Child Psychiatry Hum Dev (2010) 41:425440

DOI 10.1007/s10578-010-0179-0
ORIGINAL ARTICLE

Familism, Parent-Adolescent Conflict, Self-Esteem,

Internalizing Behaviors and Suicide Attempts Among
Adolescent Latinas
Jill A. Kuhlberg Juan B. Pena Luis H. Zayas

Published online: 23 March 2010

Springer Science+Business Media, LLC 2010

Abstract Adolescent Latinas continue to report higher levels of suicide attempts than
their African-American and White peers. The phenomenon is still not understood and is
theorized to be the result of the confluence of many cultural, familial, and individual level
factors. In Latino cultures, belief in the importance of the family, the value known as
familism, appears to protect youths emotional and behavioral health, but parent-adolescent conflict has been found to be a risk factor for suicide attempts. The role of familism in
relation to parent-adolescent conflict, self-esteem, internalizing behaviors, and suicide
attempts has not been studied extensively. To address this question, we interviewed 226
adolescent Latinas, 50% of whom had histories of suicide attempts. Using path analysis,
familism as a cultural asset was associated with lower levels of parent-adolescent conflict,
but higher levels of internalizing behaviors, while self-esteem and internalizing behaviors
mediated the relationship between parent-adolescent conflict and suicide attempts. Our
findings point to the importance of family involvement in culturally competent suicide
prevention and intervention programs. Reducing parent-daughter conflict and fostering
closer family ties has the added effect of improving self-esteem and shrinking the likelihood of suicide attempts.
Keywords Familism  Parent adolescent conflict  Internalizing behaviors 
Self-esteem  Suicide attempts  Adolescent Latinas

Introduction
Since the early 1990s, national surveys of high school youth show that Latinas attempt
suicide at higher rates than their African American and White peers, both male and female
[1].This phenomenon has been recognized over time by multiple national studies, and so

J. A. Kuhlberg (&)  J. B. Pena  L. H. Zayas

George Warren Brown School of Social Work, Washington University in St. Louis, Campus Box 1196,
One Brookings Drive, St. Louis, MO 63130-4899, USA
e-mail: jkuhlberg@wustl.edu

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far has not been found to be more prevalent in any one specific Hispanic1 ethnic group
[13]. As a previous attempt is the strongest predictor of completed suicide, and is a
leading cause of hospitalization, more research needs to be done to understand this public
health issue affecting Hispanic girls [4].
We may find many explanatory factors of the problem of suicide attempts by teenage
Hispanic girls by exploring the convergence of familial, developmental and cultural processes in the suicide attempts [5]. We follow the conceptual model advanced by Zayas
et al. [5] that posits a variety of individual, familial and socio-cultural factors are related to
the attempts of these girls. Based on the developmental theories of Vygotsky [6] and
Bronfenbrenner [7], the model highlights the interactions between Hispanic cultural values
and the relationships of girls and their families as being an integral part of understanding
the suicide attempts in this population. For this study, we focus on testing aspects of this
model by examining the relationships between cultural, familial, and individual level
constructs (i.e., familism, parentchild conflict, self-esteem, and internalizing behaviors)
with each other and with suicide attempts among an urban sample of Latinas.

Familism in Latina Adolescents and Families

Familismthe value of the central role of the family in individual psychology, identity,
and socializationhas been identified as a protective factor related to reduced parentadolescent conflict, and is associated with positive outcomes in children and adolescents
[8, 9]. Although Latinos tend to be more family-oriented than non-Hispanic Whites,
research on how familism interacts with and affects other family functions has been more
ambiguous [10]. Cauce and Domenech-Rodriguez [11] write that Latinos with high levels
of familism tend to feel personal responsibility not just for their own well-being, but also
for the well-being of others in their family. Moreover, adolescents with high levels of
familism might then present lower levels of parentchild conflict as they actively try to
preserve harmony in their roles as children. Yet, it can also collide with the developmental
strivings toward autonomy that are reinforced in the larger non-Hispanic culture.
One aspect of familism, family support, has been shown to be associated with positive
mental health outcomes in Latino families [12]. Higher levels of familism have also been
linked to lower probabilities in risk behaviors such as alcohol use in Latino adolescents,
and child maltreatment in Latino adults [8, 13]. Smokowski and Bacallao [14] have found
that familism predicted lower levels of parent-adolescent conflict in a sample of mainly
Mexican families.
Research on familism merits more attention as past studies have showed varied relationships to family processes and individual outcomes. Rodriguez et al. [10] suggest that
these mixed results can be at least partly attributed to problems of the conceptualization
and consequently the measurement of familism itself. Some definitions of familism involve
clearly defined components such as family support and conflict, and importance of family
[10]. Still other definitions include larger themes including family values [15] and an even
broader concept of familism has been applied to studies with non-Hispanic participants
[10, 13, 1619]. Valenzuela and Dornbusch [20] conclude that familism can be described
as three parts: structural familism refers to the physical proximity of family members to
one another; behavioral familism alludes to how a person demonstrates values of
familism (i.e., living close to family members, having frequent phone conversations); and
1

We use the terms Hispanic and Latino or Latina interchangeably.

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attitudinal familism has been defined as an individuals commitment to his/her family

and strong feelings of loyalty, reciprocity, and solidarity among members of the same
family[19]. The latter dimension, attitudinal familism, is considered the most complex,
and also most challenging of all three to measure [19]. Thus, such variance in the conceptualization and measurement of familism poses difficulties for generalization across
studies [21]. The present study employs an instrument of attitudinal familism to measure
the cultural factors that could be related to the familial (i.e., parent-adolescent conflict) and
individual level factors (i.e., self-esteem, internalizing behaviors) surrounding suicide
attempts in adolescent Latinas.

Development, Conflict, and Culture

Developmental Aspects of Early Adolescence and Autonomy
Conflict between parents and their children during adolescence is common in families [22].
Early adolescence brings with it the process of becoming increasingly autonomous and
independent. Adolescents begin to question rules, viewpoints, and traditions that appear to
be imposed rather than negotiated [23]. Still, the adolescent wishes and needs to be
connected to parents, resulting in an ambivalent relationship. Adolescents are often at odds
with parents and others in the household. The degree of autonomy that the adolescent may
wish to pursue, and the degree of autonomy that parents allow him or her to achieve, varies
across cultures [2426]. These varying expectations related to autonomy-seeking could be
a source of higher levels of conflict in immigrant and minority families, such as Latinos,
since the importance of individualistic values versus collective values may be viewed
differently between foreign-born parents and their U.S. raised children [9, 27]. Where
parents might see the actions and behaviors of their adolescent children as disrespectful
and unacceptable in the context of their culture of origin, children may perceive their own
actions as being normative, when comparing themselves with their peers in the U.S.
Conversely, Latino adolescents might interpret their parents actions as being irrational and
overly strict instead of understanding the cultural perspective of their parents [28].
The clash between traditional Latino gender roles and those associated with mainstream
U.S. culture may be yet another source of conflict between Hispanic girls and their parents
during adolescence [5]. The same traditional Hispanic family values that include the
subjugation of self for others, upholding family honor, respect for elders, and extended
family support networks, may take on different meanings for males and females [19]. For
females, subjugation of self before others could mean physically staying at home to be a
caretaker for others in the family. Upholding family honor may mean rules that monitor or
forbid dating and sex, which more acculturated teenage girls could find restrictive [29, 30].
If Latina adolescents do not share the same cultural values that reinforce those rules
enforced by their parents, and they simultaneously see their male siblings, peers, and
female friends from other cultures not held to the same expectations, they may find reason
to engage in arguments and other forms of conflict with their parents [31].
Conflict within the family and between parents and their children has been associated
with numerous negative outcomes in adolescents, including internalizing behaviors and
low self-esteem. Female adolescents may be especially sensitive to conflict in the family,
in part due to gender socialization that leads to females valuing the maintenance of harmonious relationships more than males [3234]. Using data from two distinct communities
with Latino families from the more recent immigrant population in North Carolina and the

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longstanding immigrant community in Arizona, higher levels of parentchild conflict have

been found to predict higher rates of internalizing behaviors and lower levels of selfesteem in adolescents [9, 35]. Similarly, using a sample of Hispanic adolescents who were
either immigrants themselves, or who had at least one immigrant parent, Portes and Zady
[36] also found a direct relationship between parent and child conflict and both lower selfesteem levels, and higher depression levels.
Some research has also shown a direct relationship between parent-adolescent conflict
and suicide attempts [37, 38]. Conflict in the dyad as expressed through serious fights [39],
parental criticism [40], and unresolved conflicts between the adolescents and their parents
[41] have all been found to distinguish suicidal adolescents from their non-suicidal peers.
However, since parent-adolescent conflict is known to be related to mental health outcomes
in adolescents, its effect on suicide attempts may be indirect, either in addition to or instead
of the direct effect other studies have indicated [42].
Individual Factors Predicting Adolescent Suicide Attempts
Extensive research on suicide in adolescents has described individual factors including
internalizing behaviors (depression, anxiety, etc.) and low self-esteem as being predictors
of suicidal behavior. Depression and depressive symptoms have been found to be linked to
suicide ideation [43, 44], and in a sample of exclusively MexicanAmerican adolescents,
two studies have found that depressive symptoms predict suicidal behavior [45, 46]. Low
self-esteem and self-derogation are also two individual factors related to adolescent suicidal behavior [47, 48]. Razin et al. [49] found that Latina adolescent suicide attempters
often blamed themselves for problems in the family. Negative feelings towards the self
may put adolescents at risk for using a suicide attempt as a maladaptive coping strategy
[50].
Although much of the research shows that Latina adolescents are at a greater risk for
suicidal behavior than their African American or White counterparts, few studies have
examined any differences that may exist between Hispanic subgroups (i.e., Puerto Rican,
Mexican, Dominican, etc.) of suicide attempters [1, 2]. Some studies that have included
variables for Hispanic subgroups found differences between groups, however, none of
them focused on Hispanic adolescent girls, the adolescent segment at most risk [51, 52].
Considering this, Duarte Velez and Bernal [53] suggest that for studies focusing on allLatino samples, analyzing subgroup differences will help researchers to understand the
phenomenon better than continuing to characterize all Hispanics as a homogeneous group.
Studies have shown that a number of demographic characteristics are related to adolescent suicide attempts. Adolescent suicidal behavior has often been explained in a
developmental context. For example, the aforementioned parent-adolescent conflict is
correlated to the adolescents age, as the likelihood for attempting suicide increases in midadolescence and then decreases in late adolescence [2, 54]. Socio-economic status has also
shown to have a relationship to suicidal behavior [49, 55]. In a study of high school
students, parent education (used as a proxy for social class) was shown to have a strong
relationship to suicide attempts especially in girls [56].

The Present Study

In this report, we contribute to the knowledge base on Latina adolescents with suicide
attempt histories by examining the influence of family factors (i.e., parent-adolescent

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429

Fig. 1 Path model predicting suicide attempts in adolescent Latinas. Note: positive and negative symbols
indicate the direction of the relationship between the variables

conflict), cultural factors (i.e., familism), and individual factors (i.e., self-esteem; internalizing behaviors). Our aims are to explore how these factors interact to protect or
potentiate suicidal behavior among Latinas in adolescence. Our primary research questions
are: What is the relationship between parent-adolescent conflict, self-esteem, internalizing
behaviors, and suicide attempts in Latina adolescents? What role does familism play as a
cultural asset in building self-esteem and protecting against parent-adolescent conflict,
internalizing behaviors, and suicide attempts? Building from the model proposed by Zayas
et al. [5], we examine the model depicted in Fig. 1. We test the following direct effects and
indirect effects (i.e., mediation effects) in the model.
Direct Relationships
1. Familism will be positively related to adolescent self-esteem and negatively related to
parent-adolescent conflict and internalizing behaviors.
2. Parent-adolescent conflict will be negatively related to self-esteem and positively
related to internalizing behaviors and suicide attempts.
3. Internalizing behaviors will be positively related to suicide attempts.
4. Self-esteem will be negatively related to suicide attempts.
5. Internalizing behaviors and self-esteem will be negatively associated with each other.
Indirect Relationships
1. Internalizing behaviors and self-esteem will mediate the relationship between familism
and suicide attempts.

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2. Internalizing behaviors and self-esteem will both serve as mediators between parentadolescent conflict and suicide attempts .
3. Parent-adolescent conflict will mediate the relationship between familism and both
self-esteem and internalizing behaviors.

Method
This study used cross-sectional data from a project on the sociocultural processes in the
suicide attempts of adolescent Hispanic females. Participants in the study who had
reported having attempted suicide in the past 6 months were recruited in the New York
City area from social service agencies and general and psychiatric hospitals that serve
largely Hispanic populations. A comparison group of Latina adolescents with no known
histories of suicide attempts were also recruited through primary care health care
agencies and community programs from the same New York boroughs as the sample of
suicide attempters. Adolescent girls and participating parents were administered questionnaires with a number of standardized measures. About half of the girls and parents
also participated in an in-depth ethnographic interview. In this report, we utilize only
data from the scales administered to both groups of adolescents and their participating
parents.
We followed the definition of a suicide attempt as any non-fatal self-injury reported by
the adolescent after having made the attempt [57]. No adolescent was rejected on the basis
of the degree of lethality of the attempt. Potential participants were excluded from participation in the study if they were not between the ages of 11 and 19, had been diagnosed
with a severe mental illness (e.g., schizophrenia), substance abuse, mental retardation, or
living in foster care at the time of the project. Our recruitment sites were able to avoid
including any girls with co-morbid disorders.
All girls with suicidal histories were cleared for participation by their mental health
clinician, since they were all recruited from mental health services. All adolescent participants provided both assent and consent to participate, and their parents provided their
consent for both their adolescent daughters participation and their own, if they chose to
participate. Interviews were all conducted by doctorate and masters level clinicians, who
were bilingual and bicultural Hispanic women. The Human Research Protections Office at
Washington University in St. Louis approved all procedures.
Participants
A total of 121 adolescent Latina suicide attempters and 105 non-attempters were recruited.
Participants parents were recruited and completed study measures; 105 parents of suicide
attempters (86 mothers, 19 fathers) and 95 parents of non-attempters (78 mothers, 17
fathers) participated. The majority of our sample of girls (72%) was U.S.-born. Most girls
identified with a Hispanic group or culture: 79 Puerto Rican, 64 Dominican, 27 Mexican,
23 Colombian, 10 Ecuadorian, three Guatemalan, two Salvadorian, and one each Cuban,
Honduran, Peruvian, and Venezuelan. Eleven girls identified themselves as other (three
MexicanAmerican, three Puerto RicanDominican, one DominicanAmerican, one
DominicanCuban, one EcuadorianAmerican, one PeruvianPuerto Rican, and one Black
Puerto Rican) and three girls identified as American but were classified as Hispanic
based on their mothers Hispanic origin.

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Variables
The adolescents age at the time of the interview was measured in years. For the purposes
of the current study, girls were categorized by self-report into the four largest subgroups
represented: Puerto Rican, Dominican, Mexican, and Colombian, and one group Other
Hispanic Culture, which included those girls from subgroups with smaller representation
in the sample, and who identified with more than one subgroup. Parent education was
assessed by asking the highest level of education completed by the parent who provided
consent for the adolescent.
Self-esteem was measured by the Rosenberg Self-Esteem Scale [58]. It consists of ten
items that assess the adolescent respondents level of global self-esteem by scores ranging
from 10 to 40, with higher scores indicating higher levels of self-esteem. The Cronbachs
alpha scale of reliability for our sample was 0.86.
Internalizing Behaviors were measured using the internalizing behavior items included
in the Youth Self-Report [59]. Responses to these three-point Likert-scale questions
include not true, somewhat true, and very true or often true. Scores range from 0 to
48, with higher scores indicating higher levels of internalizing behaviors [59]. The
Cronbachs alpha for this subscale of the YSR in this study was 0.91.
Parent-adolescent conflict was measured by 15 dichotomous yes or no items from
the Conflict Behavior Questionnaire [60]. Instead of asking respondents to describe their
relationship with only one parent in these items, the questions probe the adolescents
description of both parents at once (e.g., My parent(s) dont understand me, and My
parent(s) are good friends to me.). Higher scores indicate increased levels of perceived
conflict and negative communication between the parent and adolescent, with scores
ranging from 0 to 15. The alpha coefficient for this scale in this study was 0.91.
Familism was measured with an attitudinal familism scale tapping familial support,
familial interconnectedness, familial honor, and subjugation of self to family [19]. Lugo
Steidel and Contreras report a full-scale Cronbachs alpha of 0.83; the alpha reported for
Latina adolescents in our study was 0.87.
Suicide attempter status was the outcome variable for the path. This is a binary variable,
coded as 1 for those girls who have attempted suicide and 0 for those who have never
attempted suicide.
Data Analysis Strategy
We used Mplus Version 5.2 [61] to run a path analysis to explore the direct and indirect
relationships hypothesized in our model. Control variables for path analysis included
parental education level, adolescent age, and Hispanic cultural group. A weighted least
squares estimator was used for the path analysis model, which calculates statistical differences in a model for both direct and indirect effects, and also provides the CFI/TLI,
RMSEA, and WRMR fit indices. Coefficients using this estimator yield are comparable to
regression betas with continuous outcomes and probit coefficients when there is a binary
outcome.
Missing data was handled using an inclusive multiple imputation strategy. Collins et al.
(2001) have shown this strategy to be the most successful in reducing, and in some cases
eliminating bias that otherwise would occur in listwise deletion and other ad-hoc missing
data methods (e.g., mean substitution). This strategy works particular well in scenarios
with little to modest missing data, which was the case for the variables in our model [62].
We generated the ten datasets using the ICE function, created by Royston [63] for STATA,

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and then analyzed them using the TYPE = IMPUTED command in Mplus [61]. Besides
variables in our model, we used auxiliary variables either correlated with variables in the
model (e.g., public or private insurance) or potentially associated with missingness (i.e.,
social desirability) to create multiple datasets.

Results
Sample Demographics
All the adolescents were between the ages of 11 and 19 (M = 15.47, SD = 2.01). Suicide
attempters comprised 53.54% of the sample (n = 121), and 46.46% (n = 105) of the
sample had reported never having attempted suicide (non-attempters) in their lifetime. The
girls self-identified as being Puerto Rican (n = 79, 34.96%), Dominican (n = 64, 28.32%),
Mexican (n = 27, 11.95%), and Colombian (n = 23, 10.18%), with the remaining portion
of the participants (n = 33, 14.59%) reporting as being from other Hispanic cultures and
ethnic groups including Venezuelan, Cuban, Honduran, Ecuadorian, Salvadoran, Nicaraguan, or a combination of two groups. The education level of their parents ranged from
1 year of formal schooling to over 17 years (M = 10.57, SD = 3.66). Table 1 contains a
more detailed description of the sample.
The following information about the entire sample of adolescents is described below in
Table 1. Girls reported an average score 7.42 (SD = 1.19) for familism, with the lowest
score being 3.22 and the highest being 10.00 points. The mean score for parent-adolescent
conflict was 5.26 (SD = 4.59), with scores ranging from 0 (very little/no conflict) to 15
(the maximum score possible for the set of items). The average self-esteem score for the
Table 1 Demographic characteristics of Latina adolescent suicide attempters and non-attempters
Total sample Attempters (n = 121)
(N = 226)

Non-attempters
(n = 105)

M (n) SD
(%)

SD

t/v2 Values
SD

Age

15.47

2.01

15.33

1.80

15.64 2.23 t(224) = 1.14

Parent education
level

10.57

3.66

10.17

3.81

11.01 3.46 t(175) = 1.53

Puerto Rican

79.00

0.35 43.00 0.36

36.00 0.34

v2(1) = 0.04

Dominican

64.00

0.28 38.00 0.31

26.00 0.25

v2(1) = 1.22

Mexican

27.00

0.12 17.00 0.14

10.00 0.10

v2(1) = 1.10

Colombian

23.00

0.10

5.00 0.04

18.00 0.17

v2(1) = 10.41**

Other ethnicity

33.00

0.15 18.00 0.15

15.00 0.14

v2(1) = 0.02

Ethnicity

Familism

7.42

1.19

7.33

1.31

7.51 1.02 t(222) = 1.14

Parentadolescent
conflict

5.20

4.61

6.59

4.84

3.72 3.85 t(206) = -4.70

Internalizing

20.67 11.13

25.98 10.70

14.95 8.47 t(212) = -8.31

Self-esteem

29.28

26.85

31.94 4.95 t(209) = 7.20***

5.72

* p \ 0.05; ** p \ 0.01; *** p \ 0.001

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entire group was 29.45 (SD = 5.70), with the lowest score being 15 and the highest being
40 (note: the lowest possible score for the Rosenberg Self Esteem Scale is 10). Internalizing behaviors scores ranged from 0 to 48, with the average score being 20.37
(SD = 11.20).
Bivariate Results
Bivariate analyses revealed that attempters reported statistically higher levels of conflict
with their parents (M = 6.59, SD = 4.84) than non-attempters (M = 3.72, SD = 3.86), as
well as higher levels of internalizing behaviors (M = 25.98, SD = 10.70) than non-attempters (M = 14.95, SD = 8.547). Latina non-attempters showed significantly higher
levels of self-esteem (M = 31.94; SD = 4.95) than attempters (M = 26.85; SD = 5.29).
There were, however, no reported statistically significant differences in parent education
level, adolescent age, or familism between the two groups. Bivariate results comparing
attempters and non-attempters are shown in Table 1.
Correlations between variables used in this study are found in Table 2. A number of
variables were related to each other, but none so much that would cause concern for
multicolinearity. Kline [64] states that multicolinearity should be addressed when variables
report r coefficients greater than 0.85, and the highest in this sample was -0.68. Selfesteem was significantly correlated to suicide attempts (r = -0.45, p \ 0.001), familism
(r = 0.25, p \ 0.001), parent-adolescent conflict (r = -0.43, p \ 0.001), and internalizing behaviors (r = -0.69, p \ 0.001). Internalizing behaviors showed a significant correlation to suicide attempts (r = 0.50, p \ 0.001) and parent-adolescent conflict (r = 0.41,
p \ 0.001). In addition to the significant correlations already described to internalizing
behaviors and self-esteem, parent-adolescent conflict was significantly related to suicide
attempts (r = 0.34, p \ 0.001) and familism (r = -0.38, p \ 0.001).
Path Analysis Results
The path model (Fig. 1), which included covariates (adolescent age, parent education level,
and Hispanic ethnic/cultural group), and internalizing behaviors and self-esteem mediating
the relationship between the risk factor of parent-adolescent conflict and cultural protective
factor familism was fitted using Mplus Version 5.2, using the weighted least squared
estimator, which calculates the significance of direct and specified indirect paths [61].
Model results will be reported using the standardized coefficients (the standard deviation change in the dependent variable for every one unit change in the standard deviation of
Table 2 Correlations between study variables
1

1. Age at interview

2. Parent education

-0.06

3. Familism

-0.07

-0.11

4. Parent-adolescent conflict

0.08

0.09

5. Self-esteem

0.08

0.06

-0.38***

6. Internalizing behaviors

-0.12

-0.08

-0.07

0.41***

-0.69***

7. Suicide attempter

-0.08

-0.13

-0.10

0.34***

-0.45***

0.25***

-0.43***
0.50***

* p \ 0.05; ** p \ 0.01, *** p \ 0.001

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the independent variable), but both standardized and unstandardized coefficients can be
found in Fig. 2,with the unstandardized coefficients shown in parentheses. The path model
demonstrated good model fit (CFI = 0.99, TLI = 0.99, RMSEA = 0.02). The results from
the path model showed that familism had a negative relationship with parent-adolescent
conflict (b = -1.43, p \ 0.001) and a positive relationship with internalizing behaviors
(b = 0.12, p \ 0.05), and the relationship between familism and self-esteem was no longer
significant in the path model. Parent-adolescent conflict was negatively related to selfesteem (b = -0.57, p \ 0.001) and positively related to internalizing behaviors (b = 1.25,
p \ 0.001). Both self-esteem (b = -0.04, p \ 0.05) and internalizing behaviors
(b = 0.04, p \ 0.001) showed significant relationships with suicide attempts in the
hypothesized directions. Neither parent education level, nor adolescent age showed significant relationships to any of the variables in the path model, and no Hispanic subgroup
had a significant relationship to any of the variables in the model after adjusting for
pairwise comparisons.
Using Sobels test, we found that the several indirect paths in our model were also
significant (Table 3). Both paths from parent-adolescent conflict through adolescent selfesteem (z = 6.87, p \ 0.001) and internalizing behaviors (z = 6.92, p \ 0.001) to suicide
attempts were significant. The indirect path from familism through internalizing behaviors
to suicide attempts was also significant (z = 10.44, p \ 0.001). In addition, the paths from
familism to internalizing behaviors (z = -4.45, p \ 0.001) and self-esteem, (z = 4.84,
p \ 0.001) both via parent-adolescent conflict, were significant.

Fig. 2 Full model results for path analysis. Note: Standardized coefficients are listed on the model paths,
followed by unstandardized coefficients in parentheses. Model Fit Indices: CFI = 0.99, TLI = 0.99,
RMSEA = 0.02. Results for covariates were not significant and are not shown. * p \ 0.05; ** p \ 0.01;
*** p \ 0.001

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Table 3 Sobels test results for indirect path significance

a

Sa

Sb

ab

b2  s2a a2  s2b

Familism ? internalizing
behaviors ? suicide attempt

1.13 0.56

0.04

0.00

10.44***

Familism ? self-esteem
? suicide attempt

0.55 0.29 -0.04 0.02 -0.02

0.02

-1.41

P-A conflict ? internalizing

behaviors ? suicide attempt

1.20 0.17

0.03 0.01

0.03 0.01

0.04

0.01

6.92***

P-A conflict ? selfesteem ? suicide attempt

-0.57 0.08 -0.04 0.02

0.02

0.00

6.87***

Familism ? P-A conflict

? Self-esteem

-1.43 0.27 -0.57 0.08

0.82

0.17

4.84***

Familism ? P-A
conflict ? internalizing
behaviors

-1.43 0.27

1.20 0.17 -1.72

0.39

-4.45***

* p \ 0.05; ** p \ 0.01; *** p \ 0.001

Discussion
From self-report data provided by a group of adolescent Latinas living with their families
in a large northeastern metropolitan area, we undertook analyses that focused on familism,
parent-adolescent conflict, self-esteem, internalizing behaviors, and suicide attempts.
Controlling for adolescent age, Latino ethnicity, and parent education level, we sought
answers to several hypotheses that support an ecological model when seeking to understand the phenomenon of suicide attempts in adolescent Latinas.
Consistent with our expectations, familism was a protective factor against parent-adolescent conflict, and parent-adolescent conflict was in-turn related to higher levels of
internalizing behaviors and lower self-esteem. Both internalizing behaviors and selfesteem were related to suicide attempts, with higher levels of the former predicting
attempts, and higher levels of the latter protecting against them. Although we had
hypothesized that familism would be a cultural protective factor against internalizing
behaviors, our results suggested a relationship in the opposite direction, since familism
predicted higher levels of internalizing behaviors in the adolescent girls. Various indirect
paths to adolescent suicide attempts were also significant in our model, including the two
paths from parent-adolescent conflict to suicide attempts, mediated by internalizing
behaviors and self-esteem, and the path from familism to attempts through internalizing
behaviors. The mediation paths from familism to both internalizing behaviors and selfesteem through parent-adolescent conflict were both significant as well.
Familism in this study was related to both individual level variables and the familial
level variable of parent-adolescent conflict. The complexity of the concept and measurement of familism was evident in this study in that as the girls familistic attitudes rose, they
evinced lower levels of conflict but higher levels of internalizing behaviors. Girls with a
suicidal history did not differ in their endorsement of familism from girls without such a
history.
Familisms relationship to lower conflict between the parent and adolescent can be
interpreted in several ways. In using an attitudinal measure of familism that measures
deference to elders among other domains, we may have an indication that girls with higher
familism may refrain from engaging in conflict with parents as it is deemed disrespectful to

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them [19]. Girls with higher levels of familism may also be more in-tune with their
parents values but it is possible that as the disparity grows between parents and
daughters familistic attitudes with the girls increasing acculturation and maturation,
conflict may also increase [3].
Traditional Hispanic family values may have different meanings across genders [19].
For example, respecting elders for a Latina adolescent could mean internalizing problems
in order to maintain harmonious family relationships [5]. As familism is a multi-faceted
concept, it may be that certain components are more related to higher levels of internalizing behaviors, and other components account more for reduced levels of parent-adolescent conflict. This merits more research attention that could explore the interactions of
the separate dimensions of the familism construct.
Parent-adolescent conflict at the familial level emerged as the variable most strongly
associated with other variables. This is not surprising and illuminates the importance of the
interpersonal changes that dawn in early adolescence. That Latinas who perceived more
conflict with their parents also reported higher levels of internalizing behaviors and lower
levels of self-esteem is consistent with findings of higher internalizing behaviors in the
presence of parent-adolescent conflict among Latino and non-Latino youth [35, 50, 65, 66].
There is room to speculate that adolescent perception of high conflict with parents may have
particular salience in the context of Latino family dynamics and child socialization. With
considerable emphasis given to the individuals obligation to the family through familism
and deference to parents that is transmitted through child-rearing practices, Latino adolescents may experience conflict differently than youth from mainstream American culture who
are encouraged to assert themselves and establish their independence. As conflict with their
parents escalates, adolescent Latinas may feel especially guilty for not conforming to the
deferential posture expected of them and to traditional gender norms that urge them to
sacrifice autonomy for their parents and family. Like other females in this age group, Latinas
may turn their stress inward, raising the possibilities of depression and other internalizing
disorders [67, 68]. In sum, familism presents a very interesting dynamic in the lives of the
Latinas in our study: it can have a double-edged effect. On one side, familism has protective
effects on Latino adolescents that enhance self-esteem. On the other side, familism can blunt
the conflict between adolescents and parents. Restricting a young womans rights to deviate
from parents values, attitudes, beliefs and practices may cause a turning inward that can lead
to lowered self-esteem, more internalization of emotions, depression, and suicidality.
Although our results did not show a direct relationship from parent-adolescent conflict
to suicide attempts, the indirect paths from parent-adolescent conflicts mediated by
internalizing behaviors and self-esteem were significant, which gives support to the suggestion made by Gould et al. [42], that researchers should take caution in interpreting direct
effects from parent-adolescent conflict to suicide because of the likely presence of these
indirect paths. Self-esteem and internalizing behaviors were also correlated with each
other, a finding consistent with past research that shows that this relationship can arguably
run in both directions [69, 70].
Limitations
There are some limitations of this study. One limitation is the purposive sampling strategy
we used in which we sought girls from mental health centers who had attempted suicide
and the convenience sample of our comparison group. We also did not account for any
group differences that may be present in the types of clients and/or patients served at the
community facilities. Not controlling for lethality introduced variability in our sample that

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437

limits our conclusions. Because the girls in our study do not represent participants from
other parts of the country, our findings can only be interpreted as applicable to girls in the
metropolitan area we surveyed; they do not necessarily generalize to other Latina girls.
Although, a longitudinal study also examining familism and parent-adolescent conflict,
internalizing behaviors, and self-esteem showed the temporal order we posit to be significant [35], our data were collected at one time point, not prospectively, and so no lines of
causation can be drawn from the relationships examined. Another limitation is that we used
the girls reports of conflict with parents only; we did not include parents perceptions of
conflict or familism in this report.
Implications for Practice
In spite of these limitations, this study contributes to knowledge about the characteristics of
Latina adolescents who attempt suicide and to the general body of research on adolescent
suicide attempts. With the limited literature on the correlates and explanations for the high
rates of suicidal behavior in adolescent Latinas, and even fewer studies with a clear
theoretical frame [53], our study and our findings are a step in closing gaps on this topic.
Furthermore, many of our findings support the results reported by other researchers who
have studied both non-Latino and Latino youth in rural and urban settings in different parts
of the United States [44].
The fact that the girls themselves report that familistic attitudes provide positive outcomes, like heightened self-worth and lower conflict with their parents, should be viewed
as a target of interventions for these girls and families. Communication between Latino
parents and daughters [3] can reduce conflict and the risk of suicidal actions by improving
the emotional connection and sense of support and affection that comes from talking with
parents in open, trusting, and reliable interactions. Besides reinforcing cultural values and
ethnic identity that promotes prosocial and adaptive behaviors [71, 72], communication is
the pathway toward enhancing shared familistic values in families.
For the clinical realm, we can glean some insights that can help program developers and
practitioners who work with this vulnerable population. Suicide prevention and intervention programs for Latina adolescents must involve the parents and siblings, and possibly
extended family. Reports by Rossello and Bernal [73] indicate that cultural adaptations for
Puerto Rican youth include the incorporation of parents as part of the therapy that is
provided. Results of our study suggest not only that Latina adolescents can benefit from
parent-involved suicide prevention and intervention programs, but that services that target
reducing conflict in the parentchild dyad can also help build or retain adolescent-self
esteem and reduce risks for internalizing behaviors. Program developers and practitioners
should take carefully into consideration the values of familism when working with Hispanic populations. Familism can be an enormous support in the treatment of suicidal girls
but it also needs to be recognized as restrictive on girls through its emphasis on selfsacrifice and obligations to parents and siblings. These findings support the development of
suicide prevention programs that are both culturally competent and focused on the parentdaughter relationship in adolescence.

Summary
This study analyzed the relationships between cultural, familial, and individual variables in
a sample of adolescent 115 Latina suicide attempters and 111 non-attempters in New York

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City. Our results point to the importance of familism in suicide attempts in our sample,
through its relationship to parent-adolescent conflict, self-esteem, and internalizing behaviors. While familism acted as a protective factor against parent-adolescent conflict, it was
also related to higher levels of internalizing behaviors. Parent-adolescent conflict also
showed a strong positive relationship to internalizing behaviors and a negative relationship
with self-esteem; however, its effects on suicide attempts were completely mediated by
internalizing behaviors and self-esteem. These findings emphasize the importance of
involving families in suicide interventions and prevention programs that target Latina
adolescents, as improving the relationship between adolescents and their parents reduces the
likelihood for suicide attempts by lowering levels of internalizing behaviors and building
self-esteem. As the phenomenon of high suicide attempts among adolescent Latinas is still
not understood, future research should work to further disentangle and the confluence of
cultural, familial, and individual factors that could be predicting these attempts.
Acknowledgments Support for this paper was provided by grant R01 MH070689 from the National Institute
of Mental Health to Luis H. Zayas. Additional support was provided by the Center for Latino Family Research.
We extend our gratitude to the adolescent girls and their families who participated in this study.

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