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Abstract

Adolescence is a developmental period associated with heightened risk for both the onset and escalation of suicidal ideation (SI). Given that SI is a potent predictor of suicidal behavior, it is important to develop models of vulnerability for and protection against SI, particularly among young adolescents. This study examined the relative impact of several cognitive vulnerabilities, as well as protective factors, for SI among young adolescents over a 2-year interval encompassing their transition to mid-adolescence. At baseline, 324 adolescents (M = 12.39 years; SD = 0.63; 52.5 % female) completed measures of depressive symptoms, self-referent information processing biases, negative inferential style, and responses to negative affect. Further, the adolescents and their mothers were administered a diagnostic interview to assess current and past depressive disorders and SI. Over follow-up, adolescents and their mothers were administered the diagnostic interview every 12 months and adolescents completed a self-report measure inquiring about SI every 6 months to assess interviewer-rated and self-reported SI. Logistic regressions indicated that preferential endorsement of negative adjectives as self-referent (only among girls), rumination in response to negative affect, and a negative inferential style prospectively predicted SI. Additionally, young adolescents' tendency to respond to negative affect with distraction and problem-solving buffered against their risk for exhibiting SI. When these factors were entered simultaneously, preferential endorsement of negative adjectives as self-referent and the use of distraction and problem-solving skills remained the only significant prospective predictors of SI. No previous studies have examined these variables as predictors of SI, thereby highlighting their potential utility in improving the predictive validity of extant models of suicide risk and resilience.
Cognitive Risk and Protective Factors for Suicidal Ideation:
A Two Year Longitudinal Study in Adolescence
Taylor A. Burke
1
& Samantha L. Connolly
1
& Jessica L. Hamilton
1
& Jonathan P. Stange
1
&
Lyn Y . Abramson
2
& Lauren B. Alloy
1
#
Springer Science+Business Media New York 2015
Abstract Adolescence is a developmental period associated
with heightened risk for both the onset and escalation of sui-
cidal ideation (SI). Given that SI is a potent predictor of sui-
cidal behavior, it is important to develop models of vulnera-
bility for and protection against SI, particularly among young
adolescents. This study examined the relative impact of sev-
eral cognitive vulnerabilities, as well as protective factors, for
SI among young adolescents over a 2-year interval
encompassing their transition to mid-adolescence. At base-
line, 324 adolescents (M=12.39 years; SD=0.63; 52.5 % fe-
male) com pl ete d measures of depressive s ym ptoms , s el f-
referent information processing biases, negative inferential
style, and responses to negative affect. Further, the adolescents
and their mothers were administered a diagnostic interview to
assess current and past depressive disorders and SI. Over fol-
low-up, adolescents and their mothers were administered the
diagnostic interview every 12 months and adolescents com-
pleted a self-report measure inquiring about SI every 6 months
to assess interviewer-rated and self-reported SI. Logistic re-
gressions indicated that preferential endorsement of negative
adjectives as self-referent (only among girls), rumination in
response to negative affect, and a negative inferential style
prospectively predicted SI. Additionally, young adolescents
tendency to respond to negative affect with distraction and
problem-solving buffered against their risk for exhibiting SI.
When these factors were entered simultaneously, preferential
endorsement of negative adjectives as self-referent and the use
of distraction and problem-solving skills remained the only
significant prospective predictors of SI. No previous studies
have examined these variables as predictors of SI, thereby
highlighting their potential utility in improving the predictive
validity of extant models of suicide risk and resilience.
Keywords Suicidal ideation
.
Information processing biases
.
Negative inferential style
.
Rumination
.
Distraction
.
Problem-solving
Adolescence is a developmental period associated with a
heightened risk for both the onset and the escalation of suicid-
al thoughts and behaviors (Nock et al. 2008). In fact, the
lifetime prevalence of suicidal ideation (SI) among adoles-
cents is documented at 12.1 %, with 4 % who have made
suicide plans, and 4.1 to 8.5 % who have attempted suicide
(Grunbaum et al. 2004; Nock 2012;Nocketal.2013). Given
that SI is a potent predictor of suicide attempts and completed
suicide, it is important to develop models of vulnerability for
and protection against SI among young adolescents in order to
* Lauren B. Alloy
lalloy@temple.edu
Taylor A. Burke
taylor.burke@temple.edu
Samantha L. Connolly
samantha.connolly@temple.edu
Jessica L. Hamilton
jessica.leigh.hamilton@temple.edu
Jonathan P. Stange
jstange@temple.edu
Lyn Y. Abramson
lyabrams@wisc.edu
1
Department of Psychology, Temple University, Weiss Hall, 1701 N.
13th St, Philadelphia, PA 19122, USA
2
Department of Psychology, University of Wisconsin-Madison,
Brogden Hall, 1202 West Johnson Street, Madison, WI 53706-1969,
USA
J Abnorm Child Psychol
DOI 10.1007/s10802-015-0104-x
implement early prevention and intervention programs
(Lewinsohn et al. 1994).
The suicide literature consistently has implicated a wide
range of cognitive predictors of the initiation and mainte-
nance of SI and suicidal behavior (OConnor 2011;
Weishaar 1996;OConnor 2011). Cognitive factors have
been broadly defined as the style in which individuals ha-
bitually Bsearch for, acquire, interpret, categorize, remember,
and retrieve information in making decisions and in problem
solving^ (Sheehy and OConnor 2014, p. 69). The current
study examine d a range of cognitive ri sk and protectiv e
factors previously found to provide vulnerability for and
protection against suicide-related outcomes and/or depres-
sion and their relationship to SI among young adolescents
(ages 12 to 13) over a two-year interval encompassing their
transition to mid-adolescence (Hankin et al. 1998; Kessler
et al. 2001). Risk factors are defined as Bameasurablechar-
acterization of each subject in a specified population that
precedes the outcome of interest and which can be used to
divide the population into 2 groups (the high risk and the
low risk groups that comprise the total population)^
(Kraemer et al. 1997, p. 377). Further, protective factors
are defined as Bantecedent conditions associated with a de-
crease in the likelihood of undesirable outcomes or with an
increase in the likelihood of positive outcomes^ (Kazdin
et al. 1997,p.377).^
Although the transition from early adolescence to mid-
adolescence is associated with increased suicidal thoughts
and behaviors as well as increased rates of major depres-
sive disorder, few studies have examined the predictive
capacity of cognitive risk factors for suicide-related out-
comes over this time period. Even fewer studies have
examined the predictive capacity of cognitive protective
factors for suicide-related outcomes, not only across this
sensitive time period, but also across all age groups
(Johnson et al. 2011). Research on protective factors for
SI among youth is sorely needed, as suicide prevention
efforts have been hampered by focusing solely on mitigat-
ing risk factors, as opposed to incorporating resiliency
findings (Brent 2011). In fact, the 2012 National
Strategy for Suicide Prevention called for a better under-
standing of protective factors against su icide to bolster
prevention efforts (United States Department of Health
and Human Services Office of the Surgeon General and
National Action Alliance for Suicide Prevention 2012).
Furthermore, very few studies have concurrently examined
cognitive risk and protective factors to ascertain their rel-
ative significance in conferring risk for and/or protection
against SI. This study aimed to fill these research gaps by
examining the relative impact of negative inferential style,
response styles, and self-referent information processing on
rates of SI to determine which risk and protective factors
may be the most robust predictors of SI.
Cognitive Model of Suicide
Wenzel and Beck (2008) put forth a model of suicide based on
Becks cognitive theory of psychopathology. Their cognitive
model of suicide suggests that three classes of factors influ-
ence the initiation of suicidal thoughts and behaviors: dispo-
sitional factors, maladaptive cognitive processes associated
with psychopathology, and cognitive processes more specifi-
cally related to suicidal thoughts and acts. Dispositional fac-
tors are tho se that are more dista l in nature, and may put
individuals at risk for experiencing psychopathology in gen-
eral (i.e., impulsivity, deficits in problem solving). According
to Wenzel and Beck (2008), cognitive processes associated
with psychopathology include the content of cognitions, as
well as information processing biases, reflecting the manner
in which cognitions are formed. The theory purports that the
more an individual tends to exhibit negative cognitive content
and maladaptive information processing biases, the more like-
ly it is that suicide relevant cognitive processes will be trig-
gered in response to stressful life events, thus spurring the
development of suicidal thoughts (Wenzel and Beck 2008).
According to this cognitive model of suicide, suicidal acts
occur when an individual reaches his or her threshold for
tolerating the pain associated with a suicidal crisis (Wenzel
and Beck 2008). The current study aims to examine the pre-
dictive capacity of specific maladaptive cognitive processes
identified by the cognitive model of suicidal behavior among
young adolescents, as well as test additional cognitive factors
that have not yet been examined in relation to this model, to
potentially build on the model. Of note, the cognitive model of
suicidal behavior includes little emphasis on protective fac-
tors, and thus, the current study also aims to fill that gap by
examining one potential cognitive protective factor.
Negative Self-Referent Information Processing
Becks(1976, 1987) cognitive model of depression theorizes
that individuals who are vulnerable to depression possess neg-
ative self-schemas (e.g., believing that they are characterized
by failure, worthlessness) that can influence their perception,
interpretation, attention, and memory for self-referent infor-
mation. Individuals with a negative self-schema are hypothe-
sized to exhibit information processing biases, such that cog-
nitive resources are disproportionately allotted to attending to
and processing negative information, therefore leaving deplet-
ed resources to attend to and process positive information
(Disner et al. 2011;Ingram1984). According to Wenzel and
Becks(2008) cognitive model of suicidal behavior, suicidal
crises are more likely to occur as the frequency, intensity,
and duration of information processing biases increase, as
these biases escalate psychological disturbance, a context in
JAbnormChildPsychol
which it is more likely for a stressful life event to engender
suicidal thoughts.
The Self-Referent Encoding Task (SRET; Alloy et al.
1997; Derry and Kuiper 1981; Hammen and Zupan 1984)
measures information processing biases that may be influ-
enced by negative self-schemas, by instructing participants
to rapidly judge whether a series of negative and positive
adjectives are self-referent and then complete a free recall
component in which participants list as many words as they
can remember from the task. Self-referent information pro-
cessing biases as measured by the SRET have been found to
concurrently and prospectively predict depressive symptom-
atology among both clinical and non-clinical samp les of
adults and adolescents (Connolly et al. 2015; Jacobs et al.
2008). Among adolescents, several studies examining current-
ly and remitted depressed youth have found that depression is
associated with significantly greater endorsement and recall of
negative adjectives, with some studies reporting decreased
endorsement and recall of positive adjectives as well (Alloy
et al. 2012; Gençöz et al. 2001;HammenandZupan1984;
Timbremont and Braet 2004). Furthermore, among communi-
ty samples of adolescents, recall of fewer positive adjectives
predicted increases in depressive symptoms over a 9-month
follow-up period (Connolly et al. 2015), and recall of more
negative adjectives interacted with rumination to predict in-
creases in depression longitudinally (Black and Pössel 2013).
No studies to our knowledge have examined the associa-
tion between the SRET and SI directly, although low reported
levels of self-esteem, a related explicit measure of self-con-
cept, has been linked to increased SI in adolescents
(Overholser et al. 1995). Given that depression is highly as-
sociated with SI, and that information processing biases serve
as a vulnerability factor for depression and suicide (Alloy et al.
1997; Black and Pössel 2013; Connolly et al. 2015; Wenzel
and Beck 2008), we propose that SRET information process-
ing may also serve as a risk factor for SI.
Negative Inferential Style
Negative inferential style is defined as the tendency to attri-
bute negative life events to stable and global causes, as well as
to infer negative implications for the self and negative future
consequences from their occurrence. As outlined in Wenzel
and Becks(2008) cognitive theory of suicidal behavior, the
stronger ones tendency to process information about negative
life events in this manner, the greater the likelihood one may
develop suicidal thoughts in response to their occurrence.
Although literature examining the relationship between
negative inferential style and SI is more consistent and ro-
bust among adults, aspects of negative inferential style have
been examined among adolescents and have demonstrated
some varied results in predicting SI. For example, several
longitudinal studies have found that mid-to-late adolescents
with a more negative inferential style were significantly
more likely to experience prospective SI over follow-up than
those with a less negative inferential style (Schwartz et al.
2000; Smith et al. 2006). Furthermore, in a large longitudi-
nal study of late adolescents, Lewinsohn et al. (1996)dem-
onstrated that a combined measure of negative depressotypic
cognitions, inferential style, self-esteem, and coping skills
mediated the relationships between psychopathology, physi-
cal illness, negative events, interpersonal events and a com-
bined measure of SI and suicidal behavior (SB). However, a
recent study by Labelle et al. (2013) indicates that a dys-
functional inferential style did not predict SI among a com-
munity sample of adolescents ages 14 to 18. Given the
mixed results regarding the impact of negative inferential
style on SI among mid-to-late adolescents, and the relative
dearth of information regarding this relationship among
young adolescents, more research is needed to clarify the
role of this negative information processing style.
Response Style: Rumination
and Distraction/Problem-Solving
A ruminative response style is a cognitive style characterized
by a chronic, repetitive focus on ones dysphoric emotions as
well as their causes and consequences (Nolen-Hoeksema
1991). Several theories have proposed that rumination serves
as a risk factor for SI. Research indicates that rumination is
perseverative and may inhibit ones ability to problem-solve
by depleting concentration and contributing to inflexible
think ing ( Davis and Nolen-Hoekse ma 2000; Miran da and
Nolen-Hoeksema 2007). In turn, exhibiting deficits in
problem-solving is itself a risk factor for SI and SB
(Lyubomirsky and Nolen-Hoeksema 1995). Furthermore, ac-
cording to the res ponse styles theory, the passive style in
which individuals focus on their symptoms is thought to
heighten and prolong the presence o f affective symptoms
(Nolen-Hoeksema 1991).
Therefore, this type of thinking also may interfere with
ones ability to adaptively regulate ones mood, with deficits
in mood regulation also strongly linked to SI and SB (Miranda
and Nolen-Hoeksema 2007; Williams et al. 2005).
Furthermore, OConnors(2011) theory of suicide suggests
that suicide risk comes about from the experience of defeat
and entrapment, which rumination might foster.
Given these suggestions, it is not surprising that there is a
consistent link between rumination and suicide risk in the
literature (for a review, see Morrison and OConnor 2008).
For example, in a 2.5 year longitudinal study, rumination pre-
dicted hopelessness and both the severity and duration of SI
among a sample of non-depressed university students (Smith
et al. 2006). Among a community adult sample, rumination
J Abnorm Child Psychol
predicted SI at 1 year follow-up, controlling for baseline SI,
with depressive symptoms mediating the relationship
(Miran da and N olen -H oeks em a 2007). Longitudinal and
cross-sectional research also has found that rumination medi-
ates the relationships between self-criticism, cognitive flexi-
bility, depressive symptoms, negative life events, suicide at-
tempts, and SI (Chan et al. 2009;OConnor and Noyce 2008;
Krajniak et al. 2013; Miranda et al. 2013). Although the link
between rumination and SI appears to be consistent among
college students and adults, no studies to our knowledge have
examined th is link among young adolescents. However,
existing literature documenting the significant role rumination
plays in predicting prospective depressive symptoms among
adolescents provides compelling reason to believe that this
response style may also be a vulnerability for suicidal
thoughts among adolescents and, if so, may serve to extend
Wenzel and Becks(2008) cognitive model of suicide to in-
corporate maladaptive cognitive processes in response to neg-
ative affect (Abela et al. 2007, 2009; Stange et al. 2014).
More recently, factor analyses of common measures of re-
sponse styles among adolescents have suggested that there are
two aspects of responses to negative affect: rumination, the
tendency to repetitively think about ones low mood as well as
its negative consequences, and distraction/problem-solving,
the tendency to distract oneself and/or problem-solve as a
response to low mood (Abela et al. 2007). According to the
response styles theory (Nolen-Hoeksema 1991), responding
to negative affect by distracting oneself inhibits inward think-
ing, which, in turn, may serve as a protective factor,
preventing negative affect from resulting in greater dysfunc-
tional cognitions. This technique subsequently allows individ-
uals to more efficiently problem-solve without intrusion from
the biased depressogenic thinking that negative affect often
produces (Nolen-Hoeksema et al. 1993). Therefore, it has
been hypothesized that initially distracting oneself from de-
pressive symptoms, followed by engaging in active problem-
solving once negative affect has improved, may be the optimal
method of decreasing depressed mood (Nolen-Hoeksema
1991).
Given this hypothesis, distraction and problem-solving
may be considered protective factors against depression.
Indeed, a collection of evidence among adult and child
samples supports this claim. Importantly, a longitudinal
study of 6 to 14 year-olds found that engaging in both
distraction and problem-solving techniques buffered against
the development of depressive symptoms over time (Abela
et al. 2007). Among dysphoric adult samples, undergoing
a distraction induction has consistently been shown to de-
crease depressed mood, indicating its ben eficial e ffects
(see Wisco and Nolen-Hoeksema 2008). Furthermore, en-
gaging in distraction also has been shown to increase ef-
fective problem-solving, providing support for the purport-
ed relationship between distraction, subsequently improved
problem-solving, and decreases in depressive symptoms
(see Nolen-Hoeksema et al. 2008).
However, contradictory findings also have been reported in
which distraction and problem-solving were not found to buff-
er against depressive symptoms within samples of children
(Abela et al. 2002) as well as adults (see Nolen-Hoeksema
et al. 2008). Issues in the measurement of distraction and
problem-solving are thought to be responsible in part for these
observed null findings. Indeed, Abela and colleagues (2002)
did not find significant protective effects of distraction and
problem-solving in their study in which they assessed these
domains using separate subscales. Upon utilizing factor ana-
lytic techniques, Abela and colleagues (2007)proposedthat
distraction and problem-solving were best represented as a
unified factor; when examined as such, this combined re-
sponse style was found to prospectively protect against de-
pressive symptoms in a young adult sample.
In contrast to rumination, no study to our knowledge has
ex
amined the link between distraction and problem-solving in
response to negative affect and SI among any age gr oup.
Despite these mixed findings in relation to depression, we
propose that employing distraction and problem-solving will
buffer against the activation of suicide-relevant cognitive pro-
cesses, and therefore, protect against the development of sui-
cidal cognitions among young adolescents. Specifically, we
posit that these more adaptive response styles may lessen the
likelihood that ones negative affect may produce state-
dependent dysfunctional cognitions, and may hamper genera-
tion of escapist suicidal behaviors as solutions when problem-
solving. The current study aims to fill the identified gaps in the
literature by investigating the respective risk associated with
rumination and protection associated with distraction/
problem-solving in the development of SI among young ado-
lescents, and therefore, possibly extend Wenzel and Becks
(2008) cognitive model of suicide.
Sex Differences in the Pathway Between Cognitive
Factors and Suicidal Ideation
Although SI increases among both boys and girls during the
adolescent years (Nock 2012), research has consistently doc-
umented that adolescent girls are at greater risk for SI and
attempted suicide (Lewinsohn et al. 1996). In addition to in-
creased rates of SI among adolescent girls, research has con-
sistently demonstrated that adolescent girls also have greater
negative inferential styles (Hankin and Abramson 2002)and
are more likely to develop ruminative tendencies during the
adolescent years (e.g., Hamilton et al. 2015). Although few
studies have evaluated sex as a potential moderator of the
relationship between cognitive factors and SI, numerous stud-
ies have demonstrated that cognitive vulnerabilities predict
depression more strongly among adolescent girls than boys
JAbnormChildPsychol
(e.g., Jose and Brown 2008; Mezulis et al. 2010). Further, one
study found that girls with greater hopelessness were more
likely to experience SI, which suggests that girls with cogni-
tive vulnerabilities may be particularly at risk for SI compared
to boys. Given the documented sex differences in SI, it is
important to determine factors that may exacerbate the risk
of SI, particularly among girls.
The Current Study
The present study assessed several cognitive factors that have
received varying degrees of research support in conferring risk
for or protection against the development of SI. This study
aimed to elucidate which of these cognitive factors are most
potent in predicting SI in the transition from early to mid-
adolescence, a developmental period that has received rela-
tively scant attention in lon gitudinal suicide research.
Investigating this developmental period is of particular impor-
tance, as it provides the opportunity to identify key risk and
protective factors that may be present and identifiable before
the adolescent surge in depression and suicidal thoughts and
behaviors occurs, particularly among girls (Hankin et al. 1998;
Abela and Hankin 2008). Consistent with Wenzel and Becks
(2008) cognitive model of suicide, it was hypothesized that
greater endorsement of negative adjectives as self-referent and
greater recall of endorsed negative adjectives on the SRET
would serve as prospective risk factors for SI.
Correspondingly, it was expected that less endorsement of
positive adjectives as self-referent and less recall of endorsed
positive adjectives on the SRET would also serve as risk fac-
tors for SI over the transition from early to mid-adolescence.
Furthermore, in line with the cognitive model of suicidal be-
havior, it was hypothesized that negative inferential style
would independently pose risk for SI over time. Although
ruminative response to negative affect has not yet been exam-
ined in relation to SI among young adolescents nor incorpo-
rated in the cognitive model of suicidal behavior (Wenzel and
Beck 2008), the tendency to respond to negative affect by
engaging in rumination was expected to serve as a risk factor
for future SI and the tendency to respond to negative affect by
engaging in self-distraction and/or problem-solving was ex-
pected to serve as a protective factor against future SI. Given
mixed results and scant literature aimed at determining the
relative impact of each of these cognitive factors in the pre-
diction of SI, we did not generate specific hypotheses regard-
ing which cognitive factors may be the most potent predictors
of SI. Rather, we explored which cognitive variables emerged
as the strongest predictors of SI when examined simultaneous-
ly. Further, given research demonstrating that girls are at great-
er risk for cognitive vulnerabilities (e.g., Mezulis et al. 2010)
and SI (Lewinsohn et al. 1996), we expected that the cognitive
vulnerabilities tested would predict SI more strongly among
adolescent girls than boys.
Method
Participants and Procedure
Sample Recruitment
Participants included in these analyses completed at least the
baseline assessment and one additional follow-up session of
the Temple University Adolescent Cognition and Emotion
(ACE) Project, a longitudinal study examining risk factors
for the development of depressive disorders in adolescence
(see Alloy et al. 2012 for a detailed description of the sample).
This study recruited early adolescents (12 to 13 years old) and
their primary female caregivers (93 % were the adolescents
biological mothers; herea fter referred to as Bmothers^)
from Philadelphia area public and private middle schools.
Inclusion criteria required participants to be age 12 or 13 at
the time of the baseline assessment, to identify as white, black,
or biracial, and to be able to attend assessments with their
mothers. Participants were excluded if either the mother or
adolescent was unable to speak or read English, or if they
demonstrated a history of psychosis, severe cognitive impair-
ment or any medical problems that would not allow study
participation. Dyads who met inclusion and exclusion criteria
were invited to complete a baseline assessment that was sep-
arated into two sessions, referred to as Time 1 Session 1 and
Time 1 Session 2.
Procedures
Adolescents and their mothers attended both Time 1 sessions
and all prospective assessments in person. The Time 1 ses-
sions each lasted approximately 2 to 3 h and included ques-
tionnaires, behavioral tasks, and diagnostic interviews.
Adolescents and mothers were each compensated $30 per
session. At Time 1, adolescents completed self-report mea-
sures of suicidal ideation, depressive symptoms, negative in-
ferential style, and response styles. Adolescents also complet-
ed the SRET behavioral task measuring self-referent informa-
tion processing. Adolescents and mothers completed diagnos-
tic interviews assessing the adolescents lifetime history of
psychiatric disorders and suicidal ideation with a trained doc-
toral student in clinical psychology, post-baccalaureate re-
search assistant, or a Ph.D. level clinical psychologist.
Participants who completed Time 1 of the study were invited
to participate in longitudinal assessments every 6 months, dur-
ing which they were again administered the self-report ques-
tionnaires and behavioral tasks listed above. Diagnostic inter-
views were conducted every 12 months to assess for change in
J Abnorm Child Psychol
diagnoses and SI over time. Adolescents were followed for an
average of 503.68 days (SD=222.59 days). Mothers provided
written consent and adolescents provided written assent to
participate in this prospective study.
Study Sample
The present study sample consisted of 324 adolescents who
completed baseline measures and at least 1 of 4, 6-month
follow-up sessions over approximately 24 months. The sam-
ple was 12.39 years old (SD=0.63) at Time 1, 53.5 % female,
47.50 % White, and 52.5 % African-American; 48.42 % of the
sample qualified for free or reduced lunch at school, a measure
of socioeconomic status that accounts for the number of de-
pendents being supported by a family income. (See Table 1 for
sample demographics).
Measures
Current and Past Depressive Disorders
The Kiddie Schedule for Affective Disorders and
Schizophrenia Epidemiological Version (K-SADS-E;
Orvaschel 1995), a semistructured diagnostic interview, was
administered to both adolescents and mothers at baseline and
at each 12-month follow-up session for the primary purpose of
diagnosing psychiatric disorders within the sample. The K-
SADS-E assesses current and past Diagnostic and Statistical
Manual of Mental Disorders Fourth Edition (DSM-IV-TR;
American Psychiatric Association 2000) Axis I psychopathol-
ogy in youth. The K-SADS-E interview was revised to addi-
tionally al low for the assessment of Research Diagnostic
Criteria (RDC; Spitzer et al. 1978) diagnoses. Trained inter-
viewers administered the K-SADS-E first to mothers and then
to adolescents, subsequently generating a summary rating of
symptoms and diagnoses. The interviewers were charged with
summarizing the ratings of the mothers and adolescents based
upon Bbest-estimate^ clinical judgment, in line with the K-
SADS-E procedures. Previous research on the K-SADS-E
has demonstrated good inter-rater and test-retest reliability
(e.g., Major Dep ression [= .73]; Dysthymia [κ =.72])
(Orvaschel 1995). For the purposes of this study, adolescents
were considered to have exhibited a current or past episode of
a depressive disorder if he/she met criteria for DSM-IV-TR
Definite Major Depressive Disorder (MDD), Depressive
Disorder Not Otherwise Specified (NOS) or Dysthymia or if
he/she met criteria for RDC MDD, Minor Depressive
Disorder (MDD), or Intermittent Depressive Disorder (IDD).
All interviewers were subject to reliability checks.
Disagreement in diagnosis was handled by bringing the case
to a case meeting to discuss with the Principal Investigator and
other licensed clinicians and expert diagnosticians to deter-
mine the diagnosis. Interrater reliability based on 120 pairs
of ratings (10 interviews, randomly selected, 5 raters for each
of 24 diagnoses) was κ=.85 (BLINDED FOR REVIEW).
Suicidal Ideation
Suicidal ideation was assessed by adolescents response on
the suicidal i deation item of the self-report Childrens
Depression Inventory (CDI; Kovacs 1992)andby
interviewer-rated responses to the suicide item in the K-
SADS-E (based on both mother and adolescent report), de-
scribed previously. The CDI was administered at baseline and
approximately every 6 months. The CDI is a 27-item self-
report measure used to evaluate depressive symptomatology
among children and adolescents ages 7 to 17. The scale mea-
sures depression symptoms experienced by youth over the
previous 2 weeks. Items are scored on a scale from 0 to 2,
with higher scores indicating greater severity of symptomatol-
ogy. For the purposes of this study, we used only the suicide
item (Item 9), with zero indicating BI do not think about killing
myself,^
one indicating BI
think about killing myself but I
Tabl e 1 Demographic and cognitive factors as a function of SI status
T2 No SI (N=261) T2 SI (N=63) t/x2
T1 Age 12.43 (0.61) 12.25 (0.67) 1.95
Sex 47.51 % female 71.43 % female 11.64**
Race 51.73 % AA 55.56 % AA 0.30
48.28 % White 44.44 % White
SES (Lunch) 51.43 % 48.57 % 4.13
Days In Study 496.15 (229.72) 534.05 (189.94) 1.16
# F/U Sessions 2.78 (1.30) 2.83 (1.37) 0.28
T1 SI 6.13 % 30.16 % 30.41***
T1 Current Dep 3.16 % 1.59 % 0.41
T1 Past Dep 11.88 % 11.11 % 0.03
SRET Neg Me 1.67 (1.56) 2.95 (2.69) 5.00***
SRET Neg Rec .12 (0.15) .19 (0.19) 2.70**
SRET Pos Me 9.85 (1.32) 9.35 (1.92) 2.44*
SRET Pos Rec .58 (0.25) .56 (0.22) 0.55
ACSQ 113.72 (36.98) 129.92 (45.35) 2.98**
HSC 2.90 (1.90) 3.43 (2.68) 1.82
CRSQ-R 23.53 (6.72) 27.62 (8.21) 4.14***
CRSQ-DPS 19.58 (4.45) 17.51 (3.83) 3.40**
*p<0.05; ** p<0.01; *** p<0.001
Standard deviations are in parentheses. T1=Time 1 (baseline); T2=Time
2 (follow-up); SI=Suicidal Ideation; SES (Lunch)=measure of socioeco-
nomic status that accounts for the number of dependents being supported
by a family income; # F/U Sessions=Number of follow-up sessions com-
pleted; SRET Neg Me/SRET Pos Me=Total number of negative/positive
words endorsed as BMe^; SRET Neg Rec/SRET Pos Rec=[# positive/
negative words endorsed and recalled/total #words endorsed and recalled
across all conditions]; ACSQ-M=The Adolescent Cognitive Style
Questionnaire-Modified; HSC=Hopelessness Scale for Children;
CRSQ=Childrens Response Style Questionnaire; CRSQ-R=Rumina-
tion; CRSQ-DPS=Distraction/Problem Solving
JAbnormChildPsychol
would not do it,^ and two indicating BIwanttokillmyself.^
Adolescents indicating a score of one or two were considered
to exhibit SI. Previous studies have demonstrated the validity
of measuring SI using single suicide items derived from self-
reported depression scales (e.g., Desseilles et al. 2012). The
CDI has shown good reliability and validity (Klein et al. 2005)
and had a .85 internal consistency in this sample.
At Time 1, in the K-SADS-E, all adolescents and mothers
were asked if the adolescent had made any suicide plans (BDid
you ever have a specific plan to kill yourself, that you didnt
follow or carry out or try?^) in their lifetime. At 12-month and
24-month follow-ups, adolescents and mothers were asked if
the adolescent had made any suicide plans since their previous
interview. Furthermore, at Time 1, 12, and 24 months, any
adolescent or mother who endorsed that the adolescent expe-
rienced any symptoms of current or past depression and
screened into those sections of the K-SADS-E were asked if
the adolescent exhibited suicidal ideation (BDo (did) you think
about hurting or killing yourself?^), or made any suicide plans
(BWhat do (did) you think of doing?^). Only adolescents
whose summary scores indicated suicidal ideation and or/ sui-
cide plans on the K-SADS-E were considered as exhibiting
suicidal ideation.
A combination dichotomous score was calculated such that
adolescents were considered to exhibit suicidal ideation at
baseline if they endorsed suicide items on either the CDI or
the K-SADS-E (0=Suicidal Ideation Not Present; 1=Suicidal
Ideation Present), thereby incorporating both self-report and
interview-based assessment information.
A combination dichotomous follow-up score also was cal-
culated such that adolescents were considered to exhibit SI
over follow-up if they endorsed suicide items on either the
CDI at 6, 12, 18, or 24 month follow-up or on the K-SADS-
E (0=Suicidal Ideation Not Present; 1=Suicidal Ideation
Present) at 12 or 24 month follow-up, thereby incorporating
both self-report and interview-based assessment information.
Self-Referent Information Processing
The Self-Referent Encoding Task (SRET; Derry and
Kuiper 1981;HammenandZupan1984)measurespartic-
ipants judgments of negative and positive emotionally-
valenced words as self-descriptive, as well as their free
recall of these words. The SRET was adapted for the
computer using E-Prime software for the purposes of this
study (Alloy et al. 2012; Connolly et al. 2015).
Adolescents completed a total of 44 trials in which either
a positive or a negative adjective appeared on the com-
puter above a question instructing them to either make a
self-referent judgment (BLike Me?^), rapidly judging
whether the adjective describes them, or to make a struc-
tural judgment (BHas an E?^), rapidly judging whether
the adjective contains the letter
BE^.
Structural trials served
as control trials, in order to assess for differences in the
recall of self-referent negative/positive adjectives compared
to the recall of negative/positive adjectives that were not
encoded self-referentially. Adolescents were prompted to
respond by pressing either a BYes^ or a BNo^ button
labeled on the keyboard. Once adolescents responded they
were advanced to the next trial immediately. The 44 total trials
were divided into 22 structural judgment trials and 22 self-
referent judgment trials, each with 11 positively (e.g., happy,
attractive) and 11 negatively (e.g., ugly, loser) valenced adjec-
tives. Positive adjectives and negative adjectives were
matched on word length and frequency in the lexicon, and
the order in which they were presented to participants was
randomly determined. Immediately after completion of the
computerized trials, a trained research assistant prompted par-
ticipants to freely recall all words they remembered from the
computer task. Participants were given up to 5 min to provide
answers. The tasks rapid assessment format may help limit
response bias as participants rate their self-concept, and its
surprise recall component is intended to measure the depth
with which this negative self-referent information has been
encoded.
In this study, the SRET variables analyzed were: 1)
Number of negative adjectives endorsed as self-referent, 2)
Number of positive adjectives endorsed as self-referent, 3)
Number of correctly recalled negative adjectives endorsed as
self-referent (judged Blike me^) divided by the total number of
positive and negative words endorsed and recalled across both
the self-referent and structural conditions, and 4) Number of
correctly recalled positive adjectives endorsed as self-referent
(judged Blike me^) divided by the total number of positive and
negative words endorsed and recalled across both the self-
referent and structural conditions.
Negative Inferential Style
The Adolescent Cognitive Style Questionnaire-Modified
(ACSQ-M; Alloy et al. 2012) is a revised version of the orig-
inal scale (ACSQ; Hankin and Abramson 2002), which mea-
sures adolescents tendency to make negative inferences about
the causes, consequences and self-implications of negative life
events. In addition to assessing adolescent inferential style for
negative achievement and interpersonal-related events, the
modified version of the ACSQ also assesses appearance-
related events. Therefore, the ACSQ-M presents four hypo-
thetical events per domain (achievement, interpersonal, and
appearance-related) and subsequently prompts adolescents to
endorse inferences about the causes of the events (i.e.,
internal/ external, stable/ unstable, global/ specific), conse-
quences of the events, and self-worth implications of the
events. Each dimension is rated on a one to seven scale, with
higher scores indicating a more negative inferential style. In
the present study, we examined participants overall negative
J Abnorm Child Psychol
score, which is a composite of ratings of event stability,
globality, consequences, and self-implications in the achieve-
ment and interpersonal domains, in line with scoring of the
original ACSQ (Alloy et al. 2006). Previous literature has
shown that the ACSQ exhibits good internal consistency and
test-retest reliability (Hankin and Abramson 2002).
Furthermore, a study examining the scales factor structure
in measuring cognitive vulnerability to depression among ad-
olescents demonstrated validity (Hankin and Abramson
2002). The internal consistency of the ACSQ-M in this sample
was α=.94 for the overall negative composite.
Response Styles
The Childrens Response Styles Questionnaire (CRSQ; Abela
et al. 2004) is a self-report questionnaire designed for youth
that assesses response to dysphoric mood. The scale has a total
of 25 items that prompt participants to indicate how often they
respond to feeling depressed in a particular way. The 25 items
represent two different respo nse styles: ruminatio n and
distraction/problem-solving (DPS). The rumination subscale
consists of items measuring self-focused responses to de-
pressed mood (e.g., BThink about how alone you feel^). The
DPS subscale measures the tendency to attempt to direct ones
attention away from onesmood(e.g.,BWhen I am sad, I do
something fun with a friend^) and the tendency to attempt to
problem-solve and overcome a depressed mood (BWhen I am
sad, I think of a way to make my problem better^). Each item
is measured on a 4-point scale (never, sometimes, often, al-
most always) and higher scores on each subscale reflect a
stronger tendency to engage in rumination, distraction, or ac-
tive problem-solving when experiencing depressed mood.
The CRSQ has demonstrated good validity and internal con-
sistency (Abela et al. 2007). The rumination and DPS sub-
scales exhibited good internal consistency in the present sam-
ple (α=.84 and .67, respectively).
Statistical Analysis
Before conducting a series of logistic regressions to test the
main study hypotheses, we ran independent samples t-tests to
determine if any demographic variables (age at baseline, sex,
race, SES) were associated with concurrent or prospectively
measured SI. Further, given the participants varying length of
time in the study, we also ran an independent samples t-test to
determine if number of days in the study and if number of
follow-up assessments were associated with prospectively
measured SI. Only sex was significantly associated with SI
prospectively, in that females were more likely to exhibit in-
creased SI over time. Thus sex was controlled for in all sub-
sequent prospective analyses when sex was not examined as a
moderator (in whi ch it was entered as a main effect). An
additional set of preliminary analyses examined bivariate cor-
relations between the main study variables (see Table 2).
To evaluate study hypotheses and examine each cognitive
factor as an independent prospective predictor of SI, we con-
ducted a series of logistic regression analyses, controlling for
sex, Time 1 SI, Time 1 current depressive diagnoses, and Time
1 past depressive diagnoses. In order to determine the relative
predictive value of each cognitive factor, we ran separate hi-
erarchical logistic regressions to determine which cognitive
factors predicted prospective SI. Next, to examine the relative
strength and predictive ability of each cognitive factor, we
entered each significant cognitive factor simultaneously in
Step 2 of a combined logistic regression, controlling for the
previously mentioned covariates in Step 1. We centered the
cognitive variables when they were entered simultaneously
into the multiple logistic regression analysis so as to combat
the potential for multicollinearity.
To examine our hypothesis that the relationship between
ea
ch cognitive risk and protective factor and SI may be par-
ticularly strong among adolescent girls compared to boys, we
conducted a s eries of moderation analyses using the
PROCESS macro in SPSS (Hayes 2013). Thus, we controlled
for Time 1 SI, Time 1 current depressive diagnoses, and Time
1 past depressive diagnoses during all analyses predicting to
prospective SI. To test each cognitive factor separately, the
main effect of sex and the cognitive factor of interest were
entered into the model in addition to the interaction term of
sex and each cognitive factor. For all significant interactions,
we probed the simple slopes for boys and girls.
Results
Preliminary Analyses
At baseline, 10.8 % of the sample reported SI on either the
CDI or via diagnostic interview on the K-SADS-E. Over the
2-year follow-up period (M=503.68 days; SD=222.5 9),
19.4 % of the sample endorsed SI. At baseline, a dichotomous
indicator of SI utilizing CDI Item 9 and a dichotomous indi-
cator of SI measured by the K-SADS-E were significantly
correlated (r=.34, p<0.001). Follow-up SI results utilizing
the CDI #9 and the K-SADS-E were also significantly corre-
lated (r=.34, p<0.001). There were no significant differences
in SI status at baseline or follow-up based on age, race or SES.
At baseline, sex was not significantly related to S I status
(males=1 0.32 %; females=11.24 %, χ
2
(1, N=324)=0.70,
p>0.05). However, at follow-up, there was a significant dif-
ference in SI for males (11.61 %) and females (26.70 %), χ
2
(1,
N=324)=11.64, p=0.001, such that females demonstrated
higher rates of SI.
We found significant differences in length of time in study
and number of follow-up sessions based on race (r=.18,
JAbnormChildPsychol
p<0.01; r =.13, p<0.05, respectively) and baseline age
(r=.24, p<0.001; r=.50, p<0.001, respectively). However,
number of follow-ups, length of time in study, race, and age
were all not significantly associated with the presence of SI
over the follow-up period. Furthermore, sensitivity analyses
indicated that all study results remained consistent when also
controlling for race and age. Given the consistent results, the
following analyses presented were run without controlling for
these demographic variables. Tables 1 and 2 provide an over-
view of descriptive statistics and correlations between study
variables, respectively.
Correlational Relationships Between Cognitive Factors
and SI at Baseline and Follow-Up
Relationship Between Negative Self-Referent Information
Processing and Suicidal Ideation
The number of negative adjectives adolescents endorsed as
self-referent was significantly positively correlated with both
baseline (r =.29, p <0.001) and follow-up SI (r =.27,
p<0.001). Furthermore, the proportion of self-referent nega-
tive adjectives correctly recalled relative to all words endorsed
and recalled w as positively correlated with follow-up SI
(r=.18, p<0.01), but not with baseline SI (r=.11, p>0.05).
The number of positive adjectives adolescents endorsed as
self-referent was significantly negatively correlated with both
baseline (r = .31, p<0.001) and follow-up SI (r = .14,
p<0.01). Additionally, the proportion of positive words en-
dorsed as self-referent that were subsequently correctly
recalled relative to all words endorsed and recalled was sig-
nificantly associated with baseline SI (r=.12, p<0.05), but
not with follow-up SI (r=0.03, p>0.05).
Relationship Between Negative Inferential Style and Suicidal
Ideation
We hypothesized that negative inferential style would be as-
sociated with SI at both baseline and over the 2 year follow-up
period. In line with these hypotheses, negative inferential style
was significantly associated with baseline SI (r =.21,
p<0.001) and follow-up SI (r=.26, p<0.01).
Relationship Between Response Styles of Rumination
and Distraction/Problem-Solving and Suicidal Ideation
We hypothesized that greater levels of rumination would be
co
rrelated with baseline and follow-up SI. Rumination was, in
fact, significantly correlated with both baseline (r=.34,
p<0.001) and follow-up SI (r=.23, p<0.001). Although
responding to negative emotion by engaging in distraction/
problem-solving was not significantly correlated with baseline
SI (r=.10, p>0.05), it was significantly negatively correlated
with prospective SI (r=.19, p<0.01).
Cognitive Factors as Prospective Predictors of SI
over Two-Year Follow-Up
All SRET variables, negative inferential style, rumination, and
distraction/problem-solving were examined separately as pre-
dictors of follow-up SI, controlling for baseline SI, current and
past depressive diagnoses, and sex. Other demographic vari-
ables and time in study were not covaried, as they were not
correlated with prospective SI.
After adjusting for these covariates, the number of negative
words endorsed as BMe^ on the SRET significantly predicted
SI over follow-up (OR=1.31; 95 % CI [1.12, 1.54], p<0.01).
Furthermore, th e ratio of nega tive self-referent adjectives
Tabl e 2 Bivariate correlations between study variables
123456789
T1 SI
T2 SI 0.31***
SRET Neg Me 0.29*** 0.27***
SRET Neg Rec 0.11 0.18** 0.45***
SRET Pos Me 0.31*** 0.14* 0.33*** 0.28***
SRET Pos Rec 0.12* 0.03 0.29*** 0.40*** 0.23***
ACSQ-M 0.21*** 0.16** 0.23*** 0.03 0.16** 0.01
CRSQ-R 0.34*** 0.23*** 0.35*** 0.09 0.23*** 0.01 0.34***
CRSQ-DPS 0.10 0.19** 0.16** 0.12 0.17** 0.10 0.05 0.08
* p<0.05, ** p<0.01, *** p<0.001
T1=Time 1 (baseline); T2=Time 2 (follow-up); SI=Suicidal Ideation; SRET Neg=Me/SRET Pos=Me=Total number of negative/positive words
endorsed as BMe^; SRET Neg Rec/SRET Pos Rec=[# positive/negative words endorsed and recalled/total #words endorsed and recalled across all
conditions]; ACSQ-M=The Adolescent Cognitive Style Questionnaire-Modified; CRSQ=Childrens Response Style Questionnaire; CRSQ-R=Rumi-
nation; CRSQ-DPS=Distraction/Problem Solving
J Abnorm Child Psychol
correctly recalled to the total number of adjectives endorsed
and recalled was trending toward significance in predicting SI
at follow-up (OR=1.31; 95 % CI [1.12, 1.54], p =0.053).
Neither the number of positive words endorsed as self-
referent on the SRET nor the recall of these words was pre-
dictive of SI at follow-up, after controlling for study covariates
(OR=.90; 95 % CI [0.74, 1.11], p>0.05; OR=.88; 95 % CI
[0.24, 3.16], p>0.05).
Consistent with hypotheses, n egative inferential style
(OR=1.01; 95 % CI [1.00, 1.02], p<0.05), and the response
styles of rumination (OR=1.06; 95 % CI [1.01, 1.10], p<0.01)
and distraction/problem-solving (OR=.90; 95 % CI [0.83,
0.96], p<0.01) each significantly predicted adolescent SI
over follow-up in the expected directions after adjusting
for covariates (see Table 3).
The most potent predictor of SI over the 2-year fol-
low-up period was baseline SI, conferring five times
higher odds of reporting SI at future timepoints. Sex
served as the second strongest predictor of prospective
SI, with females being three times more likely to report
SI over the 2 year follow-up period (see Table 4). Of
note, being diagnosed with a current depressive disorder
at Time 1 was minimally predictive of prospective SI
(OR=0.0 4; 95 % CI [0.00, 0.71] , p<0.05), with a past
depressive episode not significantly predicting prospec-
tive SI (OR=0.51; 95 % CI [0.16, 1.61], p>0.05).
Strongest Cognitive Predictors of Suicidal Ideation
among Early Adolescents
In a combined regression model including all significant
cognitive predictors, the number of negative adjectives
endorsed as self-referent on the SRET remained signif-
icant as a risk factor for prospective SI (OR=0.01;
95 % CI [1.04, 1.45], p < 0.05) and distraction/
problem-solving remained a significant protective factor
for SI (OR=.91; 95 % CI [0.85, 0.98], p<0.05). The
degree to which adolescents engaged in rumination and
exhibited a negative inferential s tyle were no longer
predictive of SI when entered with all cognitive factors
simultaneously.
Tabl e 3 Relationship between individual cognitive variables and prospective SI status controlling for Time 1 SI, Time 1 current and past depressive
disorders, and sex
Predictor β Wald OR 95 % CI p ΔR
2
SRET Neg=Me 0.52 11.24 1.68 1.242.26 0.001 0.05
SRET Neg Rec 2.12 3.74 8.40 0.9771.80 0.053 0.00
SRET Pos=Me 0.10 0.92 0.90 0.741.11 .337 0.00
SRET Pos Rec 0.13 0.04 0.88 0.243.16 .842 0.00
ACSQ-M 0.37 5.60 1.45 1.071.97 0.018 0.03
CRSQ-R 0.40 6.22 1.49 1.092.03 0.013 0.03
CRSQ-DPS 0.48 8.92 0.62 0.450.85 0.003 0.04
T1=Time 1 (baseline); T2=Time 2 (follow-up); SI=Suicidal Ideation; SRET Neg=Me/SRET Pos=Me=Total number of negative/positive words
endorsed as BMe^; SRET Neg Rec/SRET Pos Rec=[# positive/negative words endorsed and recalled/total #words endorsed and recalled across all
conditions]; ACSQ-M=The Adolescent Cognitive Style Questionnaire-Modified; CRSQ=Childrens Response Style Questionnaire; CRSQ-R=Rumi-
nation; CRSQ-DPS=Distraction/Problem Solving; ΔR
2
=Change in R2 beyond step 1 covariates
Tabl e 4 Logistic regression evaluating significant cognitive predictors of SI simultaneously
Step Predictor β Wald OR p 95 % CI ΔR
2
1 Sex 1.16 11.13 3.19 0.001 1.616.30 .19
T1 SI 1.72 12.98 5.58 0.000 2.1912.24
T1 Curr Dep 3.14 4.85 0.04 0.028 0.000.71
T1 Past Dep 0.68 1.32 0.51 .250 0.161.61
2 SRET Neg=Me 0.39 6.02 1.48 0.014 1.082.02 0.09
ACSQ-M 0.23 1.78 1.26 .182 0.901.76
CRSQ-R 0.20 1.27 1.22 .259 0.861.73
CRSQ-DPS 0.41 6.03 0.66 0.014 0.480.92
T1=Time 1 (baseline); T2=Time 2 (follow-up); SI=Suicidal Ideation; Curr=Current; Dep=Depression; SRET Neg=Me Total number of negative
words endorsed as BMe^; ACSQ-M=The Adolescent Cognitive Style Questionnaire-Modified; CRSQ=Childrens Response Style Questionnaire;
CRSQ-R=Rumination; CRSQ-DPS=Distraction/Problem Solving; ΔR
2
=Change in R2 beyond step 1 covariates
JAbnormChildPsychol
Sex Differences in the Prospective Relationship
Between Cognitive Factors and SI
We examined potential sex differences in the relationship be-
tween cognitive factors and prospective SI, controlling for
baseline SI and current and past depressive diagnoses.
Consistent with hypotheses, there was a significant interaction
between sex and the number of negative words endorsed as
BMe^ on the SRET (B=.41, SE=.19, Z=2.11, p=0.04).
Specifically, the number of negative words endorsed predicted
prospective levels of SI over follow-up among adolescent girls
(B=.38, SE=.10, Z=3.73, p<0.001), but not among boys (B=
0.03, SE=.17, Z=.20, p=.84; Fig. 1). Contrary to hypoth-
eses, there was no significant interaction between sex and any
other SRET variables, negative inferential style, rumination,
or distraction/problem-solving in predicting prospective SI. In
sum, it appears that although there is a significant main effect
of sex on prospective SI, the number of negative adjectives
endorsed as self-referent more strongly predicted SI among
girls than boys.
Discussion
A multitude of cognitive factors have been implicated as pre-
dicto rs of SI and ha ve been incorporated into a cognitive
model of suicidal behavior (Wenzel and Beck 2 008).
However, very few studies have prospectively examined mul-
tiple cognitive predictors of SI in non-clinical samples of
young adolescents over their transition to mid-adolescence,
despite the fact that this period of time coincides with a sig-
nificant surge in psychopathology and suicidality (Hankin
et al. 1998; Kessler et al. 2001;Nocketal.2008).
Furthermore, very few studies have simultaneously examined
suicide-relevant cognitive factors in order to determine their
relative importance in conferring risk for and/or protection
against SI. In line with Wenzel and Becks(2008)modelof
suicidal behavior, the current study demonstrates that both
cognitive content and cognitive processes pose significant risk
for the development of SI. Specifically, the results indicate
that the preferential endorsement of negative adjectives as
self-referent and a negative inferential style are significant
indicators of risk for the development of SI over a 2-year
follow-up period among early adolescents. Adding to the pos-
tulates of Wenzel and Becks(2008) cognitive model of sui-
cidal behavior, findings suggest that young adolescents ten-
dencytoruminateinresponsetonegativeaffectalsoincreases
risk for experiencing suicidal thoughts. Further building on
this model, the current study found that the cognitive tendency
to respond to negative affect by engaging in distraction and
problem-solving reduces the risk of exhibiting SI over the
transition from early- to mid-adolescence. It is important to
note that these relationships remained significant even after
adjusting for consistently robust prospective predictors of SI
including sex, baseline SI and depressive disorders, and past
depressive disorders (Nock et al. 2008).
When examining these cognitive factors simultaneously,
negative self-schema (measured by the number of negative
adjectives an adolescent endorsed as self-referent during a
computerized self-referent encoding task) and the tendency
to engage in distraction and problem-solving when faced with
low mood, remained the only significant predictors of SI over
follow-up. Although we did not offer specific hypotheses re-
garding which cognitive factors would serve as the strongest
predictors of SI given the dearth of literature available to sup-
port such conjectures, these findings are surprising, as this is
the first study to our knowledge to examine either of these
factors as prospective predictors of SI. Our finding that these
variables predicted SI even when accounting for baseline SI,
depression diagnoses, sex, and the well-established cognitive
factors of negative inferential style and rumination, highlights
their potential utility in improving the predictive validity of
extant models of risk pathways to suicide.
Although rates of SI did not vary by sex at baseline, girls
displayed greater SI at follow-up, in line with previous re-
search (Lewinsohn et al. 1996). Furthermore, a significant
interaction was found between the number of negative self-
referent adjectives endorsed on the SRET and sex in the pre-
diction of SI, such that negative word endorsement was only a
significant predictor of SI among girls. This finding suggests
that the presence of a negative self-schema may be a particu-
larly important risk factor for the development of SI in fe-
males. No other interactions between sex and cognitive vul-
nerabilities emerged in the current sample. The finding that
the preferential endorsement of negative adjectives as self-
referent is a significant predictor of prospective SI is in line
with Wenzel and Becks(2008) cognitive model of suicide.
Specifically, in this model of suicide, as the frequency, inten-
sity, and duration of information processing biases increase,
one is at greater risk of experiencing suicidal cognitions. The
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
Low SRET High SRET
Probability of SI
Girls
Boys
Fig. 1 Gender moderates the relationship between SRET Neg words and
SI
J Abnorm Child Psychol
greater number of negative words attributed to oneself might
signify a higher likelihood that one possesses a negative self-
schema, which causes biases in the interpretation and
encoding of environmental stimuli. Given that the SRET re-
quired adolescents to quickly decide whether or not a negative
adjective was self-referent, it is possible that this task may tap
into automatic self-associations to a greater degree than to
explicit self-beliefs. Whereas explicit self-beliefs are theorized
to signify ones carefully weighted assessment of the truth of
alternative ideas, automatic self-associations are theorized to
more truthfully reflect how closely two constructs (such as the
self and negative characteristics) are linked in onesmemory
(Gawronski and Bodenhausen 2 006). Automatic self-
associations may be more reflective of deep-seated self-
schemas, as they are hypothesized to be less affected by social
desirability biases and introspection deficits (Greenwald and
Farnham 2000). Becks theory indicates that the deeper-seated
the negative self-schemas, the more likely they are to have a
dysfunctional effect on information processing biases, and
therefore, the greater likelihood that they may lead to suicidal
cognitions (Beck 1976, 1987).
It is intriguing that negative adjective endorsement on the
SRET emerged as the only cognitive variable to significantly
interact with sex in predicting SI, as sex differences have not
typically been reported in previous SRET research within the
depression literature. However, to our knowledge, the current
study is the first to examine SRET performance as a predictor of
SI, finding that the possession of a negative self-schema is a
particular risk factor for SI in girls but not boys. It is possible
that negative self-concept predicts SI more strongly among girls
due to a stronger internalization of negative views; indeed, it
has been shown that women engage in a greater degree of self-
focus compared to men (Ingram et al. 1988). In keeping with
this idea, if girls attend to and identify more strongly with this
negative self-schema than boys, they may be more likely to
adopt a hopeless or defeatist attitude and in turn, engage in SI.
A previous study of the relationship between self-esteem and SI
in adolescence somewhat supporte d this concept, demonstrat-
ing that girls displayed both higher rates of SI and lower self-
esteem; ho wever, no significant interaction was reported
(Overholser et al. 1995). Future research should aim to further
examine this relationship between negative self-concept and SI,
and potential differences that may exist between sexes.
Beckstheoryofdepression(1987) hypothesized that neg-
ative self-schemas cause individuals to encode negative infor-
mation more deeply than positive information. Therefore,
consistent with Wenzel and Becks(2008) cognitive model
of suicide, individuals at risk for SI may be better able to re-
trieve negative information than positive information.
However , contrary to hypotheses, the current study did not find
strong support for this hypothesis. Although increased negative
self-referent recall on the SRET trended toward significance as
a predictor of SI, the relationship between decreased positive
self-referent recall and SI was nonsignificant. It is possible that
the use of a clinical sample with higher rates of depression and
SI would be necessary in order for these relationships to reach
significance, and thus, further research is warranted.
A significant body of research supports the role of rumina-
tion as a robust prospective predictor of SI in late adolescent
and adult samples (Morrison and OConnor 2008). Although
rumination served as a significant independent predictor of SI
over follow-up in our sample, it is somewhat surprising that it
was not predictive beyond the effect of the other cognitive
factors in our study. It is possible that high levels of shared
variance between the constructs of rumination and negative
inferential style led to their loss of significance when entered
into a model simultaneously along with the remaining risk and
protective factors of interest. Rather, our results suggest that a
response style characterized by the tendency to distract one-
self and engage in problem-solving when faced with negative
affect is a more potent predictor of prospective SI. Our find-
ings complement Abela et als. (2007) report that a response
style characterized by distraction and problem-solving pre-
dicted decreases in depressive symptoms over time among
adolesce
nts, therefore operating as a protective factor. The
response styles theory (Nolen-Hoeksema 1991)suggeststhat
responding to negative mood by first engaging in distraction
to lower arousal and s ubsequently engaging in problem-
solving to resolve the issue that induced the low mood may
be an effective way to reduce negative affect. In an extension
of this theory, our current results suggest that utilizing distrac-
tion and problem-solving techniques also may lessen the like-
lihood that adolescents consider suicide as a means of
responding to or regulating depressed mood. Given that this
measure of distraction/problem-solving has not been exam-
ined in relation to SI in prior studies, this finding highlights
this response style as a potentially important protective factor
against the onset of SI, and future research will be needed to
replicate and extend these findings.
Clinical Implications
Future research should probe whether quantifying information
processing biases using the SRET might be a feasible way to
assess non-clinical adolescent samples for suicide risk, while
avoiding the inherent biases associated with self-report mea-
sures of sensitive information. The present findings addition-
ally suggest that targeting maladaptive self-schemas in thera-
py (e.g., with cognitive therapy; Wenzel et al. 2009)maybe
worthwhile among young adolescents, and particularly among
girls, as self-concept is still developing and may be relatively
more malleable at this stage of development than in later ad-
olescence (Abela and Hankin 2008;Krogeretal.2010).
Furthermore, our results suggest that assessing the use of
adaptive response styles to negative affect (problem-solving
JAbnormChildPsychol
and distraction) also may be important in quantifying suicide
risk, and may represent a point of intervention clinically. For
those who already employ distraction and problem-solving in
response to depressive affect, building upon these skills may
enhance resiliency. For those who do not utilize these skills at
all, teaching problem-solving strategies and the distress toler-
ance skill of distraction may be very helpful in preventing
future SI. These strategies have been successfully implement-
ed within treatments such as dialectical behavioral therapy for
adolescents (DBT-A; Miller et al. 2006). Numerous treatments
also have been developed to reduce the use of rumination,
including mindfulness-based cognitive therapy (Segal et al.
2012), rumination-focused cognitive behavioral therapy
(Watkins et al. 2011), emotion regulation therapy (Mennin
and Fr esco 2014), and cognitive control training (Siegle
et al. 2007). These treatments originally were developed for
adults, but ideally could be extended to adolescents to help
prevent the onset or recurrence of SI.
Study Strengths and Limitations
Although we arguably examined not only empirically
established cognitive predictors (i.e., negative inferential style
and rumination), but also cognitive predictors that have re-
ceived less empirical attention in the field (i.e., self-referent
information processing and distraction/problem-solving in re-
sponse to negative affect), we did not exhaustively cover all
potentially important cognitive variables that may predict SI.
For example, examining cognitive variables such as autobio-
graphical memory (e.g., Arie et al. 2008;Williamsand
Broadbent 1986) and cognitive flexibility (e.g., Miranda
et al. 2012, 2013) might further enhance predictive models
of SI among young adolescents and should be investigated
in tandem with the cognitive variables examined in the current
study. Wenzel and Becks(2008) model of suicidal behavior
purports that maladaptive cognitive processes serve to in-
crease the chance of activating a suicide schema, such as
hopelessness, which may trigger cognitive processes associat-
ed with suicidal acts (i.e., selective attention to suicide-
relevant environmental cues and attentional fixation). Future
research should explore how both the maladaptive and adap-
tive cognitive processes supported in the current study influ-
ence the activation of suicide schemas and cognitive processes
associated with suicidal acts to build empirical evidence for
this model.
Although our study covered approximately 2 years of fol-
low-up, future studies may consider extending the follow-up
period to examine how these cognitive factors may differen-
tially impact SI among early, middle, and late adolescents.
Future work that includes more follow-up assessments, par-
ticularly among high-risk samples in which base rates of SI are
higher, could use other statistical approaches to model and
predict trajectories of SI over time. Specifically, multi-wave
data collection could allow researchers to perform mediation
analyses to identify potential mechanisms that underlie the
relationships between our studys cognitive factors and risk
for or protection against SI. In addition, given the low base
rate of SI in our community sample of early adolescents, our
study only examined a combined measure of suicidal ideation
with and without plans, which limited our ability to differen-
tiate whether certain cognitive factors more strongly predict
those at greater risk with suicidal plans versus those without
plans. Therefore, future research would benefit from separate
examination of adolescents with and without suicidal plans. In
addition, given the low base rate of MDD in our sample, the
present study was unable to longitudinally examine the rela-
tionship between MDD and SI across the study period, which
would be important to demonstrate the unique prediction of
cognitive factors to MDD versus SI over time. Additionally, in
the current study, eight adolescents reported a suicide attempt
over the 2-year follow-up. Given this low rate, we were unable
to conduct analyses examining predictors of suicidal behavior
due to minimal power. Future studies should examine this
studys cognitive factors as predictors of suicidal behaviors
among community sampled young adolescents.
Nevertheless, given that SI is a strong predictor of future sui-
cide attempts (e.g., Beck et al. 1999; Brown et al. 2000;
Lewinsohn et al. 1994; Myers et al. 1991), understanding
factors that precede the onset of SI may be important in atten-
uating suicide risk.
The current studys prospective design and 2 year follow-
up period beginning at early adolescence (ages 12 to 13)
allowed us to uniquely predict SI in early adolescence, a sen-
sitive period prior to the sharp emergence of psychopathology
(Hankin et al. 1998; Kessler et al. 2001). Prospective studies
of SI among community samples of young adolescents are
relatively rare, with those that exist being primarily reliant
on self-report measures of SI. Therefore, an important strength
of this study was its use of a combined indicator of SI incor-
porating both interviewer-administered and self-report mea-
sures and both mother and adolescent report. Nevertheless,
as with most methods of measuring SI, the measures used in
the present study likely are imperfect. For example, only SI
occurring in the prior 2 weeks is captured by responses on the
CDI. Although the K-SADS covers a longer period of follow-
up, due to demand characteristics, adolescents may be more
reluctant to disclose the occurrence of SI to interviewers on
the K-SADS than they are on self-report measures. Future
studies might use multiple modes (e.g., interview, self-report)
that cover the same period of follow-up, as well as implicit
measures of SI, to assess SI more completely. However, this is
the first study that we know of that examines a computerized
self-referent encoding task and the distraction and problem-
solving subscale of the Childrens Response Style
Questionnaire (Abela et al. 2007) as predictors of SI. Early
J Abnorm Child Psychol
detection of risk for SI is crucial in order to prevent suicide.
This study identified multiple prospective predictors of ado-
lescent SI that will aid in further strengthening the cognitive
model of suicidal behavior (Wenzel and Beck 2008), thus
informing suicide prevention efforts among a non-clinical
sample of diverse early adolescents.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
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