Relationships among resilience,self-esteem,and depressive symptoms in Chinese adolescents

Abstract

This study explored the relationships among resilience, self-esteem, and depressive symptoms in Hong Kong Chinese adolescents. We selected a stratified random sample of 1816 Form 1 students from all 18 districts of Hong Kong. This study revealed that about 21 percent adolescents are experiencing some depressive symptoms. Our results contribute novel findings to the literature showing that resilience is a strong indicator of adolescents at a higher risk of depression and increasing adolescents’ resilience to psychological distress is crucial to enhance their mental well-being. It is crucial to develop interventions that can enhance resilience and promote positive mental well-being among adolescents.

Keywords

adolescents Chinese depressive symptoms resilience self-esteem suicide

Introduction

Mental health problems in adolescents are a global problem (Hunt and Eisenberg, 2010; Kieling et al., 2011) and are becoming more prevalent. According to World Health Organization (2018a), approximately 10–20 percent of children and adolescents experience mental disorders worldwide, which may potentially affect their development, educational attainments, and productive lives. Indeed, the rising incidence of emotional disturbances, adjustment and eating problems, depression, and suicidal tendencies has become major public health concerns (Kieling et al., 2011; Li et al., 2010a).

Over the past few decades, Hong Kong has experienced a significant change in family structure, with small nuclear families gradually replacing extended families (Census and Statistics Department, 2012). Therefore, children receive more attention and may be overprotected by parents as a result of having fewer, if any, siblings. This may explain why children are more fragile, more vulnerable, and less resilient to psychological distress than were previous generations (Lam et al., 2004; Li et al., 2010b; Shek, 2002). Moreover, parents’ high expectations for academic achievement may also contribute to increased mental health problems among adolescents in Hong Kong (Li and Chung, 2009; Li et al., 2013). Most parents in Hong Kong believe that better careers and brighter futures are the inevitable results of higher academic achievement (Tsoi and Pryde, 1999). Given this context, Hong Kong Chinese adolescents are exposed to considerable pressure within their families and schools while growing up (Li et al., 2013).

Between October 2016 and June 2017, the Baptist Oi Kwan Social Service (2017) conducted a survey of the mental health of 15,560 Form 1 to Form 6 pupils from 37 schools. They reported that 53 percent of respondents exhibited various depression symptoms, such as crying, and changes to appetite and sleeping patterns. Another study of 12,518 Form 1 to Form 7 pupils was conducted by the Christian Family Service Centre (2015) between 2011 and 2014. Among respondents, 62.1 percent exhibited slight to very serious depression symptoms. Moreover, of those demonstrating very serious depression symptoms, approximately 80 percent had thought about hurting themselves or committing suicide. Indeed, evidence suggests that depressive symptoms predict suicidal tendencies among children and adolescents (Koplin and Agathen, 2002). Although suicide rates in Hong Kong have dropped significantly from 18.8 per 100,000 in 2003 to 11.7 per 100,000 in 2016, a trend to increases in youth suicides in the past few years remains a concern (The HKJC Centre for Suicide Research and Prevention, 2018). It is vital therefore for healthcare professionals to early detect and identify those adolescents with depressive symptoms and take measures to prevent such crises.

Previous research has provided evidence of a relationship between self-esteem and depression in adolescents (Byrne, 2000; Kim, 2003). In a previous study, we observed that adolescents with lower self-esteem reported more depressive symptoms (Li et al., 2010a). Therefore, self-esteem may be a useful measure to identify adolescents who are potentially at high risk of depression. Likewise, resilience is an important construct that associated with depressive symptoms. Resilience is defined as the ability of an individual to utilize protective factors, such as personal and social resources and perceived level of family cohesion, to maintain mental well-being in the face of stress and adversity (Davydov et al., 2010; Luthar et al., 2000). Studies have shown that resilience could change individuals’ perceptions, and cultivate positive mindsets, which in turn reduce depressive symptoms (Davydov et al., 2010; Hjemdal et al., 2007, 2011). In a study to examine the relationship between resilience and depression among Norwegian high school students, the results showed that higher resilience could predict lower levels of depressive symptoms (Hjemdal et al., 2011). Given that self-esteem and resilience are correlated to depressive symptoms, assessing these two psychological constructs is essential for developing a thorough understanding on how adolescents respond to stress and adversity. In particular, understanding the interrelationships among resilience, self-esteem, and depressive symptoms can contribute to the development and evaluation of appropriate interventions that foster positive mental well-being in adolescents. Nevertheless, a review of the literature reveals that a paucity of research examining these relationships in adolescents. Moreover, despite the fact that resilience may be an important protective factor for depression in adolescents, no previous studies have examined resilience in adolescents in a Hong Kong Chinese context. In this study, we aimed to explore relationships among resilience, self-esteem, and depressive symptoms in Hong Kong Chinese adolescents.

Methods

Design and sample

We surveyed a large sample of Hong Kong Chinese adolescents to develop a better understanding of resilience and its relationship with self-esteem and depressive symptoms in this group. We collected a stratified random sample of Form 1 students (Grade 7) from 18 secondary schools across 18 districts in Hong Kong. A serial code was assigned to every secondary school in the identified districts according to its alphabetic order. Using the serial codes, a computer program then randomly selected one school from each district. An invitation letter describing the nature and purpose of the study was sent to identified secondary schools to invite their students to participate in the study. If a selected school refused to participate, the computer program would randomly select another school from the same district.

After an explanation of the purpose of the study, we invited 1821 adolescents who are able to speak Cantonese and read Chinese to participate in the study between September 2017 and January 2018. However, we subsequently received five largely incomplete questionnaires. Therefore, 1816 questionnaires from a total eligible pool of 1821 students were used for the analysis.

We had several reasons for inviting Form 1 students to participate in the study. The move from primary to secondary school can be a very stressful experience, which may create a potential threat to adolescents (Mackenzie et al., 2012). This may be compounded by changes to academic and social expectations, which render children more psychologically vulnerable (Mackenzie et al., 2012). In addition, according to social development theory (Erikson, 1993), children at this age have entered the stage of “fidelity,” which is dominated by role confusion, the search for a personality identity, and the influence of peers. Hence, they are undergoing a stage of complex transition, making them more susceptible to stress and adversity compared with children in other age groups.

Instruments

Resilience Scale-14 (RS-14)

The RS, developed by Wagnild and Young, measures resilience in community samples (Wagnild and Young, 1993). Following the validation of the RS, a 14-item version (RS-14) was developed (Wagnild, 1993, 2009). The RS-14 was derived from the original 25-item scale and constructed at a 4.9 Flesch–Kincaid reading level (a year lower than the Grade 6 reading level of the RS; Smith-Osborne and Whitehill, 2013). This facilitates comprehension and ensures the scale is appropriate for adolescents. The RS-14 measures two factors: personal competence and acceptance of self and life. Each item is answered on a 7-point Likert scale ranging from “strongly disagree” to “strongly agree,” with total scores ranging from 14 to 98. Higher scores indicate higher levels of resilience.

The RS-14 has been widely used in resilience research and has been translated into and validated in a variety of languages, including simplified and traditional Chinese for mainland and Taiwanese Chinese participants, respectively (Tian and Hong, 2013; Yang et al., 2012). The psychometric properties of the Chinese version of the RS-14 have been tested, with a test–retest reliability of .82 and internal consistency Cronbach’s α of .93 (Tian and Hong, 2013).

Center for Epidemiologic Studies Depression Scale for Children

Depressive symptoms were assessed with the Chinese version of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC). The CES-DC comprises 20 fully standardized items to evaluate depressive symptoms. All items are evaluated on a 4-point self-report scale in relation to their incidence during the previous week and scored from 0 to 3. Total possible scores range from 0 to 60, with higher scores indicating greater symptomatology.

The psychometric properties of the Chinese version of the CES-DC have been empirically tested, showing adequate internal consistency reliability (r = .82), good content validity (content validity index = 95%), and appropriate convergent (r = .63) and discriminant (r = −.52) validity (Li et al., 2013).

Rosenberg’s Self-Esteem Scale

Self-esteem was assessed with the Chinese version of the Rosenberg’s Self-Esteem Scale (RSES). The RSES is designed to measure global self-esteem of children and adolescents. It comprises 10 items, rated with a 4-point Likert scale ranging from 1 to 4, and with total possible scores ranging from 10 to 40. Higher scores indicate higher levels of self-esteem.

The Chinese version of the RSES has previously been used with children (Li et al., 2010b). Findings demonstrate adequate internal consistency reliability (r = .84) and appropriate discriminant validity (r = −.52).

Data collection procedures

All participants were asked to complete a demographic data sheet, following which they completed the Chinese versions of the RS-14, RSES, and CES-DC. Demographic data included gender, age, religion, parental educational attainment, and parental marital status (living with both parents/single-parent family). Questionnaires were distributed and collected by research nurses with assistance from schoolteachers. As students generally required 12–15 minutes to complete the questionnaires, the survey caused minimal disturbance to normal class activities. After the survey, all students received an information pamphlet about mental health (Chinese version) published by the Central Health Education Unit of the Department of Health in Hong Kong. Professional counseling hotlines were also provided in the information pamphlet.

This study protocol was approved by the institutional review board of the University of Hong Kong and the Hospital Authority of Hong Kong, West Cluster. The principal and teachers of each school were fully informed about the study’s purpose, nature, design, and duration. In addition, parents were sent an information sheet with a reply slip via the schools to inform them that a study was to be conducted to examine issues relevant to adolescent health. Parents were given the option to participate or refuse their child’s involvement in the study. This procedure is commonly practiced and consistent with authority bestowed on schools in Hong Kong.

Data analyses

We conducted data analysis with the Statistical Package for Social Sciences (SPSS) software, version 23.0 for Windows (IBM, Armonk, NY, USA). The internal consistencies of various instruments used in the study were determined by calculating their Cronbach α. Descriptive statistics were used to calculate the mean, standard deviation (SD), and range of scores for the different scales. An independent t test was conducted to compare mean scores of the RS-14, RSES, and CES-DC between male and female students. Relationships among the RS-14, CES-DC, RSES, and participants’ demographic data were investigated with Pearson’s product–moment correlation coefficients. Hierarchical multiple regression analysis was employed to explore whether self-esteem and gender could predict psychological distress, risk of depression, and physical health of adolescents while controlling for the possible effects of gender, age, religion, parental educational attainment, and parental marital status. Although stepwise regression is commonly used, the selection of independent variables depends on a set of statistical criteria, and hence some of the independent variables which are relevant to the research question may not be included in an equation because of statistical insignificance. Whereas, hierarchical multiple regression allows a set of independent variables to be entered in blocks, with the predictability of each block contributing to the outcome variable assessed by controlling for the previous block. Therefore, we could identify the predictability of each independent variable and obtain a more comprehensive understanding of the interrelationships between these variables (Pallant, 2010).

Results

Table 1 presents demographic data for the participants. The data indicate that there were similar numbers of boys and girls. Around 15 percent of students came from single-parent families. The mean score for the CES-DC was 20.86 (range: 0 to 52). About 21 percent of students scored 30 or more, indicating that they presented with some depressive symptoms.

Table 1.

Demographic characteristics of the participants recruited in the secondary schools (N = 1816).

	Frequency	%
Age (years)
11	191	10.5
12	1181	65.0
13	417	23.0
14	22	1.2
15	5	0.3
Sex
Male	878	48.3
Female	938	51.7
Parental marital status
Live with both parents	1542	84.9
Single-parent family	274	15.1
Parents’ educational attainment
Primary school or below	108	5.9
Lower secondary school	472	26.0
Upper secondary school	865	47.7
Tertiary education	371	20.4
Religion
Yes	1223	67.3
No	593	32.7

Table 2 presents the mean scores for the RS-14, RSES, and CES-DC in male and female participants. An independent t test indicated significantly higher RS-14 and RSES scores and lower CES-DC scores in female compared with male participants.

Table 2.

Mean scores for the RS-14, RSES, and CES-DC as listed by sex in secondary schools.

	Male (n = 878)	Female (n = 938)	t value	p value
	M (SD)	M (SD)	t value	p value
RS-14	66.31 (13.64)	68.51 (12.94)	−3.52	<.001
RSES	26.51 (3.80)	26.83 (3.09)	−2.02	.043
CES-DC	21.44 (9.93)	20.32 (10.04)	2.37	.018

RS-14: the Resilience Scale-14; CES-DC: the Center for Epidemiologic Studies Depression Scale for Children; RSES: Rosenberg’s Self-Esteem Scale; M (SD): mean (standard deviation).

Table 3 presents interrelationships among RS-14 scores, CES-DC scores, RSES scores, age, gender, parental marital status, parental educational attainment, and religion. With reference to Cohen (1992), correlation coefficients of .10 to .29, .30 to .49, and .50 to 1.0 are typically interpreted as small, medium, and large effects, respectively. Our results suggest a strong negative correlation between RS-14 and CES-DC scores. Furthermore, a moderate positive correlation was observed between RS-14 and RSES scores. Finally, we observed relatively weak correlations between RSES and CES-DC scores, RS-14 scores and parental educational attainment, RS-14 scores and parental marital status, RSES scores and parental marital status, and CES-DC scores and parental marital status.

Table 3.

Interrelationships among the RS-14 scores, RSES scores, and CES-DC scores, age, sex, parental marital status, parents’ educational attainment, and religion (N = 1816).

	A	B	C	D	E	F	G	H
Age (A)	1
Sex (B)	−.03	1
Parental marital status (C)	.04	−.02	1
Parents’ Educational Attainment (D)	−.06	.07	−.13	1
Religion (E)	−.05	−.01	−.05	.05	1
RS-14 (F)	.06	.08	−.17^a	.25^a	.04	1
RSES (G)	.11	−.05	−.26^a	.10	.01	.33^a	1
CES-DC (H)	−.03	.05	.15^a	−.13	.02	−.50^b	−.22^a	1

RS-14: the Resilience Scale-14; CES-DC: the Center for Epidemiologic Studies Depression Scale for Children; RSES: Rosenberg’s Self-Esteem Scale.

Correlation is significant at the .05 level (two-tailed).

Correlation is significant at the .01 level (two-tailed).

Table 4 shows the summary results of a multiple regression analysis for variables (resilience and self-esteem) predicting CES-DC scores. When all variables were included in the model, three variables (type of treatment received, depressive symptom, and therapy-related symptom) made a statistically significant contribution to predicting CES-DC scores in adolescents.

Table 4.

Summary of multiple regression for variables (age, gender, parental marital status, parents’ educational attainment, religion, resilience and self-esteem) predicting depressive symptoms (N = 1816).

Variable predicting depressive symptoms	B	SE B	β	p value
Step 1
Age	−.62	.37	−.04	.09
Gender	−.90	.46	−.05	.05
Parental marital status	3.76	.65	.14	.00
Parents’ educational attainment	−1.34	.29	−.11	.00
Religion	.50	.49	.23	.31
Step 2
Age	.12	.33	.01	.72
Gender	−.23	.41	−.01	.57
Parental marital status	1.57	.59	.06	.01
Parents’ educational attainment	.06	.26	.01	.81
Religion	.78	.43	.04	.07
Resilience	−.36	.02	−.48	.00
Self-esteem	−.16	.06	−.05	.02
R² = .26
Adjusted R² = .26
R² change = .22

B: unstandardized coefficient; SE B: standard error of unstandardized coefficient; β: standardized coefficient.

Discussion

Suicide is the second leading cause of death for adolescents globally (World Health Organization, 2018b) and has been the leading cause of death for adolescents in Hong Kong for decades (The HKJC Centre for Suicide Research and Prevention, 2018). Therefore, it is of paramount importance to consider how best to engage adolescents to seek help and receive interventions early enough to prevent such crises. However, initial early detection and identification of adolescents with depressive symptoms, and subsequent appropriate interventional steps are crucial. In this study, we examined relationships among resilience, self-esteem, and depressive symptoms in Chinese adolescents, an area that is underrepresented in the literature. This study is important in terms of its originality and potential impact on adolescent well-being. Moreover, it included secondary schools from all 18 districts of Hong Kong, which enhances the generalizability of the findings.

This study measured the depressive symptoms by CES-DC, and we identified 21 percent of participants presented with some depressive symptoms. Given that depressive symptoms predict suicidal tendencies, these symptoms cannot be overlooked or underestimated. Furthermore, our results suggest that female students report higher resilience and self-esteem and display fewer depression symptoms than do male students. However, caution must be taken when interpreting these findings because mean differences in resilience, self-esteem, and depressive symptoms between male and female were trivial. In large samples, such as ours, even very small differences between male and female participants might reflect significantly different results. Nonetheless, further studies should be conducted to explore whether such differences have any theoretical or practical significance.

Similar to findings from previous studies (Chung, 2000; Li et al., 2010a), our results suggest that adolescents from a single-parent family have lower resilience and self-esteem and more depressive symptoms than do adolescents living with both parents. Therefore, greater attention and more resources and health services should be allocated to adolescents from single-parent family. In particular, more strategies or interventions should be implemented aiming to enhance resilience and self-esteem among such adolescents to promote their mental well-being.

Consistently with a previous local study (Li et al., 2010a), we observed a relationship between self-esteem and depressive symptoms in Chinese adolescents. Nevertheless, we observed a much smaller negative correlation compared with the strong negative correlation reported previously. However, we did observe a strong negative correlation between resilience and depressive symptoms, which is a novel finding suggesting that resilience may be a better indicator of adolescents at a higher risk of depression.

We conducted a multiple regression analysis to examine whether resilience and self-esteem can predict depressive symptoms in adolescents, after controlling for the possible effects of age, sex, parental marital status, parental educational attainment, and religion. The overall model explained 26 percent of the variance in depressive symptoms. After controlling for the possible effects of demographics, we calculated a R² change value of .22, that is, resilience and self-esteem explained an additional 22 percent of variance in depressive symptoms. With all variables entered into the model, three variables (parental marital status, resilience, and self-esteem) made a statistically significant contribution (p < .05), implying that these factors can predict depressive symptoms. However, β coefficients for parental marital status, resilience, and self-esteem were .06, −.48, and −.05, respectively, indicating that resilience was a comparatively strong predictor of depressive symptoms.

Implications for future practice

Our findings have important implications for future practice. As resilience is a strong predictor of depressive symptoms in adolescents, measuring resilience could be a useful tool to screen for adolescents who are likely at high risk of depression. Most importantly, it is vital for healthcare professionals, educators, and school social workers to work together in the planning, development, and evaluation of appropriate and effective interventions to enhance resilience in adolescents, support development of coping mechanisms, and promote mental well-being.

Over the past decade, several Western studies have focused on developing and evaluating community-based interventions for siblings of children with chronic illness or disability (Hancock, 2011). The results of these studies reveal that summer camp experiences have a therapeutic effect on psychosocial well-being of well siblings. By integrating teaching and practice of psychosocial skills at a summer camp, participants’ behavior problems, social confidence, and self-esteem all improved (Hancock, 2011).

In Hong Kong, there has been an increase in the use of adventure-based training for youth substance abusers, schoolchildren with behavioral problems, and children suffering from chronic illness. Such training aims to change participants’ feelings and patterns of thought and behavior through experiences and practice in an outdoor environment (Wong, 2004). Ewert and Yoshino (2011) conducted an exploratory study to investigate the level of resilience of university students after participating in a 3-week adventure-based training trip. The training incorporated a variety of outdoor activities such as rock climbing and a 3-day outward bound experience in the wilderness. The results suggested that resilience is a variable of interest in adventure-based contexts, and such adventure-based learning experiences might support enhanced resilience.

We previously conducted a randomized controlled trial of the effectiveness of an adventure-based training program in promoting psychological well-being in primary schoolchildren (Li et al., 2013). Our results provided some evidence that the adventure-based training program effectively enhanced self-esteem and reduced depressive symptoms among schoolchildren. Moreover, it demonstrated the feasibility of implementing an adventure-based training program in Hong Kong, with the content and nature shown to be acceptable to children and their parents. However, no previous research has been conducted to evaluate the effectiveness of adventure-based training to enhance resilience among adolescents. More rigorous empirical scrutiny is required to determine the effectiveness of adventure-based training before it can be used as an intervention to enhance resilience among adolescents and promote mental well-being.

Limitations

Limitations include the use of convenience sampling and the fact that only young adolescents (Grade 7) were recruited into the study. Another limitation is that only relatively healthy adolescents were recruited in this study. It may be interesting in future study to examine whether there is any difference in resilience between healthy adolescents and those with chronic illness.

Conclusion

Recognition of and concern for mental health problems in adolescents are increasing. Healthcare professionals play a vital role in raising public awareness of mental well-being in adolescents. Assessing resilience is a prerequisite to better understand how adolescents respond to stress and adversity.

This study has addressed the literature gap by exploring the relationships among self-esteem, resilience, and depressive symptoms in Hong Kong Chinese adolescents. In comparison with self-esteem, resilience is found to be a stronger predictor of depressive symptoms. It is thereby crucial to increase adolescents’ resilience to psychological distress and enhance their mental well-being. In particular, healthcare professionals must develop effective health promotion programs that support adolescents to boost their resilience in the face of adversity, engage in healthy lifestyles, and promote mental well-being. Most importantly, healthcare professionals should collaborate with the education sector and school social workers to build effective health promotion programs in schools such that adolescents can better combat mental health problems and lead healthier lives.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by the Seed Fund for Basic Research (grant number 201705159005), The University of Hong Kong.

ORCID iDs

Ankie Tan Cheung

WHC Li

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