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

Risk and Protective Factors for Suicidal

Ideation Among Taiwanese Adolescents
Ruey-Hsia Wang

Hsiao-Jung Lai

b Background: Suicide is the ninth leading cause of death in

adolescents aged 15Y19 years in Taiwan. Suicidal ideation
is an important predictor of committing suicide among
adolescents.
b Objectives: The aim of this study was to examine the
important 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 southern
Taiwan were recruited for this study. An anonymous selfreported 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 reported
having 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 adaptation (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 be
targeted to female adolescents. School-based efforts that
provide adolescents with self-esteem enhancement, emotional 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

Hsiu-Yueh Hsu

Min-Tao Hsu

uicide is the third leading cause of death in adolescents

aged 15Y24 years in the United States (Centers for
Disease Control and Prevention, 2011). In Taiwan, suicide
is the ninth leading cause of death in adolescents aged
15Y19 years (Department of Health, Executive Yuan,
Taiwan, 2011). Adolescence is a special stage of human
development that bridges childhood to adulthood. In this
crucial period, adolescents experience drastic changes in
not only physical body growth but also cognition, social relations, and emotions that can arouse many pressures in such a transition stage of human life. If adaptations
are not successful in allowing adolescents to pass through
stages of development, many of them may become determined to commit suicide (Manor, Vincent, & Tyano,
2004).
Suicidal ideation is an important predictor of committing suicide; it can be an indicator for suicidal prevention
(Chamberlain, Goldney, Delfabbro, Gill, & Dal Grande,
2009). Suicidal ideation is defined as wishes, thoughts, or desires to take ones own life violently (OCarroll et al., 1996).
Approximately one third of adolescents have reported having suicidal ideation at some time (Evans, Hawton, Rodham,
& Deeks, 2005).
The factors that influence adolescents at risk for suicidal ideation are complex. Many demographic factors
are related to adolescent suicidal ideation. Cheng et al.
(2009) found that female adolescents are at greater risk
for suicidal ideation than are male adolescents. In addition, adolescents living in single-parent families experience
significantly more suicidal ideation than those from twoparent families (Bearman & Moody, 2004). Furthermore,
lower socioeconomic status is associated with higher levels
of suicidal ideation in Taiwanese and American adolescents
(Chan et al., 2009; Yoder & Hoyt, 2005).
Several risk factors are crucial for predicting adolescent suicidal ideation. Stress is a response of the human

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 of
Nursing, Meiho University, Pingtung, Taiwan.
Min-Tao Hsu, PhD, RN, is Professor, College of Nursing,
Kaohsiung Medical University, Kaohsiung, Taiwan.
DOI: 10.1097/NNR.0b013e3182337d83

Nursing Research November/December 2011 Vol 60, No 6

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413

414 Suicidal Ideation Factors

Nursing Research November/December 2011 Vol 60, No 6

body to any stimulus that disrupts the

moderate the effect of risk factors on
individuals homeostasis and has been
problem behaviors in Taiwanese and
found to relate to emotional and psyAmerican adolescents (Jessor et al.,
chological problems. Previous studies
2003; Wang, Hsu, Lin, Cheng, & Lee,
have supported that high perceived life
2010). Until now, little research has
stress significantly increases the risk for
addressed the relationship between risk
More than 50% of
suicidal ideation among Taiwanese and
factors and protective factors on the
adolescents who commit
American adolescents (Chang, Yang, Lin,
suicidal ideation of Asian adolescents.
suicide were diagnosed
Ku, & Lee, 2008; Portzky, Audenaert,
The purpose of this study was to
& van Heeringen, 2009). Depression has
identify the important risk and protecwith depression
been identified as the most significant
tive factors and the role of protective
(Chiou et al., 2006).
risk for suicidal ideation in Eastern and
factors on the relationship of risk facWestern countries (Bearman & Moody,
tors on suicidal ideation of Taiwanese
2004; Chan et al., 2009). More than
adolescents aged 15Y19 years. Risk
50% of adolescents who commit suicide
and protective factors were hypothewere diagnosed with depression (Chiou,
sized to relate directly to suicidal ideqqq
Chen, & Lee, 2006).
ation; furthermore, protective factors
An ecological model emphasizes the
moderate the negative effects of risk
influence of environmental context such as family and peers
factors on suicidal ideation. The hypothesized conceptual
on adolescent risk behaviors (Bronfenbrenner & Morris,
framework is shown in Figure 1.
1998). Peer and parental suicidal ideation are correlated significantly to suicidal ideation among adolescents (Bearman
Methods
& Moody, 2004). Peer bullying is a specific form of agSample
gression that occurs commonly among adolescents, espeThis study was a cross-sectional study. The sample size was
cially in school settings (Smith-Khuri et al., 2004). Bullying
predetermined using power analysis based on the small
victimization has been found to be associated positively with
effect size (, = 0.20) in a bivariate correlation situation,
suicidal ideation (Hinduja & Patchin, 2010).
with the alpha level being .05 and the power being .80.
However, not all adolescents with risk factors have
Four hundred participants were determined as adequate for
suicidal ideation. Protective factors can minimize the threat
analysis (Polit & Hungler, 2004). With the use of conof risk factors on suicidal behaviors and play an essential
venience sampling, three senior high schools were selected
role in preventing suicide (Benard, 2002). Self-esteem refrom Pingtung County and Kaohsiung City in southern
flects a persons overall evaluation or appraisal of his or
Taiwan. Two classes were selected randomly from each
her own worth, and it is a powerful protective factor for
included school, and students in the selected classes were
suicidal ideation (Kidd & Shahar, 2008; Wilburn & Smith,
invited to participate in the study. Of the 653 students
2005). In addition, emotional adaptation involves effective
invited to participate in this study, 577 (88.4%) provided
responses to stress (Greenberg, 2006) and was proven to be
complete data for the variables of interest in this study and
related to suicidal ideation (Cha & Nock, 2009). Morewere included in the final analysis. Data were collected
over, adolescents having high levels of family communicafrom October 2006 to March 2007.
tion with their parents will cope successfully with life
changes because they can turn to their families for support
(Davalos, Chavez, & Guardiola, 2005). These high levels
of family communication with parents reduce the risk of
suicidal ideation (Garcia, Skay, Sieving, Naughton, &
Bearinger, 2008). Future aspirations are positive views for
their future and can be a protective factor of suicidal ideation. However, previous studies have focused on how future aspirations reduce sexual risk behaviors and tobacco
use (Atkins, Oman, Vesely, Aspy, & McLeroy, 2002; Vesely
et al., 2004). Not much is known about the relationship
between future aspirations and adolescent suicidal ideation.
Conceptually, risk factors increase the probability of
engaging in risky behaviors, whereas protective factors
decrease the likelihood of engaging in risky behaviors. However, protective factors play a different role in influencing
the relationship of risk factors to risky behaviors (Fergus &
Zimmerman, 2005). The compensatory model assumes that
the effect of protective factors is independent of the effect of
risk factors on risky behaviors. The protective factor model
assumes that protective factors moderate the negative effects
FIGURE 1. Hypothesized conceptual framework outlining the role of
of risk factors on risky behaviors. Previous studies found
risk and protective factors on suicidal ideation.
that protective factors are not only related directly but also

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Nursing Research November/December 2011 Vol 60, No 6

Instrumentation
An anonymous questionnaire was used to collect the following data.
Demographic Characteristics Information on the partici-

pants age, gender, socioeconomic status, and family structure (living in a family with or without both parents) was
collected. Socioeconomic status was determined based on
the highest levels of education and the occupation of both
parents.
Suicidal Ideation The suicidal ideation of participants
was measured using a single item adopted from the questionnaire of the Youth Risk Behavior Surveillance System
(National Center for Chronic Disease Prevention and Health
Promotion, n.d.). This item has been used in periodic U.S.
national surveillance. The item is During the past 12
months, 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 measured

in two dimensions: life stress and depression. Life stress
during the past 6 months was measured using a 35-item
scale developed by Harn (1999). An example item is I am
punished by my parents. Responses ranged from doesnt
bother me (0 points) to bothers me very much (4 points).
Higher scores indicate higher perceived life stress.
Depression was measured using a single item adopted
from the questionnaire of the Youth Risk Behavior Surveillance System (National Center for Chronic Disease Prevention and Health Promotion, n.d.). This item also has
been used in periodic U.S. national surveillance. The item is
During the past 12 months, did you ever feel sad or
hopeless almost every day for at least 2 weeks in a row that
you stopped doing some usual activities? Responses were
yes or no.
Environmental risk factors were measured using four
dimensions: suicidal ideation of the father, mother, and
peers and bullying victimization at school. The suicidal
ideation of the father, mother, and peers was measured
from the adolescents subjective perception. A single item
was used: Did your father/mother/good friends have suicidal 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 experiences
in the past 12 months: being threatened by a weapon, personal property being deliberately stolen or damaged, or
being deliberately harmed by others. Each item was scored
with a yes (1 point) or no (0 points) response. The scores of
these three items were combined into a single score, with
higher total scores indicating greater bullying victimization.
Protective Factors Protective factors were measured using
four multi-item scales assessing self-esteem, future aspiration,
emotional adaptation, and family communication. The selfesteem scale was developed by Lin (1996), adopted from the
self-esteem scale developed by Rosenberg (1965). Although
it was originally a 10-item scale, one item was deleted after

Suicidal Ideation Factors 415

explanatory factor analysis in this study. An example item is

In general, I am satisfied with myself. Future aspiration
and emotional adaptation were measured using three items
developed by the authors. An example item of future aspiration is I think I will have a great future. An example
item of emotional adaptation is My behavior is easily
influenced by my emotions.
The family communication scale included three items
modified from the Youth Asset Survey scale (Oman et al.,
2002). An example item is How often does your mother
or father discuss your worries with you? Responses of
self-esteem, future aspiration, and emotional adaptation
were scored from strongly disagree (0 points) to strongly
agree (3 points). Reversed items were coded oppositely.
Responses on the family communication scale were scored
from almost never (0 points) to almost always (3 points).
The scores of individual items were combined into total
scores for each scale. Higher total scores indicated better selfesteem, future aspiration, emotional adaptation, or family
communication.
Validity and Reliability of Measures
Five experts in nursing and adolescent health confirmed the
content validity of the scales used in this study. These
experts rated the relevance of each item in each scale from
1 (irrelevant) to 4 (very relevant). The items rated with a
relevance of 3Y4 by the experts were divided by the total
numbers of items in each scale to produce the content
validity index of each scale. The content validity index for
all the scales ranged from .90 to 1.00, indicating that all
scales had acceptable content validity (Waltz, Strickland, &
Lenz, 1991). Some items were revised based on the experts
suggestions. Revised questionnaires were given to four
junior high students to test item clarity. They responded
that the items of the questionnaire were adequate for adolescents to understand.
Cronbachs alpha was calculated to test internal consistency using data for all participants in the study. A
convenience sample of 36 adolescents who satisfied the
research criteria were recruited from another school. They
completed the revised questionnaire to determine the
testYretest reliability of the scales over a 2-week interval.
Cohens kappa (one-item scale) or intraclass correlation
coefficient (multi-item scale) was used to examine the
testYretest reliability. Principal axis factor analysis with
Promax rotation was performed to examine the construct
validity of each multi-item scale using data for all participants in the study. As shown in Table 1, Cronbachs
alpha, testYretest reliability, and construct validity of each
scale are acceptable in this study.
Ethical Considerations
This study was approved by the institutional review board
of Kaohsiung Medical University. In this study, passive
parental 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 want
their child to participate in the study. The students whose
parents or guardians consented were asked to sign consent forms.

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416 Suicidal Ideation Factors

Nursing Research November/December 2011 Vol 60, No 6

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

Protective factors
Future aspirations
Emotional adaptation
Family communication
Self-esteem
Risk factors
Life stress
Depression
Bullying victimization
Fathers suicidal ideation
Mothers suicidal ideation
Peers suicidal ideation

Cronbachs !

ICC

No. of factors

Explained variance (%)

.69
.62
.80
.84

0.81
0.67
0.76
0.75

1
1
1
2a

61.93
57.33
71.95
59.56

.92
NA
NA
NA
NA
NA

0.90
1.0c
0.78
1.0c
1.0c
0.8c

5b
NA
NA
NA
NA
NA

53.83
NA
NA
NA
NA
NA

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

ipants under the direction of a trained assistant. Students

were assured of the confidentiality and anonymity of the
data provided and were informed of their right to withdraw from the study at any stage without penalty or prejudice. After completing the questionnaire, the students
received a gift for their participation.

Procedures
Permission and support for this study were obtained from
each selected school. An anonymous questionnaire with a
cover page to ensure confidentiality was distributed to each
student during a regular class period. After teachers left
the classroom, questionnaires were administered to particq

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

Suicidal ideation
Variables
Age
15Y16 years
16Y17 years
917 years
Gender
Male
Female
Family structure
Living with both parents
Living without both parents
Socioeconomic status (n = 531)a
Low
Middle
High

Total, n (%)

No, n (%)

Yes, n (%)

323 (56.0)
211 (36.6)
43 (7.5)

261 (80.8)
181 (85.8)
34 (79.1)

62 (19.2)
30 (14.2)
9 (20.9)

283 (49.0)
294 (51.0)

253 (89.4)
223 (75.9)

30 (10.6)
71 (24.1)

465 (80.6)
112 (19.4)

391 (84.1)
85 (75.9)

74 (15.9)
27 (24.1)

362 (62.7)
139 (24.1)
30 (5.2)

294 (81.2)
119 (85.6)
25 (83.3)

68 (18.8)
20 (14.4)
5 (16.7)

#2

2.57

0.277

18.33

G.001

4.19

.041

1.35

0.507

Forty-six missing cases.

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Suicidal Ideation Factors 417

Nursing Research November/December 2011 Vol 60, No 6

tion, and lower scores of emotional adaptation than did

those without suicidal ideation (Tables 2 and 3).
Before hierarchical logistic regression, the correlation
matrix and collinearity diagnostics were carried out to examine the collinearity among independent variables. All
values of tolerance were larger than 0.67, variance inflation
factors were smaller than 1.53, and condition indexes were
smaller than 21.18. The results indicated that there was no
collinearity among the independent variables. Then, hierarchical logistic regression was used to identify the most
important explanatory variables of suicidal ideation. Participants of middle and high socioeconomic status were combined 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 middle
or high socioeconomic status were used as reference groups.
Demographic characteristics were entered in Step 1 of
the hierarchical logistic regression analysis. As shown in
Table 4, demographic variables accounted for 6.7% of the
variance in suicidal ideation (# 2 = 22.10, df = 5, p = .001).
Female gender (odds ratio [OR] = 2.50) and not living in a
family with both parents (OR = 1.78) were statistically
significant explanatory variables to suicidal ideation in
Step 1. The model correctly identified 82.5% of the participants with suicidal ideation.

Data Analysis
Data analysis was done using SPSS Version 16.0 for
Windows. Chi-squared tests and t tests were performed to
analyze the relationships between demographic characteristics, risk factors, protective factors, and suicidal ideation.
Hierarchical logistic regression was used to analyze the
important explanatory variables of suicidal ideation. Each
step reported j2 log likelihood; Nagelkerke R2, indicating
proportion of explained variance; and the chi-square value
associated with the change in j2 log likelihood measuring
improved model fit. The HosmerYLemeshow goodness-of-fit
test measured whether the data fit the model. In all tests,
p values of less than .05 were interpreted as statistically
significant.

Results
Of the participants, 17.5% (n = 101) reported having
suicidal ideation. Participants who were female, who were
living without both parents, who had depression, or whose
mother or peers had suicidal ideation had a significantly
higher proportion of suicidal ideation than others did. Adolescents who had suicidal ideation had significantly higher
scores of life stress, higher scores of bullying victimization,
lower scores of self-esteem, lower scores of future aspira-

TABLE 3. Distribution and Comparison of Risk Factors and Protective Factors to Suicidal
Ideation (n = 577)

Risk factors
Depression
Yes
No
Mothers suicidal ideation
Yes
No
Fathers suicidal ideation
Yes
No
Peers suicidal ideation
Yes
No

Life stress
Bullying victimization
Protective factors
Self-esteem
Future aspirations
Emotional adaptation
Family communication

Total, n (%)

No, n (%)

Yes, n (%)

60 (10.4)
517 (89.6)

30 (50.0)
446 (86.3)

30 (50.0)
71 (13.7)

#2

48.96

G.001

17.04

G.001

0.31

.57

63.86

G.001

28 (4.9)
549 (95.1)

15 (53.6)
461 (84.0)

13 (46.4)
88 (16.0)

8 (1.4)
569 (98.6)

6 (75.0)
470 (82.6)

2 (25.0)
99 (17.4)

114 (19.8)
463 (80.2)

65 (57.0)
411 (88.8)

49 (43.0)
52 (11.2)

M T SD

M T SD

M T SD

40.21 T 21.03
0.27 T 0.58

37.04 T 20.01
0.22 T 0.52

55.14 T 18.81
0.48 T 0.78

j8.35
j3.19

G.001
.002

6.05
2.78
5.14
1.55

G.001
.006
G.001
.121

15.77
5.88
7.37
3.26

T
T
T
T

4.49
1.66
2.40
2.21

16.27
5.97
7.61
3.33

T
T
T
T

4.36
1.65
2.36
2.25

13.39
5.47
6.29
2.95

T
T
T
T

4.33
1.66
2.31
2.01

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418 Suicidal Ideation Factors

Nursing Research November/December 2011 Vol 60, No 6

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

Step 1
Variables
Demographics
Age (16Y17 years)a
Age (917 years)a
Gender (female)b
Family structure (living without both parents)c
Socioeconomic status (low)d
Risk factors
Life stress
Depression
Fathers suicidal ideation
Mothers suicidal ideation
Peers suicidal ideation
Bullying victimization
Protective factors
Self-esteem
Future aspirations
Emotional adaptation
Family communication

Step 2

Step 3

OR

95% CI

OR

95% CI

OR

95% CI

0.69
1.07
2.50***
1.78*
1.35

0.42Y1.13
0.46Y2.50
1.53Y4.05
1.04Y3.06
0.81Y2.26

0.90
1.16
4.67***
1.47
1.26

0.50Y1.60
0.41Y3.24
2.46Y8.86
0.77Y2.81
0.70Y2.26

0.99
1.10
4.23***
1.40
1.45

0.54Y1.80
0.39Y3.16
2.20Y8.14
0.72Y2.73
0.79Y2.67

1.03***
4.13***
2.62
1.62
3.71***
1.76**

1.02Y1.05
2.06Y8.28
0.41Y16.74
0.59Y4.39
2.10Y6.57
1.16Y2.68

1.03***
3.41***
2.86
1.28
4.15***
1.80**

1.01Y1.04
1.66Y7.01
0.43Y19.11
0.44Y3.70
2.29Y7.51
1.16Y2.81

0.92*
1.03
0.88*
1.00

0.85Y0.99
0.86Y1.24
0.78Y1.00
0.88Y1.14

Note. R 2 = 40.6%. The results of Step 4 are not shown because all statistics were not significant. OR = odds ratio; CI = confidence interval.
a
Reference group: age of 15 years.
b
Reference group: male.
c
Reference group: living with parents.
d
Reference group: middle and high socioeconomic status.
*p G .05.
**p G .01.
***p G .001.

The six risk factors were added in Step 2. The model

explained that the total variance of suicidal ideation significantly 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 risk
factors of suicidal ideation. The model correctly identified
84.7% of the participants with suicidal ideation.
The four protective factors were added in Step 3. The
model explained that the total variance of suicidal ideation 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) were
significant risk factors of suicidal ideation. Self-esteem
(OR = 0.92) and emotional adaptation (OR = 0.88) were
significant protective factors of suicidal ideation. The model
correctly identified 86.1% of the participants with suicidal
ideation.
The interaction effects of the protective factors and the
risk factors of suicidal ideation were tested in Step 4. Significant risk factors (life stress, depression, peers suicidal
ideation, and victimization) and significant protective

factors (self-esteem and emotional adaptation) of suicidal

ideation were selected in Step 3 analyses to produce risk
factors and protective factors cross-products. The eight
interaction terms were added in Step 4. Compared with
Step 3, the explained variance (42.1%) did not increase
significantly (# 2 = 6.23, df = 8, p = .622). The protective
factors were unable to moderate the negative effect of the
risk factors on suicidal ideation. The HosmerYLemeshow
test for goodness of fit from Steps 1 to 3 were 2.95 with
df = 7 (p = .890), 8.39 with df = 8 (p = .397), and 5.60 with
df = 8 (p = .693), respectively, indicating a good model fit
for these three steps of analysis.
A post hoc power analysis of multiple linear regression
indicated a power of 1.0 for the study. The sample size was
judged to be adequate.

Discussion
Results showed that 17.5% of adolescents reported having
suicidal ideation in the previous year. This prevalence is
similar to that of a previous systematic review showing
that 19.3% (95% confidence interval = 11.7Y27.0) of
adolescents had suicidal thoughts in the previous year

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Nursing Research November/December 2011 Vol 60, No 6

(Evans et al., 2005). The results showed that the risk of

suicidal ideation in female adolescents increased from 2.50
to 4.23 times that of male adolescents after controlling for
the risk and protective factors. Some factors related to the
female gender may explain the increasing risk of suicidal
ideation in female adolescents that need to be explored
further. Family structure was not a statistically significant
explanatory variable of suicidal ideation after controlling
for the effects of risk and protective factors. This finding
is similar to that of a previous study (Reinherz, Tanner,
Berger, Beardslee, & Fitzmaurice, 2006).
Results show that life stress and depression are
important risk factors for adolescent suicidal ideation after
controlling for demographics and protective factors. Intervention programs aimed at preventing suicidal ideation in
adolescents should include stress management skills. Furthermore, screening for depression may help identify adolescents at risk for suicidal ideation.
Suicidal ideation of participants mothers was related to
adolescent suicidal ideation, but their fathers suicidal
ideation was not. This result is similar to that of the study
of An, Ahn, and Bhang (2010) in Korea. This might be
because mothers take more responsibility in the direct care
of their children in Taiwan; consequently, children are
more influenced by their mothers suicidal ideation than by
their fathers. Peer identity is important to adolescent
psychosocial development (Smetana, Campione-Barr, &
Metzger, 2006). The developmental characteristics of
adolescents might cause them to be more influenced by
their peers suicidal ideation than by their mothers suicidal
ideation. School-based programs focused on building
adolescent peer norms of appropriate attitudes for life
and help-seeking strategies that might help reduce suicidal
ideation in adolescents.
Bullying is recognized as a serious problem in high
schools in the United States (Spriggs, Iannotti, Nansel, &
Haynie, 2007). However, it is a new phenomenon that
does not get much attention in Taiwan. Bullying victimization was found in this study to be an important risk
factor of suicidal ideation. Victims of bullying in the school
setting are relatively easy to identify, and antibullying
programs in schools can also help in detecting bullied
adolescents (Mytton, DiGuiseppi, Gough, Taylor, &
Logan, 2006). Hopefully, consciousness can be raised
about implementing antibullying programs in high school
to reduce youth suicidal ideation. Of note, bullying victimization was based solely on reports of physical bullying
victimization in this study. However, adolescent bullying
may take other forms, such as verbal, relational, or social
(Wang, Iannotti, & Nansel, 2009). To understand the
relationships of different types of bullying victimization to
suicidal ideation more fully, future research should include
forms of bullying victimization.
Self-esteem and emotional adaptation were found to be
important protective factors for suicidal ideation. Selfesteem has been linked to better psychological function
and adjustment. Moreover, adolescents with good emotional adaptation may cope well with stress. The results
suggest that interventions to decrease suicidal ideation
should include content to enhance self-esteem and improve
the emotional adaptation skills of adolescents.

Suicidal Ideation Factors 419

Self-esteem and emotional adaptation compensate for

but do not moderate the negative effect of risk factors on
suicidal ideation in this study. The role of self-esteem on
suicidal ideation in this study is consistent with that of
Wilburn and Smith (2005). However, by using different
protective factors, emotional intelligence and problemsolving skills were found to moderate the negative effect
of stress on adolescent suicidal ideation (Cha & Nock,
2009; Grover et al., 2009). Different protective factors
might have different roles in influencing the relationship of
risk factors on suicidal ideation. Other protective factors
should be explored, such as emotional intelligence and
problem-solving skills in adolescent suicidal ideation in the
future.
Cognitive and situational factors such as privacy and
confidentiality can influence the validity of self-reported
risk behaviors in adolescents (Brener, Billy, & Grady,
2003). However, such effects were minimized because great
care was taken when designing the questionnaire and
collecting data. The final model explained 40.6% of the
total variance in suicidal ideation and correctly predicted
86.1% of the participants with suicidal ideation. This
model is appropriate to explain suicidal ideation in
Taiwanese adolescents.
The low reliability coefficients for scales of future
aspiration (.69) and emotional adaptation (.62) indicate
that these scales require further revision. Efforts such as
adding items should be made to increase the reliability of
these scales. Some data collected in the study relied on a
single item. Although the testYretest reliability in this study
is acceptable, to measure the concept more comprehensively, multiple items should be used in the future. The
sample was selected by convenience from southern Taiwan,
which limits the generalizability of the results to other
areas. Conducting further studies in more heterogeneous
and national adolescent populations is needed to confirm
these results. A cross-sectional design was used in this
study, precluding an exploration of the causal associations
between risk and protective factors and suicidal ideation.
Prospective longitudinal studies examining the causal
relationships between risk and protective factors and their
interaction on suicidal ideation of adolescents are suggested
for the future.
Conclusions
The findings of this study highlight that risk and protective
factors independently influence the suicidal ideation of
adolescents. Results from this study make a unique
contribution to existing knowledge about the role of risk
and protective factors on suicidal ideation in Asian
adolescents. Because adolescents spend most of their time
in school, a whole-school approach is ideal to provide
interventions to reduce the suicidal ideation of adolescents.
On the basis of the results of this study, nurses, especially
school nurses, working with teachers and other healthcare
providers to provide intervention programs in schools may
help to reduce suicidal ideation. Some interventions can be
class based, such as self-esteem enhancement, emotional
adaptation and stress management skills training, and
antibullying programs. Others can change the ethos of the
school, such as positive peer norms for life. q

Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

420 Suicidal Ideation Factors

Accepted for publication August 1, 2011.
We thank R.F. Oman, P.C. Harn, and P.C. Lin for providing permission to use their scale.
This research was supported by funding from the National Science
Council 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-Ming
District, Kaohsiung City 807, Taiwan (e-mail: wrhsia@kmu.edu.tw).

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