Journal of Affective Disorders 300 (2022) 392–399

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

School bullying associated suicidal risk in children and adolescents from

Yunnan, China: The mediation of social support
Yuanyuan Xiao a, *, Hailiang Ran a, Die Fang a, Yusan Che a, Ahouanse Roland Donald a,
Sifan Wang a, Junwei Peng a, Lin Chen a, Jin Lu b, *
a
School of Public Health, Kunming Medical University, Kunming, Yunnan, China, 650500
b
Department of Psychiatry, The First Affiliated Hospital, Kunming Medical University, Kunming, Yunnan, China, 650032

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: : We aimed to investigate the mediation of social support in the association between school bullying
School bullying and suicidal risk among a large group of Chinese children and adolescents.
Suicidal risk Method: : In this two-wave cross-sectional study, we analyzed 6,063 children and adolescents from southwest
Social support
China. A two-stage simple random clustering sampling method with probability proportionate to sample size
Mediation
design had been used to select study subjects. Univariate and multivariate Logistic regression models were
Path model
adopted to determine the inter-associations between school bullying, suicidal risk indicators, and social support.
Path models were further fitted to estimate the mediation of social support.
Results: : Compared with students who were not involved in school bullying, only victimization was associated
with increased suicidal risk, the adjusted ORs for suicidal ideation, suicidal plan, and suicidal attempt were 2.06
(95% CI: 1.61–2.65), 2.07 (95% CI: 1.62–2.64), and 2.41 (95% CI: 1.90–3.05), respectively. Path model indicated
that parental social support significantly mediated the association between bullying victimization and suicidal
risk. For different types of victimization, only relational bullying victimization was associated with increased
suicidal risk, social support from classmates and close friends presented as significant mediators.
Limitations: : Causal inference cannot be made because of cross-sectional study design. Information was collected
by using self-reporting method, the possibility of information bias exists. Generalization of study results could be
limited.
Conclusions: : Intervention measures on improving parental and peer social support may be effective in reducing
school bullying victimization associated suicidal risk for Chinese children and adolescents.

1. Introduction
Children and adolescents are at increased risk of suicide. Worldwide,
suicide is the third leading cause of death in adolescents aged 15–19
years (World Health Organization, 2020). Suicide has also become a
major cause of death in children and adolescents in China: previously
published cross-sectional studies of large sample sizes have revealed
that, the prevalence rates of suicidal ideation (SI) and suicidal attempt
(SA) can be as high as 32% and 2.7% (Tan et al., 2018). Identified factors
for increased suicidal risk in youth include mental disorders, like
depression, anxiety, and substance abuse (Bridge et al., 2006); person­
ality characteristics, typically impulsivity (Apter and Wasserman,
2006); family problems, such as domestic violence, incomplete family
structure, poor communication within the family (Brent and Mann,
2006).
School bullying is a type of interpersonal violence. It is usually
defined as a form of unwanted aggressive behavior which has been
repeatedly and habitually delivered to other individuals at a school
setting (Nansel et al., 2004). School bullying is a global public health
issue among children and adolescents, it is typically seen in the forms of
traditional bullying (physical, verbal, relational), and more recently,
cyber bullying. Individuals involved in school bullying play different
roles: as victims (been bullied), as bullies (bully others), or as
bully-victims (simultaneously been bullied and bully others). In China,
the reported prevalence of bullying victimization and perpetration were
66% and 37% (Chan and Wong, 2015). School bullying can bring about
adverse mental consequences to those who involved (Antila et al.,
2017). The positive association between school bullying involvement

* Corresponding authors.
E-mail addresses: 33225647@qq.com (Y. Xiao), jinlu2000@163.com (J. Lu).

https://doi.org/10.1016/j.jad.2022.01.032
Received 27 August 2021; Received in revised form 2 January 2022; Accepted 4 January 2022
Available online 5 January 2022
0165-0327/© 2022 Elsevier B.V. All rights reserved.
Y. Xiao et al.
and increased suicidal risk has also been repeatedly reported: a recently
published study based on the Global School-based Health Survey (GSHS)
data from 83 countries found that, adolescents who were victims of
school bullying were observed increased risk of SI, SP, and SA (Tang
et al., 2020).
In consideration of the high prevalence of school bullying, and the
devastating consequences of youth suicide, it is imperative to reduce
bullying associated suicidal risk. However, a direct intervention on
school bullying seems less plausible, considering the huge expenses
caused by multiple participants and extended process (Farrell et al.,
2018). Besides, the effects of whole school anti-bullying programs have
been limited, only can reduce bullying perpetration and victimization by
about 20% and 15% (Gaffney et al., 2019). Under this circumstance,
finding other modifiable factors which lie in the association between
bullying and suicidal risk is crucial for bullying associated suicide pre­
vention in youth.
Social support is the perception and actuality that the assistance
available from family, friends, and significant others (Thoits, 2011). The
positive linkage between social support and school bullying has been
well established, individuals who reported poorer social support were
more likely be bullying victims (Evans et al., 2014). However, this
relationship can also be inverse, a newly published study in 5012 Chi­
nese university students revealed that, bullying involvement was asso­
ciated with less perceived social support, for both bullies and victims
(Lin et al., 2020). Meanwhile, accumulated empirical evidence supports
the association between social support and suicidal behaviors in ado­
lescents (Ibrahim et al., 2019; Zhu et al., 2021). Therefore, it is possible
that social support plays as a mediator in the association between
bullying and suicidal risk. This suspected mediation of social support
can also be explained by existing theoretical models. For instance,
stress-buffering theory has found that a higher level of social support can
play a buffering effect on stress-related negative outcomes for students
(Cohen et al., 2000), social support deterioration theory illustrates that
eroded social support by stress leads to psychological distress and mal­
adjustment of children and adolescents (Barrera Jr., 1986).
Nevertheless, to our best knowledge, the mediation of social support
in the association between school bullying and suicidal risk has not been
thoroughly discussed in Chinese teenagers. Currently, only a study of
946 Chinese adolescents reported a noticeable mediation of social sup­
port in the association between school bullying victimization and SI (Liu
et al., 2017). The suspected mediation of social support for other roles of
school bullying involvement and other indicators of suicidal risk should
be further discussed. In this study, by using the combined data of a
two-wave survey in southwest China, we intend to discuss the associa­
tion between school bullying and suicidal risk among 6063 Chinese
children and adolescents, more importantly, the suspected mediation of
social support will be analyzed. Different roles of school bullying
involvement, various sources of social support, multiple indicators of
suicidal risk will be simultaneously investigated. We test the following
two major hypotheses:
Hypothesis 1. Different roles (victims, bullies, bully-victims) of school
bullying are significantly but discordantly associated with three suicidal risk
indicators (one-year suicidal ideation, suicidal plan, suicidal attempt);
Hypothesis 2. Social support plays as a significant mediator in the asso­
ciations between school bullying involvement and the three suicidal risk
indicators.
Except for the two proposed hypotheses, we intend to extra investi­
gate the following research question: Whether different sources (family,
friends, teachers, classmates) of social support present incongruent
mediation in the associations between school bullying and the three
suicidal risk indicators?
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Journal of Affective Disorders 300 (2022) 392–399
2. Material and methods
2.1. Study design and participants
A two-wave survey had been conducted in two cities (Kaiyuan,
Kunming) of southwestern China Yunnan province from October to
November 2020 (Kaiyuan in October, Kunming in November). In the
two study sites, a two-stage simple random clustering sampling method
with probability proportionate to sample size (PPS) design was used to
select study subjects: in stage one, altogether 19 primary, secondary, and
senior high schools were randomly chosen from all schools within the
two cities; in stage two, based on the required sample size, 2–4 classes in
each grade of the chosen school were further randomly selected, all
students within the chosen class were initially included. In Kaiyuan, all
the 7 districts or counties within its jurisdiction were included into the
sampling process, whereas in Kunming, among all the 13 districts or
counties, only Panlong district was included.
Students were further excluded if: aged below 10 years in consider­
ation that children can fully understand the concept and consequence of
suicide by the age of 10 (Mishara, 1999); aged 18 years and above for the
fact that they were adults. Other exclusion criteria can be referred to in
our previously published paper (Xiao et al., 2021). In the end, 4603 and
1612 students from Kaiyuan and Kunming were eligible participants
been surveyed. The study protocol was reviewed and approved by the
Ethics Committee of Kunming Medical University. Written informed
consents were obtained from both the legal guardians and the partici­
pants prior to the survey.
2.2. Instruments
We used a structured questionnaire to collect information from the
study subjects. Questionnaires were self-reported by the respondents. A
group of quality control personnel was deployed at site to check for
completeness and logical errors for the finished questionnaires. The
questionnaire is comprised of different modules, the modules that we
used for the analysis in this study were: general characteristics, school
bullying, depression and anxiety, social support, suicidal risk indicators.
2.2.1. General characteristics
This part was self-developed, contains only factual questions
regarding to the demographics (age, sex, ethnicity), family features
(residence type, marriage status of the parents, family income, left-
behind status, whether single child), and study information (type of
school, grade, whether boarding student, time of school transfer) of the
respondents. Within family features, family income was measured by
using a single question “What is the income status of your family?”, the
answers included “Stable: with regular payments” and “Unstable:
receiving social assistance or help from others”. Left-behind children
was defined as children who are under 18 years old, with one or both of
the parents migrated to other places for work, and the separation
exceeded a consecutive 6 months in the past year (Zhou and Duan,
2006).
2.2.2. School bullying
We used the Chinese version of the Olweus Bully/Victim Question­
naire (OBVQ) to measure physical, verbal, and relational bullying
happened in the current semester (Olweus, 1996). For each type of
bullying, two questions were used to measure the occurrence and fre­
quency of the behavior. Participants who reported “2 to 3 times per
month” or more frequent being bullied, bully others, being bullied while
bully others were classified as victims, bullies (perpetrators), and
bully-victims as recommended (Peng et al., 2020; Solberg and Olweus,
2003). For cyber bullying, we used a single question: have you ever been
bullied on internet or via cell phone? Those who answered once or above
were deemed victims, as suggested by a previous study (Kowalski and
Limber, 2007). Cyber bullying perpetration had not been measured in
Y. Xiao et al. Journal of Affective Disorders 300 (2022) 392–399

the questionnaire. Respondents who had not bullied others or been Table 1
bullied by others were categorized as “non-involved”. Bullying victim­ General characteristics of study subjects (N = 6063).
ization was measured in detail by using a single multinomial variable: Characteristics All subjects Bullying Bullying un- p
physical, verbal, relational, cyber, and multiple (victims of more than (N = 6063) involved(N involved(N = value
one type of bullying victimization). = 818) 5245)

Demographics
2.2.3. Depression and anxiety Locality: Kaiyuan (N, 4474 647 (79.10) 3827 (72.96) <0.01
Longitudinal studies suggested that higher baseline depression and %) (73.79)
Sex: Boys (N,%) 3023 452 (55.26) 2571 (49.02)
anxiety level was associated with increased risk of future bullying
<0.01
(49.86)
involvement among teens (Cross et al., 2015; Le et al., 2019). Moreover, Ethnicity: Han 2554 332 (40.59) 2222 (42.36) 0.36
both depression and anxiety are well-established risk factors in pre­ majority (N,%) (42.12)
dicting SI in children and adolescents (Lawrence et al., 2021). Therefore, Age (Mean, SD) 13.39 12.69 (1.99) 13.50 (1.97) <0.01
(1.99)
depression and anxiety were included into the analysis as potential
Family features
important confounding factors which should be simultaneously Residence: Township 2777 361 (44.13) 2416 (46.06) 0.99
controlled for. They were measured by using the Patient Health Ques­ (N,%) (45.80)
tionnaire (PHQ-9) (Kroenke et al., 2001) and the Generalized Anxiety Parents’ marriage 5286 659 (80.56) 4627 (88.22) <0.01
Disorder Assessment (GAD-7) (Spitzer et al., 2006). PHQ-9 contains 9 status: In marriage (87.18)
(N,%)
items, measures two-week depressive symptoms, the response to each Age of father (Mean, 42.28 41.70 (6.59) 42.37 (7.66) 0.04
item can be assigned a score from 0 to 3. Although initially developed for SD) (7.54)
depression screening in adults, subsequently published studies sug­ Age of mother (Mean, 39.70 39.15 (5.92) 39.77 (9.32) 0.04
gested ideal sensitivity and specificity of the PHQ-9 in adolescent pop­ SD) (8.96)
Family income: Stable 5589 732 (89.49) 4857 (92.60)
ulations (Richardson et al., 2010). The same scoring method is used for <0.01
(N,%) (92.18)
GAD-7, and the validity of GAD-7 in detecting anxiety in adolescents has Left-behind children: 1050 171 (20.90) 879 (16.76) <0.01
been verified (Mossman et al., 2017). For the two instruments, a higher Yes (N,%) (17.32)
combined score indicates a higher level of depression or anxiety. In the Single child: Yes (N, 1471 205 (25.06) 1266 (24.14) 0.60
current study, we adopted a uniform cut-off of 4 (>4) to dichotomize %) (24.26)
Study information
study subjects as recommended (Spitzer et al., 1999, 2006). The Cron­
Type of school (N,%) <0.01
bach’s α for PHQ-9 and GAD-7 in this study were 0.893 (95% CI: Primary 1496 318 (38.88) 1178 (22.46)
0.887–0.899) and 0.916 (95% CI: 0.911–0.921). (24.67)
Junior high 3323 419 (51.22) 2904 (55.37)
(54.81)
2.2.4. Social support
Senior high 1244 81 (9.90) 1163 (22.17)
The Chinese version of Child and Adolescent Social Support Scale (20.52)
(CASSS) was used for gaging perceived social support (Malecki and Boarding student: Yes 2725 303 (37.04) 2422 (46.18) <0.01
Demary, 2002). The CASSS is a well-validated instrument which con­ (N,%) (44.94)
tains 40 items, with 10 items collectively measuring one of the four School transfer 899 121 (14.79) 778 (14.83) 1.00
experience: Yes (N, (14.83)
primary sources of social support: parents, teachers, classmates, and
%)
close friends. Every item has a 5-point Likert style response, from Depression: Yes 2444 473 (57.82) 1971 (37.58) <0.01
“Never” to “Always”, and can be scored from 1 to 5. A higher combined (PHQ-9>4) (N,%) (40.31)
score reflects better perceived social support. The Cronbach’s α for Anxiety: Yes (GAD- 1866 417 (50.98) 1449 (27.63) <0.01
7>4) (N,%) (30.78)
CASSS was 0.931 (95% CI: 0.928–0.933).
Social support: total 154.38 145.43 155.77 <0.01
(Mean, SD) (21.72) (24.09) (20.99)
2.2.5. Suicidal risk Social support: 36.55 35.07 (7.45) 36.78 (6.78) <0.01
Suicidal risk of the respondents was measured by using one-year parents (Mean, SD) (6.90)
suicidal ideation (SI), suicidal plan (SP), and suicidal attempt (SA) Social support: 41.42 39.97 (7.28) 41.65 (6.35) <0.01
teachers (Mean, SD) (6.51)
from the Suicidal Behaviors Questionnaire-Revised (SBQ-R) (Osman
Social support: 37.06 33.55 (8.14) 37.61 (6.75) <0.01
et al., 2001). For one-year SI, those who answered “1 time” or more classmates (Mean, (7.09)
frequent (the answers include: never, 1 time, 2 times, 3–4 times, 5 times SD)
and above) to the question “How often have you thought about killing Social support: close 39.34 36.84 (8.87) 39.73 (6.92) <0.01
friends (Mean, SD) (7.28)
yourself in the past year?” were classified as positive. Similarly, for
One-year SI: Yes (N, 2402 468 (57.21) 1934 (36.87) <0.01
one-year SP and SA, those who answered “1 time” or more frequent to %) (39.62)
the questions “How often have you planned to end your life in the past One-year SP: Yes (N, 1343 315 (38.51) 1028 (19.60) <0.01
year?” and “How often have you attempted to suicide but failed in the %) (22.15)
past year?” were classified as positive. One-year SA: Yes (N, 541 (8.92) 178 (21.76) 363 (6.92) <0.01
%)

2.3. Data management and statistical analysis SI: suicidal ideation; SP: suicidal plan; SA: suicidal attempt.

The survey data were all double entry to guarantee quality.
Descriptive statistics were used to illustrate the major characteristics of
the participants. Statistical tests, mainly t-test, χ2 test, were used to
determine the statistical differences between groups. Univariate and
multivariate Logistic regression models were adopted to determine the
crude and adjusted associations between covariates and binary de­
pendents. A series of path models were fitted to estimate the mediation
of social support in the associations between school bullying and sui­
cidal risk indicators. The statistical significance was set as a two-tailed
probability less than 0.05, except for univariate Logistic regression
analysis, which adopted a comparatively low criterion of 0.10 to screen
for possible covariates. All the analyses in this study were performed by
using the R software (Version 3.6.10).
3. Results
3.1. General characteristics of study subjects
Among the 6215 eligible respondents, 6063 provided complete

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Table 2
Univariate and multivariate analysis results on associated factors of suicidal risk indicators.
Covariates One-year SI One-year SP One-year SA

Crude OR(90% Adjusted OR (95% Crude OR (90% Adjusted OR (95% Crude OR (90% Adjusted OR (95%
CI) CI) CI) CI) CI) CI)

Locality (Ref: Kaiyuan): Kunming 2.08 (1.89, 1.47 (1.19, 1.81) 1.86 (1.67, 2.07) 1.23 (0.98, 1.55) 1.78 (1.52, 2.07) 1.82 (1.39, 2.39)
2.30)
Sex (Ref: Boys): Girls 1.98 (1.82, 1.77 (1.51, 2.06) 2.32 (2.09, 2.58) 2.13 (1.78, 2.55) 2.54 (2.17, 2.99) 2.23 (1.81, 2.75)
2.17)
Ethnicity (Ref: Han majority): Minorities 0.64 (0.58, 0.97 (0.81, 1.16) 0.67 (0.60, 0.74) 1.03 (0.84, 1.26) 0.74 (0.64, 0.86) 1.01 (0.80, 1.28)
0.69)
Age: +1 year 1.14 (1.12, 0.99 (0.91, 1.07) 1.10 (1.08, 1.13) 0.96 (0.88, 1.06) 0.99 (0.95, 1.03)
1.17)
Residence (Ref: Township): Rural 0.60 (0.55, 0.85 (0.68, 1.05) 0.54 (0.48, 0.59) 0.71 (0.56, 0.90) 0.65 (0.56, 0.76) 1.09 (0.84, 1.42)
0.66)
Parents’ marriage status (Ref: Other status): In 0.60 (0.53, 0.72 (0.56, 0.92) 0.57 (0.49, 0.65) 0.79 (0.62, 1.01) 0.50 (0.41, 0.60) 0.72 (0.56, 0.93)
marriage 0.68)
Age of father: +5 years 1.06 (1.02, 1.01 (0.94, 1.06) 1.02 (0.98, 1.06) 1.01 (0.94, 1.06)
1.11)
Age of mother: +5 years 1.13 (1.08, 1.04 (0.99, 1.14) 1.07 (1.02, 1.13) 1.03 (0.99, 1.09) 1.01 (0.95, 1.04)
1.19)
Family income (Ref: Stable): Unstable 0.86 (0.73, 0.92 (0.76, 1.12) 0.99 (0.74, 1.30)
1.01)
Left-behind children (Ref: No): Yes 1.20 (1.07, 1.18 (0.96, 1.45) 1.22 (1.07, 1.39) 1.20 (0.96, 1.50) 1.44 (1.20, 1.72) 1.29 (1.01, 1.64)
1.34)
Single child (Ref: No): Yes 1.21 (1.09, 0.90 (0.75, 1.09) 1.18 (1.05, 1.32) 0.86 (0.70, 1.06) 1.11 (0.94, 1.31)
1.33)
Type of school (Ref: Elementary)
Middle high 1.85 (1.66, 1.33 (0.98, 1.81) 1.94 (1.69, 2.23) 1.29 (0.90, 1.84) 1.44 (1.20, 1.74) 0.77 (0.59, 1.02)
2.07)
Junior high 2.51 (2.20, 0.98 (0.59, 1.62) 2.09 (1.78, 2.46) 0.79 (0.44, 1.41) 0.98 (0.77, 1.25) 0.33 (0.22, 0.49)
2.87)
Boarding student (Ref: No): Yes 0.70 (0.64, 0.78 (0.63, 0.96) 0.60 (0.54, 0.66) 0.69 (0.54, 0.87) 0.57 (0.48, 0.66) 0.66 (0.51, 0.87)
0.77)
School transfer experience (Ref: No): Yes 1.39 (1.23, 1.46 (1.18, 1.79) 1.33 (1.16, 1.52) 1.29 (1.02, 1.62) 1.30 (1.07, 1.58) 1.28 (0.98, 1.66)
1.56)
Depression (Ref: No): Yes 6.55 (5.95, 3.40 (2.83, 4.10) 8.24 (7.31, 9.29) 3.90 (3.13, 4.88) 7.45 (6.21, 9.01) 3.12 (2.33, 4.18)
7.21)
Anxiety (Ref: No): Yes 5.86 (5.30, 2.32 (1.92, 2.81) 7.68 (6.87, 8.59) 3.14 (2.57, 3.86) 7.85 (6.64, 9.31) 3.50 (2.70, 4.56)
6.47)
Bullying involvement (Ref: Non-involved)
Victims 2.44 (2.14, 2.06 (1.61, 2.65) 2.67 (2.32, 3.06) 2.07 (1.62, 2.64) 3.80 (3.19, 4.51) 2.41 (1.90, 3.05)
2.79)
Bullies 1.14 (0.68, 0.66 (0.27, 1.62) 1.33 (0.72, 2.30) 0.99 (0.38, 2.44) 2.48 (1.18, 4.69) 1.88 (0.72, 4.35)
1.88)
Bully-victims 1.83 (1.19, 0.94 (0.40, 2.17) 2.55 (1.63, 3.94) 1.60 (0.69, 3.61) 4.09 (2.40, 6.69) 2.41 (1.19, 4.64)
2.81)

information, with an effective response rate of 97.6%. A total of 818
individuals were involved in school bullying, with a reported prevalence
of 13.49% (95% CI: 12.65%− 14.37%). Respondents who were and were
not involved in school bullying were statistically different in nearly all
aspects, only except for residence type (township or rural), ethnicity,
whether single child, and school transfer experience. Bullying involved
students reported significantly higher level of all suicidal risk indicators:
compared with un-involved students, their one-year prevalence rates of
SI, SP, SA were 1.55, 1.96, and 3.14 times. Meanwhile, they were also
observed higher prevalence of depression and anxiety, together with
reduced level of all types of social support (Table 1).
Among the 818 adolescents who had involved in bullying, 713
(87.16%) were pure victims, 45 were pure bullies (5.50%), 60 (7.33%)
were bully-victims. Nearly all general characteristics were comparable
for different roles of bullying involvement, except for sex, as a much
higher proportion of boys had been observed in bullies (82.22%),
compared with which in bully-victims (68.33%) and victims (52.45%).
3.2. Hypothesis 1: roles of school bullying with suicidal risk indicators
Multivariate binary Logistic regression models suggested that, after
controlled for possible covariates, especially depression and anxiety,
compared with students who had not experienced school bullying, only
bullying victims were observed consistently increased suicidal risk: the
odds ratios (ORs) for one-year SI, SP, SA were 2.06 (95% CI: 1.61–2.65),
2.07 (95% CI: 1.62–2.64), and 2.41 (95% CI: 1.90–3.05), respectively.
For bully-victims, only the OR for SA was significant (2.41, 95% CI:
1.19–4.64). Among other features, sex, whether boarding students,
depression, and anxiety were strongly associated with all suicidal risk
indicators (Table 2).
3.3. Hypothesis 2: mediation of social support
Analytical results suggested that social support in general was
significantly associated with one-week SI (OR=0.87, 95% CI:
0.83–0.90), SP (OR=0.85, 95% CI: 0.82–0.89), and SA (OR=0.84, 95%
CI: 0.81–0.88). As to the specific types of social support, only parental
social support presented prominent association with all three suicidal
risk indicators (see in supplementary material, Table S1). Moreover,
compared with un-involved respondents, all roles of bullying involve­
ment (as victims, as bullies, as bully-victims) were related to signifi­
cantly reduced level of social support, victims reported significantly
decreased parental social support (see in supplementary material,
Table S2). Based on these preliminary findings, a series of path models
were constructed, and the results were jointly summarized in Fig. 1:
social support in general and parental social support in particular were
presented as significant mediators in the associations between bullying
victimization and all three suicidal risk indicators, their mediation

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Y. Xiao et al.
Fig. 1.. Path analysis results for mediation of general social support (General SS) and parental social support (Parental SS).
tended to be the strongest for one-year SI, accounted for 11.73% and
5.89% of the total association.
3.4. Research question: mediation of different sources of social support
The adjusted associations between different types of bullying
victimization and suicidal risk indicators were analyzed, and the results
were summarized in Fig. 2. First thing to notice is that, among the four
types of bullying victimization, only relational bullying victims were
seen consistently increased suicidal risk: compared with students who
were not involved in school bullying, their ORs of SI, SP, and SA were
2.62 (95% CI: 1.58–4.49), 2.23 (95% CI: 1.43–3.50), and 3.82 (95% CI:
2.58–5.62), respectively. Second, students who were victims of multiple
types of bullying were also at significantly increased risk of SI and SA
(adjusted ORs: 2.14, 2.44; 95% CIs: 1.11–4.21; 1.37–4.24).
We further analyzed the mediation of different sources of social
support in the associations between relational bullying victimization
and the three suicidal risk indicators. Among the four sources of social
support identified in this study (parents, teacher, classmates, close
friends), only social support from classmates and close friends presented
significant mediation. For one-year SI and SA, the proportions of
mediation from the two sources accounted for 9.58% and 3.32% of the
total associations. For one-year SP, the entire mediation of social support
(4.79%) was solely ascribed to classmates (Fig. 3).
4. Discussion
4.1. Major findings of the current study
In this two-wave cross-sectional study of 6063 Chinese children and
adolescents, we found that school bullying was prevalent. For all roles of
school bullying involvement, victims were seen consistently increased
suicidal risk. Besides, social support in general and from the parents,
significantly mediated the association between school bullying victim­
ization and suicidal risk indicators. When analyzing by specific types,
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Journal of Affective Disorders 300 (2022) 392–399
only relational bullying victimization showed elevated suicidal risk,
social support from peers, typically classmates and close friends,
partially mediated this association.
4.2. Bullying victimization with increased suicidal risk
The reported school bullying involvement prevalence in this study
was 13.49%, much lower than some previously published studies on
Chinese children and adolescents (Han et al., 2017), but similar to our
previous study in another city of Yunnan (13.14%) (Xiao et al., 2021),
and an Australian study on a national representative sample of 2967
youth which used the same instrument and definition to measure school
bullying involvement (Thomas et al., 2017). Partly as expected, for all
roles of school bullying involvement, only victims were observed
significantly and consistently increased risk of SI, SP, and SA. This
finding is different from some previously published studies, which re­
ported generally increased suicidal risk for any role of bullying
involvement, especially for bully-victims, who generally have the
highest level of adjustment problems (Holt et al., 2015; Arseneault et al.,
2010). However, a Norwegian longitudinal study on 2813 adolescents
aged 12–15 years had reported that, compared with individuals who
were not involved in school bullying at the baseline, bullying victims
were seen particularly increased total sum of depressive symptoms in
the follow-up period, whereas the same phenomenon had not been
observed for bullies or bully-victims (Sigurdson et al., 2015). As
depression is the most important established risk factors of suicide, the
consistent significant associations between school bullying victimization
and suicidal risk indicators that we found probably can be partly justi­
fied. Nevertheless, incongruity in published studies regarding to this
topic illustrates the necessity of further investigation.
4.3. Mediation of social support, particularly parental social support, in
bullying victimization associated suicidal risk
Path analysis results revealed a prominent mediation of social
Y. Xiao et al.
Fig. 2.. Types of school bullying victimization with suicidal risk. Results were based on multivariate Logistic regression adjustment, with Bonferroni correction.
Fig. 3.. Proportions of mediation for different sources of social support in
relational bullying victimization and suicidal risk. SS (social support).
support in the associations between school bullying victimization and all
the three suicidal risk indicators. Studies investigating the mediation of
social support in the association between school bullying involvement
397
Journal of Affective Disorders 300 (2022) 392–399
and suicidal risk remain scarce. A cross-sectional study of 946 middle
school students in central China Hunan province concluded a positive
mediation of perceived social support in the relationship between
bullying victimization and SI: social support mediated about 10% of the
total association (Liu et al., 2017). Their findings, together with the
proportion of mediation via social support, were very comparable to that
of ours. However, because of the cross-sectional design of our study,
there exists a possibility that poor social support may predict bullying
victimization and suicidality.
Among the four sources of social support, we found that parental
social support was the only prominent mediator in the associations be­
tween bullying victimization and suicidal risk indicators. The psycho­
logically beneficial role of parental support has been repeatedly verified,
for instance, higher level of parental support protected adolescent girls
from developing suicidal symptoms following a stressor, and the support
from peers was less effective (Mackin et al., 2017). Moreover, family
support, instead of friend support, was the only prominent associated
factor of SI in Malaysian marginalized adolescents (Ibrahim et al., 2019).
The underlying mechanism in explaining this unique mediation of
parental social support in bullying victimization and suicidal risk re­
mains unclear. However, the phenomenon itself highlights the prom­
ising role of consolidating parental support in reducing school bullying
victimization associated suicidal risk.
Y. Xiao et al.
4.4. Relational bullying victimization with increased suicidal risk
For the specific types of school bullying victimization, only relational
bullying victims were seen increased risk of SI, SP, and SA. Relational
bullying is to use relationship to hurt others, it includes spreading ru­
mors, gossiping, and social exclusion. Relational bullying is common in
children and adolescents, particularly in girls. Unlike physical bullying,
it is usually covert, and can last for a long time without being noticed.
Peer relationship is the most important social connection during pu­
berty, considering the perpetrators of relational bullying are usually
peers, relational bullying may impose the most detrimental effect on
victims (Xie et al., 2002). Relational victimization has been linked to
deteriorated mental health status, especially depression and anxiety,
well established risk factors of suicide (Zimmer-Gembeck and Pronk,
2012). Moreover, in a 2017 Australian study, the researchers observed
that compared with physical bullying victims, suicidal risk was higher
for adolescents exposed to relational bullying (Ford et al., 2017). The
above theory was partly reflected by our analytical results: only social
support from peers, typically classmates and close friends, significantly
mediated the association between relational bullying victimization and
suicidal risk.
4.5. Implications in bullying victimization associated suicidal risk
intervention
The major findings of our study have great implications in prevent­
ing bullying associated suicidal risk in Chinese children and adolescents.
Improving parental social support for bullying victims in general,
rebuilding or repairing broken peer relationships for relational bullying
victims, could be beneficial in reducing school bullying related suicidal
risk. Parental and peer relationships are core parts of interpersonal
relationship, therefore, interpersonal therapy (IPT), a structured,
attachment-focused psychotherapy probably can be used. IPT is an
effective treatment for depression (Cuijipers et al., 2016). It focuses on
rebuilding all types of social support. In a randomized controlled trial of
60 Chinese college students, the authors concluded that, group-based
IPT can significantly improve social support of the study subjects, and
the effect was lasting (Li et al., 2019). The effectiveness of IPT in
intervening school bullying associated suicidal risk is to be verified.
4.6. Limitations of the current study
Our study is among the first exhaustive attempts in uncovering the
mediation of social support in the relationship between school bullying
and suicidal risk among Chinese children and adolescents. Population
representative large sample size, scientific sampling design, and infor­
mative analytical strategy further consolidated the validity of study re­
sults. Nevertheless, several limitations should be noticed. First, time
intervals for measuring bullying involvement (in the current semester)
and suicidal risk indicators (in the past year) were partly overlapping, it
may be reasonable to suspect that suicidal risk indicators can precede
bullying involvement. Second, because of the cross-sectional design,
results from the path model should be explained prudently, any causal
inference cannot be reached. Moreover, information was collected by
using self-reporting method, the possibility of information bias exists.
Finally, all study subjects were drawn from a single province in China,
the generalization of study results should be made cautiously.
5. Conclusions
In this cross-sectional study, we identified a prominent mediation of
social support in the association between school bullying victimization
and suicidal risk indicators in a large sample of Chinese children and
adolescents. Particularly, social support from parents and peers pre­
sented as significant mediators. Our study results probably suggest that,
for children and adolescents who are victims of school bullying,
398
Journal of Affective Disorders 300 (2022) 392–399
intervention strategies that focusing on improving parental and peer
social support may be effective in reducing school bullying victimization
associated suicidal risk. The major findings of our study should be
further corroborated by longitudinal studies.
Contributors
YX and JL conceived the study. HR, DF, YC, ARD, SW, JP and LC
collected, verified, and analyzed the data. YX drafted the manuscript. All
authors provided critical revision of the manuscript for important in­
tellectual content.
Role of funding source
None.
Declaration of Competing Interest
The authors have no conflicts to disclose.
Acknowledgments
This study is supported by National Natural Science Foundation of
China (82060601), Top Young Talents of Yunnan Ten Thousand Talents
Plan (YNWR-QNBJ-2018-286), and the Innovative Research Team of
Yunnan Province (202005AE160002).
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2022.01.032.
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