PEDIATRICS Vol. 108 No. 2
August 2001,
p. e30
ELECTRONIC ARTICLE:
Adoption as a Risk Factor for Attempted Suicide During
Adolescence
Received Dec 27, 2000; accepted Apr 9, 2001.
Gail Slap,
Elizabeth Goodman, and
Bin Huang
From the Division of Adolescent Medicine, Department of
Pediatrics, Children's Hospital Medical Center, University of
Cincinnati College of Medicine, Cincinnati, Ohio.
Objective. Depression, impulsivity,
and aggression during adolescence have been associated with both
adoption and suicidal behavior. Studies of adopted adults suggest that
impulsivity, even more than depression, may be an inherited factor that
mediates suicidal behavior. However, the association between adoption
and adolescent suicide attempts and the mechanisms that might explain
it remain unknown. The objective of this study was to determine the
following: 1) whether suicide attempts are more common among
adolescents who live with adoptive parents rather than biological
parents; 2) whether the association is mediated by impulsivity, and 3) whether family connectedness decreases the risk of suicide attempt regardless of adoptive or biological status.
Methods. A secondary analysis of Wave I data from the
National Longitudinal Study of Adolescent Health was conducted, which
used a school-based, clustered sampling design to identify a nationally representative sample of 7th- to 12th-grade students, with oversampling of underrepresented groups. Of the 90 118 adolescents who completed the National Longitudinal Study of Adolescent Health in-school survey,
17 125 completed the in-home interview and had parents of identified
gender who completed separate in-home questionnaire. The subset of
adolescents for this study was drawn from the in-home sampling
according to the following criteria: 1) adolescent living with adoptive
or biological mother at the time of the interview, 2) adolescent had
never been separated from mother for more than 6 months, 3) mother was
in first marriage at the time of the interview, and 4) the adoptive
mother had never been married to the adolescent's biological father.
Of the 6577 adolescents in the final study sample, 214 (3.3%) were
living with adoptive mothers and 6363 (96.7%) were living with
biological mothers.
Variables. The primary outcome measured was adolescent
report of suicide attempt(s) in the past year. Other variables included
in the analyses were sociodemographics characteristics (gender, age, race/ethnicity, family income, parental education), general health (self-rated health, routine examination in the past year, need for
medical care in the past year that was not obtained), mental health
(depressive symptoms, self-image, trouble relaxing in the past year,
bad temper, psychological or emotional counseling in the past year),
risk behaviors (cigarettes, alcohol, marijuana, sexual intercourse
ever, delinquency, physical fighting in the past year, impulsive
decision making), school-related characteristics (grade point average,
school connectedness), and family interaction (family connectedness,
parental presence, maternal satisfaction with parent-adolescent
relationship).
Data Analysis. Univariate analyses were used to compare
adoptees versus nonadoptees, suicide attempters versus nonsuicide
attempters, and adopted suicide attempters versus nonadopted suicide
attempters on all variables. Variables that were associated with
attempted suicide were entered into a forward stepwise logistic
regression procedure, and variables that were associated with the log
odds of attempt were retained in the model. The area under the model's receiver operating characteristic curve was calculated as a measure of
its overall performance. After the association of adoption with
attempted suicide was demonstrated, the potential mediating effect of
impulsivity was explored by adding it to the model. The same procedure
was followed for any variable that was associated with adoption in the
full sample or the subsample of suicide attempters. To determine
whether any variable in the model moderated the association between
adoption and suicide attempt, the interaction term for that
variable × adoption was forced into the model.
Results. Adoptees differed significantly from nonadoptees
on 4 of 26 variables. They were more likely to have attempted suicide
(7.6% vs 3.1%) and to have received psychological or emotional
counseling in the past year (16.9% vs 8.2%), and their mothers
reported higher parental education and family income. Attempters
differed significantly from nonattempters on all variables except for
age, race/ethnicity, parental education, family income, and routine
examination in the past year. On logistic regression, 9 variables were
independently associated with attempted suicide: depression (adjusted
odds ratio [AOR]: 3.41), counseling (AOR: 2.83), female gender (AOR:
2.31), cigarette use (AOR: 2.31), delinquency (AOR: 2.17), adoption
(AOR: 1.98), low self-image (AOR: 1.78), aggression (AOR: 1.48), and high family connectedness (AOR: 0.60). The receiver operating characteristic curve for the model had an area of 0.834, indicating performance significantly better than chance. The AOR for adoption did
not change when parental education, family income, and impulsivity were
forced into the model. None of the interaction terms (adoption × another risk factor) demonstrated a significant effect.
Conclusions. Attempted suicide is more common among
adolescents who live with adoptive parents than among adolescents who
live with biological parents. The association persists after adjusting
for depression and aggression and is not explained by impulsivity as
measured by a self-reported tendency to make decisions quickly.
Although the mechanism underlying the association remains unclear,
recognizing the adoptive status may help health care providers to
identify youths who are at risk and to intervene before a suicide
attempt occurs. It is important to note, however, that the great
majority of adopted youths do not attempt suicide and that adopted and nonadopted youths in this study did not differ in other aspects of
emotional and behavioral health. Furthermore, high family connectedness decreases the likelihood of suicide attempts regardless of adoptive status and represents a protective factor for all
adolescents.
Key words:
adoption,
suicide attempt,
adolescence,
depression,
aggression,
impulsivity.
