidal behavior, and compro-mised functioning at age 30. American Journal of Psychiatry,163, 1226Y1232.

Rosenberg, M. (1965). Society and the adolescent self-image.Princeton, NJ: Princeton University Press.

Smetana, J. G., Campione-Barr, N., & Metzger, A. (2006).Adolescent development in interpersonal and societal contexts.Annual Review of Psychology, 57, 255Y284.

Smith-Khuri, E., Iachan, R., Scheidt, P. C., Overpeck, M. D.,Gabhainn, S. N., Pickett, W., & Harel, Y. (2004). A cross-national study of violence-related behaviors in adolescents.Archives of Pediatrics & Adolescent Medicine, 158, 539Y544.

Spriggs, A. L., Iannotti, R. J., Nansel, T. R., & Haynie, D. L.(2007). Adolescent bullying involvement and perceived family,peer and school relations: Commonalities and differences acrossrace/ethnicity. Journal of Adolescent Health, 41(3), 283Y293.

Vesely, S. K.,Wyatt, V. H., Oman, R. F., Aspy, C. B., Kegler,M. C.,

Rodine, S., I McLeroy, K. P. (2004). The potential protectiveeffects of youth assets from adolescent sexual risk behaviors.Journal of Adolescent Health, 34, 356Y365.

Waltz, C. F., Strickland, O. L., & Lenz, E. R. (1991). Measure-ment in nursing research (2nd ed.). Philadelphia: Davis Press.

Wang, J., Iannotti, R. J., & Nansel, T. R. (2009). School bullyingamong adolescents in the United States: Physical, verbal, rela-tional, and cyber. Journal of Adolescent Health, 45, 368Y375.

Wang, R. H., Hsu, H. Y., Lin, S. Y., Cheng, C. P., & Lee, S. L.(2010). Risk behaviours among early adolescents: Risk andprotective factors. Journal of Advanced Nursing, 66, 313Y323.

Wilburn, V. R., & Smith, D. E. (2005). Stress, self-esteem, andsuicidal ideation in late adolescents. Adolescence, 40, 33Y45.

Yoder, K. A., & Hoyt, D. R. (2005). Family economic pres-sure and adolescent suicidal ideation: Application of the fam-ily stress model. Suicide & Life-Threatening Behavior, 35,251Y264.



150225_risk and protective factors for suicidal ideation among taiwanese adolescents

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