Suicidal ideation among Chinese adolescents in

Hong Kong and Shanghai

Sylvia Kwok (Dr.) Associate Professor,Dr. He Xuesong, Professor,

Department of Applied Social Studies,City University of Hong Kong.

Suicidal ideation in HK & China

• The yearly number of suicides increased considerably in the past 10 years by 61% from 784 (12.1%) in 1997 to 1264 (18.6%) in 2003 in Hong Kong.

• China’s suicide rate was 23 per 100,000 or 287,000 people killed themselves each year.

• According to a study in Beijing and Shanghai, among those who have suicidal ideation, 29.5 % made a plan and 32.3% attempted to commit suicide (Lee et al., 2007)

Correlates of suicidal ideation

• The cognitive-emotive-behavioral theory stresses the importance of hopelessness, emotional competence and social problem solving in influencing suicidal ideation (Ellis & Bernard, 2006).

• The family models emphasize the impact of family processes (e.g. family functioning and parent-adolescent communication) on suicidal ideation (Beavers et al., 1990; Epstein et al., 1993; Olson et al., 1989)

Hopelessness as a mediator on suicidal ideation

• Anxiety and suicidal behavior (Thompson et al., 2005)

• Negative life events and suicidal behavior (Yang & Clum, 2000)

• Problem-solving deficits and suicidal ideation (Miros, 2000)

• Negative affect and suicidal ideation (Pinto & Whisman, 1996)

• Previous literature showed that hopelessness was a mediator between:

• Depression and suicide intent (Weishaar & Beck, 1992)

Objectives

• To study and compare the personal and family correlates of suicidal ideation among the adolescents in Hong Kong and Shanghai.

• To examine the mediating role of hopelessness on the relationship between the correlates and suicidal ideation among the adolescents in Hong Kong and Shanghai.

Procedure in Hong Kong

• 10 secondary schools in Hong Kong Island, Kowloon and the New Territories

• Age of participants (M= 14, SD= 1.47)• Intact family (92.5%), non-intact family (7.5%)

• Cross-sectional survey design• Convenience sampling• 536 self-administered

questionnaires

Procedure in Shanghai

• Cross-sectional survey design• Convenience sampling• 527 self-administered

questionnaires• 3 government-run and subvented schools in Shanghai• Age of participants (M= 14, SD= 1.23)• Intact family (96.1%), non-intact family (3.9%)

Sample Demographics - Gender

Male; 58.4%Female; 41.6%

Hong Kong

Male; 52.4%Female; 47.6%

Mainland

Sample Demographics - Age

11-12;

13.6%

13-14; 49.6%

15-16; 34.5%

17-18; 2.3%

Hong Kong

11-12; 11.6%

13-14; 53.3%

15-16; 34.3%

17-18; 0.8%

Mainland

Sample Demographics – Annual Family Income

< $30,000 , 6.0%

$30,001 - $70,000, 19.6%

$70,001 - $130,000;

53.0%

$130,001 - $190,000,

13.6%

> $190,001, 7.8%

Hong Kong

< $10,000 ; 81.1%

$10,001 - $70,000;

18.5%

$70,001 - $130,000; 0.2%

$130,001 - $190,000; 0.2%

Mainland

Sample Demographics – Religious Belief

Yes ; 36.9%

No; 63.1%

Hong Kong

Yes; 18.9%

No; 81.1%

Mainland

Sample Demographics – Parent’s Marital Status

Married or liv-ing together;

92.5%

Separated or divorced; 7.5%

Hong Kong

Married or liv-ing together;

96.1%

Separated or divorced; 3.9%

Mainland

Measuring Instruments Name of the instrument

Developed by Year No. of items

Measuring area Scale

Suicidal ideation sub-scale (C-SIS) of the Suicidal Risk Scale

Tse W.L. 2002 13 Adolescent suicidal ideation

4-point Likert scale

Chinese Hopelessness Scale (C-HOPE)

Shek DTL(original version by Beck et al.)

1993(1974)

10 Hopelessness 4-point Likert scale

Chinese Emotional Intelligence Scale (C-EIS-R short form)

Chan D(original version by Schutte et al.)

2003(1998)

12 •Utilization of emotions•Self-management of emotions•Social skills•Empathy

5-point Likert scale

Measuring Instruments (con’t)Name of the instrument

Developed by Year No. of items

Measuring area Scale

Chinese Social Problem Solving Inventory (C-SPSI-R short form)

Siu & Shek(original version by D’Zurilla)

2005(1996

15 •Negative problem orientation•Impulsiveness / carelessness style•Rational problem solving

5-point Likert scale

•Father-Adolescent Communication Scale (FACS)•Mother –Adolescent Communication Scale (MACS)

Shek DTL 2002, 2006

25, 25 Parent-adolescent communication

4-point Likert scale

Chinese Family Assessment Instrument (C-FAI short form)

Shek DTL 2000 24 •Mutuality•Conflict & Harmony•Parental Concern•Parental Control

5-point Likert scale

Suicidal ideation

• I believe that death is a kind of relief• I really want to put an end to all this so that I

don’t have to continue to bear the pain

Sample items:• I feel that dying is no big deal• I think being dead may be better

than what it is now

Hopelessness

Sample items:• My future seems dark

to me• I don’t expect to get

what I really want• I might as well give up

because I can’t make things better for myself

Emotional competence• Social skills, e.g. help others feel

better • Empathy, e.g. know how others

feel by their tone of voice • Self-management of emotions,

e.g. control over own emotions • Utilization of emotions, e.g. see

new possibilities when mood changes

Social problem solving• Negative problem orientation, e.g. feel afraid

when having problems to solve • Rational problem solving, e.g. use systematic

method for comparing alternatives• Impulsiveness / carelessness style, e.g. act on

the first idea that occurs

Family functioning• Mutuality e.g. Family members accommodate

each other• Conflict and harmony e.g. There is much friction

among family members• Parental concern e.g. Parents take good care of

their children• Parental control e.g. Parents

force children to do things• Systemic level of communication

e.g. family members enjoy talking with one another

Parent-adolescent communication• Father-adolescent

communication• Mother-adolescent

communication• e.g. I can voice out my thinking

and feeling to my father/ mother in our communication

• Father/mother knows my feeling even when he/she has not asked me.

Table 1Summary of multiple regression analyses predicting hopelessness from family functioning, emotional competence, and social problem solving (N = 1063)

Hong Kong (n = 536) Mainland (n = 527) Variable ΔR2 β t df ΔR2 β t df

Controlled demographics Gender .077 2.17 * -.045 -1.22 Age .022 .61 -.022 -.62 Religion .013 .37 .000 .00 Family income .016 .47 .008 .23

Family Functioning Mutuality .030 .52 -.019 -.38 Father-adolescent communication -.169 -3.54 *** -.180 -3.79 *** Mother-adolescent communication -.164 -3.62 *** -.038 -.83 Conflict & harmony -.089 -1.68 -.127 -.260 ** Parental concern -.138 -3.01 ** -.042 -.97 Parental control -.123 -2.79 ** -.180 -3.89 ***

Emotional Management Utilization of emotions -.077 -2.03 * .017 .45 Self-management of emotions -.080 -2.00 * .054 1.35

Social Problem Solving Rational problem solving -.032 -.82 -.128 -3.39 ** Negative problem orientation .163 3.96 *** .251 5.77 *** Impulsiveness/carelessness style .037 .96 -.003 -.07

Total R2 .392 *** 521 .330 *** 512

Direct and indirect effect of predictors on suicidal ideation (Hong Kong Sample)

Father-adolescent communication

Mother-adolescent communication

Parental Concern

Parental Control

Utilization of emotions

Self-management of emotions

Negative problem orientation

Hopelessness Suicidal Ideation

-.169***

-.164***

-.138**

-.123**

-.077*

-.080*

.163***

^Only significant paths are shown; regression coefficients shown are standardized

.585***

Conflict & Harmony

-.158**

Direct and indirect effect of predictors on suicidal ideation (Mainland Sample)

Father-adolescent communication

Parental Control

Rational problem solving

Negative problem orientation

Hopelessness Suicidal Ideation

-.127***

-.180***

-.128**

.251***

.676***

Conflict & Harmony

-.093*

-.180*** -.077*

.081*

^Only significant paths are shown; regression coefficients shown are standardized

Discussion• Hopelessness is a mediator in both samples• Father-adolescent communication, parental control and

negative problem orientation are significant predictors of hopelessness that lead to suicidal ideation for both samples

• Mother-adolescent communication, parental concern, utilization of emotions, self-management of emotions are significant predictors of hopelessness in the Hong Kong sample

• Conflict and harmony, Rational problem solving are the significant predictors of hopelessness in the Shanghai sample

Implication

• Cultivate the sense of hope:• life goals enhancement• positive psychology

(emphasize on positive emotions and individual traits)

• reinforcement of positive traditional Chinese beliefs about coping with adversity

Implication

• Enhance emotional competence, especially self-management of emotions, utilization of emotions, for the HK adolescents

• Enhance social problem solving skills, i.e. decrease negative problem orientation for both samples, enhance rational problem solving skills for the Shanghai sample.

Implications: Enhancement of parent-adolescent communication

• Parallel groups and workshops on communication skills training (e.g. positive parenting program, adolescent communication training) for both parents (especially the fathers) and the adolescents.

Positive parenting program

• Guide the parents to:• Be kind and friendly• Respect and trust the

adolescents• Provide space, a free

and relaxing atmosphere for communication

Positive parenting program• Answer the adolescents’

questions sincerely• Guide them to think out

different solutions, evaluate their pros and cons, and let them make decisions

• Encourage the adolescents to express their thinking and feeling openly, and to raise problems for discussion

Positive parenting program

• Take initiative to communicate with the adolescents

• Look at things from the adolescents’ perspectives

• Be willing to listen to what the adolescents talk

• Reflect the adolescents’ thinking and feeling

Positive parenting program• Things to avoid:• Dominating the discussion• Ordering, ridiculing, criticizing,

provoking, indoctrinating the adolescents

• Troubling and nagging the adolescents continuously

• Using double-bind messages

Adolescent communication training• Guide the adolescents to:• Respect, trust the parents• Take initiative to communicate

with the parents• Express their feeling and thinking• Discuss problems with their

parents• Look at things from the parents’

perspectives• Understand the parents’ thinking

and feeling

Practice implications – enhancing family functioning

• Family workshops and programs to enhance family harmony, parental concern and minimize family conflict and parental control.

Practice implications - enhancing family functioning

• Decrease family conflict and enhance family harmony by:

1. Decreasing family friction, quarrels and fighting

2. Enhancing marital and family relationship

Practice implications – enhancing family functioning

• Guide the parents to :• Increase parental concern

and decrease parental control (e.g. scolding, forcing the adolescents to do things)

References• Beavers, W. R., Hampson, R. B., & Hulgus, Y. F. (1990). Manual: Beavers Systems Model

of Family Assessment. Dallas: Southwest Family Institute.• Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of

pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861-865.

• Chan, D. W. (2003). Dimensions of emotional intelligence and their relationships with social coping among gifted adolescents in Hong Kong. Journal of Youth and Adolescence, 32, 409-418.

• D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (1996). Manual for the Social Problem-Solving Inventory-Revised (SPSI-R). North Tonawanda, NY: Multi-Health System, Inc.

• Ellis, A., & Bernard, M. E. (2006). Rational Emotive Behavioural Approaches to Childhood Disorders: Theory, Practice and Research. New York: Springer.

• Epstein, N. B., Bishop, D., Ryan, C., Miller, I., & Keitner, G. (1993). The McMaster Model: View of healthy family functioning. In F. Walsh (Ed.), Normal Family Processes (pp. 138-160). New York: Guilford Press.

• Lee, S., Fung, S. C., Tsang, A., Liu, Z. R., Huang, Y. Q., He, Y. L., . . . Kessler, R. C. (2007). Lifetime prevalence for suicide ideation, plan and attempt in metropolitan China. Acta Psychiatrica Scandinavica, 116(6), 429-437.

References (con’t)• Miros, N. J. (2000). Depression, anger, and coping skills as predictors of suicidal ideation

in young adults: Examination of the diathesis-stress-hopelessness theory. Dissertation Abstracts International: Section B: The Sciences and Engineering, 61, 3286.

• Olson, D. H., Russell, C. S., & Sprenkle, D. H. (1989). Circumplex Model: Systemic Assessment And Treatment of Families. New York: Haworth Press.

• Pinto, A., & Whisman, M. A. (1996). Negative affect and cognitive biases in suicidal and nonsuicidal hospitalised adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 158-165.

• Schuttle, S. Malouff, M., Hall, L., Haggerty, D., Cooper, J., Goldern, C., et al. (1998). Development and validation of a measure of emotional intelligence. Personality and Individual Differences, 25, 167-177.

• Shek, D. T. L. (1993). Measurement of pessimism in Chinese adolescents: The Chinese hopelessness scale. Social Behaviour and Personality, 21, 107-119.

• Shek. D. T. L. (2000). Assessment of family functioning in Chinese adolescents. In N. N. Singh (Ed.), International Perspectives on Child and Adolescent Mental Health. Holland: Elsevier.

References (con’t)• Shek, D. T. L. (2002). Assessment of family functioning in Chinese adolescents: The

Chinese version of the family assessment device. Research on Social Work Practice, 12, 502-524.

• Shek, D. T. L., Lee, T. Y., Lee, B. M., & Chow, J. (2006). Perceived parental control and psychological well-being in Chinese adolescents in Hong Kong. International Journal of Adolescent Medicine and Health, 18, 535-545.

• Siu, A. M. H., & Shek, D. H. L. (2005). Psychometric properties of the Chinese Family Assesssment Instrument in Chinese adolescents in Hong Kong. Adolescence, 40, 817-830.

• Thompson, A., Mazza, J., Herting, R., Randell, P., & Eggert, L. (2005). The mediating roles of anxiety, depression, and hopelessness on adolescent suicidal behaviours. Suicide and Life-threatening Behaviour, 35, 14-34.

• Tse, J. W. L., & Bagley, C. (2002). Suicidal Behaviour, Bereavement and Death Education in Chinese Adolescents. London, UK: Ashgate Publishing.

• Weishaar, M. E., & Beck, A. T. (1992). Hopelessness and suicide. International Review of Psychiatry, 4, 177-184.

• Yang, B. & Clum, G. A. (1996). Childhood stress leads to later suicidality via its effect on cognitive functioning. Suicide and Life-threatening Behaviour, 30, 183-198.