Emotion Regulation Difficulties, Youth–Adult Relationships, and Suicide Attempts Among High School Students in Underserved Communities
To develop and refine interventions to prevent youth suicide, knowledge is needed about specific processes that reduce risk at a population level. Using a cross-sectional design, the present study tested hypotheses regarding associations between self-reported suicide attempts, emotion regulation difficulties, and positive youth–adult relationships among 7,978 high-school students (48.6 % male, 49.9 % female) in 30 high schools from predominantly rural, low-income communities. 683 students (8.6 %) reported a past-year suicide attempt. Emotion regulation difficulties and a lack of trusted adults at home and school were associated with increased risk for making a past-year suicide attempt, above and beyond the effects of depressive symptoms and demographic factors. The association between emotion regulation difficulties and suicide attempts was modestly lower among students who perceived themselves as having higher levels of trusted adults in the family, consistent with a protective effect. Having a trusted adult in the community (outside of school and family) was associated with fewer suicide attempts in models that controlled only for demographic covariates, but not when taking symptoms of depression into account. These findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. Reaching these targets in a broad population of adolescents will require new delivery systems and “option rich” (OR) intervention designs.
KeywordsYouth suicide Suicide prevention Emotion regulation Youth–adult relationships Youth–adult communication Underserved populations Suicide attempts
The authors wish to thank Caitlyn Eberle and Jane Fitzgerald for their help collecting data and preparing tables for this manuscript and William Morrison for proofreading our final drafts. We gratefully acknowledge support from the National Institute of Mental Health (R01MH091452, K24MH066252); the University of Rochester CTSA award number KL2 RR024136 from the National Center for Research Resources and the National Center for Advancing Translational Sciences of the National Institutes of Health; New York State-Office of Mental Health; and the Locker Family Fund. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or any of our other funders.
A.P. conceived of the study, conducted most analyses, and drafted the manuscript. P.W. led the trial from which data are generated and participated at all stages of study design, analysis, interpretation, and manuscript preparation. M.P. helped to recruit schools, coordinated the study, and supervised data collection, entry, and cleaning. K.S-C managed data, conducted preliminary analysis, and assisted with analytic interpretation. D.G. assisted interpretation of findings and helped to draft the manuscript. Y.X. reviewed analyses and assisted in interpretation. M.G. contributed to the study design and manuscript preparation. All authors read and approved the final manuscript.
- Angold, A., Costello, E. J., Messer, S., Pickles, A., Winder, F., & Silver, D. (1996). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research, 5, 237–249.Google Scholar
- Bagge, C. L., Glenn, C. R., & Lee, H.-J. (2012). Quantifying the impact of recent negative life events on suicide attempts. Journal of Abnormal Psychology. doi: 10.1037/a0030371.
- Barber, B. K., Stolz, H. E., Olsen, J. A., Collins, W. A., & Burchinal, M. (2005). Parental support, psychological control, and behavioral control: Assessing relevance across time, culture, and method. Monographs of the Society for Research in Child Development.Google Scholar
- Barnes, H., & Olson, D. (1982). Parent adolescent communication scale. In D. Olson, H. McCubbin, H. Barnes, M. Larsen, M. Muxen, & M. Wilson (Eds.), Family inventories: Inventories used in a national survey of families across the family life cycle (pp. 33–48). St. Paul: Family Social Science, University of Minnesota.Google Scholar
- Bean, R. A., Barber, B. K., & Crane, D. R. (2006). Parental support, behavioral control, and psychological control among African American youth: The relationships to academic grades, delinquency, and depression. Journal of Family Issues, 27(10), 1335–1355.Google Scholar
- Boutelle, K., Eisenberg, M. E., Gregory, M. L., & Neumark-Sztainer, D. (2009). The reciprocal relationship between parent–child connectedness and adolescent emotional functioning over 5 years. Journal of Psychosomatic Research, 66(4), 309–316. doi: 10.1016/j.jpsychores.2008.10.019.PubMedCrossRefGoogle Scholar
- Call, K. T., & Mortimer, J. (2001). Arenas for comfort in adolescence: A study of adjustment in context. Mahwah, NJ: Lawrence Erlbaum.Google Scholar
- Cameron, A., & Trivedi, P. (2009). Microeconomics using stata. College Station, TX: Stata Press.Google Scholar
- Centers for Disease Control, Prevention. (2010). Youth risk behavior surveillance—United States, 2009. Morbidity and Mortality Weekly Report, 59(SS-5), 1–142.Google Scholar
- Centers for Disease Control and Prevention. (2012). Trends in suicide rates among persons ages 10 years and older, by sex, United States, 1991–2009. Web-based injury statistics query and reporting system (WISQARS) fatal injury reports. Retrieved March 9, 2012, from http://www.cdc.gov/injury/wisqars/index.html.
- Costello, E. J., Pescosolido, B., Angold, A., & Burns, B. J. (1998). A family network-based model of access to child mental health services. In J. P. Morrissey (Ed.), Research in community and mental health: Social networks and mental illness (Vol. 9, pp. 165–190). Stamford, CT: JAI Press.Google Scholar
- Daniels, A., Taylor, S. C., Post, S., Pilsner, A. M., Hunt, Y. M., & Auguston, E. (2012). Tech to treat: The smokefree teen approach to cessation. Paper presented at the National Conference on Health Communication Marketing and Media, Atlanta, GA.Google Scholar
- Eaton, D., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., et al. (2010). Youth risk behavior surveillance—United States, 2009. MMWR. Surveillance summaries: Morbidity and mortality weekly report. Surveillance summaries/CDC, 59(5), 1.Google Scholar
- Goldin, P. R., Manber, T., Hakimi, S., Canli, T., & Gross, J. J. (2009). Neural bases of social anxiety disorder: Emotional reactivity and cognitive regulation during social and physical threat. Archives of General Psychiatry, 66(2), 170–180. doi: 10.1001/archgenpsychiatry.2008.525.PubMedCrossRefGoogle Scholar
- Goldston, D. B., Daniel, S. S., Erkanli, A., Reboussin, B. A., Mayfield, A., Frazier, P. H., et al. (2009). Psychiatric diagnoses as contemporaneous risk factors for suicide attempts among adolescents and young adults: Developmental changes. Journal of Consulting and Clinical Psychology, 77(2), 281–290. doi: 10.1037/a0014732.PubMedCrossRefGoogle Scholar
- Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. doi: 10.1023/B:JOBA.0000007455.08539.94.CrossRefGoogle Scholar
- Greenberg, M. T., Weissberg, R. P., O’Brien, M. U., Zins, J. E., Fredericks, L., Resnik, H., et al. (2003). Enhancing school-based prevention and youth development through coordinated social, emotional, and academic learning. American Psychologist, 58(6–7), 466–474. doi: 10.1037/0003-066X.58.6-7.466.PubMedCrossRefGoogle Scholar
- Hinshaw, S. P. (2002). Process, mechanism, and explanation related to externalizing behavior in developmental psychopathology. Journal of Abnormal Child Psychology: An official publication of the International Society for Research in Child and Adolescent Psychopathology, 30(5), 431–446. doi: 10.1023/A:1019808712868.Google Scholar
- Hunter, E. C., Katz, L. F., Shortt, J. W., Davis, B., Leve, C., Allen, N. B., et al. (2010). How do I feel about feelings? Emotion socialization in families of depressed and healthy adolescents. Journal of Youth and Adolescence, 40(4), 428–441. doi: 10.1007/s10964-010-9545-2.PubMedCrossRefGoogle Scholar
- Jacobson, C. M., Marrocco, F., Kleinman, M., & Gould, M. S. (2010). Restrictive emotionality, depressive symptoms, and suicidal thoughts and behaviors among high school students. Journal of Youth and Adolescence, 1–10. doi: 10.1007/s10964-010-9573-y.
- Kaminski, J. W., Puddy, R. W., Hall, D. M., Cashman, S. Y., Crosby, A. E., & Ortega, L. A. G. (2009). The relative influence of different domains of social connectedness on self-directed violence in adolescence. Journal of Youth and Adolescence, 39(5), 460–473. doi: 10.1007/s10964-009-9472-2.PubMedCrossRefGoogle Scholar
- Khurana, A., & Romer, D. (2012). Modeling the distinct pathways of influence of coping strategies on youth suicidal ideation: A national longitudinal study. Prevention Science, 1–11. doi: 10.1007/s11121-012-0292-3.
- King, C. A., Klaus, N., Kramer, A., Venkataraman, S., Quinlan, P., & Gillespie, B. (2009). The youth-nominated support team–version ii for suicidal adolescents: A randomized controlled intervention trial. Journal of Consulting and Clinical Psychology, 77(5), 880–893. doi: 10.1037/a0016552.PubMedCrossRefGoogle Scholar
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.Google Scholar
- LoMurray, M. (2005). Sources of strength facilitators guide: Suicide prevention peer gatekeeper training. Bismarck, ND: The North Dakota Suicide Prevention Project.Google Scholar
- Lyson, T. A. (2002). What does a school mean to a community? Assessing the social and economic benefits of schools to rural villages in New York. Journal of Research in Rural Education, 17(3), 131–137.Google Scholar
- Marmot, M., Friel, S., Bell, R., Houweling, T.A., Taylor, S., on behalf of the Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. The Lancet, 372(9650), 1661–1669. doi: 10.1016/S0140-6736(08)61690-6.Google Scholar
- Merikangas, K. R., Avenevoli, S., Costello, E. J., Koretz, D., & Kessler, R. C. (2009). National comorbidity survey replication adolescent supplement (NCS-A): I. Background and measures. Journal of the American Academy of Child and Adolescent Psychiatry, 48(4), 367–379. doi: 10.1097/CHI.0b013e31819996f1.PubMedCrossRefGoogle Scholar
- Messer, S., Angold, A., Costello, E., Loeber, R., Van Kammen, W., & Stouthamer-Loeber, M. (1995). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents: Factor composition and structure across development. International Journal of Methods in Psychiatric Research, 5, 251–262.Google Scholar
- Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press.Google Scholar
- Pisani, A. R., Schmeelk-Cone, K., Gunzler, D., Petrova, M., Goldston, D. B., Tu, X., et al. (2012). Associations between suicidal high school students’ help-seeking and their attitudes and perceptions of social environment. Journal of Youth and Adolescence, 41(10), 1312–1324. doi: 10.1007/s10964-012-9766-7.PubMedCrossRefGoogle Scholar
- Schmeelk-Cone, K., Pisani, A. R., Petrova, M., & Wyman, P. A. (2012). Three scales assessing high school students’ attitudes and perceived norms about seeking adult help for distress and suicide concerns. Suicide and Life Threatening Behavior, 42(2), 157–172. doi: 10.1111/j.1943-278X.2011.00079.x.PubMedCrossRefGoogle Scholar
- Shneidman, E. S. (1996). The suicidal mind. New York, NY: Oxford University Press.Google Scholar
- StataCorp. (2011). Stata statistical software: Release 12. College Station, TX: StataCorp LP.Google Scholar
- Suicide Prevention Resource Center and Suicide Prevention Action Network USA. (2010). Charting the future of suicide prevention: A 2010 progress review of the national strategy and recommendations for the decade ahead. Retrieved December 4, 2012, from http://www.sprc.org/library_resources/items/charting-future-suicide-prevention-2010-progress-review-national-strategy-an.
- U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. (2012). 2012 national strategy for suicide prevention: Goals and objectives for action. Washington, DC: HSS.Google Scholar
- U.S. Dept. of Health and Human Services. (2001). National strategy for suicide prevention: Goals and objectives for action. Retrieved February 10, 2009, from http://mentalhealth.samhsa.gov/publications/allpubs/SMA01-3517/.
- Williams, J. M. G., & Pollock, L. R. (2008). The pschology of suicidal behaviour. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide. John Wiley & Sons, West Sussex, England. doi: 10.1002/9780470698976.ch5.
- WWAMI Rural Health Research Center. (2004). 2004 zip ruca code files. Retrieved March 13, 2012, from http://depts.washington.edu/uwruca/ruca-download.php.
- Wyman, P. A., Brown, C. H., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., et al. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76(1), 104–115. doi: 10.1037/0022-006X.76.1.104.PubMedCrossRefGoogle Scholar
- Wyman, P. A., Brown, C. H., LoMurray, M., Schmeelk-Cone, K., Petrova, M., Yu, Q., et al. (2010). An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. American Journal of Public Health, 100(9), 1653–1661.PubMedCrossRefGoogle Scholar
- Wyman, P. A., Gaudieri, P. A., Schmeelk-Cone, K., Cross, W., Brown, C. H., Sworts, L., et al. (2009). Emotional triggers and psychopathology associated with suicidal ideation in urban children with elevated aggressive-disruptive behavior. Journal of Abnormal Child Psychology, 37(7), 917–928. doi: 10.1007/s10802-009-9330-4.PubMedCrossRefGoogle Scholar