This study aimed to explore the rates of suicidal behaviours and NSSI, and the association between parenting style and S/NSSI in undergraduate students at a South African university. We identified suicidal attempts in 6.3%, suicidal threats in 9.2%, suicidal thoughts in 35.7%, thoughts of wanting to die in 50.7%, and NSSI in 22.7% of the participants. Interestingly we saw no significant differences in these rates between male and female students. In terms of parenting styles, authoritative parenting was the most highly endorsed by participants. In contrast to our hypothesis, we did not observe a negative correlation between authoritative parenting style and S/NSSI. Instead, perceived authoritative mothering and fathering showed positive associations with NSSI. Authoritarian parenting styles did not show significant associations with any S/NSSI behaviours, but permissive parenting (mothers and fathers) showed many associations with S/NSSI.
The results of our study showed rates of most S/NSSI behaviours to be either higher than the national average for adults, adolescents and young adults in South Africa, or towards the high end of previously reported rates [6, 7, 19, 42]. These findings are in keeping with the literature where a youthful preponderance in suicidal behaviours is well described both locally and internationally [1, 5, 6].
The rate of suicide attempts in this study was slightly lower than those seen in South African adults over the age of 18 and adolescents [6, 43], with the exception of a study of South African adolescents by Shilubane et al. [7] that reported rates of suicide attempts almost four times the rates found in the current study at 22.7%. Nevertheless, the results of this study revealed higher rates of suicide attempts than those seen in students internationally [17, 44, 45] and Korean adolescents [11]. We found that the rates of suicide threats in this study were consistently higher than reported international, local and student-related rates of suicidal threats [6, 17, 44], and more than double the rate of suicide threats seen in South African adults [6].
Similarly, suicidal thoughts were reported at much higher rates than found in local and international literature [6, 7, 11, 17, 18, 22, 44]. The exception was a South African study of suicidal behaviours in adolescents that reported marginally lower rates of suicidal thoughts (32.3% vs 35.7%) [7]. Unlike the current study, the South African study on adolescent suicidal behaviours reported on a much smaller sample size, making any direct comparison difficult.
Comparison of rates of NSSI behaviours showed mixed results. One Canadian study of undergraduate students showed a rate double that of our study [46], but other studies of NSSI in students reported much lower rates than reported in this study (1.4–14.3%) [13, 45, 47]. Notably, a study of South African students reported slightly lower rates of NSSI (19.4% vs 22.7%) [19].
We were not able to identify any previous studies that had measured the presence of thoughts of dying. However, the very high rate observed in our study (50.2%) suggests that thoughts of dying (even if not accompanied by thoughts of wanting to harm or kill oneself) are very common in university students.
Even though the S/NSSI rates reported here were all towards the higher end or more than previously reported rates, we remain mindful that students in this study were able to opt out of answering any or all questions about suicide. It is therefore possible that the true rate of S/NSSI behaviours in the study population might have been higher if participants affected by these behaviours avoided answering the questions, or lower if unaffected students opted out of answering these questions if they felt questions were not relevant to them. We also acknowledge that there was no consistency in the way S/NSSI behaviours were measured across studies, with no other study using the SHBQ to assess S/NSSI behaviours. Studies in similar populations of South African students had smaller sample sizes and used different measures to assess S/NSSI behaviours [7, 19, 43], thus making direct comparison difficult.
In the international literature, there is a clear female preponderance of suicide attempts [4, 6] and it was therefore surprising not to find significant differences in our study. The pattern of rates for suicidal attempts and other S/NSSI behaviours did show higher rates in women for most items, even if there were not statistically significant differences. Interestingly, there have been suggestions from international studies of university students, that the rate of NSSI may be higher among males, suggesting that perhaps not all S/NSSI behaviours are predominant among women. We are also mindful that the relatively low participation rate for men and the possibility of opting out of questions may have influenced our findings. Nevertheless, our observations suggest, if nothing else, that all undergraduate students (male and female) may present with a range of S/NSSI behaviours that may require support or intervention.
In a study conducted at the University of Cape Town around the same time as our investigations, Van der Walt et al. [48] showed that 25% of medical students were diagnosed with depressive disorder, 20.5% with an anxiety disorder, and that 28.1% of students were receiving psychotropic medications. In their study, female sex was significantly associated with both diagnoses [48]. Unfortunately, their study did not investigate any S/NSSI variables.
On the PSDQ, the dimensions of authoritative parenting showed the highest mean scores, and permissive parenting the lowest mean scores. These findings are in keeping with other South African data, suggesting that the parenting style dimensions measured in this study were representative of the South African population [37]. The associations between parenting style and S/NSSI, however, yielded some unexpected results. A positive correlation between maternal and paternal authoritative parenting and NSSI in our study contrasted with other studies reporting a negative correlation between authoritative parenting and S/NSSI [22, 33], and contrasted with findings that demonstrated a positive correlation between authoritative parenting and positive psychological outcomes in adolescents in the form of the pursuit of intrinsic over extrinsic goals [34]. It is difficult to make a definitive interpretation of these findings, except perhaps to acknowledge that the correlation coefficients in our study (Spearman rho values, ρ) were modest (ρ = 0.098 for authoritative mothers; ρ = 0.1 for authoritative fathers), suggesting that, even though statistically significant, the association should not be over-interpreted. If nothing else, our results suggest that, even with authoritative parents, university students may engage in S/NSSI behaviours and thoughts.
Permissive parenting in both mother and father was associated with higher rates of reported S/NSSI behaviours in our study, albeit also with modest Spearman rho correlation coefficient values. We had not made any a priori hypotheses about permissive parenting, given unclear evidence in the scientific literature.
We acknowledge that several parental behaviours have been associated with both positive and negative behavioural outcomes in the international literature. Maternal neglect has, for instance, been associated with younger age of onset of substance use [49], while overall parental neglect or hostility was associated with greater suicidal intent and increased risk of delinquent behaviour in adolescents [50, 51]. Individuals who had experienced more fear and alienation, and less communication and trust in their relationship with their parents were more likely to engage in NSSI behaviour [28]. Conversely, high parental care had been associated with lowered risk of S/NSSI behaviours [24]. The dimension of ‘permissiveness’ as defined by Baumrind combines ‘parental warmth’ with a relative lack of boundary-setting. Most of the parental characteristics outlined in the literature above were related to a lack of emotional warmth, which was not the case in our participants with permissive parents.
Given the very modest Spearman rho values observed in our study, we are very cautious not to over-interpret our findings in any definitive way. Instead, we will make a few tentative suggestions that could be explored further in future research.
First, the absence of a negative association between authoritative parenting style and suicidal behaviours (attempts, threats, thoughts, and thoughts of death) may suggest that, at least in university students, the contribution of this parenting style is becoming a lesser contributor to positive behavioural outcomes in the broader ecological context of these young adults. This may reflect the fact that students straddle aspects of adolescence and adulthood, and may be best understood to be emerging into adulthood. Their needs for parental affirmation, and the impact of parenting style may be diminishing. Given the novelty of this observation, the finding may be particular to the South African context where many students are the first generation in their families to enter tertiary education. This may lead to immense pressure to succeed, become financially independent and lift their extended families out of poverty. The authoritative parent that was able to support the adolescent in secondary school, may not have the repertoire and insight into the pressures and constraints under which the emerging adult student is expected to perform, in turn leading to inadequate or inappropriate support and loss of the ‘protectiveness’ of their authoritative parenting style.
Second, the association observed between authoritative parenting styles and NSSI may suggest differential psychological and ecological pathways to NSSI as opposed to suicidal behaviours. However, this finding contradicts the established literature showing a clear correlation between suicidal and NSSI behaviours. Third, the higher ‘signal’ of S/NSSI associations seen here with permissive parenting may suggest the importance not only of parental warmth, but also of clear and appropriate expectations and boundary-setting by parents, as a contributor to the psychological well-being of university students. For example, during the student phase of emerging adulthood, high levels of parental warmth may be welcomed and appreciated by the student, and experienced as comforting. However, individuation and development of independence and self-efficacy are crucial developmental tasks during this phase. A permissive parent may not set clear expectations or boundaries on their ‘emerging adult’ student, which in turn may prevent the student from developing the necessary repertoire to prioritise the use of time to achieve academic goals and delay gratification in the form of social and other pleasures. The lack of adequate preparation for the inevitable and necessary constraints of university life may thus undermine the benefits of high levels of warmth.
Limitations and Future Recommendations
We acknowledge a range of potential limitations to our study. First, we had already raised the fact that, at the request of our ethics committee, answering any or all questions in the SHBQ was optional and only a portion of participants in the larger study completed any of the items in the questionnaire. While we agreed with the ethical principle in doing so, this may have led to an under-reporting of S/NSSI in our study. However, the sample size was still relatively large in comparison to similar studies. Second, the study had a cross-sectional design and was correlational in nature. We were therefore not able to make any causal inferences. Instead, we tried to be cautious in our language not to imply any causal associations between S/NSSI and parenting styles, but rather tried to examine these as potential risks or protective markers. Third, we acknowledge that the study did not account for other potential confounding variables such as co-morbid mental illness or psychosocial variables that could have influenced our findings. However, a highly multivariate study would have required a very large sample size and was outside the scope of our work. Fourth, we acknowledge that we did not examine parenting styles in relation to South Africa’s racial and ethnic groups, where clear differential profiles may have existed [37, 52]. This would be an important next step in future research. Similarly, we acknowledge that the psychometric properties of the SHBQ has not been examined in a South African context, and this will also be an important next step for research.
Despite these limitations, the study showed students to remain developmentally vulnerable as they face the transition from childhood dependence into adulthood and independence and showed an association between permissive parenting style and S/NSSI behaviours. However, further work is required to determine the relative contribution parenting and other factors associated with developmental outcomes in adolescents and young adults (e.g. childhood adversity) make towards S/NSSI behavioural outcomes in students. Such data could assist in developing interventions in earlier schooling years to improve outcomes in university students. This data could also inform the design of university-based interventions that may include families and parents, as a significant proportion of students remain relatively dependent on their families for the duration of their student years.
The differential correlations between permissive parenting and S/NSSI behaviours versus authoritative parenting and NSSI behaviours suggests the possibility that different developmental mechanisms underly the genesis of suicidal and NSSI behaviours. Further research exploring these possible differential pathways could be helpful in designing parenting interventions for at-risk adolescents and emerging adults.