Higher Childhood Peer Reports of Social Preference Mediates the Impact of the Good Behavior Game on Suicide Attempt

Social network structure as a suicide prevention target

PURPOSE

The structure of relationships in a social network affects the suicide risk of the people embedded within it. Although current interventions often modify the social perceptions (e.g., perceived support and sense of belonging) for people at elevated risk, few seek to directly modify the structure of their surrounding social networks. We show social network structure is a worthwhile intervention target in its own right.

METHODS

A simple model illustrates the potential of interventions to modify social structure. The effect of these basic structural interventions on suicide risk is simulated and evaluated. Its results are briefly compared to emerging empirical findings for real network interventions.

RESULTS

Even an intentionally simplified intervention on social network structure (i.e., random addition of social connections) is likely to be both effective and safe. Specifically, this illustrative intervention had a high probability of reducing the overall suicide risk, without increasing the risk of those who were healthy at baseline. It also frequently resolved stable, high-risk clusters of people at elevated risk. These illustrative results are generally consistent with emerging evidence from real social network interventions for suicide.

CONCLUSION

Social network structure is a neglected, but valuable intervention target for suicide prevention.

Child maltreatment and youth suicide risk: A developmental conceptual model and implications for suicide prevention

Experiences of child abuse and neglect are risk factors for youth suicidal thoughts and behaviors. Accordingly, suicide risk may emerge as a developmental process that is heavily influenced by the rearing environment. We argue that a developmental, theoretical framework is needed to guide future research on child maltreatment and youth (i.e., adolescent and emerging adult) suicide, and to subsequently inform suicide prevention efforts. We propose a developmental model that integrates principles of developmental psychopathology and current theories of suicide to explain the association between child maltreatment and youth suicide risk. This model bears significant implications for future research on child maltreatment and youth suicide risk, and for suicide prevention efforts that target youth with child maltreatment experiences.

The Good Behaviour Game: Maintaining students' physical distancing in physical education classes during the COVID-19 pandemic

Background

Maintaining physical distancing is one of the most important steps to enforce in educational institutions to reduce the risk of transmission of COVID-19. However, close proximity and physical contact between students are often considered 'normal' during physical education (PE) classes, making it challenging for PE teachers to ensure physical distancing.

Objectives

The aim of this study was to assess the effect of the implementation of the Good Behaviour Game (GBG) in maintaining physical distancing in PE settings in times of the COVID-19 pandemic.

Method

In a quasi-experimental design, two groups were separately designated as an experimental group (20 classes involving 220 students) and a control group (20 classes involving 231 students). They were all enrolled in the eighth grade of the Tunisian education system. In the experimental group, the PE teacher managed physical distancing by administering the GBG. Physical distancing was evaluated by direct observation of videos of filmed PE sessions using a code grid. It was measured twice for the two groups using Kinovea software.

Results

Quantitative data analyses showed that the level of maintaining physical distancing increased after the GBG intervention in the experimental group (p < .001). Furthermore, greater percent changes between pre- and post-intervention were identified in the experimental group compared to the control group (120% vs 1%, respectively).

Conclusion

The GBG was effective in ensuring students' physical distancing when implemented in PE settings.

Preventing Youth Suicide: Potential "Crossover Effects" of Existing School-Based Programs

Notable increases in youth mental health problems combined with strains on the already stretched mental health workforce raise concerns that there will be an ensuing increase in youth suicide thoughts, behaviors, and even deaths. Schools are recognized as crucial settings for youth mental health support and suicide prevention activities, yet schools also face staff shortages and ever-increasing responsibilities for student well-being. Evidence is emerging that prevention programs originally designed to improve problem-solving skills and social-emotional functioning in youth have demonstrated downstream, "crossover effects," that is, unanticipated benefits, on youth suicidal behavior. Relatively little research on crossover effects has been conducted within school settings, despite the strong potential for commonly administered programs to have an impact on later suicide risk. We review key suicide risk factors and their proposed mechanisms of action; we also discuss factors that may protect against suicide risk. We then identify upstream prevention programs targeting the same factors and mechanisms; these programs may hold promise for downstream, crossover effects on youth suicide risk. This paper is intended to provide a framework to help researchers, practitioners, and policymakers as they consider how to prevent youth suicide using existing school-based resources. Rigorous investigation of upstream prevention programs is urgently needed to determine ideal approaches schools and communities can deploy to prevent youth suicide.

Adolescent suicide attempts in the United States: When suicide ideation and suicide capability interact

INTRODUCTION

Guided by the interpersonal theory of suicide, this study examined whether the relationship between level of suicide ideation and attempted suicide varies as a function of suicide capability.

METHODS

Cross-sectional data were obtained from the 2017 and 2019 Youth Risk Behavior Survey in which 28,442 respondents were sampled. Confirmatory factor analysis was conducted to create a latent suicide capability variable. Structural equation modeling was used to test the moderating effects of suicide capability on the relationship between level of suicide ideation and attempted suicide, adjusting for sociodemographic characteristics, sadness/hopelessness, and the sampling design.

RESULTS

Compared to adolescent with no reported ideation, those reporting single and dual ideation experienced increased odds of attempted suicide. The relationship between level of suicide ideation and attempted suicide significantly varied as a function of capability. While adolescents with dual suicide ideation experienced higher rates of attempted suicide at increasing levels of capability, faster rates of change of attempted suicide at increasing levels of capability were observed among those with single and no reported ideation.

CONCLUSION

Capability may heighten the risk of suicide attempts among youth, suggesting that treatment efforts could be directed at reducing exposure to painful and provocative experiences associated with suicide behaviors.

What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review

Mental health (MH) difficulties are on the increase among children and young people (CYP). Evidence has shown that educational settings contain both risk and protective factors for MH. This review investigated which structural and cultural factors and interventions within educational settings promote positive MH and prevent poor MH in 4–18 year olds. Searches were conducted in PsychINFO, Embase, ERIC, ASSIA and British Education Index, and reference lists from key studies and relevant systematic reviews were hand-searched. Intervention, cohort, and qualitative studies were included. Of the 62 included papers, 36 examined cultural factors (30 social/relational and six value-related) while 12 studies examined structural factors (eight organisational and four physical) and 14 studies examined multiple factors. There was strong evidence for the impact of positive classroom management techniques, access to physical activity, and peer mentoring on student MH. Studies examining the impact of positive school culture, teacher training in MH and parent involvement in school MH activities also found predominantly positive results for student MH, albeit the evidence was of lower quality or from a low number of studies. Few studies explicitly examined the impact of interventions on MH inequalities; those that did indicated limited if any reduction to inequalities. A very small number of studies suggested that interventions targeting those at risk of poor MH due to socioeconomic factors could successfully improve wellbeing and reduce depression, anxiety and behavioural problems. Studies exploring the effect of management and leadership strategies within schools, policies, and aspects of the physical environment other than green space were scarce or absent in the literature. This review highlights the need to consider the ways in which educational settings are organised, the culture that is created and the physical space in order to improve the MH of CYP.

Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis

BACKGROUND

Suicidal thoughts and behaviors (STBs) among adolescents have hardly decreased despite preventative efforts. School-based prevention programs could have a great reach, yet suicide prevention is not an easy topic to address. To increase acceptability of school-based suicide prevention, it is important to evaluate whether programs that target known risk factors of STBs, such as depression, could be equally effective.

METHODS

We conducted a systematic literature search in major electronic databases. Outcomes were suicidal ideation and behaviors. Multivariate random effects meta-regression-analyses were conducted.

RESULTS

Eleven primary studies met the inclusion criteria, totalling 23,230 participants. The post-test effect size was small for both suicidal ideation (g = 0.15) and suicidal behaviors (g = 0.30). Meta-regression indicated that targeting known risk factors of STBs was not a significant modifier of effect size for ideation, indicating equal effectiveness. However, it was significant modifier of effect for behaviors, but only one intervention targeted know risk factors. Effects at follow-up (3-12 months) were also significant but small for both outcomes.

LIMITATIONS

Substantial heterogeneity between studies was noted. Only few and small sample size studies could be included that targeted known risk factors of STBs. Therefore, these results should be interpreted with caution.

CONCLUSIONS

School-based prevention of STBs shows some promise within three months post-test assessments, and potentially also have effects that are sustained over time. More studies are needed to make conclusions regarding school-based interventions that target risk factors of STBs.

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

Although global rates of suicide have dropped in the last 30 years, youth in low- and middle-income countries (LMICs) continue to be highly represented in suicide statistics yet underrepresented in research. In this review we present the epidemiology of suicide, suicidal ideation, and suicide attempts among youth in LMICs. We also describe population-level (attitudes toward suicide, socioeconomic, and societal factors) and individual-level clinical and psychosocial risk factors, highlighting specific considerations pertaining to youth in LMICs. These specific considerations in risk factors within this population can inform how multi-level prevention strategies may be targeted to meet their specific needs. Prevention and intervention strategies relying on the stepped-care framework focusing on population-, community-, and individual level targets while considering locally- and culturally relevant practices are key in LMICs. In addition, systemic approaches favoring school-based and family-based interventions are important among youth. Cross-culturally adapted multimodal prevention strategies targeting the heterogeneity that exists in healthcare systems, suicide rates, and risk factors in these countries should be accorded a high priority to reduce the burden of suicide among youth in LMICs.

Effectiveness of the Elos 2.0 prevention programme for the reduction of problem behaviours and promotion of social skills in schoolchildren: study protocol for a cluster-randomized controlled trial

BACKGROUND

Early interventions benefit the mental health, academic performance and productivity of children and adolescents throughout their life. The present study protocol will evaluate the effectiveness of the Elos 2.0 Programme, which is a version adapted for Brazil by the Ministry of Health, in reducing problem behaviours (e.g., disruptiveness, aggressivity and shyness) and promoting social skills in the school context in children 6 to 10 years of age. The Elos Programme is based on the Good Behaviour Game, which is widely used and prevents and/or reduces students' disruptive behaviours by establishing cooperation contingencies.

METHOD

A cluster-randomized controlled trial will be performed in 30 schools in three cities (15 controls and 15 in the experimental group), with a total of 3800 children participating in the test (1900 in the control group and 1900 in the intervention group). Data will be collected by having teachers in the control and experimental classes complete the Teacher Observation of Classroom Adaptation (TOCA) questionnaire, which is an instrument used to observe children's behaviour in the classroom. We will collect data before and after the intervention period in the same year. Due to the hierarchical structure of the data, multilevel analysis will be performed to detect simultaneous differences in prevalence over time and across groups to control for sociodemographic variables.

DISCUSSION

The current study will examine the effectiveness of the Elos 2.0 Programme in reducing problem behaviours (e.g., disruptiveness, aggressivity and shyness) and promoting social skills in the school context. The findings of this school-based prevention programme for children will influence the development and implementation of similar programmes for schools and educational policymakers by identifying mechanisms that are central to achieving positive outcomes for participants.

TRIAL REGISTRATION

Registry of Clinical Trials of the Ministry of Health RBR-86c6jp . Registered February 2, 2019.

The PAX Good Behavior Game: One Model for Evolving a More Nurturing Society

This paper describes the culture and components of the PAX Good Behavior Game and offers it as one model for how to enhance the well-being of populations through the diffusion of nurturing practices into several venues of society. The PAX components, also known as evidence-based kernels, are proposed to be useful in classrooms, families, organizations, criminal justice, and in improving public discussion and government. Kernels affect behavior in the short- and long-term through combinations of antecedents, reinforcers, relational networks, and physiological effects. Identifying common strategies, tools, and clear targets of change is suggested as a way to work towards evolving freely available evidence-based tools that can be combined to improve social conditions in multiple contexts.

Effects of Social Development Intervention in Childhood on Adult Life at Ages 30 to 39

Elementary schools can be effective sites for universal preventive interventions. Less is known about how long effects of intervention in elementary grades last. Can they improve outcomes in adulthood? To test effects of a social developmental intervention in the elementary grades on adult life through the 30s, the Seattle Social Development Project, a nonrandomized controlled trial, followed all consenting 5th-grade students (N = 808) from 18 Seattle public elementary schools from age 10 (in 1985) to age 39 (in 2014), with 88% retention. The sample was gender balanced and ethnically and economically diverse. The full intervention, called Raising Healthy Children, continued from Grades 1 through 6 and consisted of teacher in-service training in classroom management and instructional methods; cognitive, social, and refusal skills training for children; and parent workshops in child behavior monitoring and management, academic support, and anticipatory guidance. Using structural equation modeling, we examined intervention effects from age 30 to age 39 across 9 constructs indicating 3 domains of adult life: health behavior, positive functioning, and adult health and success. An omnibus test across all 9 constructs indicated a significant positive overall intervention-control difference. Examined individually, significant intervention effects included better health maintenance behavior, mental health, and overall adult health and success. Significant effects were not found on substance use disorder symptoms, sex-risk behaviors, or healthy close relationships in the 30s. Results indicate that sustained, theory-based, multicomponent intervention in the elementary grades can produce lasting changes in health maintenance, mental health, and adult functioning through the 30s.

Nonsuicidal Self-Injury Among African American and Hispanic Adolescents and Young Adults: a Systematic Review

While African American and Hispanic adolescents and young adults living in the USA are exposed to myriad stressors that may increase their risk for mental health difficulties, few studies have examined nonsuicidal self-injury (NSSI) among these youth. The purpose of this systematic review was to critically examine and synthesize current literature on NSSI among these understudied youth. Using multiple search terms related to NSSI, race/ethnicity, and developmental stage, electronic literature searches of PubMed, PsychINFO, and Google Scholar databases retrieved 3036 relevant articles published in the English language between 2000 and 2018; manual reference checks yielded an additional 17 articles. Ultimately, a total of 52 full-text studies were assessed for eligibility, and 15 articles were included in the present review. Although the majority of studies reported higher prevalence of NSSI among non-Hispanic White youth, evidence suggests that African American males are also at high risk of engaging in self-harm. Emotional dysregulation emerged as a common risk factor, while social support and feelings of connection were protective for some African American and Hispanic youth. Although racism and discrimination were not linked to NSSI in the reviewed studies, this remains an important area of future research for prevention and intervention efforts.

Contribution of genes and environment to the longitudinal association between childhood impulsive-aggression and suicidality in adolescence

BACKGROUND

Population-based and family studies showed that impulsive-aggression predicts suicidality; however, the underlying etiological nature of this association is poorly understood. The objective was to determine the contribution of genes and environment to the association between childhood impulsive-aggression and serious suicidal ideation/attempt in young adulthood.

METHODS

N = 862 twins (435 families) from the Quebec Newborn Twin Study were followed up from birth to 20 years. Repeated measures of teacher-assessed impulsive-aggression were modeled using a genetically informed latent growth model including intercept and slope parameters reflecting individual differences in the baseline level (age 6 years) and in the change (increase/decrease) of impulsive-aggression during childhood (6 to 12 years), respectively. Lifetime suicidality (serious suicidal ideation/attempt) was self-reported at 20 years. Associations of impulsive-aggression intercept and slope with suicidality were decomposed into additive genetic (A) and unique environmental (E) components.

RESULTS

Additive genetic factors accounted for an important part of individual differences in impulsive-aggression intercept (A = 90%, E = 10%) and slope (A = 65%, E = 35%). Genetic (50%) and unique environmental (50%) factors equally contributed to suicidality. We found that 38% of the genetic factors accounting for suicidality were shared with those underlying impulsive-aggression slope, whereas 40% of the environmental factors accounting for suicidality were shared with those associated with impulsive-aggression intercept. The genetic correlation between impulsive-aggression slope and suicidality was 0.60, p = .027.

CONCLUSIONS

Genetic and unique environmental factors underlying suicidality significantly overlap with those underlying childhood impulsive-aggression. Future studies should identify putative genetic and environmental factors to inform prevention.

A Meta-Analytic Review of Randomized Controlled Trials of the Good Behavior Game

The Good Behavior Game (GBG) is widely recognized as an evidence-based intervention that reinforces prosocial behaviors and discourages disruptive behaviors among students in the classroom setting. The current meta-analysis synthesized randomized controlled trials of the GBG to examine its impact on proximal student outcomes across seven studies representing 4,700 children. Although recent reviews focusing on single-case studies of the GBG have reported moderate to large treatment effects, our results were quite modest in comparison (hedges' g = 0.09-0.32). Treatment effect sizes also varied according to outcome and sex. The GBG significantly outperformed the comparison conditions for peer-rated conduct problems and shy/withdrawn behavior as well as teacher-rated conduct problems for which a greater effect was found for girls relative to boys. Moreover, the treatment effect in favor of the GBG for reading comprehension was specific to boys and not girls. No significant differences were found between the GBG and comparison conditions for inattention and teacher-rated shy/withdrawn behavior. These results suggest that the GBG may not be as impactful as originally reported and the intended population and treatment targets should be considered before its implementation in the classroom.

Master Clinician Review: Saving Holden Caulfield: Suicide Prevention in Children and Adolescents

OBJECTIVE

The rate of adolescent suicide and suicidal behavior has risen dramatically in the past decade. The title of this article comes from the classic coming-of-age novel by J.D. Salinger, The Catcher in the Rye. Its protagonist, Holden Caulfield, is a precocious adolescent who, in the face of his inability to cope with his own self-destructives urges, imagines himself saving "little kids playing some game in this big field of rye." He is standing on the edge of a cliff trying to catch "thousands of little kids" before they fall to their demise. This vignette from The Catcher in the Rye provides a useful metaphor for the relationship between mental health professionals and youth at risk for suicide, and suggests more efficient and effective alternative interventions to prevent youth suicide compared to standing by a cliff.

METHOD

These four alternative approaches are described, namely: (1) leading youth away from the cliff (ie, prevention); (2) going to where youth are (ie, improving access to care); (3) working with others to change the rules in the field (ie, changing the way care is delivered); and (4) putting a fence around the cliff (ie, restriction of access to lethal agents). The evidence to support the utility and cost-effectiveness of each of these approaches is reviewed.

CONCLUSION

There are extant, empirically supported, cost-effective approaches to the prevention and management of adolescent suicidal behavior that, if implemented widely, are likely to significantly reverse the decade-long rise in adolescent suicide.

Aggressive Behaviors and Suicide Ideation in Inpatient Adolescents: The Moderating Roles of Internalizing Symptoms and Stress

The present study examined a conceptual model in which the association between aggressive behaviors and suicide ideation is moderated by internalizing symptoms and ongoing stress. Participants were 304 psychiatric inpatient adolescents (65.8% girls) ranging in age from 12 to 17 years (Mean age = 14.69). The association between aggressive behaviors and suicide ideation was significantly moderated by internalizing symptoms and ongoing stress; the association was positive in adolescents low in internalizing symptoms or high in ongoing stress, but negative in adolescents high in internalizing symptoms or low in ongoing stress. The three-way interaction between aggressive behaviors, internalizing symptoms, and ongoing stress was not statistically significant. The current findings indicate that in adolescents who display high levels of aggressive behaviors, the presence of high ongoing stress provides a more useful indicator of levels of suicide ideation than the presence of high internalizing symptoms. Implications for case identification and prevention are discussed.

Adapting and enhancing PAX Good Behavior Game for First Nations communities: a mixed-methods study protocol developed with Swampy Cree Tribal Council communities in Manitoba

INTRODUCTION

High rates of mental health problems, such as suicidal behaviours, among First Nations youth in Canada are a major public health concern. The Good Behavior Game (GBG) is a school-based intervention that provides a nurturing environment for children and has been shown to promote positive outcomes. PAX Good Behavior Game (PAX GBG) is an adaptation and enhancement of the GBG. While PAX GBG has been implemented in Indigenous communities, little research exists examining the cultural and contextual appropriateness and effectiveness of the intervention in First Nations communities.

METHODS AND ANALYSIS

The present paper describes a protocol of the mixed-methods approach guided by an Indigenous ethical engagement model adopted to implement, adapt and evaluate PAX GBG in First Nations communities in Manitoba, Canada. First, implementation outcomes (eg, acceptability, adoption) of PAX GBG will be evaluated using qualitative interviews with teachers, principals and community members from Swampy Cree Tribal Council (SCTC) communities. Second, by linking administrative databases to programme data from schools in 38 First Nations communities, we will compare PAX GBG and control groups to evaluate whether PAX GBG is associated with improved mental health and academic outcomes. Third, the qualitative results will help inform a cultural and contextual adaptation of PAX GBG called First Nations PAX (FN PAX). Fourth, FN PAX will be implemented in a few SCTC communities and evaluated using surveys and qualitative interviews followed by the remaining communities the subsequent year.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Manitoba Health Research Ethics Board and will be obtained from the Health Information Privacy Committee and respective data providers for the administrative database linkages. Dissemination and knowledge translation will include community and stakeholder engagement throughout the research process, reports and presentations for policymakers and community members, presentations at scientific conferences and journal publications.