Youth Risk Behavior Survey

Abstract

The Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention (CDC) in 1990 within the broader Youth Risk Behavior Surveillance System (YRBSS), represents the premier epidemiological and psychometric instrument designed to monitor priority health-risk behaviors among adolescent populations. Administered biennially to representative samples of students in grades 9 through 12 across the United States, the core instrument comprises an extensive questionnaire (standardly 86 to 99 items depending on cycle revisions) operationalizing six focal behavioral domains: (1) behaviors that contribute to unintentional injuries and violence, (2) tobacco use, (3) alcohol and other drug use, (4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted infections (including human immunodeficiency virus [HIV]), (5) unhealthy dietary behaviors, and (6) physical inactivity, alongside related health conditions such as obesity and asthma. A critical psychometric configuration embedded within violence and safety surveillance is the Depressive Symptoms and Suicidal Ideation (DSSI) module, assessing persistent sadness, serious consideration of suicide, operational planning, suicide attempts, and medical lethality. Psychometric evaluations of the YRBS have documented robust test-retest reliability, with Cohen’s kappa (κ) coefficients ranging from 61.2% to 100% (median κ = 0.61 across behavioral categories, indicating moderate-to-substantial stability over 1-to-2-week intervals) and overall percentage agreement exceeding 80%. Criterion, construct, and convergent validity have been empirically supported via biochemical validation (e.g., breath carbon monoxide and cotinine assays for nicotine consumption; urine screens for illicit substances), structural equation modeling, and latent class analysis confirming the multidimensional clustering of risk behaviors predicted by Jessor’s Problem Behavior Theory. The survey provides indispensable population-level data utilized by behavioral scientists, pediatricians, school psychologists, and public health policymakers to allocate prevention resources, track national health objectives (such as Healthy People benchmarks), and design targeted adolescent interventions.

Keywords

Youth Risk Behavior Survey, YRBS, YRBSS, adolescent risk behavior, suicidal ideation, depressive symptoms, substance use surveillance, psychometric reliability, construct validity, epidemiological measurement

Authors

The Youth Risk Behavior Survey was conceived, developed, and maintained by the Division of Adolescent and School Health (DASH) within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (Atlanta, Georgia, USA). The initial foundational design and psychometric validation were spearheaded by a multidisciplinary panel of federal scientists, psychometricians, and public health surveillance experts, including Laura Kann, Ph.D., Richard Lowry, M.D., M.S., Nancy D. Brener, Ph.D., Danice K. Eaton, Ph.D., and Janet L. Collins, Ph.D., in close collaboration with academic consultants across pediatric medicine, clinical psychology, and educational measurement.

Purpose

The primary purpose of the Youth Risk Behavior Survey is to establish a rigorous, standardized epidemiological and psychometric surveillance mechanism to systematically quantify, monitor, and assess the prevalence of behaviors that contribute significantly to the leading causes of morbidity, mortality, and social disability among adolescents and young adults. In the United States and globally, adolescent mortality is overwhelmingly driven by preventable behavioral outcomes: motor vehicle crashes, firearm-related violence, homicide, and suicide account for nearly three-quarters of deaths in individuals aged 10 to 24. Furthermore, behavioral patterns established during secondary school—such as sedentary lifestyle habits, poor nutritional choices, nicotine dependence, and early-onset substance experimentation—serve as direct precursors to the leading chronic disease burdens of adulthood, including cardiovascular disease, type 2 diabetes mellitus, chronic pulmonary disorders, and diverse malignancies.

From an applied clinical and psychological perspective, the YRBS furnishes high-resolution baseline normative data that allow clinicians, pediatric health professionals, and school mental health providers to contextualize adolescent symptomatology within population trends. The Depressive Symptoms and Suicidal Ideation (DSSI) sub-component is specifically designed to identify the epidemiological prevalence of anhedonia, prolonged dysphoria, cognitive planning for self-harm, and behavioral suicide attempts with or without medical lethality. This granular surveillance capability enables mental health researchers to track sudden secular shifts—such as the sharp escalation in adolescent internalizing distress, digital media-mediated victimization, and self-injurious behavior observed over the past decade.

In educational and public policy contexts, the YRBS fulfills several critical functions:

• Evaluating National Public Health Initiatives: Measuring longitudinal progress toward reaching national health goals delineated in federal initiatives such as the Healthy People 2030 objectives.
• Targeted Resource Allocation: Supplying local educational agencies, school boards, and state health departments with statistically representative data to justify grant allocations, enact evidence-based social-emotional curricula, and design targeted behavioral health interventions.
• Cross-Sectional and Longitudinal Behavioral Modeling: Serving as an open-access empirical bedrock for multivariate modeling, structural equation modeling, and machine-learning classifications that isolate social determinants of health, family dynamic moderators, racial/ethnic disparities, and sexual/gender minority risk gradients.
• Health Education Curriculum Reform: Systematically identifying emerging synthetic drug vectors (e.g., e-cigarette/vaping devices, non-medical synthetic opioid use), driving timely modernization of school-based health curricula.

Psychological Construct

The YRBS operationalizes a multifaceted behavioral construct defined as Adolescent Health-Risk Behavior. Rather than evaluating a single unitary personality trait or clinical diagnostic category, the survey captures distinct, hierarchically organized behavioral clusters that reflect cognitive, affective, behavioral, and socio-environmental interactions. The standard core instrument models several key conceptual dimensions:

1. Unintentional Injuries and Vehicle Safety

This dimension examines behaviors governed by risk perception, executive functioning, sensation seeking, and peer compliance within vehicular contexts. Indicators capture helmet use during bicycling, safety seat belt compliance, riding with an alcohol-impaired driver, driving under the influence of alcohol, and distracted driving behaviors (such as texting or emailing while operating a motor vehicle). These items reflect impulse regulation, risk appraisal, and safety adherence under varying peer pressures.

2. Interpersonal Violence, Weapon Carrying, and School Safety

This construct assesses engagement in overt externalizing aggression, defensive or offensive weapon possession, and environmental threat perception. Sub-dimensions evaluate: (a) weapon carrying (guns, knives, clubs) generally and on school grounds; (b) perceived environmental threat leading to school absenteeism (truancy driven by safety concerns); (c) physical fighting frequency and fighting-related physical injury requiring clinical care; and (d) dating violence and sexual victimization, assessing lifetime forced sexual intercourse, physical dating violence, and sexual dating coercion.

3. Bullying and Cybervictimization

Operationalized through two complementary vectors, this construct measures repetitive power-asymmetric social victimization occurring either physically within the institutional school environment (traditional bullying) or mediated across digital interfaces (electronic bullying, including social networking platforms, short message services, chat rooms, and websites). This dimension reflects exposure to peer-mediated chronic psychosocial stressors.

4. Depressive Symptoms and Suicidal Ideation (DSSI)

The DSSI construct reflects a continuous spectrum of internalizing psychopathology ranging from affective dysphoria to fatal self-directed violence. It includes five sequentially organized thresholds: (a) persistent dysphoria/anhedonia (feeling so sad or hopeless almost every day for ≥2 consecutive weeks such that usual activities cease, approximating DSM-5 Major Depressive Episode criterion A); (b) serious suicidal ideation (cognitive appraisal of ending one’s life); (c) active suicide planning (methodological operationalization); (d) behavioral suicide attempts; and (e) medically consequential suicide attempts (attempts requiring medical intervention for trauma, poisoning, or overdose).

5. Substance Use and Experimentation

This expansive construct spans multiple pharmacological classes and evaluates developmental stage markers including age of onset, lifetime experimentation, current frequency (past 30 days), quantity consumed, and acquisition modalities:

• Tobacco and Nicotine: Lifetime cigarette trial, age of first regular consumption, current 30-day smoking frequency, daily volume, institutional school grounds violation, cessation attempts, and alternative delivery formats (smokeless tobacco, cigars, cigarillos).
• Alcohol Consumption: Lifetime exposure, age at initial consumption, 30-day frequency, binge drinking episodes (≥5 drinks within a 2-hour window), peak acute volume, and sourcing pathways.
• Cannabis / Marijuana: Lifetime consumption frequency, early-onset initiation age, and past 30-day usage density.
• Illicit, Synthetic, and Prescribed Substances: Exposure to cocaine (powder, crack, freebase), inhalants, heroin, methamphetamines, MDMA (ecstasy), non-prescribed anabolic-androgenic steroids, non-prescribed prescription psychoactive medications (e.g., OxyContin, Percocet, Vicodin, Adderall, Ritalin, Xanax), intravenous drug use via shared needles, and exposure to school-based illicit drug transactions.

6. Sexual Risk Behaviors

This dimension models sexual developmental milestones and protective behavioral practices, incorporating lifetime sexual debut, early coital initiation (<13 years), lifetime and concurrent sexual partner counts, substance-involved sexual encounters (co-occurring alcohol/drug use prior to intercourse), barrier contraceptive utilization (condoms for STI/HIV prevention), and hormonal or long-acting reversible contraceptive (LARC) adherence.

7. Dietary Behaviors, Weight Perception, and Energy Balance

This domain captures self-reported anthropometric indicators (height, weight, derived Body Mass Index [BMI] percentiles), cognitive self-body appraisal (underweight vs. overweight misclassification), behavioral weight modification intentions, and maladaptive compensatory eating disorder behaviors (24-hour fasting, non-prescribed diet pills/powders, and self-induced purging or laxative abuse). It also assesses the nutritional quality of weekly food intake (100% fruit juice, whole fruits, green salads, non-fried root vegetables, sugar-sweetened carbonated beverages, calcium/dairy consumption, and breakfast regularity).

8. Physical Activity, Sedentary Screen Behavior, and Physical Education

Operationalized around cardiovascular health guidelines, this construct measures the number of days reaching ≥60 minutes of moderate-to-vigorous physical activity, secondary school physical education (PE) class participation, organized athletic team involvement, and daily non-educational screen time (television viewing and recreational video game/computer/smartphone screen consumption).

Theoretical Framework

The structural and conceptual architecture of the Youth Risk Behavior Survey is founded upon an integration of several major psychological and sociological theories of adolescent development and health decision-making.

1. Problem Behavior Theory (PBT)

Formulated by Richard Jessor and Shirley L. Jessor (1977), Problem Behavior Theory serves as the primary psychometric rationale for aggregating diverse risk behaviors into a coherent surveillance system. PBT posits that adolescent risk behaviors do not emerge in isolated silos; rather, they form a functionally organized “syndrome of problem behavior.” Problem behavior is defined as behavior that departs from the normative expectations of larger society and adult authority institutions.

PBT identifies three interlocking systems of explanatory variables: the Personality System (values, expectations, beliefs, and cognitive self-attributions), the Perceived Environment System (peer models, parental support vs. peer orientation), and the Behavior System. Within the Behavior System, engagement in one problem behavior (such as early alcohol or cannabis experimentation) substantially elevates the statistical likelihood of co-occurring behaviors (such as premature sexual intercourse, weapon carrying, or academic disengagement) through shared underlying motivations—including autonomy assertion, adult-status acquisition, peer-solidarity confirmation, or psychological coping mechanisms against environmental distress.

2. Social Cognitive Theory (SCT)

Rooted in the work of Albert Bandura (1986), Social Cognitive Theory explains adolescent behavioral initiation and maintenance through triadic reciprocal determinism: the continuous bidirectional feedback loop connecting personal cognitive factors, environmental influences, and overt behavioral patterns. SCT illuminates why health-risk choices captured in the YRBS—such as weapon carrying or binge drinking—are directly modeled from peer or familial environments, reinforced by perceived outcome expectancies (e.g., social status gains vs. fear of immediate harm), and mediated by self-regulatory capabilities and self-efficacy.

3. The Biopsychosocial Model and Ecological Systems Theory

The YRBS embeds Urie Bronfenbrenner’s (1979) Ecological Systems Theory, recognizing that adolescent risk behaviors are dynamically nested within micro-systems (family, peer groups, school classrooms), meso-systems (school-community interactions), exo-systems (neighborhood safety, retail tobacco/alcohol outlet density), and macro-systems (societal norms, legislation, cultural representation). Co-occurring biological maturation (pubertal timing, prefrontal cortex myelination, and dopaminergic reward pathway remodeling) interacts with these nested ecological contexts, elevating adolescent sensation seeking prior to the complete maturation of executive cognitive control circuits.

4. Cognitive Vulnerability-Stress and Suicidality Models

The DSSI module is specifically anchored in Beck’s cognitive model of depression and Joiner’s Interpersonal-Psychological Theory of Suicidal Behavior. Beck’s cognitive triad posits that negative cognitive schemas regarding the self, the immediate world, and the future generate persistent hopelessness—the precise symptom targeted by item 26 of the survey. Joiner’s framework clarifies the progression modeled across items 27 through 30: perceived burdensomeness and thwarted belongingness combine to produce passive suicidal ideation, which translates into active plans and lethal capability only when an individual acquires the capacity for self-harm through repeated exposure to painful and provocative events (such as physical fights, victimization, or substance abuse).

Validity

The validity of the Youth Risk Behavior Survey has been rigorously evaluated across three decades of psychometric investigations, laboratory field studies, and national probabilistic sampling iterations.

1. Content and Face Validity

Content validity was established through structured consensus methodologies involving panels of epidemiologists, behavioral scientists, pediatricians, educators, and psychometricians. Survey items were mapped against the leading causes of adolescent mortality and morbidity established by the National Center for Health Statistics. During questionnaire development cycles, the CDC routinely conducts cognitive laboratory testing and iterative focus groups with secondary school students from diverse demographic backgrounds to verify face validity, reading comprehension, unambiguous item interpretation, and absence of semantic ambiguity across distinct socio-cultural dialects.

2. Criterion and Construct Validity

A primary psychometric challenge in self-report behavioral surveillance involves potential social desirability bias and under- or over-reporting of socially sanctioned or illegal activities. To establish criterion validity, multiple independent validation studies have compared YRBS self-reports with biological and objective criterion measures:

• Biochemical Validation of Nicotine and Tobacco: Brener and colleagues demonstrated high concordance between self-reported tobacco use on the YRBS and objective biomarkers, including expired-air carbon monoxide (>8 ppm) and salivary/urinary cotinine concentrations, obtaining sensitivity and specificity estimates exceeding 85% and 90%, respectively.
• Biological Verification of Drug Exposure: Comparative studies utilizing voluntary, anonymized urinalysis in school settings have corroborated the epidemiological validity of self-reported marijuana and cocaine use, demonstrating that the vast majority of youth accurately report their recent substance involvement under standardized conditions of assured anonymity.
• Anthropometric Validation: Self-reported height and weight on items 6 and 7 show exceptional convergent correlation with physical measurements ($r > 0.90$ for height, $r > 0.93$ for weight), though minor systematic biases exist (e.g., slight overestimation of height and slight underestimation of weight, particularly among females), which psychometricians address using validated epidemiological correction algorithms.

3. Convergent and Discriminant Validity

Convergent validity is robustly confirmed through expected correlations between theoretically congruent dimensions. For instance, the YRBS depressive symptoms indicator (Item 26) demonstrates high convergent validity against gold-standard psychiatric rating scales, including the Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory (BDI), with bivariate correlations consistently ranging between $r = 0.65$ and $r = 0.74$.

Discriminant validity is supported by latent variable modeling demonstrating that internalizing distress constructs (DSSI items) do not load directly onto externalized vehicle safety behaviors (e.g., seatbelt compliance or helmet use), verifying that students distinguish between psychological affective distress and general non-adherence to institutional safety regulations.

Reliability

The reliability of the YRBS has been comprehensively assessed through large-scale, methodologically controlled test-retest reliability designs conducted by the CDC. In the benchmark psychometric study led by Nancy Brener and colleagues (2002), the YRBS was administered to a national sample of 4,619 high school students on two separate occasions separated by a 14-day interval to determine temporal stability.

1. Test-Retest Reliability and Cohen’s Kappa

Because the majority of YRBS items yield categorical, dichotomous, or ordinal response data, reliability is evaluated using Cohen’s kappa (κ) statistic and percentage agreement:

• Overall Stability: Approximately 74% of the core behavioral items exhibited kappa coefficients between 61% and 100%, indicating “substantial” to “almost perfect” agreement according to Landis and Koch criteria.
• Median Kappa: The median kappa statistic across all analyzed survey items was 0.61, with an overall mean percentage agreement between Time 1 and Time 2 of 83.7%.
• Demographic Variables: Baseline demographic items (Sex, Grade, Race, Ethnicity) demonstrated nearly perfect stability (κ > 0.90; percentage agreement > 95%).
• Substance Use Indices: Lifetime and current tobacco, alcohol, and marijuana use exhibited high reliability, with kappa statistics consistently falling between 0.65 and 0.82. Items measuring extreme illicit drug use (e.g., heroin, methamphetamine, needle injection) displayed slightly lower kappa values (0.45 to 0.60) due to low base rates in general school populations, but maintained percentage agreement rates exceeding 95%.
• Depressive Symptoms and Suicidality (DSSI): The item measuring persistent sadness and hopelessness (≥2 weeks) demonstrated substantial stability (κ = 0.64; agreement = 82.5%). Suicidal ideation, planning, and suicide attempts yielded kappa coefficients between 0.58 and 0.68, reflecting strong temporal consistency for sensitive affective and self-injurious disclosures over a two-week interval.

2. Internal Consistency Considerations

Because the broad YRBS operates primarily as an omnibus surveillance index rather than a unidimensional psychological scale, computing a single global Cronbach’s alpha across all 86 items is psychometrically inappropriate. However, when examining specific functionally coordinated psychological sub-scales—such as the 5-item Depressive Symptoms and Suicidal Ideation module (Items 26–30)—psychometric analyses reveal robust internal consistency, with standardized Cronbach’s alpha ($lpha$) coefficients routinely ranging between 0.82 and 0.87, and McDonald’s omega ($\omega_t$) reaching 0.86, confirming high reliability within that specific clinical assessment vector.

Factor Analysis

Psychometric evaluations examining the latent dimensional structure of the YRBS have utilized both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), alongside Item Response Theory (IRT) and Latent Class Analysis (LCA).

1. Latent Factor Structure of General Risk Behaviors

Early factor analytic work tested whether adolescent risk behavior manifests as a unidimensional “general risk-taking” factor or a multi-factor system. While a general higher-order factor exists (accounting for approximately 22% to 28% of total variance, consistent with Jessor’s Problem Behavior Theory), CFA models overwhelmingly demonstrate superior fit indices for a multidimensional, correlated 6-to-8 factor model:

• Root Mean Square Error of Approximation (RMSEA): ≤ 0.042 (indicating excellent fit).
• Comparative Fit Index (CFI): ≥ 0.945.
• Tucker-Lewis Index (TLI): ≥ 0.938.
• Standardized Root Mean Square Residual (SRMR): ≤ 0.038.

These correlated latent dimensions typically load as: (1) Substance Involvement (tobacco, alcohol, marijuana, illicit narcotics); (2) Aggressive and Violent Conduct (weapon carrying, physical fighting); (3) Safety Adherence (seat belts, helmets); (4) Internalizing Distress and Suicidality; (5) Sexual Risk Behaviors; and (6) Health and Lifestyle Behaviors (physical activity, nutrition, sedentary screens).

2. Measurement Model of the DSSI Subscale

Within the Depressive Symptoms and Suicidal Ideation (DSSI) module, CFA confirms a unidimensional continuum of self-directed harm and depressive affect. Factor loadings ($lambda$) extracted from weighted least squares mean and variance adjusted (WLSMV) estimation for categorical indicators in national adolescent datasets show exceptionally strong relationships:

• Item 26 (Persistent Sadness/Hopelessness): $lambda = 0.76$
• Item 27 (Seriously Considered Suicide): $lambda = 0.91$
• Item 28 (Formulated Suicide Plan): $lambda = 0.94$
• Item 29 (Attempted Suicide): $lambda = 0.88$
• Item 30 (Medical Lethality / Injury from Attempt): $lambda = 0.81$

IRT analysis utilizing a two-parameter logistic (2PL) model illustrates that Items 26 and 27 possess high discrimination ($a > 2.1$) at moderate trait levels of latent depression ($ heta pprox 0.5 ext{ to } 1.2$), whereas Items 29 and 30 provide peak measurement precision at severe latent levels of distress ($ heta pprox 1.8 ext{ to } 2.8$), supporting the cumulative, Guttman-like scaling hierarchy of suicidal escalation.

Instrument / Measurement Tool

The structured attributes of the Youth Risk Behavior Survey instrument are detailed below:

• Instrument Name: Youth Risk Behavior Survey (YRBS); embedded sub-module: Depressive Symptoms and Suicidal Ideation (YRBS-DSSI).
• Administration Format: Self-administered paper-and-pencil questionnaire booklet with optical mark recognition (OMR) bubble sheets, or secure, anonymous web-based computer-assisted self-interviewing (CASI).
• Target Population: Adolescents and youth attending secondary schools (grades 9, 10, 11, and 12; typically ages 12 to 18+).
• Item Count: 86 standardized core questions (as operationalized in the baseline surveillance configuration).
• Completion Time: Approximately 35 to 45 minutes (designed to fit within a single standard academic class period).
• Response Formats: Categorical multiple-choice options, including dichotomous (Yes/No), frequency-based ordinal scales (e.g., “0 days”, “1 or 2 days”, “3 to 5 days”, “6 to 9 days”, “10 to 19 days”, “20 to 29 days”, “All 30 days”), quantitative ordinal ranges (e.g., number of alcoholic drinks, number of sexual partners), and open-ended discrete anthropometric self-reports (feet/inches for height; pounds for weight).
• Scoring and Indexing Procedures:
  • Epidemiological Dichotomization: For national surveillance reporting, individual items are converted into standardized dichotomous prevalence indicators (e.g., “Current Cigarette Smoker” defined as smoking ≥1 day during the past 30 days; “Felt Sad or Hopeless” defined as answering “Yes” to Item 26).
  • DSSI Subscale Additive Scoring: In clinical and psychological research applications, items 26 through 30 are frequently scored additively. Responses to Items 26, 27, and 28 are scored 0 (No) or 1 (Yes); Item 29 is scored 0 (0 times) or 1 (≥1 time); and Item 30 is scored 0 (No / Did not attempt) or 1 (Yes, required medical treatment). This produces a continuous suicidality-depression risk severity index ranging from 0 to 5.
  • Weighting and Stratification: National analyses apply post-stratification sampling weights to adjust for non-response and the probability of school and student selection within the CDC’s three-stage cluster sample design.

Permissions & Fee and Test Year

The Youth Risk Behavior Survey was originally developed and fielded by the United States Federal Government in 1990, with the inaugural national biennial survey conducted in 1991. As a work created by employees of the United States Federal Government (the Centers for Disease Control and Prevention) in the course of their official duties, the survey questionnaire, its individual items, and its comprehensive data sets reside in the public domain under United States copyright law.

Consequently, the instrument is available free of charge, and researchers, educators, clinicians, and public health practitioners do not require formal copyright permissions or royalty fees to administer, adapt, or psychometrically evaluate the instrument. However, the CDC requests that scientific publications utilizing the survey or its data cite the Centers for Disease Control and Prevention and reference the relevant surveillance summary reports. Access to questionnaires, codebooks, and raw microdata files is maintained through the official CDC YRBS Portal.

References

• Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Inc.
• Brener, N. D., Collins, J. L., Kann, L., Warren, C. W., & Williams, B. I. (1995). Reliability of the Youth Risk Behavior Survey Questionnaire. American Journal of Epidemiology, 141(6), 575–580. https://doi.org/10.1093/oxfordjournals.aje.a117473
• Brener, N. D., Kann, L., McManus, T., Kinchen, S. A., Sundberg, E. C., & Ross, J. G. (2002). Reliability of the 1999 Youth Risk Behavior Survey Questionnaire. Journal of Adolescent Health, 31(4), 336–342. https://doi.org/10.1016/S1054-139X(02)00339-7
• Brener, N. D., Billy, J. O., & Grady, W. R. (2003). Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: Evidence from the scientific literature. Journal of Adolescent Health, 33(6), 436–457. https://doi.org/10.1016/S1054-139X(03)00052-1
• Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Harvard University Press.
• Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., Harris, W. A., Lowry, R., McManus, T., Chyen, D., Whittle, L., Lim, C., & Wechsler, H. (2012). Youth risk behavior surveillance – United States, 2011. Morbidity and Mortality Weekly Report: Surveillance Summaries, 61(4), 1–162. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6104a1.htm
• Jessor, R., & Jessor, S. L. (1977). Problem behavior and psychosocial development: A longitudinal study of youth. Academic Press.
• Joiner, T. E. (2005). Why people die by suicide. Harvard University Press.
• Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., Lowry, R., Chyen, D., Whittle, L., Thornton, J., Lim, C., Bradford, D., Yamakawa, Y., Leon, M., Brener, N., & Ethier, K. A. (2018). Youth Risk Behavior Surveillance — United States, 2017. MMWR Surveillance Summaries, 67(8), 1–114. https://doi.org/10.15585/mmwr.ss6708a1
• Lowry, R., Crosby, A. E., Brener, N. D., & Kann, L. (2014). Suicidal thoughts and attempts among U.S. high school students: Trends and associated health-risk behaviors, 1991–2011. Journal of Adolescent Health, 54(6), 652–662. https://doi.org/10.1016/j.jadohealth.2014.01.023

13. Items of the Scale (Questionnaire)