Measures of Suicidal Thoughts and Behaviors in Children and Adolescents: A Systematic Review and Recommendations for Use in Clinical and Research Settings.

Empirically supported measures of suicidal thoughts and behaviors (STBs) are needed to serve as reference outcomes for suicide risk screening tools and to monitor severity and treatment progress in children and adolescents with STBs. The present paper systematically reviewed existing measures of STBs in youth and studies evaluating their psychometric properties and clinical utility. Measures were then evaluated on reliability, validity, and clinical utility. Sixteen articles (20 independent samples) were found with psychometric data with youth samples for eight measures. Interview-based measures were found to have the strongest psychometric support and clinical utility. Significant limitations exist for all self-report measures due to inherent characteristics of these measures that cannot be remedied through additional psychometric study. There is an urgent need for the development and validation of new self-report measures of STBs, particularly for preadolescent children, sexual and gender minority youth, and racial/ethnic minority youth.

Sexual and gender minority stress and clinical symptom severity in psychiatrically hospitalized adolescents.

This study examined the role of lifetime and past 30-day experiences of sexual and gender minority (SGM) stress on clinical symptom severity in 286 psychiatrically hospitalized adolescents. Participants completed measures of clinical symptoms, and SGM adolescents (n = 176, 61.5 %) reported on minority stress experiences across three domains (i.e., negative expectancies, internalized homonegativity, homonegative climate). SGM adolescents reported greater clinical symptom severity than non-SGM adolescents. Most SGM adolescents (77.3%) reported lifetime minority stress exposure, endorsing an average of 3.3 stressors (SD = 2.9). Among those endorsing lifetime minority stress history, 76.1% reported past 30-day minority stress exposure. Lifetime and recent minority stress exposure were positively associated with clinical symptom severity. Findings support the importance of assessing SGM identities and minority stress experiences in psychiatric settings and supporting youth in coping with these experiences.

Autistic traits in adolescents in psychiatric inpatient care: Clinical and demographic characteristics and correlates.

Background: Rates of psychiatric hospitalization among adolescents in the United States are rising, with many adolescents presenting to these settings with diverse clinical presentations, including autistic traits. To our knowledge, there has been little research identifying clinical characteristics of adolescents with autistic traits admitted to psychiatric inpatient units, which may be leveraged to improve assessment and treatment practices. Method: In the current study, we examined clinical and demographic characteristics of 195 adolescents admitted to an adolescent psychiatric inpatient unit. Specifically, we investigated the prevalence of adolescents endorsing elevated autistic traits and tested associations between autistic traits, psychiatric symptoms (anxiety, depression, suicidal thoughts), and key demographic variables (age, sex, gender, sexual orientation). Results: Results show that over half of the adolescents admitted to the psychiatric inpatient unit reported elevated autistic traits on a short screening questionnaire. Higher autistic traits were significantly associated with more severe depressive symptoms, though to a small degree. Autistic traits were not associated with anxiety symptoms, suicidal thoughts, nor social disconnectedness, and did not differ by sex, gender identity, nor sexual orientation. Conclusions: Findings highlight the challenge of diagnostic overshadowing among adolescents in crisis and the need for more rigorous measures designed for an inpatient setting to improve risk stratification, clinical assessments, intervention approaches, and discharge planning.

Disclosures of self-injurious thoughts and behaviors to parents in the context of adolescent therapy: A qualitative investigation.

Self-injurious thoughts and behaviors (SITBs), including suicidal thoughts, suicide attempts, and nonsuicidal self-injury, are highly prevalent among adolescents. Identifying adolescents at risk for SITBs relies on their disclosure, and these disclosures commonly occur in therapy context. Moreover, therapists often breach confidentiality to inform adolescents' parent or guardian when they disclose SITBs. Research has explored rates of and barriers to disclosure among adolescents, yet no studies have examined adolescents' experiences of disclosure in the therapy context. Further, no studies have examined adolescents' experiences when their parents are then informed. In this study, we examined qualitative responses from 1495 adolescents who had experienced a SITB disclosure in the therapy context. Qualitative questions included asking adolescents to describe how the SITB disclosure occurred, how their parents were informed, and their parents' reactions. Using open and axial coding, several themes emerged. Adolescents described therapist breaches of confidentiality as collaborative, noncollaborative, or unclear. Adolescents described their parents' affective responses, communication about SITBs, validating and invalidating responses, treatment-oriented responses, and ways that parents restricted their access to people, places, and activities. Findings have implications for the development of clinical guidelines when adolescents disclose SITBs in therapy and highlight areas for future research in adolescent SITB disclosure.

Nonsuicidal Self-Injury in Preadolescents.

OBJECTIVES: There is a dearth of literature on the prevalence and predictors of nonsuicidal self-injury (NSSI) history and onset among preadolescent youth. This gap in the literature is significant given evidence suggesting that NSSI is a robust predictor of negative mental health outcomes, and that early onset NSSI may be associated with a more severe course of self-injurious thoughts and behaviors. This study aimed to evaluate sociodemographic characteristics, psychiatric disorders, and suicidal ideation (SI) in relation to NSSI onset and history in preadolescents. METHODS: Data were drawn from the Adolescent Brain and Cognitive Development (ABCD) study, which recruited a diverse sample of 11 875 youth aged 9 to 10 years. The primary outcome measures were lifetime history and recent onset of NSSI. Measures included sociodemographics and the K-SADS diagnostic interview assessing psychopathology and SI. RESULTS: Female sex and identifying as Black were associated with lower odds of lifetime NSSI. Identifying as a sexual minority, having unmarried parents, and a low family income were associated with higher odds of lifetime NSSI. Although depression was most predictive of NSSI history and onset, a range of internalizing and externalizing disorders, greater comorbidity, and SI also were predictive. CONCLUSIONS: Given that NSSI was associated with a range of mental health disorders and comorbidity, it may be best conceptualized as a transdiagnostic phenomenon. Findings highlight key sociodemographic and diagnostic factors that may help to direct screening efforts in preadolescents, particularly sexual minority status and depression.

Key Challenges and Potential Strategies for Engaging Youth with Lived Experience in Clinical Science.

Centering the perspectives of youth with lived experience (YWLE) in psychopathology is critical to engaging in impactful clinical research to improve youth mental health outcomes. Over the past decade there has been a greater push in clinical science to include community members, and especially community members with lived experience, in all aspects of the research process. The goal of this editorial is to highlight the need for and importance of integrating YWLE into every stage of clinical science research, from idea generation to interpretation and dissemination of research findings. We identify five key problems associated with pursuing research on adolescent mental health without involvement of YWLE and propose strategies to overcome barriers to youth engagement in clinical science research. We conclude with a call to action, providing guidance to clinical scientists, institutions, and funding agencies in conducting research on youth psychopathology with YWLE.

Characterizing Adolescent Disclosures of Suicidal Thoughts and Behavior to Parents.

PURPOSE: Suicidal ideation and suicidal behavior (SI/SB) are prevalent among adolescents. Treatment of SI/SB in adolescents relies on their disclosure, yet there is limited research on adolescent SI/SB disclosure experiences. Understanding who they disclose to and how they experience their parents' responses to their disclosures is important, as parents are often involved in adolescent mental health treatment. METHODS: The present study characterized adolescent SI/SB disclosures in a sample of psychiatrically hospitalized adolescents, examining to whom they disclosed SI/SB, perceived parental responses to SI/SB disclosures, and what they would prefer their parents did differently in response to SI/SB disclosures. RESULTS: Results indicate that over 50% of youth disclosed their SI/SB directly to their parent and approximately 15%-20% of youth did not disclose their SI/SB to anyone prior to psychiatric hospitalization. Perceived parental responses to disclosures varied, including both validating and invalidating responses. DISCUSSION: Findings have important implications for supporting parents and adolescents in discussing SI/SB.

Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science.

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

Self-injurious thoughts and behaviors and alterations in positive valence systems: A systematic review of the literature.

Self-injurious thoughts and behaviors (SITBs), which include suicidal ideation (SI), suicide attempts (SA), and nonsuicidal self-injury (NSSI), are prevalent and associated with impairments in functioning and elevated risk of suicide deaths. Preventing suicide is a complex problem, with numerous systems likely contributing to the onset and maintenance of SITBs, and there is a critical need to identify more precise predictors of risk. Positive valence systems (PVS) are an understudied domain with promise for improving understanding of risk processes underlying SITBs. In this systematic review, we evaluate the evidence for the potential role of altered PVS function in SI, SA, and/or NSSI, including alterations in reward responsiveness, learning, and valuation assessed through behavioral, physiological and circuit measures. Results provide preliminary support for associations between distinct aspects of PVS function and alterations in SITBs. Specifically, SI appears to be characterized by low reward responsiveness, whereas little research has examined reward responsiveness in SA, and NSSI has been characterized by hyper-responsiveness to rewards. Alterations in reward learning and valuation are commonly examined in SA, with some evidence that they may be more strongly associated with attempts than SI or NSSI. At the same time, the literature is limited in that some constructs are commonly examined in one form of SITBs but not others. Further, research is predominantly cross-sectional and focused on adults, raising questions about the role of PVS function in developmental pathways to SITBs. We conclude by integrating the research to date and highlighting promising directions for future research.

Measurement-Based Care in the Adolescent Partial Hospital Setting: Implementation, Challenges, & Future Directions.

In this paper, we describe the process of implementing measurement-based care (MBC) in the adolescent partial hospital program setting. First, we outline the rationale for incorporating MBC in this treatment setting. Second, we describe the partial hospital setting in which implementation took place, including the patient population, treatment providers, and structure of programming. Next, we outline the initial implementation of standardized assessments into our programming, including key initial considerations and challenges during implementation. We describe the importance of considering the primary symptom presentations of the patient population when selecting assessment tools, the importance of leveraging existing electronic health record tools to efficiently track and record data collection, and the ability to integrate assessments into clinical workflows. Fourth, we present data describing compliance with implementation, patient outcomes, and providers' attitudes towards and knowledge of MBC following implementation. We found after the initial implementation period, compliance was high. We also found providers had an overall positive perception of the use of MBC, reporting they perceived it to be helpful to both their clinical practice and patient outcomes. Finally, we discuss future directions for best utilizing standardized assessments in intensive treatment settings.

Digital Technologies for Emotion-Regulation Assessment and Intervention: A Conceptual Review.

The ability to regulate emotions in response to stress is central to healthy development. While early research in emotion regulation predominantly employed static, self-report measurement, the past decade has seen a shift in focus toward understanding the dynamic nature of regulation processes. This is reflected in recent refinements in the definition of emotion regulation, which emphasize the importance of the ability to flexibly adapt regulation efforts across contexts. The latest proliferation of digital technologies employed in mental health research offers the opportunity to capture the state- and context-sensitive nature of emotion regulation. In this conceptual review, we examine the use of digital technologies (ecological momentary assessment; wearable and smartphone technology, physical activity, acoustic data, visual data, and geo-location; smart home technology; virtual reality; social media) in the assessment of emotion regulation and describe their application to interventions. We also discuss challenges and ethical considerations, and outline areas for future research.

Longitudinal predictors of depression, anxiety, and alcohol use following COVID-19-related stress.

The COVID-19 pandemic imposed profound effects on health and daily life, with widespread stress exposure and increases in psychiatric symptoms. Despite these challenges, pandemic research provides unique insights into individual differences in emotion and cognition that predict responses to stress, with general implications for understanding stress vulnerability. We examined predictors of responses to COVID-19-related stress in an online sample of 450 emerging adults recruited in May 2020 to complete questionnaires assessing baseline stress and psychiatric symptoms, rumination, cognitive reappraisal use and intolerance of uncertainty. Stress and symptoms were re-assessed 3 months later (N = 200). Greater pandemic-related stressful events were associated with increases in symptoms of depression, anxiety and alcohol use severity. Additionally, individual differences in emotional and cognitive styles emerged as longitudinal predictors of stress responses. Specifically, greater rumination predicted increased depression. Reduced cognitive reappraisal use interacted with stress to predict increases in alcohol use. An unexpected pattern emerged for intolerance of uncertainty, such that stress was associated with increases in depression for those high in intolerance of uncertainty but increases in alcohol use at relatively low levels of intolerance of uncertainty. These results highlight unique vulnerabilities that predict specific outcomes following stress exposure and offer potential prevention targets.

COVID-19-Specific Suicidal Thoughts and Behaviors in Psychiatrically Hospitalized Adolescents.

This study examined the presence and correlates of COVID-specific suicidal thoughts and behaviors (i.e., thoughts of or engaging in intentional COVID-19 exposure with associated suicidal intent) among psychiatrically hospitalized adolescents. Adolescents (N = 143) completed study measures as part of the standard intake process between March 13th and August 14th, 2020. Participants answered questionnaires assessing COVID-specific passive and active suicidal ideation (SI) and suicidal behavior, as well as COVID-related stressors and emotions, and public health guidance compliance. Findings highlights that COVID-specific SI is common in high-risk youth. COVID-specific SI was associated with COVID-19-related negative emotions, elevated stress, and decreased public health guidance compliance. Results suggest that COVID-specific suicidal thoughts and behaviors, and risk correlates, should be assessed within high-risk populations to facilitate prevention of risky behavior associated with intentional COVID-19 exposure.

Observed Maternal Coping Socialization and Child Internalizing Symptoms: The Roles of Maternal Depressive Symptoms and Peer Stress.

Empirical evidence relying primarily on questionnaire reports indicates parent coping socialization messages play an important role in children's psychological functioning. The present study utilized a multi-informant, multi-method design to build on previous coping socialization research in childhood and adolescence. A novel coding system was developed to measure observed parental socialization of coping messages from observations of a discussion-based peer stress task. Questionnaires and direct observations were obtained from mothers with and without a history of depression (N = 116; 50% with a history of depression) and their children (9 to 15 years). Observed maternal coping socialization messages were not significantly correlated with mother or child reports of child internalizing symptoms in bivariate analyses. However, in multiple linear regression analyses, current maternal depressive symptoms and children's level of peer stress emerged as significant moderators of the association between observed maternal coping socialization messages and children's internalizing symptoms. The conceptual and methodological contributions of the current study are discussed, limitations and strengths are noted, and implications for future research are outlined.

COVID-19 Related Daily Stressors, Coping, and Suicidal Ideation in Psychiatrically Hospitalized Youth.

Background: Given reports of the adverse effects of COVID-19 on adolescent mental health, it is critical to understand how it impacts psychiatrically hospitalized youth who may be particularly vulnerable to its effects. Objective: This study aimed to advance our understanding of high-risk adolescents' experiences of COVID-19, including COVID-19-related stress, changes in daily functioning, and coping as they relate to suicidal ideation (SI). Method: Participants were 107 youth (ages 11-18; M = 15.06, SD = 1.79) admitted to an adolescent psychiatric inpatient unit during the time when the initial COVID-19 safety measures (i.e., school closure, stay-at-home- order) and reopening initiatives (Phase I, II, and III) were implemented in Rhode Island between March 13th and July 19th 2020. Adolescents completed measures of COVID-19-related stress, coping, functioning, and SI at the time of admission. Results: Nearly half of the sample (43%) reported a negative impact of COVID-19 on daily functioning. Youth who endorsed COVID-19-related decline in functioning evidenced higher levels of SI compared to youth with no change or improvement in functioning due to COVID-19. Overall levels of stress were not associated with SI. Greater coping repertoire, but not the use of specific coping strategies was associated with higher levels of SI. Conclusions: Findings demonstrate the importance of examining COVID-19-related changes in functioning and broadening repertoire of coping strategies among adolescents at high risk for SI. Supplementary Information: The online version contains supplementary material available at 10.1007/s10566-021-09641-1.

Emotional Responses to Social Media Experiences Among Adolescents: Longitudinal Associations with Depressive Symptoms.

OBJECTIVE: The degree to which adolescent social media use is associated with depressive symptoms has been the source of considerable debate. Prior studies have been limited by a reliance on cross-sectional data and measures of overall "screen time." This study examines prospective associations between adolescents' emotional responses to social media experiences and depressive symptoms, and examines gender differences in these processes. METHOD: A school-based sample of 687 adolescents (48.6% girls; Mage = 14.3; 38.1% White, 29.4% Hispanic, 23.0% Black) completed measures of positive and negative emotional responses to social media experiences and depressive symptoms at two time points, one year apart. RESULTS: Higher levels of depressive symptoms were associated with more frequent negative emotional responses to social media experiences one year later, whereas greater positive emotional responses to social media were associated with later depressive symptoms. Girls reported overall greater emotional responses to social media experiences, but gender did not moderate associations between these emotional responses and depressive symptoms. CONCLUSION: Findings highlight the importance of examining adolescents' positive and negative emotional experiences in the context of social media use, and the ways in which these experiences intersect with depressive symptoms, so as to identify youth who may be most vulnerable to negative effects of social media use.

Exploring Adolescent Experiences with Disclosing Self-Injurious Thoughts and Behaviors Across Settings.

Disclosure of self-injurious thoughts and behaviors (SITBs) is critical to current treatment and prevention programs. Limited research has examined patterns of and barriers to SITB disclosure in adolescents. This work is critical given the limits of confidentiality in this population. Over 1,000 adolescents aged 13-17 with a history of mental health treatment and SITBs were recruited online. Participants reported their history with disclosing SITBs across a range of relationships, honesty in and barriers to disclosure to health care providers, and their experiences with breaches of confidentiality to parents/guardians. We examined relationships among these experiences and a range of outcomes, including perceived likelihood of future disclosure. Participants reported most frequent disclosure of all SITBs to friends, and more frequent disclosure of nonsuicidal self-injury compared to suicide ideation or attempts. Adolescents were most likely to disclose SITBs when directly asked by health care providers, though many participants reported continued SITB concealment. The most commonly endorsed barrier to disclosure was fear that the provider would tell a parent/guardian. Experiences with confidentiality breaches involving a non-collaborative breach were negatively associated with future disclosure, mental health symptoms, and adolescent-parent relationships. SITB disclosure is a cornerstone to their treatment and prevention. Better understanding of to whom and when, barriers, and the impact of disclosure experiences is critical. Our research suggests that most adolescents do not want their parents to know about their SITBs, and that fear of parent involvement prevents disclosure. Results have several implications for SITB assessment across physical and mental healthcare settings.

Prevalence and correlates of suicidal ideation and suicide attempts in preadolescent children: A US population-based study.

The present study evaluated sociodemographic and diagnostic predictors of suicidal ideation and attempts in a nationally representative sample of preadolescent youth enrolled in the Adolescent Brain Cognitive Development Study. Rates and predictors of psychiatric treatment utilization among suicidal youth also were examined. Eleven thousand eight hundred and seventy-five 9- and 10-year-old children residing in the United States were assessed. Children and their parents/guardians provided reports of children's lifetime history of suicidal ideation, suicide attempts, and psychiatric disorders. Parents also reported on sociodemographic characteristics and mental health service utilization. Multivariate logistic regression analyses were employed to evaluate sociodemographic and diagnostic correlates of suicidal ideation, suicide attempts among youth with suicidal ideation, and treatment utilization among youth with suicidal ideation and suicide attempts. Lifetime prevalence rates were 14.33% for suicidal ideation and 1.26% for suicide attempts. Youth who identified as male, a sexual minority, or multiracial had greater odds of suicidal ideation, and sexual minority youth and youth with a low family income had greater odds of suicide attempts. Comorbid psychopathology was associated with higher odds of both suicidal ideation and suicide attempts. In youth, 34.59% who have suicidal ideation and 54.82% who had attempted suicide received psychiatric treatment. Treatment utilization among suicidal youth was lower among those who identified as female, Black, and Hispanic. Suicidal ideation and attempts among preadolescent children are concerningly high and targeted assessment and preventative efforts are needed, especially for males, racial, ethnic, and sexual minority youth, and those youth experiencing comorbidity.

Disclosure of Self-Injurious Thoughts and Behaviors Across Sexual and Gender Identities.

OBJECTIVES: Evidence suggests that sexual minority (SM) and gender minority (GM) youth are more likely to experience self-injurious thoughts and behaviors (SITBs) than heterosexual and cisgender youth. A major barrier to identifying and treating SITBs is nondisclosure. In this study, we explored differences in SITB disclosure patterns between SM and GM youth and their heterosexual and cisgender peers. In this study, we further examined the association between discrimination experiences and SITB disclosure. METHODS: Adolescents (N = 931) completed questionnaires assessing demographics, SITBs, disclosure history, disclosure barriers, future intentions to disclose SITBs, and discrimination history. RESULTS: Few differences in SITB disclosure patterns emerged between SM and GM youth and heterosexual and cisgender youth (P > .05). SM and GM youth endorsed greater rates of fear of disclosure to and worrying parents, two parent-related barriers ([Formula: see text] = 8.11, P = .017; [Formula: see text] = 7.25, P = .027). GM youth reported greater discrimination experiences than SM youth (F = 6.17, P = .002); discrimination experiences impacted their willingness to disclose future SITBs more so than their SM and heterosexual and cisgender peers (F = 11.58, P < .001). Among the full sample, more discrimination experiences were associated with lower previous disclosure honesty to therapists and pediatricians (r = -0.09 to -0.10, P < .05). Among SM and GM youth, discrimination experiences were associated with lesser odds of disclosing suicide attempts in the future (r = -0.12, P < .05). CONCLUSIONS: Minority stress experiences may interfere with SITB disclosure, particularly among GM youth. Targeted interventions should be considered to reduce minority stress and support disclosure.