Examining Youth Anxiety Symptoms and Suicidal Ideation in the Context of the Tripartite Model of Emotion

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1 DOI /s Examining Youth Anxiety Symptoms and Suicidal Ideation in the Context of the Tripartite Model of Emotion Farrah N. Greene & Bruce F. Chorpita & A. Aukahi Austin # Springer Science + Business Media, LLC 2009 Abstract This study sought to clarify the relation of anxiety symptoms and suicidal ideation in children and adolescents by examining these variables in the context of depression and negative affect. As outlined in the tripartite model of anxiety and depression, negative affectivity is common to both emotional constructs; therefore negative affectivity may best explain the relation of each to suicidal ideation. Self report measures of generalized anxiety, depression, negative affectivity, and suicidal ideation were assessed in a primarily externalizing sample of children ages Results suggested that the relation between anxiety and suicidal ideation was best accounted for by depression, not negative affectivity. Results also suggested that negative affectivity was associated with suicidal ideation but did not account for the relations among anxiety, depression, and suicidal ideation. Further, depression, negative affect, and anxiety all significantly contributed to the prediction of suicidal ideation scores (r 2 =.307, p<.01). Keywords Anxiety. Suicidal thinking. Tripartite model. Negative affectivity. Depression Suicide is the third leading cause of death for youth ages (CDC 2005). Suicidal ideation (SI) is often the precursor to completed or attempted suicide (Brent et al. 1993; F. N. Greene (*) Department of Psychiatry, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39202, USA fgreene@hawaii.edu F. N. Greene : B. F. Chorpita : A. Aukahi Austin University of Hawai i at Manoa, Manoa, USA Lewinsohn et al. 1994; Prinstein et al. 2008), with adolescents having the highest suicide attempt and ideation rates (Ash 2007). In longitudinal studies, suicidal ideation in either childhood (Greening et al. 2008; Herba, Ferdinand, van der Ende, & Verhulst 2007) or adolescence (Fergusson et al. 2005) predicted suicidal ideation and attempt in adulthood. Therefore, it is important to study suicidal ideation itself in childhood and adolescence, as well as important closely associated risk factors, such as psychopathology (Brent et al. 1993) which discriminates between attempters and ideators (Shaffer et al. 2001). Externalizing psychopathology including impulsivity (Apter et al. 1995; Greening et al. 2008) and conduct disorder (CD) is related to future suicidal ideation or behavior (Beautrais et al. 1996; Feldman and Wilson 1997). One study found an indirect impulsivity association with aggression and depressive symptoms as mediators (Greening et al. 2008). Depression and conduct disorder are also interrelated (Fombonne et al. 2001; Harrington et al. 1991; Rapp and Wodarski 1997), such that the International Classification of Diseases includes a category of depressive conduct disorder (World Health Organization (WHO) 1993). Moreover, combining depression with externalizing behavior or SI increases the probability of the third (Langhinrichsen- Rohling et al. 2004). Thus depression seems intimately involved in the association of externalizing symptoms and SI or behavior. Furthermore, evidence exists, which suggests that anxiety precedes depression in development (Seligman and Ollendick 1998), and that anxiety and externalizing disorders co-occur in children (Jarrett and Ollendick 2008; Lahey et al. 2008). Therefore the study of anxiety symptoms and their relation to suicidal ideation is relevant for children with various presentations of psychopathology. Relative to the literature on externalizing syndromes and suicidal ideation and behavior, the literature on internalizing

2 syndromes including anxiety (Esposito and Clum 2002; Pinto and Whisman 1996) and depression (Beck et al. 1985;Joiner and Rudd 1996) seems more substantive. Several studies establish that suicidal thoughts and behaviors are associated with adult anxiety symptoms (Olfson et al. 2000; Weissman et al. 1989), and youth anxiety symptoms (Jackson and Nuttall 2001; Steer et al. 1993) and diagnoses (Esposito and Clum 2002; Strauss et al. 2000). Moreover, in adolescent inpatients anxiety significantly correlates with suicidal ideation after controlling for depression and hopelessness (Pinto and Whisman 1996) and co-morbid generalized anxiety is significantly associated with higher rates of suicidal ideation than depression alone in adults (Zimmerman and Chelminski, 2003). Other research challenges the association between anxiety and suicidality (Brent et al. 1993; Strauss et al. 2000) finding that several anxiety syndromes do not differentiate suicidal and non-suicidal youth (Strauss et al. 2000). Researchers explain the long noted intercorrelations between anxiety and depression (Chorpita et al. 1998; Watson and Clark 1984) using the tripartite model of emotion (Mineka et al. 1998). In this model, (1) negative affectivity (NA) is a stable, highly heritable general trait dimension with a multiplicity of aspects ranging from mood to behavior (Clark et al. 1994, p. 104); (2) physiological hyperarousal (PH) is a somatic anxiety factor that includes feelings of tension and panic; and (3) positive affectivity is a factor related to pleasure and engagement. Depression is related to high levels of NA and low levels of PA, while anxiety is related to high levels of NA (with high levels of PH related to panic). Evidence demonstrates that anxiety and depression share variance with NA (e.g., Chorpita et al. 1998, 2000a; Joiner and Rudd 1996; Lonigan et al. 1994, 2003). Recent examinations suggest that the tripartite model may be more pertinent for older children (Cole et al. 1997) particularly older adolescent girls (Jacques and Mash 2004), highlighting the importance of age and gender factors. While, there is no direct research on the relation between NA and SI, the hypothesized role of NA as an overarching temperamental factor suggests that NA and SI are related. Given the current literature it appears that at least two models can be proposed to explain the relations among the constructs. The first suggests that NA may most parsimoniously explain the association between anxiety and suicidal ideation. The second suggests that depression may explain the relation between anxiety and suicidal ideation. Two studies directly support the second model (Brent et al. 1993; Steer et al. 1993). First, Steer and colleagues (1993) suggest that anxiety is not associated with suicidality after controlling for depressive symptomatology. Similarly, in a sample of adolescents anxiety disorders are associated with a risk for suicidality only when combined with a mood disorder (Brent et al. 1993). However, other studies suggest that anxiety is associated with suicidality beyond what can be accounted for by its comorbidity with depression (Pinto and Whisman 1996; Zimmerman and Chelminski 2003). This study examined the relations among generalized anxiety, depression, NA, and suicidal ideation in a clinical sample of adolescents and children. Firstly, this study hypothesized that a direct relation between NA and suicidal ideation existed, and secondly that anxiety would be related to suicidal ideation, as has been shown in some studies. Thirdly, this paper predicted that NA, GAD symptoms, and depressive symptoms would be interrelated. Fourth, this study predicted that Model 1, with NA as a shared construct, would provide the best explanation for any observed association between anxiety and suicidal ideation or depression and suicidal ideation in the current sample. Method Participants Participants were 88 children referred for a mental health assessment to the Child and Adolescent Stress and Anxiety Program at the Center for Cognitive-Behavioral Therapy at the University of Hawai i at Manoa. The present sample consisted of 56 boys and 32 girls with a mean age of years (SD=2.87; range 7 18). A percentage of participants (34.09%) did not provide information regarding ethnicity. The remaining 58 participants primarily identified themselves as multi-ethnic (37.5%) and Caucasian (7.95%). Primary diagnoses included both internalizing and externalizing disorders (see Table 1), with the majority of children meeting criteria for a primary externalizing disorder (70.5%). The sample was highly co-morbid with over half of the sample (60.2%) having an additional comorbid (50%) or primary co-morbid diagnosis (10.2%). Inclusion criteria for this study stated that participants must be 7 years of age or older, have an Axis I disorder, and complete all questionnaires. Exclusion criteria for this study included having a diagnosis of mental retardation or psychotic disorder. Measures Anxiety Disorders Interview Schedule for DSM- IV, Child and Parent Versions (ADIS-IV -C/P; Silverman and Albano 1996) The ADIS-IV-C/P is a semi-structured clinical interview designed for DSM-IV diagnosis of anxiety, mood, behavioral, and attentional disorders in children between the ages of 7 and 17. Separate diagnostic profiles are derived from each child and parent interview and are then combined to form a consensus diagnosis (see Silverman and Albano

3 Table 1 Summary diagnoses for sample Frequency % Primary diagnoses Adjustment disorder % Anxiety disorders % Aspberger s disorder % Attention deficit/hyperactive disorder % Conduct disorders % Eating disorder-nos % Encopresis % Major depression % Relational disorders % Co-morbid primary diagnoses Attention deficit/hyperactive Disorder & % conduct disorders Cannabis dependence & conduct disorder % Major depression & anxiety disorders % Posttraumatic stress disorder & conduct % disorder Social phobia & generalized anxiety % disorder Additional diagnoses % Major Depression (MDD) and Generalized Anxiety (GAD) scales of the RCADS were used to measure depressive symptomatology and anxious symptomatology, respectively. One question on the GAD subscale was removed due to overlap with the SIQ-jr. In a clinical sample, the MDD subscale of the RCADS correlated with the Children s Depression Inventory, a common measure of child depression, at r=.70; the GAD subscale correlated with the Revised Children s Manifest Anxiety Scale, a common measure of child anxiety, at r=.65 (Chorpita et al. 2005). Suicidal Ideation Questionnaire- Junior (SIQ-jr; Reynolds 1987) The SIQ-jr is a 15-item self-report inventory used to measure participants current thoughts about suicide. Items are scored on a 7-point scale ranging from 0 6, with six being the most severe. The internal consistency reliability coefficient was.94. Validity coefficients, as compared with measures of anxiety and depression, ranged from Though this measure was standardized on children in grades 7 12, it has been used with younger participants with similar results (Reynolds and Mazza 1999). 1996). Excellent reliability has been suggested for the ADIS-IV-C/P (κ= ; Silverman et al. 2001). Children s Inventory for Psychiatric Syndromes (ChIPS, Parental Version: P-ChIPS; Weller et al. 1999) The ChIPS/ P-ChIPS is a semi-structured clinical interview designed for DSM-IV diagnosis of childhood anxiety, mood, behavioral, and attentional disorders in children between the ages of 7 and 17. Separate diagnostic profiles are derived from each child and parent interview and are then combined to form a consensus diagnosis. Adequate interrater reliability has been found for each syndrome in inpatient and outpatient samples (κ= ; Weller et al. 2000). Positive and Negative Affect Schedule for Children (PANAS-C; Laurent et al. 1999) The PANAS-C is a 27- item questionnaire measuring symptoms of positive and negative affectivity. It yields two scale scores: a Positive Score, thought to measure the construct of PA, and a Negative Score, thought to measure the construct of NA. Evidence suggests that the PANAS-C has adequate reliability and validity in both clinical and non-clinical samples (Chorpita and Daleiden 2002; Laurent et al. 1999). Revised Child Anxiety and Depression Scale (RCADS; Chorpita et al. 2000b) is a 47-item adaptation of the Spence Children s Anxiety Scale and is intended to measure children s self-report of symptoms consistent with DSM- IV criteria for anxiety and mood disorders. The RCADS yields six subscale scores, as well as a total score. The Procedure This study was approved by the University of Hawai i s IRB. After receiving informed assent from the children and consent from their parent or guardian, participants and their parents participated in semi-structured diagnostic assessment interviews and were asked to complete the study questionnaires as part of a standard intake assessment battery. Diagnoses were determined using either the ChIPS or the ADIS-IV as clinic assessment procedures were revised during the course of data collection. There are no differences between cohorts on any study measures. The suicidal behavior questions (questions 11b 11d) from the Major Depression section of the ADIS-IV-C were used for both interviews for a sub-sample of the population as described below for validating the SIQ-jr. Results Analysis of Measures Assumptions The SIQ-jr, RCADS-GAD, and PANAS-C-NA scales all displayed significant positively-skewed patterns, which violated assumptions of normality. Transformations were performed according to Tabachnick and Fidell (2001) using inverse function (SIQ-jr), or square root function (PANAS-C-NA and RCADS-MDD). Specifically, the SIQjr was transformed using the inverse function (Tabachnick and Fidell 2001) with 1 added to the total score of the SIQ-jr

4 to shift zero scores, and -1 multiplied to the new total to maintain scale interpretability such that high scores represent higher suicidality. Following all transformations, normality was improved, and statistical analyses are generally reported using the untransformed variables. Transformed variables are reported where results differed from those obtained with untransformed variables. Internal Consistency of Indicators Cronbach s alpha coefficients were calculated for all continuous measures used in the present study. All symptom measures demonstrated adequate inter-item reliability, including the SIQ-jr (α=.89), the RCADS-MDD scale (α=.87), the RCADS-GAD scale (α=.85), and the PANAS-C-NA scale (α=.92). Validity of SIQ-jr The SIQ-jr was validated using a subsample (N=43) of participants. An ANOVA was conducted between suicidal and non-suicidal groups, using questions about suicide taken from an independent diagnostic interview. Specifically, the ADIS-IV questions were photocopied and placed inside every folder for clinicians to ask. In cases where clinicians did not use the specific ADIS-IV- C suicidal questions, participants were excluded from the sample. On the basis of the ADIS-IV interview questions, suicidality was defined as endorsing any of the following three questions: (1) In the past 2 weeks have you thought of killing yourself, (2) Have you ever thought of a way to kill yourself, (3) Have you ever tried to kill yourself? The sample was divided into suicidal (N=9) and non-suicidal (N=34) groups based on their answers to the ADIS-IV questions. The difference between suicidal and non-suicidal groups on the SIQ-jr was significant (F(1, 42), p<.01), supporting the validity of the SIQ-jr. Age Differences for SIQ-jr An ANOVA analysis was conducted separating participants into those younger than 13 and those 13 and older in order to test for differences due to age, as the SIQ-jr was originally validated for junior high school students (ages 13 and older). The ANOVA suggested that participants under age 13 performed similarly to older participants on this measure (p=0.32, ns). Similar to past research results suggest suitability for use with younger participants (King et al. 1995; Reynolds and Mazza 1999). Gender Differences ANOVA analyses were calculated between boys and girls for all scales. No significant differences were found on any scales for gender. Correlational Analyses Pearson correlations were calculated among the RCADS-GAD scale, the RCADS-MDD scale, the NA scale of the PANAS-C, and the SIQ-jr, using the raw data. All measures were significantly (p<.01) positively correlated with each other (see Table 2), supporting the first three hypotheses that anxiety, depression, and NA would be related to each other, and suicidality. Additionally, significant negative correlations with age were found all scales (p<.05) except the SIQ-jr. Several tests were performed to assess which model best accounted for the observed relation between anxiety and suicidal ideation. To provide a test of Model 1, NA was partialed out of the correlation between anxiety and suicidal ideation. The correlation between generalized anxiety and suicidal ideation was smaller, yet still significant, after controlling for NA, pr=0.35, p<.01 for transformed data (see Table 3), and a significant trend for untransformed data, pr=0.21, p=.05. This partially supported Model 1, which stated that the anxiety-suicidal ideation correlation is explained by the shared association with NA. As a further test, a partial correlation analysis was conducted to determine whether Model 2 provided a better explanation of the findings than Model 1. In this analysis, depression was partialed out of the correlation between anxiety and suicidal ideation to assess whether depression accounted for this relationship. The correlation between anxiety and suicidal ideation was smaller and no longer significant after controlling for depression using both untransformed (pr= 0.15, p=.16), and transformed data, (pr=0.15, p=.17, see Table 3). These findings supported Model 2 over Model 1, suggesting that the relation between anxiety and suicidal ideation was primarily due to their common association with depression. In a final test to evaluate which model better accounted for the relation between anxiety and suicidal ideation, NA was partialed out of the correlation between depression and Table 2 Pearson correlations for all measures Subscale N=88 1. SIQ-jr 0.55** 0.35** 0.33** RCADS-MDD 0.53** 0.78** 0.65** 0.22* 3. RCADS-GAD 0.49** 0.78** 0.59** 0.26* 4. PANAS-C-NA 0.39** 0.67**.61** 0.27* 5. AGE ** 0.28** SIQ-jr = Suicidal Ideation Questionnaire-Junior Total Score, RCADS- MDD = Revised Child Anxiety and Depression Scale Major Depressive Disorder Scale Raw Score, RCADS-GAD = Revised Child Anxiety and Depression Scale Generalized Anxiety Disorder Scale Raw Score, PANAS-C-NA = Positive and Negative Affect Schedule for Children Negative Affect Scale Raw Score. Values below the diagonal are calculated using transformed scales for the PANAS- C, RCADS-GAD, and SIQ-jr. Values above the diagonal use untransformed scores. *p<.05. **p<.01.

5 Table 3 Transformed partial correlations Correlation Controlled variable pr p Significance SIQ-jr with RCADS-GAD RCADS-MDD 0.15 p=.17 ns SIQ-jr with RCADS-GAD PANAS-C-NA 0.35 p=.001 ** SIQ-jr with RCADS-MDD PANAS-C-NA 0.39 p<.01 ** SIQ-jr = Suicidal Ideation Questionnaire-Junior Total Score **p<.01. suicidal ideation to test whether NA accounted for the relation between depression and suicide. The correlation between depression and suicidal ideation remained significant after controlling for NA (p<.01) for both untransformed (pr=0.47) and transformed data (pr=0.39, see Table 3). These results provided a challenge to Model 1 and support for Model 2 because it suggested that NA does not account for the relationship between depression and suicidal ideation, indicating that depression is the more proximally related construct. Regression Analyses Further analyses were conducted to establish predictive values of these constructs, and to examine the effects of such variables as age and gender on the prediction of suicidal ideation. Hierarchical Regression analyses were used to examine these variables and transformed scales were used where applicable (see Table 4). In step 1 age and gender were entered and found not to significantly predict scores on the SIQ (r 2 =.003).Instep2NAwasadded,which did significantly predict SI r 2 =.154, p<.01. In step 3 GAD also significantly predicted SI (r 2 =.267, p<.01). Finally, adding MDD further increased the predictive value (r 2 =.307, p<.01). In a second regression analysis, when MDD is added after age and gender, again age and gender do not significantly predict SI scores, and MDD accounts for 28.5% of the variance, with NA only increasing this amount to 28.8%, and GAD to 30.7%. Discussion This study contributes to the extant literature by fully examining several competing models to explain the association between anxiety and suicidality. Although other studies have examined the effect of depression on the association between anxiety and suicidality, none has examined the role of NA in accounting for the observed relations. Moreover, this was the first study to document an association between NA and suicidal ideation, using an actual measure of NA. This study also demonstrated an association between generalized anxiety symptoms and suicidality in both children and adolescents in a clinical sample, contradicting the findings of Strauss and colleagues (2000). It also extended Pinto and Whisman s (1996) research, which found anxiety to be related to suicidality in youth ages However, unlike the investigation by Pinto and Whisman, this study no longer found anxiety to be related to suicidality after partialling out depression. These finding imply that simply examining depressive symptomatology may be helpful but not sufficient to identify clients at risk for suicide. This study also implies that children with high negative affectivity and anxiety or co-morbid anxiety and depressive symptoms may be at greater risk for suicidal thinking than those with anxiety alone. Several limitations should be considered. Although this study showed depression to be the most important factor when considering suicidality, it should be emphasized that this refers to depressive symptoms and not actual diagnoses. In this study, only four participants had a primary diagnosis of Major Depressive Disorder. Moreover, the measurement of anxiety symptomatology was limited to generalized anxiety disorder symptoms. Other major categories of anxiety symptoms, such as social anxiety, panic, etc... were not examined and may evidence different patterns of relations to suicidality (Strauss et al. 2000). Finally, these variables only accounted for 30.7% of the variance in SI Table 4 Summary of hierarchical regression analysis for predicting suicidal ideation Variable B SE B R 2 β Step 1 Gender Age Step 2 NA ** 0.41 Step 3 GAD ** 0.43 Step 4 MDD ** 0.35 SI = Suicidal Ideation Questionnaire-Junior Total Score, MDD = Revised Child Anxiety and Depression Scale Major Depressive Disorder Scale Raw Score, GAD = Revised Child Anxiety and Depression Scale Generalized Anxiety Disorder Scale Raw Score, NA = Positive and Negative Affect Schedule for Children Negative Affect Scale Raw Score. Values are calculated using transformed scales for the PANAS-C, RCADS-GAD, and SIQ-jr. **p<.01.

6 suggesting that other important variables need to be considered. Given that this literature has been characterized by a diversity of measurement strategies, future investigations might examine whether Model 1 can be corroborated using actual diagnoses of depression and anxiety to determine which is more associated with suicidality. Further, understanding the impact of these disorders on suicidal ideation and behavior when they co-occur will extend knowledge in this area. Future research might establish the effect of other anxiety symptoms on suicidality. Given that the relation between anxiety and suicidality differs depending on type of symptoms (Strauss et al. 2000), other symptom categories might be examined. Although this study did not support Model 1, future investigations might benefit from examining the developmental trajectory of high NA, anxiety, and depression in more detail in order to determine the onset of suicidal thinking and behavior. The current study supported Model 2, in which depression has the more proximal influence on the development of suicidal ideation in youth with high levels of anxious symptomatology. However, given that past research has supported a developmental model in which temperament, specifically high negative affectivity, precedes the development of both depression and anxiety, it is worth examining whether high NA can be detected earlier than anxious and depressive symptoms, which might point to earlier opportunities for intervention and prevention of suicidal ideation. It appears that suicidal ideation warrants further investigation within the context of the tripartite model, based upon its relations with depression, NA, and to a lesser extent, GAD symptoms. 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