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Research Article                                                                                                                                        Open Access

## Risk factors for suicide attempts in the total population of Faroese eighth graders

Tóra Petersen 1,2* & Ask Elklit 1,3

1 National Centre for Psychotraumatology, University of Southern Denmark, Odense, Denmark 2 The National Hospital of the Faroe Islands, Torshavn, Faroe Islands 3 University of Ulster

*Corresponding author:

tpetersen@health.sdu.dk

## Abstract

Objectives: Suicide is still one of the leading causes of youth mortality, and amongst others previous suicide attempts have been found to  be  one  of  the  strongest  risk  factors  for  suicide.  The  objective  of  this  study  is  to  examine  risk  factors  of suicide attempts in a total population of Faroese adolescents. It is expected that anxious attachment, high scores on negative affectivity  and  low  scores  on  past  and  present  social  support  were  correlated  to  an  increased  risk  of  life-time  suicide attempts in both female and male adolescents.

Method: Analyses were conducted based on data from The Faroese Adolescent Trauma Study, a self-report questionnaire survey including a total population of Faroese eighth graders ( N = 687; 85 % response rate, mean age 14.2 years, SD = 2.1). The questionnaire included The Revised Adult Attachment Scale (RAAS), The Trauma Symptom Checklist (TSC), and The Crisis Support Scale (CSS).

Results: In the total population 9.9 % (N = 68) of the participants reported life-time suicide attempt; of those 28 % were boys and 72 % were girls. In line with the expectations, the initial comparison showed that adolescents reporting life-time suicide attempt had significantly higher scores on attachment anxiety and negative affectivity, and  had significantly lower scores on attachment closeness, and both past and present social support. Further analyses stratified on gender, however, revealed unexpected results, as a high  score on  negative affectivity only was a significant risk factor for life-time  suicide attempt among the girls, and high score on attachment closeness only was a significant protective factor of life-time suicide attempt among the boys.

Conclusions: This study provides important data about the role of attachment, negative affectivity, and social support in suicide attempts in a total population of Faroese adolescents. Moreover the results show the necessity of taking gender into account in research of risk and protective factors of suicide attempts, and when establishing arrangements to prevent and treat suicide attempts in adolescents.

Keywords: Risk factors, suicide attempt, negative affectivity, adolescents, social support

## Introduction

Although the number of completed youth suicides has declined during recent years, suicide is still one of the leading causes of youth  mortality (1,2). Motivated by this fact and by an identified growth in  suicide  attempts  among  youths,  the  number  of studies of the prevalence and etiology of suicide has risen (3). Although the majority of suicide attempts are  of  low  lethality  (4),  previous  suicide  attempts have been  shown  to  be  one  of  the strongest predictors of future attempts and completions (5).

A  suicide  attempt  is,  by  nature,  very  distressing. Being in a state of mind in which a suicide attempt is  part  of the behavioral repertoire may prevent an adolescent  from  living  a  healthy  life  and  lead  to maladaptive trajectories that emerge during an important developmental period of life. Therefore, the prevention and treatment of suicide and suicide attempts are of utmost importance, and studies that have increased the knowledge of related risk factors have yielded significant contributions to this field.

Epidemiologic studies have demonstrated a range of 3% to 15% for lifetime rates of suicide attempts

(6) when national, ethnic, and gender differences in the variance of the prevalence have been identified (6,7).

Contrary to this, we found no significant national differences in suicide attempt levels among adolescents  examined  with  the  use  of  the  same questionnaire  in  three  Scandinavian  and  European probability samples and one total population sample (8).  Of  the  1466  adolescents  who  were  14  and  15 years,  125  reported  one  or  more  suicide  attempts, and the prevalence ranged from 6% (Denmark and Lithuania) to 10% in Iceland and the Faroe Islands.

The purpose of this article is to contribute to the extant  research  of  risk  factors  for  suicide  attempts based on data from the total population of Faroese eighth  graders  who  participated  in  The  Faroese Adolescent Trauma Study.

Adolescence is frequently described as a vulnerable period that is characterized by intrapersonal and interpersonal changes (9,10), and numerous studies have shown a correlation between depression and suicide (11). In an attempt to identify risk factors for adolescent suicide attempts, the literature has also reported other variables, such as  female  gender,  psychopathology,  low  tolerance for  stress,  and  frustration  and  loneliness  (10-20). The majority of studies of suicide attempts, however, are based on small or convenience samples; only very few are based on national surveys (21). Although research into the risk factors of  suicide  has  increased,  too  many  studies  have focused  solely  on  psychopathology  (10),  thereby underlining the importance of applying multifaceted approaches (21). A more complex and multivariate distinction between the triggers of suicidal behavior and their underlying causes has been suggested (10). Accordingly, studies have identified strained relationships with parents and difficult family histories as risk  factors for  suicide  and  suicide attempt among adolescents (10).

One possible underlying mechanism for explaining  these  correlations  may  be  attachment. Attachment theory is the joint work of John Bowlby and Mary Ainsworth, and it was originally developed to describe attachment patterns between caregiver  and  child  (22-24).  The  original  theory suggests that early in life, through interactions with a caregiver, children develop internal working models of themselves and of others that characterize how threats are perceived, how stress is responded to, and how emotions are regulated (2527). Two attachment dimensions have been agreed upon:  the  anxiety  dimension  and  the  avoidance dimension. The anxiety dimension is described as a positive  or  negative  view  of  the  self  that  indicates how  one  sees  others'  availability  and  how  one requires the positive regard of others. The avoidance  dimension  is  described  as  a  positive  or negative view of others that indicates how comfortable one is with closeness to and dependence  on  others.  These  attachment  patterns are  thought  to  be  relatively  stable  throughout  life (27), although some studies have shown that interpersonal trauma may have a negative impact on attachment (28). Recently, attachment studies have taken  a  broader  perspective,  and  studies  of  adults (29) and adolescents (30) have shown attachment to be related to both psychological and social functioning.  There  has  been  increased  focus  on obtaining empirical data that contribute to a better understanding of attachment's relevance to the development of psychopathology (31-33). Nevertheless, more research still is needed.

Studies of the relationship between suicide attempts and attachment as a risk factor are scarce (29),  although  some  results  suggest  that  anxious attachment  may  be  an  underlying  risk  factor  for suicidal  behavior  in  depressed  individuals.  A  study of 524 adult patients with major depression (mean age, 37 years; standard deviation, 13.3 years) showed that anxious attachment was a strong risk factor for suicidal  behavior  (29),  whereas  other  studies  that include  older  participants  identified  anxious  and avoidant  attachment  styles  to  be  risk  factors  for suicide attempts later in life (34,35). Although literature  regarding  attachment  in  general  among adolescents is limited (36), the importance of studying  the  relationship  between  attachment  and suicide attempts among  adolescents is evident. Adam and colleagues  (37)  studied  adolescents  and found  that  those  with high scores for suicidal behavior were significantly more likely to be characterized as having a preoccupied or unresolved attachment  style.  Limited  studies  have  suggested  a significant relationship between insecure attachment style,  interpersonal problems, and psychopathology in  adolescents.  However,  the  results  have  been somewhat divergent (30).

Although  most  attachment  research  focuses  on childhood  or  adult  attachment,  attachment  during adolescence  has  been  shown  to  have  a  central motivational  role  (31).  The  cognitive  development that  occurs  during  adolescence,  the  acquiring  of new reflective capacities and the movement toward formal operational thinking opens up the opportunity for a revision and consolidation of the internal working models (31). A greater understanding of adolescent attachment, psychopathology, and suicidal behavior may contribute  to  knowledge-based  early  intervention and prevention in this area.

Aim of the study

The  aim  of this study is to examine  possible underlying risk factors for suicide attempts in a total population of Faroese adolescents.  The  chosen variables  are  attachment,  negative  affectivity,  and past and present social support. It is expected that anxious attachment, high scores for negative affectivity, and low scores for social support correlate  with  an  increased  risk  of  lifetime  suicide attempts in both girls and boys.

## Method

Procedure

The data used in this article were obtained from the self-report  questionnaire  survey  used  in  the  The Faroese Adolescent Trauma Study, which was conducted in 2006 (8). The Faroe Islands are in the North  Atlantic, and  they  consist of 18  islands inhabited  by  approximately  48,000  people  (38).  In the Faroe Islands, education is compulsory until the ninth grade. In 2006, the public school system was the only teaching offered in the country and therefore  included  all  Faroese  adolescents.  All  20 schools  that  were  teaching  eighth  graders  were contacted,  and  all  but  one  (with  only  one  eighthgrade  student)  agreed  to  participate.  The  schools were situated on the six largest islands. Letters that explained the survey, the possibility of not participating, and the anonymity of the participants were sent to the headmasters, who further distributed  these  letters  to  the  students  and  their parents.  On  the  day  of  the  data  collection,  the researchers  went  out  to  the  schools  to  ensure  that the students once again received appropriate instructions. The students filled out the questionnaires in their classrooms, and the researchers  were  present  to  ensure  confidentiality and  to  seal  the  questionnaires  in  a  box  in  each classroom. The study was approved by the Faroese Data Protection Agency and the Faroese Ministry of Education (8,39).

## Measures

The  total questionnaire consisted of self-report measurements  that  had  previously  been  used  to measure various  psychological  and  social  variables. The measurements were translated from English to the  Faroese  language,  and  native  Faroese  clinical psychologists working in the Faroe Islands conducted the translation. Back-translation was also conducted  and  led  to  minor  corrections.  The  first part of the questionnaire contained questions about gender, age, and living arrangements (i.e., living with both parents, one parent, or others, such as grandparents or in an institution).

Lifetime  suicide  attempt  rate  was  measured  with one  item:  'Have  you  had  a  suicide  attempt?'  It therefore  was  left  to  each  adolescent  to  define whether his or her experience could be categorized as a suicide attempt. However, the authors use the definition  described  by  Silverman  and  colleagues (40):  'Suicide  attempt  is  defined  as  a  self-inflicted, potentially injurious behavior with a nonfatal outcome for which there is evidence (either explicit or implicit) of intent to die.'

The Revised Adult Attachment Scale (41,42) is an 18-item self-report scale based on attachment theories (23,25) that measures an individual's attachment and closeness to significant others. The items  are  scored  on  a  five-point  Likert  scale  that ranges  from  'Not  at  all  characteristic  of  me'  (this was  scored  as  a  1)  to  'Very  characteristic  of  me' (this  was  scored  as  a  5).  The  attachment  anxiety subscale consisted of six items (Cronbach's alpha = 0.82).  The  attachment  closeness  and  dependency subscale consisted of 12 items (Cronbach's alpha = <0.45). However, after excluding item number 6 ('I am afraid if people come too close to me') and item number 18 ('I am sure that people are there when I need  them'),  the  reliability  became  moderate  (43) (Cronbach's alpha = 0.65).

The  Trauma  Symptom  Checklist  (44)  is  a  selfreport scale that measures general distress symptoms  on  a  four-point  Likert  scale,  with  1 indicating  that  a  statement  is  never  true  and  4 indicating  that  it  is  true  almost  all  the  time.  The negative affectivity and somatization subscales have been identified as having good internal consistency, reliability,  and  factorial  and  criterion  validity  (45). Negative affectivity refers to a general tendency to have negative  view  of  and  reactions  toward  oneself  and the  surrounding  environment.  The  subscale  that measures negative affectivity consists of nine items such as 'Do you have a bad appetite or have you lost weight?' 'Do you feel sad?,' and 'Do you have feelings of inferiority?' The internal consistency of this checklist as measured by Cronbach's alpha was 0.78.

The  Crisis  Support  Scale  (46),  which  involves  a seven-point  Likert  scale,  is  a  self-report  scale  that was used to measure social support. The scale has seven  items, including the  following:  'Are  you satisfied  with  the  support  you  received?'  'Whenever you want to talk, how often is someone willing to  listen?,'  and  'Are  people  helpful  in  a  practical sort of way?' The participants were asked to make self-reports using statements that ranged 'Not at all characteristic  of  me'  (this  was  scored  as  a  1)  to 'Very characteristic of me' (this was scored as a 7). The mean sum score for the study population was 32.00 (standard deviation, 7.07) and the Cronbach's alpha was moderate (0.71) (43). The Crisis Support Scale  has  been  used  in  trauma  studies  (47),  and  it has been demonstrated to have good internal consistency and discriminatory power (48).

## Participants

All  but two pupils were permitted by their parents to participate in the study, and the response rate was 85%  (N  =  687).  The  remaining  15%  of  students were not in school on the day of the data collection. The  mean  age  was  14.2  years  (standard  deviation, 2.1 years), and the gender distribution was 320 boys (46.6%) and 353 girls (51.4%). Fourteen adolescents (2%)  did  not  state  their  gender.  Six  hundred  and seventy-nine  participants  (99%)  stated  with  whom they  lived.  The  majority  lived  with  both  of  their parents (N = 562, 82%), and a minority lived with one parent (N = 111, 16%). One percent (N = 6) had other arrangements, such as living with grandparents or in a children's home, and 1% (N = 8) did not state where they lived.

## Analyses

Initially, one-way analyses of variance were conducted  to  compare  the  mean  scores  of  the variables for boys versus girls. To look more closely at  the  variable  scores  among  those  adolescents reporting  lifetime  suicide  attempts,  independent ttests  were  conducted  on  the  psychological  and social  variables  to  compare  boys  and  girls.  Binary logistic  regression  analyses  were  conducted  with lifetime  suicide  attempt  as  the  dependent  variable, and finally the model was stratified for gender. All analyses  were  conducted  with  the  use  of  SPSS software (version 21). Only subjects who  had answered all the questions in the separate questionnaires were included in the analyses, so the values of N vary and are stated in every table.

## Results

The one-way analyses of variance (Table 1) conducted  on  all subjects showed  a  significant difference  between  boys  and  girls  with  regard  to attachment  anxiety  scores  and  negative  affectivity, with  the  girls  reporting  significantly  higher  scores. The  analyses  also  revealed  that  the  girls  reported significantly  higher  scores for present and  past social support.

## Suicide attempts

Of  the  participants  in  this  study,  9.9%  (N  =  68) reported lifetime suicide attempts. Of those respondents, 27.9% (N = 19) were boys and 72.1% (N = 49) were girls.

Only those who answered all of the questions in the separate questionnaires were included in further analyses;  these  additional  analyses  were  conducted on 52 subjects. The subjects composed 76.5% of all subjects  reporting  lifetime  suicide  attempts;  26.9% (N = 14) of those 52 were boys, and 73.1 % (N = 38) were girls. Initial  analysis  (not  shown)  revealed that  the  adolescents  who  reported  lifetime  suicide attempts had significantly higher scores in the areas of  attachment  anxiety  and  negative  affectivity  and significantly lower scores in the areas of attachment closeness/dependency  and  past  and  present  social support  compared  with  adolescents  who  did  not report  lifetime  suicide  attempts.  To  study  possible gender differences in these findings, independent t -tests  of  the  psychological  and  social  variable  mean scores  were  conducted  after  separating  boys  and girls  with  and  without  lifetime  suicide  attempts (Table 2). These analyses revealed interesting gender differences: no significant differences were found in the mean scores of attachment anxiety and present social  support  among  the  boys  with  and  without lifetime  suicide  attempts,  whereas  the  girls  with lifetime  suicide  attempts  had  significantly  higher mean scores in the area of attachment anxiety and significantly lower mean  scores  in the area of present social support.

TABLE 1 Gender differences for a number of study factors

| Variable                        | Gender (N)                         | Mean           | SD          |   F value |   p value |
|---------------------------------|------------------------------------|----------------|-------------|-----------|-----------|
| Age                             | Boys (320)                         | 14.3           | 1.3         |      0.26 |      .610 |
| Attachment anxiety              | Girls (353) Boys (320) Girls (353) | 14.4 14.2 16.7 | 1.2 6.2 6.1 |     27.45 |     .0005 |
| Attachment closeness/dependency | Boys (285) Girls (321)             | 39.9 39.6      | 5.3 5.3     |      0.73 |      .390 |
| Negative affectivity            | Boys (274) Girls (296)             | 21.2 25.5      | 5.7 6.9     |     66.24 |     .0005 |
| Past social support             | Boys (239) Girls (276)             | 30.9 32.5      | 7.3 7.4     |      6.06 |      .010 |
| Present social support          | Boys (249) Girls (269)             | 31.2 32.9      | 7.0 7.0     |      7.54 |      .006 |

Note. SD = Standard Deviation

TABLE 2 Comparisons of participants with and without suicide attempts

| Variable                        | Gender     | Suicide attempt   | N*         | Mean score (SD)                  | F value   | p value    |
|---------------------------------|------------|-------------------|------------|----------------------------------|-----------|------------|
| Attachment anxiety              | Boys       | No Yes            | 301 19     | 14.2 (6.0) 14.8 (8.8)            | -0.4      | .677       |
|                                 | Girls Boys | No Yes No         | 304 49 273 | 16.2 (5.8) 19.5 (6.8) 40.2 (5.1) | -3.5 4.0  | .0005 .005 |
| Attachment closeness/dependency | Girls      | Yes No Yes        | 15 280 44  | 34.7 (5.8) 39.9 (5.1) 37.1 (5.5) | 3.4       | .001       |
| Negative affectivity            | Boys       | No Yes            | 301 19     | 19.8 (6.8) 25.7 (8.7)            | -3.6      | .0005      |
| Past social support             | Girls      | No Yes            | 304 49 221 | 23.3 (7.0) 32.1 (7.8)            | -8.7      | .0005      |
|                                 | Boys       | No Yes No         | 18 232     | 31.2 (7.2) 27.0 (8.6)            | 2.4       | .019       |
| Present social support          | Girls      | Yes               | 44         | 33.3 (7.0) 28.5 (8.2)            | 4.0       | .0005      |
|                                 | Boys       | No Yes            | 233 18     | 31.4 (6.8) 28.1 (9.5)            | 1.9       | .058       |
|                                 | Girls      | No Yes            | 231 43     | 33.6 (6.5) 28.4 (8.0)            | 4.6       | .0005      |

*Only those who filled out all questions in the distinct questionnaires are included

Note.

SD = Standard Deviation To  analyze  the  contribution  of  each  variable  to the risk of lifetime  suicide attempts, we conducted binary  regression  analyses  with  suicide  attempts  as the  dependent  variable  (Table  3).  Seven  variables included in the model explained 29%  of the variance: gender, age, attachment anxiety, attachment closeness/dependency, negative affectivity,  and  past  and  present  social  support. Higher age and higher attachment closeness/ dependency scores had a weak protective effect on the likelihood of a suicide attempt, whereas a high score for negative affectivity was a risk factor for a suicide attempt. The other variables were not significant, although past social support had a weak protective effect that came close to significant level ( p = .06).

TABLE 3 . Binary logistic regressions of suicide attempts

Model summary: Nagelkerke R 2 = 0.29; p < .0005; N = 476; reported suicide attempts, N = 52

| Variables                       |   Exp (β) |   p value | 95% CI       |
|---------------------------------|-----------|-----------|--------------|
| Gender (1 = boy; 2 = girl)      |      0.60 |      .190 | [0.28, 1.28] |
| Age                             |      0.81 |      .020 | [0.67, 0.96] |
| Attachment anxiety              |      1.02 |      .660 | [0.94, 1.10] |
| Attachment closeness/dependency |      0.93 |      .040 | [0.86, 1.00] |
| Negative affectivity            |      1.12 |     .0005 | [1.06, 1.18] |
| Past social support             |      0.95 |      .060 | [0.90, 1.00] |
| Present social support          |      1.01 |      .790 | [0.95, 1.07] |

Note. CI = confidence interval

The  interaction  analyses  shown  in  Table  4  were conducted with the use of past suicide attempts as the dependent  variable.  These  analyses  showed significant interactions between attachment closeness/dependency and gender and between negative affectivity and gender.

TABLE 4 . Interaction analysis with gender

Model summary: Nagelkerke R 2 = 0.34; p < .0005; N = 476; reported suicide attempts, N = 52

| Variables                                |   Exp (β) |   p value | 95% CI       |
|------------------------------------------|-----------|-----------|--------------|
| Attachment anxiety * gender              |      0.95 |      .550 | [0.80, 1.13] |
| Attachment closeness/dependency * gender |      1.22 |      .020 | [1.04, 1.45] |
| Negative affectivity * gender            |      1.15 |      .020 | [1.02, 1.29] |
| Past social support * gender             |      0.89 |      .090 | [0.77, 1.02] |
| Present social support * gender          |      1.09 |      .220 | [0.95, 1.25] |

Binary logistic regression analyses were conducted for boys and girls separately, again with the use of a past suicide attempt as the dependent variable. The results presented in Table 5 show that a high score for attachment closeness/dependency was a significant  protective  factor  among  boys  (but  not among  girls)  and  that  negative  affectivity  was  a significant risk factor for girls (but not boys).

TABLE 5 . Binary logistic regressions of suicide attempts by gender Boys Model summary: Nagelkerke R 2 = 0.16; p <0 .0005; reported suicide attempts, N = 19

| Variables                       |   Exp (β) |   p value | 95% CI       |
|---------------------------------|-----------|-----------|--------------|
| Attachment closeness/dependency |      0.84 |      .005 | [0.75, 0.94] |
| Negative affectivity            |      1.04 |      .290 | [0.96, 1.13] |

Girls

Model summary: Nagelkerke R 2 = 0.30; p < 0.0005; reported suicide attempts, N = 49

| Variables                       |   Exp (β) |   p value | 95% CI       |
|---------------------------------|-----------|-----------|--------------|
| Attachment closeness/dependency |      0.96 |      .370 | [0.90, 1.04] |
| Negative affectivity            |      1.19 |     .0005 | [1.12, 1.26] |

Note. CI = confidence interval

## Discussion

The  prevalence  of  suicide  attempts  among  the Faroese  adolescents  in  the  present  study  is  very much in line with what Weihe (49) found in three total  population  studies  of  Faroese  ninth  graders conducted  in  2003,  2007  and  2011,  in  which  the prevalence  of  suicide  attempts  was  approximately 9% to 12%. Despite the fact that the importance of implementing  multifaceted  approaches  to  reduce suicidal  behavior  has  been  underlined,  studies  of risk  factors  for  suicide  attempts  and  completed suicides have provided conflicting results. The relationship  between  risk  factors  and  suicide  thus has proven to be complex (21,50). The aim of the present  study  was  to  examine  possible  underlying risk factors for suicide attempts in the total population of Faroese adolescent boys and girls. We included  psychological  attachment;  although  this has been only sparsely described in the literature, it may  be  an  important  variable  that  contributes  to adolescent suicide. Alternatively, gender differences with  regard  to  the  incidence  and  prevalence  of suicidal  behavior  have  been  well  described  in  the literature, although the results have been diverse. As compared with the present study, in which 72% of the subjects reporting lifetime suicide attempts were girls and 28% were boys, other studies conducted in the United States and Canada have shown rates of suicide attempts to be two to three times higher for adolescent  girls  as  compared  with  adolescent  boys (4,6,51). In fact, studies of older and mainly Caucasian  adolescents  (mean  age,  19.6  years)  have found  that  boys  report  significantly  more  suiciderelated  behaviors  as  compared  with  girls  (52).  Age was found to have an independent protective effect on the risk of lifetime suicide attempt in the present study,  although  this  is  in  opposition  with  other studies,  which  have  shown  suicidal  behavior  to  be more prevalent among older adolescents and young adults  (53).  However,  the  age  span  in  the  present population  is  very  small  as  compared  with  other studies,  which  have  included  populations  with  an age span of five to ten years. This may indicate that the  protective  effect  of  older  age  found  in  the present  study  would  vanish  if  the  age  group  had been broader.

Psychiatric disorders and  especially  depression have  been  shown  to  be  among  the  strongest  risk factors  for  suicide  among  youth  of  both  genders (14). Other studies of adolescents have demonstrated  school and parent connectedness, good peer relations, and high school functioning to be  protective  factors  against  suicide  (54).  This  is somewhat in line  with  the  present  study,  in  which the initial analyses demonstrated that the adolescents  reporting  lifetime  suicide  attempts  had higher  scores  for  negative  affectivity  and  lower scores  for  both  past  and  present  social  support  as compared with those without lifetime suicide attempts.  Although  negative  affectivity  does  not equal  depression,  many  of  the  questions  in  the subscale that measures negative affectivity encompass  symptoms  of  depression  as  defined  by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (see the Measures  section of this article). The initial analyses in the present study also found  that  adolescents  with  suicide  attempts  had significantly  higher  scores  for  attachment  anxiety and significantly lower scores for attachment closeness/dependency. This is comparable with previous studies, which showed that a low tolerance for stress and frustration, strained relationships with parents, and difficult family histories-all of which are  correlated  with  unsecure  attachment-are  risk factors  for  suicide  and  suicide  attempts  among adolescents  (10).  However,  when  further  analyses were  conducted  in  the  present  study  and  included all of the variables in one  regression analysis, gender,  attachment  anxiety,  and  past  and  present social support lost their significant contributions to the rate of suicide attempts. Furthermore, stratification on the basis of gender revealed somewhat  unexpected  gender  differences:  a  high score in the area of attachment closeness/ dependency  was  only  a  protective  variable  among boys,  whereas  a  high  score  in  the  area  of  negative affectivity  was  only  a  risk  factor  among  girls.  The absolute  mean  scores  for  attachment  closeness/ dependency  among  boys  and  girls  in  the  present study were  similar, whereas  the  absolute  mean scores for negative affectivity were  significantly higher  among  girls  as  compared  with  boys.  The finding  that  high  scores  in  the  area  of  attachment closeness/dependency  only  had  a  protective  effect against  the  risk  of  suicide  attempts  among  boys  is somewhat contrary to the results of a pilot study in a clinical population of 35 adolescents (50). However, contrary the present study, this study did not examine  gender as a possible contributing variable,  which  may  explain  the  divergent  results. Wright and colleagues (50) identified three groups: 1)  a  clinical  group  with  high  suicide  risk  (N  =  10; mean age, 16.9 years), in which the majority (60%) was characterized by a preoccupied attachment style and in which the remaining individuals (40%) were characterized by an avoidant attachment style; 2) a clinical  group with low suicide risk (N = 15; mean age,  17.5  years),  in  which  the  majority  (58%)  was characterized  by  an  avoidant  attachment  style;  and 3)  the  control  group,  in  which  the  vast  majority (70%)  was  characterized  by  a  secure  attachment style (50).

In  the  present  study,  only  adolescent  boys  with high  scores  in  the  area  of  attachment  closeness/ dependency had a lowered risk for lifetime suicide attempts, which means that only boys with a secure or  a  preoccupied  attachment  style  (and  not  girls) had a lowered risk. Alternatively, only girls (and not boys)  with  high  scores  for  negative  affectivity  had an increased risk of a lifetime suicide attempt. The pilot study mentioned previously did not report the specific psychopathology of the clinical populations or discuss the analyses of the distribution of attachment  styles on  the basis of gender  (50). Another  study  has  shown  that  adolescents  with  a preoccupied attachment style and passive and enmeshed mothers had higher levels of depression (55); other studies have indicated that anxious attachment  could  be  a  causal  factor  of  depression (56). However, a common  limitation of those studies is that gender is not included as a variable in their  analyses.  The  present  study  indicates  that  the impact  of  attachment  as  a  risk  factor  for  lifetime suicide  attempts  may  be  dependent  on  gender.  In comparison, a survey found that high social capital as  measured  by  the  perception  of  an  individual's trustworthiness  and  helpfulness  toward  others  at school  was  a  stronger  protective factor against suicide attempts among girls as compared with boys (51).  Anxious  attachment  could  be  the  common underlying risk factor for both  depression  and suicide  attempts.  The  presented  results  emphasize the  importance  of  future  research  to  take  gender into account when studying attachment as a possible  risk  factor  for  suicide  attempts  and  when studying  attachment  in  general.  Attachment  style has been found to be associated with affect regulation (26,27). Although general attachment research  has  concluded  that  clinical  populations seem  to  be  overrepresented  by  individuals  with insecure attachment types, no systematic correlations  between  distinct  psychopathology  and distinct insecure attachment types have been identified (50). It could be fruitful for future research to examine whether attachment organization is related to gender and whether attachment behavior and mental representations are expressed differently among boys as compared with girls.

## Limitations

It  is  important to note that the present study does have some limitations. Although they are less time consuming  and  less  expensive,  self-report  tests  of attachment in adolescents have also been criticized for  possibly  not  being  able  to  capture  the  more subtle characteristics of attachment; therefore, timeconsuming interviews are often recommended (32). However,  the  use  of  self-report  assessment  in  the present  study  made  it  possible  to  study  a  total population of Faroese adolescents and thereby gather  data  about  a  broad population. The  initially low  reliability  of  the  closeness/dependency  scale, which  consisted  of  twelve  items,  is  a  limitation  of measures;  however,  reliability  was  improved  when two  items  were  excluded.  The  low  reliability  may possibly be explained by the presence of a different way  in understanding the questions concerning closeness  and  dependency  among  adolescents  as compared  with  adults.  Collins  and  colleagues  (57) proposed  that  adolescent  girls  may  interpret  the closeness questions as looking for information about  sexual  rather  than  emotional  connections. Another  limitation  involves  the  fact  that  a  suicide attempt  is  solely  rated  according  to  self-judgment and only addressed by one questionnaire item. No additional definition of the question (see the Measures  section  of  this  article)  was  provided  for the  participants,  so  it  is  possible  that  reports  of lifetime  suicide  attempts  in  the  present  study  may include  adolescents  who  reported  intentional  and non-intentional self-injury and not just suicidal behavior (40,58). This leads to the recommendation that the present results be replicated with the use of more comprehensive measures of suicidal behavior. The  low  number  of  boys  who  reported  suicide attempts is another limitation of the present study, because this may influence the results of the analysis and the possibility of reaching the level of significance.  A  final  limitation  is  that  the  present study does not include measurements of psychopathology. Future studies should include measurements of mental illnesses such as depression, post-traumatic stress disorder, and anxiety.

## Conclusions

The present study provides important data regarding the roles of attachment anxiety and attachment closeness/dependency, negative affectivity,  and  past  and  present  social  support  in the risk for suicide attempts among Faroese adolescents. Moreover, it reveals a possible important gender difference in these relations. The analysis  involving  the  whole  population  of  eighth graders-including both adolescents with and without lifetime suicide  attempts-demonstrated that the absolute  mean  scores  in  the  areas of attachment  anxiety,  negative  affectivity,  and  past and present social support were significantly higher among  girls  as  compared  with  boys.  Alternatively, the absolute mean scores in the area of attachment closeness/dependency  were  similar for the  two genders. Further analyses that compared adolescents with lifetime suicide attempts with those  adolescents  without  such  suicide  attempts pointed at more gender differences, including in the areas of psychosocial variables and their effects on the risk of suicide attempts.  The  final analysis showed that attachment closeness/dependency only had a  protective  effect  on  suicide  attempts  among the boys and that negative affectivity only enhanced the  risk  of  suicide  attempt  among  girls.  Therefore, the results demonstrate  the  necessity of taking gender  into  account  in  future  research  and  when establishing arrangements to prevent suicide.

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