ADHD, Familial Liability, and Absence of Regret: A Clinically Actionable Triad for Identifying Psychobiological Risk in Adolescent Suicide Attempters

ADHD, Familial Liability, and Absence of Regret: A Clinically Actionable Triad for Identifying Psychobiological Risk in Adolescent Suicide Attempters | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ADHD, Familial Liability, and Absence of Regret: A Clinically Actionable Triad for Identifying Psychobiological Risk in Adolescent Suicide Attempters Dilek Altun Varmış, Serkan Güneş, Gonca Gül, Perihan Çam Ray, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9066592/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Suicide attempts during adolescence are common and clinically varied. Although assessments after an attempt often emphasize internalizing disorders, externalizing dysregulation may define a subgroup with different clinical needs. We explored whether neurodevelopmental factors, family psychiatric history, and emotional responses after the crisis could help identify adolescents with a heavier burden of externalizing symptoms following a suicide attempt. Methods This cross-sectional study involved 102 adolescents aged 12–18 years (88.2% female) who were evaluated after a suicide attempt at a university hospital in Türkiye. Psychiatric diagnoses were established using the Kiddie Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version (K-SADS-PL). Externalizing symptom severity was measured with the parent-rated Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S). Multiple linear regression was used to examine whether ADHD diagnosis, family psychiatric history, and post-attempt regret were independently related to externalizing severity after controlling for age and sex. Results ADHD was the most common diagnosis (17.6%), followed by major depressive disorder and post-traumatic stress disorder (14.7% each). Nearly half of the sample met the cutoff for at least one disruptive behavior disorder domain, and drug ingestion was the most frequent method of attempted suicide (84.3%). In multivariable regression analyses, ADHD diagnosis, a positive family psychiatric history, and the absence of post-attempt regret were each independently associated with greater externalizing symptom severity, together accounting for about 26% of the variance in total T-DSM-IV-S scores. Age and sex were not significant predictors. Conclusions In this high-risk post-attempt group, readily available clinical markers—ADHD diagnosis, family psychiatric history, and the absence of post-attempt regret—may help identify adolescents with more severe externalizing dysregulation. These findings support a developmentally informed approach to post-attempt assessment that goes beyond internalizing symptoms and also considers family context and trauma-informed care. Prospective studies should examine whether this pattern predicts clinical course, recurrence, and treatment response. Suicide attempt Adolescents Externalizing symptoms ADHD Family psychiatric history Post-attempt regret Figures Figure 1 Figure 2 Background Adolescent suicide attempts remain a major clinical and public health concern worldwide. The World Health Organization estimates that more than 720,000 people die by suicide each year, and suicide is among the leading causes of death in young people aged 15–29 years [ 1 ]. In Türkiye, suicide represents a substantial public health burden, underscoring the need for context-specific research to inform prevention and post-crisis care [ 2 ]. Within developmental psychopathology frameworks, suicidal behavior in adolescence is commonly conceptualized as emerging from transactions between biological vulnerability, environmental stressors, and psychological processes across development [ 3 ]. Historically influential models have emphasized internalizing psychopathology—particularly depressive and anxiety disorders and trauma-related symptoms—and related cognitive processes, such as hopelessness, as proximal pathways to suicidal behavior [ 4 , 5 ]. Complementary interpersonal models highlight perceived burdensomeness and thwarted belongingness in the development of suicidal desire [ 6 ]. However, clinical cohorts assessed after a suicide attempt are heterogeneous, and a focus confined to internalizing presentations may obscure clinically meaningful variation in regulatory capacity among adolescents who have already engaged in suicidal self-harm [ 3 ]. Converging evidence indicates that externalizing psychopathology constitutes an additional and clinically important risk axis and heterogeneity factor in adolescent suicidality. Externalizing conditions are characterized by impulsivity, behavioral disinhibition, and emotion regulation difficulties, which may shorten the interval between acute distress and action and lower the threshold for rapid escalation under stress [ 8 – 10 ]. In particular, attention-deficit/hyperactivity disorder (ADHD) has been linked to an elevated risk across the suicidal spectrum behaviors, even after accounting for psychiatric comorbidity [ 11 ]. The dual pathway model of ADHD provides an organizing framework for how executive (inhibitory control) and motivational (delay aversion) pathways may contribute to cascading dysregulation that becomes clinically salient during adolescence [ 12 , 13 ]. Translating such vulnerability profiles into clinically scalable assessment targets remains a challenge, especially in routine post-attempt settings where rapid decision-making is required. Family context may further shape the severity and expression of externalizing dysregulation following a suicide attempt. A positive family psychiatric history can index intergenerational liability as well as shared environmental risk, and transactional models suggest that dysregulated family processes may amplify externalizing behavior over time [ 3 , 7 ]. Sociocultural factors, including religiosity and attitudes towards suicide, may also influence coping and help-seeking in Muslim-majority settings, potentially modifying how distress is expressed and managed in clinical encounters [ 17 ]. In addition, post-attempt affective-cognitive responding may be clinically informative. Reduced post-attempt regret has been discussed as a potential marker of heterogeneity in moral-emotional engagement and guilt-related responding, while also requiring careful differentiation from trauma-related numbing or state-dependent disengagement [ 19 , 20 ]. Together, these observations suggest that combining neurodevelopmental, familial, and post-crisis affective indicators may help clinicians identify subgroups of adolescent attempters who present with more severe externalizing dysregulation and may require tailored post-attempt formulations and interventions. Despite increasing recognition of externalizing contributions to suicide risk, most post-attempt research and clinical practice still prioritize internalizing symptom assessment. Studies that examine whether brief, clinically obtainable markers can identify adolescents with a greater externalizing symptom burden within an already high-risk post-attempt cohort are needed, particularly in trauma-enriched clinical settings where adversity exposure may be common. Against this background, the present study focused on Turkish adolescents after a suicide attempt and adopted a dimensional developmental psychopathology framework to assess the severity of externalizing symptoms. The primary objective was to determine whether three clinically accessible markers—current ADHD diagnosis (reflecting neurodevelopmental vulnerability), family psychiatric history (indicating intergenerational and contextual risk), and the absence of post-attempt regret (capturing post-crisis affective-cognitive response)—were independently associated with a greater externalizing symptom burden after adjusting for age and sex. As a secondary objective, we examined whether externalizing severity differed across major sociodemographic, family-structural, and attempt-related variables, including family structure, reported precipitating factor, suicide attempt method, and history of repeated attempts, in order to better understand heterogeneity within this post-attempt sample. We hypothesized that both ADHD diagnosis and a positive family psychiatric history would be linked to greater externalizing severity, and that the absence of post-attempt regret would further distinguish adolescents with a higher externalizing symptom burden. Methods Study Design and Setting This cross-sectional observational study was conducted in the Department of Child and Adolescent Psychiatry, Çukurova University Faculty of Medicine, Adana, Türkiye. The hospital is a major tertiary university center that serves a broad catchment area and includes a specialized forensic child psychiatry board. The study protocol was approved by the local Ethics Committee and carried out in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participating adolescents and their legal guardians. Participants and Procedure The sample included 102 adolescents aged 12–18 years who were evaluated after a suicide attempt. Participants were recruited through two pathways: (i) psychiatric consultation in the emergency department or intensive care unit after medical stabilization, with assessments conducted only when the adolescent’s physical and cognitive condition allowed a comprehensive interview; and (ii) outpatient or forensic board referrals within 30 days of the attempt. A suicide attempt was defined as a self-initiated act performed with the intent to die, as confirmed through clinical interview. Exclusion criteria included autism spectrum disorder, intellectual disability (IQ < 70), psychotic disorders, and active substance use. Kiddie Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version (K-SADS-PL) The K-SADS-PL is a semi-structured diagnostic interview used to assess a broad range of psychiatric disorders in children and adolescents according to DSM-IV criteria [ 21 ]. The interview consists of separate sessions with the adolescent and the parents, followed by a final synthesis of information from all sources by a child and adolescent psychiatrist to establish a consensus diagnosis. The Turkish adaptation has been validated for individuals aged 6–18 years [ 22 ]. The instrument has shown high diagnostic accuracy, with inter-rater reliability reported as very good for externalizing and tic disorders (κ = 0.81–1.00), good for ADHD and anxiety disorders, and moderate for mood disorders. Test-retest reliability is also high, supporting the stability of diagnoses across the developmental period [ 22 ]. Turgay DSM-IV-Based Disruptive Behavior Disorders Rating Scale—Parent Form (T-DSM-IV-S) The T-DSM-IV-S is a detailed 41-item parent-report scale developed to quantify ADHD and disruptive behavior symptoms based on DSM-IV criteria [ 23 ]. Each item is rated on a 4-point Likert scale (0 = not at all, 1 = just a little, 2 = much, 3 = very much), where higher cumulative scores reflect greater symptom severity. The scale is structured into five distinct subscales: inattention (IN; 9 items assessing focus and distractibility), hyperactivity (H; 6 items assessing physical restlessness), impulsivity (I; 3 items assessing inhibitory control), oppositional defiant disorder (ODD; 8 items assessing defiant behavior), and conduct disorder (CD; 15 items assessing rule-breaking and aggression). In this study, the primary dimensional outcome was the T-DSM-IV-S total score, calculated as the sum of all 41 items (range, 0–123). Additionally, a hyperactivity/impulsivity (HI) composite (9 items) was utilized descriptively. The Turkish version has been extensively validated, and in the current sample, the total scale demonstrated excellent internal consistency with a Cronbach’s α of 0.88 [ 23 , 24 ]. Sociodemographic and Clinical Information Form A structured form developed by the researchers was used to systematically collect participant characteristics and clinical history. Family psychiatric history was strictly defined and coded as “present” only when at least one first-degree biological relative (mother, father, or sibling) had a lifetime history of a diagnosed psychiatric disorder or had received psychiatric treatment. Post-attempt regret was recorded as a dichotomous variable (present/absent) based on the adolescents’ direct responses during the clinical interview about their feelings regarding the index attempt. Additional variables included age, sex, educational status, family structure, and the specific method used in the suicide attempt. Statistical Analysis Analyses were conducted using IBM SPSS Statistics version 25.0. Continuous variables are presented as mean ± standard deviation. Normality was confirmed using Kolmogorov–Smirnov tests. Independent-samples t-tests and one-way ANOVA with Tukey HSD post-hoc tests were used for group comparisons. Multiple linear regression was employed to identify independent correlates of the total T-DSM-IV-S score, with age, sex, regret status, family history, and K-SADS-PL ADHD diagnosis entered as predictors a priori. Significance was set at α = 0.05. Results Sample characteristics The study sample consisted of 102 adolescents aged 12–18 years who were evaluated after a suicide attempt, including 12 boys (11.8%) and 90 girls (88.2%). The mean age was 15.3 years (SD = 1.4). Information on family structure was available for 100 participants; of these, 78 (78.0%) came from intact families and 22 (22.0%) came from divorced or separated families. The most common method of suicide attempt was drug ingestion (84.3%), followed by wrist cutting (9.8%). The leading reported precipitants were parental conflict (42.2%) and sexual abuse (20.6%). Remorse or regret following the attempt was reported by 75.5% of the adolescents. According to K-SADS assessments, the most frequent diagnoses were ADHD (17.6%), major depressive disorder (14.7%), and PTSD (14.7%). On the parent-reported Turgay Scale, 49 adolescents (48.0%) met the cutoff in at least one disruptive behavior disorder domain. The most common clinical profiles were ADHD combined with oppositional defiant disorder (12.7%) and ADHD combined type (7.8%). Comparison of Turgay Scale total scores according to demographic and clinical characteristics The mean total Turgay Scale score, reflecting overall externalizing symptom burden, was 28.31 (SD = 1.93). As presented in Table 1 , boys had higher total scores than girls (Welch’s t(12.41) = 2.83, p = 0.015). Scores were also markedly higher among adolescents who did not report post-attempt remorse or regret compared with those who did (Welch’s t(32.65) = 5.59, p < 0.001). Higher total scores were likewise observed among adolescents with multiple suicide attempts (Welch’s t(53.97) = 4.64, p < 0.001), those with a family history of psychiatric disorders (Welch’s t(28.90) = 7.07, p < 0.001), and those from divorced or separated families (Welch’s t(29.94) = 4.51, p < 0.001). Across diagnostic groups, adolescents diagnosed with ADHD had the highest mean total score, and the differences between diagnosis groups were statistically significant (F(3, 98) = 24.36, p < 0.001). Total scores also varied significantly according to the reported precipitant of the suicide attempt (F(4, 97) = 3.96, p = 0.005). Post-hoc analyses showed that adolescents in the sexual abuse group had higher scores than those in the peer bullying group (p = 0.02). These findings should be interpreted with caution because some subgroups were small, particularly the peer bullying group (n = 5). These main subgroup differences are presented in Fig. 1 . Table 1 Comparison of Turgay Scale Total Scores by Demographic and Clinical Characteristics Variable n (%) Turgay Total Score (Mean ± SD) Test Statistic p-value Gender Welch's t(12.41) = 2.83 0.015 Male 12 (11.8) 30.42 ± 2.85 Female 90 (88.2) 28.02 ± 1.95 Suicide Regret Welch's t(32.65) = 5.59 < 0.001 Present 77 (75.5) 27.55 ± 1.76 Absent 25 (24.5) 30.48 ± 2.42 Number of Suicide Attempts Welch's t(53.97) = 4.64 < 0.001 Single 71 (69.6) 27.84 ± 1.91 Multiple 31 (30.4) 29.84 ± 2.04 Family History of Psychiatric Disorders Welch's t(28.90) = 7.07 < 0.001 Present 22 (21.6) 31.16 ± 2.25 Absent 80 (78.4) 27.48 ± 1.81 Family Structure Welch's t(29.94) = 4.51 < 0.001 Divorced 22 (22.0) 30.10 ± 2.23 Intact 78 (78.0) 27.75 ± 1.88 K-SADS Diagnosis F(3, 98) = 24.36 < 0.001 ADHD 18 (17.6) 31.24 ± 2.32 Depression 15 (14.7) 29.65 ± 2.05 PTSD 15 (14.7) 28.96 ± 2.11 Other/None 54 (52.9) 27.05 ± 1.69 Reason for Suicide Attempt F(4, 97) = 3.96 0.005 Parental Conflict 43 (42.2) 28.72 ± 2.11 Sexual Abuse 21 (20.6) 30.08 ± 2.31 Peer Bullying 5 (4.9) 27.20 ± 1.75 Breakup 17 (16.7) 29.60 ± 1.90 Other 16 (15.6) 27.95 ± 1.83 Note. SD = standard deviation. Welch’s independent-samples t-tests were used for binary variables, and one-way ANOVA with Tukey post-hoc tests was used for variables with more than two categories. Total N = 102. Family structure data were available for n = 100 participants (percentages for this variable are based on n = 100). The Tukey post-hoc test indicated that the ADHD group scored significantly higher than the Other/None group (p = 0.008). *p < 0.05. **p < 0.01. Descriptive statistics and internal consistency coefficients (Cronbach's α) for the Turgay Scale subscales are shown in Table 2 . The Inattention (IN) subscale had the highest mean score (9.55 ± 0.64), followed by the Oppositional Defiant Disorder (ODD) subscale (7.22 ± 0.49). The Hyperactivity/Impulsivity (HI) composite score was 6.44 ± 0.53, and the separate Impulsivity (I) factor score was 3.88 ± 0.27. The Conduct Disorder (CD) subscale had the lowest mean score (1.62 ± 0.38). The total scale demonstrated excellent internal consistency (α = 0.88). Table 2 Descriptive Statistics and Internal Consistency of Turgay Scale Subscales Subscale Mean ± SD Observed Range Cronbach's α Inattention (IN) 9.55 ± 0.64 7–12 0.82 Hyperactivity/Impulsivity (HI)ᶜ 6.44 ± 0.53 5–9 0.79 Impulsivity (I)ᶜ 3.88 ± 0.27 3–5 0.76 Oppositional Defiant Disorder (ODD) 7.22 ± 0.49 5–9 0.81 Conduct Disorder (CD) 1.62 ± 0.38 0–3 0.71 Total Score 28.31 ± 1.93 22–34 0.88 Note. SD = standard deviation. ᶜThe HI composite includes the I items; therefore, these scores are not independent (see Methods section). As presented in Table 3 , all Turgay subscales were positively and significantly intercorrelated. The strongest association was observed between the ODD and CD subscales (r = 0.62, p < 0.001). Moderate to strong correlations were also found between HI and I (r = 0.54, p < 0.001) and between IN and HI (r = 0.48, p < 0.001). The intercorrelation pattern is additionally shown in Additional file 1: Fig. S1. Table 3 Pearson Correlations Among Turgay Scale Subscales Subscale 1 2 3 4 5 1. Inattention (IN) — 2. Hyperactivity/Impulsivity (HI) 0.48** — 3. Impulsivity (I) 0.41** 0.54** — 4. Oppositional Defiant Disorder (ODD) 0.32* 0.49** 0.45** — 5. Conduct Disorder (CD) 0.29* 0.36** 0.38** 0.62** — Note. *p < 0.05. **p < 0.01. Multivariate predictors of total Turgay scores Multiple linear regression analysis was conducted to identify factors associated with total Turgay scores. The model was statistically significant (F(5, 96) = 6.85, p < 0.001) and explained 26% of the variance (R² = 0.26). As presented in Table 4 , a positive family history of psychiatric disorders (β = 0.29, p = 0.005), the absence of suicide regret (β = 0.25, p = 0.017), and an ADHD diagnosis based on the K-SADS (β = 0.27, p = 0.009) were significant independent predictors of higher total scores. Age and sex were not significant predictors in the model. Standardized regression coefficients are displayed in Fig. 2 . Table 4 Predictors of Turgay Total Score: Multiple Linear Regression Analysis Independent Variable β t p Family History of Psychiatric Disorders (Present vs. Absent) 0.29 2.88 0.005** Suicide Regret (Absent vs. Present) 0.25 2.43 0.017* ADHD Diagnosis per K-SADS (Yes vs. No) 0.27 2.69 0.009** Age 0.08 0.79 0.430 Gender (Female vs. Male) −0.11 −1.01 0.310 Note. β = standardized beta coefficient. Reference categories: Male for Gender, Present for Suicide Regret, and Absent for Family History. Model: R² = 0.26, Adjusted R² = 0.22, F(5, 96) = 6.85, p < 0.001. *p < 0.05. **p < 0.01. Discussion This study explored differences in the severity of externalizing symptoms among Turkish adolescents who were assessed after a suicide attempt. In the multivariable analyses, three easily obtainable clinical factors—having a current ADHD diagnosis, the presence of psychiatric disorders in first-degree relatives, and a lack of regret following the attempt—were each independently associated with higher levels of parent-reported externalizing symptoms. Together, these factors accounted for approximately 26% of the variance in total T-DSM-IV-S scores. Since the sample included only adolescents evaluated after a suicide attempt, these findings should not be interpreted as etiological predictors of the development of suicidal behavior. Instead, they underscore clinically meaningful differences in the degree of externalizing dysregulation within a high-risk population of adolescents following a suicide attempt. The diagnostic profile of the sample further reflects the heterogeneity that was observed. ADHD was the most common current diagnosis, identified in 17.6% of participants, while MDD and PTSD were each present at similar rates of 14.7%. Importantly, more than half of the adolescents did not meet criteria for a current psychiatric diagnosis on the K-SADS-PL at the time of assessment. Comparable post-attempt clinical samples have likewise shown heterogeneous psychopathological profiles rather than a single dominant diagnostic pattern [ 25 ]. This pattern aligns with broader evidence showing that suicidal thoughts and behaviors in young people can emerge alongside subthreshold symptoms, acute stress reactions, and transdiagnostic vulnerabilities that are not fully accounted for by categorical diagnostic systems alone [ 3 , 5 ]. These findings underscore the value of adopting a dimensional clinical approach after a suicide attempt, even in the absence of a formal psychiatric diagnosis. Externalizing symptoms also stood out as a key feature across the cohort. Nearly half of the adolescents met the threshold in at least one disruptive behavior disorder domain on the parent-rated Turgay scale, and the most common diagnostic combination was ADHD with oppositional defiant disorder. All subscales were positively associated with one another, with the strongest correlation found between oppositional defiant and conduct symptoms. This pattern indicates that defiance and rule-breaking were more likely to cluster as part of a broader tendency toward behavioral dysregulation rather than appear as isolated symptom domains. Inattention likewise emerged as a clinically meaningful dimension, in line with longitudinal research linking attentional dyscontrol and impulsivity to later suicidal outcomes [ 9 , 13 ]. ADHD was strongly associated with more severe externalizing symptoms, which fits with broader evidence that externalizing psychopathology is an important dimension of risk across suicidal presentations [ 10 , 11 , 26 ]. Prior research, including meta-analytic studies, has shown that ADHD is linked to a higher risk of suicidal behaviors, including suicide attempts, even after psychiatric comorbidity is taken into account [ 11 ]. From a conceptual standpoint, this relationship may reflect neurodevelopmental mechanisms such as impaired inhibitory control and delay-related motivational processes, as outlined in the dual-pathway model [ 12 ], along with difficulties in emotion regulation that may make it easier for distress to rapidly translate into action [ 10 , 27 ]. At the same time, some overlap in measurement should be recognized, since the T-DSM-IV-S total score includes symptom domains related to ADHD. The present findings should therefore be interpreted with caution. Rather than establishing ADHD as an independent causal factor, they suggest that clinician-identified ADHD may mark a subgroup of adolescents in this high-risk post-attempt sample whose caregivers report more pervasive behavioral dysregulation. The characteristics of the attempts also help frame the externalizing pattern observed in the sample. Drug ingestion was the most common method. This is consistent with what has been described in adolescence as an “access and rapid escalation” scenario: when potentially harmful means are readily available in the home, they may be used during periods of acute conflict or intense emotional distress, often with little prior planning [ 10 – 12 , 26 – 27 ]. Although the present study does not allow conclusions about the mechanisms involved, the clinical implications are clear. Post-attempt care should include systematic counselling on means restriction and the safe storage of medications, especially for adolescents with attentional difficulties and problems with behavioral regulation. Family-related factors appeared to distinguish the severity of externalizing symptoms just as clearly as neurodevelopmental features. In the multivariable analysis, a psychiatric history among first-degree relatives was one of the strongest correlates of more severe externalizing symptoms, possibly reflecting both intergenerational vulnerability and shared exposure to environmental stress [ 29 , 30 ]. This interpretation is also consistent with genetically informed studies linking inherited liability—including suicide-related, depression-related, and ADHD-related polygenic risk—to suicidal thoughts and behaviors in youth [ 28 , 29 , 36 ]. Caregiver psychopathology may also shape everyday family functioning, including supervision, emotional regulation within the household, and overall stability. These influences are especially relevant for adolescents who display oppositional behavior and difficulties with impulse control. Developmental transactional models suggest that parenting practices and disruptive behavior affect one another over time [ 7 , 30 , 31 ], and family conflict was the most commonly reported precipitating factor in this sample. More broadly, family-context variables and adverse life events have been associated with suicidal ideation, self-injury, and first-time suicide attempts across development [ 32 , 33 ]. Taken together, these findings suggest that post-attempt assessments should address not only the adolescent’s symptoms but also caregiver mental health, current relational stressors, and the patterns through which family conflicts escalate. A lack of post-attempt regret also helped distinguish adolescents with a greater burden of externalizing symptoms. Most participants reported regret, suggesting that many attempts occurred in the context of acute distress rather than a sustained wish to die. In contrast, adolescents who expressed no regret showed markedly higher levels of externalizing symptoms, and this association remained significant after adjustment. Clinically, however, the absence of regret should not be interpreted as a single, stable trait marker. In the immediate aftermath of a crisis—particularly among young people exposed to significant adversity—it may instead reflect state-related emotional numbing, dissociation, avoidance, or a reduced ability to process consequences under conditions of acute dysregulation [ 14 ]. At the same time, it may overlap with more enduring differences in moral and emotional processing, including callous-unemotional traits, which may have distinct implications for prognosis and treatment [ 19 , 20 ]. Because regret was measured using a single binary clinical item, it is best understood as a practical clinical signal that warrants more structured follow-up assessment, rather than as a proxy for any specific personality construct. A trauma-informed reading is especially important for this cohort. Sexual abuse was often reported as a trigger (20.6%), and PTSD occurred as often as major depression. Earlier work suggests that trauma-related symptoms and difficulties regulating emotions may help explain the link between abuse exposure and self-injurious behavior in adolescents [ 14 ], while longitudinal research has also found an association between childhood sexual abuse and later suicidal behavior in high-risk groups [ 34 ]. More recent work further emphasizes that child maltreatment may contribute to suicidal behavior over and above diagnosable mental disorders alone [ 35 ], and high-risk developmental studies indicate that suicidal behavior can emerge in the context of multiple converging early risk factors [ 37 ]. Because this study was carried out in a tertiary-care hospital with a forensic child protection board that evaluates suspected abuse cases, adolescents with more severe adversity-related problems may have been overrepresented. As a result, the level of trauma observed here may not reflect what would be seen in community samples. Even so, these findings highlight that, in routine care after a suicide attempt, externalizing dysregulation and trauma-related symptoms can occur together and should be evaluated side by side rather than viewed as competing explanations. Adolescents with a history of multiple suicide attempts showed more severe externalizing symptoms than those with only one attempt. Although the cross-sectional design prevents conclusions about the direction of this relationship, the finding is clinically plausible. Persistent behavioral dysregulation may raise the risk of repeated crises, while repeated crises may in turn intensify family stress and erode coping resources. Previous suicidal behavior is one of the most reliable predictors of future suicidal behavior across studies [ 5 ], and the present findings suggest that externalizing dysregulation may provide additional clinically meaningful information when deciding on the intensity of follow-up care and identifying treatment targets after an attempt. Sex differences should be interpreted carefully. While boys showed higher externalizing scores in the bivariate analyses, sex was no longer a significant factor in the multivariable model. In addition, the sample was mostly female, which reduced the statistical power to draw firm sex-specific conclusions. This pattern aligns with epidemiological evidence indicating that non-fatal suicide attempts are more common among adolescent girls, whereas suicide deaths are more frequent among boys [ 3 , 18 ]. Age was also not a significant predictor, which suggests that within a relatively narrow adolescent age range, symptom-related and family-related factors may provide more useful information than age alone. From a clinical perspective, these findings indicate that post-attempt assessments should extend beyond internalizing symptoms. Screening should also cover difficulties in neurodevelopmental regulation, family psychiatric history and current family stressors, and the adolescent’s emotional reaction to the attempt. For adolescents with marked ADHD symptoms and behavioral dysregulation, it may be helpful to optimize evidence-based ADHD treatment and add skills-based interventions focused on impulse control and emotion regulation. Randomized controlled trials support dialectical behavior therapy for adolescents (DBT-A) as an effective approach for reducing self-harm and suicidal behaviors in high-risk youth [ 38 ]. When there is a substantial family psychiatric burden along with ongoing conflict, family-based assessment and intervention are advisable, with attention to caregiver mental health whenever possible. If an adolescent expresses no regret after the attempt, clinicians may want to explore trauma-related emotional numbing and reflective functioning more closely. In such cases, mentalization-based treatment for adolescents (MBT-A) may be especially relevant for adolescents whose crises arise in the context of interpersonal dysregulation and limited perspective-taking [ 39 ]. Future prospective studies should use validated measures of post-attempt emotional responses, trauma severity, and real-time symptom fluctuations, such as ecological momentary assessment [ 15 ], along with psychophysiological markers of dysregulation [ 16 ]. This work could help clarify whether these clinically observable indicators predict recurrent suicidal behavior and different responses to treatment. Limitations Several limitations should be taken into account when interpreting these findings. First, the cross-sectional design does not permit causal conclusions and makes it impossible to determine the temporal relationship between externalizing dysregulation and characteristics of the suicide attempt. The sample was also recruited from a single tertiary child and adolescent psychiatry service and consisted mainly of female adolescents, which limits the generalizability of the results and reduces the ability to examine sex-specific effects. In addition, the recruitment process included adolescents assessed after medical stabilization in the emergency department or intensive care unit, those presenting to outpatient services within one month of an attempt, and those referred for medicolegal psychiatric evaluation. This tertiary referral pattern may have led to an overrepresentation of clinically complex and high-risk cases. Measurement-related limitations should also be acknowledged. Externalizing symptom severity was assessed only through parent report, and data from other informants, such as adolescent self-reports or teacher ratings, were not available. Family psychiatric history relied on caregiver report and was not independently confirmed through diagnostic assessment. Post-attempt regret was measured using a single binary clinical item, and suicidality-related characteristics were obtained through clinician questioning during the interview rather than through validated multi-item instruments. Furthermore, the dependent variable (T-DSM-IV-S total score) includes ADHD symptom domains, which may create criterion overlap with the ADHD diagnosis predictor. Finally, the lack of a psychiatric comparison group without suicide attempts and the absence of prospective follow-up limit conclusions about the specificity and prognostic value of these findings. Future multi-site longitudinal studies using multi-informant assessments are needed to clarify these relationships further. Conclusions Among adolescents seen in a tertiary clinical setting after a suicide attempt, three readily identifiable clinical factors—a current ADHD diagnosis, a first-degree family history of psychiatric illness, and not feeling regret after the attempt—were each independently linked to higher levels of parent-reported externalizing symptoms. Together, these factors accounted for roughly one-quarter of the variance in total T-DSM-IV-S scores. These results suggest that adolescents who present after a suicide attempt are a heterogeneous group and support a developmentally informed assessment strategy that goes beyond internalizing symptoms alone. In practice, this means systematically assessing neurodevelopmental dysregulation, family psychiatric burden and relational stressors, and the adolescent’s emotional reaction to the attempt. Prospective research is needed to determine whether incorporating these markers into post-attempt care can improve risk stratification for repeat attempts and better inform behavioral, family-based, and trauma-informed interventions, including structured counseling on means restriction and safe medication storage. Abbreviations ADHD Attention-Deficit/Hyperactivity Disorder CD Conduct Disorder CU Callous-Unemotional DBT-A Dialectical Behavior Therapy for Adolescents HI Hyperactivity/Impulsivity IN Inattention K-SADS-PL Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version MBT-A Mentalization-Based Treatment for Adolescents MDD Major Depressive Disorder ODD Oppositional Defiant Disorder PTSD Post-Traumatic Stress Disorder TÜİK Turkish Statistical Institute (Türkiye İstatistik Kurumu) WHO World Health Organization Declarations Ethics approval and consent to participate The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Ethics Committee of Çukurova University (approval date: May 9, 2014; decision no. 31/9). Written informed consent was also obtained from the adolescent participants. Consent for publication Not applicable. Competing interests The authors declare that they have no conflicts of interest. Authors’ information Dilek Altun Varmış, MD – Department of Child and Adolescent Psychiatry, Adana City Research and Training Hospital, Adana, Türkiye. E-mail: [email protected] Serkan Güneş, Associate Professor – Department of Child and Adolescent Psychiatry, Adana City Research and Training Hospital, Adana, Türkiye. E-mail: [email protected] Gonca Gül, Professor – Department of Child and Adolescent Psychiatry, Çukurova University Faculty of Medicine Hospital, Adana, Türkiye. E-mail: [email protected] Perihan Çam Ray, MD – Department of Child and Adolescent Psychiatry, Çukurova University Faculty of Medicine Hospital, Adana, Türkiye. E-mail: [email protected] Özge Metin, MD – Department of Child and Adolescent Psychiatry, Çukurova University Faculty of Medicine Hospital, Adana, Türkiye. E-mail: [email protected] Ayşegül Yolga Tahiroğlu, Professor – Department of Child and Adolescent Psychiatry, Çukurova University Faculty of Medicine Hospital, Adana, Türkiye. E-mail: [email protected] Funding This study did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution DAV, GG, PÇR, ÖM, and AYT designed the study. DAV acquired the data. DAV and SG analyzed the data. DAV interpreted the results with SG ’scontribution. DAV wrote the paper. All authors read and approved the final manuscript. Acknowledgements Not applicable. Data Availability The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request. References World Health Organization. Suicide worldwide in 2021: global health estimates. Geneva: WHO. 2025. Available from: https://www.who.int/publications/i/item/9789240110069 Türkiye İstatistik Kurumu. Ölüm ve ölüm nedeni istatistikleri. 2024. 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Kaufman J, Birmaher B, Brent D, Rao U, Ryan ND. K-SADS-PL: initial reliability and validity data. J Am Acad Child Adolesc Psychiatry. 1997;36(7):980–8. https://doi.org/10.1097/00004583-199707000-00021 . Gökler B, Ünal F, Pehliventürk B, Kültür EÇ, Akdemir D, Taner Y. Turk J Child Adolesc Ment Health. 2004;11(3):109–16. https://doi.org/10.5505/cogep.2004.109 . Reliability and validity of the Turkish version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL). Turgay A. DSM-IV-based child and adolescent behavior disorders screening and rating scale. Toronto: Integrative Therapy Institute; 1994. Ercan ES, Amado S, Somer O, Çıkoğlu S. Development of a test battery for the assessment of attention deficit hyperactivity disorder and disruptive behavior disorders based on DSM-IV. Turk J Child Adolesc Ment Health. 2001;8:132–44. https://cogepderg.com/jvi.aspx?un=COGEP-46481 . García-Fernández A, Martínez-Cao C, Pérez-Díez I, Andreo-Jover J, Ayad-Ahmed W, Bobes-Bascarán T, et al. Psychopathological profiles of adolescents presenting to emergency departments following a suicide attempt: a comprehensive analysis. J Psychiatr Res. 2025;190:169–80. https://doi.org/10.1016/j.jpsychires.2025.07.035 . Lin PI, Chen YL, Chen YC, Liao SC. Pathway from attention-deficit/hyperactivity disorder to suicide/self-harm. Psychiatry Res. 2024;337:115936. https://doi.org/10.1016/j.psychres.2024.115936 . Shahnovsky E, Silberg J, Mackay C. Hyperactivity/impulsivity and suicide attempt risk in pediatric emergency cohorts: a clinical profile analysis. Eur J Investig Health Psychol Educ. 2024;14(10):1726–40. https://doi.org/10.3390/ejihpe14100172 . Lee PH, Anttila V, Won H, Feng YCA, Rosenthal J, Zhu Z, et al. Associations between genetic risk for adult suicide attempt and suicidal behaviors in young children in the US. JAMA Psychiatry. 2022;79(10):971–80. https://doi.org/10.1001/jamapsychiatry.2022.2379 . Tate AE, Mathieson I, Karlsson R, Kendler KS, Larsson H, Lundström S, et al. A genetically informed prediction model for suicidal and aggressive behaviour in teens. Transl Psychiatry. 2022;12(1):488. https://doi.org/10.1038/s41398-022-02245-w . Burke JD, Pardini DA, Loeber R. Reciprocal relationships between parenting behavior and disruptive psychopathology from childhood through adolescence. J Abnorm Child Psychol. 2008;36(5):679–92. https://doi.org/10.1007/s10802-008-9219-7 . Patterson GR. Coercive family process. Eugene: Castalia Publishing Company; 1982. Khan S. Can life events predict first-time suicide attempts? A nationwide longitudinal study. Longit Life Course Stud. 2024;15(3):371–93. https://doi.org/10.1332/17579597Y2024D000000020 . DeVille DC, Whalen D, Breslin FJ, Morris AS, Khalsa SS, Paulus MP, et al. Prevalence and family-related factors associated with suicidal ideation, suicide attempts, and self-injury in children aged 9 to 10 years. JAMA Netw Open. 2020;3(2):e1920956. https://doi.org/10.1001/jamanetworkopen.2019.20956 . Rabinovitch SM, Kerr DCR, Leve LD, Chamberlain P. Suicidal behavior outcomes of childhood sexual abuse: longitudinal study of adjudicated girls. Suicide Life Threat Behav. 2015;45(4):431–47. https://doi.org/10.1111/sltb.12141 . Townsend ML, Hasking P, Melvin GA, Borschmann R. Beyond mental disorders: the role of child maltreatment in childhood suicidal behaviour. Aust N Z J Psychiatry. 2026;60(3):203–9. https://doi.org/10.1177/00048674251413021 . Orri M, Galera C, Turecki G, Boivin M, Tremblay RE, Côté SM. Joint contribution of polygenic scores for depression and attention-deficit/hyperactivity disorder to youth suicidal ideation and attempt. Mol Psychiatry. 2025;30:1180–91. https://doi.org/10.1038/s41380-025-02989-z . Zelazny J, Melhem N, Engstrom N, Porta G, Brent D. Risk factors for pre-adolescent onset suicidal behavior in a high-risk sample of youth. J Affect Disord. 2021;291:246–54. https://doi.org/10.1016/j.jad.2021.04.059 . McCauley E, Berk MS, Asarnow JR, Adrian M, Cohen J, Korslund K, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. JAMA Psychiatry. 2018;75(8):777–85. https://doi.org/10.1001/jamapsychiatry.2018.1109 . Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304–e13133. https://doi.org/10.1016/j.jaac.2012.09.018 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9066592","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":609097568,"identity":"65781157-feb1-40ab-b9a4-bbfdb0ec55a7","order_by":0,"name":"Dilek Altun Varmış","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDCCw8wNjA0gBjMD4wMgxcNHWAsjXAuzAUgLG0EtB2BaGBjYJMAkIR18xxkbH85ss8vXbWd/Vvk1x06GjYH54aMbeLRIHmZsNtzYlmy57TCP2W3ZbclAh7EZG+fg0WJwmLFN8sEZZgOzwzxstyW3MQO18LBJE9DS/vPBmXqgFvZnxZLb6onS0sa4oeIwUAuDGeNHoPMIagH5RXJGxXGQw4ylGbcd52FjJuAXvvOHD37sMag2MDt//OHHn9uq7fnZmx8+xqcFBTDzgElilYMA4w9SVI+CUTAKRsGIAQAlakbzI24cdgAAAABJRU5ErkJggg==","orcid":"","institution":"adana city hospital","correspondingAuthor":true,"prefix":"","firstName":"Dilek","middleName":"Altun","lastName":"Varmış","suffix":""},{"id":609097569,"identity":"707b8e4f-2a01-4eca-a6f9-424fcc84e753","order_by":1,"name":"Serkan Güneş","email":"","orcid":"","institution":"adana city hospital","correspondingAuthor":false,"prefix":"","firstName":"Serkan","middleName":"","lastName":"Güneş","suffix":""},{"id":609097570,"identity":"b3f0d561-a0fa-4d57-9836-47e4036939f4","order_by":2,"name":"Gonca Gül","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Gonca","middleName":"","lastName":"Gül","suffix":""},{"id":609097571,"identity":"1b4f747f-9c5c-4040-9f0a-2d8c42b6ba9a","order_by":3,"name":"Perihan Çam Ray","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Perihan","middleName":"Çam","lastName":"Ray","suffix":""},{"id":609097572,"identity":"534dc314-5076-4a57-ba48-0dfc3377bc68","order_by":4,"name":"Özge Metin","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Özge","middleName":"","lastName":"Metin","suffix":""},{"id":609097573,"identity":"90287264-3f19-43c6-9daa-54b188d8dc22","order_by":5,"name":"Ayşegül Yolga Tahiroğlu","email":"","orcid":"","institution":"Cukurova University","correspondingAuthor":false,"prefix":"","firstName":"Ayşegül","middleName":"Yolga","lastName":"Tahiroğlu","suffix":""}],"badges":[],"createdAt":"2026-03-08 21:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9066592/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9066592/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105088801,"identity":"7c9d697e-6e29-49a3-a575-15b11890aa80","added_by":"auto","created_at":"2026-03-20 21:09:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":133419,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKey subgroup differences in externalizing symptom burden. Points indicate subgroup means for the Turgay total score, and whiskers indicate 95% confidence intervals reconstructed from the summary statistics in Table 1. The dashed vertical line indicates the overall sample mean (28.31). Panel A shows the family history of psychiatric disorders, Panel B shows suicide regret, and Panel C shows the primary K-SADS diagnostic groups. Abbreviations: ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; K-SADS, Schedule for Affective Disorders and Schizophrenia for School-Age Children; T-DSM-IV-S, Turgay DSM-IV-Based Disruptive Behavior Disorders Rating Scale (Parent Form).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9066592/v1/bf6407f869f6860db155d392.jpg"},{"id":105088804,"identity":"3ae662cf-e259-45c7-9fac-a7862020d2ec","added_by":"auto","created_at":"2026-03-20 21:09:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":174606,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003ePredictors of total Turgay score in the multiple linear regression model. Points represent standardized regression coefficients (β), and whiskers indicate the approximate 95% confidence intervals reconstructed from the published β and t statistics in Table 4. Abbreviation: β, standardized coefficient.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9066592/v1/305b8b0785fdf7b22b518de4.jpg"},{"id":105563390,"identity":"706a30c8-3828-40d3-a294-9231e016f2d6","added_by":"auto","created_at":"2026-03-27 12:46:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1288471,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9066592/v1/dd455e2f-47e9-41bd-acc2-d1c265c5b2a9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"ADHD, Familial Liability, and Absence of Regret: A Clinically Actionable Triad for Identifying Psychobiological Risk in Adolescent Suicide Attempters","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescent suicide attempts remain a major clinical and public health concern worldwide. The World Health Organization estimates that more than 720,000 people die by suicide each year, and suicide is among the leading causes of death in young people aged 15\u0026ndash;29 years [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In T\u0026uuml;rkiye, suicide represents a substantial public health burden, underscoring the need for context-specific research to inform prevention and post-crisis care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWithin developmental psychopathology frameworks, suicidal behavior in adolescence is commonly conceptualized as emerging from transactions between biological vulnerability, environmental stressors, and psychological processes across development [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Historically influential models have emphasized internalizing psychopathology\u0026mdash;particularly depressive and anxiety disorders and trauma-related symptoms\u0026mdash;and related cognitive processes, such as hopelessness, as proximal pathways to suicidal behavior [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Complementary interpersonal models highlight perceived burdensomeness and thwarted belongingness in the development of suicidal desire [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, clinical cohorts assessed after a suicide attempt are heterogeneous, and a focus confined to internalizing presentations may obscure clinically meaningful variation in regulatory capacity among adolescents who have already engaged in suicidal self-harm [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConverging evidence indicates that externalizing psychopathology constitutes an additional and clinically important risk axis and heterogeneity factor in adolescent suicidality. Externalizing conditions are characterized by impulsivity, behavioral disinhibition, and emotion regulation difficulties, which may shorten the interval between acute distress and action and lower the threshold for rapid escalation under stress [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In particular, attention-deficit/hyperactivity disorder (ADHD) has been linked to an elevated risk across the suicidal spectrum behaviors, even after accounting for psychiatric comorbidity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The dual pathway model of ADHD provides an organizing framework for how executive (inhibitory control) and motivational (delay aversion) pathways may contribute to cascading dysregulation that becomes clinically salient during adolescence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Translating such vulnerability profiles into clinically scalable assessment targets remains a challenge, especially in routine post-attempt settings where rapid decision-making is required.\u003c/p\u003e \u003cp\u003eFamily context may further shape the severity and expression of externalizing dysregulation following a suicide attempt. A positive family psychiatric history can index intergenerational liability as well as shared environmental risk, and transactional models suggest that dysregulated family processes may amplify externalizing behavior over time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Sociocultural factors, including religiosity and attitudes towards suicide, may also influence coping and help-seeking in Muslim-majority settings, potentially modifying how distress is expressed and managed in clinical encounters [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In addition, post-attempt affective-cognitive responding may be clinically informative. Reduced post-attempt regret has been discussed as a potential marker of heterogeneity in moral-emotional engagement and guilt-related responding, while also requiring careful differentiation from trauma-related numbing or state-dependent disengagement [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Together, these observations suggest that combining neurodevelopmental, familial, and post-crisis affective indicators may help clinicians identify subgroups of adolescent attempters who present with more severe externalizing dysregulation and may require tailored post-attempt formulations and interventions.\u003c/p\u003e \u003cp\u003eDespite increasing recognition of externalizing contributions to suicide risk, most post-attempt research and clinical practice still prioritize internalizing symptom assessment. Studies that examine whether brief, clinically obtainable markers can identify adolescents with a greater externalizing symptom burden within an already high-risk post-attempt cohort are needed, particularly in trauma-enriched clinical settings where adversity exposure may be common.\u003c/p\u003e \u003cp\u003eAgainst this background, the present study focused on Turkish adolescents after a suicide attempt and adopted a dimensional developmental psychopathology framework to assess the severity of externalizing symptoms. The primary objective was to determine whether three clinically accessible markers\u0026mdash;current ADHD diagnosis (reflecting neurodevelopmental vulnerability), family psychiatric history (indicating intergenerational and contextual risk), and the absence of post-attempt regret (capturing post-crisis affective-cognitive response)\u0026mdash;were independently associated with a greater externalizing symptom burden after adjusting for age and sex. As a secondary objective, we examined whether externalizing severity differed across major sociodemographic, family-structural, and attempt-related variables, including family structure, reported precipitating factor, suicide attempt method, and history of repeated attempts, in order to better understand heterogeneity within this post-attempt sample. We hypothesized that both ADHD diagnosis and a positive family psychiatric history would be linked to greater externalizing severity, and that the absence of post-attempt regret would further distinguish adolescents with a higher externalizing symptom burden.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis cross-sectional observational study was conducted in the Department of Child and Adolescent Psychiatry, \u0026Ccedil;ukurova University Faculty of Medicine, Adana, T\u0026uuml;rkiye. The hospital is a major tertiary university center that serves a broad catchment area and includes a specialized forensic child psychiatry board. The study protocol was approved by the local Ethics Committee and carried out in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participating adolescents and their legal guardians.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Procedure\u003c/h3\u003e\n\u003cp\u003eThe sample included 102 adolescents aged 12\u0026ndash;18 years who were evaluated after a suicide attempt. Participants were recruited through two pathways: (i) psychiatric consultation in the emergency department or intensive care unit after medical stabilization, with assessments conducted only when the adolescent\u0026rsquo;s physical and cognitive condition allowed a comprehensive interview; and (ii) outpatient or forensic board referrals within 30 days of the attempt. A suicide attempt was defined as a self-initiated act performed with the intent to die, as confirmed through clinical interview. Exclusion criteria included autism spectrum disorder, intellectual disability (IQ\u0026thinsp;\u0026lt;\u0026thinsp;70), psychotic disorders, and active substance use.\u003c/p\u003e\n\u003ch3\u003eKiddie Schedule for Affective Disorders and Schizophrenia—Present and Lifetime Version (K-SADS-PL)\u003c/h3\u003e\n\u003cp\u003eThe K-SADS-PL is a semi-structured diagnostic interview used to assess a broad range of psychiatric disorders in children and adolescents according to DSM-IV criteria [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The interview consists of separate sessions with the adolescent and the parents, followed by a final synthesis of information from all sources by a child and adolescent psychiatrist to establish a consensus diagnosis. The Turkish adaptation has been validated for individuals aged 6\u0026ndash;18 years [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The instrument has shown high diagnostic accuracy, with inter-rater reliability reported as very good for externalizing and tic disorders (κ\u0026thinsp;=\u0026thinsp;0.81\u0026ndash;1.00), good for ADHD and anxiety disorders, and moderate for mood disorders. Test-retest reliability is also high, supporting the stability of diagnoses across the developmental period [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eTurgay DSM-IV-Based Disruptive Behavior Disorders Rating Scale—Parent Form (T-DSM-IV-S)\u003c/h3\u003e\n\u003cp\u003eThe T-DSM-IV-S is a detailed 41-item parent-report scale developed to quantify ADHD and disruptive behavior symptoms based on DSM-IV criteria [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Each item is rated on a 4-point Likert scale (0\u0026thinsp;=\u0026thinsp;not at all, 1\u0026thinsp;=\u0026thinsp;just a little, 2\u0026thinsp;=\u0026thinsp;much, 3\u0026thinsp;=\u0026thinsp;very much), where higher cumulative scores reflect greater symptom severity. The scale is structured into five distinct subscales: inattention (IN; 9 items assessing focus and distractibility), hyperactivity (H; 6 items assessing physical restlessness), impulsivity (I; 3 items assessing inhibitory control), oppositional defiant disorder (ODD; 8 items assessing defiant behavior), and conduct disorder (CD; 15 items assessing rule-breaking and aggression). In this study, the primary dimensional outcome was the T-DSM-IV-S total score, calculated as the sum of all 41 items (range, 0\u0026ndash;123). Additionally, a hyperactivity/impulsivity (HI) composite (9 items) was utilized descriptively. The Turkish version has been extensively validated, and in the current sample, the total scale demonstrated excellent internal consistency with a Cronbach\u0026rsquo;s α of 0.88 [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eSociodemographic and Clinical Information Form\u003c/h3\u003e\n\u003cp\u003eA structured form developed by the researchers was used to systematically collect participant characteristics and clinical history. Family psychiatric history was strictly defined and coded as \u0026ldquo;present\u0026rdquo; only when at least one first-degree biological relative (mother, father, or sibling) had a lifetime history of a diagnosed psychiatric disorder or had received psychiatric treatment. Post-attempt regret was recorded as a dichotomous variable (present/absent) based on the adolescents\u0026rsquo; direct responses during the clinical interview about their feelings regarding the index attempt. Additional variables included age, sex, educational status, family structure, and the specific method used in the suicide attempt.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAnalyses were conducted using IBM SPSS Statistics version 25.0. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Normality was confirmed using Kolmogorov\u0026ndash;Smirnov tests. Independent-samples t-tests and one-way ANOVA with Tukey HSD post-hoc tests were used for group comparisons. Multiple linear regression was employed to identify independent correlates of the total T-DSM-IV-S score, with age, sex, regret status, family history, and K-SADS-PL ADHD diagnosis entered as predictors a priori. Significance was set at α\u0026thinsp;=\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eThe study sample consisted of 102 adolescents aged 12\u0026ndash;18 years who were evaluated after a suicide attempt, including 12 boys (11.8%) and 90 girls (88.2%). The mean age was 15.3 years (SD\u0026thinsp;=\u0026thinsp;1.4). Information on family structure was available for 100 participants; of these, 78 (78.0%) came from intact families and 22 (22.0%) came from divorced or separated families. The most common method of suicide attempt was drug ingestion (84.3%), followed by wrist cutting (9.8%). The leading reported precipitants were parental conflict (42.2%) and sexual abuse (20.6%). Remorse or regret following the attempt was reported by 75.5% of the adolescents.\u003c/p\u003e \u003cp\u003eAccording to K-SADS assessments, the most frequent diagnoses were ADHD (17.6%), major depressive disorder (14.7%), and PTSD (14.7%). On the parent-reported Turgay Scale, 49 adolescents (48.0%) met the cutoff in at least one disruptive behavior disorder domain. The most common clinical profiles were ADHD combined with oppositional defiant disorder (12.7%) and ADHD combined type (7.8%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eComparison of Turgay Scale total scores according to demographic and clinical characteristics\u003c/h2\u003e \u003cp\u003eThe mean total Turgay Scale score, reflecting overall externalizing symptom burden, was 28.31 (SD\u0026thinsp;=\u0026thinsp;1.93). As presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, boys had higher total scores than girls (Welch\u0026rsquo;s t(12.41)\u0026thinsp;=\u0026thinsp;2.83, p\u0026thinsp;=\u0026thinsp;0.015). Scores were also markedly higher among adolescents who did not report post-attempt remorse or regret compared with those who did (Welch\u0026rsquo;s t(32.65)\u0026thinsp;=\u0026thinsp;5.59, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eHigher total scores were likewise observed among adolescents with multiple suicide attempts (Welch\u0026rsquo;s t(53.97)\u0026thinsp;=\u0026thinsp;4.64, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), those with a family history of psychiatric disorders (Welch\u0026rsquo;s t(28.90)\u0026thinsp;=\u0026thinsp;7.07, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and those from divorced or separated families (Welch\u0026rsquo;s t(29.94)\u0026thinsp;=\u0026thinsp;4.51, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAcross diagnostic groups, adolescents diagnosed with ADHD had the highest mean total score, and the differences between diagnosis groups were statistically significant (F(3, 98)\u0026thinsp;=\u0026thinsp;24.36, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Total scores also varied significantly according to the reported precipitant of the suicide attempt (F(4, 97)\u0026thinsp;=\u0026thinsp;3.96, p\u0026thinsp;=\u0026thinsp;0.005). Post-hoc analyses showed that adolescents in the sexual abuse group had higher scores than those in the peer bullying group (p\u0026thinsp;=\u0026thinsp;0.02). These findings should be interpreted with caution because some subgroups were small, particularly the peer bullying group (n\u0026thinsp;=\u0026thinsp;5).\u003c/p\u003e \u003cp\u003eThese main subgroup differences are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Turgay Scale Total Scores by Demographic and Clinical Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTurgay Total Score (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest Statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch's t(12.41)\u0026thinsp;=\u0026thinsp;2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (11.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e30.42\u0026thinsp;\u0026plusmn;\u0026thinsp;2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90 (88.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.02\u0026thinsp;\u0026plusmn;\u0026thinsp;1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuicide Regret\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch's t(32.65)\u0026thinsp;=\u0026thinsp;5.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e30.48\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Suicide Attempts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch's t(53.97)\u0026thinsp;=\u0026thinsp;4.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.84\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.84\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily History of Psychiatric Disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch's t(28.90)\u0026thinsp;=\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (21.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.16\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily Structure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWelch's t(29.94)\u0026thinsp;=\u0026thinsp;4.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (22.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e30.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78 (78.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eK-SADS Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF(3, 98)\u0026thinsp;=\u0026thinsp;24.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (17.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.24\u0026thinsp;\u0026plusmn;\u0026thinsp;2.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.96\u0026thinsp;\u0026plusmn;\u0026thinsp;2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther/None\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.05\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReason for Suicide Attempt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eF(4, 97)\u0026thinsp;=\u0026thinsp;3.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParental Conflict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e28.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual Abuse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e30.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer Bullying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBreakup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e29.60\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e27.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote. SD\u0026thinsp;=\u0026thinsp;standard deviation. Welch\u0026rsquo;s independent-samples t-tests were used for binary variables, and one-way ANOVA with Tukey post-hoc tests was used for variables with more than two categories. Total N\u0026thinsp;=\u0026thinsp;102. Family structure data were available for n\u0026thinsp;=\u0026thinsp;100 participants (percentages for this variable are based on n\u0026thinsp;=\u0026thinsp;100). The Tukey post-hoc test indicated that the ADHD group scored significantly higher than the Other/None group (p\u0026thinsp;=\u0026thinsp;0.008). *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDescriptive statistics and internal consistency coefficients (Cronbach's α) for the Turgay Scale subscales are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The Inattention (IN) subscale had the highest mean score (9.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64), followed by the Oppositional Defiant Disorder (ODD) subscale (7.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49). The Hyperactivity/Impulsivity (HI) composite score was 6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53, and the separate Impulsivity (I) factor score was 3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27. The Conduct Disorder (CD) subscale had the lowest mean score (1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38). The total scale demonstrated excellent internal consistency (α\u0026thinsp;=\u0026thinsp;0.88).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics and Internal Consistency of Turgay Scale Subscales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eObserved Range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCronbach's α\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInattention (IN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperactivity/Impulsivity (HI)ᶜ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImpulsivity (I)ᶜ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOppositional Defiant Disorder (ODD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConduct Disorder (CD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e28.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.93\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e22\u0026ndash;34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.88\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote.\u003c/em\u003e SD\u0026thinsp;=\u0026thinsp;standard deviation. ᶜThe HI composite includes the I items; therefore, these scores are not independent (see Methods section).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, all Turgay subscales were positively and significantly intercorrelated. The strongest association was observed between the ODD and CD subscales (r\u0026thinsp;=\u0026thinsp;0.62, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Moderate to strong correlations were also found between HI and I (r\u0026thinsp;=\u0026thinsp;0.54, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and between IN and HI (r\u0026thinsp;=\u0026thinsp;0.48, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe intercorrelation pattern is additionally shown in Additional file 1: Fig. S1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson Correlations Among Turgay Scale Subscales\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Inattention (IN)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Hyperactivity/Impulsivity (HI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.48**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Impulsivity (I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.41**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.54**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Oppositional Defiant Disorder (ODD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.45**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Conduct Disorder (CD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.29*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.36**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMultivariate predictors of total Turgay scores\u003c/h2\u003e \u003cp\u003eMultiple linear regression analysis was conducted to identify factors associated with total Turgay scores. The model was statistically significant (F(5, 96)\u0026thinsp;=\u0026thinsp;6.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and explained 26% of the variance (R\u0026sup2; = 0.26). As presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, a positive family history of psychiatric disorders (β\u0026thinsp;=\u0026thinsp;0.29, p\u0026thinsp;=\u0026thinsp;0.005), the absence of suicide regret (β\u0026thinsp;=\u0026thinsp;0.25, p\u0026thinsp;=\u0026thinsp;0.017), and an ADHD diagnosis based on the K-SADS (β\u0026thinsp;=\u0026thinsp;0.27, p\u0026thinsp;=\u0026thinsp;0.009) were significant independent predictors of higher total scores. Age and sex were not significant predictors in the model. Standardized regression coefficients are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePredictors of Turgay Total Score: Multiple Linear Regression Analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndependent Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily History of Psychiatric Disorders (Present vs. Absent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuicide Regret (Absent vs. Present)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.017*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADHD Diagnosis per K-SADS (Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.009**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Female vs. Male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote. β\u0026thinsp;=\u0026thinsp;standardized beta coefficient. Reference categories: Male for Gender, Present for Suicide Regret, and Absent for Family History. Model: R\u0026sup2; = 0.26, Adjusted R\u0026sup2; = 0.22, F(5, 96)\u0026thinsp;=\u0026thinsp;6.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. **p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored differences in the severity of externalizing symptoms among Turkish adolescents who were assessed after a suicide attempt. In the multivariable analyses, three easily obtainable clinical factors\u0026mdash;having a current ADHD diagnosis, the presence of psychiatric disorders in first-degree relatives, and a lack of regret following the attempt\u0026mdash;were each independently associated with higher levels of parent-reported externalizing symptoms. Together, these factors accounted for approximately 26% of the variance in total T-DSM-IV-S scores. Since the sample included only adolescents evaluated after a suicide attempt, these findings should not be interpreted as etiological predictors of the development of suicidal behavior. Instead, they underscore clinically meaningful differences in the degree of externalizing dysregulation within a high-risk population of adolescents following a suicide attempt.\u003c/p\u003e \u003cp\u003eThe diagnostic profile of the sample further reflects the heterogeneity that was observed. ADHD was the most common current diagnosis, identified in 17.6% of participants, while MDD and PTSD were each present at similar rates of 14.7%. Importantly, more than half of the adolescents did not meet criteria for a current psychiatric diagnosis on the K-SADS-PL at the time of assessment. Comparable post-attempt clinical samples have likewise shown heterogeneous psychopathological profiles rather than a single dominant diagnostic pattern [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This pattern aligns with broader evidence showing that suicidal thoughts and behaviors in young people can emerge alongside subthreshold symptoms, acute stress reactions, and transdiagnostic vulnerabilities that are not fully accounted for by categorical diagnostic systems alone [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These findings underscore the value of adopting a dimensional clinical approach after a suicide attempt, even in the absence of a formal psychiatric diagnosis.\u003c/p\u003e \u003cp\u003eExternalizing symptoms also stood out as a key feature across the cohort. Nearly half of the adolescents met the threshold in at least one disruptive behavior disorder domain on the parent-rated Turgay scale, and the most common diagnostic combination was ADHD with oppositional defiant disorder. All subscales were positively associated with one another, with the strongest correlation found between oppositional defiant and conduct symptoms. This pattern indicates that defiance and rule-breaking were more likely to cluster as part of a broader tendency toward behavioral dysregulation rather than appear as isolated symptom domains. Inattention likewise emerged as a clinically meaningful dimension, in line with longitudinal research linking attentional dyscontrol and impulsivity to later suicidal outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eADHD was strongly associated with more severe externalizing symptoms, which fits with broader evidence that externalizing psychopathology is an important dimension of risk across suicidal presentations [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Prior research, including meta-analytic studies, has shown that ADHD is linked to a higher risk of suicidal behaviors, including suicide attempts, even after psychiatric comorbidity is taken into account [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. From a conceptual standpoint, this relationship may reflect neurodevelopmental mechanisms such as impaired inhibitory control and delay-related motivational processes, as outlined in the dual-pathway model [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], along with difficulties in emotion regulation that may make it easier for distress to rapidly translate into action [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. At the same time, some overlap in measurement should be recognized, since the T-DSM-IV-S total score includes symptom domains related to ADHD. The present findings should therefore be interpreted with caution. Rather than establishing ADHD as an independent causal factor, they suggest that clinician-identified ADHD may mark a subgroup of adolescents in this high-risk post-attempt sample whose caregivers report more pervasive behavioral dysregulation.\u003c/p\u003e \u003cp\u003eThe characteristics of the attempts also help frame the externalizing pattern observed in the sample. Drug ingestion was the most common method. This is consistent with what has been described in adolescence as an \u0026ldquo;access and rapid escalation\u0026rdquo; scenario: when potentially harmful means are readily available in the home, they may be used during periods of acute conflict or intense emotional distress, often with little prior planning [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although the present study does not allow conclusions about the mechanisms involved, the clinical implications are clear. Post-attempt care should include systematic counselling on means restriction and the safe storage of medications, especially for adolescents with attentional difficulties and problems with behavioral regulation.\u003c/p\u003e \u003cp\u003eFamily-related factors appeared to distinguish the severity of externalizing symptoms just as clearly as neurodevelopmental features. In the multivariable analysis, a psychiatric history among first-degree relatives was one of the strongest correlates of more severe externalizing symptoms, possibly reflecting both intergenerational vulnerability and shared exposure to environmental stress [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This interpretation is also consistent with genetically informed studies linking inherited liability\u0026mdash;including suicide-related, depression-related, and ADHD-related polygenic risk\u0026mdash;to suicidal thoughts and behaviors in youth [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Caregiver psychopathology may also shape everyday family functioning, including supervision, emotional regulation within the household, and overall stability. These influences are especially relevant for adolescents who display oppositional behavior and difficulties with impulse control. Developmental transactional models suggest that parenting practices and disruptive behavior affect one another over time [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and family conflict was the most commonly reported precipitating factor in this sample. More broadly, family-context variables and adverse life events have been associated with suicidal ideation, self-injury, and first-time suicide attempts across development [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Taken together, these findings suggest that post-attempt assessments should address not only the adolescent\u0026rsquo;s symptoms but also caregiver mental health, current relational stressors, and the patterns through which family conflicts escalate.\u003c/p\u003e \u003cp\u003eA lack of post-attempt regret also helped distinguish adolescents with a greater burden of externalizing symptoms. Most participants reported regret, suggesting that many attempts occurred in the context of acute distress rather than a sustained wish to die. In contrast, adolescents who expressed no regret showed markedly higher levels of externalizing symptoms, and this association remained significant after adjustment. Clinically, however, the absence of regret should not be interpreted as a single, stable trait marker. In the immediate aftermath of a crisis\u0026mdash;particularly among young people exposed to significant adversity\u0026mdash;it may instead reflect state-related emotional numbing, dissociation, avoidance, or a reduced ability to process consequences under conditions of acute dysregulation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. At the same time, it may overlap with more enduring differences in moral and emotional processing, including callous-unemotional traits, which may have distinct implications for prognosis and treatment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Because regret was measured using a single binary clinical item, it is best understood as a practical clinical signal that warrants more structured follow-up assessment, rather than as a proxy for any specific personality construct.\u003c/p\u003e \u003cp\u003eA trauma-informed reading is especially important for this cohort. Sexual abuse was often reported as a trigger (20.6%), and PTSD occurred as often as major depression. Earlier work suggests that trauma-related symptoms and difficulties regulating emotions may help explain the link between abuse exposure and self-injurious behavior in adolescents [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], while longitudinal research has also found an association between childhood sexual abuse and later suicidal behavior in high-risk groups [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. More recent work further emphasizes that child maltreatment may contribute to suicidal behavior over and above diagnosable mental disorders alone [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and high-risk developmental studies indicate that suicidal behavior can emerge in the context of multiple converging early risk factors [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Because this study was carried out in a tertiary-care hospital with a forensic child protection board that evaluates suspected abuse cases, adolescents with more severe adversity-related problems may have been overrepresented. As a result, the level of trauma observed here may not reflect what would be seen in community samples. Even so, these findings highlight that, in routine care after a suicide attempt, externalizing dysregulation and trauma-related symptoms can occur together and should be evaluated side by side rather than viewed as competing explanations.\u003c/p\u003e \u003cp\u003eAdolescents with a history of multiple suicide attempts showed more severe externalizing symptoms than those with only one attempt. Although the cross-sectional design prevents conclusions about the direction of this relationship, the finding is clinically plausible. Persistent behavioral dysregulation may raise the risk of repeated crises, while repeated crises may in turn intensify family stress and erode coping resources. Previous suicidal behavior is one of the most reliable predictors of future suicidal behavior across studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], and the present findings suggest that externalizing dysregulation may provide additional clinically meaningful information when deciding on the intensity of follow-up care and identifying treatment targets after an attempt.\u003c/p\u003e \u003cp\u003eSex differences should be interpreted carefully. While boys showed higher externalizing scores in the bivariate analyses, sex was no longer a significant factor in the multivariable model. In addition, the sample was mostly female, which reduced the statistical power to draw firm sex-specific conclusions. This pattern aligns with epidemiological evidence indicating that non-fatal suicide attempts are more common among adolescent girls, whereas suicide deaths are more frequent among boys [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Age was also not a significant predictor, which suggests that within a relatively narrow adolescent age range, symptom-related and family-related factors may provide more useful information than age alone.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, these findings indicate that post-attempt assessments should extend beyond internalizing symptoms. Screening should also cover difficulties in neurodevelopmental regulation, family psychiatric history and current family stressors, and the adolescent\u0026rsquo;s emotional reaction to the attempt. For adolescents with marked ADHD symptoms and behavioral dysregulation, it may be helpful to optimize evidence-based ADHD treatment and add skills-based interventions focused on impulse control and emotion regulation. Randomized controlled trials support dialectical behavior therapy for adolescents (DBT-A) as an effective approach for reducing self-harm and suicidal behaviors in high-risk youth [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. When there is a substantial family psychiatric burden along with ongoing conflict, family-based assessment and intervention are advisable, with attention to caregiver mental health whenever possible. If an adolescent expresses no regret after the attempt, clinicians may want to explore trauma-related emotional numbing and reflective functioning more closely. In such cases, mentalization-based treatment for adolescents (MBT-A) may be especially relevant for adolescents whose crises arise in the context of interpersonal dysregulation and limited perspective-taking [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Future prospective studies should use validated measures of post-attempt emotional responses, trauma severity, and real-time symptom fluctuations, such as ecological momentary assessment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], along with psychophysiological markers of dysregulation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This work could help clarify whether these clinically observable indicators predict recurrent suicidal behavior and different responses to treatment.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eSeveral limitations should be taken into account when interpreting these findings. First, the cross-sectional design does not permit causal conclusions and makes it impossible to determine the temporal relationship between externalizing dysregulation and characteristics of the suicide attempt. The sample was also recruited from a single tertiary child and adolescent psychiatry service and consisted mainly of female adolescents, which limits the generalizability of the results and reduces the ability to examine sex-specific effects. In addition, the recruitment process included adolescents assessed after medical stabilization in the emergency department or intensive care unit, those presenting to outpatient services within one month of an attempt, and those referred for medicolegal psychiatric evaluation. This tertiary referral pattern may have led to an overrepresentation of clinically complex and high-risk cases.\u003c/p\u003e \u003cp\u003eMeasurement-related limitations should also be acknowledged. Externalizing symptom severity was assessed only through parent report, and data from other informants, such as adolescent self-reports or teacher ratings, were not available. Family psychiatric history relied on caregiver report and was not independently confirmed through diagnostic assessment. Post-attempt regret was measured using a single binary clinical item, and suicidality-related characteristics were obtained through clinician questioning during the interview rather than through validated multi-item instruments. Furthermore, the dependent variable (T-DSM-IV-S total score) includes ADHD symptom domains, which may create criterion overlap with the ADHD diagnosis predictor. Finally, the lack of a psychiatric comparison group without suicide attempts and the absence of prospective follow-up limit conclusions about the specificity and prognostic value of these findings. Future multi-site longitudinal studies using multi-informant assessments are needed to clarify these relationships further.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAmong adolescents seen in a tertiary clinical setting after a suicide attempt, three readily identifiable clinical factors\u0026mdash;a current ADHD diagnosis, a first-degree family history of psychiatric illness, and not feeling regret after the attempt\u0026mdash;were each independently linked to higher levels of parent-reported externalizing symptoms. Together, these factors accounted for roughly one-quarter of the variance in total T-DSM-IV-S scores. These results suggest that adolescents who present after a suicide attempt are a heterogeneous group and support a developmentally informed assessment strategy that goes beyond internalizing symptoms alone. In practice, this means systematically assessing neurodevelopmental dysregulation, family psychiatric burden and relational stressors, and the adolescent\u0026rsquo;s emotional reaction to the attempt. Prospective research is needed to determine whether incorporating these markers into post-attempt care can improve risk stratification for repeat attempts and better inform behavioral, family-based, and trauma-informed interventions, including structured counseling on means restriction and safe medication storage.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAttention-Deficit/Hyperactivity Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConduct Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCallous-Unemotional\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDBT-A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDialectical Behavior Therapy for Adolescents\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHyperactivity/Impulsivity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInattention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eK-SADS-PL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSchedule for Affective Disorders and Schizophrenia for School-Age Children\u0026mdash;Present and Lifetime Version\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMBT-A\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMentalization-Based Treatment for Adolescents\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMajor Depressive Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eODD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOppositional Defiant Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePTSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePost-Traumatic Stress Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT\u0026Uuml;İK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTurkish Statistical Institute (T\u0026uuml;rkiye İstatistik Kurumu)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Ethics Committee of \u0026Ccedil;ukurova University (approval date: May 9, 2014; decision no. 31/9). Written informed consent was also obtained from the adolescent participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthors\u0026rsquo; information\u003c/h2\u003e \u003cp\u003eDilek Altun Varmış, MD \u0026ndash; Department of Child and Adolescent Psychiatry, Adana City Research and Training Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003cp\u003eSerkan G\u0026uuml;neş, Associate Professor \u0026ndash; Department of Child and Adolescent Psychiatry, Adana City Research and Training Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003cp\u003eGonca G\u0026uuml;l, Professor \u0026ndash; Department of Child and Adolescent Psychiatry, \u0026Ccedil;ukurova University Faculty of Medicine Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003cp\u003ePerihan \u0026Ccedil;am Ray, MD \u0026ndash; Department of Child and Adolescent Psychiatry, \u0026Ccedil;ukurova University Faculty of Medicine Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003cp\u003e\u0026Ouml;zge Metin, MD \u0026ndash; Department of Child and Adolescent Psychiatry, \u0026Ccedil;ukurova University Faculty of Medicine Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003cp\u003eAyşeg\u0026uuml;l Yolga Tahiroğlu, Professor \u0026ndash; Department of Child and Adolescent Psychiatry, \u0026Ccedil;ukurova University Faculty of Medicine Hospital, Adana, T\u0026uuml;rkiye. E-mail: [email protected]\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDAV, GG, P\u0026Ccedil;R, \u0026Ouml;M, and AYT designed the study. DAV acquired the data. DAV and SG analyzed the data. DAV interpreted the results with SG \u0026rsquo;scontribution. DAV wrote the paper. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304\u0026ndash;e13133. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jaac.2012.09.018\u003c/span\u003e\u003cspan address=\"10.1016/j.jaac.2012.09.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suicide attempt, Adolescents, Externalizing symptoms, ADHD, Family psychiatric history, Post-attempt regret","lastPublishedDoi":"10.21203/rs.3.rs-9066592/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9066592/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSuicide attempts during adolescence are common and clinically varied. Although assessments after an attempt often emphasize internalizing disorders, externalizing dysregulation may define a subgroup with different clinical needs. We explored whether neurodevelopmental factors, family psychiatric history, and emotional responses after the crisis could help identify adolescents with a heavier burden of externalizing symptoms following a suicide attempt.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study involved 102 adolescents aged 12\u0026ndash;18 years (88.2% female) who were evaluated after a suicide attempt at a university hospital in T\u0026uuml;rkiye. Psychiatric diagnoses were established using the Kiddie Schedule for Affective Disorders and Schizophrenia\u0026mdash;Present and Lifetime Version (K-SADS-PL). Externalizing symptom severity was measured with the parent-rated Turgay DSM-IV Disruptive Behavior Disorders Rating Scale (T-DSM-IV-S). Multiple linear regression was used to examine whether ADHD diagnosis, family psychiatric history, and post-attempt regret were independently related to externalizing severity after controlling for age and sex.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eADHD was the most common diagnosis (17.6%), followed by major depressive disorder and post-traumatic stress disorder (14.7% each). Nearly half of the sample met the cutoff for at least one disruptive behavior disorder domain, and drug ingestion was the most frequent method of attempted suicide (84.3%). In multivariable regression analyses, ADHD diagnosis, a positive family psychiatric history, and the absence of post-attempt regret were each independently associated with greater externalizing symptom severity, together accounting for about 26% of the variance in total T-DSM-IV-S scores. Age and sex were not significant predictors.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn this high-risk post-attempt group, readily available clinical markers\u0026mdash;ADHD diagnosis, family psychiatric history, and the absence of post-attempt regret\u0026mdash;may help identify adolescents with more severe externalizing dysregulation. These findings support a developmentally informed approach to post-attempt assessment that goes beyond internalizing symptoms and also considers family context and trauma-informed care. Prospective studies should examine whether this pattern predicts clinical course, recurrence, and treatment response.\u003c/p\u003e","manuscriptTitle":"ADHD, Familial Liability, and Absence of Regret: A Clinically Actionable Triad for Identifying Psychobiological Risk in Adolescent Suicide Attempters","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-20 21:08:44","doi":"10.21203/rs.3.rs-9066592/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-21T06:11:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T15:47:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T10:21:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61644644041660367369614828201430217354","date":"2026-04-15T09:49:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23647887876980874450794756262911280365","date":"2026-04-15T06:03:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91584318084552896654631290379044888003","date":"2026-04-12T09:32:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253549520037958623563681638575351625650","date":"2026-04-03T18:36:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100863858397724345013118281610208573601","date":"2026-03-27T11:27:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T17:46:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-12T16:48:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-10T11:41:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-10T11:41:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2026-03-08T21:11:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be43b2e4-0555-4764-90be-142aff7718ab","owner":[],"postedDate":"March 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-20T21:08:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-20 21:08:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9066592","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9066592","identity":"rs-9066592","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}