Structural adverse childhood experiences associated with suicidal ideation, suicide attempts, and repetitive nonsuicidal self-injury among racially and ethnically minoritized youth

INTRODUCTION

High rates of suicidal ideation (SI), suicide attempts (SA), and repetitive nonsuicidal self-injury (NSSI) among some ethnoracially minoritized United States youth populations may be related to adverse childhood experiences (ACEs) with structural roots.

METHODS

Using the 2013-2019 Minnesota Student Surveys, we assessed associations of student-reported structural ACEs (parental incarceration, housing instability, food insecurity, and foster care involvement) with SI, SA, and repetitive NSSI within the past 12 months using multilevel logistic regression stratified by ethnoracial group (American Indian/Alaskan Native [AIAN], Hmong, other Asian, Black Latino, other Latino, Somali, other Black/African American [AA], Native Hawaiian/Pacific Islander [NHPI], and multiracial), and adjusted for sex, grade, ACEs experienced within one's household, mental health treatment, and perceived safety.

RESULTS

Structural ACEs were strongly associated with increasing SI, SA, and NSSI. At ≥2 structural ACEs, repetitive NSSI rates ranged from 7% to 29% (female), 8% to 20% (male); SA rates ranged from 13% to 35% (female), 10% to 22% (male); and SI rates ranged from 31% to 50% (female), 20% to 32% (male). Black Latino, NHPI, AIAN, and Black/AA students most often reported structural ACE exposures.

CONCLUSION

Reducing structural ACEs may reduce SI, SA, and repetitive NSSI among ethnoracially minoritized youth populations. Disaggregating diverse youth groups revealed variations in these outcomes that remain hidden when subpopulations are aggregated.

Translating Suicide Safety Planning Components Into the Design of mHealth App Features: Systematic Review

BACKGROUND

Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps.

OBJECTIVE

This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps.

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps.

RESULTS

Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies.

CONCLUSIONS

Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.

Improving capacity to identify, assess, and manage adolescents engaging in non-suicidal self-injury using patient avatars

PURPOSE

We developed and evaluated a training comprising a didactic and virtual practice session with human-guided patient avatars to increase pediatric residents' competence to identify and assess non-suicidal self-injury (NSSI) and suicide risk.

METHODS

Thirty pediatric residents at three children's hospitals in Florida participated in the training and completed pre-, one-month post-, and three-months post-training surveys. One-way repeated measures ANOVA with post-hoc comparisons determined changes in confidence, comfort, behavioral intentions, attitudes, knowledge, and behavior over time. Qualitative responses provided feedback on the training, especially the novel practice session with adolescent patient avatars.

RESULTS

Three-months post-training residents expressed significantly greater confidence in talking to adolescents who self-injure, applying the SOARS method to assess self-injury, and assessing functions/reasons for self-injury; reported feeling significantly more comfortable asking about self-injury, well-equipped to handle the emotional aspects of self-injury, and comfortable treating adolescents who self-injure; reported greater behavioral intentions to talk to adolescents about self-injury, assess an adolescent's stage of change for stopping self-injury, and provide brief interventions for adolescents who self-injure; and used SOARS to evaluate current NSSI with a greater proportion of adolescent patients. Qualitative feedback expressed positive perceptions, especially related to the virtual-reality role-play session.

CONCLUSIONS

Incorporating an interactive, human-guided virtual experience using role-playing and feedback with patient avatars represents a viable option comparable to using typical standardized patients to expand the scalability of NSSI trainings for pediatric residents, especially when they occur virtually.

Adolescent Predictors of Deliberate Self-Harm Thoughts and Behavior Among Young Adults: A Longitudinal Cross-National Study

PURPOSE

This study builds upon and extends previous longitudinal research on deliberate self-harm (DSH) among youth by investigating which risk and protective factors during adolescence predict DSH thoughts and behavior in young adulthood.

METHODS

Self-report data came from 1,945 participants recruited as state-representative cohorts from Washington State and Victoria, Australia. Participants completed surveys in seventh grade (average age 13 years), as they transitioned through eighth and ninth grades and online at age 25 years. Retention of the original sample at age 25 years was 88%. A range of risk and protective factors in adolescence for DSH thoughts and behavior in young adulthood were examined using multivariable analyses.

RESULTS

Across the sample, 9.55% (n = 162) and 2.83% (n = 48) of young adult participants reported DSH thoughts and behaviors, respectively. In the combined risk-protective factor multivariable model for young adulthood DSH thoughts, depressive symptoms in adolescence (adjusted odds ratio [AOR] = 1.05; confidence interval [CI] = 1.00-1.09) increased risk, while higher levels of adolescent adaptive coping strategies (AOR = 0.46; CI = 0.28-0.74), higher levels of adolescent community rewards for prosocial behavior (AOR = 0.73; CI = 0.57-0.93), and living in Washington State decreased risk. In the final multivariable model for DSH behavior in young adulthood, less positive family management strategies during adolescence remained the only significant predictor (AOR = 1.90; CI = 1.01-3.60).

DISCUSSION

DSH prevention and intervention programs should not only focus on managing depression and building/enhancing family connections and support but also promote resilience through efforts to promote adaptive coping and connections to adults within one's community who recognize and reward prosocial behavior.

Adolescent risk and protection profiles for violence perpetration: Insights for family- and community-based prevention

Youth violence continues to be a major developmental and health concern. Preventative resources at individual, family, and community levels may reduce risk, yet the extent to which youth violence perpetration differs by patterns of risk and protective factors remains unknown. Using data from the Florida Youth Substance Abuse Survey (N = 4630; 49% female; M_age  = 14.69), we conducted person-centered, latent profile analyses to identify four patterns for risk of violence perpetration among middle and high school youth. Youth in the Low Risk-High Protection profile (37%) had low likelihood of violence perpetration. Youth in the Low Risk-Low Protection profile (4%) were characterized by poor family functioning, low school belonging, and low community protection. These youth had similar odds of violence perpetration as youth in the Moderate Risk-Moderate Protection profile (44%), which were elevated compared to the Low Risk-High Protection profile. Youth in the High Risk-Low Protection profile (15%), which had the highest levels of risk factors and lowest levels of protective factors, had the highest likelihood of violence perpetration. The High Risk-Low Protection profile was expected based on past research, but the emergence of the Low Risk-Low Protection profile is a unique contribution to the research. Findings contribute to the literature by going beyond a cumulative risk model, identifying subgroups with various patterns of risk and protection in the population, and highlighting the importance of selected prevention for subgroups of youth with high risk or challenging family and community environments.

Reported Beliefs About COVID-19 Vaccines Among Unvaccinated Hispanic Adults Utilizing a Free Clinic in Orlando, Florida

BACKGROUND

Subgroups of the general population including Hispanic/Latinx individuals report higher rates of COVID-19 vaccine hesitancy than non-Hispanic White individuals. The purpose of this study was to identify factors that influence attitudes toward COVID-19 vaccines among unvaccinated Hispanic adults utilizing a free community clinic in Orlando, Florida, USA.

METHODS

From May 2021 to July 2021, we used convenience sampling to recruit 20 self-identified Hispanic adults who were unvaccinated to complete an individual, semi-structured interview. Interview questions were derived from constructs from the Health Belief Model. Interviews were audio-recorded, transcribed, translated (when necessary), and qualitatively analyzed using inductive content analysis to identify recurring themes.

RESULTS

Of the 20 participants in this study, 65% were female (n=13) and they ranged from 21 to 73 years of age (median age =42.5). We identified three primary themes in participant responses regarding their beliefs about COVID-19 vaccines. Primary theme 1: trust and clarity of COVID-19 vaccine information, with subthemes (1a) source trustworthiness, and (1b) clarity of COVID-19 vaccine information. Primary theme 2: personal contextual factors, with subthemes (2a) underlying health conditions, (2b) personal experiences with COVID-19, and (2c) immigration. Primary theme 3: lack of confidence, yet willingness to be vaccinated, with subthemes (3a) fear and distrust and (3b) willingness to be vaccinated. In summary, participants felt hesitant, although not completely opposed, to receiving COVID-19 vaccinations due to the information they gathered on vaccines from various sources received in the context of important personal factors (e.g., immigration, underlying health concerns, etc.).

CONCLUSIONS

Overcoming vaccine hesitancy in vulnerable populations such as the Hispanic communities may require addressing issues of message clarity through trusted sources while considering personal contextual factors. Healthcare professionals can begin by initiating discussions with patients to understand individual circumstances and concerns and provide information on COVID-19 vaccines that clarify areas of confusion.

Substance use and victimization experiences among college students in Spain

OBJECTIVE

We examined relationships between different types and patterns of substance use and victimization experiences.

PARTICIPANTS

College students from two universities in Spain completed an online, cross-sectional survey.

METHOD

A series of tetrachoric correlations were estimated to examine the bivariate associations between different types of substances and victimization experiences. Regression analyses then examined relationships between patterns of substance use (non-users, mono-users, and poly-users), and victimization.

RESULTS

Slightly over half (57.7%) of students reported any form of victimization during the previous year, and most students (87.0%) reported using substances during the last three months. Polysubstance users were more likely than non-users to experience any victimization, as well as multiple forms of victimization.

CONCLUSIONS

Findings highlight the importance of differentiating types and patterns of substance use when developing prevention and intervention programs. Implementing intervention strategies that target polysubstance users and decrease substance use could reduce rates of victimization among college students.

Perspectives on inadequate preparation and training priorities for physicians working with sexual minority youth

OBJECTIVES

To understand pediatric and family medicine residents' and practitioners' perceived ability to work with lesbian, gay, bisexual, and queer (LGBQ) youth, assessment of their prior educational experiences, and recommendations for medical training to better prepare physicians to provide quality care to this population.

METHODS

We conducted semi-structured individual interviews with 24 pediatric/family medicine residents (n=20) and practicing physicians (n=4) in the U.S. Recorded interviews were professionally transcribed. Data were analyzed using Grounded Theory and qualitative content analysis approaches.

RESULTS

Most physicians did not feel adequately prepared to provide quality care to LGBQ youth, and many who felt knowledgeable obtained their knowledge from on-the-job experiences of caring for LGBQ patients. Findings regarding physicians' recommendations for implementing a formal training program revealed three themes: (I) medical school training (implemented earlier in medical school within a structured program as part of the normal curriculum), (II) training content (LGBQ-specific health needs, self-awareness of implicit biases, interviewing techniques, and resources), and (III) training strategies (panels of LGBQ patients, role-playing/standardized patients, and online modules).

CONCLUSIONS

Understanding physicians' assessment of abilities and recommendations for training improvements based on their experiences is important for advancing the quality of healthcare for LGBQ youth. Guidance came mostly from residents who recently completed medical school. Thus, their perspectives are especially useful to improve medical education and, ultimately, the care provided to LGBQ youth. Findings suggest a multi-pronged approach that offers several training modalities encompassing individual, intrapersonal, and institutional/systemic/community levels can improve medical school curricula on caring for LGBQ youth.

Suicidality Among College Students in Spain: Prevalence and Associations With Substance Use, Social Support, and Resilience

Few studies have examined protective factors associated with reduced risk of suicidality among college students. We sought to address gaps in the literature by conducting a cross-sectional survey of 636 college students from a public university in Spain. We assessed substance use, social support, resilience, severity of suicidal ideation and suicide attempts. Twenty percent of students reported low severity and 27% reported high severity suicidal ideation, while 5% reported attempting suicide during the past year. Higher levels of social support represented a protective factor associated with reduced risk of suicidal ideation and suicide attempts.

Factors associated with emotional distress and suicide ideation among international college students

Objective: To identify risk and protective factors associated with greater emotional distress and suicide ideation among international college students. Participants: International students (n = 435) from two Midwestern and two Southeastern universities in the US. Methods: Online surveys were administered that measured emotional distress, past-year suicide ideation, entrapment, cultural stress, family conflict, perfectionism, ethnic discrimination, interpersonal needs, ethnic identity, and cultural sanctions against suicide. Results: In final linear regression analyses, higher levels of entrapment, unmet interpersonal needs, and ethnic discrimination were significantly associated with increased emotional distress. Only unmet interpersonal needs remained significantly associated with greater past-year suicide ideation in a multivariate regression analysis. Conclusions: Clinicians working with international students and prevention programmers targeting this population should address students' perceptions of entrapment, ethnic discrimination, and especially unmet interpersonal needs in efforts to decrease or prevent students' feelings of emotional distress and suicide ideation.

Associations between connections to parents and friends and non-suicidal self-injury among adolescents: The mediating role of developmental assets

BACKGROUND

We tested a model that incorporated potential developmental assets through which connections to parents and friends reduce the likelihood of engaging in non-suicidal self-injury (NSSI) among adolescents.

METHOD

Data came from the 2016 Minnesota Student Survey, a population-based survey of 8th, 9th, and 11th grade students (N = 119,452). Chi-square test, t-test, and correlations evaluated bivariate relationships between all variables. Indirect effects of three developmental assets (social competency, positive identity, and empowerment) were modeled simultaneously on associations between connections to parents and friends, and past-year NSSI.

RESULTS

Bivariate analyses demonstrated protective effects of parent and friend connections on NSSI and that all developmental assets were negatively associated with NSSI. After accounting for demographic variables and associations between developmental assets in a multiple mediator path model, connections to parents showed a stronger, negative direct relationship with NSSI than did connections to friends. Developmental assets, especially positive identity and empowerment, accounted for a greater proportion of the effect of connections to friends on NSSI than the effect of connections to parents. Finally, social competency was no longer significantly related to NSSI in the multiple mediator path model.

CONCLUSION

Clinical efforts to prevent NSSI should focus on enhancing adolescents' sense of positive identity and empowerment, as well as connections to parents and prosocial friends.

Profiles of Risk and Protection for Violence and Bullying Perpetration Among Adolescent Boys

BACKGROUND

Violence and bullying perpetration among boys are major public health problems. We address gaps in the literature by examining: (1) how risk and protective factors co-occur, and (2) how different risk/protection profiles are associated with violence and bullying perpetration among adolescent boys.

METHODS

Data came from the population-based 2016 Minnesota Student Survey. The analytic sample included boys in grades 8, 9, and 11 (N = 63,818). Latent profile analyses identified patterns of 22 behavioral, intrapersonal, family, and school and community risk/protective factors. Logistic regression analyses examined how these patterns related to violence and bullying perpetration.

RESULTS

We identified 5 groups: Class 1: Low risk, high safety, high connectedness; Class 2: Low risk, moderate safety, moderate connectedness; Class 3: Moderate risk, high safety, moderate connectedness; Class 4: High risk, moderate safety, low connectedness; and Class 5: High risk, low safety, low connectedness. Compared to Class 1, Class 5 students had the highest odds of all for violence and bullying perpetration. Class 4 students also demonstrated high odds of violence and bullying, compared to Class 1. Though not as high as Classes 4 or 5, Class 2 and 3 students showed higher odds for both outcomes, compared to Class 1.

CONCLUSIONS

Substantive variations exist in boys who engage in violence and bullying. We highlight cumulative, co-occurring risk factors, connectedness to parents and other prosocial adults (eg, teachers), and school and neighborhood safety as important factors to address in school health programs seeking to prevent violence and bullying perpetration among boys.

Function and progression of non-suicidal self-injury and relationship with suicide attempts: A qualitative investigation with an adolescent clinical sample

AIM

To investigate the function and progression of non-suicidal self-injury (NSSI) and its relationship with suicide attempts.

METHOD

Qualitative in-depth interviews were conducted with 15 adolescents psychiatrically hospitalized following a suicide attempt who reported NSSI. Applied thematic analysis was used to identify and examine themes from the interview data.

RESULTS

Thematic analysis revealed that the primary function of NSSI was relief from emotional pain, though the function often changed over time. NSSI was often not directly related to patients' suicide attempts, yet risk of suicidal behavior seemed to increase once NSSI lost its effectiveness, and suicide became the only option.

CONCLUSION

Clinicians need to understand and monitor the functions of NSSI, and its relationship with suicidality, to prevent suicide attempts among adolescents.

Social Connectedness Factors that Facilitate Use of Healthcare Services: Comparison of Transgender and Gender Nonconforming and Cisgender Adolescents

OBJECTIVE

To compare social connectedness factors that facilitate use of primary, dental, and mental healthcare services among transgender and gender nonconforming (TGNC) and cisgender adolescents.

METHODS

Data from the cross-sectional 2016 Minnesota Student Survey were used to examine protective social connectedness factors associated with use of different healthcare services among matched samples of 1916 TGNC and 1916 cisgender youth. Stratified, logistic regression analyses were used to examine background characteristics and social connectedness factors (parent connectedness, connections to other nonparental adults, teacher-student relationships, and friend connections) associated with use of each healthcare service within the last year.

RESULTS

For TGNC youth, but not for cisgender youth, higher levels of parent connectedness were associated with receipt of primary (OR, 2.26; 95% CI, 1.40-3.66) and dental (OR, 3.01; 95% CI, 1.78-5.08) care services, and lower levels of connectedness to nonparental adults was associated with receipt of mental healthcare (OR, 0.55; 95% CI, 0.33-0.93). Among cisgender youth, no protective factors were significantly associated with receipt of primary care services, higher levels of friend connections were associated with receipt of dental services (OR, 1.85; 95% CI, 1.10-3.09), and lower levels of parent connectedness were associated with receipt of mental healthcare (OR, 0.20; 95% CI, 0.10-0.40).

CONCLUSIONS

To promote the health of TGNC youth, clinicians should understand the distinct factors associated with obtaining healthcare among this population such as the need for tailored efforts focused on strengthening connectedness between TGNC youth and their parents to facilitate receipt of needed care.

Risk and Protective Factors for Self-Harm in a Population-Based Sample of Transgender Youth

This study sought to identify factors distinguishing transgender/gender non-conforming (GNC) adolescents across three groups: no self-harm, non-suicidal self-injury (NSSI) only, and NSSI and suicide attempt (NSSI + SA). Data were from the 2016 Minnesota Student Survey. The final analytic sample included 1,635 transgender/GNC students in grades 9 and 11. Logistic regression analyses determined factors that best distinguished transgender/GNC students who reported self-harm (NSSI only or NSSI + SA) from those who reported no self-harm, and transgender/GNC adolescents who reported NSSI + SA from those who reported NSSI only. Final models were developed over 3 stages of analysis that tested associations of variables within risk factor, protective factor, and health-risk behavior domains to self-harm. Over half (51.6%) of transgender/GNC adolescents reported past-year self-harm behavior. Factors that consistently distinguished transgender/GNC youth who reported self-harm from those who reported no self-harm included reports of a mental health problem, depression, running away from home, and substance use (alcohol or marijuana use). Factors that distinguished the NSSI + SA group from the NSSI only group were reports of a mental health problem, physical or sexual abuse, relationship violence, bullying victimization, less parent connectedness, lower grades, lower levels of perceived school safety, and running away from home. Clinicians and school personnel need to be prepared to address risk factors and enhance protective factors that may reduce the likelihood this population of vulnerable youth will engage in NSSI and/or attempt suicide.

Supporting Transgender and Gender Diverse Youth: Protection Against Emotional Distress and Substance Use

INTRODUCTION

Important mental and physical health disparities exist for transgender and gender diverse youth compared with cisgender youth (i.e., those whose birth-assigned sex and gender identity align), yet little is known about factors that protect transgender and gender diverse youth from health problems. The objective of this paper is to identify modifiable protective factors in the lives of transgender and gender diverse adolescents, with the goal of informing efforts to eliminate disparities in depression, suicidality, and substance use in this population.

METHODS

Secondary data analysis of the 2016 Minnesota Student Survey examined associations between eight protective factors (connectedness to parents, adult relatives, friends, adults in the community, and teachers; youth development opportunities; and feeling safe in the community and at school) and depression, suicidality, and substance use (alcohol, binge drinking, marijuana, nicotine) among 2,168 adolescents who identified as transgender, genderqueer, genderfluid, or questioning their gender. Logistic regressions assessed the role of each protective factor separately and simultaneously.

RESULTS

Each protective factor was associated with lower odds of emotional distress and substance use. When protective factors were examined simultaneously, parent connectedness was protective for all measures. Feeling safe at school and connected to adults in one's community protected against depression and suicidality; teacher connectedness buffered risk of substance use.

CONCLUSIONS

Given that transgender and gender diverse youth report lower levels of connectedness and safety, bolstering an explicitly transgender and gender diverse-friendly network of caring parents, safe and supportive schools, and connections to adults in the community may support efforts to eliminate disparities in depression, suicidality, and substance use.

Connections that moderate risk of non-suicidal self-injury among transgender and gender non-conforming youth

We examined associations between social connections and non-suicidal self-injury (NSSI) among transgender/gender non-conforming (TGNC) youth. Data came from the 2016 Minnesota Student Survey (N = 2168). Logistic regression analyses determined connectedness factors associated with any past-year NSSI and repetitive NSSI, as well as moderating effects of significant connectedness factors on different risk factors. Almost 55% of TGNC students engaged in NSSI, and 40% of self-injurers reported repetitive self-injury. Parent connectedness, connections to non-parental adults, and school safety emerged as robust protective factors. Strategies to prevent/reduce NSSI should focus on fostering connections with prosocial adults, and ensuring schools represent safe places.

Nonsuicidal Self-Injury and Suicidality Among Sexual Minority Youth: Risk Factors and Protective Connectedness Factors

OBJECTIVE

We investigated differences in prevalence of repetitive nonsuicidal self-injury (NSSI), suicidal ideation, and a suicide attempt among youth who identified as bisexual, gay/lesbian, and questioning. In addition, we examined which types of social connections were associated with reduced risk of repetitive NSSI and suicidality among youth who identified with a specific sexual minority group.

METHODS

Data came from the 2013 Minnesota Student Survey. The analytic sample included 77,758 students in grades 9 and 11. Connectedness factors included parent connectedness, teacher caring, connectedness to other nonparental adults, school safety, and friend caring. Logistic regression analyses, stratified according to sexual minority group, determined social connectedness factors associated with repetitive NSSI, suicidal ideation, and a suicide attempt, as well as moderating effects of significant connectedness factors on different risk factors (depression, anxiety, bullying, and violence victimization).

RESULTS

Approximately 3% identified as bisexual or questioning their sexual orientation, and <1% identified as gay/lesbian. Sexual minority youth, particularly bisexual youth, were significantly more likely than heterosexual youth to report repetitive NSSI and suicidality. Effects of connectedness varied across sexual minority groups and outcomes on the basis of types of connections. Parent connectedness emerged as a robust protective factor for all self-harm behaviors among bisexual and questioning youth. Feeling connected to nonparental adults and safe at school represented additional factors that reduced risk of repetitive NSSI and suicidality among certain groups.

CONCLUSIONS

In addition to facilitating connections between youth and parents, clinicians might consider encouraging sexual minority youth to remain connected to trusted nonparental adults who could offer support and care. Schools might consider implementing sociocultural norms of acceptance, tolerance, and positive identity development to reduce risk of self-harm.

Suicide Ideation and Attempts Among Adolescents Engaged in Risk Behaviors: A Latent Class Analysis

This study addressed gaps in the literature regarding how different profiles of adolescent risk behavior relate to suicide. Data came from the 2010 Minnesota Student Survey of 9th and 12th grade students. Latent class analysis derived a set of four classes reflecting unique patterns of eight behaviors: maladaptive dieting, prescription drug misuse, illegal drug use, marijuana use, problem drinking, risky sexual behavior, perpetration of interpersonal violence, and self-injury. A class demonstrating high engagement in all risk behaviors, and a class highest on self-injury and maladaptive dieting but low on several other risk behaviors, showed high risk for suicide. Practitioners should carefully monitor adolescents engaging in multiple risk behaviors for suicide, especially if self-injury and maladaptive dieting are present.

Factors associated with current versus lifetime self-injury among high school and college students

We sought to identify factors associated with current versus lifetime nonsuicidal self-injury (NSSI) and factors that show consonant and distinct relationships with current NSSI for adolescents and young adults. Data came from a population-based survey of high school students (n = 9,985) and a national survey of college students (n = 7,801). Among both samples, factors associated with current NSSI included male gender, younger age, greater depressive symptoms, more hopelessness, and being the victim of a verbal or physical assault. For high school students, greater anxiety, and for college students, identifying as non-White, negative perceptions of one's weight, a same-sex sexual experience, and involvement in dating violence also distinguished the groups. Findings suggest that clinical and research assessments of lifetime NSSI might not extend to current behavior, and some differences exist in the factors associated with current behavior between adolescents and young adults. Clinical practice and prevention programming efforts should target certain intrapersonal and interpersonal factors associated with current NSSI among younger students during stressful transition periods in their lives, such as entering high school or college, when they might consider initiating or continuing this behavior.

Risk factors associated with self-injurious behavior among a national sample of undergraduate college students

OBJECTIVE

Nonsuicidal self-injury (NSSI) and suicidality among undergraduates represent important public health issues. This analysis identified risk factors that distinguished 3 groups, those who reported no history of self-harm; self-injury, but no suicide attempts (NSSI only); and self-injury and a suicide attempt (NSSI + SA) in the past year.

METHODS

Data came from 16,044 undergraduates who completed the Fall 2010 National College Health Assessment.

RESULTS

Over 3% of students reported NSSI, and one third of these individuals also attempted suicide. Factors that distinguished the NSSI only and NSSI + SA groups from the no self-harm group included current depressive symptoms, nonheterosexual orientation, an eating disorder/extreme weight control behavior, and diagnosis of an internalizing disorder. Factors that distinguished the NSSI + SA group from the NSSI only group were current depressive symptoms and diagnosis of an internalizing disorder.

CONCLUSIONS

Students experiencing mental health problems demonstrate increased risk for NSSI and/or suicidal behavior.

Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year

Data from the 2010 Minnesota Student Survey was analyzed to identify risk and protective factors that distinguished adolescents across three groups: no suicidality, suicidal ideation only, and suicide attempt. The population-based sample included 70,022 students in grades 9 and 12. Hopelessness and depressive symptoms emerged as important risk factors to distinguish youth who reported suicidal ideation or behavior from those without a history of suicidality. However, these factors were not as important in differentiating adolescents who attempted suicidal from those who considered suicide but did not act on their thoughts. Instead, for both genders, self-injury represented the most important factor to distinguish these youth. Other risk factors that differentiated the latter groups, but not the former groups, for males were dating violence victimization and cigarette smoking, and for females was a same-sex sexual experience. Running away from home also seemed to increase the risk of a suicide attempt among youth in this study. Parent connectedness and academic achievement emerged as important protective factors to differentiate all the groups, yet neighborhood safety appeared to protect against the transition from suicidal thoughts to behavior. Findings from this study suggest risk and protective factors practitioners should target in clinical assessments and intervention programs to help prevent suicidal behavior among youth at greatest risk.

Suicidal thinking and behavior among youth involved in verbal and social bullying: risk and protective factors

PURPOSE

To identify risk and protective factors associated with thinking about or attempting suicide among youth involved in verbal and social bullying.

METHODS

We analyzed data on 130,908 students in the sixth, ninth, and twelfth grades responding to the 2010 Minnesota Student Survey. Among students involved in frequent bullying (once a week or more during the past 30 days), we compared those who did and did not report suicidal ideation or a suicide attempt during the past year. Separate analyses were conducted for perpetrators only, victims only, and bully-victims.

RESULTS

Overall, 6.1% of students reported frequent perpetration only, 9.6% frequent victimization only, and 3.1% both. Suicidal thinking or a suicide attempt was reported by 22% of perpetrators only, 29% of victims only, and 38% of bully-victims. In logistic regression models controlling for demographic and other risk and protective factors, a history of self-injury and emotional distress were risk factors that cross-cut the three bullying involvement groups. Physical abuse, sexual abuse, a mental health problem, and running away from home were additional risk factors for perpetrators only and victims only. Parent connectedness was a cross-cutting protective factor, whereas stronger perceived caring by friends and by nonparental adults were additional protective factors for some groups.

CONCLUSIONS

A range of risk and protective factors were associated with suicidal ideation and a suicide attempt among youth involved in verbal and social bullying. Findings may assist in identifying youth at increased risk for suicidal thinking and behavior and in promoting key protective factors.

Nonsuicidal self-injury among adolescents: a training priority for primary care providers

Primary care providers were surveyed to determine how prepared they feel to address nonsuicidal self-injury (NSSI) among adolescents, their interest in training on NSSI, and factors associated with routinely asking about NSSI when providing health supervision. Participants included family medicine physicians (n = 260), pediatricians (n = 127), family nurse practitioners (n = 96), and pediatric nurse practitioners (n = 54). Almost 50% felt unprepared to address NSSI, and over 70% wanted training in this area. Overall, relative to other areas of mental health care, clinicians felt least prepared to address and wanted more training on NSSI. Just 27% reported they routinely inquired about NSSI during health supervision. Factors associated with routinely asking about NSSI were identifying as female (OR = 2.37; 95% CI = 1.25-4.49), feeling better prepared to address NSSI (OR = 1.51; 95% CI = 1.04-2.20), and more frequently using a psychosocial interview to identify adolescents in distress (OR = 1.23; 95% CI = 1.02-1.48). Teaching clinicians to assess NSSI within a psychosocial interview may increase screening for and identification of the behavior among adolescents in primary care.

Depression screening and management among adolescents in primary care: factors associated with best practice

OBJECTIVE

To compare depression identification and management perceptions and practices between professions and disciplines in primary care and examine factors that increase the likelihood of administering a standardized depression screening instrument, asking about patients' depressive symptoms, and using best practice when managing depressed adolescents.

METHODS

Data came from an online survey of clinicians in Minnesota (20% response rate). Analyses involved bivariate tests and linear regressions.

RESULTS

The analytic sample comprised 260 family medicine physicians, 127 pediatricians, 96 family nurse practitioners, and 54 pediatric nurse practitioners. Overall, few differences emerged between physicians and nurse practitioners or family and pediatric clinicians regarding addressing depression among adolescents. Two factors associated with administering a standardized instrument included having clear protocols for follow-up after depression screening and feeling better prepared to address depression among adolescents.

CONCLUSIONS

Enhancing clinicians' competence to address depression and developing postscreening protocols could help providers implement universal screening in primary care.

Beyond prevention: promoting healthy youth development in primary care

Training primary care providers to incorporate a youth development approach during clinical encounters with young people represents an opportunity to integrate public health into primary care practice. We recommend that primary care providers shift their approach with adolescents from focusing on risks and problems to building strengths and assets. Focusing on strengths rather than problems can improve health by fostering resilience and enhancing protective factors among adolescents. A strength-based approach involves intentionally assessing and reinforcing adolescents' competencies, passions, and talents, as well as collaborating with others to strengthen protective networks of support for young people. Training programs should incorporate interactive strategies that allow clinicians to practice skills and provide tools clinicians can implement in their practice settings.

Factors distinguishing youth who report self-injurious behavior: a population-based sample

OBJECTIVE

To identify factors distinguishing adolescents across 3 groups: no self-harm, nonsuicidal self-injury (NSSI) only, and NSSI and suicide attempt (NSSI + SA).

METHODS

Data were from the 2007 Minnesota Student Survey. The sample included 61,330 students in grades 9 and 12. Logistic regression analysis determined factors that best distinguished adolescents who reported NSSI from those who reported no self-harm, and adolescents who reported NSSI + SA. Final models were developed over 3 stages of analysis that tested the importance of variables within risk factor, protective factor, and co-occurring health-risk behavior domains.

RESULTS

For male and female subjects, factors that consistently distinguished youth who reported NSSI from those who reported no self-harm included depressive symptoms, hopelessness, physical abuse, less parent connectedness, running away from home, and maladaptive dieting behavior. Factors that distinguished the NSSI + SA group from the NSSI only group for both sexes were a mental health problem, depressive symptoms, hopelessness, physical abuse, and running away from home. Other factors, such as sexual abuse, were significant in models for males or females only. Hopelessness constituted the leading factor to increase the likelihood that youth who self-injured also attempted suicide.

CONCLUSIONS

Youth engaging in NSSI experience diverse psychosocial stressors and significant distress. Clinicians and school personnel are well-positioned to offer support to these youth. Furthermore, they can help address NSSI among youth by identifying those who self-injure early, assessing for hopelessness and suicidality, facilitating connections to prosocial adults, addressing maladaptive dieting behavior, and supporting runaway youth.

Health behaviors and mental health of students attending alternative high schools: a review of the research literature

PURPOSE

The purpose of this review is to describe current knowledge about health-risk behaviors and mental health among alternative high school students.

CONCLUSIONS

Substance use, diet and/or physical activity, sexual-risk behaviors, mental health, and violence were reviewed. Students were described as marginalized youth facing significant social environmental challenges. Findings from 43 studies published from 1997-2010 suggested a high prevalence of health-risk behaviors among alternative high school students. Very few studies were conducted by nurse researchers. Suggestions for future research include addressing social environmental factors, resiliency, and emotional/mental health outcomes.

PRACTICE IMPLICATIONS

Alternative high schools offer a venue to conduct research and implement nursing interventions with high-risk, yet resilient, youth.

We have the evidence to enhance adolescent sexual and reproductive health--do we have the will?

The negative outcomes of early childbearing and sexually transmitted infections (STIs), including HIV/AIDS, threaten the health of adolescents more than any other age group. Ensuring the sexual and reproductive health of the more than 1.5 billion young people aged 10 to 25 around the world is central to global health. Country-level indicators show dramatic variations in sexual risk. Percentages of those who engage in sexual intercourse range from less than 1% of females in Pakistan to 54% of males in Cuba. Divergent rates of early pregnancy and STIs between countries and regions parallel variations in sexual behaviors, including age of sexual debut; number of partners; and use of contraception, including condoms. To understand these variations, many factors affecting the sexual and reproductive health of young people around the world such as age of marriage, norms and expectations around sexual behavior, gender inequities, and educational and economic opportunities must be considered.

Relationships between physical activity and depressive symptoms among middle and older adolescents: a review of the research literature

PURPOSE

The purpose of the review was to describe current knowledge regarding relationships between physical activity (PA) and depressive symptoms among adolescents.

CONCLUSIONS

Inverse relationships were found between PA, particularly sports participation, and depressive symptoms. Limitations of the current research are discussed, including measurement issues. A major gap exists regarding research with youth at high risk for depressive symptoms and low levels of PA, including older, low-income, minority females. Future research should focus on high-risk populations such as youth attending alternative high schools.

PRACTICE IMPLICATIONS

Nurses should consider promoting PA among middle and older adolescents as a way to prevent depressive symptoms and consider integrating PA into care plans for those experiencing depressive symptoms.

Sport participation during adolescence and suicide ideation and attempts

BACKGROUND

Most research regarding sport participation and suicide risk found protective relationships. However, all studies in this area were based on cross-sectional designs.

OBJECTIVE

To fill a gap in research by exploring associations between sport involvement and suicide ideation and attempts (suicidality) based on a 5-year longitudinal, population-based study.

STUDY GROUP

Participants (n = 739) completed surveys in middle school and high school.

METHODS

Logistic regression analysis compared suicidality during high school across four groups: youth who participated in sport in both middle and high school, youth who participated only in middle school or only in high school, and youth who did not participate in sport during adolescence.

RESULTS

Compared to non-participants, youth involved in sport in both middle and high school had lower odds of suicidal ideation during high school. Youth who discontinued sport after middle school had higher odds of attempting suicide during high school than non-participants.

CONCLUSIONS

Remaining involved in sport throughout adolescence can offer mental health benefits. Future research should identify mechanisms that account for protective relationships between involvement in sport throughout adolescence and suicidality, and identify factors that explain deleterious relationships for youth who discontinue sport early in adolescence.

Perspective: Physician education: a promising strategy to prevent adolescent suicide

Many young people who present to primary care providers (PCPs) have high levels of emotional distress and/or suicidal ideation. Therefore, PCPs are in an ideal position to recognize and respond to early symptoms and distress signals that accompany suicide warning signs, yet they underrecognize mood disorders and suicidality among youth. Medical school and residency programs typically provide inadequate training on pediatric mental health and adolescent suicide prevention. Thus, PCPs lack complete knowledge of risk factors and feel unprepared to handle mental health problems among youth. In this article, the authors provide an overview of the epidemiology of adolescent suicide and describe risk factors, protective factors, and warning signs. They propose that physician education represents a promising strategy to prevent adolescent suicide, and they establish the need for improved educational opportunities that would provide PCPs with the necessary skills and supports to identify and respond to psychosocial concerns that may increase suicide risk among youth. They recommend strategies, methods, and content areas for addressing educational gaps, as well as organizational approaches to support enhanced physician education. They also suggest areas for future research.

Potential mediating pathways through which sports participation relates to reduced risk of suicidal ideation

Suicide ranks as the third leading cause of death for American youth. Researchers examining sport participation and suicidal behavior have regularly found inverse relationships. This study represents the first effort to test a model depicting potential mechanisms through which sport participation relates to reduced risk of suicidal ideation. The participants were 450 undergraduate students. Measures assessed participants' involvement in university-run sports and other activities; frequency of physical activity; and perceived social support, self-esteem, depression, hopelessness, loneliness, and suicidal ideation. Regression analyses confirmed a path model and tested for mediation effects. Vigorous activity mediated relationships between sport participation and self-esteem and depression; and self-esteem and depression mediated the relationship between vigorous activity and suicidal ideation. Social support mediated relationships between sport participation and depression, hopelessness, and loneliness; and each of these risk factors partially mediated the relationship between social support and suicidal ideation. However no variable fully mediated the relationship between sport participation and suicidal ideation. This study provides a foundation for research designed to examine pathways through which sport participation relates to reduced risk of suicidal behavior.

Relationships between youth sport participation and selected health risk behaviors from 1999 to 2007

BACKGROUND

How adolescents spend their out-of-school time represents one of the most important factors for predicting positive youth development. Sport participation relates to many beneficial outcomes. However, current economic conditions threaten high school sport programs around the United States. This investigation examined relationships by year between sport participation and numerous health risk behaviors among high school students.

METHODS

Data were derived from the Centers for Disease Control and Prevention's Youth Risk Behavior Surveys administered every 2 years from 1999 through 2007. Items assessed were sport participation, vigorous physical activity, dietary habits, weight loss, sexual activity, interpersonal violence and suicidality, and substance use. Multiple logistic regression analyses were used to examine relationships between sport participation and each health behavior. Interaction effects tested whether relationships varied by year, sex, age, and/or race/ethnicity.

RESULTS

Analyses revealed some consistencies across years in relationships between sport participation and health risk behaviors for both sexes. However, most relationships varied by race/ethnicity. Among White students, sport participation related to multiple positive health behaviors. Conversely, African American, Hispanic, and Other athletes showed fewer positive health behaviors and some negative behaviors.

CONCLUSIONS

Findings suggest that participation in organized sports affords many health benefits to most adolescents, but relates to some negative health behaviors in certain subgroups. Information regarding sport participation and health risk behaviors among subgroups across years can inform school policy, practice, and future research.

Spiritual well-being and suicidal ideation among college students

OBJECTIVE

This study explored whether specific dimensions of spiritual well-being (religious well-being and existential well-being) relate to reduced suicidal ideation, and whether associations persisted after controlling for religiosity and psychosocial variables associated with suicide.

PARTICIPANTS

Participants were 457 college students who completed measures that assessed spiritual well-being, religiosity, hopelessness, depression, social support, and suicidal ideation.

METHODS

The authors used linear regression modeling to assess religious and spiritual correlates of suicidal ideation.

RESULTS

After controlling for demographic variables and psychosocial factors, neither involvement in organized religion nor religious well-being significantly contributed to suicidal ideation. However, even after controlling for significant correlates, existential well-being remained a significant predictor of suicidal ideation.

CONCLUSIONS

This investigation highlighted existential well-being as an important factor associated with lower levels of suicidal ideation among college students. Findings from this study focusing on the association between spiritual well-being and suicidality may prove especially beneficial to suicide prevention efforts.

Associations between physical activity and reduced rates of hopelessness, depression, and suicidal behavior among college students

OBJECTIVE

The authors explored associations among types of physical activity and hopelessness, depression, and suicidal behavior among college students.

PARTICIPANTS

Participants included 43,499 college students aged 18 to 25 who completed the 2005 National College Health Assessment conducted by the American College Health Association.

METHODS

The authors used logistic regression modeling to compare the odds of experiencing hopelessness, depression, and suicidal behavior in students who engaged in various levels of aerobic and strength or toning activity with students who did not perform these activities.

RESULTS

Men and women who engaged in some physical activity each week demonstrated a reduced risk of hopelessness, depression, and suicidal behavior compared with their inactive counterparts.

CONCLUSIONS

This study provides empirical evidence that establishes the association between physical activity, especially aerobic activity, and reduced risk of hopelessness, depression, and suicidal behavior among college students.

High school youth and suicide risk: exploring protection afforded through physical activity and sport participation

BACKGROUND

Suicide ranks as the third leading cause of death for adolescents. Recent data from the Centers for Disease Control and Prevention (CDC) indicate that the adolescent suicide rate increased 18% between 2003 and 2004. Sport may represent a promising protective factor against adolescent suicide. This study examined the relative risk of hopelessness and suicidality associated with physical activity and sport participation.

METHODS

Data from the CDC's 2005 Youth Risk Behavior Survey were analyzed. Logistic regression modeling was used to compare the odds of hopelessness and suicidality in students who engaged in various levels of physical activity to inactive students. Similar analyses were performed comparing risks of athletes to nonathletes, and the risks of highly involved athletes to nonathletes.

RESULTS

Findings showed that frequent, vigorous activity reduced the risk of hopelessness and suicidality among male adolescents. However, low levels of activity actually increased the risk of feeling hopeless among young females. Yet, for both males and females, sport participation protected against hopelessness and suicidality.

CONCLUSION

These findings indicate that involvement in sport confers unique psychosocial benefits that protect adolescents against suicidality. Findings suggest that mechanisms other than physical activity contribute to the protective association between sport and reduced suicidality. Social support and integration may account for some of the differences found in suicidality between athletes and nonathletes.

Sex differences in the adequacy of pain management among patients referred to a multidisciplinary cancer pain clinic

Few studies have evaluated sex differences in the adequacy of pain management in cancer. Existing studies have been marked by methodological limitations and results have been mixed. The present study sought to determine whether sex was associated with pain severity and pain management in cancer patients newly referred by their primary oncology team to a multidisciplinary cancer pain clinic. One hundred thirty-one cancer patients completed the Brief Pain Inventory-Short Form and medical chart review was conducted to obtain patients' clinical characteristics and pain treatment data. There were no differences between males and females in ratings of worst pain in the last week. Females were significantly less likely to have been prescribed high potency opioids by their primary oncology team and significantly more likely to report inadequate pain management as measured by Pain Management Index scores. These results suggest a sex bias in the treatment of cancer pain and support the routine examination of the effect of sex in cancer pain research.

Sexual health in women treated for cervical cancer: Characteristics and correlates

OBJECTIVE

A large proportion of women with a history of cervical cancer experience sexual problems as a result of treatment. The present study examined whether differences in sexual health between cervical cancer survivors and women with no history of cervical cancer could be explained by selected demographic, clinical, and psychosocial and physical factors.

METHODS

Women treated between 1 and 5 years previously for stage 0 to II cervical cancer and age- and education-matched women with no history of cancer undergoing routine cervical cancer screening were recruited to participate. All participants had a partner with whom they had ever been sexually active. Women completed measures of sexual health, vaginal changes, partner relationship quality, perceived physical appearance, and sexual self-concept.

RESULTS

Cervical cancer survivors reported significantly (p<.05) less sexual interest, more sexual dysfunction, and lower sexual satisfaction. The most consistent predictors of sexual health after treatment among survivors were time since diagnosis, receipt of radiotherapy, partner relations, and perceived physical appearance, as well as vaginal changes. These variables accounted for about 50% of the variance in sexual health outcomes.

CONCLUSION

The findings suggest that efforts to improve sexual health in women with a history of cervical cancer must move beyond the direct effects of cancer treatment on vaginal anatomy and physiology. Sexual rehabilitation interventions should consider partner relationships, perceived physical appearance, and women's attitudes toward themselves as sexual beings, in addition to vaginal changes. Future research should use prospective longitudinal research designs incorporating appropriate comparison groups to further explore this issue.

Pilot study of a self-administered stress management and exercise intervention during chemotherapy for cancer

GOALS OF WORK

This pilot project explored the feasibility, safety, and effectiveness of a self-administered exercise and stress management intervention for cancer patients receiving chemotherapy.

PATIENTS AND METHODS

Thirty-nine of 56 eligible patients (acceptance =69%) with a variety of solid tumors volunteered for the study. Participants were advised to exercise 20-40 min at 50-75% estimated heart rate reserve 3-5 times per week. In addition, patients were provided with instruction and written materials regarding stress management techniques. Follow-up data were collected during regularly scheduled outpatient visits at the start of the second, third, and fourth chemotherapy cycles using diary entries and the same questionnaires previously administered at baseline.

MAIN RESULTS

Twenty-four of 39 patients (62%) completed all study requirements. These participants completed 438 of the 678 exercise sessions assigned (adherence =62%). Of the stress management techniques, positive thinking most practiced most frequently (48%), followed by deep breathing (38%) and active relaxation (37%). Paired t tests, comparing baseline values with final recorded values, indicated a significant improvement over time in bodily pain (p<0.03) and mental health (p<0.04) subscale scores. Participants' evaluations of the combined intervention were favorable: 90% felt it was helpful to them and 100% would recommend it to another patient.

CONCLUSIONS

A self-administered intervention combining aerobic exercise and stress management was acceptable and safe for cancer patients receiving chemotherapy. Preliminary data demonstrating intervention efficacy should be confirmed in subsequent randomized clinical trials.