Mediating Effects of Depression and Anxiety on the Relationship between Bullying Involvement and Pain Problems among Adolescents in Taiwan Cheng-Fang Yen, I.-Mei Lin, Tai-Ling Liu, Huei-Fan Hu, Chung-Ping Cheng PII: DOI: Reference:
S0010-440X(14)00118-7 doi: 10.1016/j.comppsych.2014.05.006 YCOMP 51311
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
11 March 2014 13 May 2014 13 May 2014
Please cite this article as: Yen Cheng-Fang, Lin I.-Mei, Liu Tai-Ling, Hu Huei-Fan, Cheng Chung-Ping, Mediating Effects of Depression and Anxiety on the Relationship between Bullying Involvement and Pain Problems among Adolescents in Taiwan, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.006
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ACCEPTED MANUSCRIPT Mediating Effects of Depression and Anxiety on the Relationship between Bullying Involvement and Pain Problems among Adolescents in Taiwan
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical
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Cheng-Fang Yena,b, I-Mei Linc, Tai-Ling Liua,b, Huei-Fan Hud,*, Chung-Ping Chenge,*
University, Taiwan
Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College
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of Medicine, Kaohsiung Medical University, Taiwan c
Department of Psychology, Kaohsiung Medical University, Taiwan
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Department of Psychiatry, Tainan Municipal Hospital, Taiwan
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Department of Psychology, National Cheng Kung University, Taiwan
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*Dr. CF Yen and Dr. IM Lin contributed equally to this study
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Running title: Bullying Involvement and Pain
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Corresponding author
Chung-Ping Cheng, Ph.D., Department of Psychology, National Cheng Kung University, No.1, University Road, Tainan City 701, Taiwan. E-mail: [email protected] Tel: 886-6-275-7575 FAX: 886-6-275-2029 Huei-Fan Hu, M.D. Department of Psychiatry, Tainan Municipal Hospital, 670 Chongde Road, East District, Tainan 701, Taiwan E-mail: [email protected] Tel: +886-6-2609926886 Fax: +886-6-2606351 1
ACCEPTED MANUSCRIPT Abstract Background: This study aimed to examine the mediating effects of depression and anxiety
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on the relationships of bullying victimization and perpetration with pain among adolescents in
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Taiwan.
Method: A total of 4,976 students of junior and senior high schools completed the
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questionnaires. Bullying victimization and perpetration, pain problems, depression, and
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anxiety were assessed. The mediating effects of depression and anxiety on the relationship between bullying involvement and pain problems and the moderating effects of sex on the medicating roles of depression and anxiety were examined by structural equation model. Results: Both depression and anxiety were significant mediators of the relationship between
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bullying victimization and pain problems among adolescents. Depression was also a significant mediator of the relationship between bullying perpetration and pain problems
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among adolescents. Sex had no moderating effect on the mediating role of depression/anxiety
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on the association between bullying involvement and pain problems. Conclusions: Medical and educational professionals should survey and intervene in
bullying.
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depression and anxiety when managing pain problems among adolescents involved in
Key words: Adolescents, anxiety, bullying, depression, pain, sex.
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ACCEPTED MANUSCRIPT 1. Introduction Victimization of bullying is one of the most traumatic experiences for youths. Meta-analyses
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of previous studies in children and adolescents have found that a significant association of
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bullying victimization exists not only with internalizing [1] and externalizing problems [2] but also with psychosomatic problems [3]. Pain is one of the psychosomatic problems that have
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been frequently examined among victims of bullying. A six-month cohort study on children in
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the Netherlands found that victims of bullying had a significantly higher chance of developing new abdominal pain than those not involved in bullying [4]. A significant association between victimization and pain was not only found in Western youths [4] but also in non-Western youths [5, 6]. These findings stress the importance for clinicians and health practitioners to
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establish whether bullying victimization plays a contributing role in the etiology of pain symptoms [4].
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Compared with bullying victimization, the relationship of bullying perpetration with
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pain has been examined less in previous studies. Meanwhile, the results of previous studies were mixed. Some studies found that bullying perpetrators were more likely to report
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headache, neck and shoulder pain, stomachache, or backache than those who did not perpetrate bullying [7-10], whereas some studies did not find a significant association between bullying perpetration and pain symptoms [11,12]. Bullying perpetrators have been found to have poor mental health [13, 14]. Whether or not pain is a significant psychosomatic problem among bullying perpetrators as it is among victims requires further study. How the relationship between bullying involvement and pain develops is still unknown. One of possible mechanisms is that physical bullying may directly result in victims’ physical pain symptoms. However, this direct mechanism cannot be applied to victims of non-physical bullying and perpetrators of bullying. There may be factors that mediate the relationship between bullying victimization and perpetration and pain. Emotional problems are the factors 3
ACCEPTED MANUSCRIPT that have strong potentials to mediate the association between bullying victimization and perpetration and pain because of several reasons described below. First, research has found
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that both youths who are bullied [15, 16] and those who bully others [14, 17] have
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significantly greater risks of depression and anxiety than those who are not involved in bullying. Second, significant associations of depression and anxiety with pain were found [18].
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Third, based on the Transactional model of coping [19], experiencing bullying victimization is an event with potential stress, and those who experience bullying victimization may use
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primary appraisal to evaluate whether this event is harmful, threatening, or challenging. Then, in secondary appraisal, victims evaluate whether their own coping abilities and resources are sufficient to overcome the harm, threat, or challenge. If the victims evaluate their coping
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abilities and resources as insufficient, they may develop physiological (such as physical symptoms), cognitive (such as a negative attitude toward themselves), emotional (such as
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depression and anxiety), and behavioral (such as avoidance) responses to bullying. Given that there are significant associations among bullying involvement, depression, anxiety, and pain,
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it is reasonable to hypothesize that depression and anxiety may mediate the relationship
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between bullying involvement and pain. However, based on our best knowledge, there has been no study examining this hypothesis. If depression and anxiety are mediators of the relationship between bullying involvement and pain among adolescents, depression and anxiety should be targets of intervention when clinical and educational professionals try to help those who are involved in bullying to manage pain problems. Sex differences in the relationship between bullying involvement and pain among adolescents and the mediating effects of depression and anxiety are other issues that need further study. Although sex differences have been found in the prevalence of bullying involvement [20], depression [21], anxiety [22], and pain symptoms [23] among adolescents, sex difference in the relationship between bullying involvement and pain among adolescents 4
ACCEPTED MANUSCRIPT has seldom been examined, and the results of limited studies were mixed. A previous study found that being bullied had a strong relationship with the development of abdominal pain in
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girls, whereas there was no such relationship in boys [4]. Another study found that the
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associations of bullying victimization with headache and backache were stronger in boys than in girls [11]. However, one study found that the significant association between bullying
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victimization and poor physical health was similar in both sexes [24]. Meanwhile, if depression and anxiety mediate the relationship between bullying involvement and pain,
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whether sex has a moderating effect on the mediating roles of depression and anxiety needs further study. If there are sex differences in the relationship between bullying involvement and pain and in the mediating roles of depression and anxiety, clinical and educational
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professionals must take sex differences into consideration when helping adolescents who are involved in bullying to manage pain problems.
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The aims of this study were to examine the mediating effects of depression and anxiety on the relationships of bullying victimization and perpetration with pain problems among
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adolescents in Taiwan. This study also aimed to examine the moderating roles of sex in the
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relationships of bullying victimization and perpetration with pain problems and the mediating effects of depression and anxiety on the relationships. We hypothesized that both bullying victimization and perpetration are significantly associated with pain problems by the mediation of depression and anxiety. We also hypothesized that sex has a moderating effect on the relationship between bullying involvement and pain problems and on the mediating effects of depression and anxiety.
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ACCEPTED MANUSCRIPT 2. Methods 2.1. Participants
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This study was based on data from the 2009 Project for the Health of Children and
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Adolescents in Southern Taiwan, which was a mental health research survey of adolescents in grades 7 through 12 (age 12 to 18) [22]. This health survey project recruited adolescent
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students from 3 metropolitan areas and 4 counties in southern Taiwan. On the basis of the
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definitions of rural and urban districts in the Taiwan-Fukien Demographic Fact Book [25] and based on school and grade characteristics, a stratified random sampling strategy was used to ensure that there was proportional representation of districts, schools, and grades. In 2009, there were 202,883 students in 143 senior high/vocational schools and 254,130 students in
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205 junior high schools in this area. Five junior high schools and 4 senior high/vocational schools were randomly selected from rural districts; similarly, 5 senior high/vocational
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schools and 5 junior high schools were randomly selected from urban districts. The classes in
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these schools were further stratified into 3 levels based on grade in primary, junior high, and senior high/vocational schools. Then, a total of 6,703 high school students were randomly
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selected based on the ratio of students in each grade. The Institutional Review Board of Kaohsiung Medical University agreed to the use of passive consent from parents and students. Before conducting the study, we prepared a leaflet explaining the purpose and procedures of the study. Students took the leaflet home to their parents or main caretakers, who could telephone the researchers, write in a communication book, or ask their children directly to refuse to join the study. The students also had the right to refuse to participate in this study by returning blank questionnaires along with those from other students. 2.2. Instruments 2.2.1. Chinese version of the School Bullying Experience Questionnaire (C-SBEQ). The 6
ACCEPTED MANUSCRIPT self-reported C-SBEQ was used to evaluate participants’ involvement in school bullying in the previous one year. The 16 items on the C-SBEQ were rated on a Likert 4-point scale, with
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scores ranging from 0 (never) to 3 (all the time) [26]. Items 1 to 8 on this scale evaluate the
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severity of bullying victimization, including social exclusion, being called a mean nickname, being spoken ill of, being beaten up, being forced to do work, and having money, school
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supplies, and snacks taken away. Items 9 to 16 evaluate the severity of bullying perpetration. Higher total scores of items 1 to 8 and items 9 to 16 indicate more severe levels of bullying
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victimization and perpetration, respectively. A previous study found that the test-retest and internal reliability values of all subscales of the C-SBEQ and their congruent validity with bullying involvement nominated by classmates and teachers were satisfactory [27].
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2.2.2. Pain subscale of the Taiwanese Quality of Life Questionnaire for Adolescents (TQOLQA). In this study the three items on the Pain Subscale of the self-administered
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TQOLQA were applied to measure pain problems over the preceding 2 weeks [28], including “Do you worry about pain?” “Do you have any difficulty in managing or coping with pain?”
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and “Does your pain interfere with things you need to do?” Each item is rated on a 5-point
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Likert scale, with scores ranging from 1 (not at all) to 5 (very much). A higher total score indicates more severe pain problems. Cronbach’s α coefficient was .77 for the Pain Subscale [28].
2.2.3. Mandarin Chinese version of the Center for Epidemiological Studies-Depression Scale (MC-CES-D). The 20-item MC-CES-D is a self-administered four-point evaluation scale assessing the frequencies of depressive symptoms in the preceding week, with scores ranging from 0 (none or very few) to 3 (always) [29, 30]. Higher CES-D scores indicate more severe depression. The psychometrics of the MC-CES-D for assessing depressive symptoms among nonreferred adolescents in Taiwan were examined in a previous study [31]. The internal consistency (Cronbach’s alpha) of the MC-CES-D in the present study was 0.94. 7
ACCEPTED MANUSCRIPT 2.2.4. Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T). The MASC-T evaluates the level of anxiety symptoms in adolescents, with 39 items answered on
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a Likert 4-point scale, with scores ranging from 0 (never true) to 3 (often true) [32, 33].
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Higher scores on the total MASC-T indicate more severe anxiety symptoms. The psychometrics of the MASC-T were examined in a community sample of 12,536 Taiwanese
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children and adolescents across gender and age and the results have been described elsewhere [33]. The internal consistency (Cronbach’s alpha) of the MASC-T in the present study was
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0.89. Because one item on the MASC-T inquired about participants’ pain feeling, we excluded this item and summed the scores of the other 38 items for analysis. 2.3. Procedure and Statistical Analysis
A total of 6,445 students (96.2%) agreed to join this study. Of the 258 students who
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refused to join this study, 68 students refused based on their parents’ opinion, 128 returned
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blank questionnaires, and 62 were absent when the research assistants visited their classes. Each participant completed the research questionnaire anonymously under the direction of
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research assistants in each classroom during school hours. All students received a gift worth
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NT$33 (one US dollar) at the end of the assessment. The hypothesized model of the associations among bullying involvement (victimization and perpetration), depression, anxiety, and pain problems in adolescents is shown in Figure 1. The mediating effects of depression/anxiety on the associations between bullying involvement and pain problems were tested by the multiple-group structural equation model (SEM) in girls and in boys separately, and age was also included as a covariate. The moderating effects of sex on the three paths from bullying involvement to pain problems were tested by ΔChi-squared of SEM between main effect models with and without a moderating term (sex). The main effects of sex on bullying involvement, depression, anxiety, and pain problems were also tested by ΔChi-squared of SEM. 8
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3. Results
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3.1. Characteristics of the Participants
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A total of 4,976 participants (77.2%) completed the research questionnaires without omission. Male participants (n = 653, 54.1%) were more likely to have missing data in the
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questionnaires than females (n = 553, 45.9%, χ2 = 22.96, p < 0.001). Those who had missing
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data in the questionnaires were younger than those who had no missing data (14.36 ± 1.80 years vs. 14.89 ± 1.80 years, t = 9.17, p < 0.001). Among those who completed the research questionnaires without omission, 3,894 (78.3%) and 3,922 (78.8%) participants reported any experience of bullying victimization and perpetration on the on the C-SBEQ. respectively.
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Among the participants reporting experience of bullying victimization, 2,140 participants (55.0%) were girls and 1754 (45.0%) were boys. Their mean age (standard deviation [SD])
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was 14.9 years (1.8 years). Their severities of bullying victimization, depression, anxiety, and
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pain were 3.5 (2.5), 16.7 (9.8), 40.3 (15.0), and 4.5 (2.0), respectively. Among the participants reporting experience of bullying perpetration, 2,109 participants (53.8%) were girls and 1,813
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(46.2%) were boys. Their mean age (standard deviation [SD]) was 14.9 years (1.8 years). Their severities of bullying perpetration, depression, anxiety, and pain were 3.3 (2.4), 16.1 (9.7), 39.3 (15.0), and 4.4 (2.0), respectively. Relationship between Bullying Involvement and Pain Problems and the Mediating Effects of Depression and Anxiety The results of examining the mediating effects of depression/anxiety on the relationship between bullying involvement and pain problems by SEM are shown in Table 1. The results indicated that in both girls and boys, severe bullying victimization and perpetration were significantly associated with severe depression, and severe depression was significantly associated with severe pain problems. Depression mediated the relationships of both bullying 9
ACCEPTED MANUSCRIPT victimization and perpetration with pain problems in both girls and boys. The results of SEM also indicated that in both girls and boys, severe bullying
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victimization was significantly associated with severe anxiety, and severe anxiety was
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significantly associated with severe pain problems. Anxiety mediated the relationship between bullying victimization and pain problems in both girls and boys. However, severe bullying
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perpetration was not significantly associated with severe anxiety, and the mediating role of anxiety in the relationship between bullying perpetration and pain problems was not
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supported (Table 1).
After controlling for the effects of depression and anxiety, the relationships between bullying involvement and pain were not significant, indicating that the paths from bullying victimization to pain problems in girls and boys were completely mediated by depression and
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anxiety. It also indicated that the paths from bullying perpetration to pain problems in girls
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and boys were completely mediated by depression. The final models of the associations among bullying victimization and perpetration, depression, anxiety, and pain problems are
[Table 1 and Figure 2 about here]
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shown in Figure 2.
The moderating effects of sex on the mediating effects of depression and anxiety were further examined (Table 2). The results of SEM did not support that sex had a moderating effect on the mediating role of depression and anxiety in the associations of bullying victimization and perpetration with pain problems. However, sex differences were significant in bullying victimization, perpetration, and anxiety (Table 3), which indicated that sex difference should be considered when approaching bullying involvement and related mood problems. [Tables 2 and 3 about here]
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ACCEPTED MANUSCRIPT 4. Discussion The first important finding of this study was that both depression and anxiety are significant
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mediators of the relationship between bullying victimization and pain problems among
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adolescents. The Transactional Model of Coping [19] can contribute to the understanding of the relationships among bullying involvement, depression and anxiety, and pain problems [34].
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Based on the Transactional Model of Coping [19], both depression/anxiety and pain problems
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might be common stress responses to bullying when victims evaluate their coping abilities and resources as insufficient. Meanwhile, depression/anxiety might be a new stress event that bullying victims could not effectively manage, and thus further pain problems develop. Another possible explanation is that bullying victims with a higher severity of
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depression/anxiety reaction may have a higher level of sensitivity to pain [35]. It is also noteworthy that the measurement of pain problems used in this study may contribute to the
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mediating effects of depression/anxiety. Difficulty in managing or coping with pain was one
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component of pain problems measured in this study. Depression and anxiety may increase adolescents’ difficulty in managing or coping with pain, which partially accounts for the
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association between depression/anxiety and pain problems [36]. This study also measured the “worry” about pain. The similarity shared by “worry” and anxiety may increase the predictive value of anxiety for pain problems. This study also found that depression is a significant mediator of the relationship between bullying perpetration and pain problems among adolescents. Research has found that children who habitually bully are significantly more likely to experience high levels of depression [14] and suicidal ideation [37]. It has been hypothesized that the psychological effects of having engaged repeatedly in unjustifiable acts of aggressiveness against less powerful individuals result in depression among bullying perpetrators [36]. It is also possible that both aggressive behaviors and depression are secondary to a chaotic lifestyle, adverse 11
ACCEPTED MANUSCRIPT psychosocial environments and family background [38]. Depression may further increase individuals’ sensitivity to pain [35] or difficulty in coping with pain [36]. The results of this
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study did not find a significant association between bullying perpetration and anxiety.
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Meanwhile, bullying perpetration had no significant direct or indirect association with pain problems. This raises the possibility that bullying perpetrators have a lower physical arousal
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to pain than non-perpetrators. A previous study found that bullying perpetrators have a lower level of harm avoidance than non-perpetrators [39]. Further study is needed to examine
bullying perpetration in adolescents.
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whether low physical arousal to pain and low harm avoidance account for the tendency of
Given that there are sex differences in bullying involvement [20], depression [21],
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anxiety [22], and pain symptoms [23] among adolescents, one might hypothesize that sex may play a moderating role on the medicating effects of depression/anxiety on the relationship
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between bullying involvement and pain among adolescents. However, the present study did not support the hypothesis. Although sex did not moderate the mediating effects of
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depression/anxiety, sex differences were significant in bullying victimization, perpetration,
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and anxiety in the present study, which further support that adolescent health problems are related to different social contexts for boys and girls [40]. The results of this study have several important implications. Clinical and educational professionals should provide programs to prevent the development of bullying, as well as psychological intervention programs to improve depression and anxiety among adolescents involved in bullying. Clinical and educational professionals should be aware of the possibility that youths may be involved in bullying when pain complaints are presented. Meanwhile, clinical and educational professionals should take depression and anxiety into consideration and provide psychological and pharmacological interventions to improve depression and anxiety. 12
ACCEPTED MANUSCRIPT This study is one of the first to examine the mediating effects of depression and anxiety on the relationship of bullying victimization and perpetration with pain problems and the
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moderating effects of sex among adolescents. However, there were several limitations of our
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investigation that deserve attention. First, the cross-sectional research design of this study limited our ability to draw conclusions regarding the causal relationships between bullying
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involvement, depression/anxiety, and pain problems. Second, the data were provided by the adolescents themselves, and further study applying other sources of information or
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measurement is needed to replicate the results of this study. Meanwhile, the problem of shared-method variance resulted from the sole information source requires careful consideration. Third, this study did not inquire as to specific types of pain symptoms, such as
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abdomen pain, headache, and muscle pain. Whether bullying involvement has different relationships with different types of pain symptoms needs further study. However, this study
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not only examined general pain feeling but also examined participants’ difficulty in coping with pain and interference with daily activity. The evaluation of pain symptoms in this study
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could provide a comprehensive understanding toward adolescents’ pain problems. Lastly, the
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time span is various among the measuring scales. For example, the C-SBEQ measured bullying experience during the last year, whereas pain problems, depression, and anxiety symptoms were assessed during recent two weeks, one week and one month, respectively. The discrepancy of time span among the measurements may lessen the inference among bullying experience, depression/anxiety, and pain problems. 4.1. Conclusion This study found that depression and anxiety mediated the relationship between bullying involvement and pain problems. When managing pain problems among adolescents involved in bullying, clinical and educational professionals should take depression and anxiety into consideration and provide psychological and pharmacological interventions to improve 13
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depression and anxiety.
Acknowledgements: This study was partially supported by grants NSC
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98-2410-H-037-005-MY3 and 99-2314-B-037-028-MY2 awarded by the National Science Council, Taiwan (ROC) and grant KMUH 100-0R48 awarded by Kaohsiung Medical
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University Hospital.
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Association between types of involvement in school bullying and different dimensions of anxiety symptoms and the moderating effects of age and gender in Taiwanese
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adolescents. Child Abuse Negl 2013; 37:263-72.
40. Hetland J, Torsheim T, Aarø LE. Subjective health complaints in adolescence:
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dimensional structure and variation across gender and age. Scand J Public Health. 2002;
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30:223-30.
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Table 1 Mediating effects of depression and anxiety on the paths from bullying victimization and perpetration to pain: structural equation modela
BIDepression
DepressionPain BIDepressionPain BIAnxiety
beta
beta
CR I
Bullying
Anxiety
involvement (BI) t
beta
t
beta
0.37 15.79*** 0.14 0.07 2.99** 0.14
5.44*** 5.44***
.05 .01
5.14*** 2.62**
0.36 14.25*** 0.09 0.12 4.63*** 0.09
3.26** 3.26**
.03 .01
3.18** 2.67**
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Perpetration
Perpetration
BIAnxietyPain BIPain
beta
beta
t
beta
0.27 11.16*** 0.41 17.22*** .11 -0.01 -0.39 0.41 17.22*** -.00
9.36*** -0.39
-0.05 -1.86 0.04 1.65
0.31 11.58*** 0.47 19.01*** .16 -0.04 -1.58 0.47 19.01*** -.02
9.89*** -1.58
0.00 0.01
: Controlling for the effect of age in the analyses. The hypothetic path model is saturated, so the model-data fit is mathematically perfect. All fit indices are not shown.
**: p < .01; ***: p < .001
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a
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BI: bullying involvement
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Victimization
D
Boys
t
AnxietyPain
t
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t
Girls Victimization
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Depression
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t
0.17 0.40
ACCEPTED MANUSCRIPT Table 2 Moderating effects of sex on the paths from bullying victimization and perpetration to pain and on the mediating effects of depression and anxiety: structural equation modela Moderating effect of sex BIPain
BIDepressionPain
ΔChi-squared
ΔChi-squared
Victimization
2.80
3.02
Perpetration
.98
.09
1.04
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.72
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PT
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: Controlling for the effect of age in all analyses. All effects are nonsignificant.
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a
21
ΔChi-squared
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involvement (BI)
BI: bullying involvement
BIAnxietyPain
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Bullying
ACCEPTED MANUSCRIPT Table 3 Main effects of sex on bullying victimization, perpetration, depression, anxiety and pain: structural equation modela Mean Anxiety
Pain
Girls
17.90
43.16
3.41
3.07
14.89
Boys
15.82
37.31
3.77
a
16.90***
67.65***
1.72
3.78
b
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ΔChi-squared
T
Victimization Perpetration Depression
22.26***
14.91 b
1.64c
: Controlling for the effect of age in all analyses; b: Controlling for the effect of bullying involvement; c:
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Controlling for the effects of bullying involvement, depression and anxiety
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***: p < .001
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Depression
Bullying victimization or perpetration
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Anxiety
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Pain problems
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Sex
Figure 1. Hypothesized model of the associations among bullying involvement, depression,
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anxiety, and pain problems in adolescents.
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Depression
Bullying victimization
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Anxiety
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Pain problems
Figure 2a
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Depression
Pain problems
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Bullying perpetration
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Figure 2b
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Figure 2. Final models of the associations among bullying victimization (2a) and perpetration (2b), depression, anxiety, and pain problems in adolescents.
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S0010-440X(14)00118-7 doi: 10.1016/j.comppsych.2014.05.006 YCOMP 51311
To appear in:
Comprehensive Psychiatry
Received date: Revised date: Accepted date:
11 March 2014 13 May 2014 13 May 2014
Please cite this article as: Yen Cheng-Fang, Lin I.-Mei, Liu Tai-Ling, Hu Huei-Fan, Cheng Chung-Ping, Mediating Effects of Depression and Anxiety on the Relationship between Bullying Involvement and Pain Problems among Adolescents in Taiwan, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.05.006
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Mediating Effects of Depression and Anxiety on the Relationship between Bullying Involvement and Pain Problems among Adolescents in Taiwan
Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung Medical
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a
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Cheng-Fang Yena,b, I-Mei Linc, Tai-Ling Liua,b, Huei-Fan Hud,*, Chung-Ping Chenge,*
University, Taiwan
Department of Psychiatry, Faculty of Medicine, and Graduate Institute of Medicine, College
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b
of Medicine, Kaohsiung Medical University, Taiwan c
Department of Psychology, Kaohsiung Medical University, Taiwan
d
Department of Psychiatry, Tainan Municipal Hospital, Taiwan
e
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Department of Psychology, National Cheng Kung University, Taiwan
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*Dr. CF Yen and Dr. IM Lin contributed equally to this study
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Running title: Bullying Involvement and Pain
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Corresponding author
Chung-Ping Cheng, Ph.D., Department of Psychology, National Cheng Kung University, No.1, University Road, Tainan City 701, Taiwan. E-mail: [email protected] Tel: 886-6-275-7575 FAX: 886-6-275-2029 Huei-Fan Hu, M.D. Department of Psychiatry, Tainan Municipal Hospital, 670 Chongde Road, East District, Tainan 701, Taiwan E-mail: [email protected] Tel: +886-6-2609926886 Fax: +886-6-2606351 1
ACCEPTED MANUSCRIPT Abstract Background: This study aimed to examine the mediating effects of depression and anxiety
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on the relationships of bullying victimization and perpetration with pain among adolescents in
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Taiwan.
Method: A total of 4,976 students of junior and senior high schools completed the
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questionnaires. Bullying victimization and perpetration, pain problems, depression, and
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anxiety were assessed. The mediating effects of depression and anxiety on the relationship between bullying involvement and pain problems and the moderating effects of sex on the medicating roles of depression and anxiety were examined by structural equation model. Results: Both depression and anxiety were significant mediators of the relationship between
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bullying victimization and pain problems among adolescents. Depression was also a significant mediator of the relationship between bullying perpetration and pain problems
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among adolescents. Sex had no moderating effect on the mediating role of depression/anxiety
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on the association between bullying involvement and pain problems. Conclusions: Medical and educational professionals should survey and intervene in
bullying.
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depression and anxiety when managing pain problems among adolescents involved in
Key words: Adolescents, anxiety, bullying, depression, pain, sex.
2
ACCEPTED MANUSCRIPT 1. Introduction Victimization of bullying is one of the most traumatic experiences for youths. Meta-analyses
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of previous studies in children and adolescents have found that a significant association of
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bullying victimization exists not only with internalizing [1] and externalizing problems [2] but also with psychosomatic problems [3]. Pain is one of the psychosomatic problems that have
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been frequently examined among victims of bullying. A six-month cohort study on children in
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the Netherlands found that victims of bullying had a significantly higher chance of developing new abdominal pain than those not involved in bullying [4]. A significant association between victimization and pain was not only found in Western youths [4] but also in non-Western youths [5, 6]. These findings stress the importance for clinicians and health practitioners to
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establish whether bullying victimization plays a contributing role in the etiology of pain symptoms [4].
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Compared with bullying victimization, the relationship of bullying perpetration with
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pain has been examined less in previous studies. Meanwhile, the results of previous studies were mixed. Some studies found that bullying perpetrators were more likely to report
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headache, neck and shoulder pain, stomachache, or backache than those who did not perpetrate bullying [7-10], whereas some studies did not find a significant association between bullying perpetration and pain symptoms [11,12]. Bullying perpetrators have been found to have poor mental health [13, 14]. Whether or not pain is a significant psychosomatic problem among bullying perpetrators as it is among victims requires further study. How the relationship between bullying involvement and pain develops is still unknown. One of possible mechanisms is that physical bullying may directly result in victims’ physical pain symptoms. However, this direct mechanism cannot be applied to victims of non-physical bullying and perpetrators of bullying. There may be factors that mediate the relationship between bullying victimization and perpetration and pain. Emotional problems are the factors 3
ACCEPTED MANUSCRIPT that have strong potentials to mediate the association between bullying victimization and perpetration and pain because of several reasons described below. First, research has found
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that both youths who are bullied [15, 16] and those who bully others [14, 17] have
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significantly greater risks of depression and anxiety than those who are not involved in bullying. Second, significant associations of depression and anxiety with pain were found [18].
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Third, based on the Transactional model of coping [19], experiencing bullying victimization is an event with potential stress, and those who experience bullying victimization may use
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primary appraisal to evaluate whether this event is harmful, threatening, or challenging. Then, in secondary appraisal, victims evaluate whether their own coping abilities and resources are sufficient to overcome the harm, threat, or challenge. If the victims evaluate their coping
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abilities and resources as insufficient, they may develop physiological (such as physical symptoms), cognitive (such as a negative attitude toward themselves), emotional (such as
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depression and anxiety), and behavioral (such as avoidance) responses to bullying. Given that there are significant associations among bullying involvement, depression, anxiety, and pain,
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it is reasonable to hypothesize that depression and anxiety may mediate the relationship
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between bullying involvement and pain. However, based on our best knowledge, there has been no study examining this hypothesis. If depression and anxiety are mediators of the relationship between bullying involvement and pain among adolescents, depression and anxiety should be targets of intervention when clinical and educational professionals try to help those who are involved in bullying to manage pain problems. Sex differences in the relationship between bullying involvement and pain among adolescents and the mediating effects of depression and anxiety are other issues that need further study. Although sex differences have been found in the prevalence of bullying involvement [20], depression [21], anxiety [22], and pain symptoms [23] among adolescents, sex difference in the relationship between bullying involvement and pain among adolescents 4
ACCEPTED MANUSCRIPT has seldom been examined, and the results of limited studies were mixed. A previous study found that being bullied had a strong relationship with the development of abdominal pain in
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girls, whereas there was no such relationship in boys [4]. Another study found that the
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associations of bullying victimization with headache and backache were stronger in boys than in girls [11]. However, one study found that the significant association between bullying
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victimization and poor physical health was similar in both sexes [24]. Meanwhile, if depression and anxiety mediate the relationship between bullying involvement and pain,
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whether sex has a moderating effect on the mediating roles of depression and anxiety needs further study. If there are sex differences in the relationship between bullying involvement and pain and in the mediating roles of depression and anxiety, clinical and educational
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professionals must take sex differences into consideration when helping adolescents who are involved in bullying to manage pain problems.
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The aims of this study were to examine the mediating effects of depression and anxiety on the relationships of bullying victimization and perpetration with pain problems among
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adolescents in Taiwan. This study also aimed to examine the moderating roles of sex in the
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relationships of bullying victimization and perpetration with pain problems and the mediating effects of depression and anxiety on the relationships. We hypothesized that both bullying victimization and perpetration are significantly associated with pain problems by the mediation of depression and anxiety. We also hypothesized that sex has a moderating effect on the relationship between bullying involvement and pain problems and on the mediating effects of depression and anxiety.
5
ACCEPTED MANUSCRIPT 2. Methods 2.1. Participants
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This study was based on data from the 2009 Project for the Health of Children and
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Adolescents in Southern Taiwan, which was a mental health research survey of adolescents in grades 7 through 12 (age 12 to 18) [22]. This health survey project recruited adolescent
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students from 3 metropolitan areas and 4 counties in southern Taiwan. On the basis of the
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definitions of rural and urban districts in the Taiwan-Fukien Demographic Fact Book [25] and based on school and grade characteristics, a stratified random sampling strategy was used to ensure that there was proportional representation of districts, schools, and grades. In 2009, there were 202,883 students in 143 senior high/vocational schools and 254,130 students in
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205 junior high schools in this area. Five junior high schools and 4 senior high/vocational schools were randomly selected from rural districts; similarly, 5 senior high/vocational
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schools and 5 junior high schools were randomly selected from urban districts. The classes in
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these schools were further stratified into 3 levels based on grade in primary, junior high, and senior high/vocational schools. Then, a total of 6,703 high school students were randomly
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selected based on the ratio of students in each grade. The Institutional Review Board of Kaohsiung Medical University agreed to the use of passive consent from parents and students. Before conducting the study, we prepared a leaflet explaining the purpose and procedures of the study. Students took the leaflet home to their parents or main caretakers, who could telephone the researchers, write in a communication book, or ask their children directly to refuse to join the study. The students also had the right to refuse to participate in this study by returning blank questionnaires along with those from other students. 2.2. Instruments 2.2.1. Chinese version of the School Bullying Experience Questionnaire (C-SBEQ). The 6
ACCEPTED MANUSCRIPT self-reported C-SBEQ was used to evaluate participants’ involvement in school bullying in the previous one year. The 16 items on the C-SBEQ were rated on a Likert 4-point scale, with
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scores ranging from 0 (never) to 3 (all the time) [26]. Items 1 to 8 on this scale evaluate the
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severity of bullying victimization, including social exclusion, being called a mean nickname, being spoken ill of, being beaten up, being forced to do work, and having money, school
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supplies, and snacks taken away. Items 9 to 16 evaluate the severity of bullying perpetration. Higher total scores of items 1 to 8 and items 9 to 16 indicate more severe levels of bullying
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victimization and perpetration, respectively. A previous study found that the test-retest and internal reliability values of all subscales of the C-SBEQ and their congruent validity with bullying involvement nominated by classmates and teachers were satisfactory [27].
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2.2.2. Pain subscale of the Taiwanese Quality of Life Questionnaire for Adolescents (TQOLQA). In this study the three items on the Pain Subscale of the self-administered
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TQOLQA were applied to measure pain problems over the preceding 2 weeks [28], including “Do you worry about pain?” “Do you have any difficulty in managing or coping with pain?”
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and “Does your pain interfere with things you need to do?” Each item is rated on a 5-point
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Likert scale, with scores ranging from 1 (not at all) to 5 (very much). A higher total score indicates more severe pain problems. Cronbach’s α coefficient was .77 for the Pain Subscale [28].
2.2.3. Mandarin Chinese version of the Center for Epidemiological Studies-Depression Scale (MC-CES-D). The 20-item MC-CES-D is a self-administered four-point evaluation scale assessing the frequencies of depressive symptoms in the preceding week, with scores ranging from 0 (none or very few) to 3 (always) [29, 30]. Higher CES-D scores indicate more severe depression. The psychometrics of the MC-CES-D for assessing depressive symptoms among nonreferred adolescents in Taiwan were examined in a previous study [31]. The internal consistency (Cronbach’s alpha) of the MC-CES-D in the present study was 0.94. 7
ACCEPTED MANUSCRIPT 2.2.4. Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T). The MASC-T evaluates the level of anxiety symptoms in adolescents, with 39 items answered on
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a Likert 4-point scale, with scores ranging from 0 (never true) to 3 (often true) [32, 33].
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Higher scores on the total MASC-T indicate more severe anxiety symptoms. The psychometrics of the MASC-T were examined in a community sample of 12,536 Taiwanese
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children and adolescents across gender and age and the results have been described elsewhere [33]. The internal consistency (Cronbach’s alpha) of the MASC-T in the present study was
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0.89. Because one item on the MASC-T inquired about participants’ pain feeling, we excluded this item and summed the scores of the other 38 items for analysis. 2.3. Procedure and Statistical Analysis
A total of 6,445 students (96.2%) agreed to join this study. Of the 258 students who
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refused to join this study, 68 students refused based on their parents’ opinion, 128 returned
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blank questionnaires, and 62 were absent when the research assistants visited their classes. Each participant completed the research questionnaire anonymously under the direction of
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research assistants in each classroom during school hours. All students received a gift worth
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NT$33 (one US dollar) at the end of the assessment. The hypothesized model of the associations among bullying involvement (victimization and perpetration), depression, anxiety, and pain problems in adolescents is shown in Figure 1. The mediating effects of depression/anxiety on the associations between bullying involvement and pain problems were tested by the multiple-group structural equation model (SEM) in girls and in boys separately, and age was also included as a covariate. The moderating effects of sex on the three paths from bullying involvement to pain problems were tested by ΔChi-squared of SEM between main effect models with and without a moderating term (sex). The main effects of sex on bullying involvement, depression, anxiety, and pain problems were also tested by ΔChi-squared of SEM. 8
ACCEPTED MANUSCRIPT [Figure 1 about here]
3. Results
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3.1. Characteristics of the Participants
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A total of 4,976 participants (77.2%) completed the research questionnaires without omission. Male participants (n = 653, 54.1%) were more likely to have missing data in the
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questionnaires than females (n = 553, 45.9%, χ2 = 22.96, p < 0.001). Those who had missing
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data in the questionnaires were younger than those who had no missing data (14.36 ± 1.80 years vs. 14.89 ± 1.80 years, t = 9.17, p < 0.001). Among those who completed the research questionnaires without omission, 3,894 (78.3%) and 3,922 (78.8%) participants reported any experience of bullying victimization and perpetration on the on the C-SBEQ. respectively.
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Among the participants reporting experience of bullying victimization, 2,140 participants (55.0%) were girls and 1754 (45.0%) were boys. Their mean age (standard deviation [SD])
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was 14.9 years (1.8 years). Their severities of bullying victimization, depression, anxiety, and
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pain were 3.5 (2.5), 16.7 (9.8), 40.3 (15.0), and 4.5 (2.0), respectively. Among the participants reporting experience of bullying perpetration, 2,109 participants (53.8%) were girls and 1,813
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(46.2%) were boys. Their mean age (standard deviation [SD]) was 14.9 years (1.8 years). Their severities of bullying perpetration, depression, anxiety, and pain were 3.3 (2.4), 16.1 (9.7), 39.3 (15.0), and 4.4 (2.0), respectively. Relationship between Bullying Involvement and Pain Problems and the Mediating Effects of Depression and Anxiety The results of examining the mediating effects of depression/anxiety on the relationship between bullying involvement and pain problems by SEM are shown in Table 1. The results indicated that in both girls and boys, severe bullying victimization and perpetration were significantly associated with severe depression, and severe depression was significantly associated with severe pain problems. Depression mediated the relationships of both bullying 9
ACCEPTED MANUSCRIPT victimization and perpetration with pain problems in both girls and boys. The results of SEM also indicated that in both girls and boys, severe bullying
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victimization was significantly associated with severe anxiety, and severe anxiety was
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significantly associated with severe pain problems. Anxiety mediated the relationship between bullying victimization and pain problems in both girls and boys. However, severe bullying
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perpetration was not significantly associated with severe anxiety, and the mediating role of anxiety in the relationship between bullying perpetration and pain problems was not
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supported (Table 1).
After controlling for the effects of depression and anxiety, the relationships between bullying involvement and pain were not significant, indicating that the paths from bullying victimization to pain problems in girls and boys were completely mediated by depression and
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anxiety. It also indicated that the paths from bullying perpetration to pain problems in girls
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and boys were completely mediated by depression. The final models of the associations among bullying victimization and perpetration, depression, anxiety, and pain problems are
[Table 1 and Figure 2 about here]
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shown in Figure 2.
The moderating effects of sex on the mediating effects of depression and anxiety were further examined (Table 2). The results of SEM did not support that sex had a moderating effect on the mediating role of depression and anxiety in the associations of bullying victimization and perpetration with pain problems. However, sex differences were significant in bullying victimization, perpetration, and anxiety (Table 3), which indicated that sex difference should be considered when approaching bullying involvement and related mood problems. [Tables 2 and 3 about here]
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ACCEPTED MANUSCRIPT 4. Discussion The first important finding of this study was that both depression and anxiety are significant
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mediators of the relationship between bullying victimization and pain problems among
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adolescents. The Transactional Model of Coping [19] can contribute to the understanding of the relationships among bullying involvement, depression and anxiety, and pain problems [34].
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Based on the Transactional Model of Coping [19], both depression/anxiety and pain problems
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might be common stress responses to bullying when victims evaluate their coping abilities and resources as insufficient. Meanwhile, depression/anxiety might be a new stress event that bullying victims could not effectively manage, and thus further pain problems develop. Another possible explanation is that bullying victims with a higher severity of
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depression/anxiety reaction may have a higher level of sensitivity to pain [35]. It is also noteworthy that the measurement of pain problems used in this study may contribute to the
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mediating effects of depression/anxiety. Difficulty in managing or coping with pain was one
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component of pain problems measured in this study. Depression and anxiety may increase adolescents’ difficulty in managing or coping with pain, which partially accounts for the
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association between depression/anxiety and pain problems [36]. This study also measured the “worry” about pain. The similarity shared by “worry” and anxiety may increase the predictive value of anxiety for pain problems. This study also found that depression is a significant mediator of the relationship between bullying perpetration and pain problems among adolescents. Research has found that children who habitually bully are significantly more likely to experience high levels of depression [14] and suicidal ideation [37]. It has been hypothesized that the psychological effects of having engaged repeatedly in unjustifiable acts of aggressiveness against less powerful individuals result in depression among bullying perpetrators [36]. It is also possible that both aggressive behaviors and depression are secondary to a chaotic lifestyle, adverse 11
ACCEPTED MANUSCRIPT psychosocial environments and family background [38]. Depression may further increase individuals’ sensitivity to pain [35] or difficulty in coping with pain [36]. The results of this
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study did not find a significant association between bullying perpetration and anxiety.
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Meanwhile, bullying perpetration had no significant direct or indirect association with pain problems. This raises the possibility that bullying perpetrators have a lower physical arousal
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to pain than non-perpetrators. A previous study found that bullying perpetrators have a lower level of harm avoidance than non-perpetrators [39]. Further study is needed to examine
bullying perpetration in adolescents.
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whether low physical arousal to pain and low harm avoidance account for the tendency of
Given that there are sex differences in bullying involvement [20], depression [21],
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anxiety [22], and pain symptoms [23] among adolescents, one might hypothesize that sex may play a moderating role on the medicating effects of depression/anxiety on the relationship
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between bullying involvement and pain among adolescents. However, the present study did not support the hypothesis. Although sex did not moderate the mediating effects of
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depression/anxiety, sex differences were significant in bullying victimization, perpetration,
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and anxiety in the present study, which further support that adolescent health problems are related to different social contexts for boys and girls [40]. The results of this study have several important implications. Clinical and educational professionals should provide programs to prevent the development of bullying, as well as psychological intervention programs to improve depression and anxiety among adolescents involved in bullying. Clinical and educational professionals should be aware of the possibility that youths may be involved in bullying when pain complaints are presented. Meanwhile, clinical and educational professionals should take depression and anxiety into consideration and provide psychological and pharmacological interventions to improve depression and anxiety. 12
ACCEPTED MANUSCRIPT This study is one of the first to examine the mediating effects of depression and anxiety on the relationship of bullying victimization and perpetration with pain problems and the
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moderating effects of sex among adolescents. However, there were several limitations of our
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investigation that deserve attention. First, the cross-sectional research design of this study limited our ability to draw conclusions regarding the causal relationships between bullying
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involvement, depression/anxiety, and pain problems. Second, the data were provided by the adolescents themselves, and further study applying other sources of information or
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measurement is needed to replicate the results of this study. Meanwhile, the problem of shared-method variance resulted from the sole information source requires careful consideration. Third, this study did not inquire as to specific types of pain symptoms, such as
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abdomen pain, headache, and muscle pain. Whether bullying involvement has different relationships with different types of pain symptoms needs further study. However, this study
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not only examined general pain feeling but also examined participants’ difficulty in coping with pain and interference with daily activity. The evaluation of pain symptoms in this study
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could provide a comprehensive understanding toward adolescents’ pain problems. Lastly, the
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time span is various among the measuring scales. For example, the C-SBEQ measured bullying experience during the last year, whereas pain problems, depression, and anxiety symptoms were assessed during recent two weeks, one week and one month, respectively. The discrepancy of time span among the measurements may lessen the inference among bullying experience, depression/anxiety, and pain problems. 4.1. Conclusion This study found that depression and anxiety mediated the relationship between bullying involvement and pain problems. When managing pain problems among adolescents involved in bullying, clinical and educational professionals should take depression and anxiety into consideration and provide psychological and pharmacological interventions to improve 13
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depression and anxiety.
Acknowledgements: This study was partially supported by grants NSC
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98-2410-H-037-005-MY3 and 99-2314-B-037-028-MY2 awarded by the National Science Council, Taiwan (ROC) and grant KMUH 100-0R48 awarded by Kaohsiung Medical
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University Hospital.
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Table 1 Mediating effects of depression and anxiety on the paths from bullying victimization and perpetration to pain: structural equation modela
BIDepression
DepressionPain BIDepressionPain BIAnxiety
beta
beta
CR I
Bullying
Anxiety
involvement (BI) t
beta
t
beta
0.37 15.79*** 0.14 0.07 2.99** 0.14
5.44*** 5.44***
.05 .01
5.14*** 2.62**
0.36 14.25*** 0.09 0.12 4.63*** 0.09
3.26** 3.26**
.03 .01
3.18** 2.67**
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Perpetration
Perpetration
BIAnxietyPain BIPain
beta
beta
t
beta
0.27 11.16*** 0.41 17.22*** .11 -0.01 -0.39 0.41 17.22*** -.00
9.36*** -0.39
-0.05 -1.86 0.04 1.65
0.31 11.58*** 0.47 19.01*** .16 -0.04 -1.58 0.47 19.01*** -.02
9.89*** -1.58
0.00 0.01
: Controlling for the effect of age in the analyses. The hypothetic path model is saturated, so the model-data fit is mathematically perfect. All fit indices are not shown.
**: p < .01; ***: p < .001
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a
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BI: bullying involvement
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Victimization
D
Boys
t
AnxietyPain
t
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t
Girls Victimization
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Depression
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t
0.17 0.40
ACCEPTED MANUSCRIPT Table 2 Moderating effects of sex on the paths from bullying victimization and perpetration to pain and on the mediating effects of depression and anxiety: structural equation modela Moderating effect of sex BIPain
BIDepressionPain
ΔChi-squared
ΔChi-squared
Victimization
2.80
3.02
Perpetration
.98
.09
1.04
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.72
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: Controlling for the effect of age in all analyses. All effects are nonsignificant.
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a
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ΔChi-squared
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involvement (BI)
BI: bullying involvement
BIAnxietyPain
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Bullying
ACCEPTED MANUSCRIPT Table 3 Main effects of sex on bullying victimization, perpetration, depression, anxiety and pain: structural equation modela Mean Anxiety
Pain
Girls
17.90
43.16
3.41
3.07
14.89
Boys
15.82
37.31
3.77
a
16.90***
67.65***
1.72
3.78
b
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ΔChi-squared
T
Victimization Perpetration Depression
22.26***
14.91 b
1.64c
: Controlling for the effect of age in all analyses; b: Controlling for the effect of bullying involvement; c:
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Controlling for the effects of bullying involvement, depression and anxiety
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***: p < .001
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Depression
Bullying victimization or perpetration
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Anxiety
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Pain problems
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Sex
Figure 1. Hypothesized model of the associations among bullying involvement, depression,
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anxiety, and pain problems in adolescents.
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Depression
Bullying victimization
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Anxiety
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Pain problems
Figure 2a
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Depression
Pain problems
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Bullying perpetration
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Figure 2b
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Figure 2. Final models of the associations among bullying victimization (2a) and perpetration (2b), depression, anxiety, and pain problems in adolescents.
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