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Wildman RP, Muntner P, Reynolds K et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med 2008;168:1617-1624.

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Wildman RP, Muntner P, Reynolds K et al. The obese without cardiometabolic risk factor clustering and the normal weight with cardiometabolic risk factor clustering: prevalence and correlates of 2 phenotypes among the US population (NHANES 1999-2004). Arch Intern Med 2008;168:1617-1624.

Association Between Adolescent Suicide Ideation , Suicide Attempts and Emotional Self-Efficacy

Amy A Hunter1 , Keith J Zullig2, Robert F Valois3

1Department of Epidemiology, School of Public Health, West Virginia University

2Department of Social and Behavioral Sciences, School of Public Health, West Virginia University

3Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina






  • The YRBS is administered to all public high school students in grades 9-12 in a southern state, excluding special education students1.
  • The overall response rate ( 57%) did not meet the CDC’s Division of Adolescent and School Health criteria for weighted data of 60%, thus data was treated as random sample.
  • 215 schools were stratified by enrollment into 3 categories :
          • Small, 74-874 students
          • Medium, 875-1278 students
          • Large, greater than 1278 students

A seven item ESE scale included in the YRBS was developed and validated by

Muris with Dutch adolescents.3 The scale was modified and determined to be

valid and reliable with adolescents in the United States (Table 1).4The scale’s

internal consistency estimate in this sample was acceptable (α= .85).

  • Response options included (a) not at all, (b) a little bit, (c) pretty well, (d) well and (e) very well.

Four standard YRBS suicide ideation and attempts questions were utilized in

the study (Table 2).

White males had a significantly greater rate (52%) of low ESE than all other race/groups (Table 3).

Females, black and white, had significantly greater rates (31.6% and 44.1%, respectively) of low ESE compared to black males (27.6%, (Table 3).

No significant associations were detected between suicide ideation and behavior and midrange ESE for any of the race and sex groups; these results are neither reported nor discussed.

Table 4 displays the unadjusted and adjusted odds ratios for the association between low ESE and suicidal risk behaviors by race and sex.

Data Analysis

Analyses were conducted separately for the four sex/race groups,

controlling for tobacco; alcohol, marijuana and cocaine use (past 30 days);

relationship violence (past 12 months); feelings of depression for 2 or more

weeks, socioeconomic status ( as measured by eligibility for free or reduced

price lunch); and weapon or gun access ( past 30 days) as covariates in the

adjusted models.

Those not reporting suicide ideation, planning a suicide attempt, a suicide

attempt or being injured by a suicide attempt and had high ESE served as referent categories. Level of significance was determined a priori at alpha 0.05.

Statistical analysis was completed using SAS vs. 9.2.

This study explored the association of emotional self-efficacy (ESE) with suicide ideation and suicide attempts in a state-wide sample of public high school adolescents in a southern stateusing the CDC Youth Risk Behavior Survey (YRBS).

Unadjusted and adjusted logistic regression were modeled for sex and race. Tobacco, alcohol, marijuana, and cocaine use; relationship violence; depressed mood; socioeconomic status; and weapon/gun access were included as covariates in the models.

Suicide ideation and behavior variables were significantly related to emotional self-efficacy in the unadjusted models for the four race/sex groups. In the adjusted models, suicide ideation, planning a suicide attempt, attempting a suicide and suicide attempts resulting in injury were associated with reduced emotional self-efficacy largely for males (p <.05).

Results suggest that a substantial number of public high school adolescents are reporting low ESE and are engaging in suicide ideation and attempts. These findings have implications for community and school-based mental health services and suicide prevention programs for adolescents. Further, this study demonstrates a meaningful association between adolescent health risk behavior and ESE literature.


  • Three important pathways in understanding why low ESE and suicide ideation and attempts are associated should be noted:
      • Individuals placed in situations where they must meet highly valued standards may exhibit a low sense of affect regulation leading to anticipatory apprehension, thereby lowering ESE;
      • A low sense of affect regulation may obstruct the formation of positive relationships that enable the management of stressful situations.
      • Low ESE in controlling negative thoughts and feelings may be inhibiting and lead to increased anxiety and depression3 and increased health risk behaviors.5
  • Risk factors other than psychiatric disorder are operative for black (male and female) and white male adolescents.
  • Socio-economic disadvantage is an important dynamic associated with emotional distress, anxiety and depression6; results from the adjusted model controlled for SES.
  • Cultural competency should be a consideration in suicide intervention for white males.6
  • Risk factors for suicide specific to African American females include psychological distress, substance abuse, PTSD, relationship difficulties, poor social support, childhood and partner abuse.7
  • African American youth may put themselves in harms was as a noble escape from intolerable environments; a form of indirect suicide.8
  • Enhancing ESE should be considered as a program component for adolescent suicide risk reduction intervention research.


  • Cross sectional analysis prohibits determining a temporal sequence of ESE and suicide ideation or suicide attempts.
  • Results may not be nationally generalizable.
  • Elimination of participants with missing data on variables of interest.
  • Study did not evaluate change process for ESE.


The final sample included2,566valid observations after exclusion criteria

(non-response by subjects to variables of interest, responses that could

not be read, out of range responses (n=549) race reported as “Other”

than black or white (n=261). The relationship between ESE with race and

sex are shown in Table 3.


The Centers for Disease Control and Prevention (CDC) report suicide as the third leading cause of death among adolescents aged 15-24 in the United States.1 The ability to cope with heightened emotions and mood swings characteristic of this age group is an important determinant in the contemplation and completion of a suicide attempt.

A previous suicide attempt has been shown to be one of the most importantpredictors for a subsequent suicide attempt and completion.2 Further, three risk factors, often in combination, have been theorized to trigger a suicide attempt in young people:

  • Drug and/or alcohol use
  • Opportunity for suicide (access to a firearm )
  • Acute event ( break-up, death of family member, crisis)

Emotional self-efficacy (ESE) is an aspect of self-efficacy that pertains to

the perceived capability of coping with negative emotions; specifically, an

individual’s ability to avoid negative emotions or restore a normal

emotional state when experiencing a negative emotional state.3 When

this mechanism fails, individuals may be at an increased risk for suicide

ideation or worse.

The Youth Risk Behavior Surveillance System is a national school based survey conducted by the CDC to monitor health-risk behaviors that contribute to the leading causes of death and disability among youth.1

  • Response options for each item were (a) yes and (b) no, with the exception of the fourth questions which was

(a) I did not attempt suicide during the past 12 months, (b) yes, and (c) no. Response options (a) and (c) were collapsed into a single “no” option.

Data Analysis

The seven discrete variables from the ESE scale were pooled to form a

continuous variable ranging in score from 7 (7 X 1) to 35 (7 X 5), expressed as

a mean ESE score, with lower scores indicative of being less emotionally


Those with scores of 15 or less were categorized as having lower ESE,

scores of 16-21 were deemed as having mid-range ESE and scores of 22 or

greater were designated as having high ESE.

To account for the three levels of mean ESE outcome variable ( low,

medium and high), unadjusted and adjusted logistic regression was

conducted with those reporting high ESE as the referent group.


1. CDC-Centers for Disease Control and Prevention. (2012). Youth Risk Behavior Surveillance – United States, 2011 Surveillance Summaries, MMWR, Vol. 61, No.4

2. Harrington, R. (2001). Depression, suicide and deliberate self-harm in adolescence. British Medical Bulletin, 57, 47-60.

3. Muris, P. (2002). Relationships between self-efficacy and symptoms of anxiety disorders and depression in a normal adolescent sample. Personality and Individual Differences, 32, 337-348.

4. Valois, R.F., & Zullig, K.J. (In Press, 2013). Psychometrics of a brief measure of emotional self efficacy for adolescents in the USA. Journal of School Health.

5. Hessler, D., & Fainsibler Katz, L. (2010). Association between emotional competence and adolescent risky behaviour. Journal of Adolescence, 33(1), 1-10.

6. Murry, V.M., Berkel, C., Gaylord-Harden, N. K., Copeland-Linder, N., & Nation, M. (2011). Neighborhood poverty and adolescent development. Journal of Research on Adolescence, 21, 114-128.

7. Kaslow, N., Thompson, M., Meadows, L., Chance, S., & Puett, R. (2000). Risk factors for suicide attempts among African American women. Depression and Anxiety, 12(1), 13-20.

8. Langhinrichsen-Rohling, J., Friend, J., & Powell, A. (2009). Adolescent suicide, gender, and culture: A rate and risk factor analysis. Aggression and Violent Behavior, 14(14), 402–414.


The purpose of this study was to investigate the association between self-reported suicide ideation and suicide attempts and emotional self-efficacy among adolescents in a large cross-sectional, statewide sample.

*p<0.05; ** p<0.01, ***p<0.001, ****p<0.0001