Temperament and Adolescent Suicide Attempts: A Case-Control study with multi-ethnic Asian adolescents

doi:10.21203/rs.3.rs-2583320/v1

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Temperament and Adolescent Suicide Attempts: A Case-Control study with multi-ethnic Asian adolescents

https://doi.org/10.21203/rs.3.rs-2583320/v1

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published 15 Jun, 2023

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Background: Suicide is the leading cause of death for adolescents in several parts of Asia, including Singapore. This study examines the relationship between temperament and youth suicide attempts in a sample of multi-ethnic Singaporean adolescents.

Methods: A case-control design compared 60 adolescents (M_age = 16.40, SD_age = 2.00) with a recent suicide attempt (i.e., past 6 months) with 58 adolescents (M_age = 16.00, SD_age = 1.68) without any history of suicide attempts. Presence of suicide attempts was established using the semi-structured interviewer-administered Columbia Suicide Severity Rating Scale. Participants also completed self-report measures on temperament traits, psychiatric diagnoses, stressful life events, and perceived parental rejection in an interview-based format.

Results: Psychiatric diagnosis and comorbidity, recent stressful life events, perceived parental rejection, and all five “difficult temperament” traits, were significantly overrepresented among adolescent cases relative to healthy controls. Adjusted logistic regression models revealed significant associations between suicide attempt, major depressive disorder (MDD) (OR: 6.36, p = <.01), MDD comorbidity (OR: 10.7, p = <.01), “negative mood” trait (OR: 1.14 – 1.22, p = <.05), and the interaction term of “positive mood” and “high adaptability” traits (OR: .943 – .955, p = <.05). Specifically, “positive mood” predicted lower likelihood of a suicide attempt when “adaptability” was high (OR: .335 – .342, p < .05) but not low (OR: .968 – .993, p > .87).

Conclusion: Temperament screening may be important to identify adolescents at higher or lower risk of suicide at an early stage. However, the small sample and cross-sectional design limits any conclusions about causality.

Temperament

Suicide attempts

Adolescence

Risk factors

Protective Factors

Psychiatric Disorders

Comorbidity

Stressful life events

Parental Rejection

Asia.

Adolescent suicide is universally recognized as a public health crisis. In Asia, suicide ranked the first leading cause of death for youths aged 10–19 among several countries (South Korea, (1); China, (2); Japan, (3); Singapore, (4)). Every completed adolescent suicide was a successful suicide attempt (SA). Though SAs are rare in childhood (i.e., ≤ 13 years old), they increased dramatically through adolescence (5, 6). During this sensitive period of development, having a difficult temperament (7), a major depressive disorder (MDD) diagnosis (8) or comorbidity (9), experiencing stressful life events (10) or parental rejection (11) posed significant, independent risks to SA. Of which, temperament has garnered much attention in recent years for several reasons. First, a “difficult temperament” was found to elevate an adolescent’s susceptibility to these other SA-related risk factors. Traits remarked to be “difficult” in Western cultures, namely negative affectivity, low adaptability/inflexibility to environmental changes, high withdrawal from novelty, high activity levels, and reduced biological rhythmicity, either independently or interact to incline SA-related risks (12). For example, the propensity to experience frequent, negative affect is central to the tripartite model of depression (13). Combining this with an inflexible temperament, they increased the likelihood of alcohol and drug addictions through exacerbated emotional difficulties (14). Biological irregularity and high activity levels in children can disrupt mutually supportive relationships with their parents, which later translates to difficulties in receiving parental acceptance during adolescence (15). Highly withdrawn adolescents encountered more stressors in school and at home due to their deficits in social functioning (16). Beyond the “difficult” profile as a predisposing risk factor, specific temperament traits additionally served as a direct predictors or protective factors of adolescent SAs. Anxious, depressive, cyclothymic, and irritable styles of temperament, which were highly related to the temperament trait of “negative affectivity/mood” (17, 18), uniquely predicted SAs across all age groups (19). The “negative mood” trait retained its predictive power even after controlling for psychiatric disorders (MDD, substance use), childhood sexual abuse, an inflexible temperament, and gender (20). Currently, these robust findings were not observed among other “difficult” traits (21, 20, 22). Conversely, a growing body of research found a hyperthymic temperament to be uniquely associated with reduced likelihood of SAs even after accounting for multiple protective factors (23–27). Despite being a multifaceted temperament, researchers suggested that the sustained positive affectivity within this profile was largely responsible in providing effective defences against suicidal impulses (28).

As these findings were mainly derived from Western samples, researchers have challenged their generalizability to Asian populations (29). Culturally and universally, we believe that three areas about temperament as an indirect and direct factor linking to SAs remained relatively understudied: (a) Between individualistic and collectivistic cultures, there were self-reported differences on what constitutes a “difficult” temperament. For instance, while “highly withdrawn” adolescents in Canada typically faced maternal and peer rejection, their counterparts in China experienced entirely opposite outcomes (30, 31). Among Chinese adolescents, this trait further predicted other positive adjustments including teacher-assessed competence, leadership, academic achievements, self-efficacy, and lower feelings of loneliness and depression (32). Possibly, this is because “shyness” was commonly perceived as an expression of social maturity and competence in interdependent societies (33). In contrast, risks associated with the remaining “difficult” traits seemed to apply universally (see (34)) for a review). A careful re-evaluation of Western definitions of a “difficult temperament” and its relation to Asian adolescent SAs may be helpful so as to not misinform early screening practices in Asia. (b) Despite existing evidence on the “negative mood” trait being a robust direct predictor, few studies have comprehensively assessed and controlled for other SA-related risk factors that were also influential during adolescent development (i.e., MDD diagnosis and comorbidity, proximal stressful life events, perceived parental rejection, other difficult temperaments). (c) Recent studies investigating the protective role of hyperthymic temperament against adolescent SAs yielded mixed findings, either by failing to observe any significant associations (35) or even observing the inverse relationship (36, 37). For example, Karam et al. (2015) discovered three risk facets underlying a hyperthymic temperament, including “liking to be the boss”, “getting into heated arguments”, and “the right and privilege to do as I please”. One suggestion to reconcile these findings may be to consider the degree of “adaptability” within this profile. Adolescents with low flexibility/adaptability temperaments were more likely to exhibit self-centeredness, higher impulsivity, and confrontational behaviours (38), resembling the three risk facets. Additionally, adolescents with temperaments of positive affectivity but low adaptability previously attempted suicide (39). This finding challenged previous suggestions that sustained positive affectivity was the main protective factor underlying a hyperthymic temperament. High mood and adaptability were two traits previously associated with high self-confidence (40), which Karam et al. (2015) also found to be the only protective item against SA in hyperthymic female adults. Given these findings, the interplay between “positive affectivity” and “high flexibility/adaptability” may serve as one possible protective pathway against adolescent SAs.

The present study evaluated the risk and protective temperaments among Asian adolescents with previous suicide attempts, according to the following hypotheses: First, contemporaneously with other risk factors (i.e., MDD, psychiatric disorders, recent stressful life events, parental rejection), a “difficult temperament” but without “high withdrawal” would be significantly overrepresented among Asian adolescent suicide attempters relative to non-attempters. Second, following earlier findings, we expected the “negative affectivity/mood” temperament trait to remain a robust predictor of SA even after controlling for other risk factors. Third, we hypothesized a significant interaction between “positive affectivity/mood” and “adaptability” traits, such that high levels of positive mood and adaptability would be significantly associated with a reduced decrease likelihood of SAs suicide attempts.

2.1. Participants and Procedures

Ethics approval was obtained from the Domains-Specific Review Board (DSRB) at a large teaching hospital in Singapore. Cases were adolescents aged 13–19 who were admitted to the hospital’s emergency department for a recent SA (i.e., over the last 6 months). Controls were same-age adolescents who presented to the department with acute medical conditions without severe morbidity. After obtaining informed consent from a parent/guardian and the adolescent himself/herself, in-person interviews between every adolescent and two trained research assistants were conducted during which the case/control completed several self-reports and an interviewer-administered questionnaire. Fifteen-dollar or five-dollar supermarket vouchers were reimbursed for complete and partial responses respectively. Our final sample comprises 118 adolescents with complete responses (60 cases, 58 controls, M = 16.20, SD = 1.852), with the majority being Chinese (51%) and Females (72%).

2.2. Measures

2.2.1. Demographic Variables.

Self-reported information on demographic characteristics included age, sex, ethnicity, religious affiliation, level of education and housing information.

2.2.2. Suicide Attempts.

The semistructured interviewer-administered Columbia Suicide Severity Rating Scale (C-SSRS; (41)) consists of two subscales, each quantifying the severity of suicidal ideation and the intensity of suicidal behaviours respectively. Only the single item on “actual attempts” obtained from the “suicidal behaviour” subscale was used as a screening tool to assess the presence of a recent SA (i.e. in the past 6 months, yes/no).

2.2.3. Temperament

Adolescents’ temperaments were assessed using the Revised Dimensions Of Temperament survey (DOTS-R; (42)), which is a 54-item self-report questionnaire that measures nine temperament dimensions as described in Table 1:

Table 1

Nine Dimensions of Temperament measured by DOTS-R
Subscale	Temperament Definition
Activity Level (General)	Assesses the extent of motor activity in the adolescent
Activity Level (Sleep)	Assesses the extent of motor activity during sleep
Rhythmicity (Sleep)	Assesses the regularity of the adolescent’s sleep-wake cycle
Rhythmicity (Eating)	Assesses the regularity of the adolescent’s eating habits (e.g. quantity of food)
Rhythmicity (Daily Habits)	Assesses the regularity of the adolescent’s daily routines (e.g., bowel movements, hunger).
Mood	High scores reflect a higher predisposition of positive affect (e.g., smiling and cheerful behaviours); Low scores reflect inherently anxious, depressive, and irritable behaviors.
Approach/Withdrawal	Assesses the adolescent’s comfort or hesitancy in approaching novel situations.
Flexibility/Rigidity	Assesses the adolescent’s adaptability to changes in his/her environment(s)
Task Orientation	Assesses the adolescent’s persistence or distractibility on a single task

Each of the nine dimensions uses a four-point likert scale ranging from 1 (usually false) to 4 (usually true). Higher scores reflected lower levels of activity, approach, adaptability, persistence, positive mood, and more regular eating and sleeping habits. In our sample, all the nine subscales of the DOTS-R showed acceptable internal consistency. (α = .62 – .89).

2.2.4. Psychiatric Disorders

The Youth Inventory-4 (YI-4 ; (43)) is a self-report rating scale that assesses symptoms of DSM-4 emotional and behavioral disorders in youths between 12 and 18 years old. The YI-4 contains 120 items that assess symptoms of 8 disorders, with each item rated on a four-point likert scale (0 = never, 3 = very often). The scale yields Symptom Count scores that are summed to derive criteria for diagnosis. All 8 diagnoses (yes/no), were used in the present study. MDD Comorbidity (yes/no) was determined when the adolescent met the symptom count criteria for another diagnosis on top of MDD. The internal consistency for all the 8 symptom count scales in this study were excellent (α = .90 ~ .97).

2.2.5. Stressful Life Events

The Adolescent Stress Questionnaire (ASQ; (44)) consists of 58 items reflecting 10 common stress dimensions over the last 12 months. These are the stresses of a) home life, b) school performance, c) school attendance, d) romantic relationships, e) peer pressure, f) teacher interaction, g) future uncertainty, h) school/leisure conflict, i) financial pressure, and k) emerging adult responsibility. Each participant rated the level of stress experienced on a 5-point likert scale (1 = not at all stressful to 5 = very stressful). In this study, the 10 subscales of ASQ showed excellent psychometric properties (α = .90–96).

2.2.6. Parental Rejection

The Child Parental Acceptance-Rejection Questionnaire (PARQ; (45)) is a 60-item self-report questionnaire reflecting 4 subscales: warmth and affection (reverse scored), aggression and hostility, indifference and neglect, and undifferentiated rejection. Using a 4-point Likert scale, adolescents rated items from 1 = almost never true to 4 = almost always true, with higher scores indicating that s/he perceived the parent to be cold, aggressive, and/or neglecting. Coefficient alpha for both father and mother forms ranged from .86 to .92 for all subscales.

2.3. Data Analysis

All statistics were calculated using IBM SPSS v29.0 (46). Student’s t-tests and chi-squared analyses were conducted to examine possible group differences in demographic variables, risk factors, and temperament traits. Binary logistic-regression models (i.e. Yes/No for Suicide Attempts) were used to determine the risk and protective temperament traits after adjustment of every risk factor (i.e., MDD/MDD comorbidity, stressful life events, parental rejection). To address the third hypothesis, we included the interaction term (i.e., Flexibility/Rigidity x Mood) in each of these models. To minimize multicollinearity, all variables were centered respectively onto their means and entered into the model simultaneously.

3.1. Risk Factors of Adolescent SAs

As detailed in Table 2, the average adolescent suicide attempter was significantly more likely to be psychiatrically diagnosed (t = -6.62, p < 0.001), with MDD alone (t = -6.64, p < 0.001) or comorbid with MDD (t = -7.03, p < 0.001), experience more stressful life events (t = -5.69, p < 0.001), more paternal (t = -2.79, p < 0.01) and maternal rejection (t = -4.06, p < 0.001). Compared to non-attempters, adolescent suicide attempters experienced significantly higher rates in nearly all disorders and recent stressors (all p < 0.05), except for bipolar disorder (t = -1.23, p = 0.001). Cases and Controls were not significantly different in any of the sociodemographic characteristics (all p > 0.05). In terms of temperament (Table 3), these cases scored significantly lower than controls on four “difficult” traits (Flexibility/Rigidity: t = 3.85, p < 0.001; Rhythmicity in Sleep: t = 2.98, p < 0.01, Rhythmicity in Eating: t = 1.92, p < 0.05; Mood: t = 4.88, p < 0.001; Approach/Withdrawal: t = 2.67, p < 0.001) and higher in Activity Level (General) (t = -1.63, p = .050).

Table 2

Differences in Clinical and Demographic Characteristics between adolescent suicide attempters and non-attempters.
		Suicide Attempters (N = 60)		Non-Suicide Attempters (N = 58)		p
		Mean	SD	Mean	SD
Age		16.40	2.00	16.0	1.68	.121
ASQ (Total)		145.40	39.09	108.59	30.56	< .001
	Home Life	28.53	9.38	20.14	8.52	< .001
	School Performance	20.92	7.24	18.21	5.31	< .05
	School Attendance	7.97	3.73	5.74	2.65	< .001
	Romance	12.43	6.36	7.28	4.06	< .001
	Peer Pressure	19.97	7.18	13.7	5.44	< .001
	Teacher Interaction	14.57	6.57	11.02	3.67	< .001
	Future Uncertainty	10.72	3.10	8.57	2.95	< .001
	Social Conflict	13.52	5.37	11.16	4.58	< .01
	Finance Pressure	10.72	4.49	7.59	3.47	< .001
	Adult Responsibility	6.07	2.83	5.19	2.24	< .05
PARQ (Father)		138.52	35.71	118.96	38.99	< .01
PARQ (Mother)		120.73	37.37	96.6	25.85	< .001
		N	%	N	%	p
Sex						.605
	Male	17	28.3	14	24.1
	Female	43	71.7	44	75.9
Ethnicity						.942
	Chinese	29	48.3	31	53.4
	Malay	13	21.7	11	19.0
	Indian	15	25.0	14	24.1
	Others	3	5.1	2	3.4
Religion						.278
	Buddhist/Taoist	6	10.0	11	19.0
	Muslim	16	26.7	15	25.9
	Christian	12	20.0	10	17.2
	Hindu/Sikh	11	18.3	13	22.4
	No Religion	15	16.7	9	15.5
Education level						.670
	High School	44	73.3	41	70.7
	Diploma/Community College	16	26.7	17	29.3
Housing Type						.101
	1–2 room(s)	4	6.7	1	1.7
	3 rooms	11	18.3	8	13.8
	4–5 rooms	40	66.6	35	60.3
	Private Housing	5	8.3	14	24.1
Met Diagnostic Criteria for any Disorders		53	88.3	22	37.9	< .001
	Major Depressive Disorder	35	58.3	5	8.6	< .001
	Substance Use	10	16.7	2	3.4	< .05
	Bulimia Nervosa	19	31.7	1	1.7	< .001
	Generalized Anxiety Disorder	36	60.0	9	15.5	< .001
	Schizophrenia	15	25.0	1	1.7	< .001
	Dysthymia	44	73.3	9	15.5	< .001
	Bipolar Disorder	11	18.3	6	10.3	.217
	Anorexia Nervosa	17	28.3	2	3.4	< .001
MDD Comorbidity		35	58.3	4	6.9	< .001

Table 3

Differences in Temperament Trait scores between adolescent suicide attempters and non-attempters.
	Suicide Attempters (N = 60)		Non-Suicide Attempters (N = 58)		p
	Mean	SD	Mean	SD
Activity Level (General)	21.45	4.26	20.09	4.81	.050
Activity Level (Sleep)	10.65	2.97	10.45	3.37	.365
Rhythmicity (Sleep)	11.28	3.37	13.40	4.30	< .01
Rhythmicity (Eating)	10.07	3.26	11.36	4.05	< .05
Rhythmicity (Daily Habits)	10.05	2.63	10.50	2.74	.182
Mood	19.23	5.90	23.76	3.94	< .001
Flexibility/Rigidity (Adaptability)	12.13	2.73	14.19	3.08	< .001
Approach/Withdrawal	17.18	3.76	18.91	3.26	< .01
Task Orientation	18.55	4.54	19.6	3.78	.167

3.2. Adjusted Odds Ratios for Adolescent Suicide Attempts.

Table 4 displays the results of five binary logistic regression models with the “difficult” traits and the interaction term “Flexibility x Mood” as predictors of suicide attempts. The first model adjusted for demographic characteristics and the remaining traits, with the second, third, and fourth model additionally controlling for paternal and maternal rejection, stressful life events, and MDD respectively. As MDD and MDD comorbidity were perfectly correlated, the fifth model adjusted for MDD comorbidity in place of MDD together with the aforementioned factors. Across all five models, a unit decrease in “Mood” was significantly associated with a 14% − 22% (OR: 1.14–1.22, p = < .05) increase in the likelihood of suicide attempts. Even after controlling for all covariates, “Negative Mood” (OR: 1.22 p = < .05), MDD morbidity (OR: 6.36, p = < .01) or comorbidity (OR: 10.7, p = < .01), and stressful life events (OR: 1.02, p = < .05), remained as statistically significant predictors. Likewise, a unit increase in the interaction term “Flexibility x Mood” was significantly associated with a 5% − 6% decrease in the likelihood of suicide attempts (OR: .943 – .955, p = < .05) across all five models. This significant interaction was later probed at -1SD and + 1SD of the Flexibility/Rigidity (Adaptability) scores. Figure 1 visualized the gradual changes in the simple slopes after controlling for each additional risk factor. After adjustment of all temperament traits, demographic and risk factors, simple slope analyses revealed that “Positive Mood” significantly predicted lower probability of suicide attempts when “Adaptability” was high (b = − .288 – − .293, p < .05) but not low (b = − .003 – − .012, p > .87) (Model 5, Fig. 1).

Table 4

Adjusteda Odds Ratios for the associations between adolescent’s temperaments, risk factors, and suicide attempts.
Temperament	Model 1		Model 2		Model 3		Model 4		Model 5
	β	OR (95% Cl)	β	OR (95% Cl)	β	OR (95% Cl)	β	OR (95% Cl)	β	OR (95% Cl)
Activity Level General	.149	*1.16 (1.03–1.32)**	.147	*1.16 (1.02–1.32)**	.123	1.13 (.987 − 1.30)	.077	1.08 (.938 − 1.24)	.070	1.07 (.928 − 1.24)
Approach/Withdrawal	− .065	.937 (.799 − 1.10)	− .100	.905 (.761 − 1.08)	− .095	.909 (.760 − 1.09)	− .062	.940 (.776 − 1.14)	− .051	.951 (.780 − 1.16)
Flexibility/Rigidity	− .142	.867 (.717 − 1.05)	− .113	.893 (.733 − 1.09)	− .006	.994 (.795 − 1.24)	− .023	.977 (.767 − 1.24)	− .055	.946 (.743 − 1.20)
Mood	− .201	.818* (.727 − .921)**	− .182	.833 (.740 − .939)**	− .183	.833 (.736 − .942)**	− .138	*.871 (.767 − .990)**	− .128	*.880 (.773 − .998)**
Rhythmicity Sleep	− .171	*.843 (.710 − .973)**	− .140	.870 (.727 − 1.04)	− .095	.909 (.757 − 1.09)	− .090	.914 (.752 − 1.11)	− .108	.898 (.735 − 1.10)
Rhythmicity Eating	− .002	.998 (.858 − 1.16)	− .041	1.04 (.886 − 1.23)	− .060	1.06 (.898 − 1.26)	− .076	1.08 (.908 − 1.28)	− .075	1.08 (.904 − 1.29)
Flexibility/Rigidity x Mood	− .059	.943 (.900 − .987)**	− .054	*.948 (.902 − .996)**	− .053	*.949 (.902 − .996)**	− .044	*.957 (.907 − .990)**	− .046	*.955 (.904 − .989)**
PARQ (Father)	--	--	.006	1.01 (.991 − 1.02)	.002	1.00 (.986 − 1.02)	.004	1.00 (.987 − 1.02)	.005	1.01 (.987 − 1.02)
PARQ (Mother)	--	--	.017	*1.02 (.980 − .996)**	.013	1.01 (.994 − 1.03)	.005	1.01 (.984 − 1.03)	.002	1.00 (.981 − 1.02)
ASQ	--	--	--	--	.019	*1.02 (1.01–1.04)**	.019	*1.02 (1.01–1.04)**	.019	*1.02 (1.01–1.04)**
MDD	--	--	--	--	--	--	1.85	6.36 (1.51–26.86)**	--	--
MDD Comorbidity	--	--	--	--	--	--	--	--	2.37	10.7 (2.24–51.39)**
p < 0.05; p < 0.01; **p < 0.001

^aAdjusted for all demographic variables and the remaining temperament traits.

PARQ = Parental Acceptance and Rejection Questionnaire; ASQ = Adolescent Stress Questionnaire; MDD = Major Depressive Disorder; MDD Comorbidity = Presence of a second disorder on top of MDD.

Models 1–5 adjusted for all demographic variables (i.e., age, sex, religion, education level, housing type) and other temperament traits (i.e., Activity Level Sleep, Rhythmicity (Daily Habits), Task Orientation). None of these variables were statistically significant (all p > .05).

Note Multicollinearity diagnostics were assessed using the Values of Variance Inflation Factor (VIF), where a score below 2.5 indicates absence of multicollinearity. VIF values of all predictors were below 1.60, indicating our findings were unlikely due to spurious effects.

This study sets out to investigate three main aims. Besides greater perceived parental rejection, higher frequencies of stressful life events, psychiatric disorders, and MDD comorbidity, we expected Asian adolescent suicide attempters to fare significantly worse than non-attempters on four “difficult temperament” traits (i.e., except Approach/Withdrawal). Our first hypothesis was only partially supported, such that suicide attempters were also significantly less approachable than non-suicide attempters. This finding contradicts previous observations that a high withdrawal temperament was protective against suicidality-related stressors among Asian adolescents. There are two possible reasons. With globalization, education systems, school cultures, and parenting styles in traditionally collectivistic societies have shifted towards emphasizing individualism (47). The most recent studies of urban adolescents in China suggested robust negative relations between “withdrawal” and maladjustment (48–50), comparable to the findings of Western individualistic samples (51). Due to the likeness between urban China and contemporary Singapore culture (52), similar inferences may apply to these equally independent Singaporean adolescents. Researchers are encouraged to replicate this observation with adolescent samples in other conservative parts of Asia (e.g., Korea). Otherwise, it is plausible that all five “difficult temperament” traits can be overrepresented even among Asian adolescent suicide attempters. While highly withdrawn Asian adolescents were generally better adjusted in school and at home, they were nonetheless disadvantaged in formal situations whereby they hesitate to participate in organized learning opportunities, teenage romance, and resolving serious peer-to-peer conflicts (53). Such negative experiences could precipitate a cascade of self-esteem or self-competence issues (54). Competitiveness in the contemporary Asian societies may then aggravate the effects of these internalizing problems (55), strengthening the predictability of SAs. Together, this study found that adolescent suicide attempters significantly differed from non-attempters in scores favouring all five “difficult temperament” traits.

Our second hypothesis that the “Low/Negative Mood” trait remained a robust, significant predictor of adolescent SA was supported. Our study extended earlier findings by adjusting for additional risk factors that are important during this vulnerable stage of development (i.e., perceived parental rejection, proximal stressful life events, MDD Comorbidity). Adolescents who experienced more frequent, negative emotions were also inherently less tolerable of them, putting them at risk of using non-suicidal self-injury or SA as a maladaptive emotion regulation strategy (56). This increased risk was also independent of their psychiatric disorders or stressful life events (20). Our final hypothesis that the interaction between “Mood” and “Flexibility (Adaptability)” may be a possible pathway of buffering against SAs was also supported. This finding mirrors previous studies which demonstrated that a “hyperthymic” temperament uniquely reduced the likelihood of SAs even after controlling for sociodemographics, internalizing and externalizing disorders. While we may infer that the interplay between “Positive Mood” and “High Adaptability” underlies the protective role of a hyperthymic temperament, future researchers may further validate this suggestion using confirmatory factor analyses. Neuroimaging studies have somewhat supported this finding by revealing that “Positive Mood” and “Adaptability” temperaments share biological correlates with the personality trait resilience developed at late adolescence or young adulthood (57). Irrespective of flexibility levels, adolescents low in mood were significantly more likely to attempt suicide (Fig. 1), further justifying our earlier results on “Negative Mood” as a direct risk factor. Notably, recent stressful life events (OR: 1.02), MDD (OR: 6.36) or MDD comorbidity (OR: 10.2) also retained their significance in predicting adolescent SAs.

4.1. Implications

This study highlights the importance of early identification of temperament traits among Asian youths. Not only were the “difficult temperament” traits significantly overrepresented among suicide attempters in Asia, but also the temperament trait of “Negative Mood” should warrant greater attention as a robust predictor of adolescent SAs independent of other established high-risk factors. Clinical translations may include involving a collaborative network of school counselors, pediatricians, and general practitioners in the mandatory early screening of these difficult temperaments, especially “Negative Mood” trait. Early identification of this depressive trait could help prevent future SAs through carefully tailored early interventions. As suggested in Rosellini and Bagge (2014), restructuring cognitive vulnerabilities such as feelings of hopelessness can reduce the influence of this trait on adolescent SAs (58). In line with recent research on identifying protective traits within the multifaceted hyperthymic temperament (36), our results on the interaction between “Positive Mood” and “High Flexibility” traits being a protective mechanism challenged previous speculations that a positive outlook alone was sufficient to reduce adolescent SAs. Future researchers may leverage these resilient temperaments to better understand the nature of youth SAs.

4.2. Limitations

Several limitations of the current study should be acknowledged. First, the reporting of adolescent temperament is subject to recall biases. For example, self-reported temperaments could have been the reflections of recent states rather than traits. Nevertheless, temperament traits as measured by the DOTS-R have previously demonstrated excellent stability from early childhood to late adolescence in longitudinal studies (59), while trained research assistants who were present to clarify any queries from the respondent(s) may favour the assessment of traits more than states (60). Secondly, social desirability could have also led to the under-reporting of mental disorders or symptoms. We encourage researchers to replicate our findings using already clinically diagnosed adolescent samples. Thirdly, while our sample size may not be considered small in clinical studies, it is slightly modest compared to recent studies on temperament and suicide (61). Demographics are limited to Singaporean youths, primarily at late adolescence, which limits the generalizability of our findings across all adolescents and those beyond Asia. Possibly, our individualistic, Singaporean sample may also not be representative of highly collectivistic Asian youths. Future studies may consider re-evaluating the relationship between temperaments and SAs with cross-cultural Asian youths. Lastly, the cross-sectional nature meant that we cannot conclude causality between the two. To validate these findings, researchers are highly encouraged to consider examining longitudinal associations between temperament and suicidal behaviours throughout adolescence (e.g., (62))

Overall, this study examined difficult temperament traits, especially “Negative Mood” trait, to be indirect and direct risk factors respectively among Asian adolescent suicide attempters. This study also examined the interactive relationship between “Positive Mood” and “Adaptability” temperament traits as a possible protective pathway against adolescent SAs. Our results advocate for early temperament screening as an important means to adolescent suicide prevention.

Availability of Data and Materials

The datasets generated and/or analyzed during the current study are available from the corresponding author(s) on reasonable requests.

Acknowledgments

The authors would like to acknowledge Professor Tan Chay Hoon (NUH, Pharmacology Department), Ms Pooi Khay Chong (Research Coordinator) and Dr Adrian Loh (Recruitment, Data collection, IMH) for their contributions in the duration of the study project. In addition, the authors would like to thank Dr. Shen Liang (NUS, Medicine Biostatistics Unit) and Ms Yap Qai Ven (NUS, Medicine Biostatistics Unit) for consulting on the interpretation of the results.

Finally, the authors would like to express their fullest gratitude to the Ministry of Social and Family Development for funding this research study, the patients and their family members for their participation, and the National University Hospital’s Emergency Medicine Department and REACH (West) for their assistance in participant recruitment.

Funding

The Singapore Ministry of Community Development, Youth and Sports Family Research Fund awarded the study grant (grant number 2010-3).

Author Information

10.1. Authors and Affiliations

NUS Mind-Science Centre, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Sean Han Yang Toh, Michelle Jing Si Wan, Leoniek Mirjam Kroneman, Nyein Nyein, John Chee Meng Wong.

Department of Psychological Medicine, National University Health Systems, Singapore

Nyein Nyein, John Chee Meng Wong.

Research Department, Intellect Pte Ltd, Singapore.

Sean Han Yang Toh.

Authors’ Contributions

S.H.Y. Toh designed the research study, with support from M.J.S. Wan and J.C.M. Wong. N. Nyein collected all relevant data with supervision from J.C.M. Wong. S.H.Y. Toh led the manuscript development and direction with substantial support from J.C.M. Wong and M.J.S. Wan. S.H.Y. Toh designed the figures, analyzed all data, and interpreted the full results in consultation with L.M. Kroneman and J.C.M. Wong. All authors made substantive suggestions for revision. All authors approved the final submitted version.

Corresponding Author.

Correspondence to S.H.Y. Toh.

Ethics Declaration

Ethics Approval and Consent to Participate.

This study was approved by the National Healthcare Group (NHG) Domain Specific Review Board (DSRB) under the reference code “2010/00567”. All authors confirmed that all methods were carried out in accordance with relevant guidelines and regulations. Written Informed Consent was obtained from all the subjects before the interview. As the subjects were under 18, written informed consent was obtained from the father or mother of participants in a face-to-face position after explaining the purpose of the study. Consent was given prior to commencing study procedures.

Consent For Publication.

Not applicable.

11.2. Conflict of Interests

All authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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No competing interests reported.

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You are reading this latest preprint version

Temperament and Adolescent Suicide Attempts: A Case-Control study with multi-ethnic Asian adolescents

Status:

Journal Publication

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Abstract

Figures

1. Introduction

2. Methods

2.1. Participants and Procedures

2.2. Measures

2.2.1. Demographic Variables.

2.2.2. Suicide Attempts.

2.2.3. Temperament

2.2.4. Psychiatric Disorders

2.2.5. Stressful Life Events

2.2.6. Parental Rejection

2.3. Data Analysis

3. Results

3.1. Risk Factors of Adolescent SAs

3.2. Adjusted Odds Ratios for Adolescent Suicide Attempts.

4. Discussion

4.1. Implications

4.2. Limitations

5. Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1