Risk and protective factors for suicide attempt in emerging adulthood

Resumo O objetivo foi investigar os fatores de risco e proteção para tentativa de suicídio na adultez emergente. Participaram 189 indivíduos de 18 a 30 anos: 63 que já haviam tentado suicídio, 63 que tinham histórico de ideação suicida e 63 que nunca tiveram ideação suicida. Os dados foram coletados online com instrumentos relacionados à tentativa de suicídio e ideação suicida, ansiedade social, autoestima, autoeficácia, expressão social, relações de amizade e estressores desenvolvimentais. O grupo que não possui ideação apresentou médias superiores em autoeficácia (M = 35,35; DP = 6,44), autoestima (M = 41,33; DP = 7,02) e relacionamento familiar (M = 59,63; DP = 10,01). O grupo que apresentou ideação suicida teve médias superiores em ansiedade social (M = 26,03; DP = 10,25). Fatores protetivos são essenciais para a prevenção ao risco de suicídio e auxiliam na resolução de problemas na adultez emergente. Palavras-chave Adulto jovem, Ideação suicida, Tentativa de suicídio, Fatores de risco, Fatores de proteção Abstract The aim of this study was to investigate the risk and protective factors for suicide attempt in emerging adulthood. 189 individuals (18 to 30 years old) participated in the study: 63 had already attempted suicide, 63 had a history of suicidal ideation, and 63 have never had suicidal ideation. They all completed an online research protocol about suicidal attempt and ideation, anxiety, self-esteem, self-efficacy, developmental stressors; social expression, and friendship. Those participants with no history of suicidal attempt showed higher scores of self-efficacy (M = 35.35, SD = 6.44), self-esteem (M = 41.33, SD = 7.02), and family relationships (M = 59.63, SD = 10.01). The suicidal ideation group showed higher scores of social anxiety (M = 26.03, SD = 10.25). Protective factors were essential to prevent the risk of suicide and help in solving problems in emerging adulthood.


Introduction
A new developmental phase called emerging adulthood has been identified in industrialized countries, in which young people leaving adolescence have postponed the assumption of adult roles such as marriage, financial independence from their parents and the formation of a family 1 .Emerging adulthood is characterized by a period of exploration of identity, since in this period of life young people seek greater social and professional identity.It is a time of insecurity, as young people are inserted into new social contexts that will require specific skills, which the young people may not have, leaving them vulnerable 1 .Emerging adulthood has also been shown to be a period of exposure to risky situations, such as drug use 2 and unprotected sex 3 .This is because they are in an extended period of exploration of their identities and due to the fact that they postpone definitive commitments (e.g., marriage, children, regular employment).This can lead them to have feelings of negativity and instability, which may explain their involvement in risk behaviors 4 .The emergence of this new phase is due to a series of changes in society, such as the entry of women into the labor market, the relaxation of patterns of sexuality and the need for young people to have more years of study and training to enter a increasingly demanding labor market 1,5 .
In Brazil, the studies of Dutra-Thomé stand out because they seek to characterize this new phase in young Brazilian adults.In one of these studies 6 it was identified that some young people felt in-between adolescence and adulthood, however, emerging adulthood was more likely to be present in the young people of the higher socioeconomic levels than in those of the lower levels.Young people of lower socioeconomic status tend to assume adult roles earlier.This fact may make these young people less likely to experience this period of identity exploration.
During emerging adulthood, there are a number of problems and difficulties that may arise in the lives of young people.The presence of protective factors may mitigate the effects of negative events and the challenges faced by young people 7 .Protective factors are personal characteristics (such as self-esteem and self-efficacy) or the environment in which they live (such as relationships with friends, family and support network) that strengthen young people and support them in dealing with problem situations 8 .These factors do not act in isolation but interact to aid in behavior change, developing an expe-rience of protection against risk situations and assisting in the solution of problems 9 .It is also during emergent adulthood that young people establish a series of social interactions that occupy a considerable part of their time, in both the circles of friendship and in work and study 10,11 .These circles can function as potential support networks to help young people cope with difficulties in their lives 4 .For this, it is necessary that they present a repertoire of social skills that help them to construct and maintain social relations that can become effective support networks 12 .
Unlike protective factors, risk factors relate to negative events and characteristics in life, with their presence increasing the chances of the manifestation of physical, emotional, and social problems 9 .These factors tend to increase the vulnerability of individuals to adverse situations, with each person reacting differently to these factors.Therefore, it is not only the presence of these factors that defines their impact on the individual's life, but also the intensity, frequency, and manner in which they are interpreted.Examples of risk factors are: dysfunctional family of origin, economic instability, experiences of physical/sexual violence, living in violent communities 8,9,13 and unhealthy working conditions 14 .Risk behaviors such as drug use 3,15 and unprotected sex 16 may also be considered risk factors.
The action of protective factors and how they are reflected in the actions and reactions of young people faced with problems that arise in their lives can mitigate risks, intensify resources to deal better with stressful events and achieve positive outcomes in the situations 8 .Conversely, the absence of protective factors and the presence of risk factors generate fewer resources, increasing the chances of negative outcomes and causing vulnerability in the development of social and emotional problems 8,9 .These conditions of vulnerability can lead young people to drastic solutions such as suicide 17 .
According to the World Health Organization (WHO), nearly half of the world's violent deaths are due to suicide 18 .Suicide rates have increased since 1999 19 and every year one million people die from suicide worldwide 20 .This shows that this is a serious public health problem that affects all stages of the life cycle and requires attention.Suicide is a complex phenomenon and is studied within several areas of knowledge 21 .One of the definitions of suicide would be to cause the death or murder of oneself, ending one's life 22,23 .This definition implies an intentional act of the person to take their own life 21 , however, there is another form of suicide, which would be a pathological act without intentionality, but which causes the person's own death 24 .In addition, the rates of attempting to take one's own life can be up to ten times greater than actual de facto suicides 17 .The process starts with suicidal ideation, that is, thinking about no longer existing, taking one's life and wanting to die 25 .Suicide is still a taboo in today's society, and often young people, who are considered a population at risk for suicidal ideation, do not find adequate space to talk about it 22,[25][26][27] .
The process of thinking about taking one's own life or trying to commit suicide is understood as a period of crisis, usually including psychological questions related to the difficulty of managing complicated situations in one's life 22 .Factors associated with suicide, such as previous attempts, social isolation, family history of mental illness, family history of aggression or abuse, declarations or thoughts of intention, among other biological and socioeconomic factors, also need to be considered 17,21,28 .Protective factors that are believed to be related to suicidal ideation include significant interpersonal relationships, such as with family and friends, and a healthy working environment.Personal aspects such as self-esteem, social skills and self-efficacy 29,30 are also considered to be protective factors.
A study developed by Pereira 12 , to assess social skills and risk and protective factors in emerging adults, identified that in a sample of 510 participants there were 63 participants who reported having attempted suicide.Observing the high prevalence (more than 10% of the sample), the presence of risk and protective factors was investigated in this sample of young people with a history of attempted suicide.Thus, the overall aim of this study was to investigate risk and protective factors related to suicide attempts and/or ideation by comparing three groups that were extracted from the database of the main study: individuals who attempted suicide; individuals who presented suicidal ideation, however, had never attempted suicide; and those who had not attempted suicide or had suicidal ideation.In addition, as the specific objective, protective factors were identified for those emerging adults who attempted suicide, however, no longer had suicidal ideation, and these were compared to those who had tried and still had ideation.

Method Sample
This study is part of a larger study aimed to assess social skills and risk and protective factors in emerging adults 12 .This study had a total sample of 521 participants and the data collection was performed online through the Survey Monkey platform.The study was disseminated from e-mail lists of universities and educational institutions and social networks on pages related to topics of interest to emerging adults (such as groups of educational institutions, football, church, discussion groups on various topics).In these two ways, the aims of the study were explained from a text and, after the completion of the questionnaire, the participants were also invited to indicate new participants.This study was approved by the Psychology Ethics Committee of the Federal University of Rio Grande do Sul.All participants signed the consent form.
For the performance of the present study, all the participants who had attempted suicide (n = 63) from the database of the larger study were selected, which represented 12.09% of the sample.In order to make comparisons, two more groups of participants were selected.For this, numbers were randomly drawn from 63 numbers that corresponded to the protocol numbers of the participants who at some point had had suicidal ideation, but never tried and others who had never had any ideation or attempted suicide.All the participants were within the age range of 18 to 30 years of age and responded to the online protocol of the main study on the Survey Monkey platform.

Instruments
Questions related to suicide: a) Have you ever considered killing yourself?; b) Have you tried to kill yourself?; c) If the previous answers is yes, do you still have this thought?
Dimensional Anxiety Scale -Social Anxiety Disorder (SAD-D): a brief, dimensional, self-report measure presented in the DSM-5 as a suggested measure to diagnose social anxiety symptoms.The instrument has presented evidence of reliability in community and clinical contexts in both the original version 31 and in the version adapted to the Brazilian context that has not yet been published, which presented a Cronbach's alpha of 0.899.Rosenberg Self-Esteem Scale: Validated by Hutz and Zanon 32 , this is a self-report scale that aims to assess self-esteem.In its validation study for the Brazilian context, it presented adequate psychometric data, presenting a Cronbach's alpha of 0.90.
General Self-Efficacy Scale: A self-report scale with ten items, validated for the Brazilian context by Sbicigo et al. 33 , presenting good evidence of validity and reliability, with a Cronbach's alpha of 0.85.
Questions related to developmental stressors: 21 questions about the occurrence of stressful events in the life of the person: a) The economic level of my family continually declined; b) Someone in my house is unemployed; c) My parents separated; d) I have been hospitalized in an institution (shelter, orphanage); e) I have run away from home; f) I have lived on the street; g) I have slept on the street; h) I have worked on the street; i.) Someone in my family is or has been in prison; j) I suffered a serious accident; l) Someone very important to me passed away; m) I have been hungry; n) My father/mother is married again; o) My father/mother had a child with another partner; p) I have been robbed; q) I have completed a socio-educational measure without being incarcerated; r) I have been incarcerated (Closed institution); s) I have appeared before the Guardianship Council; t) I have had problems with the law; u) I have had problems with the police.These items are part of the Brazilian Youth Questionnaire 34 .
Multidimensional Scale of Social Expression -Motor Component -EMES-M: Self-report scale composed of 64 items in total, which assess social skills.It was developed by Caballo 35 , showing good internal consistency, and was adapted and validated for Brazil by Pereira et al. 36 , presenting an alpha of 0.95 for the total scale.
Questionnaire for evaluation of friendship relations: based on the MCGill questionnaires to evaluate the quality of friendships.It evaluates the quantity and quality of friendship relationships in three open questions and 30 sentences on the impression that the respondents have of their friendships.The items are scored on a 5-point Likert scale (1 -Strongly disagree to 5 Strongly agree).

Data analysis
Descriptive analyses of the data were performed to produce means and standard deviations.To verify differences between the three groups, ANOVAs were carried out with Bonferroni post-hoc tests.A Student's t-test was also performed to assess the difference between the participants who had attempted suicide, comparing those who still had suicidal ideation with those who did not.A significance level of p < 0.05 was adopted.

Results
The mean age of the sample was 22.68 years (SD = 3.03) and it was predominantly composed of females (69.3%, n = 131).Regarding this female predominance, it should be taken into account that this proportion reflects the female proportion of the larger study, which also obtained a larger number of women (66%) 12 .There was no statistically significant difference regarding age (p = 0.299) or gender (p = 0.394) among the three groups.The other sociodemographic data of the sample are presented in Table 1.
In order to respond to the general objective, ANOVAs were performed, which showed statistically significant differences between the means of the groups in all the variables.The Bonferroni post-hoc tests showed significant differences among the three groups regarding the social anxiety variable (Table 2).As can be seen in Table 2, only the social anxiety variable presented significant differences among the three groups.The developmental stressors variable presented differences between the group that had suicidal ideation but had never attempted suicide and the group that had made suicide attempts.
In the group comparisons, there was a statistically significant difference in the scores of all the variables related to protective factors (friendship, family relationship, social skills, self-esteem and self-efficacy) when comparing the group that did not present suicide ideation or attempts to the other groups.A similar result can be observed in relation to the comparisons of the groups in the variables of family and community violence, in which there was a statistically significant difference only in the comparisons between the group without suicide attempts or ideation and the other groups.
In order to respond to the specific objective and identify differences between people who were able to overcome suicidal ideation and those who had not yet achieved this, Student's t-tests were performed.In this analysis, the sample of people who had a history of suicide attempts (n = 63) was divided into two subgroups: one that contained participants still had ideation (n = 28) and one with participants who did not present this anymore (n = 34).The group that did not have ideation anymore had statistically significant higher means in the self-efficacy, self-esteem and family relationship variables.The group that still had ideation presented statistically significant higher means in the social anxiety variable.These analyzes can be seen in Table 3.

Discussion
The aims of this study were to investigate risk and protective factors for suicidal ideation and/ or attempts.The results highlighted factors that may be considered protective, such as self-esteem and self-efficacy, and risk factors such as social anxiety and family and community violence.
Emerging adulthood is characterized by the appearance of several new social requirements 1 .Faced with these, young people often feel vulnerable if they do not have the resources to deal with the problems that arise, making this population vulnerable to psychological disorders, which can lead to suicidal ideation and attempts 17 .
Attempting suicide is one of the only alternatives encountered by people who do not have enough resources in the problem-solving process, for example, individuals who are excluded from the family context, who have feelings of worthlessness or feel unable to cope with reality 22 .Therefore, the interaction of risk and protective factors can be determinant for a healthy outcome in problem solving 9 .It is important to be clear about the concept of resilience, which is a complex process in which a number of factors relate to determine whether people can overcome their problems in a healthy way 37 .
The means of the protective factors presented a statistically significant difference between the group that had neither ideation nor suicide attempts during their lives and the other groups.The factors used in this study can be characterized into two types: intrinsic factors, that is, the person's own strengths and abilities that can help in coping and overcoming difficulties (such as self-esteem, self-efficacy and social skills); and extrinsic factors that are characteristics and support of the context in which this person lives that can help in difficult situations (such as the family relationship and friendships) 8 .The results of this study indicate that these factors are more present in young people who do not present suicidal ideation, which demonstrates their importance in the study of this phenomenon.
Self-esteem can be defined as a set of beliefs about one's own value as a person and is consid-   ered an important indicator of mental health 38 .Self-efficacy is the person's belief in their problem-solving ability 33 .Self-esteem and self-efficacy are related characteristics.Low self-efficacy is related to a sense of vulnerability to adversity and inability to solve problems 39 , which can lead to increased anxiety when dealing with problems in life.This can lead to the development of negative beliefs about oneself and the environment in which one lives, with decreased self-esteem and increased psychological disorders such as depression 40,41 .The results of this study corroborate these findings, which presents self-efficacy and self-esteem as important protective factors for psychological disorders 42,43 and for the risk of suicide 8,44 .Social skills can be defined as a specific class of behaviors used in interaction with the other factors 12 .These behaviors aim to solve and avoid interpersonal problems and are responsible for maintaining social relationships 45,46 .Deficits in social skills are related to difficulties in social interaction, dissatisfaction in relationships, presence of social anxiety, low self-efficacy to solve interpersonal problems and low self-esteem 12,35 .
Regarding extrinsic factors, during emerging adulthood, relationships with friends and family are considered the most important in the support network of this population 4,11,47 .It is in these relationships that young people construct their identity and seek support when faced with problems 11 .As observed in this study, the quality levels in these relationships showed a significant difference between the group without suicidal ideation and attempts in their lives and the other groups.Thus, it is assumed that these relationships can prevent emerging adults from seeking suicide as an option for solving their problems.In addition, for people who have a history of suicide attempts, the family relationship proved important for overcoming this.It is necessary to consider that, in order to access the support network, these young people need a repertoire of adequate social skills, since without them, even if the relationship is good, they will not have the necessary skills to ask for help when needed 12 .
Even though there was no significant difference between the suicide attempt group and the group with suicidal ideation in relation to the quality of the family relationships, the difference between the levels of quality of this relationship was borderline (Table 2).This shows that there may be a relationship between the quality of the family relationship and the actual suicide attempt.This is highlighted when perceiving that the quality of the family relationship had a statistically significant difference between the group that had attempted suicide and still had suicidal ideation and the group that did not have this anymore.
Regarding social anxiety, there was a difference in levels among the three groups, with the suicide attempts group presenting the highest mean, followed by the group with suicidal ideation.This result demonstrates that social anxiety is a risk factor for both ideation and attempts.
Social anxiety is a serious and debilitating disorder characterized by high levels of anxiety regarding interpersonal relationships 34,48 .When faced with these interactions the person feels vulnerable, which can often lead to social isolation 48 .Social anxiety is related to low levels of self-esteem, self-efficacy, deficits in social skills and depression 35,48 .People who are affected by this disorder have difficulty relating to others and cannot effectively build or access the support network, becoming even more vulnerable and helpless when problems arise in life 49 , which may explain this difference between groups.
In relation to situations of violence, it can be seen that the presence of both family and community violence differentiated the group without ideation or attempts from the other groups.This data indicates that experiencing situations of violence lead to vulnerability, which means that the individual does not have the resources to deal with the situation.This is due to the presence of violence, especially in childhood, tending to result in a decrease in the self-esteem and self-efficacy of the victims 50 .The literature indicates that the presence of cases of violence is related to disorders such as depression, which can result in suicidal ideation and attempts [51][52][53] .
Of the variables evaluated in this study, the only variable that exclusively differentiated the group with ideation from the group with suicide attempts was the "Developmental Stressors" variable, which is related to issues such as loss of employment and family members, indebtedness, financial crises, change of residence and problems with the law.This result may indicate that the presence of destabilizing experiences may be the trigger for a suicide attempt for people with suicidal ideation.
Low self-esteem, low self-efficacy, deficits in social skills and the presence of community and family violence are risk factors for suicidal ideation, since both the ideation and the attempt groups presented suicidal ideation at some point.In addition, the presence of high levels of social anxiety and the occurrence of stressors are risk factors for suicide attempts, since only these variables differentiated the groups.
Regarding the comparison between the participants who had attempted suicide, but no longer had suicidal ideation and those who still had this, the t-test presented a significant difference in the means of the social anxiety, self-efficacy, self-esteem and family relationship variables.People have a healthier way of perceiving problems and believe that they can solve them when they have more positive beliefs about themselves 8,54 .In this way, the presence of positive beliefs about oneself (self-esteem) and one's ability to deal with situations and problems (self-efficacy) possibly helps the person find ways to solve the problems that resulted in the suicide attempt and, therefore, to abandon the suicidal ideation.Conversely, people with low self-esteem and self-efficacy do not believe in their problem-solving ability, causing suicide to remain a plausible "solution" to these situations.
The presence of high levels of social anxiety causes difficulties in establishing effective support networks and, even in their presence, the person will have difficulty accessing them.In this way, it becomes a risk factor because the support networks will become less effective, leaving the individual vulnerable to problems 12 , without the support to overcome the suicidal ideation.It was observed that the quality of the family relationships is an important aspect of the support network, since this is usually the closest social relationship in this population.When this relationship is one of quality it can help the person overcome problems and find new ways of solving them.This can lead to a decrease or abandonment of thoughts of suicide.

Conclusion
Emerging adulthood is a phase of changes in the lives of young people and, as seen in this study, several factors can contribute to problems that may make life difficult to the point of considering suicide as a solution to these problems.Suicide is a complex phenomenon that presents several related factors (both risk and protective).This study evaluated some of these factors as a way to better understand this phenomenon in this specific population.
Protective factors, such as self-esteem, self-efficacy, social skills, family relationships and friendships, are important and make a difference to problem solving in emerging adulthood.These factors were shown to be essential for individuals not to present suicidal ideation as an option to deal with challenging situations in their lives.They are also important factors so that after a failed attempt, young people can rethink their lives and seek to overcome their problems in a way that they do not commit new attempts.In this way, interventions with this age group should focus on the development of protective factors, as a way to improve the quality of life of these young people.Therefore, self-esteem and self-efficacy should be promoted, while at the same time strengthening affective bonds with the support network.
For young people who have ideation or have had failed suicide attempts, interventions should focus on organizing an effective support network so they can have someone to turn to when they are unable to cope with their problems.In addition, strategies should be proposed to improve the self-esteem and self-efficacy of these young people.The lack of further information regarding the age at which the young people carried out their suicide attempts, as well as details of how these attempts were made, may be considered limitations of this study.This information would allow other factors associated with overcoming this or not to be identified.In addition, the online data collection meant that only one profile of participants had access to the questionnaire, in this case, young people with internet access and that participated in the groups in which the study was divulged.Accordingly, new studies that seek to reach young people in other contexts should be performed to better understand this phenomenon.
This study provides data on the complex phenomenon of the suicide attempt, seeking to identify how intrinsic and extrinsic factors can contribute to the occurrence and prevention of this serious public health problem.These data may help in the development of new interventions for people with suicidal ideation or who have unsuccessfully attempted suicide, so they can overcome their problems and not repeat the attempt.

Table 1 .
Socio-demographic data of the sample.

Table 2 .
Results of ANOVAs comparing the groups with Suicide Attempt (GAS), with suicidal ideation in life (GWSI) and the group that did not have an idea or attempt (GNOT).

Table 3 .
Comparison of means between the groups with subjects with and without suicide attempt.
Note: * WT: Group of participants who have already tried suicide and still have this thought; ** WNT: Group of participants who have already tried suicide and have no thoughts of trying again.