The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts

Abstract

Objective

This paper reports the impact of two first- and second-grade classroom based universal preventive interventions on the risk of Suicide Ideation (SI) and Suicide Attempts (SA) by young adulthood. The Good Behavior Game (GBG) was directed at socializing children for the student role and reducing aggressive, disruptive behavior. Mastery Learning (ML) was aimed at improving academic achievement. Both were implemented by the teacher.

Methods

The design was epidemiologically based, with randomization at the school and classroom levels and balancing of children across classrooms. The trial involved a cohort of first-grade children in 19 schools and 41 classrooms with intervention at first and second grades. A replication was implemented with the next cohort of first grade children with the same teachers but with little mentoring or monitoring.

Results

In the first cohort, there was consistent and robust GBG-associated reduction of risk for suicide ideation by age 19–21 years compared to youths in standard setting (control) classrooms regardless of any type of covariate adjustment. A GBG-associated reduced risk for suicide attempt was found, though in some covariate-adjusted models the effect was not statistically robust. No statistically significant impact on these outcomes was found for ML. The impact of the GBG on suicide ideation and attempts was greatly reduced in the replication trial involving the second cohort.

Conclusions

A universal preventive intervention directed at socializing children and classroom behavior management to reduce aggressive, disruptive behavior may delay or prevent onset of suicide ideation and attempts. The GBG must be implemented with precision and continuing support of teachers.

Introduction

Suicide and suicide-related behavior have been studied in epidemiology for more than 150 years. Among the earliest contributions were those made by William Farr, the early 19th century father of biostatistics, who sought to test whether suicide risk varied with successful adaptation or achievement in relation to education (Farr, 2000). Later in the 19th century, Emile Durkheim's sociological theory linked higher rates of suicide to the absence of shared social values and norms (anomie) in the general population and lower rates of suicide with the opposite—greater social integration and shared values (Durkheim, 1897). In the present study we extend that research into the domain of experimental and developmental epidemiology at the school and classroom levels. The main aim of this paper is to estimate the impact of two universal classroom-based interventions on risk of Suicide Ideation (SI) and/or Suicide Attempts (SA), referred to here as suicidality. We report on evidence from a randomized controlled trial of two preventive interventions implemented in the first and second grade classrooms of elementary schools with follow-up assessments of suicidality when the participants were in young adulthood. One intervention, the Good Behavior Game (GBG), was directed at producing shared values, norms, and proper student behavior within the first- and second-grade classroom. The second, Mastery Learning (ML), was directed at learning to read, a basic task of social adaptation in first and second grades.

Suicide ideation is considered by some to be the first step toward suicide (Gili-Planas et al., 2001); it is one of the strongest predictors of a future suicide attempt in adolescents and is related to risk of completed suicide (Brent et al., 1993, Lewinsohn et al., 1996, Reinherz et al., 1995). The current public health significance of suicidal thoughts and behaviors is large in the United States and globally (Murray and Lopez, 1996, United States Public Health Service, 1999). Prevalence estimates derived from recent community studies of adolescents indicate that up to 30% have experienced suicide ideation (Fergusson and Lynskey, 1995, Ialongo et al., 2002, Juon and Ensminger, 1997, Lewinsohn et al., 1996, Reinherz et al., 1995, Velez and Cohen, 1988). In the United States alone, approximately two million adolescents attempt suicide each year, resulting in 700,000 emergency room visits, and death certifications in 2005 for 15–24 year-olds indicated that over 4000 had committed suicide (McIntosh, 2008, Shaffer and Pfeffer, 2001). Prevention of suicide has been declared a national priority (United States Public Health Service, 1999), but there is little definitive evidence on the efficacy or effectiveness of suicide prevention programs among children and adolescents (Burns and Patton, 2000, Goldsmith et al., 2002, Gould et al., 2003).

Over the past three decades, evidence from developmental epidemiological studies has consistently identified specific antecedents measured as early as first grade in the prediction of later mental and behavioral disorders during the middle school years and beyond (Cairns et al., 1989, Ensminger et al., 1983, Farrington, 1995, Hawkins et al., 1988, Hawkins et al., 1992, Kellam et al., 1983, Reid, 1993, Reid and Eddy, 1997). Randomized preventive intervention trials conducted by our group and others indicate that school-based universal interventions (i.e., those addressing all children, not merely those indicated to be at higher risk) can have beneficial effects on aggressive, disruptive behavior and achievement (Dolan et al., 1993, Ialongo et al., 1999, Ialongo et al., 2001, Kellam et al., 1994a, Reid et al., 1999), off-task behavior (Brown, 1993b), depressive symptoms in first grade (Kellam et al., 1994b), and delayed onset or reduced risk of tobacco smoking (Kellam and Anthony, 1998).

The work reported in this paper is grounded in life course/social field theory (Kellam et al., 1975), which is built on the observation that one or more main social fields are critically important in each stage of life. Within each of these social fields there are defined social task demands to which an individual must respond, a process called social adaptation. The adequacy of an individual's response to these demands, termed social adaptational status (SAS), is rated by natural raters in each social field, such as parents in the family, teachers in the classroom, significant peers in the peer group, or, later in the life course, by spouses in the intimate social field or supervisors in the work social field. In keeping with Cicchetti and Schneider-Rosen (1984), the theory posits that success in mastering social task demands specific to one stage of development and in one social field will lead to an increase in later successes in the same and other social fields. Life course/social field theory also suggests that SAS often is reciprocally related to psychological well-being (PWB), the internal psychological status of an individual in regard to constructs such as self-esteem, psychiatric symptoms or disorders, and neurobiological or neuropsychological conditions. PWB may be an antecedent and/or a consequence of SAS, and vice versa.

The social task demands of the first grade classroom have been studied and reported frequently by our research group (e.g., Kellam et al., 1994a, Kellam et al., 1994b). In general, these social task demands consist of socializing appropriately with other children and the teacher, obeying classroom rules, concentrating and attending, and learning academic subjects. The two interventions used in this study were directed at improving social adaptation to these demands; therefore, we hypothesized that decreasing aggressive, disruptive behavior in classrooms would lead to a reduction in risk of outcomes linked to this antecedent (Kellam et al., 1994a), and that improving classroom achievement would improve PWB, particularly depressive symptoms and disorders in vulnerable children (Kellam et al., 1994b).

As the course of development unfolds in relation to successes or failures at social adaptational tasks in classrooms, in peer groups, and the community, other mediating or moderating issues can stem from as well as further influence the course of development and the impact of the GBG or ML. In community studies of adolescents, the use of alcohol and illegal drugs has been identified as an influential factor contributing to observed increases in the rate of adolescent suicide (Brent et al., 1988, Fowler et al., 1986). The prevalence of substance use disorders (alcohol and other drugs) in psychological autopsy and other studies has varied between 37% and 66% (Brent et al., 1988, Fowler et al., 1986, Runeson, 1989, Shaffer et al., 1988, Shafii et al., 1988). Depression, substance abuse, and aggressive, disruptive behavior have been found to distinguish suicide attempters from non-attempters in community and clinical studies of adolescents and adults (Brent et al., 1993, Garrison et al., 1993, Kessler et al., 1999, Lewinsohn et al., 1996, Petronis et al., 1990). Drug and alcohol abuse has been associated with greater frequency of suicide attempts, more serious attempts in terms of lethality and intent, and increased levels of suicide ideation (Crumley, 1990, Lewinsohn et al., 1996). Garrison et al. (1993) found that the relationships between alcohol and illegal drug use and suicidal behaviors were most pronounced with the reported use of the more potentially dangerous or ‘harder’ drugs (e.g., cocaine) but remained even when the substance of interest was nicotine. The role of early and continuing drug use may be an important element in the developmental psychopathology of suicidality and will be considered in this report. Other potential mediators of this association could be constructs often thought to be associated with early drug and alcohol use, such as aggressive, disruptive behavior in later childhood or early adolescence, Conduct Disorder symptoms, academic self-competence, self-derogation, parental monitoring, or drug using or deviant peers.

The GBG was developed by Barrish et al. (1969) and was selected for this trial because of its efficacy in short-term non-experimental or quasi-experimental designs, and because it was acceptable to the participating school leadership and community. The GBG is a classroom team-based behavior management strategy that promotes good behavior by rewarding teams that do not exceed maladaptive behavior standards as set by the teacher. The goal of the GBG is to create an integrated classroom social system that is supportive of all children being able to learn with little aggressive, disruptive behavior. The methods involve helping teachers to define unacceptable behaviors clearly and to socialize children with regulation of teammate's behavior through a process of team contingent reinforcement and mutual self-interest. In this trial, children in the GBG classrooms were assigned to one of three heterogeneous teams containing equal numbers of boys and girls, equal numbers of aggressive, disruptive children, and equal numbers of shy, socially isolated children. At the start of the game session, the teacher described and posted basic classroom rules of student behavior. All teams could “win” during a particular game period, with the criterion for winning the game being less than four infractions of acceptable student behavior.

Evidence to date has been supportive of the GBG reducing behavioral problems in the primary and middle school years, as well as reducing risk of tobacco smoking in early adolescence, mainly for boys (Kellam et al., 1994a, Kellam and Anthony, 1998). The GBG intervention trial also has shown long-term impact on drug abuse and dependence and alcohol abuse and dependence disorders as well as antisocial personality disorder and regular tobacco smoking, especially among males who had higher levels of aggressive, disruptive behavior in first grade (Kellam et al., 2008).

ML is a teaching strategy with demonstrated effectiveness in improving achievement and the underlying theory and research posit that under appropriate instructional conditions virtually all students can learn most of what they are taught (Block and Burns, 1976, Bloom, 1976, Dolan, 1986, Guskey, 1997). Prior to and throughout this trial, all first-grade teachers in the Baltimore City Public School System were expected to teach reading using a ML curriculum. Our ML intervention teachers received a more precise, enhanced reading curriculum that they implemented in the context of a system-wide ML curriculum (Dolan et al., 1993, Kellam et al., 1991). This enhanced ML curriculum was used by both first- and second-grade teachers. Short-term ML benefits were found in reading achievement (Brown, 1993a, Dolan et al., 1993), and children with depressive symptoms in the fall of first grade who gained in achievement showed reduced depressive symptoms by the end of first grade (Kellam et al., 1994b).

The occurrence of suicidality among teenagers has been linked to the targets of both the ML and GBG interventions. Low reading achievement at school entry and other academic problems have been linked with suicidality, usually via an association with conduct problems (Beautrais et al., 1996, Beautrais et al., 1997, Bennett et al., 2003, Lewinsohn et al., 1994;) or depressive symptoms and disorder (Andrews and Lewinsohn, 1992, Beautrais et al., 1996, Brent et al., 1993, Esposito and Clum, 2002, Shaffer et al., 1996). Depressive symptoms and disorder are also considered strong predictors of suicidality in youth and young adults (Andrews and Lewinsohn, 1992, Beautrais et al., 1998, Fergusson and Lynskey, 1995, Kessler et al., 1999, Petronis et al., 1990, Reinherz et al., 1995).

The proximal target of the GBG, aggressive, disruptive behavior has also been reported as a risk factor for suicidality (Brent et al., 1993) and a number of externalizing behaviors. Such behavior outcomes are developmentally linked to aggressive, disruptive behavior and include impulsivity (Stanley et al., 1986), conduct disorder (Andrews and Lewinsohn, 1992, Shaffer et al., 1996), antisocial behavior (Beautrais et al., 1996, Fergusson and Lynskey, 1995, Shafii et al., 1985), juvenile justice involvement (Beautrais et al., 1997, Fergusson and Lynskey, 1995) and alcohol and other drug use disorders (Beautrais et al., 1996, Brent et al., 1993, Shaffer et al., 1996).

Our previously reported findings support a conclusion that the ML intervention affects its intended proximal targets. Specifically, ML showed a short-term impact on learning and mastery, particularly for those who began school with high levels of depressive symptoms (Kellam et al., 1994b). By lowering depressive symptoms, ML could hypothetically also lessen suicidality through improved mastery of the student role. Furthermore, the ML intervention appeared to have somewhat higher overall achievement results for children who began more depressed in first grade, and improvement in achievement was associated with a lessening of self-reported depressed feelings (Kellam et al., 1994b). We therefore hypothesized that ML would reduce suicidality because of the role that mastery plays in self-esteem, depression, and suicidal thoughts (Battle, 1990, Brookover, 1965, Covington, 1989, Holly, 1987).

The GBG impact was also supported by previous findings. Students in the GBG classrooms showed reduced aggressive, disruptive behavior during elementary and middle school as well as reduced drug and alcohol involvement through young adulthood (Kellam et al., 2008). Because the GBG intervenes early in the child's life before classroom maladaptive aggressive, disruptive behavior becomes intransigent, we hypothesize that the GBG should reduce the course of aggressive, disruptive behavior and many of its consequences, including suicidality. Several reasons for this continuity in aggressive, disruptive behavior are made clear in the Patterson–Reid model of conduct disorder (Reid et al., 2002). In the absence of an intervention to reduce aggressive, disruptive behavior, aggressive, disruptive children may have trouble learning academic subjects, may remain disliked by teachers and their peers, and often limit their friends to other deviant peers (Reid et al., 2002). Over time, such children are at increased risk of failing in school and engaging in drug use, and impulsive and antisocial behavior (Kellam et al., 1983, Kellam et al., 1994a, Kellam et al., 1998, Kellam et al., 2008). All of these processes and conditions place youths at higher risk for suicide (Gould et al., 2003).

In prior papers we have reported that the GBG intervention had a long-term impact into young adulthood on outcomes such as drug and alcohol abuse and dependence disorders, tobacco use, antisocial personality disorder and violent and criminal behavior, and service use, particularly among males who were at higher levels of first grade aggressive, disruptive behavior, with lesser impact among females (Kellam and Anthony, 1998, Kellam et al., 2008, Petras et al., 2008, Poduska et al., 2008). We therefore hypothesize that the largest GBG impact will be seen in highly aggressive, disruptive males. We have also reported that females show greater developmental continuity in internalizing symptoms (Kellam et al., 1983). Suicidality could have internalizing and/or externalizing pathways into young adulthood; there could also be different developmental pathways for females and males. In addition, ML might alter internalizing while the GBG might impact externalizing pathways.