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.

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.

Mental imagery of suicide and non-suicidal self-injury: A meta-analysis and systematic review.

BACKGROUND: The vast majority of research on, and clinical assessment of, cognitions related to suicide and non-suicidal self-injury (NSSI) has focused on verbal thoughts. And yet, mental imagery is more realistic and emotionally arousing than verbal thoughts. METHODS: We conducted a systematic review and meta-analysis documenting the prevalence of suicidal and NSSI mental imagery and describing the content and characteristics of suicidal and NSSI mental imagery, links between suicidal and NSSI mental imagery and suicidal and NSSI behavior, and how to intervene on suicidal and NSSI mental imagery. Studies published through December 17, 2022 were identified through a systematic search of MEDLINE and PsycINFO. RESULTS: Twenty-three articles were included. Prevalence rates of suicidal (73.56%) and NSSI (84.33%) mental imagery were high among clinical samples. Self-harm mental imagery commonly depicts engagement in self-harm behavior and is experienced as vivid, realistic, and preoccupying. When experimentally induced, self-harm mental imagery reduces physiological and affective arousal. Preliminary evidence suggests that suicidal mental imagery is associated with suicidal behavior. CONCLUSIONS: Suicidal and NSSI mental imagery are highly prevalent and may be associated with heightened risk for self-harm behavior. Assessments and interventions for self-harm should consider incorporating and addressing suicidal and NSSI mental imagery to mitigate risk.

Reimagining rumination? The unique role of mental imagery in adolescents' affective and physiological response to rumination and distraction.

Rumination is associated with increased risk for depression whereas distraction helps draw attention away from negative experiences, lowering risk. Many individuals who ruminate do so in the form of mental imagery and imagery-based rumination is more highly associated with depressive symptom severity than ruminating in the form of verbal thoughts. We do not yet understand why imagery-based rumination may be especially problematic nor how to intervene to reduce imagery-based rumination, however. Adolescents (N = 145) underwent a negative mood induction followed by experimental induction of rumination or distraction in the form of mental imagery or verbal thought while affective, high-frequency heart rate variability, and skin conductance response data were collected. Rumination was associated with similar affective, high-frequency heart rate variability, and skin conductance response regardless of whether adolescents were induced to ruminate in the form of mental imagery or verbal thought. Distraction led to greater affective improvement and greater increases in high-frequency heart rate variability, but similar skin conductance responses when adolescents were inducted to distract themselves in the form of mental imagery compared with verbal thought. Findings emphasize the importance of considering mental imagery in clinical contexts when assessing rumination and when intervening using distraction.

COVID-19 Distress Impacts Adolescents' Depressive Symptoms, NSSI, and Suicide Risk in the Rural, Northeast US.

OBJECTIVE: Widespread concern exists about the impacts of COVID-19 and related public health safety measures (e.g., school closures) on adolescent mental health. Emerging research documents correlates and trajectories of adolescent distress, but further work is needed to identify additional vulnerability factors that explain increased psychopathology during the pandemic. The current study examined whether COVID-19-related loneliness and health anxiety (assessed in March 2020) predicted increased depressive symptoms, frequency of non-suicidal self-injury (NSSI), and suicide risk from pre-pandemic (late January/early February 2020) to June 2020. METHOD: Participants were 362 middle and high school adolescents in rural Maine (M age = 15.01 years; 63.4% female; 76.4% White). Data were collected during a time in which state-level COVID-19 restrictions were high and case counts were relatively low. Self-reports assessed psychopathology symptoms, and ecological momentary assessment (EMA) was used to capture COVID-19-related distress during the initial days of school closures. RESULTS: Loneliness predicted higher depressive symptoms for all adolescents, higher NSSI frequency for adolescents with low pre-pandemic frequency (but less frequent NSSI for adolescents with high pre-pandemic frequency), and higher suicide risk for adolescents with higher pre-pandemic risk. Health anxiety predicted higher NSSI frequency for adolescents with high pre-pandemic frequency, and secondary analyses suggested that this pattern may depend on adolescents' gender identity. CONCLUSIONS: Results underscore the impact of COVID-19 on adolescent mental health, with benefits for some but largely negative impacts for most. Implications for caretakers, educators, and clinicians invested in adolescent mental health are discussed.

Which adolescents are well-suited to app-based mindfulness training? A randomized clinical trial and data-driven approach for personalized recommendations.

OBJECTIVE: Rumination heightens risk for depression and anxiety, which increase substantially during adolescence. Smartphone apps offer a convenient and cost-effective means for adolescents to access mindfulness training, which may reduce rumination. Despite their increasing popularity, it is unclear which adolescents benefit from mindfulness apps. METHOD: Adolescents (n = 152) with elevated trait rumination were randomly assigned to 3 weeks of app-based mindfulness training or a mood-monitoring control. Multilevel models tested group differences in state rumination change, assessed via ecological momentary assessment. Baseline adolescent characteristics were submitted to elastic net regularization models to develop a "Personalized Advantage Index" indicating an individual's expected outcome from the mindfulness app relative to the mood-monitoring control. Finally, we translated a predictive model (developed in an external sample) for personalized recommendations of expected benefit from the mindfulness app. RESULTS: Adolescents in the mindfulness app condition reported significantly greater reductions in rumination than adolescents in the control condition. Individuals predicted to have better outcomes from the mindfulness app relative to mood monitoring had significantly greater reductions in rumination if randomly assigned to the mindfulness condition. In contrast, between-condition differences in outcome were not significant for adolescents predicted to have better outcomes in the mood-monitoring condition. CONCLUSIONS: Findings support the efficacy of a mindfulness app to reduce state rumination in adolescents, particularly among adolescents high in trait rumination. A predictive model is put forth, which could be used to objectively communicate expected mindfulness app outcomes to adolescents prior to engagement in app-based mindfulness training. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suicidal Mental Imagery: Investigating a Novel Marker of Suicide Risk.

Rates of suicidal ideation and behavior are high and increasing in emerging adulthood. Research focused on suicidal ideation as a predictor of suicidal behavior has nearly exclusively conceptualized suicidal ideation as verbal thoughts about suicide. Emerging research suggests, however, that mentally imagining suicide may be even more impairing than verbal thoughts about suicide. Thirty-nine emerging adults with a lifetime history of suicidal cognitions completed self-report assessments of characteristics of their suicidal cognitions, histories of suicide plans and behavior, and the degree to which their suicidal cognitions took the form of mental imagery or verbal thought. Suicidal mental imagery predicted more intense and longer duration of suicidal cognitions, a higher likelihood of having made a suicide plan, and a higher likelihood of having made a suicide attempt over and above suicidal verbal thoughts. Thus, suicidal mental imagery could provide a novel target for suicide assessment and intervention for emerging adults.

"There is no joy in the family anymore": a mixed-methods study on the experience and impact of maternal mortality on families in Ghana.

BACKGROUND: Maternal mortality has a multifaceted impact on families, especially in low- and middle-income countries, where rates of maternal mortality are high and resources can be lacking. The objective of this study was to explore the ways that maternal mortality influences the physical and emotional wellbeing, financial stability, and caregiving structure of families, and identifies sources of and gaps in support. METHODS: Our study used a mixed-methods design. All maternal mortalities in an 18-month period at a tertiary hospital in Ghana were identified using death certificates. Participants were 51 family members (either husbands or other heads of households) in families affected by maternal mortality. A questionnaire assessed demographic characteristics and changes in family health, income, and family structure. Two validated scales assessing psychological wellbeing were administered: the Patient Health Questionnaire-9 and the Inventory of Complicated Grief. Semi-structured interviews were conducted to assess impact on family wellbeing. RESULTS: Quantitative and qualitative results converged to highlight large, negative impacts of maternal mortality on four areas of family wellbeing: 1) mental health and emotional wellbeing; 2) physical health; 3) family structure; 4) financial stability and security. On the Patient Health Questionnaire-9, 54% (27/50) of participants reported elevated depressive symptoms, with 14% (7/50) of scores falling in the moderately severe or severe ranges. On the Inventory of Complicated Grief, 38% (19/50) exceeded the cutoff for significant impairment in functioning. Worsened family health was associated with greater complicated grief (b = 21.41, p = .004); there were no other significant predictors of depressive symptom severity or complicated grief. Effects on family health centered on concerns about the nutritional status and health of the surviving infant. Family structure was primarily affected by fracturing of the central family unit by sending children to live with relatives. Immense economic strain resulted from hospital bills, funeral expenses, and loss of income. The majority of participants received helpful support from their family (41/51, 80.4%), the community (32/51, 62.7%), and their religious institution (43/51, 84.3%); however, support often stopped soon after the death. CONCLUSIONS: Maternal mortality has profound negative impacts on families in Ghana. Impacts are experienced by husbands and heads of households, as well as surviving children. Both immediate and sustained support is needed for families following a maternal death, especially mental health and financial support.

Passive and active suicidal ideation among left-behind children in rural China: An evaluation of intrapersonal and interpersonal vulnerability and resilience.

OBJECTIVE: Although theoretical conceptualizations of suicide hold that passive and active suicidal ideation are etiologically distinct, existing research observing this distinction is modest, with most prior studies focusing exclusively on active ideation. Understanding processes associated with passive ideation is clinically important insofar as passive ideation may precede active ideation, and thus serve as an earlier intervention target prior to potential onset of suicidal behavior. We aimed to evaluate intrapersonal and interpersonal vulnerability and resilience factors for passive ideation and differentiating passive from active ideation. METHOD: Left-behind adolescents in rural China (n = 371) were assessed for passive and active ideation, depressive symptoms, rumination, grit, peer support, and peer victimization. RESULTS: Overall, 15.9% of the sample endorsed passive ideation without active ideation, and 17.8% endorsed active ideation. In multivariate analyses, rumination and grit differentiated left-behind children with passive ideation from those with no ideation. Depressive symptom severity predicted active ideation among adolescents with passive ideation. CONCLUSIONS: The current findings suggest that rumination and grit may characterize passive ideation. Although passive and active ideation may differ modestly in vulnerability and resilience factors, depressive symptoms may be important to monitor among those with passive ideation and have not yet experience active ideation.

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.

Social media use and self-injurious thoughts and behaviors: A systematic review and meta-analysis.

Despite considerable public and scholarly debate about the role of social media in self-injurious thoughts and behaviors (SITBs), no comprehensive, quantitative synthesis of this literature has previously been undertaken. The current systematic review and meta-analysis examines associations between social media use and SITBs, including suicidal ideation, suicide plans, suicide attempts, and nonsuicidal self-injury (NSSI). A range of social media behaviors and experiences were identified, including cybervictimization and perpetration, exposure to and generation of SITB-related content, problematic use, sexting, social media importance, and frequency of use. A systematic search of PsycINFO, Medline, CINAHL, and the references of prior reviews yielded 61 eligible studies. Results largely suggested medium effect sizes for associations between specific social media constructs (cybervictimization, SITB-related social media use, problematic social media use) and SITBs. There was no association between frequency of social media use and SITBs; however, studies on this topic were limited. The majority of studies identified focused on cybervictimization, and results suggested positive associations with all SITBs, with the association between cybervictimization and suicidal ideation stronger for adolescents than adults. Overall, findings highlight the utility of examining specific social media behaviors and experiences, and point to the need for more research in this area.

Intrapersonal Emotion Regulation Difficulties and Maladaptive Interpersonal Behavior in Adolescence.

Although most research conceptualizes emotion regulation as an internal process (i.e., intrapersonal), emotions are frequently regulated in an interpersonal context. Adolescents may be particularly prone to turn to peers for assistance, given that honing emotion regulation abilities is a key task and peers become increasingly important at this stage. Adolescents each participated with a self-nominated same-gender friend (total N = 186; M age = 15.68 years). All participants provided self-reports of their own emotion regulation difficulties and their engagement in interpersonal behaviors (excessive reassurance seeking, negative feedback seeking, conversational self-focus, self-disclosure) as well as their perceptions of their friends' engagement in excessive reassurance seeking and conversational self-focus. Using a cross-lagged panel model design, the current study tested associations between adolescents' intrapersonal emotion regulation difficulties and engagement in self- and friend-reported interpersonal emotion regulation behaviors at 3 time points over 6 months. Gender and age group differences were considered. Results evidenced concurrent and longitudinal associations between emotion regulation difficulties and self-reported maladaptive (excessive reassurance seeking, conversational self-focus, negative feedback seeking), but not adaptive (self-disclosure), interpersonal regulatory behaviors. Friends' reports of adolescents' excessive reassurance seeking and conversational self-focus were associated concurrently, but not longitudinally, with self-reported emotion regulation difficulties. Implications for clinical intervention with adolescents struggling to regulate emotions are discussed.

Online Self-Injury Activities among Psychiatrically Hospitalized Adolescents: Prevalence, Functions, and Perceived Consequences.

The majority of adolescents with psychiatric disorders use social media, engaging in a range of online activities that may confer both risks and benefits. Very little work, however, has examined engagement in online activities related to self-injury among these youth, such as posting about self-injury, viewing self-injury related content, or messaging about self-injury with online or offline friends. This study examined the frequency and types of online self-injury activities in which adolescents engage, perceived functions that these activities serve, and associated risk for self-injurious thoughts and behaviors (SITBs). Participants were 589 psychiatrically-hospitalized adolescents (Mage = 14.88), who completed self-report measures assessing online self-injury activities, perceived functions and consequences of these activities, and SITBs. Results indicated that 43.3% of the sample had engaged in online self-injury activities, that the majority (74.8%) used social networking sites (e.g., Snapchat, Instagram) to do so, and that these activities were significantly more common among sexual and gender minority youth. Adolescents who talked about self-injury with friends met online were more likely to report a history of suicide attempt(s). A latent profile analysis revealed three distinct subgroups of youth based on their perceived functions of engaging in online self-injury activities. Subgroups reporting higher levels of engagement for purposes of identity exploration, self-expression, and aiding recovery were at heightened risk for negative perceived consequences of these activities and reported greater suicidal ideation severity. Findings offer new insights for identifying youth who may be at heightened risk for SITBs in the context of social media use.

Suicidal Mental Imagery in Psychiatrically Hospitalized Adolescents.

Suicide is the second leading cause of death in adolescents and suicide rates in this population have increased in recent years. A critical step in preventing suicide is improving the accuracy of suicide risk assessment. Measurement of suicidal cognitions typically emphasizes assessment of verbal thoughts about suicide. Recent research suggests, however, that suicidal mental imagery, or mentally imagining suicide-related content, may be even more strongly associated with suicidal behavior. No research has evaluated suicidal mental imagery in adolescents, however. The present study evaluated suicidal mental imagery and suicidal verbal thoughts in a sample of adolescents (N = 159) admitted to an adolescent psychiatric inpatient unit. Of those adolescents who reported suicidal cognitions, 63.73% reported suicidal mental imagery. Adolescents who reported suicidal mental imagery had 2.40 greater odds of having made a suicide attempt, after accounting for history of suicidal verbal thoughts and relevant covariates. Findings suggest that suicidal mental imagery should be directly assessed when evaluating suicide risk, and that treatments may be optimized by targeting both suicidal verbal thoughts and suicidal mental imagery.

Peer Socialization of Non-Suicidal Self-Injury in Adolescents' Close Friendships.

Non-suicidal self-injury (NSSI), or self-harming behavior without intent to die (Nock Current Directions in Psychological Science, 18, 78-83, 2009), is associated with distress and impairment across domains, including increased risk for suicidality (Kiekens et al. Journal of Affective Disorders, 239, 171-179, 2018). In adolescence, prevalence of NSSI is high (Swannell et al. Suicide and Life-threatening Behavior, 44, 273-303, 2014), and peer influence regarding NSSI is thought to be strong (Brechwald and Prinstein Journal of Research on Adolescence, 21, 166-79, 2011). Although concern regarding "clusters" of NSSI has long been documented, peer socialization of NSSI in adolescence is understudied. This paper tests peer influence on NSSI frequency within adolescent friendship dyads. Emotion regulation difficulties and friendship quality were evaluated as factors that may influence susceptibility to peer influence effects. Adolescents (N = 196, M age = 15.68, 69.9% female, 87.6% White) nested within 93 friendship dyads reported on their own NSSI frequency, difficulties in emotion regulation, and friendship quality at three time points spaced 3 months apart. Cross-lagged Actor-Partner Interdependence Models examined peer influence effects over time. Friends' Time 1 frequency of NSSI uniquely predicted adolescents' own NSSI frequency over 3 and 6 months, controlling for initial similarity among friends as well as individual risk factors for NSSI. Peer influence effects were strongest in adolescents with higher levels of emotion regulation difficulty but did not vary as a function of friendship quality. Friends' NSSI frequency is a significant and unique predictor of increases in adolescents' own NSSI frequency over time. Implications for interventions that leverage the important developmental context of peer relationships are discussed.

Imagery and verbal thought during rumination and distraction: Does imagery amplify affective response?

Rumination has long been considered a verbal thought process, though emerging evidence suggests that some individuals dwell on maladaptive imagery. This series of studies evaluated imagery and verbal thought during experimentally induced rumination and distraction. In Study 1, imagery and verbal thought during rumination resulted in similar increases in negative affect. Greater imagery during distraction, on the other hand, was associated with greater decreases in negative affect while verbal thought was not related to affect change. Given that greater verbal thought was reported in the rumination condition and greater imagery was reported in the distraction condition, Study 2 evaluated whether the rumination/distraction induction was confounded by concurrent induction of imagery or verbal thought. The rumination prompts induced both rumination and verbal thought and the distraction prompts induced both distraction and imagery. Using a revised induction, Study 3 tested whether imagery and verbal thought during rumination and distraction impacted affective response. Rumination maintained negative affect and distraction relieved negative affect, regardless of the degree to which imagery or verbal thought was experienced. This paper provides evidence that imagery-based rumination is just as impairing as verbally-based rumination and highlights imagery-based distraction as a potentially effective alternative to rumination.

Behavioral Couples Treatment for Substance Use Disorder: Secondary Effects on the Reduction of Risk for Child Abuse.

Risk for child abuse was examined prior to and after behavioral couples treatment (BCT) among 61 couples in which one or both parents were diagnosed with substance use disorder (SUD). All couples were residing with one or more school-age children. Mothers and fathers completed pretreatment, post-intervention, and 6-month post-intervention follow-up assessments. Results of piecewise latent growth models tested whether the number of BCT sessions attended and number of days abstinent from drugs and alcohol influenced relationship satisfaction and its growth over time, and in turn if relationship satisfaction and change in relationship satisfaction influenced risk for child abuse. For both mothers and fathers, attending more BCT sessions lead to a direct increase in relationship satisfaction, which in turn led to stronger reductions in risk for child abuse. This effect was maintained from the post-intervention through the 6-month post-intervention follow-up. For fathers, number of days abstinent significantly influenced reduction in child abuse potential at post-intervention via relationship satisfaction. This indirect effect was not present for mothers. The overall benefits of BCT on mothers' and fathers' risk for child abuse suggest that BCT may have promise in reducing risk for child abuse among couples in which one or both parents have SUD.

Modeling risk for child abuse and harsh parenting in families with depressed and substance-abusing parents.

Children with substance abusing parents are at considerable risk for child maltreatment. The current study applied an actor-partner interdependence model to examine how father only (n=52) and dual couple (n=33) substance use disorder, as well as their depressive symptomology influenced parents' own (actor effects) and the partner's (partner effects) overreactivity in disciplinary interactions with their children, as well as their risk for child maltreatment. Parents completed the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977), the overreactivity subscale from the Parenting Scale (Arnold, O'Leary, Wolff, & Acker, 1993), and the Brief Child Abuse Potential Inventory (Ondersma, Chaffin, Mullins, & LeBreton, 2005). Results of multigroup structural equation models revealed that a parent's own report of depressive symptoms predicted their risk for child maltreatment in both father SUD and dual SUD couples. Similarly, a parent's report of their own depressive symptoms predicted their overreactivity in disciplinary encounters both in father SUD and dual SUD couples. In all models, partners' depressive symptoms did not predict their partner's risk for child maltreatment or overreactivity. Findings underscore the importance of a parent's own level of depressive symptoms in their risk for child maltreatment and for engaging in overreactivity during disciplinary episodes.