Peer-adult network structure and suicide attempts in 38 high schools: implications for network-informed suicide prevention.

BACKGROUND: Strengthening social integration could prevent suicidal behavior. However, minimal research has examined social integration through relationship network structure. To address this important gap, we tested whether structural characteristics of school networks predict school rates of ideation and attempts. METHODS: In 38 US high schools, 10,291 students nominated close friends and trusted adults to construct social networks. We used mixed-effects logistic regression models to test individual student networks and likelihood of suicidal ideation (SI) and suicide attempts (SA); and linear regression models to estimate associations between school network characteristics and school rates of SI, SA, and SA among all with ideation. RESULTS: Lower peer network integration and cohesion increased likelihood of SI and SA across individual and school-level models. Two factors increased SA: student isolation from adults and suicidal students' popularity and clustering. A multivariable model identified higher SA in schools where youth-adult relationships were concentrated in fewer students (B = 4.95 [1.46, 8.44]) and suicidal students had higher relative popularity versus nonsuicidal peers (B = 0.93 [0.10, 1.77]). Schools had lower SA rates when more students named the same trusted adults named by friends and many students named the same trusted adults. When adjusting for depression, violence victimization and bullying, estimates for adult network characteristics were substantially unchanged whereas some peer effects decreased. CONCLUSIONS: Schoolwide peer and youth-adult relationship patterns influence SA rates beyond individual student connections. Network characteristics associated with suicide attempts map onto three theory-informed domains: social integration versus thwarted relational needs, group cohesion, and suicidal students' social influence. Network interventions addressing these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. Longitudinal and intervention studies are needed to determine how schools differentiate in network structure and clarify reciprocal dynamics between network characteristics and suicidal behavior.

Diffusion of a Peer-Led Suicide Preventive Intervention Through School-Based Student Peer and Adult Networks.

Background: Peer-led interventions have been applied to prevent various health behavior problems and may be an important complement to individual-level suicide prevention approaches. Sources of Strength trains student "peer leaders" in secondary schools to conduct prevention activities that encourage other students to build healthy social bonds and strengthen help-seeking norms. Prior work examining diffusion of peer-led programs has focused on youths' closeness to peer leaders but minimally on other factors such as connections to adults and suicidal behavior. Methods: We examined implementation and dissemination of Sources of Strength in 20 schools. Over 1 year 533 students were trained as peer leaders and 3,730 9th-12th graders completed baseline surveys assessing friendships and adults at school, and suicidal thoughts/behaviors; and end-of-year surveys reporting intervention exposure: viewed poster/video, attended presentation, direct peer communication, and activity participation. Chi-square tests compared exposure rates by student and network characteristics. Multi-level logistic regression models tested predictors of exposure across individual and school-level characteristics. Results: Exposure to the intervention varied greatly by school and by individual student characteristics and network position. Training more peer leaders increased school-wide exposure for all modalities except presentation (Bs 0.06-0.10, p's < 0.05). In multivariate models, exposure was consistently higher for students closer to peer leaders in the friendship network (ORs 1.13-1.54, p's < 0.05) and students who named more trusted adults (ORs 1.08-1.16, p's < 0.001); and lower for males (ORs 0.56-0.83, p's < 0.05). In multivariate models, training more students as peer leaders predicted exposure to poster-video and direct peer communication in larger schools (OR = 3.34 and 2.87, respectively). Network characteristics influenced exposure similarly for students with suicidal thoughts and behaviors. Discussion: Our findings confirm prior work showing the importance of personal affiliations to peer leaders and natural networks as a medium for diffusion of peer-led prevention efforts. We build on that work by showing independent effects of closeness to adults at school and number of peer leaders trained. There is a need to strategically select peer leaders to maximize closeness to students school-wide, particularly in larger schools. Additional work is required for Sources of Strength to devise messaging strategies to engage males and students isolated from adults at school.

The Sources of Strength Australia Project: study protocol for a cluster randomised controlled trial.

BACKGROUND: The school system has been identified as an ideal setting for the implementation of prevention and early intervention programs for suicide. However, in Australia, suicide-prevention programs that are routinely delivered in the schools are lacking. Internationally, evidence exists for the effectiveness of peer-led interventions that take a social connectedness approach to improve help-seeking for suicide. The aim of the current trial is to test the effectiveness of the Sources of Strength program to promote help-seeking for suicide in adolescents in Australian high schools. METHODS/DESIGN: This study is a two-arm, cluster-randomised, controlled trial that will compare the evidence-based Sources of Strength program to a wait-list control condition. Sixteen Australian high schools will be recruited to the trial, with all adolescents in years 7 to 10 (12-16 years of age) invited to participate. Peer leaders from intervention-condition schools will receive training in the Sources of Strength program and will integrate positive messages, across 3 months, with the support of adult advisors. Activities may take the form of class presentations, posters, videos, and messages on social media sites and will aim to change help-seeking norms, strengthen youth-adult connections, and promote positive coping. The primary outcome measure for the study is help-seeking intentions, whereas secondary outcomes include help-seeking behaviour, help-seeking attitudes and norms, referral of distressed peers, availability of adult help, positive coping, and suicidal behaviour. Data will be collected pre-intervention, post-intervention (after the initial 3 months of messaging), and at the end of the first (6-month follow-up) and the second year after implementation (18-month follow-up). Primary analyses will compare changes in help-seeking intentions for the intervention condition relative to the wait-list control condition using mixed-effect repeated-measures analyses to account for clustering within schools. DISCUSSION: If proven effective, this universal social connectedness program for suicide could be more widely delivered in Australian high schools, providing a valuable new resource. The Sources of Strength program has the potential to significantly contribute to the mental health of young people in Australia by improving help-seeking for suicide. The findings from this research will also contribute to the evidence-base for peer-leadership programs internationally. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616000048482 . Registered on 19 January 2016.

An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools.

OBJECTIVES: We examined the effectiveness of the Sources of Strength suicide prevention program in enhancing protective factors among peer leaders trained to conduct schoolwide messaging and among the full population of high school students. METHODS: Eighteen high schools--6 metropolitan and 12 rural--were randomly assigned to immediate intervention or the wait-list control. Surveys were administered at baseline and 4 months after program implementation to 453 peer leaders in all schools and to 2675 students selected as representative of the 12 rural schools. RESULTS: Training improved the peer leaders' adaptive norms regarding suicide, their connectedness to adults, and their school engagement, with the largest gains for those entering with the least adaptive norms. Trained peer leaders in larger schools were 4 times as likely as were untrained peer leaders to refer a suicidal friend to an adult. Among students, the intervention increased perceptions of adult support for suicidal youths and the acceptability of seeking help. Perception of adult support increased most in students with a history of suicidal ideation. CONCLUSIONS: Sources of Strength is the first suicide prevention program involving peer leaders to enhance protective factors associated with reducing suicide at the school population level.