Table 1.
Summary of child/adolescent studies examining the interaction of risk and protective factors in relation to a suicide-related outcome
| Study | Sample | Risk Factor(s) | Protective Factor(s) | Outcome(s) | Significant Findings |
|---|---|---|---|---|---|
| Armstrong & Manion (2015) | 813 Canadian secondary students (M=16.2; 52.0% F) | (1) Depressive symptoms (past 2 wks.); BDI-II (2) Self-esteem; RSES (3) Social support; SSQ (4) Risky behaviors (past 30 days); Checklist of Risk Behaviours for Youth (Armstrong, 2012) |
(1) Meaningful activity engagement (2) Breadth of engagement (3) Intensity of engagement Youth Activities Matrix |
Suicidal ideation (past 30 days); SIQ | (1) Meaningful activity engagement buffered impact of all four risk factors (2) Breadth of engagement attenuated impact of depressive symptoms and self-esteem |
| Birkett et al. (2009) | 7,376 MS students (7th/8th grade; 50.7% F; 72.7% W) | Sexual orientation; 1 multi-choice item | (1) School climate; 8 continuous items (2) Homophobic teasing (past 12 mos.); 1 continuous item |
Depression/suicidality composite (past 30 days); 2 continuous items | (1) School climate buffered impact of sexual orientation (2) Homophobic teasing interacted with sexual orientation |
| Brausch & Decker (2014) | 392 HS students (M=15.0; 48.1% F; 35.0% W) | (1) Depressive symptoms; RADS-2 (2) Eating disorder symptoms (past 6 mos.); EAT-26 |
(1) Self-esteem; RSES (2) Peer support; CASSS (3) Parent support; CASSS |
Suicidal ideation (past 30 days); SIQ | (1) Self-esteem buffered impact of depressive symptoms (2) Peer support attenuated effect of eating disorder symptoms (3) Parent support buffered impact of depressive symptoms |
| Cero & Sifers (2013) | 186 secondary students (11–16; 56.0% F; 81.0% W) | Physical abuse; 1 item from Profiles of Student Life: Attitudes and Behavior (Benson, 1990) | (1) Youth program participation; subscale from PSL-AB (2) Service to others; 1 item from PSL-AB |
Suicide attempts; 1 item from PSL-AB | (1) Youth program participation interacted with physical abuse (2) Service to others moderated indirect pathway from physical abuse to attempts via self-esteem |
| Cha & Nock (2009) | 54 psychiatric outpatients (12–19; 85.2% F; 79.6% W) | Childhood sexual abuse; subscale of CTQ | (1) Overall emotional intelligence; (2) Strategic emotional intelligence; (3) Experiential emotional intelligence; Mayer-Salovey-Caruso Emotional Intelligence Test (Mayer & Salovey, 2005) |
(1) Suicidal ideation (past 12 mos.); 1 continuous item; SITBI (2) Suicide attempts (past 12 mos.); 1 continuous item; SITBI |
(1) Overall emotional intelligence attenuated effect of childhood sexual abuse (for suicidal ideation and attempts) (2) Strategic emotional intelligence buffered impact of childhood sexual abuse (for suicidal ideation and attempts) |
| Chang (2002) | 306 HS students (14–18; 60.5% F; 96.1% W) | Life stress (past month); Inventory of High-School Students’ Recent Life Experiences (Kohn & Milrose, 1993) | Social problem-solving; Social Problem-Solving Inventory-Revised (D’Zurilla et al., 2002) | Suicidal ideation (past 30 days); SIQ | None |
| Chang et al. (2007) | 710 Taiwanese MS/HS students (12–19; 75.4% F) | Depressive symptoms (past 2 wks.); CDI | Cognitive triad (current); CTI-C | Suicidal ideation (past 2 wks.); Positive and Negative Suicide Ideation (Osman et al., 1998) | Cognitive triad interacted with depressive symptoms |
| Cui et al. (2010) | 8,778 Chinese students (11–17; 51.0% F) | Peer victimization (past 30 days); 1 continuous item | Loneliness (past 12 mos.); 1 continuous item | (1) Suicidal ideation (past 12 mos.); 1 dichotomous item (2) Suicide attempts (past 12 mos.); 1 dichotomous item |
Loneliness interacted with peer victimization (for suicidal ideation and attempts) |
| Duong & Bradshaw (2014) | 951 LGB students (9th–11th grade; 69.5% F; 9.3% W) | (1) Overall bullying (past 12 mos.); 1 dichotomous item (2) School bullying (past 12 mos.); 1 dichotomous item (3) Cyberbullying (past 12 mos.); 1 dichotomous item |
Feeling connected to an adult at school; 1 dichotomous item | (1) Suicide attempt (past 12 mos.); 1 dichotomous item (2) Medically serious attempts (past 12 mos.); 1 dichotomous item |
Feeling connected to an adult at school attenuated impact of overall bullying (for suicide attempts and medically serious attempts) |
| Espelage et al. (2008) | 13,921 LGB students (M=15.8; 50.3% F; 78.6% W) | Homophobic teasing (past 12 mos.); 1 continuous item | (1) Parent support; 2 continuous items (2) School climate; 7 continuous items |
Depression/suicidality composite (past 30 days); 2 continuous items | School climate buffered impact of homophobic teasing |
| Esposito & Clum (2002) | 200 adolescents living in juvenile detention (12–17; 29.5% F; 65.0% W) | (1) Sexual abuse; (2) Physical abuse; Subscales of Child Maltreatment Survey (Yang & Clum, 2000) |
(1) Problem-solving confidence; subscale of PSI (2) Social support satisfaction; (3) Number of social supports; Social Support Questionnaire-6 (Saranson et al., 1983) |
(1) Suicidal ideation (past 2 wks.); MSSI (2) Suicidal behavior (lifetime); Scale for Suicidal Behavior (Yang & Clum, 2000) |
(1) Problem-solving confidence buffered impact of sexual abuse and physical abuse (for ideation) (2) Social support satisfaction attenuated effect of sexual abuse (for suicidal ideation and behavior) |
| Esposito & Clum (2003) | 73 clinically referred HS students (M=16.0; 49.3% F; 94.5% W) | (1) Internalizing disorder (current); K-SADS (2) Comorbid internalizing/externalizing disorder (current); K-SADS |
Social support; Survey of Children’s Social Support (Dubow & Ullman, 1989) | Suicidal ideation (past 2 wks.); MSSI | Social support buffered impact of comorbid internalizing/externalizing disorder |
| Goodwin & Marušič (2003) | 1,456 nationally representative adolescents (15–19) | (1) Panic attack diagnosis; (2) Social phobia diagnosis; (3) Agoraphobia diagnosis; (4) Major depressive disorder diagnosis; WHO Composite International Diagnostic Interview (WHO, 1993) |
Feelings of inferiority; 1 dichotomous item | (1) Suicidal ideation (lifetime); 1 dichotomous item (2) Suicide attempts (lifetime); 1 dichotomous item |
(1) Feelings of inferiority interacted with panic attack diagnosis; trend-level interaction with social phobia and agoraphobia diagnoses (for suicidal ideation) (2) Feelings of inferiority interacted with major depressive disorder diagnosis (at trend-level for attempts) |
| Greening & Stoppelbein (2002) | 1,098 HS students (M=15.9; 53.0% F; 72.0% W) | Depressive symptoms (past 2 wks.); CDI | Religious orthodoxy; Doctrinal Orthodoxy Scale (Batson et al., 1993) | Perceived suicide risk; 1 dichotomous item based on scale (Greening & Dollinger, 1993) | Religious orthodoxy buffered impact of depressive symptoms |
| Greening et al. (2010) | 172 psychiatric inpatient children (M=9.4; 28.5% F; 31.4% W) | (1) Depressive symptoms (past 2 wks.); CDI (2) Reactive aggression; (3) Proactive aggression; Reactive-Proactive Aggression Questionnaire (Dodge & Coie, 1987) |
Authoritarian parenting; subscale of the Parental Authority Questionnaire-Revised (Reitman et al., 2002) | Suicidal behavior; Risk for Suicide Questionnaire (Horowitz et al., 2001) | Authoritarian parenting buffered impact of depressive symptoms; significant three-way interaction showed buffering effect for older children aged 10–12 and African-American children |
| Grover et al. (2009) | 102 psychiatric inpatients (13–17; 68.5% F; 28.8% W) | (1) Chronic stress (past 6 mos.); (2) Episodic life stress (past 3 mos.); Chronic Stress and Episodic Life Events Interview for Adolescents (Hammen, 2004) |
Problem-solving ability; Problem-Solving Inventory (Heppner, 1988) | (1) Suicidal ideation (past 2 wks.); MSSI (2) Suicide attempts (recent); 1 dichotomous item |
(1) Problem-solving ability buffered impact of chronic stress (for suicidal ideation) (2) Problem-solving ability buffered impact of episodic life stress (for ideation and attempts) |
| Hatzenbuehler (2011) | 31,852 HS students (11th grade; 51.2% F; 72.8% W) | Sexual orientation; 1 multi-choice item | LGB-supportive community climate; 5 continuous items | Suicide attempts (past 12 mos.); 1 dichotomous item | None |
| Hatzenbuehler et al. (2014) | 55,599 nationally representative adolescents (13–18) | Sexual orientation; 1 multi-choice item | LGB-supportive school climate; 8 continuous items | (1) Suicidal ideation (past 12 mos.); 1 dichotomous item (2) Suicide planning (past 12 mos.); 1 dichotomous item (3) Suicide attempts (past 12 mos.); 1 dichotomous item |
LGB-supportive school climate attenuated impact of sexual orientation (for suicidal ideation) |
| Hay & Meldrum (2010) | 426 MS/HS students (M=15.0; sex “evenly split”; 66.0% W) | (1) Traditional bullying peer victimization (past 12 mos.); 6 continuous items (2) Cyberbullying peer victimization (past 12 mos.); 3 continuous items |
(1) Authoritative parenting (past 12 mos.); 12 continuous items (2) Self-control (past 12 mos.); 8 continuous items |
Suicidal ideation; 1 continuous item | (1) Authoritative parenting buffered impact of traditional and cyberbullying peer victimization (2) Self-control buffered effect of traditional and cyberbullying peer victimization |
| Herba et al. (2008) | 1,526 Dutch children (M=11.09; 58.5% F) | Peer victimization; rated using peer nominations | (1) Parental rejection; EMBU-C (Markus et al., 2003) (2) Social well-being among classmates; scale based on Social Production Theory (Nieboer et al., 2005) (3) Parent internalizing disorder (lifetime); (4) Parent externalizing disorder (lifetime); TRAILS Family History Interview (Ormel et al., 2005) |
Suicidal ideation; 1 dichotomous item | (1) Parent internalizing disorder interacted with peer victimization (2) Parental rejection interacted with peer victimization |
| Hershberger & D’Augelli (1995) | 165 LGB adolescents (M=19.1; 25.0% F; 67.0% W) | Peer victimization; 3 continuous variables | (1) Family support regarding sexuality; 3 continuous items (2) Self-acceptance; 2 items from RSES |
Suicidality; 1 continuous item (current suicidal thoughts) and 1 dichotomous item (past attempts) | None |
| Kwok & Shek (2008) | 5,557 Chinese secondary students (M=13.9; 46.9% F) | Hopelessness; C-HOPE | (1) Family functioning; C-FAI (2) C-FAI subscales: Mutuality; Communication; Conflict; Parental Concern; Parental Control |
Suicidal ideation (current); C-SIS | (1) Family functioning attenuated impact of hopelessness (for females only) (2) Mutuality buffered impact of hopelessness (for females only) (3) Communication buffered impact of hopelessness (for males) (4) Conflict attenuated effect of hopelessness (for all) (5) Parental concern buffered impact of hopelessness (for all) (6) Parental control interacted with hopelessness (for females) |
| Kwok & Shek (2009) | 5,557 Chinese secondary students (M=13.9; 46.9% F) | Social problem-solving; C-SPSI-R | Family functioning; C-FAI | Suicidal ideation (current); C-SIS | Family functioning attenuated effect of social problem-solving |
| Kwok & Shek (2010) | 5,557 Chinese secondary students (M=13.9; 46.9% F) | Hopelessness; C-HOPE | (1) Mother-adolescent communication; (2) Father-adolescent communication; Mother-Adolescent and Father-Adolescent Communication Scales (Shek et al., 2006) |
Suicidal ideation (current); C-SIS | (1) Mother-adolescent communication buffered impact of hopelessness (for total sample and males only) (2) Father-adolescent communication attenuated effect of hopelessness (for males only) |
| Kwok et al. (2013) | 560 Chinese students (M=14.0; 47.2% F) | (1) Physical abuse (past 12 mos.); CTSPC (2) Psychological abuse (past 12 mos.); CTSPC |
(1) Family mutuality; C-FAI (2) Family communication; C-FAI (3) Family conflict; C-FAI (4) Parental concern; C-FAI |
Suicidal ideation (current); C-SIS | (1) Family mutuality attenuated effect of physical abuse (2) Family communication buffered impact of physical abuse |
| Kwok et al. (2015) | 527 Chinese students (M=14.0; 47.6% F) | Physical abuse (past 12 mos.); subscales of CTSPC | (1) Rational problem-solving; subscale of C-SPSI-R (2) Empathy; subscale of Chinese Emotional Intelligence Scale (Chan, 2003) |
Suicidal ideation (current); C-SIS | (1) Rational problem-solving buffered effect of physical abuse (for total sample and females only) (2) Empathy interacted with physical abuse (for total sample and females only) |
| Lau et al. (2002) | 285 Asian-American psychiatric outpatients (4–17; M=12.94) | Parent-child conflict; 1 continuous item | Acculturation; 4 items | Suicidality; 2 dichotomous items (suicidal ideation and attempts) | Acculturation attenuated effect of parent-child conflict |
| Lee (2011) | 436 Korean HS students (M=16.4; 33.0% F) | Depressive symptoms (past 2 wks.); CDI | (1) Reasons for living; Korean Reasons for Living-Adolescent (Lee, 2011) (2) K-RFL-A subscales: Future Optimism, Family Alliance, Suicide-Related Concerns, Peer Acceptance and Support, Self-Acceptance |
Suicidal ideation (past 30 days); SIQ | (1) Reasons for living buffered impact of depressive symptoms (for total sample) (2) Family alliance attenuated effect of depressive symptoms (for males only) (3) Peer acceptance and support buffered effect of depressive symptoms (females only) |
| Luster & Small (1997) | 42,568 HS students (M=14.9; sex “evenly split”; 95.0% W) | Sexual abuse (lifetime); 1 dichotomous item | (1) Parent support; 2 continuous items (2) Parental monitoring; 4 continuous items (3) Grade point average;1 continuous item |
Suicidal ideation (past 4 wks.); 1 continuous item | (1) Parent support attenuated effect of sexual abuse (2) Parental monitoring buffered effect of sexual abuse (3) Grade point average attenuated impact of sexual abuse (for females only) |
| Matlin et al. (2011) | 212 African-American HS students (M=15.5; 62.7% F) | Depressive symptoms; RADS-2 | (1) Community connectedness; subscale of Collective Efficacy Scale (Sampson et al., 1997) (2) Family support; (3) Peer support; Perception of Support Inventory (Rosen, 1981) |
Suicide risk; Reasons for Living-Adolescent (Osman et al., 1998) | (1) Community connectedness buffered impact of depressive symptoms (2) Family support attenuated effect of depressive symptoms; trend-level interaction (3) Peer support buffered effect of depressive symptoms |
| Miller & Esposito-Smythers (2013) | 185 psychiatric inpatients (M=15.0; 71.4% F; 84.0% W) | Child maltreatment (lifetime); K-SADS-PL | (1) Cognitive errors; CNCEQ (2) Cognitive triad; CTI-C (3) Alcohol-related problems (past 12 mos.); ADI (4) Drug-related problems (past 6 mos.); SASSI A-2 |
Suicidal ideation (past 30 days); SIQ | (1) Alcohol-related problems interacted with child maltreatment (2) Drug-related problems interacted with child maltreatment |
| Nrugham et al. (2010) | 2,464 Norwegian MS/HS students with depression (M=13.7; 50.8% F) | (1) Traumatic life events (lifetime); K-SADS-PL (2) Violent life events (lifetime); K-SADS-PL |
Resilience (past 4 wks.); Connor-Davidson Resilience Scale (Connor & Davidson, 2003) | Suicide attempts (lifetime); 1 dichotomous item | Resilience attenuated effect of violent life events |
| Pace & Zappulla (2010) | 403 Italian HS students (M=16.8; 51.4% F) | Depressive symptoms (past 2 wks.); CDI | (1) Emotional separation; (2) Emotional detachment; Emotional Autonomy Scale (Steinberg & Silverberg, 1986) |
Suicidal ideation (past 2 wks.); 1 continuous item | Emotional detachment buffered impact of depressive symptoms |
| Pisani et al. (2013) | 7,978 HS students from underserved schools (14–18; 49.9% F; 76.6% W) | Emotion regulation strategies; subscale of Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004) | (1) School trusted adult; 4 continuous items (2) Community trusted adult; 3 continuous items (3) Family trusted adult; subscale of the Parent-Adolescent Communication Scale (Barnes & Olson, 1985) |
Suicide attempts (past 12 mos.); 1 dichotomous item | Family trusted adult interacted with emotion regulation strategies |
| Rigby & Slee (1999) | 1,103 Australian secondary school students (12–18; M=14.9; 50.9% F) | (1) Self-rated peer victimization; Victim Scale (Rigby & Slee, 1993) (2) Peer-rated peer victimization; rated using peer nominations |
Social support; 6 continuous items | Suicidal ideation (past few wks.); 4 continuous items | None |
| Salzinger et al. (2007) | 75 children with a history of physical abuse (M=10.5; 39.0% F; 7.0% W) | Physical abuse; 2 continuous items | (1) Parent attachment; IPPA (2) Peer attachment; IPPA (3) Loneliness; Loneliness Scale (Russell et al., 1996) (4) Internalizing symptoms (past 6 mos.); YSR (5) Externalizing symptoms (past 6 mos.); YSR |
(1) Suicidal ideation (lifetime); 2 dichotomous items (2) Suicide attempts (lifetime); 2 dichotomous items |
None |
| Slap et al. (2001) | 6,577 nationally representative adolescents (7th–12th grade; 49.7% F; 65.8% W) | Adoption status; 1 dichotomous item | (1) Family connectedness; 13 continuous items (2) Depressive symptoms; CES-D (3) Self-image; 6 continuous items |
Suicide attempts (past 12 mos.); 1 dichotomous item | None |
| Tamás et al. (2007) | 407 Hungarian children with depression (M=11.7; 46.4% F; 95.1% W) | (1) Shyness; (2) Sociability; Subscales of the EAS Temperament Questionnaire (Buss & Plomin, 2014) |
Adaptive emotion regulation; Feelings and Me-Child (Kovacs, 2000) | (1) Recurrent thoughts of death; 1 dichotomous item (2) Suicidal ideation; 1 dichotomous item (3) Suicide planning; 1 dichotomous item (4) Suicide attempts; 1 dichotomous item |
Adaptive emotion regulation interacted with shyness and sociability (for attempts only) |
| Wedig & Nock (2007) | 36 psychiatric outpatients (M=15.3; 75.0% F; 75.0% W) | Parent expressed emotion; coded from Five Minute Speech Sample task | Adolescent self-criticism; 1 continuous item | Self-injurious thoughts and behavior (past 12 mos.); SITBI | Adolescent self-criticism interacted with parental expressed emotion |
| Wolff et al. (2014) | 183 psychiatric inpatients (M=15.0; 71.6% F; 84.0% W) | Peer victimization (past 12 mos.); subscale of Revised Peer Experiences Screening Questionnaire (Vernberg et al., 1999) | (1) Cognitive errors; CNCEQ (2) Negative self-talk; NASSQ (3) Peer support; (4) Family support; Survey of Children’s Social Support (Dubow & Ullman, 1989) |
Suicidal ideation (past 30 days); SIQ | (1) Cognitive errors interacted with peer victimization (2) Negative self-talk interacted with peer victimization |
| Yen et al. (2014) | 6,703 Taiwanese MS/HS students (7th–12th grades; 53.9% F) | Anxiety symptoms; Taiwanese Multidimensional Anxiety Scale for Children (Yen et al., 2010) | (1) Depressive symptoms; CES-D (2) Self-esteem; RSES (3) Family functioning; Family APGAR Index (Chau et al., 1991) (4) Peer victimization; Chinese School Bullying Experiences Questionnaire (Yen et al., 2012) (5) Alcohol abuse; CRAFFT Alcohol Abuse Screening Test (Knight et al., 2003) |
(1) Suicidal ideation; 1 dichotomous item (2) Suicide attempts; 1 dichotomous item |
Peer victimization interacted with anxiety symptoms (for ideation only) |
Note. F = female; W = White/Caucasian; MS = middle-school; HS = high-school.
Note. ADI = Adolescent Drinking Index (Harrell & Wirtz, 1989); BDI-II = Beck Depression Inventory-II (Beck et al., 1996); CASSS = Child and Adolescent Social Support Scale (Malecki & Demary, 2002); CDI = Children’s Depression Inventory (Kovacs, 1997); CES-D = Centers for Epidemiologic Studies Depression Scale (Radloff, 1977); C-FAI = Chinese Family Assessment Instrument (Shek, 2010); C-HOPE = Chinese Hopelessness Scale (Shek, 1993); CNCEQ = Children’s Negative Cognitive Errors Questionnaire (Leitenberg et al., 1986); C-SIS = Suicidal Risk Scale for Hong Kong Students (Tse & Bagley, 2002); C-SPSI-R = Chinese Social Problem-Solving Inventory (Siu & Shek, 2005); CTI-C = Cognitive Triad Inventory for Children (Kaslow et al., 1992); CTQ = Childhood Trauma Questionnaire (Bernstein et al., 1997); CTSPC = Parent-Child Conflict Tactics Scale (Chan, 2011); EAT-26 = Eating Attitudes Test (Garner & Garfinkel, 1979); IPPA = Inventory of Parent and Peer Attachment (Armsden & Greenberg, 1987); K-SADS-E = Schedule for Affective Disorders and Schizophrenia for School-Age Children (Orvaschel, 1995); K-SADS-PL = Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (Kaufman et al., 1997); MSSI = Modified Scale for Suicidal Ideation (Miller et al., 1986); NASSQ = Negative Affect Self-Statement Questionnaire (Ronan et al., 1994); RADS-2 = Reynolds Adolescent Depression Scale-2 (Reynolds, 2002); RSES = Rosenberg Self-Esteem Scale (Rosenberg, 1989); SASSI A-2 = Substance Abuse Subtle Screening Inventory Adolescent Version 2 (Miller & Lazowski, 2001); SIQ = Suicidal Ideation Questionnaire (Reynolds, 1988); Social Support Questionnaire (Sarason et al., 1987); SITBI = Self-Injurious Thoughts and Behaviors Interview (Nock et al., 2007).