Author’s Accepted Manuscript

Gender Differences and Stage-Specific Influence of

Parent–Adolescent Conflicts on Adolescent
Suicidal Ideation

Yu-Ching Chiu, Chin-Yuan Tseng, Fu-Gong Lin

www.elsevier.com/locate/psychres

PII: S0165-1781(16)31289-6
DOI: http://dx.doi.org/10.1016/j.psychres.2017.06.077
Reference: PSY10624
To appear in: Psychiatry Research
Received date: 5 August 2016
Revised date: 13 May 2017
Accepted date: 24 June 2017
Cite this article as: Yu-Ching Chiu, Chin-Yuan Tseng and Fu-Gong Lin, Gender
Differences and Stage-Specific Influence of Parent–Adolescent Conflicts on
Adolescent Suicidal Ideation, Psychiatry Research,
http://dx.doi.org/10.1016/j.psychres.2017.06.077
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 Gender Differences and Stage-Specific Influence of Parent–Adolescent Conflicts on

Adolescent Suicidal Ideation

Yu-Ching Chiua, Chin-Yuan Tsengb, Fu-Gong Linb,c*

a
Department of Psychiatry, Cardinal Tien Hospital, No.362, Zhongzheng Rd., Xindian

Dist., New Taipei City 231, Taiwan R.O.C.

b
School of Public Health, National Defense Medical Center, No. 161, Min-Chun E.

Rd., Sec. 6, Taipei 114, Taiwan.

c
Department of Optometry, University of Kang Ning, No. 137, Alley 75, Sec. 3, Kang

Ning Road, Taipei 114, Taiwan

nikoo.chiu@gmail.com

aflove4@hotmail.com

*
Corresponding author. Department of Optometry, University of Kang Ning, No. 137,

Alley 75, Sec. 3, Kang Ning Road, Taipei 114, Taiwan. Tel: 886-2- 2632-1181 # 552;

Fax: 886-2-87923147. fugong@ndmctsgh.edu.tw

Abstract

This study examined familial and peer related factors as predictors of suicidal ideation

in school students. Total 2,896 participants were included from Taiwan Youth Project

released data, a longitudinal survey of adolescent suicidal ideation at ages 15, 18, and

20. Logistic regression analysis risk factors associated with adolescent suicidal
1
ideation reveled differences during the developmental stages. After adjusted for

psychological symptoms, effect of quarrels with parents on suicidal ideation lasts in

early and middle stages; in the late adolescent stage, only cigarette or alcohol use

remained significant. Girls who reported quarrels with parents had the highest level of

suicidal ideation before age 18. Stage- and gender-specific differences may provide

appropriate intervention strategies for parents and teachers preventing adolescent

suicidal ideation.

Keywords: adolescent; suicidal ideation; gender; conflicts; psychological distress

1. Introduction

Suicide among young adolescents is a grave global health concern. A 2007 World

Health Organization (WHO) report on suicide prevention indicated that

approximately one million people commit suicide every year and that the global

suicide rate has increased by 60% in the past 45 years (World Health Organization,

2007). Among people aged 15–19 years, suicide is the fourth leading cause of death

worldwide (Wasserman et al., 2005), and among people aged 10–24 years, 6% of all

deaths worldwide in 2004 were attributed to suicide (Patton et al., 2009). Suicidal

ideation (SI) might occur before teenage years and can substantially affect

development later in life (Min et al., 2012; Muehlenkamp et al., 2012). SI is a major

risk factor for suicide attempts among adolescents and is highly correlated with
2
subsequent suicidal behaviors and serious psychopathology (Balázs et al., 2013;

Fergusson and Lynskey, 1995; Winterrowd and Canetto, 2013). Suicidal ideation and

suicide attempts are common problems among young people in Asia, and are more

prevalent in industrialized cities (Blum et al., 2012). Moreover, progression from

suicidal thinking to committing suicide is affected by sociodemographic,

socioeconomic, urban, and cultural risk factors. (Blum et al., 2012; Vijayakumar, John,

Pirkis, & Whiteford, 2005). The question of whether progression from suicidal

ideation and active rumination to the act of committing suicide is a continuum can be

elucidated through the longitudinal follow-up method adopted by this study. Suicide is

a major problem in Taiwan as well, according to the Department of Health, suicide is

the second leading cause of death among adolescents and young adults aged 15–24

years (Department of Health, Executive Yuan, Taiwan, 2012).

Familial risk factors for SI among adolescents include single-parent families (Tran

Thi Thanh et al., 2006), immigrants (Blum et al., 2012) who lack parental attachment

or support (Peltzer and Pengpid, 2012), parent–adolescent conflicts (Kuhlberg et al.,

2010; Lamis and Jahn, 2013), and familial discord (Sigfusdottir et al., 2013; Tang et

al., 2009). These factors were found in both western and eastern countries. Of the

factors related to school environment, poor peer relationships negatively influenced SI

and were associated with suicidal behavior among adolescents ((Cui et al., 2011; Fotti

3
et al., 2006; Kaess et al., 2011; Lee,2011; Tang et al., 2009; Winterrowd and Canetto,

2013).

Longitudinal evidence showed that children with familial adversity and

psychopathology expressed higher suicidal tendencies (Fergusson and Lynskey, 1995)

than those who did not. A longitudinal study conducted in Norway found that

depression is a significant predictor of subsequent suicidal acts in young people.

(Nrugham et al., 2008). In addition, studies in Asia have demonstrated that loneliness

and depression are associated with suicide in high-income countries, whereas family

problems concerning intergenerational-conflict, love-failure, and exam-failure are

more common stressful life events identified as precursors to suicide in Asian contexts.

(Nrugham et al., 2008; Vijayakumar, et al., 2005). Data from SEYLE studies across

11 European countries showed that depression increased adolescent suicidal risk

(Balázs et al., 2013). In addition, depression is not only a major direct factor for SI but

also a significant mediator between familial conflicts and SI among young people

(Lamis and Jahn, 2013; Sigfusdottir et al., 2013; Sun et al., 2006).

According to a representative study in the republic of Korea, gender affects the

prevalence of adolescent SI (Park, 2013); higher SI prevalence was observed in

females than in males. In addition, risk factors for suicidality between females and

males differed with regard to familial and school-related factors and alcohol or

4
cigarette use among the youth (Cui et al., 2011; Epstein and Spirito, 2010; Fotti et al.,

2006; Kim et al., 2014; Park, 2013). However, in the multivariate analysis controlled

for depression reported in Kaess et al., the high risk of suicidal behavior among

females disappeared (Kaess et al., 2011). Cigarette or alcohol use, adopted as

stress-coping behaviors by the youth, were positively associated with SI (Innamorati

et al., 2011; Kim et al., 2014; Sigfusdottir et al., 2013). Moreover, in South Korea,

cigarette or alcohol use showed gender-specific influence on adolescent SI; the

association was significant only among females (Park, 2013). In this study, analyzing

the longitudinal cohort data was found to be useful for exploring the major causes of

adolescent SI and for clarifying gender-specific issues in SI according to adolescent

developmental stages.

Longitudinal design studies are feasible and recommended for investigating

modifiable factors and intervention strategies for preventing suicidal behaviors during

adolescence (Christiansen et al., 2014; Kessler, 2000). Due to the lack of longitudinal

studies published in Asia, we used the released data from the Taiwan Youth Project

(TYP), which is a longitudinal study conducted from 2000 to 2008 by Academia

Sinica, Taiwan, and involved investigating the adolescent psychological well-being of

a youth cohort in Northern Taiwan. The TYP cohort data can be used to explore the

major causes of adolescent SI and for clarifying gender-specific issues in SI according

5
to adolescent developmental stages. The primary goals of this research were to (a)

determine familial and school-related factors that influence adolescent SI and (b)

examine whether gender difference exists in the factors associated with SI during

adolescent growth trajectories.

2. Materials and Methods

2.1 Study population

Participants were derived from annual interviews of the TYP released secondary

data, which was conducted by the Institute of Sociology, Academia Sinica, Taiwan,

from 2000 through 2008, as described previously (Lin et al., 2014; Yi, 2013). In brief,

the study population included the 1984/5-birth and 1987/8-birth cohorts residing in

Northern Taiwan. Inclusion of the two cohorts both began at 15-16 years, with the

1984/5-birth cohort comprising approximately 34% individuals born in 1984 and 66%

individuals born in 1985, and the 1987/8-birth cohort comprising 30% individuals

born in 1987 and 70% individuals born in 1988. The presented samples were collected

from 40 junior high schools using a school-based (adolescents in special education

schools were not included) stratified design; 16 of the schools are located in Taipei

City (i.e., urban), 15 from Taipei County (i.e., suburban), and nine are from Yilan

County (i.e., less-urbanized). A total of 81 classes were chosen, with two or three

6
classes from each school. The two cohort samples included 2,683 seventh graders

(first year junior high) and 2,851 ninth graders (last year junior high) in the beginning.

The participants were first interviewed using structured questionnaires by means of a

self-administered report, and the respondents were tracked each year from 15 to 20

years of age. Data collection from the participants by using the self-administered

questionnaires included demographic data such as family and school-related variables,

metal health evaluation, and suicidal ideation. In this study, questionnaires were

mailed at 15, 18, and 20 years of age, which were defined as early, middle, and late

adolescent stages, respectively (Yi, 2013). Data collected from the participants by

using self-administrated questionnaires included demographic data such as family and

school-related variables, metal health scale, and suicidal ideation. This was conducted

at 15, 18, and 20 years of age, which are the junior high school, senior high school,

and college stages of vocational/academic education and were defined as early,

middle, and late adolescent stages, respectively. From these two cohorts, a total of

2,896 cases were obtained with completed interview data for the early, middle, and

late adolescent stages. The demographic variables from the 2,619 missing participants

were used to compare with the original valid 5,515 participants. No significance was

identified for the variables of gender, paternal education, maternal education, and

family income between these two groups. By contrast, significant differences were

7
observed for the variables of residence and parental marriage status, as shown in

Table 1a. A lower proportion of cases were located in less-urbanized Yilan County for

the missing group than for the original population (17% vs. 23%), and a higher

proportion of cases with abnormal parental marital status were located there compared

to the original population (19% vs. 15%), as shown in Table 1a. To avoid possible

confounding effects, these two variables were included in the multiple regression

analysis. This study was approved by the Institutional Review Board of the Cardinal

Tien Hospital (Approval Number CTH-104-3-5-019).

2.2 Measurement of psychological distress and suicidal ideation

The psychological distress (PD) of participants was measured with a

self-reported 15-item short version subscale (SCL-15) extracted from the Symptom

Checklist-90-revised scale (SCL-90-R) that was originally used for a broad range of

psychological symptoms (Derogatis, 1983). The included 15 items were among items

that were typically reported by adolescent mental health-related investigations in

Taiwan as previously described (Derogatis 1983; Lin et al. 2014; Wang et al. 2003). In

the scale, there involves four dimensions as (1). Somatization with 6 items: headaches,

faintness or dizziness, soreness of your muscles, numbness or tingling in parts of your

body, a lump in your throat, feeling weak in parts of your body; (2). Depression with

3 items: feeling lonely, feeling blue, worrying too much about things; (3). Hostility

8
with 3 items: having urges to beat, injure, or harm someone, getting into frequent

arguments, shouting or throwing things and (4) Insomnia with 3 items: trouble falling

asleep, awakening in the early morning, sleep that is restless or disturbed.

In the TYP, the SCL-15 scale was measured at three time points during adolescent

developmental stages: first, in the ninth grade of the 15-year-old early adolescent

stage, second, 3 years later during their 18-year-old middle adolescent stage, and third,

5 years later during their 20-year-old late adolescent stage. Each of the 15 items was

rated on a 5-point scale from 1 to 5 as never, a little, average, serious, and very serious,

measuring the frequency of symptoms during the past week. The summation of the

15-item score was defined as the PD index, with a higher score indicating a worse PD

status. The Cronbach’s alpha for this scale in the various stages ranged from 0.70 to

0.83 (Wang et al,. 2003; Yi, 2013). Suicidal ideation (SI) was assessed by one item:

‘thoughts of ending your life’ during the past week. The single item scored from 1 to 5

reflected the level of severity of suicidal ideation as an informative measurement, as

described in previous studies (Blum et al., 2012; Tang et al., 2009). SI was rated on a

5-point scale ranging from 1 to 5 (never, a little, average, serious, and very serious),

measuring the frequency of symptoms during the past week. The measured score was

then dichotomized into a ‘no’ (never) and ‘yes’ (a little, average, serious, and very

serious) scale to analyze the odds ratio of suicidal ideation. As reported by Millner et

9
al., single-item suicidal ideation decreases the measurement’s statistical power, and

information bias from self-reporting is inevitable. However, the validity of the true

positive rate was nevertheless higher than 90%. (Millner et al., 2015). The collected

data was informative and the residual misclassification rate should be noted regarding

suicide prevention.

2.3 Measurement of the independent variable

Demographic variables were measured with gender, residences that were registered at

the first investigation, and three areas, Taipei City, Taipei County, and Yilan County,

which were categorized into urban, suburban, and rural areas, respectively. Studies

have reported that urbanicity/rurality is as potential risk factor for suicide (Blum et al.,

2012; Virayakumar et al., 2005). In Taiwan, the suicide rate exhibits significant spatial

differentiation between urbanized areas and townships (Jhou, Chi and Hsieh, 2010).

There may be differences in social economic status, vocational type, and social capital

between regions, which may influence the psychological well-being of the residents.

Thus, data analysis included the urbanization variable to examine the spatial effects

on the investigated cohorts. Family-related variables included family income, parental

education (if > 12 years), and marital status if their parents were divorced or separated

or if one parent had died, which was defined as an abnormal status. Family conflicts

included two questions regarding (i) whether parents quarreled frequently and (ii)

10
whether the participants had frequent quarrels with parents in the past year. Family

conflicts were rated on an always, frequently, occasionally, seldom, and never basis to

measure the frequency over the past year. As in ours previous study, in this study,

frequent family conflicts were found to have short and long term effects on the

adolescent psychological well-being among the same population (Lin et al., 2014a).

The answer regarding whether parents quarreled frequently was dichotomized into a

‘yes’ (always, frequently) and ‘no’ (few, seldom, never) scale for quarrelsome parents;

and the answer regarding whether the participants had frequent quarrels with parents

was dichotomized into a ‘yes’ (always, frequently) or ‘no’ (few, seldom, never) scale

for frequent quarrels with parents. Peer conflicts consisted of two questions regarding

(i) severed friendships and (ii) holding a grudge against someone during the past year,

also scored as 0/1 for yes or no. The measurements of family and peer conflicts were

collected form student self-reports. The perception of conflict could exhibit

disconcordance between parents, teachers, and adolescents. This should be noted by

parents and teachers when interpreting the results. Cigarette or alcohol use were

obtained as the frequencies of smoking or drinking behaviors during the last year,

which were categorized as never as none of the items reported, occasion as one of the

items reported and frequent for both of the items reported. Although the time ranges

of suicidal ideation (past week) and family and peer conflicts (past year) were

11
different, the long-term effects of family and peer conflicts and the independent

variables on adolescent current psychological well-being were shown to be significant,

as we reported earlier (Lin et al., 2014a).

2.4 Statistical analysis

The analysis was conducted using SPSS 20.0 software. Analysis of variance

(ANOVA) was used to compare continuous variables among the grouped data and to

test for the interaction between independent variables on outcome. For the outcome of

suicidal ideation, a logistic regression method was adopted with the independent

predictive variables of family, school-related factors with or without PD score

adjusted. The generalized estimating equation (GEE) linear model was implemented

to predict the suicidal ideation risk over time with three-stage repeat measuring

variables from early through late adolescence. In all of the tests conducted in this

study, p < .05 was considered to be statistically significant.

3. Results

3.1 Sample description

In this longitudinal investigation, 2,896 adolescents, including 1,446 males and

1,450 females, were included, and their descriptive characteristics are summarized in

Table 1b. In brief, approximately 38% of the adolescents lived in the highly urbanized

12
Taipei City, 35% in the moderately urbanized Taipei County, and 27% in the less

urbanized Yilan County. Among them, 439 adolescents (14.9%) reported SI at the

early stage, 295 (10.2%) reported SI at the middle stage, and 250 (8.6%) reported SI

at the late stage; the SCL-15 PD scores in the three developmental stages were

relatively constant at 23.8, 23.0, and 23.6, respectively.

Familial factors revealed that approximately 22% of the fathers and 15% of the

mothers had more than 12 years of education; 90% of the parents had a normal

marital status, and 94% were employed, whereas 14% had a monthly family income

of less than NT$30,000 (approximately US $1,000) at the investigation onset. Of the

familial conflict variables, 10%, 9%, and 6% of adolescents reported having

quarrelsome parents in the three developmental stages, respectively, and the rates of

adolescent quarrels with parents decreased from 10% and 8% to 5% as the

adolescents grew. Regarding peer conflicts, approximately 30%, 22.8%, and 9% of

ninth graders, middle adolescents, and late adolescents, respectively, reported severed

friendships. Furthermore, 26.3%, 22.5%, and 10% of early, middle, and late

adolescents, respectively, held grudges against their peers. Finally, 289 adolescents

(11%) reported alcohol or tobacco use during early adolescence, 652 (22.5%) during

middle adolescence, and 981 (34.9%) during late adolescence.

3.2 Factors associated with adolescent suicidal ideation at various stages

13
 Table 2 presents the personal demographics, familial and peer-related variables,

and association with adolescent SI at each stage. According to univariate analysis,

gender was a significant factor throughout the developmental duration, with female

adolescents having approximately 1.5-fold higher odds of SI than male adolescents

during the three adolescent developmental stages. Among the adolescents in the three

stages, parental unemployment status had an approximately 1.6- to 2-fold SI risk.

Regarding familial conflict variables, adolescents with quarrelsome parents had on

average 2-fold higher risk of SI than those without quarrelsome parents. Moreover,

frequent quarrels with parents significantly increased SI risks by 3.9-, 4.3- and

3.1-fold for adolescents in the early, middle, and late adolescent stages, respectively.

Regarding peer conflict variables, adolescents with severed friendships faced 2.0- to

2.4-fold SI risks compared with those without severed friendships. Moreover, grudges

against friends showed a 2.0- to 2.7-fold risk of adolescent SI at various

developmental stages. Cigarette or alcohol use significantly influenced SI at all three

adolescent developmental stages compared with those who did not. Cigarette or

alcohol use increased SI risk by 1.2- to 2.3-fold. In all three stages, PD scores were

significant factors for SI.

To evaluate the related significant factors associated with adolescent SI,

multivariate logistic regression was performed. Gender, quarrels with parents, peer

14
conflicts, and cigarette or alcohol use significantly influenced SI in all three

adolescent developmental stages, without psychological distress included in the model

(Table 3). After we adjusted for PD scores in the models, there were distinct changes

in different developmental stages. In early adolescence, gender (odds ratio (OR) =

1.4), quarrels with parents (OR = 2.0), severed friendships (OR = 1.3), and cigarette

or alcohol use (OR = 1.7) were significant risk factors for SI. In middle adolescence,

only quarrels with parents (OR = 2.1) remained a significant risk factor for SI. In late

adolescence, gender and familial and school conflict variables were not significant

factors; only cigarette or alcohol use (OR = 1.5) affected SI risk.

3.3 Gender difference in suicidal ideation

For detecting whether gender difference existed during the follow-up periods and

whether related significant factors for SI at various adolescent stages were constant,

the generalized estimating equation approach was adopted for examining the effects

of variables on SI across the three adolescent developmental stages. Analyzing the

results according to gender revealed differing influences of familial and school

conflict variables on SI risk in male and female adolescents (Table 4). Early

adolescents, particularly female adolescents, faced a higher SI risk than middle and

late adolescents did. Among male adolescents, quarrels with parents and severed

friendships showed 1.71- and 1.62-fold SI risks, respectively. Among female

15
adolescents, quarrels with parents and cigarette or alcohol use showed 1.99- and

1.63-fold risks of SI, respectively.

3.4 Interactive effect of gender on familial conflicts in suicidal ideation

Because an interaction between gender and quarrels with parents on adolescent

SI scores was demonstrated, the interactive effects of gender and quarrels with parents

on the risk of SI were further analyzed in table 5. Considering adolescent

psychological distress condition scores, the subgroup of female adolescents who

quarreled with parents had the highest risk of SI in early and middle stages. This

subgroup had a 3-fold SI risk compared with male adolescents who did not quarrel

with parents in early adolescence and had a 2-fold risk of SI compared with male

adolescents in middle adolescence. However, the enhanced effect of gender and

quarrels with parents was non-significant in late adolescents.

4. Discussion

4.1 Relatively high prevalence of suicidal ideation in early adolescence

In this study, 14.9%, 10.2%, and 8.6% of early, middle, and late adolescents

reported SI for the preceding year during their growth trajectories. The age-related

decrease in suicidal ideation may be partially attributed to adolescents learning more

social support components and adaptation skills with age (Sun et al., 2006). Although

16
SI decreased with age, the prevalence of SI among our cohorts was relatively high

compared with that in adolescents in other Asian countries (12-month SI prevalence

of 2.3%–8.1% (Blum et al., 2012; Lian et al., 2015). The high prevalence of SI in

Taiwanese adolescents may be partially attributed to the Asian cultural and severe

academic competition among young adolescents in high schools during the

compulsory education period (Tang et al., 2009; Yi, 2013). Adolescents in East Asian

societies are engaged in a unique competitive school environment and must meet the

familial expectation of succeeding in nation-wide examinations for admissions to

senior high schools and universities. This competitive educational environment and

the traditional value of obedience to parents’ expectation may exert considerable

burden on adolescents and affect their mental health during their growth trajectories

(Yi et al., 2009). Concern for and improving of adolescent mental health, and cultural

contexts such as education competition and parental expectation, should be

considered. Reports have indicated that SI may not completely reflect the risk of

suicidal behavior (Lukaschek et al., 2015). However, SI nevertheless involves internal

psychopathology symptoms that should be noted regarding adolescent mental health

(Ibrahim et al., 2014). Longitudinal study on developmental psychiatry epidemiology

can elucidate the association between SI and suicide in young people.

4.2 Stage-specific risk factors for adolescent suicidal ideation

17
 As adolescents growing up, factors influencing SI were also changing. Besides

psychological symptoms, both of family and school related factors showed significant

in the early adolescence. In middle adolescence, only family factor remained

significant for SI. And in late adolescents, family and school related factors were no

longer significant for SI. The result revealed that risk factors for SI were

stage-specific. Psychological problems among youth represented most important risks

for SI, and quarrel with parents was another independent, long-lasting influence risk

factor through early to middle adolescent stages. Preventive intervention policy for

adolescent mental health should be refined by involving developmental terms (Kessler,

2000); the stage-specific risk factors in this study, such as familial conflicts in young

adolescents, should be specially considered in adolescent SI.

4.3 Gender differences in adolescent suicidal ideation at various stages

In Asian countries, female adolescents are more likely to have SI than male

adolescents (Blum et al., 2012; Cui et al., 2011; Park, 2013; Sun et al., 2006). Our

results showed that female adolescents had a greater SI risk of 1.5- (18% vs. 12%),

1.3- (11% vs. 9%), and 1.3- (10% vs. 7%) odds than male adolescents did in the early,

middle, and late developmental stages, respectively (Table 2). Furthermore, female

adolescents had the highest SI percentage and odds in the early stage, indicating that

gender difference was stage-specific; that is, early female adolescents were more

18
vulnerable to SI than middle and late female adolescents were and thus require more

care. In addition, different risk factors for SI were noted between the genders.

Females were more sensitive to parent–adolescent conflicts and cigarette or alcohol

use, whereas males were more sensitive to severed friendships (Table 4). This finding

provides a gender-specific preventive strategy for SI.

Furthermore, emotional problems in female and male adolescents influenced SI.

Kaess et al. demonstrated that the gender-specific effect on suicidal behavior

decreased when emotional problems were considered (Kaess et al., 2011). Consistent

with our results, females were more likely to have SI than males do in all three

developmental stages regardless of PD scores. When PD was included in the logistic

regression model, the gender-specific effect was significant only in early adolescents.

The gender-specific effect showing stage dependency on adolescent SI in this study

can be adopted for a SI preventive strategy for adolescents in different growth stages.

The diminished effect of gender difference on SI may partially be attributed to

psychological disturbances during middle and late adolescence.

That females exhibited a greater SI risk in the earlier stages of adolescence might

be partially due to the physiological developmental disparity between girls and boys.

Teen girls experience pressures caused by physiological changes and social transition

earlier than boys. In Taiwan, adolescent girls exhibited lower psychological

19
well-being status than their male peers in our previous study. (Lin et al., 2014a). The

results of the present study indicate that prevention strategies involving parents and

school-based plans should start from the early adolescent stage and apply

gender-specific approaches.

4.4 Parent–adolescent quarrel as a major independent factor for SI in young

adolescents

Familial conflicts, independent of psychopathological conditions, are reported

crucial in SI (Chu et al., 2014; Nrugham et al., 2008). Experiencing familial conflicts

in early adolescence predicted later mental health problems and depression status in

American adolescents (Herrenkohl et al., 2012; Juang et al., 2012). In our school–

based study, familial conflict was the major factor for adolescent SI especially in early

and middle adolescence. Because of the Chinese cultural background, characterized

by parental authority and filial piety norms, adolescents grow up under parental

control and pressure of expectations, particularly with regard to ideal behaviors and

academic achievements (Wang and Chen, 2010). Parents’ over-expectation regarding

academic performance and the cultural expectation of obedience from youth in high

schools may become the major causes of parent–adolescent conflicts (Wang and Chen,

2010) and mental distress (Huang and Lin, 2010). Studies in Cambodia and India

have found that adverse family conflict environments are important causes of suicidal

20
behavior in young people (Jegannathan et al., 2014; Vijayakumar et al., 2005).

Reports from Vietnam, China, and Taiwan have shown that good parent–child

relationships and better family cohesion protected against SI outcomes in adolescents

(Blum et al., 2012, Le Mt et al., 2012).

Our results showed that the effects of familial conflicts on SI were diminished

and while considering psychological problems in late adolescence; however, familial

conflicts and psychological problems independently influenced SI in early and middle

adolescents. Parent–adolescent conflicts played a major role in adolescent mental

health and SI before age 18. Improving parent–adolescent relationship can improve

adolescent mental health. Our results further demonstrated that the roles of familial

conflicts and mental problems varied in different growth stages. These findings

suggest that for early SI intervention, the SI prevention policy should focus on

familial harmony.

4.5 Synergistic interaction between gender and parent–adolescent conflicts on SI risk

When psychological symptoms were considered, female adolescents were more

sensitive to parent–adolescent quarrels than male adolescents were (OR: 2.0 vs. 1.7,

respectively, Table 4). In addition, the influences of parent–adolescent arguments on

SI varied in different stages (Table 3). The impacts of parent–adolescent quarrels on

SI risk between the genders also differed in the three adolescent developmental stages

21
(Table 5). Regarding SI, female adolescents were more vulnerable to inter-parent–

adolescent quarrels than male adolescents were, particularly in adolescence before age

18. These findings suggest that parents and teachers should focus on younger

adolescents in aspects of familial discordance to improve adolescent mental health

and prevent adolescent suicide.

4.6 Effects of cigarette or alcohol use on suicidal ideation

Cigarette or alcohol use was demonstrated as a risk factor for SI among Korean

youth (Han et al., 2009; Yi, 2013), and it increased SI risk by 40%–80% in Asian

adolescents and young adults (Blum et al., 2012). In Taiwan, to protect young

adolescents, selling cigarette or alcohol to adolescents less than 18 years of age is

illegal; cigarette or alcohol use is considered a problematic behavior in high school

children. Our study showed that cigarette or alcohol use elevated SI risk in

adolescents by 1.5-fold on average consistent with previous finding (Park 2013). With

cigarette or alcohol use, the odds of SI in female adolescents were approximately 50%

higher than those in male adolescents (Table 5). Thus, cigarette or alcohol use by

female adolescents should be adequately addressed and considered by school

counseling staff to rectify the problem of youth suicides.

4.7 Conclusion

22
 In this study, stage-specific risk factors for SI among adolescents were observed.

In the early stage, familial and school-related factors were major factors for SI,

whereas in the middle and late stages, depressive symptoms mainly formed SI risks.

Moreover, risk factors for SI showed gender differences; female adolescents with

inter-parent–adolescent conflicts or cigarette or alcohol use were more vulnerable to

SI than male adolescents were, whereas male adolescents with severed friendships

were more vulnerable to SI than female adolescents were. Furthermore, the effects of

parent–adolescent conflicts on SI were observed in early and middle adolescents. The

results, after considering stage- and gender-specific effects, are useful for strategizing

adolescent suicide prevention.

4.7 Recommendation:

The results of this longitudinal follow-up study yield several recommendations for

policy marker and service planners, namely (1) Intervention programs should be

implemented from early adolescence and focus on family environments and parent–

adolescent relationships; (2). Programs should be designed according to a

stage-specific format regarding gender, parent–adolescent conflicts, peer relationships,

and cigarette or alcohol use; and (3) Gender difference should be considered in

mental health promotion as, in the context of SI, girls are more sensitive to family

conflicts whereas boys are more sensitive to peer relationships. Suicide prevention

23
policy for developing adolescents could be structured using family- and school-based

coordinated plans to develop appropriate mental health care services.

Declaration of interest

The authors report no declaration of interest.

Conflict of interests

The authors declare that they have no conflict of interest.

Acknowledgements

The Taiwan Youth Project data used in this study are available for public use, and

we applied for the research with the approval of Academia Sinica in Taiwan

(http://www.typ.sinica.edu.tw). We also gratefully acknowledge the instruction of Dr.

Chin-Chun Yi for the TYP data. Thanks are given to the Cardinal Tien Hospital for

support through a research grant (CTH-103-1-2C08).

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Table 1a Comparison of demographic variable between original population and missed subjects
Demographic Original Population Missed subjects p value Chi square
Variables N=5515 (%) N=2619 (%)
Residence
Taipei City 2072 (37.6) 973 (37.2) <0.01 38.2
Taipei County 2200 (39.9) 1195 (45.6)
Yilan County 1243 (22.5) 451 (17.2)
Gender
Male 2795 (50.7) 1349 (51.5) 0.49 0.49
Female 2720 (49.3) 1270 (48.5)
Father education
> 12 years 1157 (21.0) 531 (20.3) 0.58 0.33
=< 12 years 4124 (74.8) 1958 (74.8)
Mother education
> 12 years 794 (14.4) 359 (13.7) 0.54 0.41
=< 12 years 4500 (81.6) 2126 (81.2)
Family income
(NT dollars)
<30,000 & 356 (6.5) 174 (6.6) 0.6 1.88
30,000-80,000 833 (15.1) 370 (14.1)
80,000-120,000 3254 (39.1) 1522 (58.1)
>120,000 825 (15.0) 410 (15.7)
Parent marital
status
Normal 4713 (85.5) 2110 (80.6) <0.01 30.75
Abnormal# 798 (14.5) 505 (19.3)
#
Abnormal status includes divorce or separation or the death of one parent;
&
30,000 NT dollars is equal to 1,000 US dollars.

32
Table 1b Characteristics of adolescents in various stages (N= 2896)

Early adolescence Middle adolescence Late adolescence

Characteristics N (%) N (%) N (%)
Suicidal ideation
No 2466 (85.1) 2601 (89.8) 2646 (91.4)
Yes 430 (14.9) 295 (10.2) 250 (8.6)
Suicidal ideation score
mean±SD 1.25±0.7 1.15±0.5 1.14±0.5
SCL-15 PD score
mean±SD 23.8±7.6 23.0±7.4 23.6±7.9
Gender
Male 1446 (50) 1446 (50) 1446 (50)
Female 1450 (50) 1450 (50) 1450 (50)
Residence
Taipei City 1099 (37.9) 1099 (37.9) 1099 (37.9)
Taipei County 1005 (34.7) 1005 (34.7) 1005 (34.7)
Yilan County 792 (27.3) 792 (27.3) 792 (27.3)
Father education
> 12 years 626 (21.6) 750 (25.9)
=< 12 years 2166 (74.8) 2097 (72.4)
Mother education
> 12 years 435 (15.0) 505 (17.4)
=< 12 years 2374 (82.0) 2348 (81.1)
Family income (NT dollars)
<30,000 & 415 (14.3) 381 (13.2)
30,000-80,000 1732 (59.8) 1731 (59.8)
80,000-120,000 463 (16.0) 490 (16.9)
>120,000 182 (6.3) 165 (5.7)
Parent marital status
Normal 2603 (89.9)
Abnormal# 293 (10.1)
Parent unemployment
No 2718 (93.9) 2684 (92.7)
Yes 178 (6.1) 190 (6.6)
Family conflicts
Quarrelsome parents
No 2597 (89.7) 2489 (85.9) 2552 (88.1)
Yes 285 (9.8) 264 (9.1) 175 (6.0)
Quarrels with parents
No 2604 (89.9) 2624 (90.6) 2741 (94.6)
Yes 290 (10.0) 241 (8.3) 129 (4.5)
Peer conflict
Severed friendship

33
 No 2024 (69.9) 2212 (76.4) 2610 (90.1)
Yes 869 (30.0) 661 (22.8) 273 (9.4)
Hold a Grudge
No 2132 (73.6) 2211 (76.3) 2585 (89.3)
Yes 762 (26.3) 652 (22.5) 289 (10.0)
Cigarette/alcohol use$
Never 2593 (89.5) 2219 (76.6) 1908 (66.1)
Occasional 248 (9.6) 515 (17.8) 558 (19.3)
Frequent 41 (1.4) 137 (4.7) 423 (14.6)
#
Abnormal status includes divorce or separation or the death of one parent; & 30,000 NT dollars is equal to 1,000

US dollars.
$
Never: none of the items reported, occasion: one of the items reported, frequent: both of the items reported.

Table 2 Variables associated with the suicidal ideation risk at various adolescent stages with uni-variate
analysis
Early adolescent Middle adolescent Late adolescent
Variables (reference) Crude OR (95% CI) Crude OR (95% CI) Crude OR (95% CI)
Gender (Male) 1.53(1.25, 1.89)** 1.30(1.02,1.66)* 1.35(1.04,1.75)*
Residence (Taiepi City)
Taiepi County 1.07(0.85,1.36) 1.10(0.83,1.44) 0.73(0.53,1.00)*
Yilan County 0.68(0.52,0.89)* 0.81(0.59,1.11) 0.96(0.70,1.32)
Father education (> 12 years) $ 0.87(0.68,1.11) 0.78(0.59,1.03) 1.10(0.79,1.53)
$
Mother education (> 12 years) 0.88(0.67,1.17) 0.85(0.62,1.18) 1.21(0.82,1.78)
Family income$
(<30,000 NT/month)
30,000-80,000 0.65(0.41,1.03) 1.10(0.61,1.97) 0.72(0.37,1.38)
80,000-120,000 0.76(0.51,1.12) 1.02(0.61,1.73) 1.04(0.60,1.81)
>120,000 0.84 (0.53 1.32) 1.58(0.89,2.79) 1.67(0.91,3.04)
$
Parent marital status (Normal) 1.20(0.87,1.66) 1.22(0.84,1.78) 1.68(1.16,2.43)**
Parent unemployment (No) $ 1.86(1.29,2.66)** 2.13(1.43,3.18)** 1.63(1.03,2.58)*
Family conflicts
Quarrelsome parents (No) 2.32(1.74,3.09)** 2.42(1.73,3.38)** 1.95(1.25,3.05)**
Quarrels with parents (No) 3.91( 2.99,5.10)** 4.34(3.18,5.93)** 3.16(2.04,4.91)**
Peer conflicts
Severed friendship (No) 2.02(1.64,2.49)** 2.42(1.88,3.11)** 2.42(1.71,3.42)**
Hold a grudge (No) 2.07(1.67,2.56)** 2.07(1.60,3.08)** 2.74(1.97,3.81)**
Cigarette/alcohol use (Never)
Occasional 2.06(1.51,2.80)** 1.61(1.21,2.15)** 1.55(1.13,2.12)**
Frequent 2.31(1.15,4.65)* 1.20(0.69,2.09) 1.27(0.88,1.83)

34
SCL-15 PD score 1.16(1.14,1.18)** 1.18(1.16,1.20)** 1.18(1.16,1.12)**
$
*: p < 0.05, **: p < 0.01, Adopted from the first time investigation data.

Table 3 Variables associated with the suicidal ideation risk at various adolescent stages with
multivariate regression analysis
Early adolescence Middle adolescence Late adolescence
Variables AOR (95% AOR (95% AOR (95% AOR (95% AOR (95% AOR (95%
(reference) CI) CI) CI) CI) CI) CI)
Gender 1.65(1.31,2. 1.43(1.12,1. 1.33(1.01,1. 0.90(0.66, 1.39(1.03,1. 1.17(0.83,1.
(Male) 06)** 84)** 74)* 1.22) 87)* 64)
Family
conflicts
Quarrels 1.30(0.93,1. 1.04(0.71,1. 1.18(0.79,1. 1.02(0.65,1. 1.28(0.76,2. 0.93(0.52,1.
ome 81) 51) 77) 62) 14) 66)
parents
(No)
Quarrels 2.79(2.05,3. 2.00(1.41,2. 3.59(2.46,5. 2.12(1.37,3. 2.44(1.43,4. 1.45(0.79,2.
with 79)** 82)** 23)** 27)** 16)** 66)
parents
(No)
Peer
conflicts
Severed 1.49(1.18,1. 1.32(1.02,1. 1.65(1.21,2. 1.21(0.86,1. 1.88(1.26,2. 1.55(0.97,2.
friendship 90)** 71)* 23)** 69) 79)** 46)
(No)
Hold a 1.44(1.12,1. 0.98(0.74,1. 1.62(1.19,2. 1.08(0.77,1. 2.07(1.41,3. 1.37(0.89,2.
grudge 84)** 29) 19)** 52) 04)** 13)
(No)
Cigarette/al
cohol use
(Never)
Occasion 1.89(1.34,2. 1.75(1.20,2. 1.50(1.09,2. 1.22(0.85,1. 1.65(1.18,2. 1.54(1.05,2.
al 67)** 55)** 06)* 75) 32)** 26)*
2.33(1.11,4. 1.10(0.44,2. 0.83(0.42,1. 0.55(0.26,1. 1.25(0.81,1. 0.95(0.58,1.
Frequent
89)* 75) 63) 7) 92) 57)

SCL-15 PD 1.15(1.13,1. 1.18(1.15,1. 1.18(1.16,1.

score 17)** 20)** 21)**
Adjusted for the subject’s residence, parent marital status and parent employment status; *: p < 0.05, **: p < 0.01

35
Table 4 Generalized estimation equation (GEE) models of the factors associated with adolescent
suicidal ideation risk during the developmental stages
All Male Female
Gender (Male) 1.21 (0.99, 1.47) -- --
Stages (Early stage)
Middle stage 0.44 (0.36, 0.55)** 0.84 (0.63, 1.11) 0.54 (0.42,0.69)**
Late stage 0.65 (0.54, 0.78)** 0.52 (0.38, 0.72)** 0.38 (0.29,0.51)**
Quarrelsome parents (No) 1.00 (0.76, 1.32) 1.13 (0.71, 1.79) 0.93 (0.65,1.33)
Quarrels with parents (No) 1.85 (1.41, 2.43)** 1.71 (1.10, 2.64)* 1.99 (1.40,2.82)**
Severed friendship (No) 1.35 (1.11, 1.64)** 1.62 (1.19, 2.19)** 1.15 (0.89, 1.50)
Hold a grudge (No) 1.04 (0.85, 1.28) 0.80 (0.59, 1.09) 1.28 (0.98,1.69)
Cigarette/Alcohol (No) 1.37 (1.11, 1.68)** 1.16 (0.87, 1.56) 1.63 (1.22,2.16)**
PD score 1.16 91.15, 1.18)** 1.16 (1.15, 1.18)** 1.17 (1.15,1.19)**
Adjusted for the subject’s residence, parent marital status and parent employment status; *: p < 0.05, **: p < 0.01

Table 5 Interactive effects of quarrels with parents and gender on suicidal ideation risk
Crude OR$ (95% CI) AOR§ 95% CI) $
Early adolescence
Gender Quarrels with parents Suicidal ideation risk Suicidal ideation risk
Boy No 1 1
Boy Yes 2.20(1.40,3.45)** 1.57(0.94,2.62)
Girl No 1.50(1.18,1.92)** 1.30(0.99,1.69)
Girl Yes 4.96(3.33,7.39)** 3.07(1.96,4.80)**
Middle adolescence
Gender Quarrels with parents Suicidal ideation risk Suicidal ideation risk
Boy No 1 1
Boy Yes 2.57(1.51,4.38)** 1.67(0.91,3.06)
Girl No 1.12(0.89,1.61) 0.83(0.60,1.16)
Girl Yes 5.23(3.22,8.49)** 1.99(1.13,3.50)*
Late adolescence
Gender Quarrels with parents Suicidal ideation risk Suicidal ideation risk
Boy No 1 1
Boy Yes 3.01(1.43,6.34)** 2.31(0.99,5.39)
Girl No 1.51(1.11,2.06)** 1.30(0.92,1.84)
Girl Yes 3.62(1.85,7.10)** 1.49(0.67,3.29)
$
Adjusted for the subject’s residence, parent marital status and parent employment status, family, school conflict
variables, cigarette/alcohol use and PD score. *: p < 0.05, **: p < 0.01

36
Highlights

 Factors for suicidal ideation differ with adolescent stages.

 Familial and school factors dominate suicidal ideation at an early stage.

 Psychological symptoms account for more suicidal ideation risk in later stages.

 Impact of quarrels with parents on suicidal ideation lasts in early/middle stages.

 Girls quarreling with parents have the highest early-stage suicidal ideation risk.

37