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1.  Developmental Trajectories of Suicidal Thoughts and Behaviors From Adolescence Through Adulthood 
Little is known about the patterns among individuals in the long-term course of suicidal thoughts and behaviors (STBs). The objective of this study was to identify developmental trajectories of STBs from adolescence through young adulthood, as well as risk and protective covariates, and nonsuicidal outcomes associated with these trajectories.
180 adolescents (ages 12–18 at recruitment) were repeatedly assessed over an average of 13.6 years (2,273 assessments) since their psychiatric hospitalization. Trajectories were based on ratings of STBs at each assessment. Covariates included psychiatric risk factors (proportion of time in episodes of psychiatric disorders, hopelessness, trait anxiety, impulsivity, and aggression in adulthood, sexual and physical abuse, parental history of suicidal behavior), protective factors (survival and coping beliefs, social support in adulthood, parenthood), and nonsuicidal outcomes (social adjustment and functional impairment in adulthood, school drop-out, incarcerations).
Using a Bayesian group-based trajectory model, four trajectories of STBs were identified: (1) an Increasing Risk class (11%), (2) a Highest Overall Risk class (12%), (3) a Decreasing Risk class (33%), and (4) a Low Risk class (44%). The four classes were associated with distinct patterns of correlates in risk and protective factors and nonsuicidal outcomes.
Adolescents and young adults have heterogeneous developmental trajectories of STBs. These trajectories and their covariates may inform strategies for predicting STBs and targeting interventions for individuals at risk for suicidal behavior.
PMCID: PMC5035543  PMID: 27126854
Suicide ideation; Suicide attempts; Development; Longitudinal; Trajectories
2.  Unheard Voices: African American Fathers Speak about their Parenting Practices 
Psychology of men & masculinity  2015;16(3):274-283.
Researchers have called for qualitative investigations into African American fathers’ parenting practices that consider their social context and identify specific practices. Such investigations can inform the way we conceptualize African American fathers’ parenting practices, which can in turn contribute to prevention interventions with at-risk youth. We conducted semi-structured, qualitative interviews about parenting with 30 self-identified, African American, biological fathers of pre-adolescent sons at-risk for developing aggressive behaviors, depressive symptoms, or both. Fathers provided descriptions of their parenting practices, which were at times influenced by their environmental context, fathers’ residential status, and masculine ideologies. Our systematic analysis revealed four related themes that emerged from the data: managing emotions, encouragement, discipline, and monitoring. Of particular note, fathers in the current sample emphasized the importance of teaching their sons to manage difficult emotions, largely utilized language consistent with male ideologies (i.e., encouragement rather than love or nurturance), and engaged in high levels of monitoring and discipline in response to perceived environmental challenges and the developmental needs of their sons. The findings provide deeper insight into the parenting practices of African American fathers who are largely understudied, and often misunderstood. Further, these findings highlight considerations that may have important implications for father-focused prevention interventions that support African American fathers, youth, and families.
PMCID: PMC4562768  PMID: 26366126
African American fathers; parenting practices; prevention; at-risk youth; qualitative
3.  Suicide Attempts in a Longitudinal Sample of Adolescents Followed Through Adulthood: Evidence of Escalation 
This study was designed to examine escalation in repeat suicide attempts from adolescence through adulthood, as predicted by sensitization models (and reflected in increasing intent and lethality with repeat attempts, decreasing amount of time between attempts, and decreasing stress to trigger attempts)
In a prospective study of 180 adolescents followed through adulthood after a psychiatric hospitalization, suicide attempts and antecedent life events were repeatedly assessed (M = 12.6 assessments, SD = 5.1) over an average of 13 years, 6 months (SD = 4 years, 5 months). Multivariate logistic, multiple linear, and negative binomial regression models were used to examine patterns over time.
After age 17-18, the majority of suicide attempts were repeat attempts (i.e., made by individuals with prior suicidal behavior). Intent increased both with increasing age, and with number of prior attempts. Medical lethality increased as a function of age but not recurrent attempts. The time between successive suicide attempts decreased as a function of number of attempts. The amount of precipitating life stress was not related to attempts.
Adolescents and young adults show evidence of escalation of recurrent suicidal behavior, with increasing suicidal intent and decreasing time between successive attempts. However, evidence that sensitization processes account for this escalation was inconclusive. Effective prevention programs that reduce the likelihood of individuals attempting suicide for the first time (and entering this cycle of escalation), and relapse prevention interventions that interrupt the cycle of escalating suicidal behavior among individuals who already have made attempts are critically needed.
PMCID: PMC4380814  PMID: 25622200
suicide attempts; adolescence; sensitization; escalation; developmental trends
4.  Impact of Patients’ Psychiatric Hospitalization on Caregivers: A Systematic Review 
The purpose of this article was to systematically review literature on the impact of patients’ psychiatric hospitalizations on caregivers. Implications for practice and research are presented.
A systematic search of Web of Knowledge, PsychInfo, and Medline (PubMed) was conducted for peer-reviewed articles published before August 31, 2013. Qualitative, quantitative, and mixed method studies were included if they focused on caregiver outcomes and contained data collected directly from caregivers of patients who had been psychiatrically hospitalized.
Twenty-nine articles met the inclusion criteria. Caregivers are heterogeneous in their reaction to the psychiatric hospitalization; however, many report distress. Caregivers also often report that they experience stigma, disruptions in daily life, worse physical health, economic strain, and changes in relationships following hospitalization. Negative reactions to the hospitalization may decrease over time, but can remain elevated when compared to the general population. Nonetheless, many caregivers also experience positive changes as a result of the hospitalization. The reaction of caregivers may be influenced by the severity of the patient’s psychiatric problems as well as the caregiver’s demographics and style of coping.
Caregivers experience a range of reactions to the psychiatric hospitalizations and providing caregivers with psychoeducation on their possible reaction as well as techniques to assist them may improve clinical outcomes for patients. Future research is needed to understand the heterogeneity in caregiver’s reactions to the patient’s psychiatric hospitalization.
PMCID: PMC4516087  PMID: 25686810
5.  Psychiatric Diagnoses as Contemporaneous Risk Factors for Suicide Attempts Among Adolescents and Young Adults: Developmental Changes 
The purpose of this prospective, naturalistic study was to examine the relationships between suicide attempts and contemporaneous psychiatric disorders, and developmental changes in these relationships from adolescence to young adulthood. The sample consisted of 180 adolescents, 12-19 years of age at hospitalization, repeatedly assessed for up to 13 years (n = 1,825 assessments). Semistructured psychiatric diagnostic instruments were administered at repeated assessments to assess psychiatric disorders and suicide attempts. After controlling for demographic variables and prehospitalization suicide attempts, most contemporaneous psychiatric disorders (major depressive disorder [MDD], dysthymic disorder, generalized anxiety disorder [GAD], panic disorder, attention-deficit/hyperactivity disorder [AD/HD], conduct disorder, and substance use disorder [SUD]) were related to increased risk of attempts. The relationship between suicide attempts and MDD, GAD, AD/HD, and SUD strengthened as participants got older. MDD, dysthymic disorder, GAD, and panic disorder were more commonly associated with repeat than 1st-time suicide attempts. In sum, most major psychiatric disorders are associated with increased risk for suicide attempts, but the strength of the relationships between these disorders and attempts changes over the course of development.
PMCID: PMC2819300  PMID: 19309187
suicide attempts; psychiatric diagnoses; longitudinal; naturalistic; developmental psychopathology
6.  Cultural Considerations in Adolescent Suicide Prevention and Psychosocial Treatment 
The American psychologist  2008;63(1):14-31.
Ethnic groups differ in rates of suicidal behaviors among youths, the context within which suicidal behavior occurs (e.g., different precipitants, vulnerability and protective factors, and reactions to suicidal behaviors), and patterns of help-seeking. In this article, the authors discuss the cultural context of suicidal behavior among African American, American Indian and Alaska Native, Asian American and Pacific Islander, and Latino adolescents, and the implications of these contexts for suicide prevention and treatment. Several cross-cutting issues are discussed, including acculturative stress and protective factors within cultures; the roles of religion and spirituality and the family in culturally sensitive interventions; different manifestations and interpretations of distress in different cultures; and the impact of stigma and cultural distrust on help-seeking. The needs for culturally sensitive and community-based interventions are discussed, along with future opportunities for research in intervention development and evaluation.
PMCID: PMC2662358  PMID: 18193978
culture; suicide prevention; treatment; help-seeking; adolescents
7.  Parent and Child Psychopathology and Suicide Attempts among Children of Parents with Alcohol Use Disorder 
Parents with psychopathology such as alcohol use disorder (AUD) that confers risk for suicide attempt (SA) may have children who are more likely to develop such psychopathology and to attempt suicide, suggesting that risk may be “transmitted” from parents to children. We examined this phenomenon during the transition from childhood to adolescence, when risk for SA increases dramatically. A cohort of 418 children were examined at average age 9.4 (range 7–14) years at enrollment (Time 1, childhood) and approximately five years later, prior to reaching age 18 (Time 2, adolescence). One or both biological parents, oversampled for AUD, were also interviewed. Structural equation models (SEM) examined father-child, mother-child, and either/both parent-child associations. The primary outcome was SA over follow-up among offspring, assessed at Time 2. As hypothesized, parental antisocial personality disorder predicted conduct disorder symptoms in offspring both during childhood and adolescence (parent-child model, father-child model) and maternal AUD predicted conduct disorder symptoms during childhood (mother-child model). However, we did not find evidence to support transmission of depression from parents to offspring either during childhood or adolescence, and parent psychopathology did not show statistically significant associations with SA during adolescence. In conclusion, we conducted a rare study of parent-to-child “transmission” of risk for SA that used a prospective research design, included diagnostic interviews with both parents and offspring, and examined the transition from childhood to adolescence, and the first such study in children of parents with AUD. Results provided mixed support for hypothesized parent-child associations.
PMCID: PMC4059391  PMID: 24716789
adolescent; parent; suicide attempt; alcohol use disorder; risk factor
8.  Emotion Regulation Difficulties, Youth-Adult Relationships, and Suicide Attempts Among High School Students in Underserved Communities 
Journal of youth and adolescence  2012;42(6):807-820.
To develop and refine interventions to prevent youth suicide, knowledge is needed about specific processes that reduce risk at a population level. Using a cross-sectional design, the present study tested hypotheses regarding associations between self-reported suicide attempts, emotion regulation difficulties, and positive youth-adult relationships among 7,978 high-school students (48.6% male, 49.9% female) in 30 high schools from predominantly rural, low-income communities. 683 students (8.6%) reported a past-year suicide attempt. Emotion regulation difficulties and a lack of trusted adults at home and school were associated with increased risk for making a past-year suicide attempt, above and beyond the effects of depressive symptoms and demographic factors. The association between emotion regulation difficulties and suicide attempts was modestly lower among students who perceived themselves as having higher levels of trusted adults in the family, consistent with a protective effect. Having a trusted adult in the community (outside of school and family) was associated with fewer suicide attempts in models that controlled only for demographic covariates, but not when taking symptoms of depression into account. These findings point to adolescent emotion regulation and relationships with trusted adults as complementary targets for suicide prevention that merit further intervention studies. Reaching these targets in a broad population of adolescents will require new delivery systems and “option rich” intervention designs.
PMCID: PMC3654393  PMID: 23666604
youth suicide; suicide prevention; emotion regulation; youth-adult relationships; youth-adult communication; underserved populations; suicide attempts
9.  Working With the Suicidal Client Who Also Abuses Substances 
Cognitive and behavioral practice  2012;19(2):245-255.
Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper, we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.
PMCID: PMC3510478  PMID: 23209362
To examine whether suicidal intent and medical lethality of past suicide attempts are predictive of future attempts, the association between intent and lethality, and the consistency of these characteristics across repeated attempts among youth.
Suicide attempts in a 15-year prospective study of 180 formerly psychiatrically hospitalized adolescents (Mage at hospitalization = 14.83; 51% female; 80% Caucasian) were characterized using the Subjective Intent Rating Scale and Lethality of Attempt Rating Scale. Anderson-Gill recurrent events survival models and generalized estimating equations were used to assess predictive validity. Generalized linear models were used to examine stability of characteristics across attempts.
Neither intent nor lethality from the most recent attempt predicted future attempts. The highest level of intent and most severe lethality of attempts during the follow-up predicted subsequent attempts, but the degree to which highest intent and most severe lethality contributed to prediction after considering methods of suicide attempts, past number of attempts, or psychiatric diagnoses was mixed. Across successive attempts, there was little consistency in reported characteristics. Intent and lethality were related to each other only for attempts occurring in early adulthood.
Highest intent and lethality were better predictors of future attempts than intent and lethality of the most recent attempt. However, these characteristics should only be considered as predictors within the context of other factors. For youth, clinicians should not infer true intent from the lethality of attempts, nor assume that characteristics of future suicide attempts will be similar to previous attempts.
PMCID: PMC3314156  PMID: 22250854
suicidal ideation; suicide attempt; adolescence
11.  Associations Between Suicidal High School Students’ Help-Seeking and Their Attitudes and Perceptions of Social Environment 
Journal of youth and adolescence  2012;41(10):1312-1324.
Suicide is a leading cause of death among adolescents, many of whom fail to disclose suicide concerns to adults who might help. This study examined patterns and predictors of help-seeking behavior among adolescents who seriously considered suicide in the past year. 2,737 students (50.9 % female, 46.9 % male; racial distribution 79.5 % Caucasian, 11.9 % Hispanic/Latino, and 3.6 % Black/African-American) from 12 high schools in rural/underserviced communities were surveyed to assess serious suicide ideation (SI) in the past year, disclosure of SI to adults and peers, attempts to get help, attitudes about help-seeking, perceptions of school engagement, and coping support. Help-seeking was defined as both disclosing SI to an adult and perceiving oneself as seeking help. The relationship between adolescents’ help-seeking disclosure and (1) help-seeking attitudes and (2) perceptions of social resources was examined among suicidal help-seeking youth, suicidal non-help-seeking youth, and non-suicidal youth. Of the 381 (14 %) students reporting SI, only 23 % told an adult, 29 % sought adult help, and 15 % did both. Suicidal help-seekers were similar to non-suicidal peers on all measures of help-seeking attitudes and social environment perceptions. Positive attitudes about help-seeking from adults at school, perceptions that adults would respond to suicide concerns, willingness to overcome peer secrecy requests, and greater coping support and engagement with the school were associated with students’ increased disclosure of SI and help-seeking. This study supports prevention strategies that change student norms, attitudes and social environments to promote help-seeking among adolescents with SI. Promising intervention targets include increasing students’ perceptions of the availability and capability of adults to help them, and strengthening students’ understanding of how existing resources can help them cope.
PMCID: PMC3534737  PMID: 22562217
Youth suicide; Help-seeking; Prevention; Youth–adult relationships; Attitudes; Social support
12.  Chronic pain in adolescents is associated with suicidal thoughts and behaviors 
Adults who suffer from chronic pain are at increased risk for suicide ideation and attempts, but it is not clear whether adolescents with chronic pain are similarly at increased risk. This study investigates whether chronic pain is associated with an increase in suicidal ideation/attempts independent of depression in a population sample of adolescents.
We analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N=9,970). Most chronic pain was related to suicide ideation/attempt both in the last year (OR’s 1.3–2.1) and during the subsequent year (OR’s 1.2–1.8). After controlling for depressive symptoms, headaches (OR=1.3 last year, OR=1.2 subsequent year) and muscle aches (OR=1.3 last year) remained associated with suicide ideation but not suicide attempt.
These findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression. Youth with co-morbid depression and chronic pain are at increased risk of thinking about and attempting suicide. Clinicians should be alert to suicide ideation/attempt and co-morbid depression in this at-risk population.
PMCID: PMC3178682  PMID: 21684217
Pain; Suicide; Epidemiology; Adolescents
13.  The Garrett Lee Smith Memorial Suicide Prevention Program 
Responding to calls for greater efforts to reduce youth suicide, the Garrett Lee Smith (GLS) Memorial Act to date has provided funding for 68 state, territory, and tribal community grants, and 74 college campus grants for suicide prevention efforts. Suicide prevention activities supported by GLS grantees have included education, training programs including gatekeeper training, screening activities, infrastructure for improved linkages to services, crisis hotlines, and community partnerships. Through participation in both local- and cross-site evaluations, GLS grantees are generating data regarding the local context, proximal outcomes, and implementation of programs, as well as opportunities for improvement of suicide prevention efforts.
PMCID: PMC3107991  PMID: 20560746
14.  The Problematic Label of Suicide Gesture: Alternatives for Clinical Research and Practice 
Historically, certain terms used to describe psychopathology have evolved over time due to changing social and political contexts. This paper explores the importance of a clear and consistent language for characterizing suicide-related behaviors with a particular focus on the commonly used label “suicide gesture.” The historical and contemporary uses of the term are explored, and clinical, research, and training implications are discussed. Clinicians and researchers are strongly encouraged to consider discontinuing the use of the term suicide gesture in light of its associated dismissive connotations and inconsistent application in clinical practice and research. In lieu of the term suicide gesture, recommendations are made regarding an increased emphasis by clinicians and researchers on more precise descriptions of suicidal behaviors and the functional assessment of suicide-related behaviors.
PMCID: PMC2904564  PMID: 20640243
suicide gesture; suicide attempt; operational definitions; language for describing psychiatric symptoms; nomenclature; functional assessment
15.  Trait Anger, Anger Expression, and Suicide Attempts among Adolescents and Young Adults: A Prospective Study 
Previous studies of the relationship between anger, anger expression, and suicidal behavior have been largely cross-sectional and have yielded mixed findings. In a prospective, naturalistic study, we examined how trait anger and anger expression influenced the likelihood of suicide attempts among 180 adolescents followed for up to 13.3 years after discharge from an inpatient psychiatry unit. Results showed that higher trait anger and anger expressed outwardly over the follow-up was related to increased likelihood of suicide attempts among males. For girls, trait anger and both the inward and outward expression of anger moderated the risk for suicide attempts associated with major depression. These results are interpreted in light of theory regarding behavioral activation and behavioral inhibition systems.
PMCID: PMC2854503  PMID: 20183651
16.  Caregiver Strain and Youth Suicide Attempt: Are They Related? 
There are scant data documenting the relationship between caregiver strain and suicidal behavior among youth. This study includes data from the caregivers of 1,854 youth who received services through the Comprehensive Community Mental Health Services for Children and Their Families Program. Caregiver strain, family functioning, and youth functional impairment were assessed with the Caregiver Strain Questionnaire, Family Life Questionnaire, and Columbia Impairment Scale. Caregivers of suicidal and nonsuicidal youth differed in subjective internalizing strain (e.g., worry and guilt) and objective strain (e.g., constraints on activities). Differences in objective strain persisted even after controlling for family life and youth functional impairment.
PMCID: PMC2847271  PMID: 19527155
17.  Interventions for Suicidal Youth: A Review of the Literature and Developmental Considerations 
Suicidal behavior is developmentally mediated, but the degree to which interventions for suicidal behaviors have been developmentally tailored has varied widely. Published controlled studies of psychosocial treatment interventions for reducing adolescent suicidal behavior are reviewed, with a particular emphasis on the developmental nuances of these interventions. In addition, developmental considerations important in the treatment of suicidal adolescents are discussed. There are insufficient data available from controlled trials to recommend one intervention over another for the treatment of suicidal youth, but interventions that are sensitive to the multiple developmental contexts have potential for greater effectiveness in reducing adolescent suicidal behavior.
PMCID: PMC2819305  PMID: 19606918

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