Oppositional Defiant Disorder, Internet Gaming disorder, and Suicidal Ideation among Saudi Adolescents: A Moderated Mediation Model of Gender and Self-Control

doi:10.21203/rs.3.rs-4818995/v1

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Oppositional Defiant Disorder, Internet Gaming disorder, and Suicidal Ideation among Saudi Adolescents: A Moderated Mediation Model of Gender and Self-Control

https://doi.org/10.21203/rs.3.rs-4818995/v1

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Background

Adolescence is characterized by behaviors as well as, in some, internet gaming disorders, that may lead to suicidal ideation. Prior research has documented the relationships between oppositional defiant disorder and internet gaming addiction with suicidal ideation among adolescents, but none has studied the potential mediating role of self-control nor the moderation role of gender.

Objective

This study investigated the relationships between oppositional defiant disorder, internet gaming disorder, and suicidal ideation, and applied a moderated mediation model including the roles of gender and self-control.

Method

273 adolescents (mean age = 15.47, 57% females) participated in this study. Respondents completed the Suicidal Ideation Scale, the Internet Gaming Disorder Scale, Short Form, the Oppositional Defiant Scale, and the Self-Control Scale, as well as a set of socio-demographic questions. A moderated mediation model was applied using the PROCESS software package.

Results

As expected, oppositional defiant disorder and internet addiction were positively related with suicidal ideation. Self-control was found to mediate these relationships. Further, it was found that these relationships were stronger in females compared to males.

Conclusions

Efforts to reduce suicidal ideation among adolescents with defiant behaviors and gaming disorder should be directed at enhancing their self-control and should be gender mindful.

oppositional defiant disorder

internet gaming disorder

self-control

suicidal ideation

adolescents

Saudi Arabia

Every 40 seconds someone is dying by suicide somewhere in the world and there are countless unknown suicide attempts (1). Suicide is a major public health problem worldwide (2) (Lindstrom & Rosvall, 2018) with around 703,000 deaths every year (3). Suicide deaths have, arguably, more deleterious impacts on society than any other deaths. In fact, for every suicide death, it is believed that around 135 persons directly or indirectly get affected and may need health care services (4).

Previous studies showed that suicidal ideation precedes suicide plan, attempt, and behavior (5, 6). In fact, among all predictors of suicide, suicidal ideation is thought of as the biggest predictor of a subsequent suicidal event (7). Klonsky and colleagues claimed that intervention should focus on prevention of ideation, rather than on much more serious suicidal behaviors (8).

Adolescence is a period in which, among the various stages of life, one may be most exposed to suicide. A survey by Avenevoli and colleagues reported that 16% of students between the grades of 9 and 12 had seriously thought of committing suicide, and eight percent had attempted suicide in the previous 12 months (9). Studies focusing on adolescence and young adulthood have shown that suicide was related to oppositional defiant disorder, other conduct and psychological disorders, aggression, substance use, and internet gaming disorder or internet addiction (10–12).

It was argued that self-control was a protective factor of suicidal ideation (13), but to date no study has investigated the mediation role of self-control in the relationships between oppositional defiant disorder, internet gaming disorders, and suicidal ideation. Further, gender differences have been reported in the incidence of suicidal ideation (14), but no prior study has examined an interaction with gender among Saudi adolescents. Therefore, the purpose of this study was to investigate the relationships among oppositional defiant disorder, internet gaming disorder, and suicidal ideation, and to test a moderated mediation model of gender and self-control among Saudi adolescents.

Oppositional Defiant Disorder and Suicidal Ideation

Oppositional defiant disorder (ODD) is, typically, a childhood disorder whose characteristics include persistent defiant and antagonistic behavior, irritability, anger, and argumentativeness (15, 16). A meta-analysis that examined ODD among samples around the world reported that around 3.3% of children and adolescents had symptoms of this disorder (17). Boylan et al. (2007) studied clinic samples and reported much higher estimates, a prevalence of ODD in between 28% and 65% of children (18). When ODD is not treated in early childhood, it may be a predictor of behavioral and psychological issues during adolescence (19, 20).

Oppositional defiant disorder has been associated with social impairment, problematic interaction with others, even online, and conflict with authority figures, that is, overall, individuals with ODD encounter various challenges in their lives (21) which may lead to suicidal ideation. Others have reported that the irritability nature of ODD was related to suicidal ideation among detained teen offenders (22). Among children with ADHD, research showed that ODD was related to suicidal ideation (23).

Thus, our first hypothesis for our study is as follows:

H1: Oppositional defiant disorder is positively related to suicidal ideation

Internet Gaming Disorder and Suicidal Ideation

Internet gaming disorder (IGD) has been claimed as a public health problem worldwide. Previous studies have found that, more generally, internet addiction was related to suicidal ideation (24–26). Other studies demonstrated that people with increased IGD have high odds of thinking about suicide than their counterparts (27). Junus and colleagues found that adolescents with IGD had higher lifetime suicide attempts as compared to their counterparts (28). Cheng and colleagues carried out a meta-analysis of 15 studies and concluded that those who were addicted to internet gaming had higher odds of suicide ideation (27). A systematic literature review by Erevik and colleagues, involving 12 studies, also found a positive relationship between problem gaming and suicidal ideation and/or attempts (29).

Thus, our second hypothesis:

H2: Internet gaming disorder is positively related to suicidal ideation

The Mediation Role of Self-Control

Self-control can be defined as “the ability to change or override one’s inner responses, as well as to interrupt undesired behavioral tendencies (such as impulses) and refrain from acting on them” (30, p. 274). Prior studies reported that people with increased self-control exhibited lower levels of depression (31). Conversely, adolescents with low self-control reported increased depression (32). High self-control has been related to additional positive outcomes, including better mental and physical health, healthy relationships, and academic success (30, 33). Others revealed that high self-control was related to reduced levels of IGD (34). Previous studies have indicated that self-control can be protective with regard to suicidality; Martin and colleagues, for example, found that self-control was negatively related to suicidal ideation (13).

H3: Self-control mediates the association between oppositional defiant disorder and suicidal ideation

H4: Self-control mediates the association between internet gaming disorder and suicidal ideation

The Moderation Role of Gender

It has been shown empirically that the occurrence of suicidal ideation is different for females and males. Blum and colleagues and Peltzer and Pengpid found that females were more likely to have higher rates of suicide ideation(35, 36). Previous research also showed gender differences with regard to self-control: females had higher self-control than males, as well as less delinquent behavior (37, 38). On the other hand, males adolescents have higher oppositional defiant behaviors and excessive gaming behaviors (39–41). Given these gender differences, one might expect the relationships between ODD, IGD, and suicidal ideation to be different in females and in males.

H5: Gender moderates the mediation of self-control between oppositional defiant disorder and suicidal ideation

H6: Gender moderates the mediation of self-control between internet gaming disorder and suicidal ideation

Participants

This study adopted a cross-sectional design and convenience sampling in order to reach as many and diverse participants as possible. Permission to conduct this study was obtained from King AbdulAziz University. A link to the questionnaire was sent to respondents via email and social media. Around 550 participants returned the survey, but 273 had no missing data and were used in this study. All participants were Saudis. The mean age was 15.47 (SD = 2.65, range = 12–19). Around 57% were females, 39.2% were middle school students, 35.6% were high school students, and 25.3% were college students. Regarding their parent’s education, 15% had mothers with less than high school education, 18.9% of the mothers had high school education, 50.3% had a university degree, and 15.8% possessed a postgraduate degree. Around 13.2% had fathers with less than high school education, 19.5% with high school education, 49.1% with a university degree, and 18.2% had fathers with a postgraduate degree.

Instruments

The measures used in this study included the Suicidal Ideation Scale (42), the Internet Gaming Disorder Scale, Short Form (43), the Oppositional Defiant Scale (21), and the Self-Control Scale (30). The questionnaire also included demographic questions about the participants.

The Suicidal Ideation Scale

The Suicidal Ideation Scale (42) is a brief measure with 10 items scored on a five-point Likert scale ranging between 1 (never or none of the time) and 5 (always or a great many times). Possible total scores, the sum of all the item scores, range between 10 and 50, where higher scores indicate greater suicidal ideation (42). This scale has demonstrated good psychometric properties (44). In this study, the internal consistency reliability was good (Cronbach’s alpha = 0.94).

The Internet Gaming Disorder Scale, Short Form

The Internet Gaming Disorder Scale, Short Form (43) is a brief instrument that assesses addiction to internet gaming. The scale consists of 9 items scored on five-point Likert scale between 1 (never) and 5 (very often). Possible total scores range between 9 and 45, where higher scores indicate higher severity of IGD (43). In this study, the internal consistency reliability was good (Cronbach’s alpha = 0.87).

The Oppositional Defiant Scale

The Oppositional Defiant Scale (21) is a brief measure consisting of 8 items in the form of questions that ask respondents how frequently they experienced specific symptoms. Examples are: “how often do you lose your temper?” and “how often do you defy or refuse to comply with rules and requests from people in authority?” (21). The scale is scored on five-point Likert scale ranging between 1 (never) and 5 (very often). Possible total scores range between 8 and 40, where higher scores indicate higher oppositional defiant behavior. The internal consistency reliability was good in this study (Cronbach’s alpha = 0.80).

The Self-Control Scale

Self-Control was measured through the Self-Control Scale (30).The scale consists of 13 items that measure the degree of one’s self-control. It is scored on a five-point Likert scale ranging between 1 (not at all) and 5 (very much). Items are negatively worded and are reversely scored except three items. Possible total scores range between 13 and 65, where higher scores indicate greater self-control. The internal consistency reliability in this study was fairly good (Cronbach’s alpha = 0.72).

Data analysis

All data analyses were carried out using RStudio statistical software (45). The first phase consisted of descriptive statistics and Pearson correlations analyses. The second phase consisted of internal consistency reliabilities for the scales using the “psych” software package (46). The third phase consisted of the mediation model and the moderated mediated model using the PROCESS macro software package developed by Hayes (47).For the mediation analysis, model 4 of the PROCESS macro was preferred and for the moderated mediation analysis, model 8 was preferred. 95% confidence intervals with 10,000 bootstrap samples were set during analysis. 95% confidence intervals that do not contain 0 are significant and indicate significant conditional indirect effects. In PROCESS (47), variables that are part of the product terms are centered in order to set conditional effects for different levels of the moderator variable.

Descriptive statistics

The descriptive statistics and Pearson correlation coefficients are displayed in Table 1. The mean scores were 15.92 (SD = 8.75) for suicidal ideation, 15.92 (SD = 4.50) for ODD, 16.97 (SD = 7.06) for IGD, and 41.72 (SD = 7.27) for self-control. As expected, suicidal ideation was positively correlated with ODD (r = 0.48, p < 0.001), positively correlated with IGD (r = 0.25, p < 0.001), and negatively correlated with self-control (r = -0.40, p < 0.001). Further, self-control was negatively correlated with both ODD (r = -0.53, p < 0.001) and IGD (r = 0.55, p < 0.001).

Table 1

Descriptive statistics and Pearson correlation
Variables	Mean	SD	1	2	3	4
1. Suicidal ideation	15.92	8.75	1
2. ODD	15.92	4.50	0.48***	1
3. IGD	16.97	7.06	0.25***	0.43***	1
4. Self-control	41.72	7.27	-0.40***	-0.53***	-0.55***	1
Notes: *** p < 0.001; SD = standard deviation; column heading numbers refer to the variables with matching row heading numbers

Mediation Model

The summary of the mediation model is displayed in Table 2. We used model 4 of PROCESS to test the mediation role of self-control in the relationship between ODD and suicidal ideation, and between IGD and suicidal ideation, with age as a covariate. The findings indicated that both ODD and IGD were positively associated with suicidal ideation (β = 0.89, p < 0.001 and β = 0.31, p < 0.001, respectively) in the absence of the mediator variable. When the mediator was included in the model, only ODD was associated with suicidal ideation (β = 0.37, p < 0.001). Also in this model, ODD and IGD negatively predicted self-control (β = -0.50, p < 0.001 and β = -0.52, p < 0.001, respectively).

Table 2

Mediation role of self-control between ODD, IGD, and suicidal ideation
Outcome variable	Independent variable	β	SE	t	p	LLCI	ULCI
Suicidal ideation	Intercept	11.32	3.34	3.23	p < 0.001	5.03	20.4
	ODD	0.89	0.10	8.66	p < 0.001	0.43	0.98
	IGD	0.31	0.06	4.71	p < 0.001	0.15	0.44
	Age	-0.21	0.18	-1.17	p = 0.234	-0.23	0.12
Suicidal ideation	Intercept	12.67	4.36	2.90	p < 0.001	4.09	21.26
	ODD	0.37	0.10	6.78	p < 0.001	0.21	0.65
	IGD	0.06	0.06	0.09	p = 0.360	-0.07	0.21
	Self-control	-0.20	0.07	-3.51	p < 0.001	-0.38	-0.10
	Age	0.03	0.16	0.63	p = 0.520	-0.21	0.42
Self-control	Intercept	43.70	2.43	17.93	p < 0.001	38.91	48.50
	ODD	-0.50	0.07	-11.30	p < 0.001	-0.76	-0.43
	IGD	-0.52	0.04	-10.88	p < 0.001	-0.61	-0.42
	Age	0.24	0.12	5.50	p = 0.434	0.06	0.30
Notes: The β values are standardized coefficients; LLCI = lower limit of confidence interval; ULCI = upper limit of confidence interval

Nonetheless, in the mediation model using bootstrapping methods, the indirect relationships through self-control were significant for both ODD (β_{ind =} 0.10, CI = 0.03 to 0.18) and IGD (β_{ind =} 0.19, CI = 0.12 to 0.26). These confidence intervals do not contain 0, indicating that the indirect relationships between both ODD and IGD and suicidal ideation through self-control were significant. Thus, Hypothesis 1 and Hypothesis 2 are supported. The results are displayed in Table 3.

Table 3

Bootstrapping indirect effect and 95% confidence interval (CI) for the mediation model
Indirect path	Standardized estimated effect	BootSE	95% CI
ODD = > self-control = > suicidal ideation	0.10	0.03	[0.03, 0.18]
IGD = > self-control = > suicidal ideation	0.19	0.03	[0.12, 0.26]
Notes: BootSE = bootstrapping standard error; CI = confidence intervals. Confidence intervals that do not contain 0 are significant.

The Moderated Mediation Models

We used model 8 of PROCESS to test the moderated mediation model. The results are summarized in Table 4. In this model, ODD negatively predicted self-control (β = -1.43, CI = -1.83 to -1.04) and the interaction with gender was significant (β = 0.45, CI = 0.17 to 0.74). IGD negatively predicted self-control (β = -0.62, CI = -0.92 to -0.32), but the interaction with gender was not significant. ODD positively predicted suicidal ideation (β = 1.04, CI = 0.42 to 1.45), but the interaction was not significant. IGD also positively predicted suicidal ideation (β = 1.08, CI = 0.65 to 1.46) and the interaction with gender was significant (β = -0.70, CI = -0.92 to -0.46). The interaction with gender was significant for the relationship between ODD and self-control and for the relationship between IGD and suicidal ideation. Therefore, Hypotheses 3 and 4 were supported.

Table 4

Moderated mediation model of gender and self-control
Outcome variable	Independent variable	β	BootSE	BootLLCI	BootULCI
Self-control	Intercept	32.14	2.01	28.30	36.20
	ODD	-1.43	0.19	-1.83	-1.04
	IGD	-0.62	0.16	-0.92	-0.32
	Gender	-0.75	0.62	-2.01	0.44
	ODD x gender	0.45	0.14	0.17	0.74
	IGD x gender	0.07	0.11	-0.14	0.28
	Age	0.65	0.10	0.43	0.86
Suicidal ideation	Intercept	35.76	4.50	27.06	44.72
	ODD	1.04	0.32	0.42	1.65
	IGD	1.08	0.20	0.65	1.46
	Gender	-5.81	0.76	-7.34	-4.33
	ODD x gender	-0.30	0.18	-0.66	0.06
	IGD x gender	-0.70	0.11	-0.92	-0.46
	Age	-0.03	0.16	-0.36	0.26
Notes: the coefficients are unstandardized; SE = standard errors; LLCI = low limit of confidence interval; ULCI = upper limit of confidence interval

Table 5 summarizes the conditional indirect relationships for males and females separately. The indirect relationship between ODD and suicidal ideation through self-control was stronger in females than males (β_{ind =} 0.25, CI = 0.10 to 0.44 in females versus β_{ind =} 0.13, CI = 0.05 to 0.24 in males), and the index of moderated mediation was significant as well. The indirect relationship between IGD and suicidal ideation through self-control was slightly stronger in females than in males (β_{ind =} 0.22, CI = 0.14 to 0.32 in females versus β_{ind =} 0.19, CI = 0.11 to 0.29), and the index of moderated mediation was significant. Therefore, Hypotheses 5 and 6 were also supported. These conditional relationships in females and males are plotted in Figs. 1 and 2.

Table 5

Conditional indirect relationship of ODD, IGD, and suicidal ideation for males and females
	Classification	Indirect effects	BootSE	95% CI
ODD = > self-control = > suicidal ideation	Females	0.25	0.08	[0.10,0.44]
	Males	0.13	0.05	[0.05,0.24]
	Index of moderated mediation	-0.12	0.06	[-0.26, -0.02]
IGD = > self-control = > suicidal ideation	Females	0.22	0.04	[0.14,0.32]
	Males	0.19	0.04	[0.11,0.29]
	Index of moderated mediation	-0.03	0.04	[-0.12,0.05]
Notes: BootSE = bootstrapping standard error; CI = confidence intervals. Confidence intervals that do not contain 0 are significant.

This study applied a moderated mediation model according to Hayes and investigated a moderated mediation of gender and self-control in the relationships between ODD and suicidal ideation and between IGD and suicidal ideation among Saudi adolescents. The findings showed that ODD and IGD were positively associated with suicidal ideation. Further, self-control mediated these relationships. In addition, these relationships were stronger in females compared to males.

ODD predicted suicidal ideation in adolescents. These results corroborate those of prior research (22, 23). Among adolescents who were diagnosed with ODD, a high prevalence of suicidal ideation was reported by Hardan and Sahl (48). In another study among hospitalized adolescents, ODD was associated with episodes of suicidal ideation (49). This association may be due to the comorbidity between ODD and other types of psychopathology. Longitudinal prospective studies have related ODD to ADHD, anxiety, and depression symptoms (50, 51). It has been argued that depressive students may use self-harming behaviors and suicidal ideation in an attempt to internalize their negative emotions and decrease their anxiety (52).

Our study also found a positive association between IGD and suicidal ideation. This is also in line with previous research (27–29). Jeong and colleagues also found that online gaming overuse was associated with suicidal ideation (53). Among Chinese adolescents, Peng and colleagues found that adolescents with IGD were more likely to experience suicidal ideation (54). It is possible that adolescents who become addicted to internet gaming tend to be prone to depersonalization, affecting their overall social functioning, which makes them fail to satisfy their sense of belonging, leading to episodes of suicidal ideation (55).

Our study revealed that self-control played a mediating role in the association between ODD and IGD. These results echo previous research that self-control plays a protective role against many negative outcomes (56–58), including specifically suicide ideation and depression (13, 59). In the presence of self-control in the model, IGD was no longer a predictor of suicidal ideation, showing that self-control can protect online gamers from developing suicidal ideation. It has been argued that self-control facilitates healthy adjustment, good interpersonal relationships, and social integration (30), which reduces the likelihood of developing suicidal ideation.

The results also showed that the mediation role of self-control in the relationships among ODD, IGD, and suicidal ideation was stronger in females than in males. Prior research has reported gender differences with respect to suicidal ideation, generally, where females had higher odds of developing suicidal ideation (14). The explanation could be that females and males deal with and manage emotions very differently (60, 61). Others have claimed that females are more prone to negative affectivity because they are more likely to focus on internal emotions and thoughts (62). Similarly, it may be possible that these gender differences are due to differences in interpersonal socialization, where girls are more pressured to create and maintain social relationships (63, 64), which may increase their vulnerability to life stressors.

This study has limitations that have to be acknowledged. The study was cross-sectional. Longitudinal designs are recommended for future research. Further, this study used a convenience sample; random sampling is recommended for future research. Finally, this study was conducted online, thus we cannot know the situations respondents were involved in while completing the questionnaire.

The aim of this study was to examine the relationships between both oppositional defiant disorder and internet gaming disorder and suicidal ideation, and the mediating role of self-control, as well as the moderation role of gender. This study found that oppositional defiant disorder and internet gaming disorder predicted suicidal ideation. Further, self-control played a protective role for gamers and those with defiant behaviors with regard to developing suicidal ideation. Females seemed to be more affected by these relationships.

Implications

The findings of this study suggest that self-control can mitigate the impact of ODD and IGD on suicidal ideation among adolescents. Efforts to counteract suicidal ideation in adolescents with behavioral problems and/or a gaming disorder might place emphasis on developing and enhancing self-control in these populations. This is important for school psychologists, parents, and educators in planning effective training and interventions. The results of this study also suggest that efforts to reduce suicidal ideation among adolescents should be gender mindful, as females were found to be more highly affected.

Ethics approval and consent to participate

Ethics Board approval was obtained from the Deanship of Scientific Research (DSR), at King Abdulaziz University, Jeddah (GPIP: 1783-246-2024). All participants were informed about the aim of the study and their right to withdraw from the study at any time and informed consent was obtained from all participants. All procedures followed were carried out in accordance with the Helsinki Declaration of 1975, as revised in 2000.

Consent for publication

Not applicable.

c. Availability of data and materials

The data set used and/or analyzed during the current study available from the author on request.

d. Competing interests

The authors have no conflicts of interest to declare that are relevant to the content of this article.

e. Funding

The Deanship of Scientific Research (DSR), at King Abdulaziz University (KAU), Jeddah, Saudi Arabia has funded this Project under grant no. (GPIP: 1783-246-2024).

f. Authors' contributions

A. wrote the main manuscript text and A. prepared figures. All authors reviewed the manuscript.

g. Acknowledgements

The Deanship of Scientific Research (DSR) at King Abdulaziz University (KAU), Jeddah, Saudi Arabia has funded this Project under grant no. (GPIP: 1783-246-2024). The author, therefore, acknowledge with thanks to DSR for their technical and financial support.

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Oppositional Defiant Disorder, Internet Gaming disorder, and Suicidal Ideation among Saudi Adolescents: A Moderated Mediation Model of Gender and Self-Control

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Abstract

Background

Objective

Method

Results

Conclusions

Figures

Background

Oppositional Defiant Disorder and Suicidal Ideation

H1: Oppositional defiant disorder is positively related to suicidal ideation

Internet Gaming Disorder and Suicidal Ideation

H2: Internet gaming disorder is positively related to suicidal ideation

The Mediation Role of Self-Control

H3: Self-control mediates the association between oppositional defiant disorder and suicidal ideation

H4: Self-control mediates the association between internet gaming disorder and suicidal ideation

The Moderation Role of Gender

H5: Gender moderates the mediation of self-control between oppositional defiant disorder and suicidal ideation

H6: Gender moderates the mediation of self-control between internet gaming disorder and suicidal ideation

Methods

Participants

Instruments

The Suicidal Ideation Scale

The Internet Gaming Disorder Scale, Short Form

The Oppositional Defiant Scale

The Self-Control Scale

Data analysis

Results

Descriptive statistics

Mediation Model

The Moderated Mediation Models

Discussion

Conclusions

Implications

Declarations

References

Additional Declarations

Status:

Version 1