| BackgroundInternalizing and externalizing problems are the most frequent mental problems among adolescents,and are proved to be prodromes and predictive symptoms of mental disorders.Compared to childhood and early adolescence,studies have proved that,mental health of middle adolescence(roughly middle school students in China)is worse,and the prevalence of internalizing and externalizing problems is higher.Considering the critical period of cognitive,academic,physical and mental development of middle adolescents,internalizing and externalizing problems are not only prone to induce mental disorders during adolescents,but also influence life quality and employment during early adults.Both theoretical and empirical studies indicate that developments of internalizing and externalizing problems are dynamic,with heterogeneity and gender difference.Identifying heterogeneous trajectories of internalizing and externalizing development is meaningful for prevision intervention.However,there is no research focus on heterogeneous trajectories of internalizing and externalizing problems and gender difference among adolescents,which is the point of the first part of this research.On the basis of identified trajectories and gender difference,research on predictive factors will contribute to key points of effective screening and early intervention.Bioecological theory indicates that individual’s mental health is influenced by environment and interaction between different environments,Family and school are the most important environments to adolescents,thus parenting and peer relationship may influence the development of internalizing and externalizing problems.Besides,former studies found that there are different models of how parenting and peer relationship influence each other,including buffering model(positive parenting buffle the influence of negative peering relationship),augment model(positive parenting strengthen the influence of positive peer relationship)and additive model(parenting and peer relationship influence mental health independently).Thus,the second part of this research will study on how parenting(caring,ignorance,autonomy encouragement and over protection)and peer relationship(peer support,off-line bullying and online-bullying),influence internalizing and externalizing problems and which model they support.Previous research has found that adolescents’internalizing and externalizing problems are closely related to negative outcomes,among which suicidality is the most serious and destructive one.Suicidal idea is the proximal risk factor of adolescence suicidality(includes suicidal idea,suicidal attempt and suicidal death),and identifying the relationship between suicidal idea and internalizing externalizing trajectories will help effectively screening high-risk adolescents with of suicidal idea,thus prevent suicidal idea processes to suicidal attempt or event death,which is the point of the third part of this research.Because of problems such as stigma and accessibility of psychological services,adolescents with mental problems seldom seek professional help,and many high school students have to suffer from both academic pressure and psychological pain.In 2020,China National Health Commission requires high schools to initiate mental health files for high school students,evaluate students’ mental health and pay long-term attention to students with positive results.Considering the beginning of school mental health management and scarce psychological service,nurses with mental health education background will have great potential and advantages in school mental health program.Therefore,this study attempts to provide some reference for high school mental health services based on the above research questions.Research purposes1.Exploring heterogeneous trajectories and gender difference of internalizing and externalizing problems among high school students.2.Exploring the influence of parenting and peer relationship towards internalizing and externalizing trajectories and verify which model do they fit:buffering model,augment model and additive model.3.Exploring the influence of internalizing and externalizing trajectories towards suicidal ideas.MethodsThis research is longitudinal research,including three parts:The first part is to explore the internalizing and externalizing problems trajectories and gender difference.Among 4 municipal high schools in Tai’an City,Shandong province,2 schools were selected according to the method of stratified random sampling.In the selected 2 schools,1/2 of both fist and second grades students were selected by the method of cluster random sampling(selection of add seat numbers),and psychological assessments were carried out on these students.The required sample size was calculated as 1063.Demographic characteristics were assessed by socio-demographic information questionnaire;Internalizing and externalizing problems were assessed by Strength and Difficulties Questionnaire(SDQ).Data was processed by SPSS25.0 and Mplus7.0.Descriptive statistics was used to describe characteristics of this sample and their internalizing and externalizing score;The independent t-test and chi-square test were used to compare differences between baseline sample and follow-up sample in demographic characteristics and internalizing and externalizing scores;The latent growth model(LGM)was used to explore the general developmental trajectories of internalizing and externalizing problems in the full sample;The latent class growth model(LCGA)was used in the full sample,male sample,and female sample respectively,to identify heterogeneous trajectories and gender difference.The second part is to explore how parenting and peering relationship predict internalizing and externalizing heterogeous trajectories.The sample is same to part1;the assessment of social demographics is same to part1.Parenting was assessed by The Parenting Bonding Instrument(PBI);Peer bullying is assessed by Multidimensional Offline and Online Peer Victimization Scale(MOOPV);Peer support was assessed by Perceived Social Support Scale(PSSS).Multiple Logistic regression analysis was applied to analyze the prediction of parenting and peer relationship towards internalizing and externalizing trajectories,as well as to test which model do they fit.The third part is to explore how internalizing and externalizing heterogeneous trajectories predict suicidal idea.The sample is same to part1 and part2.The assessments of demographic character,internalizing and externalizing problems and peer relationship are same to part1 and part2.Suicidal idea was assessed by the item-9 of Patient Health Questionnaire-9(PHQ-9).Binary regression analysis was used to analyze the prediction of internalizing and externalizing heterogeneous trajectories to suicidal idea.Results1.Results of the first part(1)In this study,a total of 1299 participants were enrolled at baseline(T1),1189 at T2,1039 at T3 and 840 at T4.There are 35.4%students lost during following up.The total loss rate is similar to former research.The average age of baseline participants was 15.79.This study used the sample of participants(N=840)who participated 4 times of this research.Compared to follow-up sample,the lost samples’ parents have higher percentage of physical disease(P=0.042)(2)The general developmental trajectory of internalizing problems fit a quadratic linear ascent model(x2/df=5.41,CFI=0.993,RMSE=0.018,SRMR=0.072);The average intercept was 3.002(P<0.001);The average slop was-0.195(P<0.05);The average quadratic slope was 0.082(P<0.01).This model indicates that the development of internalizing problem among high school adolescents is in a trend of decline then increase.The general developmental trajectory of externalizing problem was linear stable model(x2/df=7.58,CFI=0.925,RMSE=0.067,SRMR=0.089).The average intercept was 5.589(P<0.001);The average slop was-0.002(P=0.124).This model indicates that the development of externalizing problem among high school adolescents is stale,without significant decreasing trend.Regardless of internalizing or externalizing problem,the P value of variance is meaningful,indicating that the developments of internalizing and externalizing problems are heterogeneous,which needs further exploring heterogeneous trajectories.(3)In the full sample(N=840),four heterogeneous trajectories were identified for internalizing problems,namely low decreasing(50.3%),medium increasing(39.8%),rapid increasing(4.7%)and high stable(5.2%).Three heterogeneous trajectories were identified for externalizing problems,namely low stable(86.5%),rapid increasing(2%)and high decreasing(11.5%).(4)Three heterogeneous internalizing trajectories were identified respectively for males and females,with different percentage and developmental trend.For males,the trajectories are low decreasing(71.3%),rapid increasing(19.2)and high stable(9.5%);for females,low decreasing(49.5%),medium increasing(43.8%)and high increasing(6.7%).(5)Two heterogeneous externalizing trajectories were identified respectively for males and females,with different percentage and developmental trend.For males,the trajectories are low stable(96.6%)and rapid increasing(3.4%);for females,low increasing(86.6%)and high decreasing(13.4%).2.Results of the second partAccording to part 1,there is gender difference among internalizing trajectories and externalizing trajectories,thus in the second part,predictive factors will be explored among male and female trajectories respectively.(1)Compared to female internalizing low group,the risk factors of high increasing group are maternal over protection(OR=1.290,95%CI:1.091～1.525)and paternal ignorance(OR=1.224,95%CI:1.034～1.449);Compared to medium increasing group,the risk factor of high increasing group is maternal overprotection(OR=1.239,95%CI:1.054～1.458).Peer support has no buffering or strengthening effect to the above negative parenting.(2)Compared to male internalizing low decreasing group,the risk factor of high stable is off-line bullying(OR=1.082,95%CI:1.016～1.152)and protective factor is peer support(OR=0.911,95%CI:0.841～0.988);compared rapid increasing group,the protective factor of high stable group is peer support(OR=0.871,95%CI:0.787-0.963).Maternal caring(P=0.036)and paternal autonomy(P=0.026)encouragement can buffer the effect of on-line bullying,supporting buffering model.(3)Compared to externalizing low stable group,the risk factor of high decreasing group is on-line bullying(OR=1.216,95%CI:1.115～1.327).Maternal caring(P=0.030)can buffer the effect of bullying,supporting buffering model.(4)Parenting and peer relationship could not predict male externalizing heterogeneous trajectories.3.Results of the third partAccording to part 1,there is gender difference among internalizing trajectories and externalizing trajectories,thus in the third part,the effect of internalizing and externalizing trajectories to suicidal idea will be explored among male and female trajectories respectively.(1)Among females,after controlling demographic character,parenting,peer relationship and baseline suicidal idea,compared to low decreasing group,medium increasing group(OR=2.907,95%CI:1.657～5.100)and high increasing group(OR=12.145,95%CI:4.131～35.708)significantly increased the possibility of suicidal idea.(2)Among males,after controlling demographic character,parenting,peer relationship and baseline suicidal idea,rapid increasing group(OR=4.743,95%CI:2.395～9.393),compared to low stable group,significantly increased the possibility of suicidal idea.(3)Higher externalizing group did not increase the possibility of suicidal idea.Conclusion1.Internalizing and externalizing problems develop heterogeneously among high school adolescents,indicating the necessity of longitudinal following-up and nursing of mental problems to identify high-risk individuals.2.Parenting and peer relationship significantly predict heterogeneous development of internalizing and externalizing problems in a different way,indicating intervention should be applied differently towards different subgroups.3.Positive parenting could buffering the effect of on-line bullying towards internalizing and externalizing problems,but positive peer relationship could not buffering the effect of negative parenting,indicating the importance of parents among high school adolescents.4.Increasing internalizing problem subgroups increase the risk of suicidal idea,indicating that longitudinal following up of internalizing problems may help identify high risk adolescents with suicidal idea. |
