Gatekeeper-training programs, designed to increase identification and referral of suicidal individuals, are widespread but largely untested. A group-based randomized trial with 32 schools examined impact of QPR (Question, Persuade, Refer) training on a stratified random sample of 249 staff with one-year average follow-up. To test QPR impact, we introduced and contrasted two models of gatekeeper-training effects in a population: Gatekeeper Surveillance and Gatekeeper Communication. Intent-to-treat analyses showed that training increased self-reported knowledge (ES 0.41) and appraisals of efficacy (ES 1.22) and service access (ES 1.07). Training effects varied dramatically. Appraisals increased most for staff with lowest baseline appraisals, and suicide identification behaviors increased most for staff already communicating with students about suicide and distress. Consistent with the Communication model, increased knowledge and appraisals were not sufficient to increase suicide identification behaviors. Also consistent with the Communication model were results from 2,059 8 th and 10 th graders surveyed showing that fewer with prior suicide attempts endorsed talking to adults about distress. Skill training for staff serving as 'naturalgatekeepers' plus interventions that modify students' help-seeking behaviors are recommended to supplement universal gatekeeper training.

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.

Study I examined relationships between an interview measure of children's future expectations and variables reflecting self-system functioning with 136 9–11-year-old urban children exposed to high psychosocial stress. As expected, future expectations related to affect regulation, self-representations, and school adjustment. Study II, done with a subsample of the original group, showed that early positive future expectations predicted enhanced socioemotional adjustment in school and a more internal locus of control 2½–3½ years later and acted as a protective factor in reducing the negative effects of high stress on self-rated competence. These findings: (a) are consistent with prior data showing positive expectations to be characteristic of resilient children; (b) suggest that early positive future expectations influence later adjustment; and (c) underscore the role children have in actively structuring their environments and, thus, influencing their development. The heuristic value of the construct of self for future studies of resilience is suggested, and implications for preventive interventions are considered.

This study investigated the relation between suicide attempts and immigrant generation status using the Latino subset of the National Longitudinal Study of Adolescent Health, a school-based, nationally representative sample. This study also examined whether generation status predicted risk factors associated with elevated suicide behaviors, namely illicit substance use, problematic alcohol use, and depressive symptoms. Finally, hypothesizing that elevated depressive symptoms and substance use mediate the relation between immigrant generation status and suicide attempts among Latino adolescents, a path model was tested. Our findings revealed immigrant generation status was a determinant for suicide attempts, problematic alcohol use, repeated marijuana use, and repeated other drug use for Latino adolescents. US-born Latinos with immigrant parents (i.e., second-generation youth) were 2.87 (95% CI, 1.34, 6.14) times more likely to attempt suicide, 2.27 (95% CI, 1.53, 3.35) times more likely to engage in problematic alcohol use, 2.56 (95% CI, 1.62, 4.05) times more likely to engage in repeated marijuana use, and 2.28 (95% CI, 1.25, 4.17) times more likely to engage in repeated other drug use than were foreign-born youth (i.e., first-generation youth). Later-generations of US-born Latino youth with US-born parents were 3.57 (95% CI, 1.53–8.34) times more likely to attempt suicide, 3.34 (95% CI, 2.18–5.11) times more likely to engage in problematic alcohol use, 3.90 (95% CI, 2.46, 6.20) times more likely to engage in repeated marijuana use, and 2.80 (95% CI, 1.46, 5.34) times more likely to engage in repeated other drug use than were first-generation youth. Results from the path analysis indicated that repeated other drug use may mediate the effect of generation status on suicide attempts.

Randomized field trials provide unique opportunities to examine the effectiveness of an intervention in real world settings and to test and extend both theory of etiology and theory of intervention. These trials are designed not only to test for overall intervention impact but also to examine how impact varies as a function of individual level characteristics, context, and across time. Examination of such variation in impact requires analytical methods that take into account the trial's multiple nested structure and the evolving changes in outcomes over time. The models that we describe here merge multilevel modeling with growth modeling, allowing for variation in impact to be represented through discrete mixtures-growth mixture models-and nonparametric smooth functions-generalized additive mixed models. These methods are part of an emerging class of multilevel growth mixture models, and we illustrate these with models that examine overall impact and variation in impact. In this paper, we define intent-to-treat analyses in group-randomized multilevel field trials and discuss appropriate ways to identify, examine, and test for variation in impact without inflating the Type I error rate. We describe how to make causal inferences more robust to misspecification of covariates * Corresponding author. Tel.: +1 813 974 6672. E-mail address: hbrown@health.usf.edu (C.H. Brown). Conflict of InterestAuthor Muthén is a co-developer of Mplus, which is discussed in this paper. There are no conflicts of interest. in such analyses and how to summarize and present these interactive intervention effects clearly. Practical strategies for reducing model complexity, checking model fit, and handling missing data are discussed using six randomized field trials to show how these methods may be used across trials randomized at different levels. NIH Public Access

In this article, we present a discussion of two general ways in which the traditional randomized trial can be modified or adapted in response to the data being collected. We use the term adaptive design to refer to a trial in which characteristics of the study itself, such as the proportion assigned to active intervention versus control, change during the trial in response to data being collected. The term adaptive sequence of trials refers to a decision-making process that fundamentally informs the conceptualization and conduct of each new trial with the results of previous trials. Our discussion below investigates the utility of these two types of adaptations for public health evaluations. Examples are provided to illustrate how adaptation can be used in practice. From these case studies, we discuss whether such evaluations can or should be analyzed as if they were formal randomized trials, and we discuss practical as well as ethical issues arising in the conduct of these newgeneration trials.

Suicide is a leading cause of death among youth worldwide. The purpose of the current review was to examine recent cross‐national trends in suicide mortality rates among 10‐ to 19‐year‐olds. This study extracted suicide mortality data from the World Health Organization's (WHO) Mortality Database for the most recent year (since 2010) from any country with available high‐quality data (as defined by the WHO's guidelines). Data on access to lethal means (firearms, railways) and measures of economic quality (World Bank Income Group) and inequality (Gini coefficients) were obtained from publicly available data sources. Cross‐national suicide mortality rates in youth were heterogeneous. The pooled estimate across all ages, sexes, and countries was 3.77/100,000 people. The highest suicide rates were found in Estonia, New Zealand, and Uzbekistan. Suicide rates were higher among older compared with younger adolescents and higher among males than females. The most common suicide methods were hanging/suffocation and jumping/lying in front of a moving object or jumping from a height. Firearm and railway access were related to suicide deaths by firearms and jumping/lying, respectively. Economic quality and inequality were not related to overall suicide mortality rates. However, economic inequality was correlated with a higher ratio of male:female suicides. This study provides a recent update of cross‐national suicide trends in adolescents. Findings replicate prior patterns related to age, sex, geographic region, and common suicide methods. New to this review are findings relating suicide method accessibility to suicide mortality rates and the significant association between income inequality and the ratio of male:female suicide. Future research directions include expanding the worldwide coverage to more low‐ and middle‐income countries, examining demographic groupings beyond binary sex and to race/ethnicity within countries, and clarifying factors that account for cross‐national differences in suicide trends.

Adolescent suicide is a major public health concern. Stressing the need for public health-based solutions, the Centers for Disease Control and Prevention identified "connectedness" as one means of pursuing this agenda. To advance this effort in suicide prevention with adolescents, (1) consistencies and variation in the literature overtly linking connectedness to suicide thoughts and behaviors (STB) are reviewed, (2) three more specific mechanistic pathways are proposed whereby connectedness may influence STB, and (3) several implications related to use of connectedness as a public health framework for adolescent suicide prevention and intervention are outlined.