Original Research
Suicidal Ideation and Related Factors Among Korean High School Students: A Focus on Cyber Addiction and School Bullying
The Journal of School Nursing 1-9 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840517734290 journals.sagepub.com/home/jsn
Min Sohn, RN, PhD1, Heymin Oh, RN, MS1, Sang-Kyu Lee, MD, PhD2,3, and Marc N. Potenza, MD, PhD3,4,5,6
Abstract The purpose of the study was to explore the association among suicidal ideation, cyber addiction, and school bullying of Korean high school students. This descriptive cross-sectional study included 416 students. The data were collected using structured questionnaires on suicidal ideation, Internet and smartphone addiction, experiences of school bullying, impulsiveness, and depression. Students who were bullied (odds ratio [OR] ¼ 3.0, 95% CI [1.1, 8.4]) and more depressed (OR ¼ 10.8, 95% CI [2.4, 48.2]) were more likely to have higher scores for suicidal ideation; however, when a lower stringency was used, female gender (OR ¼ 2.3, 95% CI [1.3, 4.0]) and addiction to smartphones (OR ¼ 2.4, 95% CI [1.1, 5.4]) were also statistically significant contributors to the presence of suicidal ideation. Students with suicidal ideation that is higher than average, but lower than the classical thresholds for risk group designation, should also be carefully assessed for early detection and intervention. Cyber addiction may be a particularly significant contributor to suicidal ideation, in addition to bullying and depressive mood, among Korean adolescents. Keywords suicidal ideation, Internet, smartphone, addiction, adolescents, school nurse
In 2014, suicide was the second leading cause of death among 10- to 19-year-old Koreans (Shin et al., 2016). The suicide rate of Korean adolescents aged 15–19 years old was 8.2 per 100,000, higher than the average rate of 6.4 per 100,000 in the 33 countries of the Organization for Economic Co-operation and Development (OECD, 2015). While the OECD reported that, on average, there has been a gradual decrease in suicide rates, Korea has presented a gradual increase in the suicide rate among adolescents. Therefore, suicidal behaviors, including suicidal ideation, suicide attempts, and suicide, remain an extremely important topic in adolescent health in Korea. Among these behaviors, suicidal ideation has particular significance because the early detection of suicidal ideation is arguably one of the best and most effective means of early intervention for the prevention of suicide. Statistics on adolescents with suicidal ideation vary considerably depending on the definition of the phenomenon and the measurement used to assess it. Korean national statistics revealed that 9.6% of boys and 13.9% of girls in general population presented suicidal ideation during the year 2014 (Yi, Pyo, Jeong, & An, 2016). Another report from Roh and their colleague (2015) indicated that 39.5% of adolescents, who visited community
mental health centers, reported that they had thoughts of suicide in last 3 months. Potential risk factors for suicidal ideation have been actively studied. Female gender, depression, impulsiveness, family integrity, socioeconomic status, anxiety, and delinquent behaviors such as illegal drug use and substance use have been associated with suicidal ideation (Kokkevi, Rotsika, Arapaki, & Richardson, 2012; Lee et al, 2016).
1
Department of Nursing, Inha University, Incheon, South Korea Department of Psychiatry, Hallym University College of Medicine, Chuncheon, South Korea 3 Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA 4 Department of Neuroscience and Child Study Center, Yale University School of Medicine, New Haven, CT, USA 5 National Center on Addiction and Substance Abuse, Yale University School of Medicine, New Haven, CT, USA 6 The Connecticut Mental Health Center, New Haven, CT, USA 2
Corresponding Author: Sang-Kyu Lee, MD, PhD, Department of Psychiatry, Hallym University College of Medicine, Chuncheon, South Korea. Email: [email protected]
2
Recently, other potential risk factors such as cyber addiction and school bullying have been described. A limited but intriguing set of studies has reported that forms of cyber addiction such as Internet (Lee et al., 2016), smartphone (Kim & Hwang, 2015), and online game addictions (Holt et al., 2015) seem to be associated with suicidal ideation among adolescents. Cyber addiction, defined as the problematic use of cyber media including Internet, smartphones, and online chatting, gaming, and gambling (Kuss, Griffiths, Karila, & Billieux, 2014; Young, Pistner, O’Mara, & Buchanan, 1999), has become a prominent topic in Korea. National statistics indicate that 92.5% of Korean adolescents have their own personal computer and 99.6% have a smartphone, and the average length of time playing online games was 1 hr during weekdays and 2 hr during the weekend in 2014 (Ministry of Science Information and Communications Technology (ICT) and Future Planning, 2016). In Korea, the prevalence of Internet addiction has been reported as 12.5% among adolescents, with the prevalence of smartphone addiction even higher at 29.2% (Ministry of Science, ICT and Future Planning, 2014). Some studies suggest that cyber addiction has an important relationship with suicidal ideation, particularly with the overuse of smartphones (Kim & Hwang, 2015), the Internet, and online games (Lee et al., 2016). However, it has been difficult to differentiate the independent contributions of different forms of cyber addiction to suicidal ideation since all multiple forms may occur together. For example, adolescents who like to use smartphones can easily access the Internet and online (or mobile) games at the same time. To our knowledge, very few studies have been conducted to examine relationships between cyber addiction and suicidal ideation while controlling for multiple other factors within the study. Another potential risk factor for suicidal ideation involves school bullying. Students who are bullied appear more likely to experience suicidal ideation (Sourander & Madelyn, 2010). School bullying involves aggressive or violent behavior that occurs in the school environment and school-associated networks (Sourander & Madelyn, 2010). Adolescents may be involved in bullying as victims, perpetrators, or both. Bullying is diverse in terms of its forms. These forms may include traditional types such as active physical assault and aggressive verbal assaults, but recently, cyberbullying has become a more frequent form of school bullying (Sampasa-Kanyinga, Roumeliotis, & Xu, 2014). Cyberbullying involves the use of information technology and occurs in various cyber environments, such as over cellular phones, by e-mail, by messenger, and by social network system (SNS; Sampasa-Kanyinga, Roumeliotis, & Xu, 2014). Cyberbullying may be more intrusive than traditional bullying since it can occur at any time or place. A recent meta-analysis indicated that cyberbullying is strongly related to suicidal ideation (Van Geel, Vedder, & Tanilon, 2014). It reported that the effects of cyberbullying are more severe than those of traditional bullying. In the past, school bullying referred to
The Journal of School Nursing XX(X)
more physical and person-to-person occurrences at school. Recently, however, school bullying has expanded to environments outside of school, such as the online environment, and it often continues even when victims move to other schools or neighborhoods. In these circumstances, SNS and free online chat applications over smartphones are often used. Recent statistics have indicated that 16.3% of elementary students, 20.0% of middle school students, 20.7% of high school students have experienced bullying over the Internet (Korea Internet & Security Agency, 2014). While suicidal ideation, cyber addiction, and school bullying are often related to one another, there exists a significant knowledge gap and methodological issues in research of the topics. Some instruments for evaluating suicidal ideation revealed positive skewed distribution particularly when the studies included general population (Glashouwer et al., 2010; Zhang, Yip, & Fu, 2014). Furthermore, selecting cutoffs for the best sensitivity and specific to predict suicidal ideation and suicidal attempt for various populations is often not easy (Zhang, Yip, & Fu, 2014). In order to advance prevention efforts, suicidal ideation in community or school settings needs to be understood across a wide spectrum, and adolescent engagement in various levels of suicidal ideation should be explored for early detection and intervention. Furthermore, newly reported potential risk factors such as the experience of bullying as both victim and perpetrator and cyber addiction have not been studied sufficiently in the context of a range of suicidal ideation. Finally, adolescents in vocational schools (Dalen, 2012) or rural areas, where suicidal ideation is high and mental health services are limited, have been less well studied (Murphy, 2014).
Study Purpose The purpose of this study is to explore various levels of suicidal ideation and associated factors among students attending a vocational high school in a rural area of South Korea (hereafter, “Korea”), focusing in particular on school bullying and cyber addiction. Suicidal ideation and associated factors will also be examined according to the level of suicidal ideation, in order to identify whether these associations differ among adolescents with various levels of suicidal ideation. We hypothesized that both cyber addiction and school bullying would relate to suicidal ideation, as would other factors (e.g., female gender and depressed mood) that have been previously associated with suicidal ideation.
Method Design This study is a cross-sectional descriptive study. The data collection period was from October 1, 2014, to December 31, 2014. We collected data after approval from the Ethics Committee of Chuncheon Sacred Heart Hospital (Institutional Review Board (IRB) No. 2014-113).
Sohn et al.
Study Participants We recruited students from 10th to 12th grade from one vocational high school with an agricultural specialization, located in Chuncheon, South Korea. Chuncheon is a midsize city surrounded by a large rural area. We included all students in the school, since the school was also willing to use these data for mental health screening purpose as a part of routine student health screening. A post hoc power analysis using G*Power (Faul, Erdfelder, Buchner, & Lang, 2009) revealed that we obtained 0.94–0.99 power on the basis of n ¼ 400 and odds ratios (ORs) and R2 in the three logistic regression models.
Measurements We collected data on basic characteristics, suicidal ideation, Internet and smartphone addiction, durations of online gaming, experiences of school bullying, impulsiveness, and depression using structured questionnaires. Basic characteristics included age, gender, experience of smoking and drinking, and length of online game play. The results of a psychometric evaluation of the structured questionnaires are presented in Table 1. Suicidal ideation was evaluated using the Suicidal Ideation Questionnaire for High School Students (SIQ-HS) originally developed by Reynolds and Baker (1988), and its validity and reliability were tested for high school students in Hong Kong (Zhang, Yip, & Fu, 2014) and France (Potard, Kubiszewski, Gimenes, & Gourtois, 2014). Shin (1992) has translated the SIQ-HS into Korean and presented Cronbach’s a of .83 with Korean high school students. Another Korean study also revealed its Cronbach’s a of .97 and good constructive validity with college students (Yang, Bang, & Kim, 2012). This instrument includes 30 items querying the frequency of suicidal thoughts among adolescents during the last 12 months. Study participants were asked to answer each question on a 7-point Likert-type scale, from 0 ¼ never to 6 ¼ almost every day. The total score is calculated as a sum of item scores and can range from 0 to 180. A higher total score designates higher frequency and more pervasive suicidal ideation. Both 41 and 31 can be used as thresholds among school students to determine the necessity of further suicidal evaluation, as either conservative or liberal thresholds (Reynolds & Baker, 1988). Internet and smartphone addiction were evaluated using the Internet Addiction Proneness Scale for Youth (KS-II; Kim, Chung, Lee, Kim, & Cho, 2008 ) and Smartphone Addiction Proneness Scale (Kim, Lee, Lee, Nam, & Chung, 2014), which were developed by the Korea Agency for Digital Opportunity and Promotion (Shin, Kim, & Jeung, 2011). Both instruments have four subdimensions diagnosing disturbance of adaptive function, tolerance, withdrawal, and virtual life orientation. Each instrument has 15 items that ask whether responders experience difficulties due to overuse of the Internet. Study participants were asked to answer on a 4-point Likert-type scale ranging from 1 ¼ not
3
at all to 4 ¼ always. The total score is calculated as the sum of the item scores and can range from 15 to 60. A higher total score refers to a greater intensity of Internet addiction. The level of Internet or smartphone addiction is categorized as a potential risk group for scores of 41–43 and as a high-risk group for scores of >44. The duration of online gaming was assessed by querying how many hours per day students played online games, on average. School bullying was evaluated using the Bullying or Bullied Scale (Choi & Chae, 2000). This instrument has a total of 30 items asking about any experience as a perpetrator or as a victim of bullying. If students had an experience of enacting or undergoing school bullying, they were asked to quantify it. Study participants were asked to answer on a 5-point Likert-type scale spanning 1 ¼ never in the past, 2 ¼ 1–2 times in the past, 3 ¼ sometimes in the past, 4 ¼ 1–2 times a week, and 5 ¼ several times a week. The total score is calculated as the sum of the item scores and can range from 0 to 60 for the experience of either bullying or being bullied. A score higher than 15 refers to any experience of bullying or being bullied, and the higher the total score, the higher the frequency of school bullying or experience of being bullied. Impulsiveness was evaluated using the Barratt Impulsiveness Scale (BIS) Version 11 (Barratt, 1985; Fossati, Di Ceglie, Acquarini, & Barratt, 2001) adapted for Korean use by Lee and colleagues (2012). This instrument includes three subscales: Cognitive Impulsiveness, Motor Impulsiveness, and Nonplanning Impulsiveness. Study participants were asked to answer about the frequency of certain impulsive behaviors on a 4-point Likert-type scale from 0 ¼ not at all to 3 ¼ all the time. The total score is calculated as the sum of the item scores and can range from 0 to 69. A higher total score refers to a higher frequency of impulsive behaviors. Depression was evaluated using the Beck Depression Inventory (BDI), translated by Lee and Song (1991). This instrument has a total of 21 items concerning somatic, cognitive, and affective symptoms. Study participants were asked which statement best explained their recent emotional state from among four statements. Statements coded as 0 describe a more neutral feeling and those coded as 3 describe a more negative feeling. The total score is calculated as the sum of item scores and can range from 63 to 0. A higher total score refers to a higher intensity of depressive feelings. Scores of 10–15 are considered to indicate mild depression, 16–23 as moderate depression, and > 24 as severe depression.
Data Collection Procedure We obtained informed consent from students. Informed consent from parents was exempted since the study had less than minimal risk, and the potential benefit of the assessment opportunity for this topic is significant among this population. Data collection occurred in the classroom by self-report from voluntary participants.
4
The Journal of School Nursing XX(X)
Table 1. Psychometric Evaluations of Study Measurements. School Bullying
N Items (n) Possible range Mean (SD) Median, (range)
SIQ-HS
K-Scale
S-Scale
Offenders
Victims
BDI
BIS
400 30 0–180 13.6 (24.0) 3 (0–161)
414 15 15–60 24.2 (7.8) 23 (15–51)
392 15 15–60 28.3 (7.9) 29 (15–54)
413 15 0–60 18.6 (6.0) 15 (15–46)
407 15 0–60 18.3 (6.1) 15 (15–59)
383 21 0–69 23.7 (9.6) 5 (0–59)
408 23 0–63 8.4 (9.9) 24 (0–63)
More addiction to Direction of high score More suicidal ideation Cronbach’s a W (p)
.978 .610 (
Suicidal Ideation and Related Factors Among Korean High School Students: A Focus on Cyber Addiction and School Bullying
The Journal of School Nursing 1-9 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840517734290 journals.sagepub.com/home/jsn
Min Sohn, RN, PhD1, Heymin Oh, RN, MS1, Sang-Kyu Lee, MD, PhD2,3, and Marc N. Potenza, MD, PhD3,4,5,6
Abstract The purpose of the study was to explore the association among suicidal ideation, cyber addiction, and school bullying of Korean high school students. This descriptive cross-sectional study included 416 students. The data were collected using structured questionnaires on suicidal ideation, Internet and smartphone addiction, experiences of school bullying, impulsiveness, and depression. Students who were bullied (odds ratio [OR] ¼ 3.0, 95% CI [1.1, 8.4]) and more depressed (OR ¼ 10.8, 95% CI [2.4, 48.2]) were more likely to have higher scores for suicidal ideation; however, when a lower stringency was used, female gender (OR ¼ 2.3, 95% CI [1.3, 4.0]) and addiction to smartphones (OR ¼ 2.4, 95% CI [1.1, 5.4]) were also statistically significant contributors to the presence of suicidal ideation. Students with suicidal ideation that is higher than average, but lower than the classical thresholds for risk group designation, should also be carefully assessed for early detection and intervention. Cyber addiction may be a particularly significant contributor to suicidal ideation, in addition to bullying and depressive mood, among Korean adolescents. Keywords suicidal ideation, Internet, smartphone, addiction, adolescents, school nurse
In 2014, suicide was the second leading cause of death among 10- to 19-year-old Koreans (Shin et al., 2016). The suicide rate of Korean adolescents aged 15–19 years old was 8.2 per 100,000, higher than the average rate of 6.4 per 100,000 in the 33 countries of the Organization for Economic Co-operation and Development (OECD, 2015). While the OECD reported that, on average, there has been a gradual decrease in suicide rates, Korea has presented a gradual increase in the suicide rate among adolescents. Therefore, suicidal behaviors, including suicidal ideation, suicide attempts, and suicide, remain an extremely important topic in adolescent health in Korea. Among these behaviors, suicidal ideation has particular significance because the early detection of suicidal ideation is arguably one of the best and most effective means of early intervention for the prevention of suicide. Statistics on adolescents with suicidal ideation vary considerably depending on the definition of the phenomenon and the measurement used to assess it. Korean national statistics revealed that 9.6% of boys and 13.9% of girls in general population presented suicidal ideation during the year 2014 (Yi, Pyo, Jeong, & An, 2016). Another report from Roh and their colleague (2015) indicated that 39.5% of adolescents, who visited community
mental health centers, reported that they had thoughts of suicide in last 3 months. Potential risk factors for suicidal ideation have been actively studied. Female gender, depression, impulsiveness, family integrity, socioeconomic status, anxiety, and delinquent behaviors such as illegal drug use and substance use have been associated with suicidal ideation (Kokkevi, Rotsika, Arapaki, & Richardson, 2012; Lee et al, 2016).
1
Department of Nursing, Inha University, Incheon, South Korea Department of Psychiatry, Hallym University College of Medicine, Chuncheon, South Korea 3 Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA 4 Department of Neuroscience and Child Study Center, Yale University School of Medicine, New Haven, CT, USA 5 National Center on Addiction and Substance Abuse, Yale University School of Medicine, New Haven, CT, USA 6 The Connecticut Mental Health Center, New Haven, CT, USA 2
Corresponding Author: Sang-Kyu Lee, MD, PhD, Department of Psychiatry, Hallym University College of Medicine, Chuncheon, South Korea. Email: [email protected]
2
Recently, other potential risk factors such as cyber addiction and school bullying have been described. A limited but intriguing set of studies has reported that forms of cyber addiction such as Internet (Lee et al., 2016), smartphone (Kim & Hwang, 2015), and online game addictions (Holt et al., 2015) seem to be associated with suicidal ideation among adolescents. Cyber addiction, defined as the problematic use of cyber media including Internet, smartphones, and online chatting, gaming, and gambling (Kuss, Griffiths, Karila, & Billieux, 2014; Young, Pistner, O’Mara, & Buchanan, 1999), has become a prominent topic in Korea. National statistics indicate that 92.5% of Korean adolescents have their own personal computer and 99.6% have a smartphone, and the average length of time playing online games was 1 hr during weekdays and 2 hr during the weekend in 2014 (Ministry of Science Information and Communications Technology (ICT) and Future Planning, 2016). In Korea, the prevalence of Internet addiction has been reported as 12.5% among adolescents, with the prevalence of smartphone addiction even higher at 29.2% (Ministry of Science, ICT and Future Planning, 2014). Some studies suggest that cyber addiction has an important relationship with suicidal ideation, particularly with the overuse of smartphones (Kim & Hwang, 2015), the Internet, and online games (Lee et al., 2016). However, it has been difficult to differentiate the independent contributions of different forms of cyber addiction to suicidal ideation since all multiple forms may occur together. For example, adolescents who like to use smartphones can easily access the Internet and online (or mobile) games at the same time. To our knowledge, very few studies have been conducted to examine relationships between cyber addiction and suicidal ideation while controlling for multiple other factors within the study. Another potential risk factor for suicidal ideation involves school bullying. Students who are bullied appear more likely to experience suicidal ideation (Sourander & Madelyn, 2010). School bullying involves aggressive or violent behavior that occurs in the school environment and school-associated networks (Sourander & Madelyn, 2010). Adolescents may be involved in bullying as victims, perpetrators, or both. Bullying is diverse in terms of its forms. These forms may include traditional types such as active physical assault and aggressive verbal assaults, but recently, cyberbullying has become a more frequent form of school bullying (Sampasa-Kanyinga, Roumeliotis, & Xu, 2014). Cyberbullying involves the use of information technology and occurs in various cyber environments, such as over cellular phones, by e-mail, by messenger, and by social network system (SNS; Sampasa-Kanyinga, Roumeliotis, & Xu, 2014). Cyberbullying may be more intrusive than traditional bullying since it can occur at any time or place. A recent meta-analysis indicated that cyberbullying is strongly related to suicidal ideation (Van Geel, Vedder, & Tanilon, 2014). It reported that the effects of cyberbullying are more severe than those of traditional bullying. In the past, school bullying referred to
The Journal of School Nursing XX(X)
more physical and person-to-person occurrences at school. Recently, however, school bullying has expanded to environments outside of school, such as the online environment, and it often continues even when victims move to other schools or neighborhoods. In these circumstances, SNS and free online chat applications over smartphones are often used. Recent statistics have indicated that 16.3% of elementary students, 20.0% of middle school students, 20.7% of high school students have experienced bullying over the Internet (Korea Internet & Security Agency, 2014). While suicidal ideation, cyber addiction, and school bullying are often related to one another, there exists a significant knowledge gap and methodological issues in research of the topics. Some instruments for evaluating suicidal ideation revealed positive skewed distribution particularly when the studies included general population (Glashouwer et al., 2010; Zhang, Yip, & Fu, 2014). Furthermore, selecting cutoffs for the best sensitivity and specific to predict suicidal ideation and suicidal attempt for various populations is often not easy (Zhang, Yip, & Fu, 2014). In order to advance prevention efforts, suicidal ideation in community or school settings needs to be understood across a wide spectrum, and adolescent engagement in various levels of suicidal ideation should be explored for early detection and intervention. Furthermore, newly reported potential risk factors such as the experience of bullying as both victim and perpetrator and cyber addiction have not been studied sufficiently in the context of a range of suicidal ideation. Finally, adolescents in vocational schools (Dalen, 2012) or rural areas, where suicidal ideation is high and mental health services are limited, have been less well studied (Murphy, 2014).
Study Purpose The purpose of this study is to explore various levels of suicidal ideation and associated factors among students attending a vocational high school in a rural area of South Korea (hereafter, “Korea”), focusing in particular on school bullying and cyber addiction. Suicidal ideation and associated factors will also be examined according to the level of suicidal ideation, in order to identify whether these associations differ among adolescents with various levels of suicidal ideation. We hypothesized that both cyber addiction and school bullying would relate to suicidal ideation, as would other factors (e.g., female gender and depressed mood) that have been previously associated with suicidal ideation.
Method Design This study is a cross-sectional descriptive study. The data collection period was from October 1, 2014, to December 31, 2014. We collected data after approval from the Ethics Committee of Chuncheon Sacred Heart Hospital (Institutional Review Board (IRB) No. 2014-113).
Sohn et al.
Study Participants We recruited students from 10th to 12th grade from one vocational high school with an agricultural specialization, located in Chuncheon, South Korea. Chuncheon is a midsize city surrounded by a large rural area. We included all students in the school, since the school was also willing to use these data for mental health screening purpose as a part of routine student health screening. A post hoc power analysis using G*Power (Faul, Erdfelder, Buchner, & Lang, 2009) revealed that we obtained 0.94–0.99 power on the basis of n ¼ 400 and odds ratios (ORs) and R2 in the three logistic regression models.
Measurements We collected data on basic characteristics, suicidal ideation, Internet and smartphone addiction, durations of online gaming, experiences of school bullying, impulsiveness, and depression using structured questionnaires. Basic characteristics included age, gender, experience of smoking and drinking, and length of online game play. The results of a psychometric evaluation of the structured questionnaires are presented in Table 1. Suicidal ideation was evaluated using the Suicidal Ideation Questionnaire for High School Students (SIQ-HS) originally developed by Reynolds and Baker (1988), and its validity and reliability were tested for high school students in Hong Kong (Zhang, Yip, & Fu, 2014) and France (Potard, Kubiszewski, Gimenes, & Gourtois, 2014). Shin (1992) has translated the SIQ-HS into Korean and presented Cronbach’s a of .83 with Korean high school students. Another Korean study also revealed its Cronbach’s a of .97 and good constructive validity with college students (Yang, Bang, & Kim, 2012). This instrument includes 30 items querying the frequency of suicidal thoughts among adolescents during the last 12 months. Study participants were asked to answer each question on a 7-point Likert-type scale, from 0 ¼ never to 6 ¼ almost every day. The total score is calculated as a sum of item scores and can range from 0 to 180. A higher total score designates higher frequency and more pervasive suicidal ideation. Both 41 and 31 can be used as thresholds among school students to determine the necessity of further suicidal evaluation, as either conservative or liberal thresholds (Reynolds & Baker, 1988). Internet and smartphone addiction were evaluated using the Internet Addiction Proneness Scale for Youth (KS-II; Kim, Chung, Lee, Kim, & Cho, 2008 ) and Smartphone Addiction Proneness Scale (Kim, Lee, Lee, Nam, & Chung, 2014), which were developed by the Korea Agency for Digital Opportunity and Promotion (Shin, Kim, & Jeung, 2011). Both instruments have four subdimensions diagnosing disturbance of adaptive function, tolerance, withdrawal, and virtual life orientation. Each instrument has 15 items that ask whether responders experience difficulties due to overuse of the Internet. Study participants were asked to answer on a 4-point Likert-type scale ranging from 1 ¼ not
3
at all to 4 ¼ always. The total score is calculated as the sum of the item scores and can range from 15 to 60. A higher total score refers to a greater intensity of Internet addiction. The level of Internet or smartphone addiction is categorized as a potential risk group for scores of 41–43 and as a high-risk group for scores of >44. The duration of online gaming was assessed by querying how many hours per day students played online games, on average. School bullying was evaluated using the Bullying or Bullied Scale (Choi & Chae, 2000). This instrument has a total of 30 items asking about any experience as a perpetrator or as a victim of bullying. If students had an experience of enacting or undergoing school bullying, they were asked to quantify it. Study participants were asked to answer on a 5-point Likert-type scale spanning 1 ¼ never in the past, 2 ¼ 1–2 times in the past, 3 ¼ sometimes in the past, 4 ¼ 1–2 times a week, and 5 ¼ several times a week. The total score is calculated as the sum of the item scores and can range from 0 to 60 for the experience of either bullying or being bullied. A score higher than 15 refers to any experience of bullying or being bullied, and the higher the total score, the higher the frequency of school bullying or experience of being bullied. Impulsiveness was evaluated using the Barratt Impulsiveness Scale (BIS) Version 11 (Barratt, 1985; Fossati, Di Ceglie, Acquarini, & Barratt, 2001) adapted for Korean use by Lee and colleagues (2012). This instrument includes three subscales: Cognitive Impulsiveness, Motor Impulsiveness, and Nonplanning Impulsiveness. Study participants were asked to answer about the frequency of certain impulsive behaviors on a 4-point Likert-type scale from 0 ¼ not at all to 3 ¼ all the time. The total score is calculated as the sum of the item scores and can range from 0 to 69. A higher total score refers to a higher frequency of impulsive behaviors. Depression was evaluated using the Beck Depression Inventory (BDI), translated by Lee and Song (1991). This instrument has a total of 21 items concerning somatic, cognitive, and affective symptoms. Study participants were asked which statement best explained their recent emotional state from among four statements. Statements coded as 0 describe a more neutral feeling and those coded as 3 describe a more negative feeling. The total score is calculated as the sum of item scores and can range from 63 to 0. A higher total score refers to a higher intensity of depressive feelings. Scores of 10–15 are considered to indicate mild depression, 16–23 as moderate depression, and > 24 as severe depression.
Data Collection Procedure We obtained informed consent from students. Informed consent from parents was exempted since the study had less than minimal risk, and the potential benefit of the assessment opportunity for this topic is significant among this population. Data collection occurred in the classroom by self-report from voluntary participants.
4
The Journal of School Nursing XX(X)
Table 1. Psychometric Evaluations of Study Measurements. School Bullying
N Items (n) Possible range Mean (SD) Median, (range)
SIQ-HS
K-Scale
S-Scale
Offenders
Victims
BDI
BIS
400 30 0–180 13.6 (24.0) 3 (0–161)
414 15 15–60 24.2 (7.8) 23 (15–51)
392 15 15–60 28.3 (7.9) 29 (15–54)
413 15 0–60 18.6 (6.0) 15 (15–46)
407 15 0–60 18.3 (6.1) 15 (15–59)
383 21 0–69 23.7 (9.6) 5 (0–59)
408 23 0–63 8.4 (9.9) 24 (0–63)
More addiction to Direction of high score More suicidal ideation Cronbach’s a W (p)
.978 .610 (
