Characteristics and Co-occurrence of Adolescent Non-Suicidal Self-Injury and Suicidal Behaviours in Pediatric Emergency Crisis Services

During the potentially tumultuous adolescent period, non-suicidal self-injury (NSSI) and suicide attempts are relatively common, particularly amongst youth who present to mental health services. These phenomena frequently co-occur but their relationship is unclear. This study evaluated clinical data from 468 youth between the ages of 12 and 17 years (63.5% female) to determine the incidence of NSSI 24 h prior to presentation at emergency crisis services, evaluated the overlap between NSSI and suicide attempt, and examined the characteristics of different types of self-harm. Half of the adolescents presenting to emergency crisis services had self-harmed within the previous 24 h, with most of these (91%) classified as NSSI only. The percentage of youth with a suicide attempt was 5% and the co-occurrence of these two behaviours was 4%. Group differences in depressive symptoms, suicidal ideation and impulsivity were identified, with the co-occurring NSSI and suicide attempt group presenting with the highest level of psychopathology. This study underscores the necessity of assessing suicidal ideation and NSSI in all youth presenting to mental health services.     

A Comparison of Adolescents Engaging in Self-Injurious Behaviors With and Without Suicidal Intent: Self-Reported Experiences of Adverse Life Events and Trauma Symptoms

Research comparing adolescents engaging in suicidal and non-suicidal self-injury (NSSI), both separately and in combination, is still at an early stage. The purpose of the present study was to examine overlapping and distinguishable features in groups with different types of self-injurious behaviors, using a large community sample of 2,964 (50.6 % female) Swedish adolescents aged 15–17 years. Adolescents were grouped into six categories based on self-reported lifetime prevalence of self-injurious behaviors. Of the total sample, 1,651 (55.7 %) adolescents reported no self-injurious behavior, 630 (21.2 %) reported NSSI 1–4 times, 177 (6.0 %) reported NSSI 5–10 times, 311 (10.5 %) reported NSSI ≥ 11 times, 26 (0.9 %) reported lifetime prevalence of suicide attempt and 169 (5.7 %) adolescents reported both NSSI and suicide attempt. After controlling for gender, parental occupation and living conditions, there were significant differences between groups. Pairwise comparisons showed that adolescents with both NSSI and suicide attempt reported significantly more adverse life events and trauma symptoms than adolescents with only NSSI, regardless of NSSI frequency. The largest differences (effect sizes) were found for interpersonal negative events and for symptoms of depression and posttraumatic stress. Adolescents with frequent NSSI reported more adversities and trauma symptoms than those with less frequent NSSI. There were also significant differences between all the NSSI groups and adolescents without any self-injurious behavior. These findings draw attention to the importance of considering the cumulative exposure of different types of adversities and trauma symptoms when describing self-injurious behaviors, with and without suicidal intent.     

Restrictive Emotionality,Depressive Symptoms,and Suicidal Thoughts and Behaviors Among High School Students

Depression and suicidal thoughts and behaviors are prevalent among youth today. The current study sought to further our understanding of the correlates of depression and suicidality by assessing the relationship between restrictive emotionality (difficulty understanding and expressing emotions) and depressive symptoms and suicidal ideation and attempts among adolescents. A large group of high school students (n = 2189, 58.3% male; 13–18 years of age) completed a self-report survey as part of a 2-stage suicide screening project. Logistic regression analyses were used to assess the association between restrictive emotionality and depressive symptoms, suicidal ideation, and suicide attempts. Those reporting high restrictive emotionality were 11 times more likely to have elevated depressive symptom scores, 3 times more likely to report serious suicidal ideation (after controlling for depressive symptoms), and more than twice as likely to report a suicide attempt (after controlling for depressive symptoms) than those reporting low restrictive emotionality. Restrictive emotionality partially mediated the relationship between depressive symptoms and suicidal ideation and behavior. The pattern of association between restrictive emotionality and the outcome variables was similar for boys and girls. Restrictive emotionality is highly associated with elevated depressive symptoms and suicidal thoughts and behaviors among high school students, and may be a useful specific target in prevention and treatment efforts.     

Help-Negation and Suicidal Ideation: The Role of Depression,Anxiety and Hopelessness

Help-negation is expressed behaviorally by the refusal or avoidance of available help and cognitively by the inverse relationship between self-reported symptoms of psychological distress and help-seeking intentions. The current study examined the association between suicidal ideation and intentions to seek help from friends, family and professional mental health sources in a sample of 302 Australian university students. Participants were 77.5% female and aged from 18–25 years old, with 85.4% aged 21 years or younger. Higher levels of suicidal ideation were related to lower help-seeking intentions for family, friends, and professional mental health care, and higher intentions to seek help from no one. Moderation effects indicated that higher levels of depressive symptoms strengthen the help-negating effect of suicidal ideation for seeking help from friends, family and no one. The results indicate that, even at subclinical levels, suicidal ideation impedes the cognitive help-seeking process at the decision making stage. The results also highlight the importance of improving our understanding of why young people become reluctant to seek help as their levels of suicidal ideation and depressive symptoms increase. Raising awareness that the experience of suicidal ideation and depressive symptoms can promote intentions to avoid help might reduce the help-negation effect when symptoms are first recognized.     

Suicidal Ideation and Distress Among Immigrant Adolescents: The Role of Acculturation, Life Stress, and Social Support

Acculturative stress and social support play important roles in suicide-related phenomena among adolescent immigrants. To examine their contributions, measures of acculturative and general life stress and a measure of multiple sources of social support were used to predict psychological distress and suicidal ideation among Korean-born high school students residing in the US. Korean students who were sojourning without both parents were compared to Korean students who immigrated with both parents, Korean students who remained in Korea, and American high school students in the US (total N = 227; 56.8% female). The sojourning group reported higher levels of life stress, distress, psychological symptoms, and suicidal ideation than the other groups. Within the two acculturating groups, levels of distress, symptoms, and suicidal ideation were associated with life stress, lack of parental support, and not living with both parents. The findings have important implications for suicide prevention among immigrant adolescents, and imply that parental support is particularly protective.     

The Relative Influence of Different Domains of Social Connectedness on Self-Directed Violence in Adolescence

Previous research has linked greater social connectedness with a lowered risk of self-directed violence among adolescents. However, few studies have analyzed the comparative strength of different domains of connectedness (e.g., family, peers and school) to determine where limited resources might best be focused. Data to address that gap were taken from the Centers for Disease Control and Prevention’s Student Health and Safety Survey, administered to 4,131 7th–12th graders (51.5% female; 43.8% Hispanic; 22.6% African American or Black). Logistic regressions (controlling for age, gender, race/ethnicity, family structure, academic performance, and depressive symptoms) suggest that family connectedness was a stronger predictor than connectedness to peers, school, or adults at school for non-suicidal self-harm, suicidal ideation, suicide plans, and non-fatal suicidal behavior. In some analyses, peer connectedness was unexpectedly a risk factor. Results have implications for prevention of suicide in adolescence, especially in the context of the current trend towards school-based prevention programs.     

Gender-related Risk and Protective Factors for Depressive Symptoms and Disordered Eating in Adolescence: A 4-year Longitudinal Study

The interplay between intrapersonal risk (low self-esteem, perfectionism and body dissatisfaction) and interpersonal protection (social support) appears relevant for delineating gender-specific pathways that lead to both depressive and eating psychopathology. The aims of this longitudinal study were to examine gender differences in the levels of depressive symptoms, disordered eating and the co-occurrence of both problems from preadolescence to mid-adolescence and to identify gender-specific risk and protective factors of depressive symptoms and disordered eating. A Spanish community-based sample initially comprising 942 early adolescents (49% females) was assessed at baseline (T1; X _age = 10.8 years) and at 2 and 4-year follow-up (T2 and T3). Gender differences emerged at T2 for disordered eating and at T3 for depressive symptoms and for co-occurring depressive symptoms and disordered eating. Predictors of depressive symptoms were body dissatisfaction, low self-esteem and fear of getting fat, for girls, and body dissatisfaction and low self-esteem, for boys. Predictors of disordered eating were body dissatisfaction, depressive symptoms, BMI and perfectionism, for girls, and low social support and BMI, for boys. In addition, for boys only, social support moderated the effect of body dissatisfaction on depressive symptoms and the effect of depressive symptoms on disordered eating. The hypotheses of the study were partially supported. Clinical implications are derived regarding the components that should be included in programs for preventing depression and eating disorders in both girls and boys.     

Youth Engagement and Suicide Risk: Testing a Mediated Model in a Canadian Community Sample

Suicide is a leading cause of death among adolescents in many industrialized countries. We report evidence from a mediation model linking greater youth activity engagement, spanning behavioral and psychological components, with lower suicide risk through five hypothesized intrapersonal and interpersonal mediating factors. Self-report survey data (15% French, 85% English) were gathered from a community sample of 5,015 Canadian adolescents participating in a mental health promotion program. Youth (M _age = 15.77, SD = 1.42, 50% female) were from two urban centers in southern Ontario, Canada. Youth engagement (youth’s most important type of activity, frequency of involvement, and psychological engagement), suicide risk predictive factors (self-esteem, current concerns, depressive symptoms, coping ability, and connections with others), and suicide risk (ideation and attempts) were assessed. Consistent with the hypothesized mediation model, enjoyment and stress in youth’s most important activity and various activity types were associated with the various hypothesized suicide risk predictive factors, which in turn were related to suicide risk. Implications for conceptualizations of youth engagement as a multidimensional construct and for suicide risk prevention efforts are discussed.     

Bullying Victimization and Adolescent Self-Harm: Testing Hypotheses from General Strain Theory

Self-harm is widely recognized as a significant adolescent social problem, and recent research has begun to explore its etiology. Drawing from Agnew’s (1992) social psychological strain theory of deviance, this study considers this issue by testing three hypotheses about the effects of traditional and cyber bullying victimization on deliberate self-harm and suicidal ideation. The data come from a school-based survey of adolescents in a rural county of a southeastern state (n = 426); 50% of subjects are female, their mean age was 15 years, and non-Hispanic whites represent 66% of the sample. The analysis revealed that both types of bullying are positively related to self-harm and suicidal ideation, net of controls. Moreover, those relationships are partially mediated by the negative emotions experienced by those who are bullied and partially moderated by features of the adolescent’s social environment and self. Regarding the latter, exposure to authoritative parenting and high self-control diminished the harmful effects of bullying victimization on self-harm and suicidal ideation. The article concludes by discussing the implications of these conclusions for future research and for policy efforts designed to reduce self-harm.     

The Intersectionality of Discrimination Attributes and Bullying Among Youth: An Applied Latent Class Analysis

Discrimination is commonly experienced among adolescents. However, little is known about the intersection of multiple attributes of discrimination and bullying. We used a latent class analysis (LCA) to illustrate the intersections of discrimination attributes and bullying, and to assess the associations of LCA membership to depressive symptoms, deliberate self harm and suicidal ideation among a sample of ethnically diverse adolescents. The data come from the 2006 Boston Youth Survey where students were asked whether they had experienced discrimination based on four attributes: race/ethnicity, immigration status, perceived sexual orientation and weight. They were also asked whether they had been bullied or assaulted for these attributes. A total of 965 (78 %) students contributed to the LCA analytic sample (45 % Non-Hispanic Black, 29 % Hispanic, 58 % Female). The LCA revealed that a 4-class solution had adequate relative and absolute fit. The 4-classes were characterized as: low discrimination (51 %); racial discrimination (33 %); sexual orientation discrimination (7 %); racial and weight discrimination with high bullying (intersectional class) (7 %). In multivariate models, compared to the low discrimination class, individuals in the sexual orientation discrimination class and the intersectional class had higher odds of engaging in deliberate self-harm. Students in the intersectional class also had higher odds of suicidal ideation. All three discrimination latent classes had significantly higher depressive symptoms compared to the low discrimination class. Multiple attributes of discrimination and bullying co-occur among adolescents. Research should consider the co-occurrence of bullying and discrimination.     

Sex differences in the causes of adolescent suicide ideation

A model that incorporates both socioenvironmental and psychological factors was developed in an attempt to explain adolescent suicide ideation. A sample of 407 high school students was used to test the model. Most of the previous research on the causes of adolescent suicidal behavior has not used multivariate data analysis techniques and has failed to explore sex differences. Results of the present study suggest that these are important omissions. Although significant at the zero-order level, factors such as self-esteem and interpersonal problems at school were not related to suicide ideation when the effects of the other explanatory variables were controlled. The incidence of suicide ideation was higher for females. Emotional problems and involvement in delinquent behavior were important predictors of ideation for females, while employment problems were the most potent predictor for males.Received his Ph.D. from Florida State University. Current interest is the etiology of various forms of deviant behavior, especially among adolescents.Therapist, Story County Center for Personal Development. Received her M.A. in clinical sociology from Iowa State University.     

Nonsuicidal Self-Harm Among Community Adolescents: Understanding the “Whats” and “Whys” of Self-Harm

This study examines self-harm in a community sample of adolescents. More specifically, the study identifies the prevalence and types of self-harm, elucidates the nature and underlying function of self-harm, and evaluates the relation of psychological adjustment, sociodemographic, and health-risk variables to self-harm. Self-report questionnaires assessing self-harm, adjustment, health behaviors, suicide history, and social desirability were completed by 424 school-based adolescents. Overall, 15% of the adolescents reported engaging in self-harm behavior. Analyses revealed gender differences across behaviors and motivations. Adolescents who indicated harming themselves reported significantly increased antisocial behavior, emotional distress, anger problems, health risk behaviors, and decreased self-esteem. Results provide support for the coping or affect regulation model of self-harm. Findings suggest that self-harm is associated with maladjustment, suicide, and other health behaviors indicative of risk for negative developmental trajectories. Doctoral student in the Department of Educational and Counseling Psychology at the University of British Columbia. Received M.A. in School Psychology from the University of British Columbia. Research interests include self-harm, anxiety, coping, and street-involved youth. Associate Professor in the Department of Educational and Counseling Psychology at the University of British Columbia. Received Ph.D. from the University of Iowa. Research interests include adolescent social-cognitive development, developmental psychopathology, and stress and coping.     

The Influence of Romantic Attachment and Intimate Partner Violence on Non-Suicidal Self-Injury in Young Adults

Several theoretical models for non-suicidal self-injury (NSSI) have been proposed. Despite an abundance of theoretical speculation, few empirical studies have examined the impact of intimate relationship functioning on NSSI. The present study examines the influence of romantic attachment and received intimate partner violence (physical, psychological and sexual) on recent reports of NSSI behaviors and thoughts. The sample was composed of 537 (79.9% female) primarily Caucasian university students between the ages of 18 and 25 years and currently involved in a romantic relationship. The results reveal that anxiety over abandonment was a significant predictor of NSSI thoughts and behaviors in women and a significant predictor of NSSI thoughts in men. Moreover, the experience of intimate partner violence emerged as a significant predictor of NSSI behaviors in both men and women. Continued empirical investigations into the influence of intimate relationship functioning on NSSI will facilitate the development of psychological interventions for young adults dealing with self-harm.     

Concurrent Trajectories of Change in Adolescent and Maternal Depressive Symptoms in the TORDIA Study

Depression has a heightened prevalence in adolescence, with approximately 15 % of adolescents experiencing a major depressive episode by age 18. Depression in adolescence also poses a risk for future distress and impairment. Despite treatment advances, many adolescents relapse after initial remission. Family context may be an important factor in the developmental trajectory of adolescent depression, and thus in enhancing treatment. This study examined concurrent change over time in adolescent and maternal depressive symptoms in the context of the Treatment of Resistant Depression in Adolescents study. Participants were 334 adolescents (mean age: 16; SD: 1.6; 70 % female, 84 % Caucasian), and their mothers (n = 241). All adolescents were clinically depressed when they entered the study and had received previous selective serotonin reuptake inhibitor (SSRI) treatment. Adolescents received acute treatment for 12 weeks and additional treatment for 12 more weeks. Adolescent depression and suicidal ideation were assessed at 0, 6, 12, 24, 48 and 72 weeks, while maternal depressive symptoms were assessed at 0, 12, 24, 48 and 72 weeks. Latent basis growth curve analyses showed a significant correlation over 72 weeks between trajectories of maternal and adolescent depressive symptoms, supporting the hypothesis of concurrent patterns of change in these variables. The trajectories were correlated more strongly in a subsample that included only dyads in which mothers reported at least one depressive symptom at baseline. Results did not show a correlation between trajectories of maternal depressive symptoms and adolescent suicidal ideation. These findings suggest that adolescent and maternal depressive symptoms change in tandem, and that treatment for adolescent depression can benefit the wider family system. Notably, most mothers in this sample had subclinical depressive symptoms. Future research might explore these trajectories in dyads with more severely depressed mothers.     

The Moderating Effects of Parenting Styles on African-American and Caucasian Children’s Suicidal Behaviors

Given that parenting practices have been linked to suicidal behavior in adolescence, examining the moderating effect of parenting styles on suicidal behavior early in development could offer potential insight into possible buffers as well as directions for suicide prevention and intervention later in adolescence. Hence, the moderating effects of parenting styles, including authoritarian, permissive, and features of authoritative parenting, on depressed and aggressive children’s suicidal behavior, including ideation and attempts, were evaluated with young children (N = 172; 72% male, 28% female) ranging from 6 to 12 years of age. African American (69%) and Caucasian (31%) children admitted for acute psychiatric inpatient care completed standardized measures of suicidal behavior, depressive symptoms, and proactive and reaction aggression. Their parents also completed standardized measures of parental distress and parenting style. Hierarchical regression analyses revealed that, while statistically controlling for age and gender, children who endorsed more depressive symptoms or reactive aggression reported more current and past suicidal behavior than children who endorsed fewer depressive or aggressive symptoms. The significant positive relationship observed between depressive symptoms and childhood suicidal behavior, however, was attenuated by parental use of authoritarian parenting practices for African-American and older children but not for younger and Caucasian children. The ethnic/racial difference observed for the buffering effect of authoritarian parenting practices offers potential theoretical and clinical implications for conceptualizing the moderating effects of parenting styles on African-American and Caucasian children’s suicidal behavior.     

Preventing Non-Suicidal Self-Injury in Adolescents: The Signs of Self-Injury Program

Non-suicidal self-injury (NSSI) continues to be a problem among youth and there is a great need for programming aimed at reducing NSSI in adolescents. The signs of self-injury program is the first known NSSI school-based prevention program for adolescents that attempts to increase knowledge, improve help-seeking attitudes and behaviors, and decrease acts of NSSI. A total of five schools implemented the program in selected classrooms (n = 274 adolescents; 51.5% female, mean age = 16.07 years) that consisted of predominantly Caucasian (73%) adolescents. Researchers collected pre-post evaluation surveys of the program and feasibility interviews were conducted with the school guidance personnel who ran the program. Results indicated the prevention program did not produce iatrogenic effects, increased accurate knowledge and improved help-seeking attitudes and intentions among students. No significant changes were found in regards to self-reported formal help-seeking actions. Feasibility responses indicate the program is user-friendly and well received by school personnel. The data offer preliminary evidence that the program may be an effective prevention program for schools.     

The Role of Exposure to Self-Injury Among Peers in Predicting Later Self-Injury

While researchers are beginning to reach consensus around key psychological correlates of non-suicidal self-injury (NSSI), comparatively less work has been done investigating the role and influence of peers. Given evidence that engagement in this behavior may be susceptible to peer influence, especially during the early stages of its course, the current study prospectively explored whether knowing a friend who self-injures is associated with the onset, severity, and subsequent engagement in NSSI. The moderating roles of adverse life events, substance use and previous suicidal behavior in this relationship also were explored. Self-report data were collected from 1,973 school-based adolescents (aged 12–18 years; 72 % female) at two time points, 1 year apart. Knowing a friend who self-injured, negative life events, psychological distress and thoughts of NSSI differentiated those who self-injured from those who did not, and also predicted the onset of NSSI within the study period. Further, adverse life events and previous thoughts of NSSI moderated the relationship between exposure to NSSI in peers and engaging in NSSI at Time 2. However, the effect of having a friend who self-injures was not related to the severity of NSSI. Having a friend who self-injures appears to be a risk factor for self-injury among youth who are experiencing high levels of distress. Implications of these findings are discussed.     

Ethnic Identity and Mental Health in American Indian Youth: Examining Mediation Pathways Through Self-esteem,and Future Optimism

Mental health functioning in American Indian youth is an understudied topic. Given the increased rates of depression and anxiety in this population, further research is needed. Using multiple group structural equation modeling, the current study illuminates the effect of ethnic identity on anxiety symptoms, depressive symptoms, and externalizing behavior in a group of Lumbee adolescents and a group of Caucasian, African American, and Latino/Hispanic adolescents. This study examined two possible pathways (i.e., future optimism and self-esteem) through which ethnic identity is associated with adolescent mental health. The sample (N = 4,714) is 28.53 % American Indian (Lumbee) and 51.38 % female. The study findings indicate that self-esteem significantly mediated the relationships between ethnic identity and anxiety symptoms, depressive symptoms, and externalizing behavior for all racial/ethnic groups (i.e., the total sample). Future optimism significantly mediated the relationship between ethnic identity and externalizing behavior for all racial/ethnic groups and was a significant mediator between ethnic identity and depressive symptoms for American Indian youth only. Fostering ethnic identity in all youth serves to enhance mental health functioning, but is especially important for American Indian youth due to the collective nature of their culture.     

Emotional Distress Among LGBT Youth: The Influence of Perceived Discrimination Based on Sexual Orientation

The authors evaluated emotional distress among 9th–12th grade students, and examined whether the association between being lesbian, gay, bisexual, and/or transgendered (i.e., “LGBT”) and emotional distress was mediated by perceptions of having been treated badly or discriminated against because others thought they were gay or lesbian. Data come from a school-based survey in Boston, Massachusetts (n = 1,032); 10% were LGBT, 58% were female, and ages ranged from 13 to 19 years. About 45% were Black, 31% were Hispanic, and 14% were White. LGBT youth scored significantly higher on the scale of depressive symptomatology. They were also more likely than heterosexual, non-transgendered youth to report suicidal ideation (30% vs. 6%, p < 0.0001) and self-harm (21% vs. 6%, p < 0.0001). Mediation analyses showed that perceived discrimination accounted for increased depressive symptomatology among LGBT males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males. Perceived discrimination is a likely contributor to emotional distress among LGBT youth.     

Suicidal Behavior Among Homeless and Runaway Adolescents

The present study considered risk factors associated with suicidal ideation and the likelihood of a suicide attempt in a sample of 297 homeless and runaway youth from four Midwestern states. It was hypothesized that sociodemographic characteristics, family factors, suicide exposure, street factors, externalizing behavior, and internalizing behavior would be related to suicidal ideation and to the likelihood of a suicide attempt. It was also hypothesized that suicidal ideation would mediate the relationship between the other predictor variables and the likelihood of a suicide attempt. Over half the sample (53.9%) endorsed some level of suicidal ideation, and over one quarter (26.3%) attempted suicide in the year prior to the interview. Univariate and multivariate results indicated that sexual abuse by a family member, knowing a friend who attempted suicide, drug abuse, and internalization were highly related to suicidal ideation. In the absence of suicidal ideation, sexual abuse, sexual victimization while on their own, and internalization were highly related to the likelihood of a suicide attempt. Finally, the hypothesized mediating effect was found for both sexual abuse and internalization.