64 Adverse Childhood Experiences and Familial Factors in Adolescent Suicidality Byoungwook D. Park1, Pauline Goger 2, & Christine B. Cha3, 4, 5 1Icahn School of Medicine at Mount Sinai, Mount Sinai Behavioral Health Center, New York, NY 2Department of Psychological and Brain Sciences, Fairfield University, Fairfield, CT 3Center for Brain and Mind Health, Yale School of Medicine, New Haven, CT 4Child Study Center, Yale School of Medicine, New Haven, CT 5Department of Counseling & Clinical Psychology, Teachers College, Columbia University, New York, NY Suicide is a major public health concern across the lifes- pan (Centers for Disease Control and Prevention [CDC], 2023). In particular, adolescents between the ages of 10 and 19 are especially vulnerable, with suicide ranking as the sec- ond leading cause of death in this age group in the United States (American Academy of Child and Adolescent Psychi- atry [AACAP], 2019). In this developmental stage, parents or primary caregivers have a unique psychosocial influence, as children are legally, emotionally, and developmentally de- pendent on them (Armsden & Greenberg, 1987; Delgado et al., 2022; Moretti & Peled, 2004). For this reason, when exam- ining adolescent suicidal thoughts and behaviors (STBs; e.g., suicide attempts, suicidal ideation, and suicide plan), familial factors are often considered (Cha et al., 2018; Shain et al., 2016; Wang et al., 2022). Furthermore, efforts are often made to in- clude parents and families in treating depressed and suicidal youth, and parents can play a key role in connecting youth with mental healthcare services (Adrian et al., 2023; Cur- ry, 2001; Diamond et al., 2003; Sander & McCarty, 2005). Suicide is a multifaceted phenomenon shaped by the interplay of diverse risk and protective factors (De Berardis et al., 2018). Among various risk and protective factors, the current study focuses on the following: suicidal ide- ation (SI), adverse childhood experiences (ACEs), family functioning (FF), and perceived parental criticism (PPC). Suicidal Ideation Suicidal ideation (SI) refers to the contemplation of suicide with or without the intent, or hope for death by self-inflicted means (De Leo et al., 2021). Individuals ex- periencing SI may have varying degrees of intensity and frequency in these thoughts, ranging from fleeting wishes to die without the intention of engaging in corresponding behaviors (i.e., passive SI) to current, persistent, suicidal thoughts with detailed plans (i.e., active SI; Harmer et al., 2024). This construct is a well-established risk factor for suicide and is prevalent among youth (Buitron et al., 2016; Chu et al., 2015; Saffer et al., 2015). Specifically, approxi- mately 22% of female and 12% of male high school students in the United States have contemplated suicide (Kann et al., 2018). While some research suggests that SI alone (i.e., SI without specific plans, intent, actual preparatory behaviors, or access to lethal means) may not indicate high suicide risk (Joiner et al., 2003), it remains a significant risk factor as indi- viduals who have expressed thoughts of killing oneself has a higher risk of completing suicide than people who had not (Hubers et al., 2018). Thus, the severity of SI plays a crucial role in risk formulation for both adolescents and adults. Adverse Childhood Experiences Adverse childhood experiences (ACEs) refer to po- tentially traumatic and stressful life events or circumstances Purpose: Adverse childhood experiences (ACEs) are risk factors for adolescent suicidal ideation (SI), but the influ- ence of immediate family factors on this association remains understudied. This study examines how family func- tioning (FF) and perceived parental criticism (PPC) moderate the relationship between ACEs and SI. Methods: 46 community-based adolescents between the ages of 15 and 19 (Mage = 17.43 years, 69.57% female) participated in a study examining cognitive risk factors for SI. Several self-report measures were administered: the Suicidal Ideation Questionnaire to assess SI severity, the Adverse Childhood Experiences Questionnaire to measure ACEs, the McMas- ter Family Assessment Device – General Functioning Scale to evaluate FF, and the Perceived Criticism Measure to determine PPC. Results: Neither the presence (ß = .26, p = .09) nor the count of ACEs (ß = .24, p = .12) significantly predicted SI severity. SI severity was significantly associated with specific ACEs such as emotional abuse, emotional neglect, and mental illness or suicide attempts in the household (ß = .39-.65, p = .00-.04), but not with others (ß = -.21-.40, p = .08-.99). Furthermore, FF (ß = .28, p < .01) and PPC (ß = .19, p =.04) independently moderated the association between ACEs and SI severity, while their combined interaction was not significant (ß = -.03, p = .74). Conclusion: Specific ACEs predicted SI severity. Moreover, lower FF and higher PPC independently amplified the impact of ACEs on SI severity in adolescents, highlighting the need for interventions that enhance FF and address PPC to mitigate adolescent suicide risk. Keywords: Suicide, Adolescent, Adverse Childhood Experiences, Family Functioning, Perceived Parental Criticism Graduate Student Journal of Psychology Spring 2025 - Vol. 24 Copyright 2025 by the Department of Counseling and Clinical Psychology Teachers College, Columbia University 65 that occur during childhood or adolescence, which can have lasting negative effects on an individual's well-being (Sahle et al., 2022). These adverse experiences typically encompass various events that can be classified into three categories: abuse (i.e., physical, emotional, or sexual), neglect (i.e., phys- ical or emotional), and household dysfunction (i.e., sub- stance abuse or mental health issues in the family, domestic violence, incarceration, or parental separation; Sahle et al., 2022). The association between ACEs and the severity of SI and suicide attempts has been consistently demonstrat- ed in both community and high-risk adolescent samples (Dunn et al., 2013; Miller et al., 2013; Sahle et al., 2017). In a nationally representative sample of 10,914 partic- ipants, the cumulative lifetime counts of ACEs influenced the prevalence of SI and suicide attempts in adulthood (Thompson & Kingree, 2022). Specifically, one ACE in- creased the odds of endorsing active SI by 1.5 times, two ACEs increased the odds of SI by 2 times and a suicide at- tempt by 3 times, and three ACEs increased the odds of SI by 3 times and a suicide attempt by 5 times. Notably, interventions such as parenting education, mental health counseling, social service referrals, and social support are shown to effectively reduce behavioral and mental health problems in children who have experienced such potential- ly traumatic events (Marie-Mitchell & Kostolansky, 2019). Family Functioning Various family-related variables have been recognized as both protective and risk factors in adolescent suicidality (Wang et al., 2022). Family cohesion and the adolescent-par- ent connection were identified as protective factors against the current SI turning into later suicide attempts (Shain et al., 2016; Sun et al., 2020). In a study involving 852 Chi- nese outpatient adolescents and adults, parental emotional warmth and less punitive mothers were recognized to be pro- tective against the development of STBs (Wang et al., 2022). On the contrary, negative family functioning (FF), im- paired parent-child relationships, family breakdown, low paternal attachment, apathetic and severe child-rearing style, adolescents not talking to family adults about concerns, do- mestic violence, arguing at home, low familial adaptability and cohesion, and low parental care have been identified as significant risk factors (Ohtaki et al., 2019; Saffer et al., 2015; Shain et al., 2016; Sheftall et al., 2013; Wang et al., 2022;; Weissinger et al., 2023). Among 5,557 adolescents in Hong Kong aged 11 to 18, lower levels of family functioning and parent–adolescent communication were significantly associ- ated with depression and suicidal ideation (Kwok & Shek, 2011). Notably, the improvement of interpersonal relation- ships with family members has been identified as a help- ful recovery factor following SI (Grimmond et al., 2019). Perceived Parental Criticism Perceived parental criticism (PPC) is a construct in ex- pressed emotion literature (i.e., critical or hostile attitudes expressed by family members or caregivers toward a person with a psychiatric disorder) that has a crucial role in family relationships (Hooley & Miklowitz, 2017). In adolescents, PPC captures how much parental criticism is perceived, in- ternalized, and affects the individual. It is hypothesized that PPC has an impact on SI and suicide attempts through its connection to constructs in the interpersonal theory of suicide (Chu et al., 2017), such as thwarted belongingness or perceived burdensomeness (Hagan & Joiner, 2017). Adolescence, a developmental stage from ages 10 to 19, is characterized by the emergence of independence, the de- velopment of sexuality, the formation of new meaningful re- lationships, and accompanying vulnerabilities (Berenbaum et al., 2015; Remschmidt, 1994; World Health Organization [WHO], 2025). During this crucial and delicate period, adolescents’ sensitivity to parental criticism may intensi- fy their feelings of loneliness or distort their perception of their worth to others. For instance, when parental criticism is interpreted as rejection or disapproval of their inherent value, it can undermine their sense of belonging within the family. Moreover, if adolescents begin to view themselves as a burden as a result of PPC, this perception may reinforce feelings of burdensomeness, increasing the risk of suicidal ideation or self-destructive behaviors. Thus, the importance of protective social networks and trusted adults during this period has been highlighted by many (Pringle et al., 2018). However, there are conflicting findings on the associa- tion between PPC and suicidality. Some studies report PPC as a significant indicator of depression, SI, and suicide attempt (Hagan & Joiner, 2017; Muyan & Chang, 2015; Rapp et al., 2021; Wang et al., 2017), while others suggest that PPC only has an indirect effect on non-suicidal self-injury (NSSI) through self-criticism (Baetens et al., 2015), or find no signif- icant association between NSSI and PPC altogether (Daly & Willoughby, 2019). Further investigation is warranted to clar- ify the association between PPC and adolescent suicidality. Aims and Hypotheses Previous research has established that SI, ACEs, FF, and PPC individually contribute to adolescent suicidality. Al- though the predictive relationship between ACEs and SI is well established, the moderating influence of FF and PPC on this association remains largely unexplored. By delving into the moderating effects of FF and PPC, we aim to identify PARK, GOGER, & CHA 6666 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY participation in the study were used as grounds for exclusion. Out of 176 community-based adolescents who en- rolled in the study, 46 completed the Adverse Childhood Experience Questionnaire (ACE-Q). Relatively few ado- lescents completed the ACE-Q because its administration was discontinued mid-study in an effort to shorten the baseline protocol. Thus, only this subgroup of adolescents (n = 46) between the ages of 15 and 19 (Mage = 17.43 years, 69.6% female; Table 1) was analyzed. The participants were racially diverse, with 45.7% identifying as white, 23.9% identifying as Black or African American, 21.7% identify- ing as Asian, and 4.3% identifying as multiracial or other. Additionally, 17.4% of the adolescents identified as Hispan- ic. The majority (67.4%) of the adolescents reported het- erosexual sexual orientation, followed by bisexual (19.6%), homosexual (8.7%), questioning (2.2%), and other (2.2%). Measures Suicidal Ideation Questionnaire (SIQ) The severity of both passive and active suicidal ideation in adolescents over the past month was assessed using the SIQ (Reynolds, 1987), a 30-item self-report measure rated on a seven-point Likert scale (0 = “I never had this thought,” 6 = “Almost every day”). An elevated score on the SIQ suggests a frequent and pervasive presence of SI (Boege et al., 2014). The SIQ is scored by summing responses to each question, and a score of 41 or higher is considered clinically signifi- cant. The SIQ was validated among 226 adolescents aged 13 to 18 years, with a Cronbach’s α = .98 (Pinto et al., 1997). Adverse Childhood Experiences Questionnaire (ACE-Q) The ACE-Q (Felitti et al., 1998) was administered to assess and quantify adverse or traumatic experiences encoun- tered throughout the participants’ lifetime. The ACE-Q con- sists of 10 yes-no items and addresses the following domains: emotional, physical, and sexual abuse, emotional and physi- cal neglect, parental separation, domestic violence, household substance abuse, mental illness or suicide attempts in the household, and incarceration of family members. Moreover, scores of four or higher (i.e., the presence of four or more dis- tinct ACEs) are deemed clinically significant. A high ACE-Q score has been associated with an increased risk for depres- sion, suicide attempts, smoking, drug abuse, adolescent preg- nancy, and impaired work performance in adulthood (Anda et al., 2004; Dube et al., 2003; Edwards et al., 2007; Felitti et al., 1998; Hillis et al., 2004). This questionnaire has been validated among 79 adolescents, with intraclass correlation coefficient values exceeding or being equal to .65 (i.e., good to excellent agreement) across all 10 items (Pinto et al., 2014). nuanced pathways through which ACEs may or may not translate into SI later in adolescence. Since the family envi- ronment plays a pivotal role in adolescents’ emotional and psychological development, investigating these interactions can offer insights into how familial factors exacerbate or miti- gate the risk of adolescent suicidality in the presence of ACEs. Thus, the current study examines how ACEs predict the severity of SI in adolescents, and to what extent this association is moderated by FF and PPC. Understanding this intricate re- lationship may offer valuable insights into protective and risk factors of adolescent suicidality, contributing to the design of targeted interventions and support systems for at-risk youth. First, this study will investigate the association be- tween ACEs and the severity of SI in adolescents, positing the following hypotheses: Hypothesis 1a: Adolescents with at least one ACE will endorse a higher severity of SI than those without ACEs. Hypothesis 1b: Subcategories of ACEs will correspond with SI severity in adolescents, such that those adolescents with a history of each type of ACE report more severe SI than their respective non- ACE comparison group. Hypothesis 1c: A higher count of ACEs will predict a higher severity of SI in adolescents. Second, the moderating effects of FF and PPC on the association between ACEs and the severity of SI in adolescents will be examined. The following hypotheses are posited: Hypothesis 2a: ACEs will be more strongly associated with SI severity among adolescents with lower FF. Hypothesis 2b: ACEs will be more strongly associ- ated with SI among adolescents with higher PPC. Hy- pothesis 2c: ACEs will be more strongly associated with SI among adolescents with higher PPC and lower FF. Methods Sample Participants were recruited from the urban communi- ty in the greater New York metropolitan area via in-person (e.g., street fairs and flyers) and online (e.g., social media advertisement and ResearchMatch) recruitment efforts for a study examining cognitive risk factors associated with SI. Post-baccalaureate- and masters-level research assistants conducted screenings via phone to determine eligibility. Eligibility was determined based on the presence of STBs in adolescence, while (1) challenges in the adolescent’s and parent/guardian’s understanding of informed consent and study procedure, (2) self-disclosure of immediate suicidal in- tent, (3) the occurrence of violent and agitated behaviors, (4) limited proficiency in the English language, and (5) psychiat- ric symptoms of adolescents which would hinder consent or 67 PARK, GOGER, & CHA McMaster Family Assessment Device – General Func- tioning Scale (FAD-GF) The McMaster Family Assessment Device (FAD; Ep- stein et al., 1983) is a 60-item self-report questionnaire that assesses an individual’s perception of their family across do- mains of problem-solving, communication, roles, affective responsiveness, affective involvement, behavior control, and general functioning. Each item is scored on a four-point Likert scale ranging from “Strongly Agree” to “Strongly Disagree.” In the current study, only 12 questions from the general functioning domain were utilized to gauge ad- olescents' perceptions of how their families work together on essential tasks (Byles et al., 1988). Lower scores on the FAD-GF indicate better general FF, and it has been validated for standalone use in 1,869 families with children between 4 to 16 years of age (Cronbach’s α = .86; Byles et al., 1988). Perceived Criticism Measure (PCM) Two items from the Perceived Criticism Measure (PCM; Hooley & Teasdale et al., 1989) were employed to assess adolescent’s PPC (i.e., “How critical do you think your parent or guardian is of you?” and “When your parent or guardian criticizes you, how upset do you get?”). Each item is scored on a 10-point Likert scale ranging from “not at all critical” to “very critical.” Responses to these two items were summed to derive the total PCM score for analysis. The PCM has robust test-retest reliability (r = .75) over a five-month period (Hooley & Teasdale et al., 1989). Some argue that the construct and assessment of the PCM merely reflect negatively biased perceptions influenced by individu- als’ moods. However, it was observed that the PCM scores did not change significantly after successful positive and negative mood inductions in 150 undergraduate students (r = -.12 and r = -.09, respectively; Gerlsma et al., 2014). Procedure Adolescents and their families who met the eligibility criteria participated in assessments during an initial labora- tory visit and subsequent follow-up evaluations conducted online via email at 3 and 6 months. Compensation included a $35 gift card for baseline assessments, with opportunities to win $50 and $100 gift cards in raffles for completing the 3- and 6-month follow-ups, respectively. Notably, the final 18.75% of the total 176 participants (n = 33) completed baseline visits virtually due to the impact of the COVID-19 pandemic. Furthermore, suicidal participants who were recruited during the pandemic indicated elevated levels of SI severity when contrasted to suicidal participants recruit- ed before the onset of the pandemic (R2 = .04; p = .04). However, data collection for the 46 participants under examination in this study occurred before the pandemic, with the last participant completing the baseline visit on December 8th, 2018. Thus, this difference in the severity of SI in suicidal adolescents did not impact current analyses. All study procedures were approved by the Institutional Review Board at Teachers College, Columbia University. Statistical Analyses All analyses were conducted with Statistical Package for the Social Sciences (SPSS; version 29; IBM SPSS Inc., Chica- go, Illinois). Linear Regression To examine whether adolescents with at least one ACE will endorse a higher severity of SI than those without ACEs (Hypothesis 1a), linear regression was utilized. Given the slightly right-skewed distribution of both SI and ACEs, linear regression was chosen for analysis due to its robust- ness against mild violations of assumptions (Ernst & Al- bers, 2017). Adolescents with a score of one or more on the ACE-Q were assigned to the ACEs group, while those with a score of zero on the ACE-Q were assigned to the non-ACES group. Subsequently, the analysis was completed while exam- ining this dichotomous classification of ACEs as an indepen- dent variable and the severity of SI as a dependent variable. Furthermore, linear regression was employed to examine whether subcategories of ACEs corresponded with SI severi- ty in adolescents, such that adolescents with a history of each type of ACE reported more severe SI than their respective non-ACE comparison group (Hypothesis 1b). 10 discrete linear regressions were conducted between individual items in ACE-Q and the severity of SI. Linear regression was em- ployed once more to assess whether a higher count of ACEs predicted a higher severity of SI in adolescents (Hypothe- sis 1c). This potential predictive relationship was assessed by examining the total score of ACE-Q as an independent variable and the total score of SIQ as a dependent variable. Moderation Analysis PROCESS Macro version 4.2 (Hayes, 2022) was used to conduct moderation analysis while examining ACEs as an independent variable, severity of SI as a dependent variable, and FF and PPC as discrete and composite mod- erators. PROCESS is an observed variable, Ordinary Least Squares (OLS), and logistic regression path analysis mod- eling tool, often used in the fields of social, business, and health sciences. It supports both mediation and modera- tion analyses by generating 5000 bootstrapped samples, automatically mean-centering continuous variables, estab- lishing product terms, and presenting confidence intervals. 68 Results Demographic Characteristics Participants with at least one ACE accounted for ap- proximately 67% (n = 31) of the sample. Furthermore, around 13% (n = 6) of the sample indicated experienc- ing four or more ACEs (i.e., clinically significant levels) in their lifetime. In terms of ACEs, this sample was rep- resentative of the population as approximately 64% of U.S adults report having at least one ACE, and 17% re- port having four or more ACEs (Swedo et al., 2023). Hypothesis 1a: Adolescents with at least one ACE will endorse a higher severity of SI than those without ACEs. There was no significant association between the history of ACE (i.e., presence of at least one ACE vs. no ACE) and SI severity (ß = 0.26, p = .09). Hypothesis 1b: Subcategories of ACEs will correspond with SI severity in adolescents, such that those adolescents with a history of each type of ACE report more severe SI than their respective non-ACE comparison group. Out of 10 subcategories of ACEs measured by ACE-Q, a significant regression was found in emotional abuse (ß = 0.49, p = .01; Table 2), emotional neglect (ß = 0.65, p < .001), and mental illness or suicide attempt in the household (ß = 0.39, p = .04) with severity of SI. For emotional abuse, R2 = 0.24, indicating that emotional abuse explained approximate- ly 24% of the variance in SI severity. In the case of emotional neglect, R2 = 0.43, signifying that approximately 43% of the variability in SI severity can be accounted for by emotional ne- glect. For mental illness or suicide attempt in the household, R2 = 0.15, indicating that being in a household with a family member who has a mental illness or who has made a suicide attempt explained 15% of the variance in SI severity. On the contrary, no significant regression was observed for physical abuse (ß = 0.37, p = .08), sexual abuse (ß = 0.40, p = .09), phys- ical neglect (ß = 0.22, p = .40), parental separation (ß = -0.02, p > .99), witnessing domestic violence (ß = 0.29, p = .20), household substance and alcohol abuse (ß = -0.21, p = .40), and incarceration of household members (ß = 0.39, p = .10). Hypothesis 1c: A higher count of ACEs will predict a higher severity of SI in adolescents. There was no significant association between the count of ACEs and the severity of SI in adolescents (ß = 0.24, p = .12). Hypothesis 2a: ACEs will be more strongly associat- ed with SI severity among adolescents with lower FF. The moderation analysis revealed that approximate- ly 68% of the variability in SI severity in adolescents was predicted by ACEs and FF (R2 = 0.68, F(3, 20) = 13.90, p < .001; Table 3). Additionally, the results indicated that ACEs (ß = 0.21, p = .04) had a significant positive effect on SI severity. While FF did not have significant effects on SI severity independently (ß = 0.19, p = .12), it was revealed that there was a significant interaction between ACEs and FF (ß = 0.28, p < .01). This significant interaction indi- cated that FF moderated the effect of ACEs on SI severity. This moderating effect is displayed in Figure 1. The graph demonstrates that the association between ACEs and SI severity is stronger for adolescents with lower FF (ß = 0.49, p < .01; Table 4), and weaker for adolescents who have moderate FF (ß = 0.20, p = .04). Furthermore, the graph suggested that ACEs had a negative impact on the severity of SI for adolescents with high FF. Specifically, adolescents in the high ACEs group within the high FF category endorsed lower SI than those in the low ACEs group. However, this decline in SI within the high FF group was not found to be statistically significant upon further investigation (ß = -0.08, p = .46). In interpreting this result, it should be noted that a significant correlation was found between ACEs and FF (r(25) = .48, p = .02). Upon further investigation, it was re- vealed that only one subcategory of ACEs was correlated to FF (i.e., emotional abuse; r(23) = .55, p < .01). To address the potential issues of multicollinearity both ACEs and FF were mean-centered. This pre-processing step aimed to re- duce the correlation between ACEs and FF, enhancing the precision of the results and contributing to a more reliable examination of their relationship (Iacobucci et al., 2017). Hypothesis 2b: ACEs will be more strongly associ- ated with SI among adolescents with higher PPC. Approximately 47% of the variability in SI severi- ty in adolescents was predicted by ACEs and PPC (R2 = 0.47, F(3, 22) = 6.42, p < .01; Table 3). The results indi- cated that both ACEs (ß = 0.48, p < 001) and PPC (ß = 0.29, p = .02) had a significant positive effect on SI sever- ity. Furthermore, there was a significant interaction be- tween ACEs and PPC (ß = 0.19, p = .04), indicating that PPC moderated the effect of ACEs on the severity of SI. Figure 2 visualizes this interaction. The prevalence of ACEs exhibited a significant positive impact on the severity of SI within all three groups of PPC, with the most pronounced association observed among adolescents with high PPC (ß = 0.67, p < .01; Table 5). A less pronounced association was observed for adolescents with moderate levels of PPC (ß = 0.47, p < .001), followed by adolescents with low PPC (ß = 0.28, p = .01). A significant correlation between ACEs and PPC was not observed (r(23) = -0.29, p = .15). Hypothesis 2c: ACEs will be more strongly associated with SI among adolescents with higher PPC and lower FF. ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY 69 PARK, GOGER, & CHA This model explained approximately 72% of the variabil- ity in SI severity (R2 = 0.72, F(4, 19) = 5.89, p < .01; Table 3). The analysis revealed that ACEs (ß = 0.18, p = .38), PPC (ß = 0.12, p = .29), and FF (ß = 0.17, p = .41) did not have a signifi- cant independent effect on the severity of SI. Interactions be- tween ACEs x PPC (ß = -0.11, p = .41), PPC x FF (ß = 0.06, p = .64), and ACEs x PPC x FF (ß = -0.03, p = .77) were also not found to be significant. Nonetheless, the interaction be- tween ACEs and FF remained significant (ß = 0.32, p = .02). The interactions are visualized in Figure 3. The figure showed that ACEs had a negative impact on the severity of SI for adolescents with high FF, irrespective of varying levels of PPC. However, upon further investigation, these inter- actions were not significant (i.e., High FF x Low PPC (ß = -0.06, p = .72; Table 6), High FF x Moderate PPC (ß = -0.15, p = .60), High FF x High PPC (ß = -0.23, p = .58). Lastly, out of nine slopes visualized in Figure 3, two showed signif- icant associations: Low PPC x Low FF (ß = 0.64, p = .01; Table 6) and Moderate PPC x Low FF (ß = 0.50, p = .01). Discussion The current study examined how ACEs predict the severity of SI in adolescents, and to what extent this rela- tionship was moderated by familial factors such as FF and PPC. The results indicated that low FF and high PPC independently exacerbated the impact of childhood ad- versity on the severity of adolescent SI. This moderating effect, however, was not observed when examining FF and PPC compositely. Furthermore, specific forms of ACEs were significantly associated with the severity of SI in ad- olescents. Nonetheless, the presence and counts of ACEs were not significantly associated with the severity of SI. Moderating Role of FF and PPC As hypothesized, ACEs were more strongly associ- ated with SI among adolescents who had lower FF. This finding suggests that the combined impact of ACEs and lower FF exacerbates the risk of SI in adolescents. Visu- alizing the moderating effects of FF revealed intriguing patterns (Figure 1). Prior to conducting post hoc analysis, positive associations between the count of ACEs and se- verity of SI were expected for all three groups of FF (i.e., low, moderate, and high). Indeed, this pattern was observed among adolescents in both low- and moderate-FF groups. Although the impact was more pronounced in the low FF group than the moderate FF group, this finding indicated that adolescents with moderate FF face comparable risks to those with low FF. Given that not talking to family adults about concerns or lacking a trusted adult in one’s life has been linked to an elevated risk of teen suicidality (Weissing- er et al., 2023), it is plausible that adolescents from families with low and moderate functioning may not perceive their parents or guardians as trusted adults with whom they can discuss concerns when experiencing potentially traumatic life events. This inability to openly share the experiences of adverse events could exacerbate SI among adolescents and prevent them from receiving timely and appropriate help. In contrast, the opposite trend was observed in the high FF group; the severity of SI decreased as the count of ACEs increased. This unanticipated trajectory can be attributed to several plausible explanations. In families with high FF, children may generally perceive their parents or guardians as trusted adults and be more inclined to seek help from them when faced with potentially traumatic events. Additional- ly, families characterized by high general FF may be better equipped to provide appropriate assistance when adolescents experience crises and reach out for help. Adolescents’ willing- ness to seek help, coupled with the family’s competency in providing necessary support, may act as a buffer against the exacerbation of SI associated with childhood adverse events. Furthermore, the increased severity of SI observed in adolescents with fewer ACEs within the high FF group could be attributed to these adolescents perceiving their few ACEs as not substantial enough to justify seeking help, despite the less apparent but surely debilitating negative consequences of ACEs. As the count of ACEs rises, ad- olescents may feel more justified and validated in seeking support from their families, which can diminish the det- rimental effects of ACEs. However, the downward trend observed in the high FF group should be interpreted with caution, as the slopes are not statistically significant (Table 4). As predicted, ACEs were more strongly associated with SI among adolescents with higher PPC. This finding suggests that the risk of SI is exacerbated when ACEs are conjoined with a higher level of adolescents’ perception of parental criticism. As visualized in Figure 2, across all varying levels of PPC, the severity of SI increased as ACEs experienced by adolescents increased. The most prom- inent association was observed in the high PPC group, followed by the moderate, and then the low PPC groups. There may be several reasons why higher levels of PPC intensify the association between adverse events in child- hood and SI in adolescence. Parental criticism is associated with the development of internalizing symptoms (i.e., sad- ness, anxiety, and loneliness) in children (Ahmadzadeh et al., 2022; Ehrenreich & Underwood, 2016). In a longitudinal study conducted by Piqueras and colleagues (2019), inter- 70 nalizing symptoms (e.g., symptoms of depression) had a significant association with current suicidal behaviors in 239 adolescents. Given this body of research, it can be speculated that persistent parental criticisms may significantly shape ad- olescents' self-perception. The internalization of critical mes- sages from a caregiver may lead to the cultivation of a more pessimistic self-view. This curtailed self-esteem in youth may intensify feelings of thwarted belongingness and perceived burdensomeness (Eades et al., 2019). Thus, adolescents may experience heightened feelings of isolation and a diminished sense of emotional support from their parents. Consequent- ly, both thwarted belongingness and perceived burden- someness can compound emotional distress, amplifying the impact of ACEs and further elevating the risk of adolescent STBs (Ogrodniczuk et al., 2023; Roeder & Cole, 2019). Given that PPC is a construct designed to gauge ado- lescents' perception of parental criticism, there is ambiguity regarding its direct correlation with the frequency or actual intensity of criticism received. It is conceivable that PPC does not solely reflect the objective frequency or severity of paren- tal reproach, but rather encompasses a subjective element influenced by individual interpretations. This suggests that certain adolescents may be more prone to interpreting their parents' feedback as highly critical, irrespective of the actual tone or intention of such expressions. Likewise, it is plausi- ble that certain adolescents exhibit greater resilience in the face of potentially unwarranted and harsh parental criticism. While PPC captures external factors (i.e., how critical the parents are), it also encompasses the subjective filters through which adolescents interpret and process parental behaviors. Finally, there was insufficient evidence to conclude that FF and PPC compositely moderate the association between ACEs and adolescent SI. Thus, we could not conclude that ACEs are more strongly associated with SI among adolescents with both lower FF and higher PPC. Since FF and PPC independently moderated the association between ACEs and adolescent SI, the absence of a signif- icant result in evaluating FF and PPC as composite mod- erators raises questions. Potentially, the interplay between FF, PPC, ACEs, and SI may have been more complex than initially hypothesized. It is also possible that other variables or interactions that were not accounted for in the study design could have contributed to the observed outcomes. In this composite model, while all other interactions were not significant, the interaction between ACEs and FF remained significant, once again validating the finding in Hypothesis 2a. This finding becomes clearer when inspect- ing Figure 3. Among the nine interactions depicted in the figure, statistical significance was exclusively observed in the interactions involving the low FF group (i.e., low FF x low PPC and low FF x moderate PPC). This illustrates the pivot- al role of FF as a moderating variable in the complex interplay between adverse events in childhood and SI in adolescence. Moreover, the intriguing pattern depicted in Figure 1 reemerged in Figure 3. The figure displayed that ACEs had a negative impact on the severity of SI for adolescents with high FF, irrespective of varying levels of PPC. Once again, this suggested that adolescents in the high ACEs group with high FF endorsed lower SI than those in the lower ACEs group. While these interactions were not significant (Ta- ble 6), this recurring trend warrants further investigation. Association Between ACEs and SI Select forms of childhood adversity were associated with the severity of SI in adolescents. These include emo- tional abuse, emotional neglect, and mental illness or suicide attempts in the household. In contrast, physical abuse, sexual abuse, physical neglect, parental separation, witnessing do- mestic violence, household substance and alcohol abuse, and incarceration of household members did not correspond to SI severity in adolescents. This finding is partially aligned with the current literature and the hypothesis. Most studies examining the association between ACEs and SI report that the majority, if not all, subcategories of ACEs predict lat- er suicidality (Wang et al., 2019). While there is conflicting evidence regarding the consistent prediction of suicidality by household challenges, such as parental separation or in- carceration of a family member (Sahle et al., 2022), a more robust body of research consistently associates emotional, physical, and sexual abuse, as well as emotional and physi- cal neglect during childhood with later STBs (Miller et al., 2013; Pournaghash-Tehrano et al., 2021; Wang et al., 2022). Given this evidence, it is worth noting that only three out of 10 subcategories of ACEs were significantly asso- ciated with SI severity in the current study. The nonsignif- icant results across seven subcategories of ACEs should be interpreted with caution, as significant outcomes were identified solely within the three most prevalent categories of ACEs in the sample, with parental separation being the only exception (i.e., parental separation was prevalent, but the interaction was not significant; Table 2). Hence, the lack of significant results in the remaining seven ACE categories associated with SI severity may be due to insufficient rep- resentation of adolescents who experienced those specific adversities in the sample. Moreover, subcategories of ACEs that are consistently associated with SI severity, such as phys- ical and sexual abuse, exhibited potential significance. While ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY 71 PARK, GOGER, & CHA not significant at p = .05, both physical abuse (β = 0.37, p = .08; Table 2) and sexual abuse (β = 0.40, p = .09) were signif- icant at p = .10. The detection of some significance despite the small sample size may suggest a moderate association between the adolescent SI severity and specific ACE types. Contrary to the hypothesis, the result did not suggest that adolescents with at least one ACE endorse a higher se- verity of SI than those without ACEs. This finding is not aligned with the existing literature and should be interpreted with caution for several reasons. Scoring one on the ACE-Q may not definitively indicate the presence of adverse events in childhood. For instance, question six on the ACE-Q evalu- ates parental separation or divorce, which is generally associat- ed with various negative mental health outcomes in children (Çaksen, 2022). However, the impact of divorce depends on factors such as the intensity and duration of the separation process, as well as the availability of familial or non-familial support (Spremo, 2020). Since the ACE-Q lacks detailed as- sessments of these nuanced aspects, it is difficult to determine whether an affirmative response to question six or other questions signifies an adverse event experienced in childhood. Moreover, Spremo (2020) suggests that family dy- namics typically stabilize two to four years after divorce. Without knowing the timing of parental divorce relative to the date of assessment, we lack the temporal context to accurately gauge how the presence of at least one ACE, es- pecially parental separation, predicts adolescent SI. Lastly, it is plausible that the negative impact of ACEs may not fully manifest itself when assessed in close proximity to the occurrence of the adverse event. However, this explana- tion appears less likely as a large body of research suggests that ACEs are generally associated with an increased risk of SI and suicide attempts across community, clinical, and high-risk samples of adolescents (Miller et al. 2013). Once again, contrary to the hypothesis, no significant association was observed between the count of ACEs and the severity of SI. This finding should also be interpret- ed with caution, considering a body of research that sug- gests an alternative perspective. For instance, a study with a sample of 989 Chinese college students concluded that a cumulative effect was observed between ACEs and SI, in- dicating that a higher count of ACEs corresponded to an increased likelihood of endorsing SI (Wang et al., 2019). While Chinese society has increasingly integrated elements of individualism through Western influence, it remains more collectivistic than the U.S., particularly in its empha- sis on family interdependence (Kolstad & Gjesvik, 2014). Cultural factors like these may influence how indi- viduals perceive and respond to adversity within the fam- ily context (Oyserman & Lee, 2008). However, cultural explanations alone appear insufficient to account for the discrepancy between the current findings and those from studies conducted in collectivistic contexts. Notably, simi- lar associations between the cumulative negative impact of ACEs on SI have been observed in a sample of 1,532 U.S.- based adolescents (Meeker et al., 2021). It is possible that the absence of a significant association in the current study is attributable, at least in part, to the limited sample size. Limitations and Future Directions There are several limitations to consider in interpreting the findings. Although the current sample was ethnically di- verse, the small sample size may impact the generalizability of the findings. Several negative findings did not align with the existing literature (i.e., nonsignificant association between the presence of one ACE, counts of ACEs, and selected forms of ACEs with SI severity). The analyses should be replicated in a larger sample for more precise and representative findings. . Furthermore, although not statistically significant, the recurring pattern of negative association between counts of ACEs and severity of SI in high FF warrants future investi- gation in a larger sample. If replicating this analysis in a larger sample reveals a statistically significant decrease in SI for ado- lescents from families with high FF, it would suggest that not only are the negative effects of ACEs on adolescent suicidality potentially more pronounced in those with lower FF, but also that higher FF could serve as a protective factor. Lastly, FF and PPC should be evaluated as composite moderators in a larger sample, as the current study may have lacked the statistical power in the analysis to detect a significant interaction effect. Additionally, the study did not include measures of psy- chiatric disorders (e.g., major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder), which are known to be closely associated with both ACE exposure (Daníelsdóttir et al., 2024) and SI (Gilmour, 2016; Panagioti et al., 2015; Rihmer & Rihmer, 2019). Due to limitations in available data, key demographic variables such as house- hold income, single-parent status, and parental education level were not included in the analyses either. The absence of these variables limits the ability to assess potential confound- ing effects or to better contextualize the observed association. The cross-sectional design of the study also limits our ability to explore the dynamic changes in adolescent experiences with ACEs over time. Future research could benefit from longitudinal investigations which capture the evolving impact of ACEs throughout adolescents’ lives. Additionally, the use of self-report measures intro- 72 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY duces potential biases. Recall bias, along with individual differences in how adolescents define events as adverse, may impact the accuracy of reported ACEs. Relatedly, FF and PPC assessments may have been influenced by transient factors such as recent adolescent-parent conflicts (e.g., arguing with parents right before the assessments). The utilization of the Ecological Momentary Assess- ment (EMA) has the potential to address both concerns. With the use of appropriate questions, the EMA method- ology may enable the capture of real-time fluctuations in family interactions. This includes assessing the frequency, intensity, and content of parental criticism, as well as ad- olescents' corresponding STBs. Finally, despite both vari- ables being mean-centered to improve the interpretability of the regression model, the multicollinearity between ACEs and FF should be noted in interpreting results. Clinical Implications Given that FF and PPC are found to independently amplify and attenuate the effects of ACEs in adolescent suicidality, strategies focused on enhancing FF while simul- taneously mitigating PPC should be considered. Clinical- ly, targeted interventions can be developed to achieve the desired goal. When treating youth with suicidal thoughts, clinicians can assess for ACEs, FF, and PPC to identify at- risk individuals and provide appropriate early prevention support within the family context (e.g., implementing targeted family therapy, providing specific parenting sup- port, or designing programs that address FF and PPC). Evidence-based treatment targeting family cohesion can also be employed (e.g., Attachment-Based Family Thera- py; ABFT; Diamond et al., 2010; Diamond et al., 2003). Fostering an environment that promotes open com- munication and supportive family relationships becomes crucial at home. Encouraging positive interactions, ac- tive listening, and constructive dialogue can enhance FF and mitigate potential PPC issues. Implementing struc- tured family activities such as shared meals may further strengthen familial bonds (Utter et al., 2013). Additional- ly, educational initiatives can be extended to parents and caregivers to raise awareness about the impact of ACEs and the role of FF and PPC in adolescent mental health. Providing resources and guidance on effective parenting strategies and communication skills can empower families to create a nurturing and resilient environment. While it is ideal for parents or guardians to be involved in treating adolescents for their STBs, there are situations in which this is not feasible (e.g., intense family conflict, abuse, neglect, or when caregiv- ers are unavailable or unwilling to participate). Cultural stig- ma or differing beliefs about mental health treatment may also limit caregiver involvement. In such cases, treatment can focus on building adolescents’ skills (e.g., emotion regulation, distress tolerance) to help them manage their well-being in- dependently. This approach may still be effective, as both FF and PPC reflect not only the objective reality of familial dy- namics but also adolescents’ subjective perceptions of them. Conclusion The present study found that family functioning (FF) and perceived parental criticism (PPC) independent- ly moderated the relationship between adverse childhood experiences (ACEs) and suicidal ideation (SI) in an ethni- cally diverse adolescent sample. This novel contribution to the literature highlights how specific family dynamics may either buffer or exacerbate the impact of early adversity on youth suicidal thoughts. Several unexpected null findings also emerged: (1) only certain forms of ACEs were signifi- cantly associated with adolescent SI; (2) the presence of at least one ACE and the total number of ACEs were not significantly associated with SI; and (3) the moderation model was nonsignificant when FF and PPC were assessed as a composite variable. These findings should be inter- preted with caution, particularly considering the study’s limitations, as they diverge from previous research. To gain a more nuanced understanding of the critical role of fam- ily in adolescent development in the context of ACEs and suicidality, future studies should replicate this research in a larger sample and collect more detailed information on ad- olescents’ perceptions and reports of ACEs, FF, and PPC. References American Academy of Child and Adolescent Psychi- atry. (2019). Suicide Prevention. Retrieved De- cember 12, 2022, from https://www.aacap.org/ AACAP/Policy_Statements/2019/AACAP_Pol- icy_Statement_on_Suicide_Prevention.aspx Adrian, M., McCauley, E., Gallop, R., Stevens, J., Jobes, D. A., Crumlish, J., Stanley, B., Brown, G. K., Green, K. L., Hughes, J. L., & Bridge, J. A. (2023). Advancing Suicide Intervention Strat- egies for Teens (ASSIST): study protocol for a multisite randomised controlled trial. BMJ Open, 13(12), e074116. https://doi.org/10.1136/bm- jopen-2023-074116 Ahmadzadeh, Y. I., Eley, T. C., Hannigan, L., Cre- swell, C., Lichtenstein, P., Spotts, E., Ganiban, J., Neiderhiser, J., Rijsdijk, F., & McAdams, T. A. 73 PARK, GOGER, & CHA (2022). Parental criticism and adolescent internal- ising symptoms: using a Children-of-Twins design with power calculations to account for genetic influence. Journal of Child Psychology and Psy- chiatry, and Allied Disciplines, 63(5), 599–607. https://doi.org/10.1111/jcpp.13498 Anda, R. F., Fleisher, V. I., Felitti, V. J., Edwards, V. J., Whitfield, C. L., Dube, S. R., & Williamson, D. F. (2004). Childhood Abuse, Household Dysfunc- tion, and Indicators of Impaired Adult Worker Performance. The Permanente Journal, 8(1), 30– 38. https://doi.org/10.7812/TPP/03-089 Armsden, G. C., & Greenberg, M. T. (1987). The in- ventory of parent and peer attachment: Individ- ual differences and their relationship to psycho- logical well-being in adolescence. Journal of Youth and Adolescence, 16(5), 427–454. https://doi. org/10.1007/BF02202939 Baetens, I., Claes, L., Hasking, P. Smits, D., Grietens, H., Onghena, P., & Martin, G. (2015). The Re- lationship Between Parental Expressed Emotions and Non-suicidal Self-injury: The Mediating Roles of Self-criticism and Depression. Journal Child and Family Studies 24, 491–498. https:// doi.org/10.1007/s10826-013-9861-8 Berenbaum, S. A., Beltz, A. M., & Corley, R. (2015). The importance of puberty for adolescent devel- opment: conceptualization and measurement. Ad- vances in child development and behavior, 48, 53– 92. https://doi.org/10.1016/bs.acdb.2014.11.002 Boege, I., Corpus, N., Schepker, R., & Fegert, J. M. (2014). Pilot study: feasibility of using the Sui- cidal Ideation Questionnaire (SIQ) during acute suicidal crisis. Child and Adolescent Psychia- try and Mental Health, 8(1), 28. https://doi. org/10.1186/1753-2000-8-28 Buitron, V., Hill, R. M., Pettit, J. W., Green, K. L., Hatkevich, C., & Sharp, C. (2016). Interperson- al stress and suicidal ideation in adolescence: An indirect association through perceived burden- someness toward others. Journal of Affective Dis- orders, 190, 143–149. https://doi.org/10.1016/j. jad.2015.09.077 Byles, J., Byrne, C., Boyle, M. H., & Offord, D. R. (1988). Ontario Child Health Study: reliability and validity of the general functioning subscale of the McMaster Family Assessment Device. Family Process, 27(1), 97–104. https://doi.org/10.1111/ j.1545-5300.1988.00097.x Çaksen, H. (2022). The effects of parental divorce on children. Psychiatrike, 33(1), 81–82. https://doi. org/10.22365/jpsych.2021.040 Centers for Disease Control and Prevention. (2023). Suicide Data and Statistics. U.S. Department of Health and Human Services. https://www.cdc. gov/suicide/suicide-data-statistics.html Cha, C. B., Franz, P. J., M Guzmán, E., Glenn, C. R., Kleiman, E. M., & Nock, M. K. (2018). Annual Research Review: Suicide among youth - epi- demiology, (potential) etiology, and treatment. Journal of Child Psychology and Psychiatry, 59(4), 460–482. https://doi-org.ezproxy.cul.columbia. edu/10.1111/jcpp.12831 Chu, C., Buchman-Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., Rog- ers, M. L., Podlogar, M. C., Chiurliza, B., Ringer, F. B., Michaels, M. S., Patros, C. H. G., & Joiner, T. E. (2017). The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research. Psychological Bulletin, 143(12), 1313–1345. https://doi-org.ezproxy.cul. columbia.edu/10.1037/bul0000123 Chu, C., Klein, K. M., Buchman-Schmitt, J. M., Hom, M. A., Hagan, C. R., & Joiner, T. E. (2015). Rou- tinized Assessment of Suicide Risk in Clinical Practice: An Empirically Informed Update. Jour- nal of Clinical Psychology, 71(12), 1186–1200. https://doi.org/10.1002/jclp.22210 Curry J. F. (2001). Specific psychotherapies for childhood and adolescent depression. Biologi- cal Psychiatry, 49(12), 1091–1100. https://doi- org.ezproxy.cul.columbia.edu/10.1016/s0006- 3223(01)01130-1 Daly, O., & Willoughby, T. (2019). A longitudinal study investigating bidirectionality among non- suicidal self-injury, self-criticism, and parental criticism. Psychiatry Research, 271, 678–683. https://doi.org/10.1016/j.psychres.2018.12.056 Daníelsdóttir, H. B., Aspelund, T., Shen, Q., Halldors- dottir, T., Jakobsdóttir, J., Song, H., Lu, D., Ku- ja-Halkola, R., Larsson, H., Fall, K., Magnusson, P. K. E., Fang, F., Bergstedt, J., & Valdimarsdóttir, U. A. (2024). Adverse Childhood Experiences and Adult Mental Health Outcomes. JAMA psychi- atry, 81(6), 586–594. https://doi.org/10.1001/ jamapsychiatry.2024.0039 74 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Delgado, E., Serna, C., Martínez, I., & Cruise, E. (2022). Parental Attachment and Peer Relation- ships in Adolescence: A Systematic Review. In- ternational Journal of Environmental Research and Public Health, 19(3), 1064. https://doi. org/10.3390/ijerph19031064 De Berardis, D., Martinotti, G., & Di Giannantonio, M. (2018). Editorial: Understanding the Complex Phenomenon of Suicide: From Research to Clini- cal Practice. Frontiers in Psychiatry, 9, 61. https:// doi.org/10.3389/fpsyt.2018.00061 De Leo, D., Goodfellow, B., Silverman, M., Berman, A., Mann, J., Arensman, E., Hawton, K., Phil- lips, M. R., Vijayakumar, L., Andriessen, K., Chavez-Hernandez, A. M., Heisel, M., & Kolves, K. (2021). International study of definitions of English-language terms for suicidal behaviours: a survey exploring preferred terminology. BMJ Open, 11(2), e043409. https://doi.org/10.1136/ bmjopen-2020-043409 Diamond, G., Siqueland, L., & Diamond, G. M. (2003). Attachment-based family therapy for de- pressed adolescents: programmatic treatment de- velopment. Clinical Child and Family Psychology Review, 6(2), 107–127. https://doi-org.ezproxy. cul.columbia.edu/10.1023/a:1023782510786 Diamond, G. S., Wintersteen, M. B., Brown, G. K., Diamond, G. M., Gallop, R., Shelef, K., & Levy, S. (2010). Attachment-Based Family Therapy for Adolescents with Suicidal Ideation: A Ran- domized Controlled Trial. Journal of the Amer- ican Academy of Child & Adolescent Psychia- try, 49(2), 122–131. https://doi.org/10.1016/j. jaac.2009.11.002 Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics, 111(3), 564–572. https://doi.org/10.1542/peds.111.3.564 Dunn, E. C., McLaughlin, K. A., Slopen, N., Rosand, J., & Smoller, J. W. (2013). Developmental timing of child maltreatment and symptoms of depres- sion and suicidal ideation in young adulthood: results from the National Longitudinal Study of Adolescent Health. Depression and Anxi- ety, 30(10), 955–964. https://doi.org/10.1002/ da.22102 Eades, A., Segal, D. L., & Coolidge, F. L. (2019). Suicide Risk Factors Among Older Adults: Ex- ploring Thwarted Belongingness and Perceived Burdensomeness in Relation to Personality and Self-Esteem. International Journal of Aging & Human Development, 88(2), 150–167. https:// doi.org/10.1177/0091415018757214 Edwards, V. J., Anda, R. F., Gu, D., Dube, S. R., & Felitti, V. J. (2007). Adverse childhood experienc- es and smoking persistence in adults with smok- ing-related symptoms and illness. The Permanen- te Journal, 11(2), 5–13. https://doi.org/10.7812/ TPP/06-110 Ehrenreich, S. E., & Underwood, M. K. (2016). Ado- lescents' Internalizing Symptoms as Predictors of the Content of Their Facebook Communication and Responses Received from Peers. Translation- al Issues in Psychological Science, 2(3), 227–237. https://doi.org/10.1037/tps0000077 Epstein N.B., Baldwin L.M., Bishop D.S. (1983). The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9(2), 171–180. https://doi.org/10.1111/j.1752-0606.1983. tb01497.x Ernst, A. F., & Albers, C. J. (2017). Regression as- sumptions in clinical psychology research prac- tice-a systematic review of common misconcep- tions. PeerJ, 5, e3323. https://doi.org/10.7717/ peerj.3323 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8 Gerlsma, C., de Ruiter, N. M., & Kingma, W. (2014). Mood dependence of perceived criticism: a sig- nificant null finding. Psychiatry Research, 220(3), 1102–1105.https://doi.org/10.1016/j.psy- chres.2014.08.061 Gilmour H. (2016). Threshold and subthreshold Gen- eralized Anxiety Disorder (GAD) and suicide ide- ation. Health reports, 27(11), 13–21. Grimmond, J., Kornhaber, R., Visentin, D., & Cleary, M. (2019). A qualitative systematic review of ex- periences and perceptions of youth suicide. PloS 75 PARK, GOGER, & CHA One, 14(6), e0217568. https://doi.org/10.1371/ journal.pone.0217568 Hagan, C. R., & Joiner, T. E. (2017). The Indirect Effect of Perceived Criticism on Suicide Ideation and Attempts. Archives of Suicide Research, 21(3), 438–454. https://doi.org/10.1080/13811118.20 16.1218398 Harmer, B., Lee, S., Duong, T. V. H., & Saadabadi, A. (2024). Suicidal Ideation. In StatPearls. StatPearls Publishing. Hayes, A. F. (2022). Introduction to mediation, mod- eration, and conditional process analysis: A regres- sion-based approach. New York: The Guildford Press. Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J., Marchbanks, P. A., & Marks, J. S. (2004). The association between adverse childhood experi- ences and adolescent pregnancy, long-term psy- chosocial consequences, and fetal death. Pediat- rics, 113(2), 320–327. https://doi.org/10.1542/ peds.113.2.320 Hooley, J. M., & Miklowitz, D. J. (2017). Perceived Criticism in the Treatment of a High-Risk Ado- lescent. Journal of Clinical Psychology, 73(5), 570– 578. https://doi.org/10.1002/jclp.22454 Hooley, J. M., & Teasdale, J. D. (1989). Predictors of relapse in unipolar depressives: expressed emotion, marital distress, and perceived criticism. Journal of Abnormal Psychology, 98(3), 229–235. https:// doi.org/10.1037//0021-843x.98.3.229 Hubers, A. A. M., Moaddine, S., Peersmann, S. H. M., Stijnen, T., van Duijn, E., van der Mast, R. C., Dekkers, O. M., & Giltay, E. J. (2018). Suicid- al ideation and subsequent completed suicide in both psychiatric and non-psychiatric populations: a meta-analysis. Epidemiology and Psychiatric Sci- ences, 27(2), 186–198. https://doi.org/10.1017/ S2045796016001049 Iacobucci, D., Schneider, M. J., Popovich, D. L., & Bakamitsos, G. A. (2017). Mean centering, multicollinearity, and moderators in multiple regression: The reconciliation redux. Behavior Research Methods, 49(1), 403–404. https://doi. org/10.3758/s13428-016-0827-9 Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., Lowry, R., Chyen, D., Whittle, L., Thornton, J., Lim, C., Bradford, D., Yamakawa, Y., Leon, M., Brener, N., & Ethier, K. A. (2018). Youth Risk Behavior Surveillance - United States, 2017. Morbidity and Mortal- ity Weekly Report, 67(8), 1–114. https://doi. org/10.15585/mmwr.ss6708a1 Kolstad, A., & Gjesvik, N. (2014). Collectivism, in- dividualism, and pragmatism in China: impli- cations for perceptions of mental health. Trans- cultural psychiatry, 51(2), 264–285. https://doi. org/10.1177/1363461514525220 Kwok, S. Y., & Shek, D. T. (2011). Family processes and suicidal ideation among Chinese adolescents in Hong Kong. The Scientific World Journal, 11, 27–41. https://doi.org/10.1100/tsw.2011.2 Marie-Mitchell, A., & Kostolansky, R. (2019). A Sys- tematic Review of Trials to Improve Child Out- comes Associated With Adverse Childhood Expe- riences. American Journal of Preventive Medicine, 56(5), 756–764. https://doi.org/10.1016/j.ame- pre.2018.11.030 Meeker, E. C., O'Connor, B. C., Kelly, L. M., Hodge- man, D. D., Scheel-Jones, A. H., & Berbary, C. (2021). The impact of adverse childhood expe- riences on adolescent health risk indicators in a community sample. Psychological trauma: theo- ry, research, practice and policy, 13(3), 302–312. https://doi.org/10.1037/tra0001004 Miller, A. B., Esposito-Smythers, C., Weismoore, J. T., & Renshaw, K. D. (2013). The relation between child maltreatment and adolescent suicidal be- havior: a systematic review and critical examina- tion of the literature. Clinical Child and Family Psychology Review, 16(2), 146–172. https://doi. org/10.1007/s10567-013-0131-5 Moretti, M. M., & Peled, M. (2004). Adolescent-par- ent attachment: Bonds that support healthy de- velopment. Pediatrics & Child Health, 9(8), 551– 555. https://doi.org/10.1093/pch/9.8.551 Muyan, M., & Chang, E.C. (2015) Perfectionism as a Predictor of Suicidal Risk in Turkish College Students: Does Loneliness Contribute to Fur- ther Risk? Cognitive Therapy and Research, 39(6), 776–784. https://doi.org/10.1007/s10608-015- 9711-7 Ogrodniczuk, J. S., Sivagurunathan, M., Kealy, D., Rice, S. M., Seidler, Z. E., & Oliffe, J. L. (2023). Suicidal ideation among men during COVID-19: Examining the roles of loneliness, thwarted be- longingness, and personality impairment. Scan- 76 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY dinavian Journal of Psychology, 64(4), 401–408. https://doi.org/10.1111/sjop.12904 Ohtaki, Y., Doki, S., Kaneko, H., Hirai, Y., Oi, Y., Sa- sahara, S., & Matsuzaki, I. (2019). Relationship between suicidal ideation and family problems among young callers to the Japanese crisis ho- tline. PloS One, 14(7), e0220493. https://doi. org/10.1371/journal.pone.0220493 Oyserman, D., & Lee, S. W. (2008). Does culture influence what and how we think? Effects of priming individualism and collectivism. Psycho- logical bulletin, 134(2), 311–342. https://doi. org/10.1037/0033-2909.134.2.311 Panagioti, M., Gooding, P. A., Triantafyllou, K., & Tarrier, N. (2015). Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systemat- ic review and meta-analysis. Social psychiatry and psychiatric epidemiology, 50(4), 525–537. https:// doi.org/10.1007/s00127-014-0978-x Pinto, R., Correia, L. & Maia, Â. Assessing the Re- liability of Retrospective Reports of Adverse Childhood Experiences among Adolescents with Documented Childhood Maltreatment. Journal of Family Violence, 29, 431–438 (2014). https:// doi.org/10.1007/s10896-014-9602-9 Pinto, A., Whisman, M. A., & McCoy, K. J. M. (1997). Suicidal ideation in adolescents: Psychometric properties of the suicidal ideation questionnaire in a clinical sample. Psychological Assessment, 9(1), 63–66. https://doi.org/10.1037/1040- 3590.9.1.63 Pournaghash-Tehrani, S. S., Zamanian, H., & Ami- ni-Tehrani, M. (2021). The Impact of Relational Adverse Childhood Experiences on Suicide Out- comes During Early and Young Adulthood. Journal of Interpersonal Violence, 36(17-18), 8627–8651. https://doi.org/10.1177/0886260519852160 Piqueras, J. A., Soto-Sanz, V., Rodríguez-Marín, J., & García-Oliva, C. (2019). What is the Role of Internalizing and Externalizing Symptoms in Adolescent Suicide Behaviors?. International Journal of Environmental Research and Public Health, 16(14), 2511. https://doi.org/10.3390/ ijerph16142511 Pringle, J., Whitehead, R., Milne, D., Scott, E., & McAteer, J. (2018). The relationship between a trusted adult and adolescent outcomes: a protocol of a scoping review. Systematic Reviews, 7(1), 207. https://doi.org/10.1186/s13643-018-0873-8 Rapp, A. M., Chavira, D. A., Sugar, C. A., & Asarnow, J. R. (2021). Incorporating family factors into treatment planning for adolescent depression: Perceived parental criticism predicts longitudinal symptom trajectory in the Youth Partners in Care trial. Journal of Affective Disorders, 278, 46–53. https://doi.org/10.1016/j.jad.2020.09.028 Remschmidt H. (1994). Psychosocial milestones in normal puberty and adolescence. Hor- mone research, 41 Suppl 2, 19–29. https://doi. org/10.1159/000183955 Reynolds, W. M. (1987). About my life: The suicidal ideation questionnaire. Psychological Assessment Resources, Inc. Rihmer, Z., & Rihmer, A. (2019). Depression and sui- cide - the role of underlying bipolarity. Psychiatria Hungarica : A Magyar Pszichiatriai Tarsasag tu- domanyos folyoirata, 34(4), 359–368. Roeder, K. M., & Cole, D. A. (2019). Simultaneous Longitudinal Examination of Hopelessness, Thwarted Belongingness, and Perceived Burden- someness as Predictors of Suicide Ideation. Suicide & Life-Threatening Behavior, 49(4), 1058–1071. https://doi.org/10.1111/sltb.12508 Saffer, B. Y., Glenn, C. R., & David Klonsky, E. (2015). Clarifying the Relationship of Parental Bond- ing to Suicide Ideation and Attempts. Suicide & Life-Threatening Behavior, 45(4), 518–528. https://doi.org/10.1111/sltb.12146 Sahle, B. W., Reavley, N. J., Li, W., Morgan, A. J., Yap, M. B. H., Reupert, A., & Jorm, A. F. (2022). The association between adverse childhood experienc- es and common mental disorders and suicidality: an umbrella review of systematic reviews and me- ta-analyses. European Child & Adolescent Psychia- try, 31(10), 1489–1499. https://doi.org/10.1007/ s00787-021-01745-2 Sander, J. B., & McCarty, C. A. (2005). Youth depres- sion in the family context: familial risk factors and models of treatment. Clinical Child and Family Psychology Review, 8(3), 203–219. https://doi-org. ezproxy.cul.columbia.edu/10.1007/s10567-005- 6666-3 Shain, B., COMMITTEE ON ADOLESCENCE, Braverman, P. K., Adelman, W. P., Alderman, E. M., Breuner, C. C., Levine, D. A., Marcell, A. V., & O’Brien, R. F. (2016). Suicide and Sui- 77 PARK, GOGER, & CHA cide Attempts in Adolescents. Pediatrics, 138(1), e20161420. https://doi.org/10.1542/peds.2016- 1420 Sheftall, A. H., Mathias, C. W., Furr, R. M., & Dough- erty, D. M. (2013). Adolescent attachment secu- rity, family functioning, and suicide attempts. Attachment & Human Development, 15(4), 368– 383. https://doi.org/10.1080/14616734.2013.78 2649 Spremo M. (2020). Children and Divorce. Psychiatria Danubina, 32(Suppl 3), 353–359. Sun, R., Ren, Y., Li, X., Jiang, Y., Liu, S. and You, J. (2020), Self-compassion and family cohesion moderate the association between suicide ide- ation and suicide attempts in Chinese adolescents. Journal of Adolescence, 79: 103-111. https://doi. org/10.1016/j.adolescence.2019.12.010 Swedo, E. A., Aslam, M. V., Dahlberg, L. L., Niolon, P. H., Guinn, A. S., Simon, T. R., & Mercy, J. A. (2023). Prevalence of Adverse Childhood Experi- ences Among U.S. Adults - Behavioral Risk Fac- tor Surveillance System, 2011-2020. Morbidity and Mortality Weekly Report, 72(26), 707–715. https://doi.org/10.15585/mmwr.mm7226a2 Thompson, M. P., & Kingree, J. B. (2022). Adverse childhood experiences, sexual victimization, and suicide ideation and attempts: A longitudinal path analysis spanning 22 years. The American Journal of Orthopsychiatry, 92(3), 302–309. https://doi. org/10.1037/ort0000613 Utter, J., Denny, S., Robinson, E., Fleming, T., Am- eratunga, S. and Grant, S. (2013), Family meals and adolescent well-being. Journal of Pediat- rics and Child Health, 49: 906-911. https://doi. org/10.1111/jpc.12428 Wang, B., You, J., Lin, M. P., Xu, S., & Leung, F. (2017). Developmental Trajectories of Nonsui- cidal Self-Injury in Adolescence and Intraper- sonal/Interpersonal Risk Factors. Journal of Re- search on Adolescence, 27(2), 392–406. https://doi. org/10.1111/jora.12273 Wang, W., Guo, X., Kang, L., Zhang, N., Ma, S., Cheng, J., Fang, L., & Liu, Z. (2022). The Influ- ence of Family-Related Factors on Suicide in Ma- jor Depression Patients. Frontiers in Psychiatry, 13, 919610. https://doi-org.ezproxy.cul.columbia. edu/10.3389/fpsyt.2022.919610 Wang, Y. R., Sun, J. W., Lin, P. Z., Zhang, H. H., Mu, G. X., & Cao, F. L. (2019). Suicidality among young adults: Unique and cumulative roles of 14 different adverse childhood experiences. Child Abuse & Neglect, 98, 104183. https://doi. org/10.1016/j.chiabu.2019.104183 Weissinger, G., Myhre, K., Ruan-Iu, L., Van Fos- sen, C., & Diamond, G. (2023). Adolescent sui- cide risk, firearm access, and family functioning: Screening in primary care. Families, Systems & Health, 41(1), 16–25. https://doi.org/10.1037/ fsh0000680 World Health Organization (2025). Adolescent Health. https://www.who.int/health-topics/adoles- cent-health#tab=tab_1 78 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Table 1 Demographic Characteristics of the Participants Note. N = 46 79 PARK, GOGER, & CHA Table 2 Linear Regression Analyses: Severity of Suicidal Ideation (SI) and Subcategories of Adverse Childhood Experiences (ACEs) Note. SE = Standard Error; LL = Lower Limit; UL = Upper Limit; SA = Suicide Attempts. *p < .05 80 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Table 3 Summary of Moderated Regression Analyses Predicting Suicidal Ideation (SI) Severity in Adolescents Note. ACEs = Adverse Childhood Experiences; FF = Family Functioning; PPC = Perceived Parental Criticism; SE = Standard Error; LL = Lower Limit; UL = Upper Limit. aACEs will be more strongly associated with SI among adolescents who have lower family functioning; n = 24, R2 = .68. bACEs will be more strongly associated with SI among adolescents who have higher perceived parental criticism; n = 26, R2 = .47. cACEs will be more strongly associated with SI among adolescents who have higher perceived parental criticism and lower family functioning; n = 24, R2 = .72. *p < .05 81 PARK, GOGER, & CHA Table 4 Conditional Effects of Adverse Childhood Experiences (ACEs) at Values of Family Functioning (FF) Note. SD = Standard Deviation; SE = Standard Error; LL = Lower Limit; UL = Upper Limit; FAD-GF = The McMaster Family Assessment Device – General Functioning. aHigher score in FAD-GF indicates worse FF. This table based on the results of FAD-GF. *p < .05 82 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Table 5 Conditional Effects of Adverse Childhood Experiences (ACEs) at Values of Perceived Parental Criticism (PPC) Note. SD = Standard Deviation; SE = Standard Error; LL = Lower Limit; UL = Upper Limit. *p < .05 83 PARK, GOGER, & CHA Table 6 Conditional Effects of Adverse Childhood Experiences (ACEs) at Values of Family Functioning (FF) and Perceived Parental Criticism (PPC) Note. SD = Standard Deviation; SE = Standard Error; LL = Lower Limit; UL = Upper Limit. *p < .05 84 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Figure 1 Moderating Effects of Family Functioning (FF) on the Association Between Adverse Childhood Experiences (ACEs) and Adolescent Suicidal Ideation (SI) Note: The interactions between variables are statistically significant (p < .05) for Low FF and Mid FF. However, the downward trend observed in High FF was not significant. Additional details are available in Table 4. 85 PARK, GOGER, & CHA Figure 2 Moderating Effects of Perceived Parental Criticism (PPC) on the Association Between Adverse Childhood Experi- ences (ACEs) and Adolescent Suicidal Ideation (SI) Note: The interactions between variables are statistically significant (p < .05) for all categories of PPC. Addition- al details are available in Table 5. 86 ADVERSE EXPERIENCES, FAMILY, AND ADOLESCENT SUICIDALITY Figure 3 Moderating Effects of Family Functioning (FF) on the Association Between Adverse Childhood Experiences (ACEs) and Adolescent Suicidal Ideation (SI) Note: Among the nine slopes depicted in the figure, only Low PPC x Low FF and Moderate PPC x Low FF were statistically significant at p < .05. Additional details are available in Table 6.