The power of being there when it matters

You began your research career studying child abuse and neglect before moving towards youth suicide prevention. What drew you to researching intentional injury in children?

One of my interests whilst studying at the University of New Mexico was epidemiology, and this science remains the way I understand disease, injury, and behavior. Mentors encouraged my interest in injury prevention, because injury is often preventable given changes to personal and environmental factors.

Caring about what happens to children is a natural sentiment for most people. I heard stories from many adult friends and acquaintances whose backgrounds helped me understand the long-term damage child abuse does. We also know from research that when children have negative life experiences, this impacts their mental and physical health long into the future.

You've spent much of your career looking at the ways childhood adversity can affect health later in life. What do we now understand about that connection that we didn't when you first began studying it?

In the late 1990s, research from the Centers for Disease Control and Prevention (CDC)-funded study of Adverse Childhood Experiences began to be published. The data from over 10,000 adults showed that, as predicted, adverse experiences such as child abuse were associated with a wide variety of negative outcomes among adults. One unsurprising finding is that the more types of adverse experiences encountered during childhood, the higher the odds of adult health problems. Less obvious may be that experiences across the seven studied categories are correlated: for example, children who experience sexual abuse also experience psychological abuse, and those who live with adult substance abusers are more likely to be neglected or abused. What changed my thinking about childhood adversity was learning that those childhood experiences are significantly associated with higher likelihood of the illnesses that are the leading causes of adult mortality—cancer, lung disease, and heart disease. Further, childhood adversity is associated with adult behaviors that impact quality of life, such as smoking, alcoholism, drug abuse, and mental illness.

In my own research, I became interested in what factors help provide resilience to pediatric suicide attempts. Twenty years ago, we had a better understanding of adolescent suicide risk factors than factors that reduced suicide risk. A colleague invited me to analyze data from a Search Institute Profiles of Student Life Attitudes and Behaviors survey of children in grades 6-12 in the state of New Mexico (NM), particularly focused on American Indian and Alaska Native children. At that time, Native children had higher rates of suicide attempt than other racial and ethnic groups. The survey was unusual because it included questions that measured attitudes my colleague and I hypothesized to be related to suicide resiliency. Several items were associated with lower risk of suicide attempt in bivariable (one predictor, one outcome) analyses: children who had optimism, who never felt that their life had no purpose, who felt they mattered to the community, and who felt they had neighbors who cared. In the multivariable model (multiple predictors, one outcome), the most important factor was disagreeing with the statement that life had no purpose. These made me believe that: 1) adults other than parents can make a difference in suicide prevention; and 2) a purpose to one’s existence gives adolescents protection from suicide attempt (Chino et al. 2006).

So a supportive environment later in childhood or adolescence can help offset some of the effects of earlier adversity?

I have worked with student mentees at every level to look at whether, and how, adult relationships are associated with youth suicide attempts. We examined different adult relationships (at home and school, or within the wider community) for children who identified as American Indian or Alaska Native. Among the Native youth, there was a relationship between them agreeing with statements related to whether they had an adult at home or at school who believed they would be a success and reduced odds of suicide attempt. All adult relationships mattered in the bivariable results but in multivariable models, the results differed by gender. Among girls, having a teacher who listened to them and a community adult who told them when they did a good job were significant. For boys, the two significant variables were having an adult at home who believed they would be a success and who knew where they were when they were out of the house. The implications of these findings seemed to be that positive relationships with various adults matter: parental relationships have the most impact on boys, while school and community relationships have more impact on girls (Fitzgerald 2017).

Our next study was similar but focused on Hispanic children, looking at factors we know to be prevalent in NM: not having enough to eat, being born outside the US, and speaking a language other than English at home. In bivariable analyses, the questions about relationships with adults at school as well as plans for continuing one’s education after high school were significantly associated with a reduced prevalence of suicide attempt. Not having enough to eat and being born outside the US were risk factors for suicide attempt for both genders, but speaking a language other than English at home was only significant for girls. The multivariable models supported these results except in one instance: for girls, having an adult at school who listens was no longer significant when other variables were controlled (Hall 2018). We later used this same sample of teens to examine adults at home and within the community, and found that in multivariable modeling, these adult relationships were associated with lower odds of suicide attempt for both male and female Hispanic adolescents (Hall 2021).

The results of these studies led me to two general conclusions. The first is optimism-giving: since we found a dose-response relationship between the strength of the positive adult support and the protective effects against suicide attempt, my message to adults at home, in schools, and in communities has been that we do not have to be rock stars or Olympic champions in our ability to make teens feel important, heard, and as though they have a future. Even when kids only partially agree with the statements about support, this confers protection against suicide attempt. The second conclusion is that relationships with adults at home are the most important of all relationships and they have the most power to make a difference. But if relationships at home are difficult, adults from other arenas can make a real difference in adolescent suicide prevention. I do not believe adults can compensate for the harm others cause, but I do have evidence that all of us have the power to impact youth suicide.

Since we last spoke, has your thinking about the role of adult relationships in protecting young people from suicide changed?

Writing about suicide prevention interventions has made me realize the importance of investing in kids and communities by addressing factors we know to be a risk, as well as those that can be protective. For example, there are programs that help provide a place for parents and children to work together on homework and other school projects, combined with providing a nutritious meal that helps address the food insecurity that is prevalent in our community. Programs of this nature give me optimism about suicide prevention. They need to be duplicated and evaluated for their impact on school attendance, grades, student well-being, and other outcomes shown to be risk factors for youth suicide attempts.

Your research has increasingly focused on protective factors rather than simply identifying sources of harm. Has that changed the questions you think researchers should be asking?

Unfortunately, science and public health seem to be influenced by the whims of political winds and funding. It is very difficult to find solutions when science and public health take time and resources to demonstrate success. The cycle for research, program implementation, evaluation, and adjustment requires years and consistent funding. However, funding cycles tend to be brief and rarely allow for multiple changes in political administrations. As a result, programs to help avert negative outcomes—such as drug abuse, homelessness, hunger, and intentional injury—are often implemented but rarely evaluated for effectiveness or cost/benefit outcomes. This leads some to say that prevention does not work, and that money has been wasted. Questions that should be asked but are difficult to answer include how much money is saved when: child abuse is prevented; a child does not start abusing drugs; a family is not hungry; or, when a parent does not have to be away from home because he or she works two or more jobs. How much can be saved, over the lifetime of an individual, when a child becomes a successful person who is not damaged by adverse experiences?

Is there a danger that talking about children in terms of "risk factors" can make us overlook their resilience?

In my research, I have learned a few important things about resilience. One is that every comment or question about a risk factor can be reworded to be about resilience. Hunger is a risk factor with many negative outcomes for children, but it is just as important to know that school breakfast and school lunch programs contribute to well-fed children, and being well-fed is protective for those same outcomes. Another feature of resilience is that it results from two general sources: natural and developmental-environmental. Some people are born with more resilience than others due to things like temperament, inherited traits, and the prenatal environment. Environmental and developmental resilience are factors that can be enhanced if we have the knowledge and skills to do so.

Is there a particular emerging issue in children's health that you think researchers should be paying more attention to?

I am not unique in my concern of how exposure to social media and artificial intelligence influence children. I have noticed in my own students a shortened attention span that I associate with social media. I also wonder if the benefits of artificial intelligence in learning may be outweighed by the fact that children will lose the ability to think or reason creatively.