Sticks and Stones May Break My Bones but Words May Lead to Suicide. Tamar Kodish. Joanna Herres. Annie Shearer. Tita Atte.

Transcription

1 Sticks and Stones May Break My Bones but Words May Lead to Suicide Tamar Kodish Joanna Herres Annie Shearer Tita Atte Drexel University Joel Fein Children s Hospital of Philadelphia Guy S. Diamond Drexel University

2 Abstract Background. Suicide is the third leading cause of death among U.S. youth (CDC, 2012), taking the lives of approximately 4,600 adolescents each year. Research has established an association between bullying and suicide risk. However, several questions remain regarding the relationship between these constructs. Aims. The present study examined (1) whether experiences of verbal, physical, and cyber bullying were uniquely associated with suicide risk (i.e. suicidal ideation and behavior), (2) whether each specific form of bullying was related to suicide attempt, and (3) whether depression, an established risk factor for suicidality, moderated the relationship between each type of bullying and suicidality. Methods. The sample included medical records of 5,429 youth screened in primary care when providers had mental health concerns. Patients were screened using the Behavioral Health Screen (BHS), assessing bullying, depression, suicide and other behavioral health symptoms and behaviors. Results. All three types of bullying were associated with higher suicide risk, but verbal bullying uniquely predicted suicide attempt. Depressive symptoms significantly moderated the relationship between each type of bullying and suicidality. Limitations. The data is cross-sectional and self-report. Conclusions. When medical providers evaluate suicide risk, bullying should be considered as a possible precipitant, especially if the patient is depressed. Verbal bullying may be particularly important in predicting severity of suicide risk.

3 Background Suicide is the third leading cause of death among U.S. youth (CDC, 2012), taking the lives of approximately 4,600 adolescents each year. An even higher percentage of high school students (16%) report seriously considering suicide, and 8% report that they have made a suicide attempt (CDC, 2012). Depression has been the most commonly identified psychiatric risk factor for suicidality (Brent et al., 1993; Marttunen, Henriksson, & Lonnqvist 1991, Shaffer, Gould, & Fisher, 1996). However, research indicates that only 20-60% of suicidal youth report clinical levels of depression (D Eramo, Prinstein, Freeman, Grapentine & Spirito, 2004). Thus, testing other potential predictive factors of suicidality is warranted. Over 70% of adolescents see a physician at least once a year, making this an ideal opportunity for suicide screening and assessment of risk factors (Frankenfield et al., 2000). Although most adolescent suicide attempters see a physician within months before they attempt,the majority of these youth are not identified as at-risk (Clark, 1993). Behavioral health screening tools can increase rates of suicide risk detection in primary care from 0.8%-3.8% (Wintersteen, 2010). In recent years, attention has turned to bullying as a risk factor for suicide. Bullying is defined as deliberate and repeated peer aggression involving an imbalance of power and intent to cause harm. Estimates indicate that about a third of high school teens report involvement in bullying. Of these, approximately 10% report being victims, 13% report being bullies, and 6% report both (Nansel et al., 2001). Bullying is related to a range of negative outcomes, including anxiety, depression, substance abuse and poor academic performance (Hinduja, & Patchin, 2010; Swearer, Song, Cary, Eagle, & Mickelson, 2001; Klomek et al., 2007; Eisenberg, Neumark- Sztainer, & Perry, 2003). Bullying has also been associated with suicide risk (Klomek, Sourander, & Gould, 2011; Kim, Koh & Leventhal, 2005; Roland, 2002).

4 Most studies examining the relationship between bullying and suicidality do not distinguish between different forms of bullying. Bullying behavior falls into several categories, including verbal harassment, physical aggression, and cyber bullying. Klomek et al. (2008) found that verbal, cyber and physical bullying were all significantly related to increased levels of suicidality. The present study extends this line of research by testing whether different forms of bullying are uniquely associated with general suicide risk and suicide attempt. We also explore whether depression moderates the relationship between distinct types of bullying and suicidality. Better understanding the impact of different forms of bullying and their interaction with depression may help medical providers improve identification and assessment of bullied youth at risk for suicide. Methods The study examined medical records data from 10 primary care offices in rural and semirural Northeastern Pennsylvania. Each practice participated in a suicide prevention project and agreed to use the Behavioral Health Screen (BHS), a comprehensive web-based, multi dimensional assessment tool to identify at-risk youth.. The screener was administered on a computer or touch pad to patients in the waiting or exam room when providers had concerns about behavioral health distress (i.e., indicated screening). Therefore, this is not an epidemiological sample of all patients in primary care. With provider and patient consent, we extracted data from the medical records system. The sample consisted of 5,429 youth, ages years (M = 16.77, SD = 2.5). The sample was 56.5% White, 56.5% female, and 24.7% Hispanic. Measures The BHS assessed fourteen domains: demographics, medical, school, family, safety, substance use, sexuality, nutrition and eating, anxiety, depression, suicide, psychosis,

5 trauma/abuse, and bullying. The BHS has been field tested and found to be feasible, acceptable and psychometrically strong (Diamond et al., 2010; Bevans, Diamond, & Levy, 2012; Diamond et al., 2012) Bullying The BHS presented questions about three different types of bullying. First, the BHS asked about verbal bullying ( How often do you feel kids tease you, make fun of you, or ignore you? ). Second, the BHS assessed physical bullying ( How often do kids physically hurt you or threaten to hurt you? ). Finally, the BHS asked about cyber bullying ( How often are you cyber bullied chat rooms, Facebook, instant messaging, text messages on your cell phone? ). Each item was rated on a frequency count: never (0), sometimes (1) or often (2). Depression The depression scale consisted of a mean of five items measuring the primary DSM depressive symptoms and related impairment (α =.82). Participants responded whether they experienced each symptom never (0), sometimes (1) or often (2) over the past two weeks. Suicidality The study used two primary dependent measures. First, to measure general suicide risk, we used a mean of three items from the suicide scale. These items included: a) Have you ever thought about killing yourself? b) Did you ever plan to kill yourself and c) Have you ever tried to kill yourself? This scale combined the score (0 = no, 1 = yes) of each item into a scale and used the mean of the three items (α=.77). This composite score has been well validated (Bevans, Diamond, & Levy, 2012). The second dependent measure was whether or not the adolescent reported having ever had a suicide attempt. Data Analytic Plan

6 First, we explored descriptive statistics and bivariate correlations for all study variables. Next, linear regression analyses examined the relationships between the three bullying variables (physical, verbal, and cyber) and level of suicide risk severity before and after controlling for depression and demographic variables. Three additional linear regressions tested the interactions between the three types of bullying and depression. Finally, logistic regression tested whether each type of bullying was uniquely associated with a higher probability of having attempted suicide. Results Means, standard deviations, and intercorrelations among study variables are presented in Table 1. Linear regression showed that all three types of bullying significantly predicted higher levels of suicide risk severity when controlling for depression, race, ethnicity, gender, and age (see Table 2). All three interactions between the bullying variables (physical, verbal, cyber) and depression were also significant (see Table 3). Figure 1 shows bullying was more strongly linked to suicide severity for patients who reported higher levels of depressive symptoms. Results of the logistic regression showed a unique effect for verbal bullying (see Table 4). Patients who reported a history of verbal bullying were 1.46 times more likely to report a suicide attempt (95% CI = ). Effects of physical and cyber bullying on suicide attempt were not significant. Discussion The goals of the present study were to test 1) whether different forms of bullying uniquely predicted suicide risk and 2) whether depression moderated the relationship between specific types of bullying and suicidality. While bullying is commonly viewed as a rite of passage, or a normal part of growing up, this research replicates prior findings linking bullying to

7 suicide risk. Consistent with prior research, our study found that verbal, physical and cyber bullying were associated with suicide risk severity (e.g., the more bullying youth reported, the more suicidal symptoms they endorsed). Bullied youth were more at risk for suicide when experiencing symptoms of depression. Perhaps the most interesting finding was that verbal bullying was the only form of bullying associated with having made a suicide attempt. Given that a previous attempt is a strong predictor of a future attempt, (Oquendo et al., 2014), this finding associated verbal bullying with the most at risk youth. Verbal bullying is much more common, and can be much more personal than physical or cyber bullying. In this sample, 25.8% of youth reported they were verbally bullied, 5.7% reported they were physical bullied and 5.9% reported there were cyber bullied. Previous research suggests that relational bullying (e.g., teasing, mocking, and social exclusion) may be especially detrimental to adolescent adjustment (Helms et al., 2015). These forms of bullying, usually delivered verbally, may be more damaging to adolescent self-esteem and social status than more overt forms of bullying (e.g., physical bullying). Cyber bullying is often anonymous and occurs behind closed doors. It is possible that the impersonal nature of the internet, or the lack of social interaction, provides some buffer to the impact of this kind of taunting. Physical bullying can certainly be painful and socially humiliating if done in public, but may have less severe psychological effects compared to relational forms of aggression. Verbal insults, mockery and social exclusion can have a more lasting negative impact on one s psychosocial and emotional well-being than other forms of bullying (Crick et al., 2002). The unique effects of verbal bullying have been associated with increased internalizing problems (Sinclair et al., 2012), including increased feelings of loneliness and social inadequacy (Woods,

8 Done, & Kalsi, 2009). Our study furthers these findings, highlighting the severity of verbal bullying as it relates to suicide attempt. The relationship between verbal bullying and suicidality in this study has significant clinical implications. Intervention programs aiming to reduce suicide attempts in youth should consider the detrimental role that verbal bullying may play. Prevention programs should involve strategies that minimize all types of bullying, but also work specifically to help teens cope with relational forms of aggression. Promising approaches include evidence-based programs such as WITS (Walk Away, Ignore, Talk It Out, Seek Help), that teach youth strategies to respond to verbal bullying (Leadbeater & Sukhawathanakul, 2011). More empirically supported treatment programs targeting relational forms of bullying in high school teens may enhance coping strategies and minimize the harmful impact bullying may have. This study also identifies depression as a moderator of the relationship between bullying and suicidality. For participants who reported higher levels of depressive symptoms, there was a stronger relationship between bullying and suicidality. Depressive symptoms have been linked with a range of social and emotional problems that may relate to increased suicide risk in bullied youth. For example, depressed adolescents may have emotion regulation difficulties, reducing their ability to cope in stressful situations, including when they are bullied (Silk, Steinberg, & Morris, 2003). Youth who are bullied may have low levels of peer support, heightening feelings of isolation and burdensomeness that come with depression, and contributing to increased suicide risk. Limitations and Future Directions Despite these important and novel findings, the study s cross-sectional design impairs our ability to infer causal relationships. In addition, this study relied on self-report measures.

9 Incorporating multi-method approaches in future research may increase the validity of the findings. Lastly, our study looked at experiencing different types of bullying at different frequencies, but only measured each type of bullying with a single item. Research that further breaks down both the content and methods of bullying that put adolescents at highest risk for suicide may be useful. In sum, this study contributes to the growing body of literature examining the relationship between bullying and suicidality by identifying the unique role of verbal bullying and depicting the moderating role of depression. The clinical implications of this study suggest that an assessment of suicide, depression and bullying is warranted when evaluating mental health status during primary care visits. Using multidimensional screening tools like the BHS can enhance medical provider s evaluation of these risk factors. The data from this study suggest that when medical providers evaluate suicide risk, bullying and depression should be assessed and considered as important risk factors.

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