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Prof Psychol Res Pr. Author manuscript; available in PMC 2019 August 01.
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Published in final edited form as:

Prof Psychol Res Pr. 2018 August ; 49(4): 274–281. doi:10.1037/pro0000200.

Parental Validation and Invalidation Predict Adolescent Self-

Harm
Molly Adrian1,2, Michele S. Berk3, Kathryn Korslund4, Kathryn Whitlock2, Elizabeth
McCauley1,2,4, and Marsha Linehan4
1University of Washington, Department of Psychiatry and Behavioral Sciences
2Seattle Children’s Research Institute, Center for Child Health, Behavior, and Development
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3Stanford University, Department of Psychiatry and Behavioral Sciences

4University of Washington, Department of Psychology

Abstract
This study was designed to evaluate family processes theoretically implicated in the onset and
maintenance of adolescent self-harm. In the present study, we focus on understanding parental
validation and invalidation in response to their adolescent in order to estimate the association
between parental responses and self-harm in a high risk group of adolescents. We also sought to
determine the influence of psychotherapy on parental validation and invalidation over time during
participation in a randomized clinical trial of psychotherapy designed to reduce self-harm. Thirty-
eight teens (Mage= 14.85; 94.1% female, 55.3% Caucasian, and 17.5% Latino) and their parents
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participated in three assessments over a six month period corresponding to pretreatment,

midtreatment and end of treatment in the trial. Results indicate a robust association between
parental validation, invalidation and adolescent self-harm. There were no significant associations
observed between parental validation, invalidation, and adolescent suicidal ideation. Observed
levels of parental validation and invalidation were not changed during the six-month course of
psychotherapy.

Keywords
Self-harm; parental validation; parent-child interactions; adolescent psychotherapy

Suicide is a leading cause of death among individuals between the ages of 10 and 34 in the
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United States (Curtin, Warner & Hedegaard, 2016). Rates of suicide increase exponentially
from childhood into adolescence and have increased over the past 20 years (Curtin, Warner
& Hedegaard, 2016). Prior self-harm, including suicide attempts (SA) and non-suicidal self-
injury (NSSI), is a reliable predictor for future self-harm (Asarnow et al., 2011; Klonsky,
May, & Glenn, 2013). Despite this substantial impact of self-harm behaviors on families,
healthcare systems, and communities, research to date has not established proven strategies
to lower the rates of suicide (Curtin et al., 2016). Given these data, self-harm is a formidable

Corresponding Author: Molly Adrian, Ph.D., University of Washington, Department of Psychiatry and Behavioral Sciences, 6200 NE
74th St., Ste. 110, Seattle, WA 98115, 206-221-1689 (phone), 206-987-2246 (fax), adriam@uw.edu.
 Adrian et al. Page 2

threat to adolescent wellbeing. Attention to the family processes that are theoretically linked
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to the development and maintenance of adolescent self-harm is an important research

priority.

Family Processes are Associated with Self-Harm

Contextual family processes studied in relation to self-harm have included family history of
suicide, abuse and neglect, family dysfunction/conflict, and poor parent-child
communication (for a review, see Bridge, Goldstein & Brent, 2006). A prominent theory in
understanding the development of self-harm is the biosocial theory (Linehan, 1993).
According to the biosocial theory (Linehan, 1993), severe and persistent difficulty regulating
emotions is seen as the primary contributing factor related to self-harm. Difficulty regulating
emotion is thought to develop in childhood based on the transaction between a biological
predisposition to emotional reactivity on the part of the child, and an invalidating
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interpersonal environment. The invalidating environment is defined as one in which

communication of emotion is met with caregiver responses that are inconsistent,
inappropriate to the emotion expressed, and/or minimize the significance of the emotional
experience. As a result, the child, who is already prone to strong emotional reactions, does
not develop adequate emotion regulation skills as opportunities for co-regulation and
teaching emotional de-escalation are missed. In this model, the function of self-harm is to
manage severe emotion dysregulation in the absence of more constructive coping strategies
(e.g., Adrian et al., 2011). Within this paradigm, adolescents who experience invalidating
responses from the environment may also respond by escalating emotions and behaviors in
an attempt to be taken more seriously, creating a coercive cycle of interactions that fuel
emotional reactivity and self-harm (Crowell, Beauchaine, & Linehan, 2009). If the
association between invalidation and self-harm was empirically supported, then reduction of
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parental invalidation would be a logical target for change in parent-adolescent interactions to

reduce self-harm.

Data Supporting Biosocial Theory of Self-Harm

A small body of experimental and developmental research supports the core components of
the biosocial theory. Not surprisingly, poor quality family relationships have been
investigated broadly in relation to self-harm (Garber, Little, Hilsman, & Weaver, 1998;
Johnson et al., 2002). There is growing evidence suggesting that negative family processes
may play a role in self-harm. For example, Wedig and Nock (2007) found that high levels of
parental expressed emotion, including criticism and emotional over-involvement, were
associated with the presence and frequency of adolescent self-harm. Moreover, the authors
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found that parental criticism interacted with self-criticism to predict the highest rates of self-
harm (Wedig & Nock, 2007). Crowell and colleagues (2008, 2013) conducted a series of
studies that utilized an observational coding system to understand parent-teen interactions
among teens with and without a history of self-harm. The authors reported that families of
self-injuring adolescents demonstrated less positive affect, more negative affect, and lower
cohesiveness compared to non-injuring controls (Crowell et al., 2008). Shenk and Fruzzetti
(2011) randomly assigned groups of college age women to receive validating versus
invalidating responses, and found distinct trajectories of emotional reactivity across both

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subjective and physiological measures consistent with the notion that invalidation impacts
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emotional reactivity (Linehan, 1993). On average, participants in the invalidating condition

had significantly higher levels of negative affect, heart rate, and skin conductance when
compared to individuals in the validating condition. The effect of invalidating responses on
emotional reactivity was evident in analyses comparing both between-group differences in
emotional reactivity as well as within-group change relative to baseline (Shenk & Fruzzetti,
2011). This pattern indicates that, on average, invalidating responses increased emotional
reactivity during a stressful situation. Increased emotional reactivity resulting from
invalidating responses may make regulation of such reactivity more difficult, especially for
those individuals with limited emotion regulation skills, and potentiate the use of
problematic behaviors to reduce such reactivity (Brain, Haines, & Williams, 1998; Nock &
Mendes, 2008).
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The Present Study

Based on the biosocial theory (Linehan, 1993), increasing validation and decreasing
invalidation are core therapeutic tasks for treatment of adolescents at risk for self-harm. The
purpose of the present study is to measure parental validation and invalidation, and the
relationship between these constructs and self-harm behaviors, in a sample of youth at high
risk for suicide. Subjects in this study were participants in a larger randomized controlled
trial (RCT) examining the efficacy of Dialectical Behavior Therapy (DBT), as compared to
Individual and Group Supportive Therapy (IGST), for decreasing self-harm (McCauley et
al., in press). To the best of our knowledge, there are no prior studies of parental validation
during adolescent treatment for self-harm. Both treatments used in the RCT, DBT and I/
GST, addressed the adolescent’s experience of validation but had different principles for the
target and methods for intervention. DBT is grounded in balancing acceptance and change
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strategies as a core principle in the treatment with explicit coaching in parental validation
strategies (Miller et al., 2006); whereas I/GST focuses solely on clinician’s validation of the
teen experience as the source of therapeutic action (Cohen et al., 2006). As reported with the
full sample in McCauley and colleagues (in press) and Linehan and colleagues (2016), both
conditions improved in treatment with respect to self-harm, with a significant advantage for
DBT through the end of treatment (6 months), suggesting small but significant effects on
self-harm outcomes.

In the present study, we examined levels of parental validation and invalidation using an
observational coding task developed in prior research on DBT (Fruzzetti, 2010) in order to
maximize ecological validity (Adrian & Berk, 2018). Parents and teens participated in a
family conflict discussion task at three time points corresponding to pre-treatment, mid-
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treatment, and end of treatment during the larger RCT in order to measure validating and
invalidating parental behaviors over time. There were four primary aims related to the
parental behaviors and self-harm. First, we estimated baseline levels of parental validation
and invalidation in this sample of youth at high risk for suicide. Second, we evaluated
changes in validation and invalidation over time. Third, we estimated the association of
baseline observed parental validation and invalidation with self-harm at the end of treatment
(combining NSSI and SA in order to increase power). We hypothesized that lower levels of
parental validation and higher levels of invalidation would be associated with greater self-

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harm. We also sought to evaluate if the association between validation and invalidation was
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significant for suicidal ideation. Because the biosocial theory specifically articulates parental
invalidation affecting self-harm and not suicidal ideation, we hypothesized that the
association between parental invalidation and suicidal ideation would not substantially
impact treatment outcomes and thus not have significant associations between baseline
parental behavior and end of treatment suicidal ideation severity. Finally, we conducted a
preliminary exploration of the trajectory of parental validation and invalidation over the
course of treatment. We hypothesized that parents of adolescents randomized to DBT would
show greater increases in use of validation and decreases in the use of invalidation when
discussing emotionally-evocative events as compared to parents of adolescents randomized
to the I/GST condition due to explicit teaching of validation skills to parents in DBT.

Method
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Participants
Participants included 38 adolescents aged 12–18 who were eligible for study procedures due
to enrollment in a multisite randomized controlled trial evaluating the efficacy of DBT and
IGST in reducing suicidal and self-harm behaviors (Collaborative Adolescent Research on
Emotions and Suicide; see Berk et al., 2014). Inclusion criteria for the larger RCT included
current suicidal ideation, repetitive self-harm, a history of suicide attempt, at least 2
borderline personality disorder features; exclusion criteria included psychotic disorders,
autism spectrum diagnosis, and intellectual disability (McCauley et al., in press). The
subsample, recruited from a single study site, was predominantly females (94.1%) and mean
age was 14.85 years (SD=1.50). Race/ethnicity of participants was identified as follows:
2.6% Asian, 39.5% biracial, 2.6% other race/ethnicity, 55.3% white. Seventeen percent
identified as Hispanic/Latino. Thirteen percent were born outside of the United States. Of
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those approached, 75% agreed to study procedures. Participants received $25 as a thank you
for participating at each assessment.

Materials
Issues checklist.—The modified revealed differences task (Strodtbeck, 1951) is a 44-item
scale that probes the frequency and intensity of the disagreements between parent and
adolescent on a range of issues. The designated parent and adolescent completed this
measure separately and rated the frequency, rated from 1 (never) to 5 (very often), and
intensity, rated between 0 (calm) and 40 (very intense), for each issue listed.

Self-harm.—The primary outcome of interest was self-harm. The Suicide Attempt Self-
Injury Count followed by the Suicide Attempt Self-Injury Interview (Linehan et al., 2006)
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measured the topography, intent, medical severity, social context, and outcomes of self-
harm. Three trained assessors blind to study hypotheses and treatment condition collected
information from the adolescent regarding the spectrum of self-harm behaviors for the six-
month period from the first treatment session to the end of treatment (~6 months). In order
to increase power, we combined SA and NSSI together into a single self-harm variable. This
approach has been used in numerous prior studies on suicidal and self-harm behavior in
adolescents (Hawton et al., 2012, Melhum et al., 2014), due to the high overlap between

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these behaviors, high association of both with subsequent suicide attempts and low base rate
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of suicide attempts in small to medium samples of suicidal youth.

Suicidal ideation.—The Suicide Ideation Questionnaire-Junior (Reynolds, 1988) was

used to measure past-month suicide ideation. Although designed for younger adolescents,
the SIQ-Jr has been widely used with both younger and older adolescents to evaluation
suicide ideation. Use of the SIQ-Jr for all participants allows for measurement to be constant
and minimize both participant burden (15 items) and reading comprehension problems. A
raw score of 31 or above has been empirically established as the clinical cutoff indicating
“potentially significant suicide risk,” with higher scores indicating more persistent suicidal
ideation.

Procedures
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All study procedures were approved by the University of Washington’s Institutional Review
Board. Adolescents and their parents reported on stress and suicidality before and after the
study procedures. Assessors were trained to intervene to reduce suicidality as needed.
Following screening assessment to determine eligibility, adolescents and their parent
completed a comprehensive assessment battery. Youth completed a questionnaire assessing
suicidal ideation and both adolescents and parents completed structured interviews assessing
adolescent self-harm. Teens and parents were next asked to engage in an interaction task.
These procedures were conducted at baseline and repeated at intervals corresponding to
assessments at mid treatment (3 months), and treatment completion (6 months). The
measures used in this sub-study are described below. Following baseline assessment, youth
were randomized to Individual/Group Supportive Therapy (I/GST) or Dialectical Behavior
Therapy (DBT). In this sample, 52.6% (N=20) were assigned to IGST and 47.4% (N=18)
were assigned to DBT.
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Interaction task.—The items that were rated as moderately contentious based on the
modified revealed differences task for the dyad were selected and presented to the dyad as
the topic for the interaction task. Following the selection of the topic for discussion, parent
and teen were asked to discuss the topic as they normally would, with a focus on how to
solve the issue for approximately 10-minutes. The data from the interaction task was coded
for parent validation and invalidation. Validation and invalidation are coded independently as
individuals can demonstrate both validating and invalidating behaviors. Trained research
assistants completed the coding using the Validating & Invalidating Behavior Coding Scale
Manual (Fruzzetti, 2010) by Dr. Fruzzetti as the gold standard for training. The Validating
and Invalidating Behavior Coding Scale is a valid and reliable measure of relationship
functioning, and has been used in prior research (Fruzzetti, 2010; Shenk & Fruzzetti, 2011).
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Coders made ratings of observable behavior moment by moment to yield a global score for
both validation and invalidation. There were seven levels of overall validation and
invalidation for each interaction task, with higher score reflecting higher levels of the
observed behavior. Participants were given global scores of validating and invalidating
behaviors, interclass correlations ranged from .72 for validation to .88 for invalidation,
consistent with the rating observed in the training manual (Fruzzetti, 2010).

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Treatment conditions.—Dialectical Behavior Therapy (DBT) is the most extensively

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studied approach to reduction of both self-harm in adults (Clarkin, Levy, Lenzenweger, &
Kernberg, 2007; Linehan et al., 2002; Linehan, Heard, & Armstrong, 1993; McMain et al.,
2009; van den Bosch, Verheul, Schippers, & van den Brink, 2002). Results for adolescents
have been slower to emerge but have shown promise for DBT as an effective intervention
(Linehan et al., 2016; Mehlum et al., 2016; Miller, Rathus, & Linehan, 2006). As noted
previously, the conceptual model of self-harm in DBT is based on a biosocial model
(Linehan, 1993) whereby biological emotion vulnerability transacts with environmental
invalidation to yield disordered functioning of both the adolescent and the environment.
Adolescents in this condition received standard DBT including individual therapy,
multifamily skills group, telephone coaching, and therapists participated in a weekly
consultation team meeting. In DBT with adolescents, increasing parental validation and
decreasing parental invalidation of teens are key treatment targets (Miller, Rathus &
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Linehan, 2007).

Individual and Group Supportive Therapy (I/GST) is an adaptation of the supportive therapy
treatment manual developed by Brent and his colleagues (Brent et al., 1997), extended by
Judy Cohen (TF CBT Trial), and modified by adding a group component to it match the
provision of group therapy in DBT. Additionally, the treatment included use of protocols to
explicitly target safety and stabilization of suicidal adolescents (See Berk et al., 2014 for
more information). The conceptual model of self-harm utilized in I/GST is that adolescent
self-harm is driven by the experience of feeling isolated, misunderstood, unloved and
unwanted and hence; that a positive relationship with a therapist who provides unconditional
positive regard will provide a corrective experience that reduces the need for self-harm.
I/GST also included a group component in which teens engaged in supportive interactions
with other teens while completing pleasant activities, in order to increase feelings of
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belongingness and acceptance. I/GST utilized a non-directive approach to support the

adolescent’s self-esteem and belief in his/her inherent abilities to solve his/her own
problems. Reduction of self-harm was conceptualized to come by therapeutic interactions
that allowed the adolescent to trust and validate themselves. Up to seven parent-only
sessions were allowed, in order to validate and increase their sense of capability related to
parenting. Because the parent sessions did not explicitly teach or practice the ways in which
parents could validate their adolescent’s experience, we did not expect parental responses
towards their child to change.

Statistical Methods
Baseline parental validation and invalidation scores and their interaction were entered into
(a) a Poisson model predicting self-harm (suicide attempts and non-suicidal self-injury) at
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the end of treatment (6 month assessment) and (b) a linear regression model predicting
suicidal ideation at the end of treatment. When not significant, the interaction term was
removed and model refit to determine statistical significance of validation and invalidation
main effects. Missing baseline parental validation scores (N=8) were replaced with non-
missing 3 month parental validation scores. Sensitivity analyses were conducted to examine
the potential impact of high outlying numbers of self-harm in which (a) reports of >10 acts
were replaced with 10; (b) participants reporting >10 acts were excluded. Similarly, in

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secondary analyses, the linear regression model predicting suicidal ideation was repeated
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with missing suicidal ideation values imputed using the Markov Chain Monte Carlo method
with 10 imputations. This approach has been shown to be superior to listwise deletion
(Sterne et al., 2009). Consistent with recommendations by Cohen, Cohen, West, and Aiken
(2003),continuous predictors were mean centered prior to forming the interaction term.
Significant interactions were probed with simple slopes analysis to examine the strength of
the relationships between independent variable (i.e., validation) and the dependent variables
(i.e., self-harm) at each level of the moderator (invalidation; Dawson, 2014).

To examine the predictive role of time and treatment on parental validation and invalidation,
global ratings of validation and invalidation at baseline, midtreatment, and end of treatment
assessments were examined with linear mixed modeling in R (R. Core Team, 2008) using
the lme4 package (Bates, Maechler, & Bolker, 2013; Raudenbush & Bryk, 2002). Mixed
modeling is flexible in its treatment of time as a continuous factor, allowing for variability in
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the actual time of assessment for each participant. In addition, mixed modeling can
accommodate incomplete data across time making analyses more powerful due to the
inclusion of more data points. All observations at the three timepoints of parental validation
and invalidation were entered. Each equation included time, treatment, and their interaction.
Time measured in days from the start of treatment was modeled using linear and quadratic
terms, allowing for nonlinear change. Time will be modeled as a level 1variable. Treatment
was dummy-variable, coded 0 for DBT and 1 for I/GST, and modeled as a level 2 variable.
The cross-level interactions between Treatment and Time will model treatment differences
in the trajectories across time. The Level 2 variance term models heterogeneity in individual
participant trajectories. This analysis allowed for exploration of the changes in overall
dimension ratings for validation and invalidation across treatment and time.
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Results
Descriptive Statistics
For the 38 teen-parent dyads entering the study, 31 (81.5%) provided follow-up data. Two
participants dropped out of the study, 2 were not able to be located, and 3 chose not to
complete all assessment procedures. Descriptive data for suicidal ideation and self-harm are
reported in Table 1. The data reveal almost ½ of the sample had a self-harm during the
treatment period. Six percent of study participants reported 1 or more suicide attempt and
48.4% reported 1 or more non-suicidal self-injury acts (range 0 to 89) during the six month
treatment period. All individuals who reported suicide attempts also engaged in NSSI. The
mean suicidal ideation score was 36.5 (SD= 26.4) at the end of treatment (6 month
assessment). Mean ratings of observed validation were level 3, showing attentive,
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functionally responding and clarifying validating behaviors. Mean ratings of observed

invalidation were rated at level 3, showing missed opportunities and insisting as most
commonly observed invalidating behaviors. There were no instances of the highest levels of
validation, which matches self-disclosure in the context of another’s vulnerability, nor were
there level 7 invalidating behavior which shows indifference to vulnerability (i.e., not
responding at all to adolescent vulnerability).

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Effects of Observed Parental Behavior on Self-Harm

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Associations of baseline parental validation and invalidation with self-harm and suicidal
ideation at the end of treatment (6 months) are presented in Table 2. The association of
higher levels of baseline parental validation with lower reported numbers of self-harm was
moderated by higher levels of parental invalidation (p<0.0001). Follow-up analyses probed
the two-way interaction between validation and invalidation. At high levels of validation,
high parental invalidation was associated with dramatically higher numbers of self-harm
(mean difference 21.0, 95% CI 6.8 to 64.9; p<.0001). At low levels of validation, the effect
of invalidation on self-harm was attenuated (Figure 1). Suicidal ideation was not
significantly associated with baseline parental validation (p=0.76) or invalidation (p=0.42).
Results were similar in sensitivity analyses conducted to assess potential influence of
outliers and missing values (details available upon request).
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Effects of Treatment Assignment of Validation and Invalidation over Time

Hierarchical mixed effect models were used to estimate the predictive role of time and
treatment on validation and invalidation at baseline, mid-treatment (3 months) and end of
treatment (~6 months). Results of the full model, with predictors are displayed in Table 2.
Neither time, treatment, nor the interaction of time and treatment predicted change in
observed levels of parental validation or invalidation (β=.002, p=.49).

Discussion
Pinpointing predictors of adolescent self-harm is needed to help identify effective methods
of suicide prevention for high-risk youth. The results of the present analyses indicate strong
associations between observed parent validation and invalidation and subsequent self-harm
behaviors. High levels of baseline parental validation interacted with low levels of
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invalidation to predict infrequent self-harm; however, at high levels of invalidation, self-

harm was at its highest frequency. This same set of associations was not revealed with
suicidal ideation, suggesting that parental invalidation may be uniquely predictive of self-
harm. Our results augment Crowell and colleagues’ (2013) study in which microanalytic
coding of parent-teen interactions identified that mothers of self-harming adolescents were
more likely to invalidate, respond aversively, and matched, or escalated, conflict. In fact,
mothers of self-harming teens only deescalated conflict in response to adolescent’s extreme
behavior. Although Crowell and colleagues did not evaluate the association between levels
of validation and invalidation with self-harm, their comparative study highlighted that the
transactions between teens who harm themselves and their parents were significantly
different than dyads without the history of self-harm. Additionally, in a longitudinal
observational study utilizing a community sample of Chinese adolescents, adolescent-
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perceived family invalidation was significantly associated with the occurrence, but not
frequency, of self-harm (You, Leung, Lai, & Fu, 2012). Taken together, these studies suggest
that the interactions between parents and adolescents are nuanced and complex, and
observational methodologies are well suited to answer questions regarding family processes.

Our findings do not provide an explanation of the mechanisms by which invalidation leads
to self-injurious behaviors. As suggested by the biosocial theory, it is likely that parental

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invalidation impedes the development of critical emotion regulation skills and capacities. Of
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note, the unique association of parental invalidation and self-harm behaviors (and lack of
association between parental invalidation and suicidal ideation) may also support the notion
that self-harm may serve an important communication function. That is, given that one
purpose of human emotions is to convey distress to others, if this communication is not
adequately received, the individual may then need to escalate expressions of distress in order
to be “heard” (Crowell et al., 2009).

The findings strengthen the empirical support that the parent-teen interactions affect future
self-harm in vulnerable adolescents. Parental invalidation appears to result in increasing the
intensity of teen’s expression of distress, which may explain the pattern of results holding
for observation behavior but not significantly associated with suicidal ideation. Interestingly,
high parental validation combined with high invalidation predicted the highest number of
self-harm behaviors. These findings highlight the importance of using real interaction tasks
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to measure potentially complex transactions of behaviors between parents and teens versus
self-reports, which may mask these nuances. It is also important to note that high levels of
validation from parents does not compensate for high levels of invalidation, as these
adolescents had the highest number of self-harm events. In fact, high levels of parental
validation in combination with high levels of invalidation may be particularly distressing for
teens, given that the parent is clearly capable of responding in appropriate ways, but does not
do so consistently. This interplay between validation and invalidation is particularly
important as it suggests that invalidation has a particularly pernicious effect on self-harm.
The finding suggest that high levels of invalidation are not compensated by high levels of
validation by parents, and perhaps any parent-teen interactions in the context of extreme
invalidation may be distressing to the adolescent.
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Given the theoretical importance of validation in the treatment of self-harm, the course of
parental validation and invalidation over time was examined to determine the influence of
time, treatment and their interaction during this clinical trial. Each treatment directly
addressed parental validation according to its theoretical premise, however, neither yielded
significant change, highlighting the need to develop additional strategies for change of this
treatment target beyond the psychotherapy approaches studied in the RCT. Of interest, given
that results of the RCT showed improvements in self-harm across conditions, with an
additional advantage for DBT, it also suggests that positive treatment outcomes may not
require changes in parental validation/invalidation as this was not the primary mechanism of
change by which self-harm was reduced in this sample of adolescents. This highlights the
importance of evaluating putative mechanisms of change, and the importance of continuing
to work to improve the treatments that are disseminated for adolescents at risk for self-harm.
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We suspect that changing parent-adolescent interactions may be important for augmenting

treatment response, and addressing the needs of those who do not respond to primarily
individual therapy modalities. Additionally, parent validation may be a treatment target that
required sustained focus, role-played practice, feedback, and significant clinical attention to
change during treatment. Future research will need to be conducted to understand the most
efficient methods of treatment to reduce self-harm; and identify the mechanisms of action.
Future work is needed to determine if improvements in parental validation/invalidation may
further augment positive treatment outcomes, especially given that treatment response rates

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were relatively low across conditions, with only 27% of youth in I/GST and-45% of youth in
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DBT ceased self-harm during treatment (McCauley et al., in press).

This study represents efforts to begin to tackle a modifiable parental behavior theoretically
linked to the development of youth self-harm. The strengths to consider in this study include
the longitudinal, carefully defined group of high risk adolescents, and observational coding
of interactions which add to our confidence in our findings. However, it is important to note
that the study had several limitations that affect its generalizability. The study had a small
sample, combined suicidal and non-suicidal behaviors, relied upon a lab-based observation
task for its assessment of parental behavior, and did not include a non-self-injuring
comparison group. The small number of male participants precluded the evaluation of sex in
analyses. Additionally, due to the low frequency of suicide attempts in the six month period,
we collapsed non-suicidal self-injury and suicide attempts into one group and therefore
could not distinguish unique relationships between parental responses and suicide attempts
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versus NSSI. The study was underpowered to detect group differences in treatment
processes; however, post-hoc analyses indicated that the estimate of effect size on treatment
and time was small, and 3138 participants would have been needed to reach significance.
Consequently, we conclude that insufficient power due to a small sample was not the driving
factor in findings supporting the null hypothesis for our second aim. Finally, given the study
sample and design, the direction of effects is not yet determined. It is plausible that
adolescent self-harm leads a parent to behave in invalidating ways or both parent and teen’s
behaviors be caused by some other factor (e.g., other extreme family stress). Causality and
direction of effects are important next steps in understanding how self-harm and parental
behaviors may be optimally targeted and changed. Given these limitations, it is difficult to
know if these findings generalize to other populations that did not share the characteristics of
the sample. We believe the strengths of this study outweigh the limitations as this is the first
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study to our knowledge to employ an observational, longitudinal assessment of parent-child

interaction patterns with adolescents at high risk for self-harm.

Research focused on family processes affecting self-harm is needed to drive prevention and
intervention of these behaviors during adolescence. Our findings add to a small but growing
literature that suggests that a problematic transaction that minimizes or dismisses emotional
experiences fuels the occurrence and frequency of future self-harm in teens. This study
assessed validation and invalidation over six months of treatment for adolescents at high risk
for suicide, indicating that the interaction of parent validation and invalidation is
significantly and robustly associated with self-harm. Importantly, this association was not
significant when examining suicidal ideation and appears to thus be unique to self-harm
behavior. These results highlight the importance of parental invalidation as a risk factor for
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self-harm behavior in adolescents. The evaluation of change in validation and invalidation

during two treatment interventions specifically designed for high risk for suicide adolescents
did not produce changes in observed validation patterns. It may be that for self-harm directly
targeting emotion regulation skills, as opposed to the contextual factors contributing to
emotional dysregulation, may be sufficient to improve adolescent functioning. It is likely
that focused attention to altering parent’s responses to be more validating towards their
teen’s emotional experience may require explicit targeting, in depth strategies, and sustained
focus throughout the psychotherapy treatment process. Given the robust associations

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 Adrian et al. Page 11

observed we would like to see future work develop brief and useful clinical strategies for
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parent-child interactions if it serves prioritized treatment targets and increases effective

parent-teen interactions.

Acknowledgments
Disclosures/Acknowledgements: Work on this publication was supported American Foundation for Suicide
Prevention, National Institute of Mental Health (NCT01528020; R01MH090159), Agency for Healthcare Research
and Quality (AHRQ K12HS022982), awarded to the first author. Dr. Linehan has disclosures related to royalties
received from DBT training materials. We would like to thank Alan Fruzzetti and Sheila Crowell for their assistance
with the interaction task development and coding.

Biography
MOLLY ADRIAN received her PhD in developmental-clinical psychology from University
of Maine. She is currently an assistant professor at the University of Washington in the
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Division of Child and Adolescent Psychiatry and Behavioral Medicine. Her areas of
professional interest include emotion regulation, etiology and treatment of adolescent
suicide risk behaviors.

MICHELE S. BERK received her Ph.D. in clinical psychology from New York University.
She is currently Assistant Professor and Director of the Adolescent Dialectical Behavior
Therapy Program in the Department of Psychiatry at the Stanford University School of
Medicine. Her areas of professional interest include treatment approaches for adolescents at
risk of suicide.

KATHRYN E KORSLUND received her PhD in clinical psychology from the Medical
College of Pennsylvania at Hahnemann University. She is currently the Clinical Director of
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THIRA Health, LLC in Bellevue, WA. Her areas of professional interest focus on Dialectical
Behavior Therapy (DBT) and include assessment of DBT adherence and DBT training,
consultation and program development.

KATHRYN WHITLOCK received her MS in applied statistics from Purdue University. She
is currently a biostatistician at the Seattle Children’s Research Institute. Her interests are in
complex survey analysis methods and nonlinear modeling for quantitative outcomes.

ELIZABETH MCCAULEY received her PhD in developmental-clinical psychology from

the State University of New York. She is currently a professor and the interim director of the
Division of Child and Adolescent Psychiatry and Behavioral Medicine at the University of
Washington and Seattle Children’s. Her areas of professional interest include differences in
sex development and the prevention of adolescent depression and suicidality.
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MARSHA LINEHAN received her PhD in psychology at Loyola University. She is

currently a professor in the Department of Psychology and the Director of the Behavioral
Research & Therapy Clinics at the University of Washington. Her areas of professional
interest include Dialectical Behavior Therapy and treatment of suicidal behavior.

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 Adrian et al. Page 12

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Public Significance Statement:

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This study found a strong association between parent responses to their adolescents and
subsequent self-harm. Additionally, it showed that two suicide-specific interventions
were not effective in changing parental responses during treatment.
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Figure 1.
The Interaction between Baseline Parental Validation and Invalidation and the Frequency of
Self-Harm at 6-months
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Table 1.

Suicidal Ideation and Self-Harm as Reported by Adolescents at Baseline and 6 months

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Baseline 6 month
N N
Reporting Reporting
Item (%) M SD range (%) M SD range

Suicide Attempts 38 (100) 3.80 10.22 1–55 2 (6.4) 0.12 0.56 0–3
NSSI 38 (100) 34.26 44.30 1–173 15 (48.4) 7.19 19.33 0–89
Suicidal Ideation -- 44.67 24.9 24–90 -- 36.46 26.42 0–90
Observed Validation -- 3.08 1.57 1–6 -- 2.80 1.40 1–6
Observed -- 3.03 1.67 1–6 2.90 1.85 1–6
Invalidation
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Table 2.

Regression Estimates for Validation and Invalidation Predicting Self-Injury Outcomes

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Self-Harm Suicidal Ideation

β (SE) P Value β (SE) P Value

Intercept 12.49 (1.19) <.0001 35.49 (32.69) 0.28

Baseline Validation −4.93 (0.55) <.0001 −4.23 (7.28) 0.56
Baseline Invalidation −2.50 (0.30) <.0001 1.06 (8.09) 0.90
Validation * Invalidation 1.28 (0.14) <.0001 1.13 (2.31) 0.62

Note. Outcomes measured at 6 months. Results remained unchanged when sensitivity analyses were conducted (data available upon request).
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Table 3.

Mixed Effects Model Estimates for Time and Treatment on Validation and Invalidation
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Parameter Validation Invalidation

Fixed Effects (β) β or σ Standard β or σ Standard Error

Estimate Error Estimate

Intercept 3.16** 0.4 2.82** 0.43

Treatment 0.14 0.59 0.32 0.61

Time 0.001 0.003 0.001 0.003
Time × Treatment 0.002 0.004 0.002 0.004

Random Effects (σ)

Within-person variability 0.4 0.63 0.66 0.81
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Note.
**
p > .001
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