Suicidal behavior inLatinas: explanatory cultural factors and implications for intervention

We posit that the high rates of suicidal behavior by teenage Hispanic females reported in large-scale surveys can be understood as a cultural phenomenon, a product of specific elements of the history, tradition, ideology, or social norms of a particular society, and that treatment interventions must take family and cultural factors into consideration. For over a decade, surveys have reported that among ethnic and racial minority youth in the United States, Latinas have the highest rates of suicidal behavior compared to African American and non-Hispanic White adolescent females. However, other research shows that the psychological profiles of suicidal Latina adolescent girls and the risk factors for Latina suicidal behavior may not be that different from non-Hispanic suicidal adolescent females. The unique situation of adolescent Latinas involves the convergence of cultural and familial factors (i.e., familism, acculturation, relatedness, autonomy, etc.) with the developmental, social, and individual factors frequently associated with suicidal behaviors. Based on this background, family-oriented interventions appear to be the most appropriate approach to the prevention and treatment of Hispanic suicidal girls. Factors implicated in Latina suicidal behavior and community-based interventions that include the adolescent and her family are suggested.     

Cognitive Behavior Therapy for Anxious Adolescents: Developmental Influences on Treatment Design and Delivery

Anxiety disorders in adolescence are common and disruptive, pointing to a need for effective treatments for this age group. Cognitive behavior therapy (CBT) is one of the most popular interventions for adolescent anxiety, and there is empirical support for its application. However, a significant proportion of adolescent clients continue to report anxiety symptoms post-treatment. This paper underscores the need to attend to the unique developmental characteristics of the adolescent period when designing and delivering treatment, in an effort to enhance treatment effectiveness. Informed by the literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review the ‘why’ and the ‘how’ of developmentally appropriate CBT for anxious adolescents. ‘Why’ it is important to consider developmental factors in designing and delivering CBT for anxious adolescents is addressed by examining the age-related findings of treatment outcome studies and exploring the influence of developmental factors, including cognitive capacities, on engagement in CBT. ‘How’ clinicians can developmentally tailor CBT for anxious adolescents in six key domains of treatment design and delivery is illustrated with suggestions drawn from both clinically and research-oriented literature. Finally, recommendations are made for research into developmentally appropriate CBT for anxious adolescents.     

Prospective Associations of Coping Styles With Depression and Suicide Risk Among Psychiatric Emergency Patients

Suicide is the second leading cause of death for those ages 13–25 in the United States. Coping is a mediator between stressful life events and adverse outcomes, and coping skills have been incorporated into interventions (e.g., cognitive-behavioral therapy, dialectical behavior therapy, safety-planning interventions) for suicidal populations. However, longitudinal research has not directly examined the prospective associations between multiple coping styles and suicide-related outcomes in high-risk samples. This study identified cross-sectional and 4-month longitudinal associations of coping styles with suicide risk factors (i.e., depression, suicidal ideation, suicidal behavior) in a sample of 286 adolescent and young adult psychiatric emergency patients. Positive reframing was the coping style most consistently associated with positive outcomes, whereas self-blame and disengagement were consistently associated with negative outcomes. Active coping protected against suicidal behavior for males, but not for females. This was the first study to examine longitudinal relationships between coping and suicide-related outcomes in a high-risk clinical sample. Findings suggest that clinical interventions with suicidal adolescents and young adults may benefit from a specific focus on increasing positive reframing and reducing self-blame.     

Hopelessness and Lack of Connectedness to Others as Risk Factors for Suicidal Behavior Across the Lifespan: Implications for Cognitive-Behavioral Treatment

The rates of suicide attempts and death by suicide vary considerably over the lifespan, highlighting the influence of different contextual, risk, and protective factors at different points in development (Daniel & Goldston, 2009). Hopelessness and lack of connectedness to others are two factors that have been associated with increased risk for suicidal thoughts and behaviors across the lifespan. The primary purposes of this paper are to describe how hopelessness and lack of connectedness to others may contribute to risk for suicidal behaviors, and to outline empirically supported cognitive-behavioral interventions for these difficulties at three developmental periods during which suicidal behavior is prevalent: (a) adolescence and young adulthood, (b) middle adulthood, and (c) older adulthood. This paper is not intended as an exhaustive review, but rather an overview of selected developmental issues related to hopelessness and lack of connectedness to others as risk factors for suicidal behavior. Special emphasis is given to clinical implications for cognitive-behavioral interventions, which are illustrated through case conceptualizations and examples at each developmental period.     

A Prospective Study of Adolescent Suicidal Behavior Following Hospitalization

Identification of factors associated with adolescent suicidal behavior following psychiatric hospitalization would facilitate development of effective aftercare interventions. This prospective study identified specific predictors of suicidal behavior in 100 adolescents during a 6-month follow-up period. Standardized baseline assessments and structured follow-up telephone interviews were conducted with adolescents and their guardians. Eighteen percent of adolescents reported suicidal behavior during the follow-up period, primarily of low medical lethality and minimal or ambivalent suicidal intent. This behavior was associated with suicidal thoughts, family dysfunction, and dysthymia. It was not associated with initial posthospitalization treatment compliance. Implications of these findings are discussed.     

When interventions harm. Peer groups and problem behavior.

This article explored developmental and intervention evidence relevant to iatrogenic effects in peer-group interventions. Longitudinal research revealed that "deviancy training" within adolescent friendships predicts increases in delinquency, substance use, violence, and adult maladjustment. Moreover, findings from 2 experimentally controlled intervention studies suggested that peer-group interventions increase adolescent problem behavior and negative life outcomes in adulthood, compared with control youth. The data from both experimental studies suggested that high-risk youth are particularly vulnerable to peer aggregations, compared with low-risk youth. We proposed that peer aggregation during early adolescence, under some circumstances, inadvertently reinforces problem behavior. Two developmental processes are discussed that might account for the powerful iatrogenic effects.     

Reduction of unsafe eating in a patient with esophageal stricture.

Previous research has demonstrated the efficacy of behavioral interventions in teaching self-feeding skills as well as in reducing inappropriate self-feeding behavior. The purpose of this study was to extend previous research on the use of prompting and reinforcement in reducing unsafe eating behaviors to the treatment of an adolescent with developmental disabilities and esophageal stricture. A behavioral assessment and treatment using prompting and reinforcement were shown to be effective in decreasing bite rate, decreasing bite size, and increasing the number of chews per bite.     

Working With Suicidal Clients: Not Business as Usual

In this introduction to a special series of articles on working with suicidal clients, we note that much of the recent growth in theory and research pertaining to suicidal individuals has been contributed by cognitive-behavioral theorists and researchers. This work has established that suicidal people manifest important cognitive vulnerabilities that can be addressed in therapeutic interventions specifically designed for them. Studies to date have produced outcomes that support this framework. We provide brief previews of the collection of articles that follow, which cover safety planning, protocols for evaluating risk, the utility of health behavior theory for informing treatment, mindfulness-based approaches for suicidality, developmental and family considerations, intensive inpatient CBT for individuals in the military, integrated interventions for substance abuse and suicidal behaviors, and coping with the impact of client suicide. We conclude that clinicians are now in a position to begin moving beyond a “therapy as usual” mindset in working with suicidal clients.     

Family-Based Cognitive-Behavioral Treatments for Suicidal Adolescents and Their Integration With Individual Treatment

A considerable research base underscores the importance of family functioning in the risk for and treatment of adolescent suicidal thoughts and behaviors. This paper reviews the extant empirical literature documenting associations between features of the family context and adolescent suicidal thoughts and behaviors. A case example is provided to illustrate how family factors may guide case conceptualization and treatment planning for suicidal adolescents. In light of the growing support for treatment approaches predicated on the principles of cognitive-behavioral therapy (CBT), the paper focuses on many of the common family treatment elements, notably interventions with parents across treatment studies with adolescent suicidal populations. A specific treatment known as CBT for Suicide Prevention (CBT-SP; Stanley et al., 2009) serves as an exemplar for how interventions with parents may be applied in the context of an integrated intervention for teen suicide. The paper reviews issues salient to the implementation of key components of treatment with parents and addresses specific treatment considerations and challenges.     

Self-Psychology,Shame, and Adolescent Suicide: Theoretical and Practical Considerations

Using the psychoanalytic self-psychology of Heinz Kohut as the theoretical foundation of this article, the authors discuss the role of shame in adolescent suicidal behaviors. Shame is described as a central component of suicidal behavior within the context of adolescence, a fundamental stage in the development of the healthy self. Normal and pathological self-development are described and important issues pertaining to the development of the self during adolescence are explored. A theoretical explanation of adolescent suicidal behavior from a self-psychology perspective is offered. Finally, suggestions for treatment of the suicidal adolescent and an illustrative clinical vignette are presented.     

Social problem solving in adolescents with suicidal behavior: a systematic review

There is an increasing focus on deficiencies in problem solving as a vulnerability factor for suicidal behavior in general and hence a target for treatment in suicide attempters. In view of the uncertainty of evidence for this in adolescents we conducted a systematic review of the international research literature examining the possible relationship between deficiencies in social problem-solving skills and suicidal behavior in this population. This was based on searching two electronic databases: Medline 1966 to September 2003 and PsychInfo 1887 to September 2003. Twenty-two studies of social problem-solving skills in adolescents with suicidal behavior were found. Most of these studies, which compared adolescent patients with suicide attempts versus either nonsuicidal psychiatric or normal controls, found evidence for problem-solving deficits in the attempters; however, few of the differences remain after controlling for depression and/or hopelessness. Because most of the studies are cross-sectional, it is difficult to differentiate between the possibilities that deficiencies in problem-solving skills lead to depression when adolescents are faced by adversity and hence to suicidal behavior, or whether depression is the main factor which undermines problem-solving skills. Future research, preferably with longitudinal research designs, is required to determine the nature of the association between problem-solving skills and suicidal behavior in adolescents. This has important implications for therapeutic interventions.     

Spirituality Moderates Hopelessness,Depression, and Suicidal Behavior among Malaysian Adolescents

Suicide is an important public health problem for adolescents, and it is essential to increase our knowledge concerning the etiology of suicide among adolescent students. Therefore, this study was designed to examine the associations between hopelessness, depression, spirituality, and suicidal behavior, and to examine spirituality as a moderator between hopelessness, depression, and suicidal behavior among 1376 Malaysian adolescent students. The participants completed measures of depression, hopelessness, daily spiritual experience, and suicidal behavior. Structural equation modeling indicated that adolescent students high in hopelessness and depression, but also high in spirituality, had less suicidal behavior than others. These findings reinforce the importance of spirituality as a protective factor against hopelessness, depression, and suicidal behavior among Malaysian adolescent students.     

The social context of adolescent suicide attempts: interactive effects of parent, peer, and school social relations

An ecological developmental model of adolescent suicidality was used to inform a hierarchical logistic regression analysis of longitudinal interactions between parent, peer, and school relations and suicide attempts. Reanalyzing data from the National Longitudinal Study of Adolescent Health, it was found that parent relations were the most consistent protective factor, and among boys with prior suicide attempts, school relations augmented the effects of parent relations when peer relations were low. Results indicated the need to understand suicidal behavior as a component of interactive social processes in the design of clinical interventions.     

The Relation Between Child Maltreatment and Adolescent Suicidal Behavior: A Systematic Review and Critical Examination of the Literature

A large body of research suggests that child maltreatment (CM) is associated with adolescent suicidal ideation and attempts. These studies, however, have not been critically examined and summarized in a manner that allows us to draw firm conclusions and make recommendations for future research and clinical work in this area. In this review, we evaluated all of the research literature to date examining the relationship between CM and adolescent suicidal ideation and attempts. Results generally suggest that childhood sexual abuse, physical abuse, emotional abuse, and neglect are associated with adolescent suicidal ideation and attempts across community, clinical, and high-risk samples, using cross-sectional and longitudinal research designs. In most studies, these associations remain significant when controlling for covariates such as youth demographics, mental health, family, and peer-related variables. When different forms of CM are examined in the same multivariate analysis, most research suggests that each form of CM maintains an independent association with adolescent suicidal ideation and suicide attempts. However, a subset of studies yielded evidence to suggest that sexual abuse and emotional abuse may be relatively more important in explaining suicidal behavior than physical abuse or neglect. Research also suggests an additive effect—each form of CM contributes unique variance to adolescent suicide attempts. We discuss the current limitations of this literature and offer recommendations for future research. We conclude with an overview of the clinical implications of this research, including careful, detailed screening of CM history, past suicidal behavior, and current suicidal ideation, as well as the need for integrated treatment approaches that effectively address both CM and adolescent suicidal ideation and suicide attempts.     

Working With the Suicidal Client Who Also Abuses Substances

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.     

Family‐Based Preventive Interventions: Can the Onset of Suicidal Ideation and Behavior Be Prevented?

Suicide is the second leading cause of death for youth aged 10–24. Research informed prevention efforts have the opportunity to decrease risk for suicidal ideation and behavior before it is manifested. Indeed, there is a small body of research findings demonstrating both proximal and distal effects of preventive interventions delivered in childhood and adolescence on suicidal ideation and/or behavior. These efforts build off of other secondary analyses of prevention research that has demonstrated benefits for multiple types of youth outcomes. This supplement provides “proof of concept” that family‐based preventive interventions aimed at reducing a number of risk factors for suicide (e.g., substance use, externalizing, and internalizing behavior) can prevent suicidal ideation and behaviors.     

Depression, hopelessness, and self-esteem: accounting for suicidality in adolescent psychiatric inpatients

The present study was designed to examine depression, hopelessness, and self-esteem as related to suicidal behavior in three groups of depressed adolescent psychiatric inpatients. Depressed adolescents who had never attempted suicide were compared to depressed adolescents who had attempted suicide once and to depressed adolescents who had attempted suicide on several different occasions. Results showed that suicidal adolescents experienced significantly greater depression and hopelessness than did the nonsuicidal adolescents. However, all three groups of depressed adolescents reported similar low levels of self-esteem. Measures of depression and hopelessness were useful in classifying the adolescents based on their suicidal behavior. Results suggest that the treatment of suicidal adolescents could benefit from strategies that focus on reducing feelings of depression and hopelessness.     

The Ethnic Context of Child and Adolescent Problem Behavior: Implications for Child and Family Interventions

This article links the empirical literature on race and ethnicity in developmental psychopathology with interventions designed to reduce adolescent problem behavior. We present a conceptual framework in which culture is endogenous to the socialization of youth and the development of specific self-regulatory strategies. The importance of cultural influence is identified at three levels: (a) intrapersonal developmental processes (e.g., ethnic identity development, development of coping modifies mechanisms and self-regulatory mechanisms), (b) family socialization processes (e.g., racial and ethnic socialization), and (c) interaction with larger societal contexts (e.g., maintenance of bicultural competence in adapting to mainstream and ethnic cultures). We discuss limitations of current assessment and intervention practices that focus on reducing adolescent problem behavior with respect to the cultural issues identified above. We propose that empirically supported adaptive and tailored interventions for adolescent problem behavior are optimal for serving multicultural children and families. To empower such interventions to better serve children and families of color, it is essential that assessments that guide the adaptation and tailoring process include culturally salient dynamics such as ethnic identity, racial socialization, and culturally informed parenting practices. This work is supported by an NRSA grant to the first author, and the following for the second author: grants DA07031, DA13773, and DA16110 from the National Institute on Drug Abuse.     

Suicidal Ideation of Psychiatrically Hospitalized Adolescents has One-Year Predictive Validity for Suicide Attempts in Girls Only

Clinicians commonly incorporate adolescents’ self-reported suicidal ideation into formulations regarding adolescents’ risk for suicide. Data are limited, however, regarding the extent to which adolescent boys’ and girls’ reports of suicidal ideation have clinically significant predictive validity in terms of subsequent suicidal behavior. This study examined psychiatrically hospitalized adolescent boys’ and girls’ self-reported suicidal ideation as a predictor of suicide attempts during the first year following hospitalization. A total of 354 adolescents (97 boys; 257 girls; ages 13–17 years) hospitalized for acute suicide risk were evaluated at the time of hospitalization as well as 3, 6, and 12 months later. Study measures included the Suicidal Ideation Questionnaire-Junior, Multidimensional Anxiety Scale for Children, Children’s Depression Rating Scale-Revised, Beck Hopelessness Scale, Youth Self-Report, and Personal Experiences Screen Questionnaire. The main study outcome was presence and number of suicide attempt(s) in the year after hospitalization, measured by the Diagnostic Interview Schedule for Children. Results indicated a significant interaction between suicidal ideation, assessed during first week of hospitalization, and gender for the prediction of subsequent suicide attempts. Suicidal ideation was a significant predictor of subsequent suicide attempts for girls, but not boys. Baseline history of multiple suicide attempts was a significant predictor of subsequent suicide attempts across genders. Results support the importance of empirically validating suicide risk assessment strategies separately for adolescent boys and girls. Among adolescent boys who have been hospitalized due to acute suicide risk, low levels of self-reported suicidal ideation may not be indicative of low risk for suicidal behavior following hospitalization.