Suicide ranks as the second leading cause of death among adolescents aged 10-19. Health risk behaviors (HRBs) have been identified as risks for suicidal behaviors isolatedly, however, adolescents often engage in multiple HRBs, and the cumulative effect of HRBs could exceed the adverse developmental impacts of singular exposures. To date, most studies on multiple HRBs among adolescents are cross-sectional with a limited number of HRBs behaviors, while few utilized longitudinal data to investigate the effect of cumulative HRBs on adolescent suicidal behaviors. Prior research also suggested future orientation as a potential factor reducing HRBs and suicidality. Yet, little is known about the moderating role of future orientation in the association between cumulative HRBs and suicidal behaviors.
To address the knowledge gap, this study aims to examine (a) the long-term effect of cumulative HRBs on suicidal behaviors, and (b) the moderating effect of future orientation in the association between cumulative HRBs and suicidal behaviors among a nationally representative sample of high school students. Given the racial/ethnic disparities in engaging in HRBs and suicides, the current study also explores whether the aforementioned effects differ across race/ethnicity. Such information may facilitate more effective screening for at-risk adolescents of suicide and designing tailored interventions for different racial/ethnic groups that incorporate future orientation as a strength-based element mitigating suicide risks.
Data and samples: Data were derived from 4,305 students (50.2% female, Mage= 14.27±1.51) in grades 9–12 from National Longitudinal Study of Adolescent Health (Wave I-II).
Measures: Suicidal behaviors were measured by self-reported suicidal ideation and suicide attempt. Cumulative HRBs was measured using 10 HRBs covering domains of diet, physical activity, sleep, social media, substance use, and safety behaviors. Future orientation was measured by standardized scores of six questions related to hopefulness and perceived likelihood of future events (e.g. going to college). Socioeconomic status was assessed using poverty status (i.e., parents receiving public assistance) and parental education level. Demographic variables included race/ethnicity, gender, and age. Depression was assessed by Center for Epidemiologic Studies Depression Scale.
Analysis: Mixed-effects logistic regression adjusting for sociodemographic characteristics, depression, and complex survey design was used to examine the associations between cumulative HRBs and suicidal behaviors. Interactions among cumulative HRBs, future orientation, and race/ethnicity were examined to investigate the potential moderating effects.
Cumulative HRBs significantly predicted the increasing odds of suicidal ideation (ORadj.= 1.25 [1.15, 1.35]) and suicide attempt (ORadj.=1.21 [1.05, 1.40]) across time. Future orientation moderated on the associations between cumulative HRBs and suicide attempts differently across race/ethnicity. Among Black adolescents, as the number of cumulative risks exceeds four, those with low future orientation had significantly higher risks of suicide attempts than those with high future orientation.
Conclusion and Implications
Findings underline cumulative HRBs as significant risk factors contributing to long-term suicidal behaviors. Social work professionals shall pay special attention to Black adolescents with high cumulative HRBs and low future orientation. Future orientation could mitigate the negative impact of cumulative HRBs on suicidal behaviors, indicating that suicide interventions targeting multiple HRBs could benefit from nurturing future orientation.