International Journal of Mental Health Nursing (2007) 16, 349–359 doi: 10.1111/j.1447-0349.2007.00483.

Feature Article
Suicide risk and protective factors among youth
experiencing school difficulties
Elaine Walsh and Leona L. Eggert
Reconnecting Youth Prevention Research Program, University of Washington School of Nursing, Seattle, Washington,
USA

ABSTRACT: Youth who experience difficulty in school are at risk for suicide, yet there is little
published information specific to risk and protective factors among this group. The purpose of this
study was to conduct an in-depth examination of risk and protective factors associated with suicidal
behaviour among youth who were experiencing problems in school and to compare these factors
between suicide risk and non-suicide risk subgroups. Participants were 730 high school students in the
Northwest and Southwest regions of the United States, aged 14–21 years. All participants were known
to be experiencing difficulty with grades and/or attendance. Students completed a paper-and-pencil
questionnaire and a one-on-one interview, which assessed suicidal behaviours as well as risk factors
(e.g. drug involvement, emotional distress, stress), and protective factors (e.g. self-esteem, coping,
support). Analysis of covariance tests, controlling for age and sex, were conducted to examine differ-
ences between the suicide risk and non-suicide risk groups on each risk and protective factor. The
suicide risk subgroup reported higher levels of all risk factors, except alcohol and marijuana use, and
lower levels of protective factors. While the groups did not differ on frequency of alcohol or marijuana
use, they did differ on other illicit drug use and consequences of alcohol and other illicit drug use.
Recommendations for nurses practising in school settings are discussed.
KEY WORDS: adolescent, prevention, protective factor, risk factor, suicide.

INTRODUCTION tion of youth suicide. One way to accomplish this is

through in-depth study of groups known to be at
Youth suicide is one of the most urgent and least under-
increased risk for suicide and suicidal behaviours.
stood issues facing health-care professionals today.
Youth experiencing school difficulties, that is, those
Suicide is the third leading cause of death among youth
who have grade, attendance, and/or behaviour problems,
aged 15–24 years [Centers for Disease Control (CDC)
are a specific group of teens known to be at increased risk
2004; National Institute of Mental Health (NIMH) 2004].
for suicide (Fergusson et al. 2003; Thompson et al. 1994)
Moreover, official suicide rates are likely underestimated
and therefore an appropriate group of young people on
in this age group, because single-driver deaths, poisoning,
which to focus prevention efforts. This is especially
and undetermined causes of death might in fact be sui-
important because their lack of academic progress and/or
cides (Mohler & Earls 2001). An understanding of factors
disruptiveness are often the behaviours that attract the
associated with suicidal behaviour is vital to the preven-
attention and concern of parents and school personnel, so
there is the potential that their suicidal behaviour may be
overlooked. Also, youth experiencing school difficulties
Correspondence: Elaine Walsh, University of Washington School of
Nursing, Psychosocial and Community Health, Box 357263, Seattle, may be under-observed by adults because they are not
WA 98195, USA. Email: emwalsh@u.washington.edu attending school regularly. Therefore, it is particularly
Elaine Walsh, PhD, ARNP.
Leona L. Eggert, PhD, RN, FAAN.
important to have reliable information about risk and
Accepted November 2006. protective factors for suicide among this group. While

© 2007 The Authors

Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
350
research about adolescent suicide risk behaviour is avail-
able, much of it comes from studies of those receiving
inpatient or outpatient treatment, or from postmortem
psychological autopsy studies. In-depth examination of
suicide risk among a broad group of youth having diffi-
culty in school is important because knowledge about
factors that increase or decrease suicide risk can be
inquired about and monitored by adults in their environ-
ments. School-based nurses are one group of profession-
als who have access to young people and are in a position
to assess for and intervene with youth who are at risk for
suicide.
Thus, the purpose of this study was to conduct an
in-depth examination of risk and protective factors asso-
ciated with suicidal behaviour among youth who were
experiencing problems in school and to compare these
factors between suicide risk and non-suicide risk sub-
groups. Knowledge about risk and protective factors for
suicide among this high-risk group provides important
and detailed information that can guide assessment and
suicide prevention interventions by school-based nurses.
REVIEW OF RELATED LITERATURE
Suicidal behaviour among high school students
The Youth Risk Behaviour Surveillance (Grunbaum et al.
2004), a comprehensive annual school-based study of risk
behaviour among adolescents in the United States,
reported that, in 2003, 16.9% of students reported seri-
ously considering suicide in the 12 months before the
survey. In addition, 16.5% of students reported making a
plan, and 8.5% of students reported having made a
suicide attempt in the 12 months before the survey. This
is of particular concern because young people who have
made suicide attempts have been found to be at higher
risk than those without a history of attempts for making
future attempts (Renaud et al. 1999; Werenko et al.
2000), and for death by suicide (Beautrais 2003; Brent
et al. 1993; Renaud et al. 1999).
When studying suicidal behaviour, sex and age are
important variables to consider. Males are four times
more likely than females to die by suicide, and females
attempt suicide approximately three times more often
than do males (CDC 2004). Rates of death by suicide
increase steadily during adolescence and young adult-
hood. For example, in 2000, suicide rates for those aged
10–14 years were 1.5 per 100 000. Rates for those aged
15–19 years were 8.2 per 100 000, and rates among young
people aged 20–24 years were 12.8 per 100 000 (NIMH
2004).
Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
E. WALSH AND L. L. EGGERT
Prevention framework
The risk and protective factor framework is applicable to
an examination of adolescent suicidal behaviour. Risk
behaviours can, directly or indirectly, endanger the health
and well-being of a young person and have the potential
to result in personally, socially, or developmentally unde-
sirable outcomes (Jessor 1998) such as suicide. Protective
factors reduce the likelihood that a person might engage
in suicidal behaviours and are proposed as essential for
building defences against suicidal impulses (Wasserman
2001). It has been recommended that the study of risk
and protective factors be combined when examining ado-
lescent suicide risk (Beautrais 2000). What follows is a
review of literature relevant to factors that were the focus
of this study.
Risk factors
Risk factors are not actual suicidal behaviours but are
associated with suicide and suicidal behaviour (Eggert
et al. 1994b; 1995b). These can encompass emotional
states as well as activities and experiences. Risk factors of
interest in this study include emotional distress; stress;
alcohol, marijuana, and other illicit drug use; risky behav-
iours; and experiencing violence/victimization.
Emotional distress
Factors such as depression, hopelessness, anxiety, and
anger have been found to influence suicide-risk behav-
iours. For example, Fergusson et al. (2003) studied a birth
cohort over 21 years and found significant relationships
between depression and suicide ideation and prior
attempts. In a cross-sectional study of high school stu-
dents, Wichstrøm and Rossow (2002) found that those
who reported a history of suicide attempts were more
depressed than those who did not.
While it is difficult to disentangle the relationship
between depression and hopelessness, there is evidence
that hopelessness is related to suicide-risk behaviour
independent of depression. Thompson et al. (2005) used
structural equation modelling to examine the effects of
risk factors on suicidal behaviours in a sample of 1287
high school students who were having difficulty in school.
They found direct effects of hopelessness on suicidal
behaviours for both males and females; depression had a
direct effect on suicidal behaviour for males but not for
females. In another large sample of high school students
(Perkins & Hartless 2002), hopelessness was a significant
predictor of suicide attempts. Csorba et al. (2003) studied
depressed outpatients (51 suicidal and 81 non-suicidal)
and found that hopelessness, along with self-esteem and
© 2007 The Authors
SUICIDE RISK AND PROTECTIVE FACTORS
proneness to fighting and self-injurious behaviour, dis-
criminated between the suicidal and non-suicidal indi-
viduals. Suicidal adolescents, however, did not have more
serious depression than their non-suicidal peers.
Other forms of emotional distress such as anxiety and
anger impact suicide risk. In a study involving adolescents
hospitalized for a suicide attempt and community-based
adolescents reporting a past suicide attempt, anxiety was
present in both groups (Grøholt et al. 2000). Ruchkin
et al. (2003) studied incarcerated male juveniles and
found significantly higher levels of anxiety and post-
traumatic stress disorder (PTSD) in those who made a
prior attempt compared with those who had suicide ide-
ation only. Walrath et al. (2001) studied 4677 youth, 21%
of whom had made a suicide attempt, and concluded that
those with a history of suicide attempts were more likely
than those without a history of attempts to be involved in
violent and aggressive behaviour. Esposito et al. (2003)
compared 74 teens who made one suicide attempt with 47
teens who had a history of multiple attempts and found
that those with multiple attempts reported significantly
higher levels of anger.
Stress
Stress is another important factor linked with suicidal
behaviour. Beautrais (2003) found that risk of suicide was
associated with recent stressful life events (interpersonal
difficulties or problems with work or finances, legal diffi-
culties) when those who died by suicide were compared
with non-suicidal controls. King et al. (2001) studied a
random sample of youth (aged 9–17 years) in the commu-
nity and found significant associations between suicide
ideation and attempts and stressful life events as mea-
sured by a modified version of the Life Events Checklist
(Brand & Johnson 1982). In a study of incarcerated ado-
lescents (Ruchkin et al. 2003), findings suggested that sui-
cidal behaviour was the result of interactions between a
vulnerable personality and situational stressors.
Family distress
Family distress has been highlighted as a stressor that can
affect risk for suicide. King et al. (2001) found that a poor
family environment and low parental monitoring were
associated with suicide ideation and suicide attempts in a
community sample of youths. In a community study of
teens and parents, Breton et al. (2002) reported that the
odds of a youth engaging in suicide-risk behaviours
increased when both the adolescent and the parent iden-
tified difficulties in the parent–child relationship. Also,
high school students who reported having made a prior
suicide attempt were more likely than their non-suicidal
© 2007 The Authors
Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
351
peers to report a poorer relationship with their parents
(Wichstrøm 2000). Family dysfunction (history of discord
among family members, chronic instability, removal of
children from the home) has been associated with death
by suicide, as well. For example, Werenko et al. (2000)
found that 33% of youth under the age of 20 years who
died by suicide had families that could be characterized as
dysfunctional. In another study of youth who died by
suicide, Beautrais (2001) found that an argument with a
family member, usually a parent, was a precipitant of
suicidal behaviour in 70.5% of cases.
Alcohol and other illicit drug use
Studies of high school students provide evidence linking
alcohol and other illicit drug use with suicide ideation and
attempts. King et al. (2001) found, after adjusting for
sociodemographic status, that young people who had
made a suicide attempt had significantly higher levels of
marijuana use and recent drunkenness than those with
suicide ideation only. Wichstrøm (2000) studied 9679
adolescents from grades 7 through 12 and found that
alcohol intoxication was a predictor of future suicide
attempts. Daily use of tobacco was associated with suicide
ideation and attempts in a cross-sectional study of high
school students (Breton et al. 2002).
Risky behaviour
Taking life-threatening risks has been linked to suicide-
risk behaviour. Many high-risk behaviours are illegal, and
engaging in illegal behaviours is in and of itself risky. In
studies of those who died by suicide (e.g. Beautrais 2001;
Gray et al. 2002), problems with discipline and/or legal
issues were often present. Community-based studies also
provide information about risky behaviours and suicidal
behaviours. King et al. (2001) found that sexual activity
and physical fighting were among the behaviours signifi-
cantly associated with suicide ideation or attempts. In
their study of a birth cohort, Fergusson et al. (2003) found
a relationship between suicide ideation and attempts and
truancy, suspension, and novelty-seeking behaviours.
Experiencing violence/victimization
There is evidence that experiencing or witnessing vio-
lence is a risk factor for suicidal behaviour. Brown et al.
(1999) studied a cohort of randomly selected individuals
for 17 years and found that adolescents and young adults
with a history of child maltreatment were three times
more likely than peers with no such history to become
depressed or suicidal. Risk of repeated suicide attempts
was eight times greater for youth with a history of sexual
352
abuse. In their study of incarcerated youth, Ruchkin et al.
(2003) found that exposure to violence played a role in
development of suicidal behaviour.
Protective factors
While the presence of risk factors is associated with
an increased risk for suicide, the presence of protective
factors appears to moderate, or lower, a young person’s
risk of suicide. Protective factors of interest in this study
include personal resources and social resources.
Personal resources
Self-efficacy (self-esteem and the feeling of being in
control of oneself) and coping resources have been iden-
tified as important protective factors. For example, in a
longitudinal study (Fergusson et al. 2003), suicide ide-
ation and attempts were related to decreased self-esteem,
with resiliency to suicidal responses associated with
increased self-esteem. In another study (Wichstrøm &
Rossow 2002), students who reported having made a
suicide attempt had lower self-esteem as measured by the
Global Self-Worth subscale of the Self-Perception Profile
for Adolescents (Harter 1988) than peers who had not.
Several hospital-based studies provide insight into the
relationship between personal control and suicidal behav-
iour. In a study of 58 youth who had made a suicide
attempt (Spirito et al. 2003), continued suicide ideation
at 3 months after discharge was associated with poorer
affect regulation as assessed by a 19-item subscale of
the Structured Interview for Measurement of Complex
PTSD (Pelcovitz et al. 1997). In other studies, suicidal
teens attributed negative events as their fault and typical,
while positive events were viewed as coming from exter-
nal sources (Summerville et al. 1996; Wilson et al. 1995).
Coping and problem-solving ability are additional per-
sonal resources that can mitigate the likelihood of suicidal
behaviour. Piquet and Wagner (2003) interviewed adoles-
cents hospitalized for making a suicide attempt and inpa-
tients with no history of suicide attempt, and found that
those who attempted suicide had significantly fewer
effortful-approach responses (e.g. taking direct action,
seeking support) and more automatic-approach responses
(e.g. impulsive, aggressive, or destructive actions) than
peers who had not made suicide attempts. Also, suicidal
youth perceived stressors as less controllable than did
peers who were not suicidal.
Social resources
Social resources such as family support and communica-
tion are also important protective factors. In a study
involving 14 922 students (Perkins & Hartless 2002),
Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
E. WALSH AND L. L. EGGERT
family support was a significant negative predictor of
suicide attempts. Yang and Clum (2000) studied 51 sui-
cidal and 130 non-suicidal college students (mean age
19 years) and found that early social support (before age
18), as measured by the UCLA Loneliness Scale (Russell
et al. 1978), had an impact on later suicidal ideation. They
hypothesized that support might decrease the impact of
early stressors and/or increase the likelihood of later social
support acquisition by increasing trust in relationships in
general.
Summary
The literature reviewed in this section demonstrates that
risk and protective factors for suicide are numerous.
Studying multiple interrelated factors is important to
understand and prevent suicidal behaviour (O’Carroll
et al. 1994; Sourander et al. 2001). Furthermore, focusing
on those who have shown increased vulnerability to
suicide-risk behaviours, such as those who experience dif-
ficulty in high school achievement, is likely to elicit critical
information and advance our understanding of adolescent
suicide risk.
Study purpose
Much of the information about suicide and suicidal
behaviours comes from studies of adolescents who were
in inpatient or outpatient treatment or died by suicide.
When behaviours of high school students were reported
in detail, distinction by school status (i.e. having difficulty
in school vs doing well in school) was rarely made. The
purpose of this study was twofold: (i) to describe high
school students who were experiencing difficulty in high
school on suicidal behaviours, risk factors, and protective
factors; and (ii) to compare the subgroups of suicide risk
and non-suicide risk participants on risk and protective
factors.
MATERIALS AND METHODS
Participants
Study participants were 730 students from seven urban
high schools in the Northwest and Southwest regions of
the United States who met established study criteria for
risk for school dropout (Herting 1990): (i) below expected
credits for grade, top 25th percentile for absences per
semester, and grade point average (GPA) less than 2.3
(GPA ranges from 0 to 4 and is the ratio of grade points to
semester hours attempted, A = 4 points, B = 3 points,
C = 2 points, D = 1 point, F = 0 points), or a precipitous
drop of greater than 0.7 from the prior semester; or (ii)
prior dropout status; or (iii) standardized school referral
© 2007 The Authors
SUICIDE RISK AND PROTECTIVE FACTORS 353

TABLE 1: Demographic characteristics of full sample (N = 730) SR (n = 300) and NSR (n = 430) groups
Full sample SR NSR
N (%) N (%) N (%)

Sex
Male 408 (56) 148 (49) 260 (60)
Female 322 (44) 152 (51) 170 (40)
Age (years)
14 83 (11) 28 (9) 55 (13)
15 212 (29) 86 (29) 126 (29)
16 194 (27) 89 (30) 105 (24)
17 167 (29) 64 (21) 103 (24)
18 65 (9) 30 (10) 35 (8)
19 6 (1) 0 (0) 6 (1)
20–21 3 (<1) 3 (1) 0 (0)
Grade
9 143 (20) 58 (19) 85 (20)
10 253 (35) 113 (38) 140 (32)
11 182 (25) 69 (23) 113 (26)
12 149 (20) 59 (20) 90 (21)
Missing 3 (<1) 1 (<1) 2 (<1)
Ethnicity
African American/Black 112 (15) 40 (13) 72 (17)
Asian/Pacific Islander 94 (13) 38 (13) 56 (13)
Caucasian/Euro American 295 (40) 118 (39) 177 (41)
Hispanic/Latino 76 (10) 45 (15) 31 (7)
Native American/Alaska Native 20 (3) 9 (3) 11 (2)
Mixed ethnicity 102 (14) 37 (12) 65 (15)
Other 31 (4) 13 (4) 18 (4)

NSR, non-suicide risk; SR, suicide risk.

as high risk for poor school performance and meeting one
of the criteria in (i). Participants in this study are a sub-
sample of participants from a larger study (Eggert 1994).
Data utilized in the present study were from cases ran-
domly selected from the larger study to represent the
typical distribution of 40% suicide risk and 60% non-
suicide risk among youth who are experiencing difficulties
in school when the Suicide Risk Screen (Thompson &
Eggert 1999) criteria are used (Eggert et al. 1995a;
Thompson et al. 1994). The acceptance rate for participa-
tion in the larger study was 80%.
Participants were 322 (44%) females and 408 (56%)
males. Of these, 300 (41%) were determined to be at
suicide risk (SR) based on the screen embedded in a
paper-and-pencil questionnaire (described below). The
other 430 students (59%) were non-suicide risk (NSR)
youth. Demographic characteristics for the full sample,
SR, and NSR groups are detailed in Table 1. Ages ranged
from 14 to 21 years, with only three participants over
the age of 19 years, and an average age of 16 years
(M = 15.93, SD = 1.22). Sixty per cent were in the 10th or
the 11th grade. Ethnic distribution was 60% from ethnic
minority (African American/Black, Asian/Pacific Islander,
Hispanic/Latino, Native American/Alaska Native) or
mixed ethnicity groups, and 40% Caucasian. Tests
revealed significant differences in sex between groups
[t(677, N = 730) = 2.98, P < 0.01]. The SR group com-
prised approximately equal numbers of females (n = 152;
51%) and males (n = 148; 49%), while the NSR group
comprised more males (260 males; 60% vs 170 females;
40%). Ethnic distribution was generally similar among
the SR and NSR groups, but the chi-square test for
independence [c2(6, N = 730) = 12.92, P < 0.05] revealed
a significant difference between groups, with the greater
proportion of Hispanic students in the SR group account-
ing for this. There were no significant differences in grade
level between groups.
Instruments
Questionnaires
The paper-and-pencil High School Questionnaire (HSQ)
(Eggert et al. 1994a) addressed a number of aspects of
a high school student’s life, including school, family,
support, coping strategies, drug use, moods, and suicide.

© 2007 The Authors

Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
354
Vulnerability for suicide was determined by a student’s
questionnaire responses to the brief Suicide Risk Screen
(SRS), embedded in the HSQ. The SRS contains seven
items related to suicide-risk behaviours; a depression score
comprising the mean of five items; and 10 items assessing
alcohol and other drug use frequency, polydrug use, and
drug use control problems (Thompson & Eggert 1999).
Interviews
The Measure of Adolescent Potential for Suicide (MAPS)
(Eggert et al. 1994b; Walsh et al. 1997) is a one-on-one,
interactive interview designed to provide a comprehensive
assessment of suicide risk. In-depth assessment covers
suicidal behaviours (suicide thoughts, threats, plans,
attempts; accepting attitudes towards suicide; exposure to
suicidal behaviour of family members or close friends), risk
factors (emotional distress, stress, drug involvement, risky
behaviours, experiencing violence/victimization), and pro-
tective factors (self-esteem, personal control, problem-
solving coping; amount, sense, and availability of support
from specific social network members; family support sat-
isfaction). The interview lasts 1.5–2 hours. It is conducted
with the interviewer using a laptop computer so that
answers can be recorded and shared with the teen at
specific points throughout the interview.
Measurement
Data reduction for the questionnaire and interview was
accomplished by averaging items in each dimension into
composite scores. Validity and reliability of the dimensions
measured in the HSQ and MAPS have been confirmed
using traditional psychometric tests and confirmatory
factor analysis (Eggert et al. 1994b; Thompson & Eggert
1999), demonstrating their construct and predictive valid-
ity in reflecting adolescent suicide potential. Dimensions
of each risk and protective factor for the combined ques-
tionnaire and interview are summarized in Table 2, as are
reliability coefficients for the current sample. Response
scales ranged from 0 to 6 unless otherwise noted. All scales
were provided in written format and contained anchoring
words appropriate to the questions (e.g. 0 = never,
2 = sometimes, 4 = usually, and 6 = always). Other scales
were similar, with 0 indicating a low endorsement (e.g. not
at all, strongly disagree), and 6 indicating a high endorse-
ment (e.g. a great deal, strongly agree). For risk factors,
higher scores on scales indicated higher risk; lower scores
on protective factors indicated higher risk.
Procedures
Institutional Review Board approval was obtained prior to
approaching potential subjects for study participation.
Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
E. WALSH AND L. L. EGGERT
Written and verbal assent/consent were obtained from
the student and a parent/guardian prior to study partici-
pation. Uniform procedures were used for questionnaire
administration. Students took the HSQ in small groups,
using confidential code numbers.
The HSQ was screened the same day at the research
office. Interviews with SR teens were conducted as soon as
possible after questionnaire screening because of potential
risk; NSR teens were interviewed within 30 days. Master’s-
prepared research staff members with experience working
with high-risk teens conducted the MAPS interviews after
completing comprehensive standardized training. Partici-
pants received a snack for completing the HSQ and a check
for US$10 for completing the MAPS as a token of appre-
ciation for their time and effort.
Data analysis
Data were analysed using the Statistical Package for
the Social Sciences software, Version 12.0 (SPSS Inc.,
Chicago, IL). Preliminary analyses included examination
of the data for completeness, accuracy, and outliers. Less
than 1% of the data were missing, and listwise deletion
was used for individual analyses if data were missing.
Descriptive statistics were computed for the full sample
and the SR and NSR subgroups in order to provide details
about each risk and protective factor. Suicidal behaviours
were compared between males and females in the SR
group using analysis of covariance (ancova) tests control-
ling for age. ancova tests, controlling for age and sex,
were conducted to examine differences between the SR
and NSR groups on each risk factor and protective factor.
Age and sex were included as covariates because of dif-
ferences in suicidal behaviour between the sexes and
differential rates related to age. Because of the number of
tests conducted, a Bonferroni correction (Miller 1981)
was used, adjusting the significance rate to control for
multiple comparisons. The significance level was com-
puted by dividing the alpha level of 0.05 by the number of
ancova tests in each risk/protective factor domain (e.g.
P = 0.05/5 items, 0.01, for the drug involvement domain).
Effect sizes for scales examined in this study ranged from
0.11 to 1.46, with the majority of scales having medium to
large effect sizes (Cohen 1988). Power ranged from 0.30
to 1.00 and was 0.94 or above for all but two scales (0.30
for marijuana use and 0.69 for alcohol use).
RESULTS
Suicidal behaviours
For the full sample, 37 participants (5%) reported suicide
ideation within the past 24 hours, while 103 (14%)
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SUICIDE RISK AND PROTECTIVE FACTORS 355

TABLE 2: Description of risk factor and protective factor scales

Number
Content measured in the scale of items a

Risk factors
Emotional distress
Depression Depressed affect, vegetative signs, cognitive impairment 16 0.90
Anxiety Frightening thoughts, uneasiness, worries, fears 13 0.87
Hopelessness Discouraged, nothing works out, no solution to problems 14 0.88
Anger Internalized and externalized anger 15 0.87
Stress
Effect of stressors Rate of how bothersome each stressor has been—past 2 weeks 32 NA†
Family distress Parent drug use, conflicts, thoughts of running away 3 0.59
Drug involvement
Alcohol use Beer/wine, hard liquor use in past month 2 0.82
Marijuana use Marijuana use in past month 1 NA‡
Other illicit drug use Other illicit drug use in past month 7 0.73
Drug use control problems Use more than intended, feel pressured to drink/use drugs, use to solve problems 4 0.71
Drug use consequences Negative consequences at home, school, with friends, and with the law due to use 8 0.75
Risky behaviours
High-risk behaviour Fights, life-threatening risks, unprotected sex 11 0.77
Experiencing violence/ Witnessing violence, being injured, experiencing physical/sexual abuse 5 0.70
victimization
Protective factors
Personal resources
Self-esteem Feeling useful, self-respect, positive attitude towards self 4 0.78
Personal control Feel in control of life, can adjust/cope with problems 9 0.85
Problem-solving coping Face problem, imagine solving problem, types of strategies 5 0.73
Social resources
Amount of support§ Amount of care/help from parents, siblings, school personnel, friends, classmates 9 NA†
Sense of support Feel integrated into peer group vs alone, close family ties, caring from others 6 0.77
Support availability Availability of parents, siblings, school personnel, friends 10 NA†
Family support satisfaction Open communication, time together, acceptance, support 5 0.89

†Variation expected in level of construct endorsed for each item, reliability calculation not appropriate; ‡Single-item scale, reliability calculation
not possible; §Scale range -10 to +10. NA, not applicable.

reported suicide ideation in the past 2 weeks. When asked
about the past year, 288 (40%) reported having thoughts
of suicide. A total of 120 youth (17%) reported making
one or more lifetime suicide attempts (39 of these 120
reported making two or more attempts). ancova tests
comparing males and females in the SR group revealed
that females reported higher levels of suicide ideation
[1.24 vs 0.89, F(2, 297) = 7.63, P < 0.001], plans (0.82 vs
0.50, F(2, 293) = 4.56, P < 0.05), threats (1.16 vs 0.80, F(2,
297) = 3.09, P < 0.05), and attempts (0.78 vs 0.36, F(2,
297) = 4.67, P < 0.01). Tests for differences between
groups included age as a covariate, and there were no
significant effects for age except on suicide ideation (F =
4.30, P < 0.05).
Risk factors
Table 3 contains risk factor mean levels for the full
sample, SR, and NSR groups, as well as results of ancova
tests for differences between groups. As shown in Table 3,
the SR and NSR groups were significantly different on
each emotional distress dimension (depression, anxiety,
hopelessness, and anger) and on both stress dimensions
(effect of stressors and family distress). In terms of drug
involvement, the SR and NSR groups did not differ sig-
nificantly on alcohol and marijuana use; however, SR
youth reported significantly higher levels of other illicit
drug use, and significantly greater adverse drug use con-
sequences and drug use control problems. In addition, SR
youth were significantly more likely than NSR youth
to have engaged in high-risk behaviours, and to have
reported witnessing or being a victim of violence.
Examination of the effects of covariates revealed that
effects of sex were significant for depression (F = 54.72,
P < 0.001), anxiety (F = 44.32, P < 0.001), hopelessness
(F = 10.53, P = 0.001), anger (F = 3.85, P = 0.05), effect of
stressors (F = 32.56, P < 0.001), family distress (F = 5.46,

© 2007 The Authors

Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
356 E. WALSH AND L. L. EGGERT

TABLE 3: Risk factor mean levels for full sample (N = 730), SR (n = 300) and NSR (n = 430) with ANCOVA comparison of SR and NSR youth
Full sample SR youth NSR youth ancova
Risk factor M (SD) M (SD) M (SD) F (d.f.)

Depression 1.69 (1.08) 2.44 (1.06) 1.17 (0.71) 154.72 (3,720)*†‡

Anxiety 1.40 (0.98) 1.95 (1.04) 1.02 (0.73) 85.40 (3,723)*†‡
Hopelessness 1.55 (0.92) 2.16 (0.92) 1.13 (0.65) 110.66 (3,720)*†
Anger 1.85 (1.05) 2.36 (1.10) 1.49 (0.86) 50.74 (3,726)*†
Effect of stressors 2.85 (0.84) 3.19 (0.83) 2.61 (0.76) 44.01 (3,724)*†
Family distress 1.79 (1.60) 2.58 (1.71) 1.24 (1.25) 52.00 (3,726)*†
Alcohol use 0.90 (1.11) 1.02 (1.19) 0.81 (1.05) 3.64 (3,723)
Marijuana use 1.15 (1.72) 1.26 (1.82) 1.07 (1.65) 0.96 (3,718)
Other illicit drug use 0.10 (0.31) 0.15 (0.41) 0.06 (0.21) 6.10 (3,723)*
Drug use control problems 0.44 (0.80) 0.66 (1.04) 0.29 (0.53) 14.53 (3,722)*
Drug use consequences 0.37 (0.63) 0.56 (0.79) 0.24 (0.45) 18.09 (3,722)*§
Risky behaviours 0.94 (0.90) 1.18 (1.02) 0.78 (0.76) 24.68 (3,722)*§
Experiencing 0.92 (1.00) 1.10 (1.14) 0.80 (0.87) 6.96 (3,725)*
violence/victimization

*P < 0.001; †Effects of sex significant, females higher than males (see text for F values); ‡Effects of age significant, older higher than younger (see
text for F values); §Effects of sex significant, males higher than females (see text for F values). Note. All scale ranges 0–6, with higher scores indicating
higher levels of related risk factors. NSR, non-suicide risk; SR, suicide risk.

TABLE 4: Protective factor mean levels for full sample (n = 730), SR (n = 300), and NSR (n = 430) with ANCOVA comparison of SR and NSR youth
Full sample SR youth NSR youth ancova
Protective factor M (SD) M (SD) M (SD) F (d.f.)

Self-esteem 4.20 (1.40) 3.22 (1.39) 4.88 (0.93) 128.63 (3,726)*†

Personal control 4.00 (1.10) 3.41 (1.07) 4.42 (0.92) 67.19 (3,723)*†‡
Problem-solving coping 3.03 (1.22) 2.68 (1.18) 3.27 (1.18) 23.17 (3,725)*‡
Amount of support§ 5.03 (2.73) 4.13 (2.82) 5.66 (2.48) 21.22 (3,726)*
Sense of support 4.67 (1.04) 4.10 (1.11) 5.07 (0.76) 69.02 (3,720)*†
Support availability 3.90 (1.10) 3.56 (1.14) 4.13 (1.00) 17.80 (3,725)*
Family support satisfaction 3.12 (1.69) 2.34 (1.48) 3.67 (1.61) 42.07 (3,714)*

*P < 0.001; †Effects of sex significant, males higher than females (see text for F values); ‡Effects of age significant, older higher than younger (see
text for F values); §Scale range -10 to +10. Note. All scale ranges 0–6, except amount of support (-10 to +10), with higher scores indicating higher
levels of protective factors. NSR, non-suicide risk; SR, suicide risk.

P < 0.05), adverse drug use consequences (F = 6.12,
P < 0.05), and high-risk behaviours (F = 28.98, P < 0.001).
When effects of sex were significant, it was females who
reported higher mean levels, except on adverse drug use
consequences and high-risk behaviours. Age was a signifi-
cant covariate for depression (F = 7.90, P < 0.01) and
anxiety (F = 4.20, P < 0.05), with older participants
reporting higher levels.
Protective factors
Information about mean levels and ancova tests for pro-
tective factors is contained in Table 4. The SR and NSR
youth differed significantly on all of the protective factors,
with SR youth reporting lower levels on all protective
factors. In terms of effects of covariates, sex had a signifi-
cant effect on self-esteem (F = 7.66, P < 0.01), personal
control (F = 4.78, P < 0.05), and sense of support (F =
9.45, P < 0.01), with males reporting higher levels of each.
Age had a significant effect on personal control (F = 4.72,
P < 0.05) and problem-solving coping (F = 23.05,
P < 0.001), with older participants reporting higher levels.
DISCUSSION
In this study, suicide risk status was determined based on
the brief SRS contained in the paper-and-pencil question-
naire, and responses on the more comprehensive MAPS
interview provided additional details about possible risk
and protective factors. Results confirmed expected differ-
ences between SR and NSR teens on risk factors and
protective factors. Reports of suicide ideation and suicide
attempts among participants in this study support the
importance of implementing prevention efforts with

© 2007 The Authors

Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
SUICIDE RISK AND PROTECTIVE FACTORS
youth experiencing school difficulties. Rates of suicide
ideation and prior suicide attempts are consistent with
other findings about elevated suicide risk among those
who are having difficulty in school (Fergusson et al. 2003;
Thompson et al. 1994) and higher than general samples of
US teens (Grunbaum et al. 2004). The covariate effect of
sex, with females higher on most of the suicide risk behav-
iours examined, is consistent with the literature related to
suicide and suicide risk behaviour. More males die by
suicide, while more females attempt suicide (CDC 2004;
NIMH 2004). In the context of prevention, the findings
underscore the need to attend to both males and females.
Examination of risk factors confirmed the complexity
and importance of these factors in understanding suicide
risk. As expected, indicators of emotional distress were
significantly higher for SR teens than for NSR teens.
Depression, hopelessness, anxiety, and anger are issues
that are difficult to tease out from typical ‘ups and downs’
that a teen experiences, and nurses who work in high
schools must be alert and willing to listen and assess for
suicide risk when helping teens deal with these emotions.
Also, support for adolescents under stress, particularly
family stress, is crucial to suicide prevention. Assessment
of suicide risk in victims of violence or abuse is important
for recovery from abuse as well as for suicide prevention.
In terms of alcohol, marijuana, and other illicit drug
use, levels of use reported by participants were low
overall. The SR and NSR groups did not differ on alcohol
or marijuana use frequency. However, other illicit drug
use frequency, drug use control problems, and adverse
drug use consequences differentiated between the
groups, with SR teens reporting higher levels than NSR
teens, even after controlling for age and sex. In this
sample, the relevance to suicide risk was not so much one
of frequency of use but rather the pattern of behaviour
around use. Despite engaging in similar levels of use, SR
youth reported more conflicts with others related to use,
got into more trouble related to use, and evidenced more
control problems than NSR youth. Thus, an assessment
not only of alcohol, marijuana, and other illicit drug use
frequency but also of problems controlling use and con-
sequences related to use is appropriate for school-based
nurses to conduct, and it is vital to ask about suicidal
behaviours when a teen presents with drug involvement.
Examination of protective factors provides additional
support for their inclusion in suicide risk assessment,
which is consistent with recommendations from other
researchers (e.g. Wasserman 2001). Participants in this
study reported general support at relatively high levels,
which was encouraging given the fact that they were expe-
riencing some difficulty in school. The fact that they were
© 2007 The Authors
Journal compilation © 2007 Australian College of Mental Health Nurses Inc.
357
willing to participate in the research questionnaires
and interviews in which parents and school personnel
were involved demonstrated some willingness to accept
support. Facilitating access to support resources might
help reduce risk for suicidal behaviour among high-risk
adolescents, and school-based nurses can facilitate access
to resources by communicating with parents/guardians,
providing referrals as appropriate, and being willing to be
resources themselves for teens and families. Education of
parents and teens about suicide risk is an appropriate
focus for prevention efforts. This is particularly important
because parents may not be aware of their teen’s suicidal
behaviour (Csorba et al. 2003; Sourander et al. 2001). On
another important note, Carlton and Deane (2000) found
that, for high school students, the higher the level of
suicide ideation, the lower the level of help seeking. Thus,
it is important for those who work with teens to reach
out to them, as opposed to waiting for teens to describe
symptoms or problems, and to ask directly about suicidal
behaviour and risk and protective factors. This can be a
component of teaching by school-based nurses in conver-
sations with parents and other school personnel.
As noted by King and Knox (2000), in order to recog-
nize and refer youth, there must be awareness of suicide
risk factors, willingness to attend to individual youth, and
willingness to take action. The association of suicidal
behaviours with numerous co-occurring difficulties
indicates that school-based nurses assessing suicide risk
should attend to youth experiencing any of these difficul-
ties and probe for related problems. School-based nurses
who work with teens can help increase knowledge among
other health-care professionals, parents, school person-
nel, and teens themselves, about warning signs and steps
to take to prevent suicide. One important step is decreas-
ing barriers to self-referral (O’Carroll et al. 1994), and
school-based nurses are in an ideal position to advocate
for changes that make it easier for teens to access help.
This might include steps that some high schools have
already taken, including having mental health services
near school or discretely housed in the school building so
that teens can access services easily without this being
obvious to others.
Limitations of the study warrant some discussion. This
study was cross-sectional, and thus conclusions cannot
address behaviours over time. The fact that the study was
conducted with teens at risk for school dropout limits
generalizability beyond this population. However, this is
an important group to target, and detailed information
from this group of young people provides valuable infor-
mation about a difficult-to-reach population. Longitudi-
nal study of suicide risk and non-suicide risk teens,
358
including those not at risk for school dropout, will provide
guidance for school-based nurses and other practitioners
in terms of assessment, prevention, and intervention
factors.
ACKNOWLEDGEMENTS
This study was supported by a research grant funded by
the National Institute of Nursing Research (R01 NR
03548) received by the second author, and a training grant
funded by the National Institute on Drug Abuse (5 T32
DA07257-04 through -07), and the Hester McLaws
Nursing Scholarship Fund from the University of Wash-
ington School of Nursing received by the first author.
Appreciation is expressed to Dr Jerald Herting for guid-
ance and helpful feedback regarding the preparation of
this paper.
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