Assessing suicidal cognitions in adolescents : establishing the reliability and validity of the Suicide Cognitions Scale

Transcription

1 The University of Toledo The University of Toledo Digital Repository Theses and Dissertations 2010 Assessing suicidal cognitions in adolescents : establishing the reliability and validity of the Suicide Cognitions Scale Danette Gibbs The University of Toledo Follow this and additional works at: Recommended Citation Gibbs, Danette, "Assessing suicidal cognitions in adolescents : establishing the reliability and validity of the Suicide Cognitions Scale" (2010). Theses and Dissertations This Dissertation is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 A Dissertation entitled Assessing Suicidal Cognitions in Adolescents: Establishing the Reliability and Validity of the Suicide Cognitions Scale by Danette Gibbs Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Psychology Joseph Hovey, Ph.D., Committee Chair Michele Knox, Ph.D., Committee Member Kamala London, Ph.D., Committee Member Gregory Meyer, Ph.D., Committee Member Laura Seligman, Ph.D., Committee Member Dr. Patricia Komuniecki, Dean College of Graduate Studies The University of Toledo August 2010

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4 An Abstract of Assessing Suicidal Cognitions in Adolescents: Establishing the Reliability and Validity of the Suicide Cognitions Scale by Danette Gibbs Submitted to the Graduate Faculty in partial fulfillment of the requirements for the Doctor of Philosophy Degree in Psychology The University of Toledo August 2010 Hopelessness has long been identified as one of the strongest psychological predictors of suicidality. However, the construct of hopelessness is diffuse, and measurement of hopelessness as a marker of suicidality is constrained by this limitation. Recent advances in cognitive theory (Beck, 1996) and cognitive-behavioral theory as specifically related to suicide (Rudd, Joiner, & Rajab, 2001) led to the development of a new measure of suicide-specific hopelessness, the Suicide Cognitions Scale (SCS; Rudd, 2004). Although recent studies have shown the SCS to be a valid and reliable measure for use with adults (e.g., Rudd et al., 2010), the current study is the first to look at the psychometric properties of the measure with a uniquely adolescent population. Participants included a clinical sample of adolescents ages 13 to 18 either in acute inpatient or a partial hospitalization program (n = 90) as well as a nonclinical sample (n = 88). Internal consistency of the measure was examined. Construct and criterion validity were explored utilizing self-report measures of depression, anxiety, hopelessness, iii

5 suicidal ideation, suicidal behaviors, an Implicit Association Test of suicidality, and data obtained from patients medical records. An exploratory factor analysis was conducted to evaluate the underlying factor structure of the measure, particularly in comparison with previous findings in adult samples. The observed factor structure varied slightly from the factor structure found in previous adult samples. The SCS demonstrated excellent reliability and validity within the adolescent sample, as well as improvement over the Beck Hopelessness Scale in explaining the variance in suicidal thoughts and behaviors. Differences between adolescents and adults in suicide-specific hopelessness, the applicability of the measure for this age group, and clinical utility are discussed. iv

6 Acknowledgements This project would not have been possible without the assistance of so many people who generously gave their time, energy, knowledge, and skills. I greatly appreciate the teens who so willingly participated and the numerous staff who graciously assisted me in obtaining the data for this project. I am also indebted to my research assistants who helped with data collection, especially Rima Kanawati, Casey Kovesdi, Chris Keiper, Amanda Johnson, and Jennifer Reinbolt, who each went above and beyond in their contributions. I also want to thank my colleagues at the University of Rochester Medical Center who helped with data management and analysis, as well as provided encouragement and support. I am especially grateful to Dr. Wendi Cross, whose guidance and motivation made completion of this project possible. I also want to thank Dr. Joseph Hovey for being a dedicated advisor over the past eight years. His wisdom, patience, direction, and support have been invaluable. I also appreciate the time and efforts of my committee members who have each contributed to this project and my professional development. Finally, I want to express my deepest appreciation to my friends and family who have stood by me throughout my education. My friends have provided me with listening ears, wise words, and continual laughter helping me to keep perspective. I am especially thankful for my wonderful family whose love and support have sustained me. In particular, I want to express my love and gratitude to my sister whose belief in me has never wavered, and my parents who have sacrificed so much for my success and happiness. I am truly blessed, and truly grateful. v

7 Table of Contents Abstract Acknowledgments Table of Contents List of Tables iii v vi ix I. Introduction 1 A. Risk Factors for Suicide 2 a. Depression 3 b. Problem solving deficits 4 c. Impulsivity 6 d. Conduct Disorder 6 e. Cognitive Distortions 7 f. Hopelessness 8 B. Development of a Model for Understanding Suicide 10 a. Beck s theory of modes 11 b. Cognitive-behavioral theory of suicide 12 c. Suicide cognitions and the suicidal belief system 15 C. Purpose of Study 16 II. Methods 20 A. Participants 20 a. Clinical sample 20 b. Control sample 22 vi

8 c. Sample sub-group differences 24 B. Procedure 25 C. Measures 26 a. Demographic questionnaire 26 b. Reynold s Adolescent Depression Scale 26 c. Multidimensional Anxiety Scale for Children Anxiety Disorders Index 27 d. Beck Hopelessness Scale 28 e. Suicide Cognitions Scale 28 f. Suicidal Ideation Questionnaire 31 g Suicidal Behaviors Questionnaire Revised 32 h. Additional Previous Attempt Items 33 i. Single Category Implicit Association Test Suicide 33 j. Validity Items 38 III. Results 40 A. Descriptive Statistics 40 B. Reliability: Internal Consistency 41 C. Validity 42 a. Construct validity 42 b. Criterion validity 44 c. Factorial validity: principal components analysis 45 IV. Discussion 47 A. Validity of the SCS 47 vii

9 a. Factor analysis clinical sample 47 b. Factor analysis control sample 49 B. Distinguishing Hopelessness, Suicide Cognitions and Suicide Ideation 50 C. Unique Aspects of Suicidality in Adolescents 51 a. Impulsivity 51 b. Helplessness 52 c. Hopelessness and depression 53 D. The SCS and the Suicide Belief System 55 E. Applicability of CBT Model with Adolescents 56 F. Clinical Implications and Future Research 58 G. Limitations 61 References 63 Appendices 96 A. Cover Sheet for Questionnaires 96 B. Additional Demographics for Hospital Participants 97 C. Additional Demographics for PHP Participants 98 D. SCS-Revised 99 E. Additional Items Added to SBQ-R 101 F. Validity Items 102 viii

10 List of Tables Table 1. Sample distributions for sociodemographic variables for all participants Table 2. Sample distributions for clinical variables for all participants Table 3. Sample distributions for suicidality characteristics of all participants Table 4. Means and standard deviations for study measures Table 5. Means, standard deviations and item-total correlations for items on the SCS-R for control, high school, and clinical samples Table 6. Correlation matrix for control sample Table 7. Correlation matrix for high school sample Table 8. Correlation matrix for clinical sample Table 9. Partial correlations for clinical sample Table 10. Partial correlations for control sample Table 11. Partial correlations for high school sample Table 12. T-tests for clinical vs. control groups Table 13. T-tests for ideators vs. attempters Table 14. T-tests for self-reported potential for future attempt Table 15. T-tests for single vs. multiple attempters Table 16. T-tests for SIQ cutoff of 41 points or greater or 3 or more critical items endorsed Table 17. T-tests for SBQ-R cutoff of 8 points or above Table 18. T-tests for reason for admission Table 19. Principal components analysis of the SCS structure matrix ix

11 Table 20. Principal components analysis of the SCS pattern matrix x

12 Chapter One The suicide rate for the United States is an alarming concern for those involved in mental health fields. In 2006, suicide was the 11th leading cause of death across all age groups (Centers for Disease Control and Prevention, 2009). Particularly concerning is the high rate of suicidal behavior among adolescents. In 2006, the death rate by suicide among children ages 10 to 14 was documented to be 1.0 per 100,000, and 7.3 per 100,000 for adolescents ages 15 to 19 (Heron, 2010). Although these numbers may seem small, suicide is the fourth leading cause of death in younger adolescents, and the third leading cause of death in older adolescents, following only accidents and homicide. Furthermore, the rates of suicidal ideation and suicide attempts highlight the extent of the problem in adolescents. According to the 2007 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention (2008), 14.5 percent of adolescents in grades 9 through 12 admitted to having seriously considered suicide in the previous year, with a higher percentage of females reporting ideation than males (18.7% versus 10.3%). Also, 6.9 percent of high school students reported having made at least one suicide attempt within the previous year. Additionally, in a longitudinal study that annually asked boys, starting at age nine, about their experience of suicidal ideation over the past week, a cumulative 45.1 percent of participants reported experiencing suicidal ideation at least once during the annual assessments by age 18 (Kerr, Owen, Pears, & Capaldi, 2008). These rates are alarmingly high and call for efforts toward prevention and provision of treatment. 1

13 The challenge of identifying individuals at risk for suicide and providing adequate prevention and intervention is a task that challenges mental health treatment providers. Although numerous efforts have been made to identify those at risk for suicidal behavior, limited success has been made in providing accurate assessment and focused interventions. Longitudinal studies that have evaluated the use of various measures to predict suicide have demonstrated that even the most commonly used and highly regarded measures for assessing suicidal risk yield a very high number of false-positives that are not acceptable for prediction purposes. One method of identification and intervention proposed has been to identify the cognitive factors specific to those individuals at risk for suicide, and subsequently, to help address those cognitions and their related behaviors in treatment. The present study examined one recently developed measure, the Suicide Cognitions Scale, which was developed based on the cognitive-behavioral theory of suicide and evaluates the hopeless cognitions related to suicidality. Risk Factors for Suicide Prior to looking at the specific theory and measure in question, psychological and cognitive factors commonly associated with suicidality, particularly in adolescents, that have direct relevance to the present study will be reviewed. Although a number of factors (e.g., ethnic identity, gender, family composition, abuse history) have been linked to suicidal behavior, few of these factors are amenable to change, and therefore, assessment and intervention efforts must focus primarily on those internal risk factors that could potentially respond to intervention. There are a number of specific psychological and cognitive vulnerabilities that are commonly regarded as indirect indicators of suicidality. 2

14 Some of the more prominent ones, such as depression, hopelessness, problem-solving deficits, and impulsivity, are reviewed below. Depression. Mental illness, and particularly depression, is often directly related to and responsible for suicidal behavior. Those adolescents currently experiencing a major depressive episode are more likely to experience suicidal ideation and/or make a suicide attempt. In a prospective study of children ages eight to thirteen being seen at an outpatient clinic for depression or other psychiatric reasons, children with MDD or dysthymic disorder were four to five times more likely to later display suicidal ideation and behavior than those with other diagnoses (Kovacs, Goldston, & Gatsonis, 1993). Approximately 85% of those with MDD or dysthymic disorder reported having experienced significant suicidal ideation and 32% reported having attempted suicide by the time they reached late adolescence. The Oregon Adolescent Depression Project, which involved a large communitybased sample of high-school aged adolescents, found that 41% of those adolescents meeting criteria for Major Depressive Disorder (MDD) reported experiencing suicidal ideation, and 21% reported having made a past suicide attempt (Lewinsohn, Rohde, & Seeley, 1998). Furthermore, suicidal ideation was related to experiencing long-lasting, chronic, and recurrent depressive episodes as well as earlier-onset MDD (Lewinsohn, Clarke, Seeley, & Rohde, 1994). Similarly, Brent, Kolko, Allan, and Brown (1990) noted that suicidal, affectively disordered adolescent inpatients had more severe and longer lasting depression as indicated by self-report on the Children s Depression Inventory than did nonsuicidal, affectively disordered inpatients. However, they suggested that this may be due to the greater endorsement of items tapping into cognitive distortion, a construct 3

15 also significantly elevated among suicidal adolescents, rather than overall depression. Comorbidity, externalizing disorders, and double depression were specifically associated with even greater suicidal intent in adolescent inpatients with an affective disorder. Problem solving deficits. Another common feature of suicidal individuals is a deficit in problem solving abilities. Based on his work with hundreds of suicidal individuals, Shneidman (1986) theorized that the suicidal person progressively develops a perceptual state of cognitive constriction, or tunnel vision due to mounting psychological pain and internal and external pressure, which demand some sort of response from the individual. The suicidal individual becomes increasingly unable to think of viable alternative solutions to the mounting perceived problems, until suicide becomes the only perceived alternative left. Numerous studies have demonstrated the role of cognitive constriction or cognitive rigidity in suicidal ideation and suicidal behavior (e.g., Patsiokas, Clum, & Luscomb, 1979; Perrah & Wichman, 1987; Schotte & Clum, 1987). Levenson and Neuringer (1971) noted that suicidal adolescents performed significantly more poorly on two problem solving tasks than did nonsuicidal psychiatric adolescent patients and normal controls. Although the tasks given were artificial measures of problem solving efficiency (i.e., Rokeach Map Test and the Arithmetic subscale of the WAIS), the authors suggest that the tasks required the same cognitive abilities (i.e., concentration, determining what is important and essential, and cognitive flexibility) as the stressful problems of daily life. They observed that adolescents who had attempted suicide were less flexible in their problem solving approach than nonsuicidal adolescents with mental illness. The authors suggested that poor problem solving 4

16 behavior is an even greater factor in adolescent suicide because of the limited life experiences of adolescents that they can use to identify solutions to problems. In addition to task-related problem solving deficits, some evidence has been found that social problem solving skills are related to suicidality. Schotte and Clum (1982) observed that poor interpersonal problem solving skills in college students mediated the relationship between excessive negative life events and high suicidal intent. Alternatively, Grover et al., (2009) found that among inpatient adolescents, perceived problem solving deficits were predictive of suicidal ideation, but not attempts. Adolescents who experienced high levels of stress only reported significant suicidal ideation when they also reported poor problem solving skills. However, perceived problem solving deficits moderated the relationship between life event stress and attempt status, although this relationship was no longer significant when controlling for depressive symptoms and hopelessness. The findings of Grover and colleagues are consistent with a review conducted by Speckens and Hawton (2005), which found that across twenty-two studies comparing adolescent patients with suicide attempts versus nonpsychiatric or normal controls, social problem solving deficits were related to suicide attempts as compared to the control groups. However, the differences between the groups were generally reduced to nonsignficance once controlling for depression and/or hopelessness. In spite of the demonstrated relevance of problem solving deficits to suicidal behavior, it is uncertain whether these deficits are the result of depression and/or hopeless attitudes that discourage the individual from identifying or carrying out solutions to problems, or if the deficits represent a true lack of divergent thinking skills which are needed to identify 5

17 various solutions, with depression acting as a mediator of the relationship between problem-solving deficits and suicidality. Impulsivity. Closely related to deficits in problem solving, particularly in adolescents, is the construct of impulsivity. It is often assumed that adolescent suicide attempts are more impulsive than attempts by adults; however, few studies have directly examined this assumption. In one of the very few studies directly comparing adolescents and adults in suicidal behavior, Hjelmeland and Groholt (2005) noted that adult attempters reported more precipitating circumstances and problems than did adolescents. Adolescents engaged in suicidal behavior following a lower number of life stressors than do adults, suggesting lower frustration tolerance. Additionally, adolescents reported less premeditation and slightly more impulsivity than adults, although the authors point out that the effect size of this difference was small. Despite the frequent references to impulsivity s role in adolescent suicidality (e.g., American Association of Child and Adolescent Psychiatry, 2001), few studies have looked directly at the relationship between impulsivity and suicidality in this age group. Withers and Kaplan (1987) noted that impulsivity was the second most predominant personality characteristic found among adolescent suicide attempters admitted to psychiatric inpatient treatment, following only depression. In fact, over half of male suicide attempters displayed this trait, with a smaller percentage of females showing elevated impulsivity. Conduct Disorder. The often suggested relationship between adolescent suicidal behavior and impulsivity is likely also inferred from the diagnostic presentations of many suicidal adolescents. Impulsivity is a common factor in disorders such as Bipolar 6

18 Disorder, Borderline Personality Disorder, and Conduct Disorder. In fact, research has indicated that one of the most significant psychiatric risk factors for suicidality in adolescents is a diagnosis of conduct disorder (Hovey & King, 2002). Accordingly, in one study of adolescent inpatients, those adolescents diagnosed with conduct disorder reported significantly greater suicidal thoughts and behaviors on the Kiddie-Schedule for Affective Disorders than did those diagnosed with major depressive disorder (Apter, Bleich, Plutchik, Mendelsohn, & Tyano, 1988). Shafii, Carrigan, Whittinghill, and Derrick (1985) conducted psychological autopsies on 20 adolescent suicide victims, and noted that 70% of these adolescents had displayed antisocial behavior in their past. Cognitive Distortions. Suicidal adolescents also experience significant cognitive distortions that contribute to their suicidality. According to Beck and colleagues theory of depression (Beck, Rush, Shaw, & Emery, 1979), the key feature of depression and thus the primary target of treatment, is cognitive distortions. Beck, Kovacs, and Weissman s (1975) conceptualization of hopelessness and suicidal behavior was also closely tied to cognitive distortions. They asserted that a suicidal individual consistently misinterprets experiences in a negative manner and anticipates failure or negative outcomes as a result of his efforts. In a comparison of suicidal and nonsuicidal adolescent inpatients with an affective disorder, suicidal adolescents were found to have significantly greater amounts of cognitive distortions, despite a lack of differences in hopelessness as measured by the Beck Hopelessness Scale (Brent et al., 1990). Furthermore, the authors noted that those items on the Children s Depression Inventory that distinguished between the suicidal and nonsuicidal adolescents were specifically related to cognitive distortions. 7

19 Attributional style has also been noted to be related to suicidal ideation. Wagner, Rouleau, and Joiner (2000) found that when controlling for depression, children and adolescents attributional style became significantly more positive as suicidal ideation diminished while in inpatient treatment. Thus, the patients no longer consistently blamed themselves for negative events which they believed would continue to reoccur in the future, nor did they continue to consistently attribute positive events to external forces that were unlikely to reoccur. Instead, they were able to view themselves as capable of creating positive change and outcomes in their own lives. Hopelessness. The most prominent characteristic of cognitive distortions related to suicidal behavior is hopelessness. Beck et al. (p. 1146, 1975) defined hopelessness as the desire to escape from what [the individual] considers an insoluble problem. Beck, Steer, Kovacs, and Garrison (1985) proposed that elevated hopelessness may indicate the activation of cognitive schemas of negative expectations, which then have an effect on an individual s confidence in his or her ability to meet goals and have a positive well-being in the future. They suggested that hopelessness is a variable state that manifests itself in predictable but elevated levels in individuals when they are experiencing intense psychological distress or disturbance. Thus, nondepressed individuals may also exhibit elevated levels of hopelessness and related suicidal behavior in the context of intense psychological distress. Hopelessness has repeatedly been shown to mediate the relationship between depression and suicidal behavior in adult clinical samples (e.g., Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck et al., 1975; Rudd, Joiner, & Rajab, 1996). Beck and colleagues (1975) found that both hopelessness, as measured by clinician ratings and a 8

20 self-report measure, and suicidal ideation, were significantly more strongly correlated than depression and suicidal ideation in an adult sample of recent suicide attempters. Furthermore, when controlling for depression, hopelessness continued to correlate significantly with suicidal ideation; however, when controlling for hopelessness, the relationship between ideation and depression was no longer significant, thus indicating that hopelessness is a better predictor of suicidal ideation than is depression. In fact, in this particular study, hopelessness explained 96% of the variance between suicidal intent and depression. In a 10-year longitudinal study of adult psychiatric patients with suicidal ideation, only the Beck Hopelessness Scale was able to distinguish between those who would eventually complete suicide and those who did not, when compared with the Scale for Suicide Ideation and the Beck Depression Inventory (Beck et al., 1985). The pessimism item of the Beck Depression Inventory also was noted to significantly distinguish between completers and noncompleters, indicating the validity of the assessment of hopelessness in determining risk for future suicide among those with suicidal ideation. Findings have been less conclusive in nonclinical samples and adolescent samples (Rudd, Joiner, & Rajab, 2001). Spirito, Williams, Stark, and Hart (1988) found that adolescent suicide attempters report greater levels of hopelessness than do nonsuicidal psychiatric outpatients. In Goldston and colleagues (2001) prospective study of adolescents released from psychiatric hospitalization, hopelessness was one of the strongest predictors of future suicide attempts for those adolescents who had a previous attempt history. However, this association did not remain after controlling for depression. Other studies have also found no relationship between hopelessness and suicidality in 9

21 adolescents (e.g., Rotheram-Borus & Trautman, 1988; Brent et al., 1990). One study found results varied by gender, with high school girls demonstrating a modest relationship between hopelessness and suicidality when controlling for depression while no such relationship was observed among boys (Cole, 1989). Likewise, in a comparison of suicidal versus non-suicidal adolescent psychiatric inpatients, a group by gender interaction effect was observed, so that female suicide attempters demonstrated slightly higher levels of hopelessness than did the male suicide attempters and the non-suicidal inpatients of both genders (Spirito, Overholser, & Hart, 1990). These conflicting findings suggest that the role of hopelessness as related to suicide assessment in adolescents should be examined further. Development of a Model for Understanding Suicide In an attempt to integrate information about causes and predictors of suicide and to provide guidelines for effective treatment, several theorists have formulated various models of suicide. One general model that has received a considerable amount of attention in the literature is the diathesis-stress model for suicidality (Clum, Pastiokas, & Luscomb, 1979; Schotte & Clum, 1982). According to this model, the individual has a vulnerability that mediates the relationship between life stress and suicidality. Some examples of vulnerabilities that may lead to suicidal behavior include: psychopathology, cognitive rigidity, social problem-solving deficits, cognitive distortions, or dysfunctional assumptions. When such an individual encounters significant life stressors, his vulnerability makes coping more difficult and may lead him to suicidal behaviors. The diathesis-stress model has served as the foundation for many other theories of suicidality. For example, Abramson and colleagues (2000), proposed a hopelessness 10

22 theory of suicidality. According to this model, an individual with a specific vulnerability of a negative cognitive style is confronted with negative events (the stressor), which leads to hopelessness and subsequent suicidality. Similarly, Bonner and Rich (1987) proposed a predictive model of suicidal behavior that they termed an interactional model. Building on Schotte and Clum s work (1982), they suggested that life stressors and cognitive distortions, coupled with social alienation and deficient adaptive intrapersonal and interpersonal resources could combine to create a path to suicidal behavior. They noted that the combination of life stress and cognitive distortions may initiate the suicidal process because of the individual s resulting inability to adequately cope. With repeated stressors, coping resources are exhausted and the individual resorts to suicidal ideation first as an imagined solution, which soon becomes the seemingly rational means of coping with their desperation. Beck s theory of modes. Although not specific to suicidality, Beck (1996) proposed a general model of psychological distress based in cognitive theory, which would eventually lead to a cognitive-behavioral theory of suicidal behavior. In this update to his original model, Beck focused on the concept of the mode, which is the structural or organizational unit that contains schemas. Modes are "specific suborganizations within the personality organization [that] incorporate the relevant components of the basic systems of personality: cognitive (information processing), affective, behavioral, and motivational" (Beck, 1996, p. 4). An individual has modes for various emotional/psychological states (e.g., a fear mode, a depressed mode, a suicidal mode). When a mode is activated, the four different domains interact with one another in a synchronous manner to respond to external demands and 11

23 internal directives. This idea differs somewhat from earlier versions of cognitive theory, which implied that the various cognitive, affective, and behavioral domains operated in a linear fashion in response to a triggering event. A mode functions as determined by the joint action of the schemas from each of the four domains. The mode is the structural or organizational unit that contains schemas, with each domain of the mode having its own schemas. Schemas are implicit beliefs and memory structures that organize information encoding, retrieval and processing (Beck, 1967). Similar to the diathesis-stress model, Beck s theory purports that schemas are predominantly inactive, although they can be triggered by specific life events. They are developed in the individual early in life, and may be reinforced and strengthened by life experiences. In the depressed and/or suicidal individual, schemas tend to be inflexible and focused on themes of inadequacy, loss, unreliability and lack of nurturance from others, hopelessness, and helplessness (Reinecke & Franklin-Scott, 2005). Thus, individuals with such schemas may have a cognitive vulnerability from early on in life to suicidal behavior. Cognitive-behavioral theory of suicide. Although Beck proposed the existence of a suicidal mode at the time of his expansion of existing cognitive theory, he did not provide details of how this might manifest. Building on Beck's work, Rudd, Joiner, and Rajab (2001) proposed a cognitive-behavioral model of suicidality, which they term the suicidal mode, and which incorporates the cognitive diathesis-stress model as well as other conceptualizations of suicidality. Using the basic premise of the diathesis-stress model, Rudd and colleagues state that an individual is vulnerable to suicidality due to faulty cognitive constructions, which vary with one s psychological disorder. Similar to 12

24 Beck s (1972) cognitive triad of depression, Rudd and colleagues (2001) asserted that the primary means to suicidality is the individual s cognition, or the private maladaptive meanings given to oneself, and one's environment, experiences, and future. Additionally, the individual may have conditional assumptions, rules, or compensatory strategies that have developed as a part of his or her cognitive schema and that combine with the suicidal cognitions to form the suicidal belief system. Once an individual s cognitive schema for suicidality is activated, the rest of the suicidal mode begins to operate. Thus, cognition is the entry point for the suicidal mode. As with all modes, Rudd and colleagues also indicated that the suicidal belief system goes on to interact with the other psychological and biological systems. Although the suicidal belief system is unique to each person, common themes are believed to exist in all individuals, including helplessness, unlovability, and poor distress tolerance, all with an underlying sense of hopelessness. According to Rudd and colleagues (2001), the potentially suicidal individual has predisposing vulnerabilities to suicidality, such as prior suicidal history, psychiatric illness, history of abuse, and/or family history of suicide. Then a trigger for a suicidal crisis presents itself, resulting in an orienting schema that leads the individual into the suicidal mode. Triggers may consist of external events, situations, or circumstances, as well as internal experiences, such as obsessive thoughts, images, or emotions. In the repeat attempter or intermittently suicidal individual, these triggers may have a recurrent precipitant such as interpersonal conflict, or a recurrent theme such as rejection or abandonment. Withers and Kaplan (1987) noted in their chart review of adolescent psychiatric inpatients that suicide attempts were most frequently precipitated by conflict 13

25 with a relative, friend, or significant other. However, job-related problems also precipitated a significant number of suicide attempts among adolescents. In a model of suicidality proposed by the American Association of Child and Adolescent Psychiatry (2001), a stress event is required to lead to changes in mood and suicidal ideation that eventually could lead to suicidal behavior. Whatever the trigger is, something happens that begins the orienting schema which leads the individual into the suicidal cognitions that characterize an active suicidal mode. Once the orienting schema is in place, it activates the four systems of the suicidal mode, starting first with the cognitive system, which then activates and interacts with the behavioral, affective, and physiological components of the mode in a synchronous manner. The cognitive system, or the suicidal belief system, includes the nature of the individual's thoughts about suicide (e.g., specificity, frequency, intensity, duration, and intent), the reasons for the individual's hopelessness that pervade their cognitive triad (i.e., their negative beliefs about the self, their environment, and their future), the conditional rules and assumptions that the client holds about what is necessary for him to experience relief, and the individual's compensatory strategies, or ideas of how to cope with the suicidal thoughts. The affective system of the mode provides for emotional experience and reinforces adaptive behavior through the experience of positive and negative affect. Within the suicidal mode, it is characterized by the combination of emotions that compose the individual's dysphoria, the intensity of the individual's emotional pain, the amount of tolerance the individual has for emotional pain, and whether or not the individual experiences a sense of urgency or immediacy with their dysphoria. The physiological system involves the activation of the individual, including 14

26 such arousal symptoms as agitation, panic, insomnia, decreased attention, and impaired concentration. The behavioral/motivational system of the mode provides for the response of the individual, which is primarily automatically activated, although it can be consciously controlled under certain circumstances. It is characterized by the deathrelated intent of the individual. Thus, this system may include maladaptive coping mechanisms, impulsivity, affect regulation, preparatory or rehearsal behaviors, and attempts. Suicidal cognitions and the suicidal belief system. The triggering events that begin the orienting schema that leads the individual into the suicidal mode cannot always be avoided or altered. However, Rudd and colleagues (2001) cognitive-behavioral theory of suicidality highlights the importance of cognitions, and specifically, the suicidal belief system, as the entry point into the suicidal mode. Therefore, by changing these cognitions, suicidality would theoretically be reduced or avoided altogether. Cognitivebehavioral therapy has been well-documented as a means of addressing and modifying maladaptive cognitions that contribute to distress and psychopathology. Much work has been done to identify the specific cognitions associated with depression, which are subsequently targeted in therapy. However, although many previously mentioned studies have noted the relationship between cognitive distortions, general hopelessness, and suicidality, current efforts at suicide intervention would benefit from identifying the specific cognitions associated with suicidality. These distortions should be a target of assessment and treatment in order to remove suicidal behavior as a perceived method of coping with stressful life events and to end the progression through and reinforcement of the suicidal mode. 15

27 Beck (1996) first proposed the categories of helplessness and unlovability as core beliefs that were present across the various parts of the cognitive triad of depression. Rudd and colleagues (2001) incorporated these categories into their conceptualization of the suicidal belief system in actively suicidal individuals, adding the concept of poor distress tolerance. These three core beliefs are all characterized by pervasive hopelessness, which is described by Rudd and colleagues as the core feature of an active suicidal mode. Building on this conceptualization of the suicidal belief system and centering on the idea of suicide-specific hopelessness, Rudd (2004) endeavored to identify specific suicide cognitions, which are the beliefs or ideas related to suicidality that go through an individual s mind and which are based on one or more of these core beliefs. Suicide cognitions are marked by the hopelessness that is characteristic of those in a suicidal state, including both acute and chronic features (Rudd et al., 2010, p. 5). Suicide cognitions differ from suicidal ideation in that suicidal ideation may also include thoughts about planning, etc. Suicide cognitions are also distinct from general hopelessness in that they are definitively related to suicidality. Purpose of Study Although many risk factors for suicidal behavior have been identified, it has been virtually impossible to accurately predict who will attempt or commit suicide. While prediction may not be an attainable goal at this time, assessments of suicidal behavior, and even more importantly, suicidal cognitions, do serve an important role in the assessment and treatment of the potentially suicidal individual. Determining the nature of 16

28 the individual s suicidal thoughts and related cognitive distortions and vulnerabilities assists the practitioner in shaping treatment to target these specific factors. Recognizing the importance of cognitions as a determinant for an individual s eventual suicidal behavior, Rudd (2004) developed the Suicide Cognitions Scale (SCS) to more adequately assess suicidal thought and predict suicidal behavior than measures previously used with clinical populations. Rather than assessing general hopelessness, the SCS looks at hopelessness themes characteristic of suicidal thought and behavior as outlined by the aforementioned core beliefs of the suicidal belief system. Items included in the SCS are based on statements made by suicidal individuals in journals, suicide notes, and interviews. Rudd (2004) suggested that the SCS is a useful measure for understanding and assessing the cognitive aspect of the suicide mode. Additionally, he stated that it contributes something unique from hopelessness as well as provides a means of examining motivations for suicidality. Furthermore, the SCS could potentially be useful for monitoring treatment progress as well as measuring treatment outcome. The SCS has demonstrated excellent statistical properties in college student and adult samples (Hovey et al., 2005; Rudd, 2004; Rudd et al., 2010) and holds noteworthy promise for use in treatment of and research with adults; however, it is unclear if this measure will also be useful with an adolescent population. Furthermore, Rudd and colleagues' model of the suicidal mode also has not been examined with adolescents. While this model may be useful with adults, it may be that adolescents require a distinct model for explaining suicidal behavior more suited to their developmental level and the unique characteristics of suicidality in adolescents. Indeed, a recent meta-analysis of the role of cognitive-behavioral therapies (CBT) in reducing suicidal thoughts and behaviors 17

29 found CBT to be an effective treatment for adults, but this treatment modality did not reveal significant treatment effects for suicidal adolescent patients (Tarrier, Taylor, & Gooding, 2008). This finding suggests that adolescents and adults experience of suicidal thoughts and/or behaviors may differ in significant ways that could potentially make the cognitive-behavioral model of suicidality less relevant to adolescents. Although adolescents and adults who have made a suicidal gesture have been found to be similar in levels of suicidal intent and depression, they differ in level of impulsivity and number of precipitating stressors leading to a suicide attempt (Hjelmeland & Groholt, 2005). The differences in adolescent suicidality may be the result of adolescents relative cognitive immaturity and less life experience in enduring difficulties. The limited amount of time spent thinking about and preparing for suicide, as well as the low distress tolerance exhibited by adolescents who display suicidal behaviors as a response to stressors, suggest that suicidal cognitions may not play a significant role in their suicidal behavior. On the other hand, it may be that suicidal cognitions are similar in both adolescents and adults, but that they are experienced for briefer periods of time in adolescents. Furthermore, the previously cited conflicting findings regarding the manifestation of hopelessness in adolescent suicidality suggest that suicidal cognitions may be less relevant to the understanding and treatment of suicidal behavior in this age group. Based on these observations we must question whether or not Rudd and colleagues cognitive-behavioral model of suicidal behavior, and more specifically, the concept of suicidal cognitions can be applied to an adolescent population. Therefore, the purpose of the present study is to examine the applicability of this construct of suicidal cognitions to an adolescent population, as measured by the Suicide 18

30 Cognitions Scale. Specifically, the construct and predictive validity of the measure will be examined through the use of other commonly used measures of hopelessness, suicidal ideation, suicidal behaviors, and an implicit measure of suicidality. Additionally, convergent and discriminant validity will be examined through associations with measures of constructs that are typically correlated with suicidality (i.e., depression, anxiety). Criterion validity will be examined through the use of medical records and selfreports of suicidal behavior. It is expected that the SCS will be significantly related to other extrinsic measures of suicidality, weakly related to an implicit measure of suicidality, and moderately related to other predictors. As found in adult samples, it is believed that the SCS will surpass a measure of general hopelessness in discriminating between suicide attempters and non-attempters. Furthermore, it is hypothesized that the SCS will contribute unique information in accounting for variance in suicidality as measured by other self-report suicidality measures when controlling for the predictor variables of depression and hopelessness. Also, the internal consistency reliability of the SCS will be examined and the factor structure of the measure will be explored. It is believed that the SCS will demonstrate adequate reliability and validity, and will provide evidence that suicidal cognitions are relevant to an adolescent population. This information will also allow us to begin determining if the suicidal mode and Rudd s conceptualization of suicidal behavior allow for changes across development. 19

31 Chapter Two Methods Participants A total of 183 participants were enrolled in the study. A control sample of 88 junior and senior high school students as well as a clinical sample of 95 adolescents admitted to a psychiatric inpatient unit or partial hospitalization program participated in the study. General exclusion criteria involved inability to adequately read or comprehend the study questionnaires, active and severe psychosis that would interfere with a participants ability to focus on and answer questionnaires in a reliable manner as deemed by hospital staff, and mental retardation. Participants ranged in age from 13 to 18 years. Demographics of the total sample and the various sub-groups can be seen in Table 1. Clinical sample. The clinical sample of 95 participants was obtained from two separate sites. Inpatient adolescents from the Adolescent Psychiatry unit at the University of Toledo Medical Center (n = 42) completed questionnaires during their hospitalization. Parents or legal guardians were first approached to obtain consent during one of the family meetings. Adolescents provided assent either along with their guardian during the family meeting, or afterwards while on the unit. Adolescents were given the opportunity to refuse participation after their guardians were no longer present, so as to minimize pressure adolescents might feel to participate. Whenever possible, patients completed study measures immediately following giving consent and assent. When this was not possible, patients were assessed on a subsequent day of their admission. Although presence of a reading disorder could not be reliably assessed, patients were asked to read 20

32 a portion of the directions out loud to the examiner in order to discern if the patient had significant difficulties with reading. A second group of clinical participants (n = 53) was obtained from the University of Rochester Medical Center Partial Hospitalization Program in Rochester, New York. Adolescents being screened during an intake appointment with their guardians were approached for consent and assent at the end of their appointment. When this was not possible, the guardian and adolescent were approached after admission, either when the adolescent was being dropped off or picked up from the program, or during a family meeting. Adolescents were most often assessed on the second, third, or fourth day following admission. Participants from both clinical sites were entered into a drawing for various prizes including gift cards and movie tickets. Four participants from the clinical sample withdrew their participation prior to or during completion of study questionnaires. A fifth clinical participant was removed from the sample due to having a higher than acceptable number of invalid responses (4 out of 7 potential items) on the validity items integrated into study questionnaires. Thus, the resulting total clinical sample included in analyses was 90 participants. Sample characteristics are listed in Table 1. The clinical sample included 57 females (63%) and 33 males (37%). The mean age was 15.4 (SD = 1.38), with an age range of 13 to 18 years. T-tests and chi-square analyses indicated that there was no difference between the two clinical groups in gender, age, and ethnicity. Clinically relevant and suicide-specific characteristics of participants are listed in Tables 2 and 3, respectively. Twenty-three participants (26%) were admitted for a selfharm attempt, which was broadly defined to include non-suicidal self-injury behaviors 21

33 (i.e., cutting), while 40 participants (44%) were admitted for the threat of self harm. A significantly greater proportion of participants from the inpatient sample were admitted for threat of self-harm or self-harm attempt as opposed to the PHP sample (χ 2 (1, n = 86) = 7.06, p =.008). Some patients were admitted for being both a threat to self and others, and therefore the cumulative percentage of reason for admission in Table 2 is greater than 100 percent. Data were not obtained from four participants (4%) from the partial hospitalization program regarding reasons for admission, as this information was not readily available in the patients charts. The vast majority of participants (62%) had been diagnosed with a mood disorder (e.g., Major Depressive Disorder, Mood Disorder NOS, Bipolar Disorder) as their primary discharge diagnosis. The number of participants with any mood disorder diagnosis on record did not differ significantly between the two clinical samples (χ 2 (1, n = 84) =.70, p =.40). However, significant differences were found in the primary discharge diagnoses of patients in the inpatient sample versus the PHP sample, even after removing those with missing data from the analysis (χ 2 (5, n = 84) = 12.88, p =.03). A greater number of PHP participants had a primary diagnosis of an anxiety disorder, whereas a mood disorder or depression was more often the primary diagnosis of inpatient participants. Control sample. A non-clinical sample of 88 junior high and high school students was obtained from three different locations. The control sample included 47 females (53%) and 41 males (47%). The mean age of control group participants was (SD = 1.56). The majority of the sample was obtained from a rural public high school in Northwest Ohio (n = 58). The goals and procedures of the study were explained 22

34 to all students attending a study hall period, and interested students were given consent and assent forms to be signed by their legal guardian. Those students who brought back completed consent and assent forms were assessed during study hall over the following two weeks. Like the clinical sample, participants were entered into a drawing for their participation. In an effort to involve adolescents younger than high school age, potential participants were also contacted through a summer day camp in Toledo, Ohio, which included seventh and eighth grade students. The study was explained to adolescents during the camp day, and guardians were approached for consent when dropping off or picking up their children from camp. All camp participants (n = 4) were given five dollars each for their participation. Few younger participants were obtained through the camp data collection, therefore a convenience sample (n = 26) was obtained through the youth group of a suburban church outside of Toledo, Ohio. These students were also entered into a drawing for movie tickets for their participation. Among control group participants, 67 adolescents (76%) reported no current or prior involvement in mental health treatment of any kind. Six participants (7%) reported currently being involved in some sort of mental health treatment, while five participants (6%) reported inpatient treatment at some point in their lifetime for mental health issues. Seventeen participants (19%) reported having been involved in some type of outpatient treatment for mental health reasons during their lifetime. Outpatient treatment was broadly defined to include both psychopharmacology and psychotherapeutic interventions. 23