J Abnorm Child Psychol

DOI 10.1007/s10802-015-0104-x

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 assess current and past depressive disorders and SI. Over fol-
with heightened risk for both the onset and escalation of sui- low-up, adolescents and their mothers were administered the
cidal ideation (SI). Given that SI is a potent predictor of sui- diagnostic interview every 12 months and adolescents com-
cidal behavior, it is important to develop models of vulnera- pleted a self-report measure inquiring about SI every 6 months
bility for and protection against SI, particularly among young to assess interviewer-rated and self-reported SI. Logistic re-
adolescents. This study examined the relative impact of sev- gressions indicated that preferential endorsement of negative
eral cognitive vulnerabilities, as well as protective factors, for adjectives as self-referent (only among girls), rumination in
SI among young adolescents over a 2-year interval response to negative affect, and a negative inferential style
encompassing their transition to mid-adolescence. At base- prospectively predicted SI. Additionally, young adolescents’
line, 324 adolescents (M=12.39 years; SD=0.63; 52.5 % fe- tendency to respond to negative affect with distraction and
male) completed measures of depressive symptoms, self- problem-solving buffered against their risk for exhibiting SI.
referent information processing biases, negative inferential When these factors were entered simultaneously, preferential
style, and responses to negative affect. Further, the adolescents endorsement of negative adjectives as self-referent and the use
and their mothers were administered a diagnostic interview to 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
* Lauren B. Alloy validity of extant models of suicide risk and resilience.
lalloy@temple.edu
Taylor A. Burke
taylor.burke@temple.edu Keywords Suicidal ideation . Information processing biases .
Samantha L. Connolly Negative inferential style . Rumination . Distraction .
samantha.connolly@temple.edu Problem-solving
Jessica L. Hamilton
jessica.leigh.hamilton@temple.edu
Jonathan P. Stange Adolescence is a developmental period associated with a
jstange@temple.edu heightened risk for both the onset and the escalation of suicid-
Lyn Y. Abramson al thoughts and behaviors (Nock et al. 2008). In fact, the
lyabrams@wisc.edu lifetime prevalence of suicidal ideation (SI) among adoles-
cents is documented at 12.1 %, with 4 % who have made
1
Department of Psychology, Temple University, Weiss Hall, 1701 N.
suicide plans, and 4.1 to 8.5 % who have attempted suicide
13th St, Philadelphia, PA 19122, USA (Grunbaum et al. 2004; Nock 2012; Nock et al. 2013). Given
2
Department of Psychology, University of Wisconsin-Madison,
that SI is a potent predictor of suicide attempts and completed
Brogden Hall, 1202 West Johnson Street, Madison, WI 53706-1969, suicide, it is important to develop models of vulnerability for
USA and protection against SI among young adolescents in order to
 J Abnorm Child Psychol

implement early prevention and intervention programs Cognitive Model of Suicide

(Lewinsohn et al. 1994).
The suicide literature consistently has implicated a wide Wenzel and Beck (2008) put forth a model of suicide based on
range of cognitive predictors of the initiation and mainte- Beck’s cognitive theory of psychopathology. Their cognitive
nance of SI and suicidal behavior (O’Connor 2011; model of suicide suggests that three classes of factors influ-
Weishaar 1996; O’Connor 2011). Cognitive factors have ence the initiation of suicidal thoughts and behaviors: dispo-
been broadly defined as the style in which individuals ha- sitional factors, maladaptive cognitive processes associated
bitually Bsearch for, acquire, interpret, categorize, remember, with psychopathology, and cognitive processes more specifi-
and retrieve information in making decisions and in problem cally related to suicidal thoughts and acts. Dispositional fac-
solving^ (Sheehy and O’Connor 2014, p. 69). The current tors are those that are more distal in nature, and may put
study examined a range of cognitive risk and protective individuals at risk for experiencing psychopathology in gen-
factors previously found to provide vulnerability for and eral (i.e., impulsivity, deficits in problem solving). According
protection against suicide-related outcomes and/or depres- to Wenzel and Beck (2008), cognitive processes associated
sion and their relationship to SI among young adolescents with psychopathology include the content of cognitions, as
(ages 12 to 13) over a two-year interval encompassing their well as information processing biases, reflecting the manner
transition to mid-adolescence (Hankin et al. 1998; Kessler in which cognitions are formed. The theory purports that the
et al. 2001). Risk factors are defined as Ba measurable char- more an individual tends to exhibit negative cognitive content
acterization of each subject in a specified population that and maladaptive information processing biases, the more like-
precedes the outcome of interest and which can be used to ly it is that suicide relevant cognitive processes will be trig-
divide the population into 2 groups (the high risk and the gered in response to stressful life events, thus spurring the
low risk groups that comprise the total population)^ development of suicidal thoughts (Wenzel and Beck 2008).
(Kraemer et al. 1997, p. 377). Further, protective factors According to this cognitive model of suicide, suicidal acts
are defined as Bantecedent conditions associated with a de- occur when an individual reaches his or her threshold for
crease in the likelihood of undesirable outcomes or with an tolerating the pain associated with a suicidal crisis (Wenzel
increase in the likelihood of positive outcomes^ (Kazdin and Beck 2008). The current study aims to examine the pre-
et al. 1997, p. 377).^ dictive capacity of specific maladaptive cognitive processes
Although the transition from early adolescence to mid- identified by the cognitive model of suicidal behavior among
adolescence is associated with increased suicidal thoughts young adolescents, as well as test additional cognitive factors
and behaviors as well as increased rates of major depres- that have not yet been examined in relation to this model, to
sive disorder, few studies have examined the predictive potentially build on the model. Of note, the cognitive model of
capacity of cognitive risk factors for suicide-related out- suicidal behavior includes little emphasis on protective fac-
comes over this time period. Even fewer studies have tors, and thus, the current study also aims to fill that gap by
examined the predictive capacity of cognitive protective examining one potential cognitive protective factor.
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 Negative Self-Referent Information Processing
efforts have been hampered by focusing solely on mitigat-
ing risk factors, as opposed to incorporating resiliency Beck’s (1976, 1987) cognitive model of depression theorizes
findings (Brent 2011). In fact, the 2012 National that individuals who are vulnerable to depression possess neg-
Strategy for Suicide Prevention called for a better under- ative self-schemas (e.g., believing that they are characterized
standing of protective factors against suicide to bolster by failure, worthlessness) that can influence their perception,
prevention efforts (United States Department of Health interpretation, attention, and memory for self-referent infor-
and Human Services Office of the Surgeon General and mation. Individuals with a negative self-schema are hypothe-
National Action Alliance for Suicide Prevention 2012). sized to exhibit information processing biases, such that cog-
Furthermore, very few studies have concurrently examined nitive resources are disproportionately allotted to attending to
cognitive risk and protective factors to ascertain their rel- and processing negative information, therefore leaving deplet-
ative significance in conferring risk for and/or protection ed resources to attend to and process positive information
against SI. This study aimed to fill these research gaps by (Disner et al. 2011; Ingram 1984). According to Wenzel and
examining the relative impact of negative inferential style, Beck’s (2008) cognitive model of suicidal behavior, suicidal
response styles, and self-referent information processing on crises are more likely to occur as the frequency, intensity,
rates of SI to determine which risk and protective factors and duration of information processing biases increase, as
may be the most robust predictors of SI. these biases escalate psychological disturbance, a context in
J Abnorm Child Psychol

which it is more likely for a stressful life event to engender longitudinal studies have found that mid-to-late adolescents
suicidal thoughts. with a more negative inferential style were significantly
The Self-Referent Encoding Task (SRET; Alloy et al. more likely to experience prospective SI over follow-up than
1997; Derry and Kuiper 1981; Hammen and Zupan 1984) those with a less negative inferential style (Schwartz et al.
measures information processing biases that may be influ- 2000; Smith et al. 2006). Furthermore, in a large longitudi-
enced by negative self-schemas, by instructing participants nal study of late adolescents, Lewinsohn et al. (1996) dem-
to rapidly judge whether a series of negative and positive onstrated that a combined measure of negative depressotypic
adjectives are self-referent and then complete a free recall cognitions, inferential style, self-esteem, and coping skills
component in which participants list as many words as they mediated the relationships between psychopathology, physi-
can remember from the task. Self-referent information pro- cal illness, negative events, interpersonal events and a com-
cessing biases as measured by the SRET have been found to bined measure of SI and suicidal behavior (SB). However, a
concurrently and prospectively predict depressive symptom- recent study by Labelle et al. (2013) indicates that a dys-
atology among both clinical and non-clinical samples of functional inferential style did not predict SI among a com-
adults and adolescents (Connolly et al. 2015; Jacobs et al. munity sample of adolescents ages 14 to 18. Given the
2008). Among adolescents, several studies examining current- mixed results regarding the impact of negative inferential
ly and remitted depressed youth have found that depression is style on SI among mid-to-late adolescents, and the relative
associated with significantly greater endorsement and recall of dearth of information regarding this relationship among
negative adjectives, with some studies reporting decreased young adolescents, more research is needed to clarify the
endorsement and recall of positive adjectives as well (Alloy role of this negative information processing style.
et al. 2012; Gençöz et al. 2001; Hammen and Zupan 1984;
Timbremont and Braet 2004). Furthermore, among communi-
ty samples of adolescents, recall of fewer positive adjectives Response Style: Rumination
predicted increases in depressive symptoms over a 9-month and Distraction/Problem-Solving
follow-up period (Connolly et al. 2015), and recall of more
negative adjectives interacted with rumination to predict in- A ruminative response style is a cognitive style characterized
creases in depression longitudinally (Black and Pössel 2013). by a chronic, repetitive focus on one’s dysphoric emotions as
No studies to our knowledge have examined the associa- well as their causes and consequences (Nolen-Hoeksema
tion between the SRET and SI directly, although low reported 1991). Several theories have proposed that rumination serves
levels of self-esteem, a related explicit measure of self-con- as a risk factor for SI. Research indicates that rumination is
cept, has been linked to increased SI in adolescents perseverative and may inhibit one’s ability to problem-solve
(Overholser et al. 1995). Given that depression is highly as- by depleting concentration and contributing to inflexible
sociated with SI, and that information processing biases serve thinking (Davis and Nolen-Hoeksema 2000; Miranda and
as a vulnerability factor for depression and suicide (Alloy et al. Nolen-Hoeksema 2007). In turn, exhibiting deficits in
1997; Black and Pössel 2013; Connolly et al. 2015; Wenzel problem-solving is itself a risk factor for SI and SB
and Beck 2008), we propose that SRET information process- (Lyubomirsky and Nolen-Hoeksema 1995). Furthermore, ac-
ing may also serve as a risk factor for SI. cording to the response styles theory, the passive style in
which individuals focus on their symptoms is thought to
heighten and prolong the presence of affective symptoms
Negative Inferential Style (Nolen-Hoeksema 1991).
Therefore, this type of thinking also may interfere with
Negative inferential style is defined as the tendency to attri- one’s ability to adaptively regulate one’s mood, with deficits
bute negative life events to stable and global causes, as well as in mood regulation also strongly linked to SI and SB (Miranda
to infer negative implications for the self and negative future and Nolen-Hoeksema 2007; Williams et al. 2005).
consequences from their occurrence. As outlined in Wenzel Furthermore, O’Connor’s (2011) theory of suicide suggests
and Beck’s (2008) cognitive theory of suicidal behavior, the that suicide risk comes about from the experience of defeat
stronger one’s tendency to process information about negative and entrapment, which rumination might foster.
life events in this manner, the greater the likelihood one may Given these suggestions, it is not surprising that there is a
develop suicidal thoughts in response to their occurrence. consistent link between rumination and suicide risk in the
Although literature examining the relationship between literature (for a review, see Morrison and O’Connor 2008).
negative inferential style and SI is more consistent and ro- For example, in a 2.5 year longitudinal study, rumination pre-
bust among adults, aspects of negative inferential style have dicted hopelessness and both the severity and duration of SI
been examined among adolescents and have demonstrated among a sample of non-depressed university students (Smith
some varied results in predicting SI. For example, several et al. 2006). Among a community adult sample, rumination
 J Abnorm Child Psychol

predicted SI at 1 year follow-up, controlling for baseline SI, problem-solving, and decreases in depressive symptoms
with depressive symptoms mediating the relationship (see Nolen-Hoeksema et al. 2008).
(Miranda and Nolen-Hoeksema 2007). Longitudinal and However, contradictory findings also have been reported in
cross-sectional research also has found that rumination medi- which distraction and problem-solving were not found to buff-
ates the relationships between self-criticism, cognitive flexi- er against depressive symptoms within samples of children
bility, depressive symptoms, negative life events, suicide at- (Abela et al. 2002) as well as adults (see Nolen-Hoeksema
tempts, and SI (Chan et al. 2009; O’Connor and Noyce 2008; et al. 2008). Issues in the measurement of distraction and
Krajniak et al. 2013; Miranda et al. 2013). Although the link problem-solving are thought to be responsible in part for these
between rumination and SI appears to be consistent among observed null findings. Indeed, Abela and colleagues (2002)
college students and adults, no studies to our knowledge have did not find significant protective effects of distraction and
examined this link among young adolescents. However, problem-solving in their study in which they assessed these
existing literature documenting the significant role rumination domains using separate subscales. Upon utilizing factor ana-
plays in predicting prospective depressive symptoms among lytic techniques, Abela and colleagues (2007) proposed that
adolescents provides compelling reason to believe that this distraction and problem-solving were best represented as a
response style may also be a vulnerability for suicidal unified factor; when examined as such, this combined re-
thoughts among adolescents and, if so, may serve to extend sponse style was found to prospectively protect against de-
Wenzel and Beck’s (2008) cognitive model of suicide to in- pressive symptoms in a young adult sample.
corporate maladaptive cognitive processes in response to neg- In contrast to rumination, no study to our knowledge has
ative affect (Abela et al. 2007, 2009; Stange et al. 2014). examined the link between distraction and problem-solving in
More recently, factor analyses of common measures of re- response to negative affect and SI among any age group.
sponse styles among adolescents have suggested that there are Despite these mixed findings in relation to depression, we
two aspects of responses to negative affect: rumination, the propose that employing distraction and problem-solving will
tendency to repetitively think about one’s low mood as well as buffer against the activation of suicide-relevant cognitive pro-
its negative consequences, and distraction/problem-solving, cesses, and therefore, protect against the development of sui-
the tendency to distract oneself and/or problem-solve as a cidal cognitions among young adolescents. Specifically, we
response to low mood (Abela et al. 2007). According to the posit that these more adaptive response styles may lessen the
response styles theory (Nolen-Hoeksema 1991), responding likelihood that one’s negative affect may produce state-
to negative affect by distracting oneself inhibits inward think- dependent dysfunctional cognitions, and may hamper genera-
ing, which, in turn, may serve as a protective factor, tion of escapist suicidal behaviors as solutions when problem-
preventing negative affect from resulting in greater dysfunc- solving. The current study aims to fill the identified gaps in the
tional cognitions. This technique subsequently allows individ- literature by investigating the respective risk associated with
uals to more efficiently problem-solve without intrusion from rumination and protection associated with distraction/
the biased depressogenic thinking that negative affect often problem-solving in the development of SI among young ado-
produces (Nolen-Hoeksema et al. 1993). Therefore, it has lescents, and therefore, possibly extend Wenzel and Beck’s
been hypothesized that initially distracting oneself from de- (2008) cognitive model of suicide.
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 Sex Differences in the Pathway Between Cognitive
1991). Factors and Suicidal Ideation
Given this hypothesis, distraction and problem-solving
may be considered protective factors against depression. Although SI increases among both boys and girls during the
Indeed, a collection of evidence among adult and child adolescent years (Nock 2012), research has consistently doc-
samples supports this claim. Importantly, a longitudinal umented that adolescent girls are at greater risk for SI and
study of 6 to 14 year-olds found that engaging in both attempted suicide (Lewinsohn et al. 1996). In addition to in-
distraction and problem-solving techniques buffered against creased rates of SI among adolescent girls, research has con-
the development of depressive symptoms over time (Abela sistently demonstrated that adolescent girls also have greater
et al. 2007). Among dysphoric adult samples, undergoing negative inferential styles (Hankin and Abramson 2002) and
a distraction induction has consistently been shown to de- are more likely to develop ruminative tendencies during the
crease depressed mood, indicating its beneficial effects adolescent years (e.g., Hamilton et al. 2015). Although few
(see Wisco and Nolen-Hoeksema 2008). Furthermore, en- studies have evaluated sex as a potential moderator of the
gaging in distraction also has been shown to increase ef- relationship between cognitive factors and SI, numerous stud-
fective problem-solving, providing support for the purport- ies have demonstrated that cognitive vulnerabilities predict
ed relationship between distraction, subsequently improved depression more strongly among adolescent girls than boys
J Abnorm Child Psychol

(e.g., Jose and Brown 2008; Mezulis et al. 2010). Further, one vulnerabilities tested would predict SI more strongly among
study found that girls with greater hopelessness were more adolescent girls than boys.
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 Method
important to determine factors that may exacerbate the risk
of SI, particularly among girls. Participants and Procedure

Sample Recruitment

The Current Study Participants included in these analyses completed at least the
baseline assessment and one additional follow-up session of
The present study assessed several cognitive factors that have the Temple University Adolescent Cognition and Emotion
received varying degrees of research support in conferring risk (ACE) Project, a longitudinal study examining risk factors
for or protection against the development of SI. This study for the development of depressive disorders in adolescence
aimed to elucidate which of these cognitive factors are most (see Alloy et al. 2012 for a detailed description of the sample).
potent in predicting SI in the transition from early to mid- This study recruited early adolescents (12 to 13 years old) and
adolescence, a developmental period that has received rela- their primary female caregivers (93 % were the adolescents’
tively scant attention in longitudinal suicide research. biological mothers; hereafter referred to as Bmothers^)
Investigating this developmental period is of particular impor- from Philadelphia area public and private middle schools.
tance, as it provides the opportunity to identify key risk and Inclusion criteria required participants to be age 12 or 13 at
protective factors that may be present and identifiable before the time of the baseline assessment, to identify as white, black,
the adolescent surge in depression and suicidal thoughts and or biracial, and to be able to attend assessments with their
behaviors occurs, particularly among girls (Hankin et al. 1998; mothers. Participants were excluded if either the mother or
Abela and Hankin 2008). Consistent with Wenzel and Beck’s adolescent was unable to speak or read English, or if they
(2008) cognitive model of suicide, it was hypothesized that demonstrated a history of psychosis, severe cognitive impair-
greater endorsement of negative adjectives as self-referent and ment or any medical problems that would not allow study
greater recall of endorsed negative adjectives on the SRET participation. Dyads who met inclusion and exclusion criteria
would serve as prospective risk factors for SI. were invited to complete a baseline assessment that was sep-
Correspondingly, it was expected that less endorsement of arated into two sessions, referred to as Time 1 Session 1 and
positive adjectives as self-referent and less recall of endorsed Time 1 Session 2.
positive adjectives on the SRET would also serve as risk fac-
tors for SI over the transition from early to mid-adolescence. Procedures
Furthermore, in line with the cognitive model of suicidal be-
havior, it was hypothesized that negative inferential style Adolescents and their mothers attended both Time 1 sessions
would independently pose risk for SI over time. Although and all prospective assessments in person. The Time 1 ses-
ruminative response to negative affect has not yet been exam- sions each lasted approximately 2 to 3 h and included ques-
ined in relation to SI among young adolescents nor incorpo- tionnaires, behavioral tasks, and diagnostic interviews.
rated in the cognitive model of suicidal behavior (Wenzel and Adolescents and mothers were each compensated $30 per
Beck 2008), the tendency to respond to negative affect by session. At Time 1, adolescents completed self-report mea-
engaging in rumination was expected to serve as a risk factor sures of suicidal ideation, depressive symptoms, negative in-
for future SI and the tendency to respond to negative affect by ferential style, and response styles. Adolescents also complet-
engaging in self-distraction and/or problem-solving was ex- ed the SRET behavioral task measuring self-referent informa-
pected to serve as a protective factor against future SI. Given tion processing. Adolescents and mothers completed diagnos-
mixed results and scant literature aimed at determining the tic interviews assessing the adolescents’ lifetime history of
relative impact of each of these cognitive factors in the pre- psychiatric disorders and suicidal ideation with a trained doc-
diction of SI, we did not generate specific hypotheses regard- toral student in clinical psychology, post-baccalaureate re-
ing which cognitive factors may be the most potent predictors search assistant, or a Ph.D. level clinical psychologist.
of SI. Rather, we explored which cognitive variables emerged Participants who completed Time 1 of the study were invited
as the strongest predictors of SI when examined simultaneous- to participate in longitudinal assessments every 6 months, dur-
ly. Further, given research demonstrating that girls are at great- ing which they were again administered the self-report ques-
er risk for cognitive vulnerabilities (e.g., Mezulis et al. 2010) tionnaires and behavioral tasks listed above. Diagnostic inter-
and SI (Lewinsohn et al. 1996), we expected that the cognitive 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 Table 1 Demographic and cognitive factors as a function of SI status
average of 503.68 days (SD=222.59 days). Mothers provided T2 No SI (N=261) T2 SI (N=63) t/x2
written consent and adolescents provided written assent to
participate in this prospective study. T1 Age 12.43 (0.61) 12.25 (0.67) −1.95
Sex 47.51 % female 71.43 % female 11.64**
Study Sample Race 51.73 % AA 55.56 % AA 0.30
48.28 % White 44.44 % White
The present study sample consisted of 324 adolescents who SES (Lunch) 51.43 % 48.57 % 4.13
completed baseline measures and at least 1 of 4, 6-month Days In Study 496.15 (229.72) 534.05 (189.94) 1.16
follow-up sessions over approximately 24 months. The sam- # F/U Sessions 2.78 (1.30) 2.83 (1.37) 0.28
ple was 12.39 years old (SD=0.63) at Time 1, 53.5 % female, T1 SI 6.13 % 30.16 % 30.41***
47.50 % White, and 52.5 % African-American; 48.42 % of the T1 Current Dep 3.16 % 1.59 % 0.41
sample qualified for free or reduced lunch at school, a measure T1 Past Dep 11.88 % 11.11 % 0.03
of socioeconomic status that accounts for the number of de- SRET Neg Me 1.67 (1.56) 2.95 (2.69) 5.00***
pendents being supported by a family income. (See Table 1 for SRET Neg Rec .12 (0.15) .19 (0.19) 2.70**
sample demographics). SRET Pos Me 9.85 (1.32) 9.35 (1.92) −2.44*
SRET Pos Rec .58 (0.25) .56 (0.22) −0.55
Measures ACSQ 113.72 (36.98) 129.92 (45.35) 2.98**
HSC 2.90 (1.90) 3.43 (2.68) 1.82
Current and Past Depressive Disorders CRSQ-R 23.53 (6.72) 27.62 (8.21) 4.14***
CRSQ-DPS 19.58 (4.45) 17.51 (3.83) 3.40**
The Kiddie – Schedule for Affective Disorders and
Schizophrenia – Epidemiological Version (K-SADS-E; *p<0.05; ** p<0.01; *** p<0.001
Orvaschel 1995), a semistructured diagnostic interview, was Standard deviations are in parentheses. T1=Time 1 (baseline); T2=Time
2 (follow-up); SI=Suicidal Ideation; SES (Lunch)=measure of socioeco-
administered to both adolescents and mothers at baseline and nomic status that accounts for the number of dependents being supported
at each 12-month follow-up session for the primary purpose of by a family income; # F/U Sessions=Number of follow-up sessions com-
diagnosing psychiatric disorders within the sample. The K- pleted; SRET Neg Me/SRET Pos Me=Total number of negative/positive
SADS-E assesses current and past Diagnostic and Statistical words endorsed as BMe^; SRET Neg Rec/SRET Pos Rec=[# positive/
negative words endorsed and recalled/total #words endorsed and recalled
Manual of Mental Disorders – Fourth Edition (DSM-IV-TR; across all conditions]; ACSQ-M = The Adolescent Cognitive Style
American Psychiatric Association 2000) Axis I psychopathol- Questionnaire-Modified; HSC = Hopelessness Scale for Children;
ogy in youth. The K-SADS-E interview was revised to addi- CRSQ=Children’s Response Style Questionnaire; CRSQ-R=Rumina-
tionally allow for the assessment of Research Diagnostic tion; CRSQ-DPS=Distraction/Problem Solving
Criteria (RDC; Spitzer et al. 1978) diagnoses. Trained inter-
viewers administered the K-SADS-E first to mothers and then of ratings (10 interviews, randomly selected, 5 raters for each
to adolescents, subsequently generating a summary rating of of 24 diagnoses) was κ=.85 (BLINDED FOR REVIEW).
symptoms and diagnoses. The interviewers were charged with
summarizing the ratings of the mothers and adolescents based Suicidal Ideation
upon Bbest-estimate^ clinical judgment, in line with the K-
SADS-E procedures. Previous research on the K-SADS-E Suicidal ideation was assessed by adolescents’ response on
has demonstrated good inter-rater and test-retest reliability the suicidal ideation item of the self-report Children’s
(e.g., Major Depression [= .73]; Dysthymia [κ = .72]) Depression Inventory (CDI; Kovacs 1992) and by
(Orvaschel 1995). For the purposes of this study, adolescents interviewer-rated responses to the suicide item in the K-
were considered to have exhibited a current or past episode of SADS-E (based on both mother and adolescent report), de-
a depressive disorder if he/she met criteria for DSM-IV-TR scribed previously. The CDI was administered at baseline and
Definite Major Depressive Disorder (MDD), Depressive approximately every 6 months. The CDI is a 27-item self-
Disorder Not Otherwise Specified (NOS) or Dysthymia or if report measure used to evaluate depressive symptomatology
he/she met criteria for RDC MDD, Minor Depressive among children and adolescents ages 7 to 17. The scale mea-
Disorder (MDD), or Intermittent Depressive Disorder (IDD). sures depression symptoms experienced by youth over the
All interviewers were subject to reliability checks. previous 2 weeks. Items are scored on a scale from 0 to 2,
Disagreement in diagnosis was handled by bringing the case with higher scores indicating greater severity of symptomatol-
to a case meeting to discuss with the Principal Investigator and ogy. For the purposes of this study, we used only the suicide
other licensed clinicians and expert diagnosticians to deter- item (Item 9), with zero indicating BI do not think about killing
mine the diagnosis. Interrater reliability based on 120 pairs myself,^ one indicating BI think about killing myself but I
J Abnorm Child Psychol

would not do it,^ and two indicating BI want to kill myself.^ as control trials, in order to assess for differences in the
Adolescents indicating a score of one or two were considered recall of self-referent negative/positive adjectives compared
to exhibit SI. Previous studies have demonstrated the validity to the recall of negative/positive adjectives that were not
of measuring SI using single suicide items derived from self- encoded self-referentially. Adolescents were prompted to
reported depression scales (e.g., Desseilles et al. 2012). The respond by pressing either a BYes^ or a BNo^ button
CDI has shown good reliability and validity (Klein et al. 2005) labeled on the keyboard. Once adolescents responded they
and had a .85 internal consistency in this sample. were advanced to the next trial immediately. The 44 total trials
At Time 1, in the K-SADS-E, all adolescents and mothers were divided into 22 structural judgment trials and 22 self-
were asked if the adolescent had made any suicide plans (BDid referent judgment trials, each with 11 positively (e.g., happy,
you ever have a specific plan to kill yourself, that you didn’t attractive) and 11 negatively (e.g., ugly, loser) valenced adjec-
follow or carry out or try?^) in their lifetime. At 12-month and tives. Positive adjectives and negative adjectives were
24-month follow-ups, adolescents and mothers were asked if matched on word length and frequency in the lexicon, and
the adolescent had made any suicide plans since their previous the order in which they were presented to participants was
interview. Furthermore, at Time 1, 12, and 24 months, any randomly determined. Immediately after completion of the
adolescent or mother who endorsed that the adolescent expe- computerized trials, a trained research assistant prompted par-
rienced any symptoms of current or past depression and ticipants to freely recall all words they remembered from the
screened into those sections of the K-SADS-E were asked if computer task. Participants were given up to 5 min to provide
the adolescent exhibited suicidal ideation (BDo (did) you think answers. The task’s rapid assessment format may help limit
about hurting or killing yourself?^), or made any suicide plans response bias as participants rate their self-concept, and its
(BWhat do (did) you think of doing?^). Only adolescents surprise recall component is intended to measure the depth
whose summary scores indicated suicidal ideation and or/ sui- with which this negative self-referent information has been
cide plans on the K-SADS-E were considered as exhibiting encoded.
suicidal ideation. In this study, the SRET variables analyzed were: 1)
A combination dichotomous score was calculated such that Number of negative adjectives endorsed as self-referent, 2)
adolescents were considered to exhibit suicidal ideation at Number of positive adjectives endorsed as self-referent, 3)
baseline if they endorsed suicide items on either the CDI or Number of correctly recalled negative adjectives endorsed as
the K-SADS-E (0=Suicidal Ideation Not Present; 1=Suicidal self-referent (judged Blike me^) divided by the total number of
Ideation Present), thereby incorporating both self-report and positive and negative words endorsed and recalled across both
interview-based assessment information. the self-referent and structural conditions, and 4) Number of
A combination dichotomous follow-up score also was cal- correctly recalled positive adjectives endorsed as self-referent
culated such that adolescents were considered to exhibit SI (judged Blike me^) divided by the total number of positive and
over follow-up if they endorsed suicide items on either the negative words endorsed and recalled across both the self-
CDI at 6, 12, 18, or 24 month follow-up or on the K-SADS- referent and structural conditions.
E (0=Suicidal Ideation Not Present; 1=Suicidal Ideation
Present) at 12 or 24 month follow-up, thereby incorporating Negative Inferential Style
both self-report and interview-based assessment information.
The Adolescent Cognitive Style Questionnaire-Modified
Self-Referent Information Processing (ACSQ-M; Alloy et al. 2012) is a revised version of the orig-
inal scale (ACSQ; Hankin and Abramson 2002), which mea-
The Self-Referent Encoding Task (SRET; Derry and sures adolescents’ tendency to make negative inferences about
Kuiper 1981; Hammen and Zupan 1984) measures partic- the causes, consequences and self-implications of negative life
ipants’ judgments of negative and positive emotionally- events. In addition to assessing adolescent inferential style for
valenced words as self-descriptive, as well as their free negative achievement and interpersonal-related events, the
recall of these words. The SRET was adapted for the modified version of the ACSQ also assesses appearance-
computer using E-Prime software for the purposes of this related events. Therefore, the ACSQ-M presents four hypo-
study (Alloy et al. 2012; Connolly et al. 2015). thetical events per domain (achievement, interpersonal, and
Adolescents completed a total of 44 trials in which either appearance-related) and subsequently prompts adolescents to
a positive or a negative adjective appeared on the com- endorse inferences about the causes of the events (i.e.,
puter above a question instructing them to either make a internal/ external, stable/ unstable, global/ specific), conse-
self-referent judgment (BLike Me?^), rapidly judging quences of the events, and self-worth implications of the
whether the adjective describes them, or to make a struc- events. Each dimension is rated on a one to seven scale, with
tural judgment (BHas an ‘E’?^), rapidly judging whether higher scores indicating a more negative inferential style. In
the adjective contains the letter BE^. Structural trials served the present study, we examined participants’ overall negative
 J Abnorm Child Psychol

score, which is a composite of ratings of event stability, additional set of preliminary analyses examined bivariate cor-
globality, consequences, and self-implications in the achieve- relations between the main study variables (see Table 2).
ment and interpersonal domains, in line with scoring of the To evaluate study hypotheses and examine each cognitive
original ACSQ (Alloy et al. 2006). Previous literature has factor as an independent prospective predictor of SI, we con-
shown that the ACSQ exhibits good internal consistency and ducted a series of logistic regression analyses, controlling for
test-retest reliability (Hankin and Abramson 2002). sex, Time 1 SI, Time 1 current depressive diagnoses, and Time
Furthermore, a study examining the scale’s factor structure 1 past depressive diagnoses. In order to determine the relative
in measuring cognitive vulnerability to depression among ad- predictive value of each cognitive factor, we ran separate hi-
olescents demonstrated validity (Hankin and Abramson erarchical logistic regressions to determine which cognitive
2002). The internal consistency of the ACSQ-M in this sample factors predicted prospective SI. Next, to examine the relative
was α=.94 for the overall negative composite. 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
Response Styles
previously mentioned covariates in Step 1. We centered the
cognitive variables when they were entered simultaneously
The Children’s Response Styles Questionnaire (CRSQ; Abela
into the multiple logistic regression analysis so as to combat
et al. 2004) is a self-report questionnaire designed for youth
the potential for multicollinearity.
that assesses response to dysphoric mood. The scale has a total
To examine our hypothesis that the relationship between
of 25 items that prompt participants to indicate how often they
each cognitive risk and protective factor and SI may be par-
respond to feeling depressed in a particular way. The 25 items
ticularly strong among adolescent girls compared to boys, we
represent two different response styles: rumination and
conducted a series of moderation analyses using the
distraction/problem-solving (DPS). The rumination subscale
PROCESS macro in SPSS (Hayes 2013). Thus, we controlled
consists of items measuring self-focused responses to de-
for Time 1 SI, Time 1 current depressive diagnoses, and Time
pressed mood (e.g., BThink about how alone you feel^). The
1 past depressive diagnoses during all analyses predicting to
DPS subscale measures the tendency to attempt to direct one’s
prospective SI. To test each cognitive factor separately, the
attention away from one’s mood (e.g., BWhen I am sad, I do
main effect of sex and the cognitive factor of interest were
something fun with a friend^) and the tendency to attempt to
entered into the model in addition to the interaction term of
problem-solve and overcome a depressed mood (BWhen I am
sex and each cognitive factor. For all significant interactions,
sad, I think of a way to make my problem better^). Each item
we probed the simple slopes for boys and girls.
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-
Results
tive problem-solving when experiencing depressed mood.
The CRSQ has demonstrated good validity and internal con-
Preliminary Analyses
sistency (Abela et al. 2007). The rumination and DPS sub-
scales exhibited good internal consistency in the present sam-
At baseline, 10.8 % of the sample reported SI on either the
ple (α=.84 and .67, respectively).
CDI or via diagnostic interview on the K-SADS-E. Over the
2-year follow-up period (M = 503.68 days; SD = 222.59),
Statistical Analysis 19.4 % of the sample endorsed SI. At baseline, a dichotomous
indicator of SI utilizing CDI Item 9 and a dichotomous indi-
Before conducting a series of logistic regressions to test the cator of SI measured by the K-SADS-E were significantly
main study hypotheses, we ran independent samples t-tests to correlated (r=.34, p<0.001). Follow-up SI results utilizing
determine if any demographic variables (age at baseline, sex, the CDI #9 and the K-SADS-E were also significantly corre-
race, SES) were associated with concurrent or prospectively lated (r=.34, p<0.001). There were no significant differences
measured SI. Further, given the participants’ varying length of in SI status at baseline or follow-up based on age, race or SES.
time in the study, we also ran an independent samples t-test to At baseline, sex was not significantly related to SI status
determine if number of days in the study and if number of (males=10.32 %; females=11.24 %, χ2(1, N=324)=0.70,
follow-up assessments were associated with prospectively p>0.05). However, at follow-up, there was a significant dif-
measured SI. Only sex was significantly associated with SI ference in SI for males (11.61 %) and females (26.70 %), χ2(1,
prospectively, in that females were more likely to exhibit in- N=324)=11.64, p=0.001, such that females demonstrated
creased SI over time. Thus sex was controlled for in all sub- higher rates of SI.
sequent prospective analyses when sex was not examined as a We found significant differences in length of time in study
moderator (in which it was entered as a main effect). An and number of follow-up sessions based on race (r=−.18,
J Abnorm Child Psychol

Table 2 Bivariate correlations between study variables

1 2 3 4 5 6 7 8 9

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=Children’s Response Style Questionnaire; CRSQ-R=Rumi-
nation; CRSQ-DPS=Distraction/Problem Solving

p< 0.01; r=−.13, p <0.05, respectively) and baseline age Relationship Between Negative Inferential Style and Suicidal
(r=.24, p<0.001; r=−.50, p<0.001, respectively). However, Ideation
number of follow-ups, length of time in study, race, and age
were all not significantly associated with the presence of SI We hypothesized that negative inferential style would be as-
over the follow-up period. Furthermore, sensitivity analyses sociated with SI at both baseline and over the 2 year follow-up
indicated that all study results remained consistent when also period. In line with these hypotheses, negative inferential style
controlling for race and age. Given the consistent results, the was significantly associated with baseline SI (r = .21,
following analyses presented were run without controlling for p<0.001) and follow-up SI (r=.26, p<0.01).
these demographic variables. Tables 1 and 2 provide an over-
view of descriptive statistics and correlations between study Relationship Between Response Styles of Rumination
variables, respectively. and Distraction/Problem-Solving and Suicidal Ideation

We hypothesized that greater levels of rumination would be

Correlational Relationships Between Cognitive Factors correlated with baseline and follow-up SI. Rumination was, in
and SI at Baseline and Follow-Up fact, significantly correlated with both baseline (r = .34,
p< 0.001) and follow-up SI (r=.23, p <0.001). Although
Relationship Between Negative Self-Referent Information responding to negative emotion by engaging in distraction/
Processing and Suicidal Ideation problem-solving was not significantly correlated with baseline
SI (r=−.10, p>0.05), it was significantly negatively correlated
The number of negative adjectives adolescents endorsed as with prospective SI (r=−.19, p<0.01).
self-referent was significantly positively correlated with both
baseline (r = .29, p < 0.001) and follow-up SI (r = .27, Cognitive Factors as Prospective Predictors of SI
p<0.001). Furthermore, the proportion of self-referent nega- over Two-Year Follow-Up
tive adjectives correctly recalled relative to all words endorsed
and recalled was positively correlated with follow-up SI All SRET variables, negative inferential style, rumination, and
(r=.18, p<0.01), but not with baseline SI (r=.11, p>0.05). distraction/problem-solving were examined separately as pre-
The number of positive adjectives adolescents endorsed as dictors of follow-up SI, controlling for baseline SI, current and
self-referent was significantly negatively correlated with both past depressive diagnoses, and sex. Other demographic vari-
baseline (r = −.31, p < 0.001) and follow-up SI (r = −.14, ables and time in study were not covaried, as they were not
p<0.01). Additionally, the proportion of positive words en- correlated with prospective SI.
dorsed as self-referent that were subsequently correctly After adjusting for these covariates, the number of negative
recalled relative to all words endorsed and recalled was sig- words endorsed as BMe^ on the SRET significantly predicted
nificantly associated with baseline SI (r=−.12, p<0.05), but SI over follow-up (OR=1.31; 95 % CI [1.12, 1.54], p<0.01).
not with follow-up SI (r=−0.03, p>0.05). Furthermore, the ratio of negative self-referent adjectives
 J Abnorm Child Psychol

Table 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 ΔR2

SRET Neg=Me 0.52 11.24 1.68 1.24–2.26 0.001 0.05

SRET Neg Rec 2.12 3.74 8.40 0.97–71.80 0.053 0.00
SRET Pos=Me −0.10 0.92 0.90 0.74–1.11 .337 0.00
SRET Pos Rec −0.13 0.04 0.88 0.24–3.16 .842 0.00
ACSQ-M 0.37 5.60 1.45 1.07–1.97 0.018 0.03
CRSQ-R 0.40 6.22 1.49 1.09–2.03 0.013 0.03
CRSQ-DPS −0.48 8.92 0.62 0.45–0.85 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=Children’s Response Style Questionnaire; CRSQ-R=Rumi-
nation; CRSQ-DPS=Distraction/Problem Solving; ΔR2 =Change in R2 beyond step 1 covariates

correctly recalled to the total number of adjectives endorsed note, being diagnosed with a current depressive disorder
and recalled was trending toward significance in predicting SI at Time 1 was minimally predictive of prospective SI
at follow-up (OR=1.31; 95 % CI [1.12, 1.54], p=0.053). (OR=0.04; 95 % CI [0.00, 0.71], p<0.05), with a past
Neither the number of positive words endorsed as self- depressive episode not significantly predicting prospec-
referent on the SRET nor the recall of these words was pre- tive SI (OR=0.51; 95 % CI [0.16, 1.61], p>0.05).
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). Strongest Cognitive Predictors of Suicidal Ideation
Consistent with hypotheses, negative inferential style among Early Adolescents
(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) In a combined regression model including all significant
and distraction/problem-solving (OR=.90; 95 % CI [0.83, cognitive predictors, the number of negative adjectives
0.96], p<0.01) each significantly predicted adolescent SI endorsed as self-referent on the SRET remained signif-
over follow-up in the expected directions after adjusting icant as a risk factor for prospective SI (OR = 0.01;
for covariates (see Table 3). 95 % CI [1.04, 1.45], p < 0.05) and distraction/
The most potent predictor of SI over the 2-year fol- problem-solving remained a significant protective factor
low-up period was baseline SI, conferring five times for SI (OR=.91; 95 % CI [0.85, 0.98], p<0.05). The
higher odds of reporting SI at future timepoints. Sex degree to which adolescents engaged in rumination and
served as the second strongest predictor of prospective exhibited a negative inferential style were no longer
SI, with females being three times more likely to report predictive of SI when entered with all cognitive factors
SI over the 2 year follow-up period (see Table 4). Of simultaneously.

Table 4 Logistic regression evaluating significant cognitive predictors of SI simultaneously

Step Predictor β Wald OR p 95 % CI ΔR2

1 Sex 1.16 11.13 3.19 0.001 1.61–6.30 .19

T1 SI 1.72 12.98 5.58 0.000 2.19–12.24
T1 Curr Dep −3.14 4.85 0.04 0.028 0.00–0.71
T1 Past Dep −0.68 1.32 0.51 .250 0.16–1.61
2 SRET Neg=Me 0.39 6.02 1.48 0.014 1.08–2.02 0.09
ACSQ-M 0.23 1.78 1.26 .182 0.90–1.76
CRSQ-R 0.20 1.27 1.22 .259 0.86–1.73
CRSQ-DPS −0.41 6.03 0.66 0.014 0.48–0.92

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=Children’s Response Style Questionnaire;
CRSQ-R=Rumination; CRSQ-DPS=Distraction/Problem Solving; ΔR2 =Change in R2 beyond step 1 covariates
J Abnorm Child Psychol

Sex Differences in the Prospective Relationship suicidal behavior, the current study demonstrates that both
Between Cognitive Factors and SI cognitive content and cognitive processes pose significant risk
for the development of SI. Specifically, the results indicate
We examined potential sex differences in the relationship be- that the preferential endorsement of negative adjectives as
tween cognitive factors and prospective SI, controlling for self-referent and a negative inferential style are significant
baseline SI and current and past depressive diagnoses. indicators of risk for the development of SI over a 2-year
Consistent with hypotheses, there was a significant interaction follow-up period among early adolescents. Adding to the pos-
between sex and the number of negative words endorsed as tulates of Wenzel and Beck’s (2008) cognitive model of sui-
BMe^ on the SRET (B = .41, SE = .19, Z = 2.11, p = 0.04). cidal behavior, findings suggest that young adolescents’ ten-
Specifically, the number of negative words endorsed predicted dency to ruminate in response to negative affect also increases
prospective levels of SI over follow-up among adolescent girls risk for experiencing suicidal thoughts. Further building on
(B=.38, SE=.10, Z=3.73, p<0.001), but not among boys (B= this model, the current study found that the cognitive tendency
−0.03, SE=.17, Z=−.20, p=.84; Fig. 1). Contrary to hypoth- to respond to negative affect by engaging in distraction and
eses, there was no significant interaction between sex and any problem-solving reduces the risk of exhibiting SI over the
other SRET variables, negative inferential style, rumination, transition from early- to mid-adolescence. It is important to
or distraction/problem-solving in predicting prospective SI. In note that these relationships remained significant even after
sum, it appears that although there is a significant main effect adjusting for consistently robust prospective predictors of SI
of sex on prospective SI, the number of negative adjectives including sex, baseline SI and depressive disorders, and past
endorsed as self-referent more strongly predicted SI among depressive disorders (Nock et al. 2008).
girls than boys. 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
Discussion to engage in distraction and problem-solving when faced with
low mood, remained the only significant predictors of SI over
A multitude of cognitive factors have been implicated as pre- follow-up. Although we did not offer specific hypotheses re-
dictors of SI and have been incorporated into a cognitive garding which cognitive factors would serve as the strongest
model of suicidal behavior (Wenzel and Beck 2008). predictors of SI given the dearth of literature available to sup-
However, very few studies have prospectively examined mul- port such conjectures, these findings are surprising, as this is
tiple cognitive predictors of SI in non-clinical samples of the first study to our knowledge to examine either of these
young adolescents over their transition to mid-adolescence, factors as prospective predictors of SI. Our finding that these
despite the fact that this period of time coincides with a sig- variables predicted SI even when accounting for baseline SI,
nificant surge in psychopathology and suicidality (Hankin depression diagnoses, sex, and the well-established cognitive
et al. 1998; Kessler et al. 2001; Nock et al. 2008). factors of negative inferential style and rumination, highlights
Furthermore, very few studies have simultaneously examined their potential utility in improving the predictive validity of
suicide-relevant cognitive factors in order to determine their extant models of risk pathways to suicide.
relative importance in conferring risk for and/or protection Although rates of SI did not vary by sex at baseline, girls
against SI. In line with Wenzel and Beck’s (2008) model of displayed greater SI at follow-up, in line with previous re-
search (Lewinsohn et al. 1996). Furthermore, a significant
0.4 interaction was found between the number of negative self-
referent adjectives endorsed on the SRET and sex in the pre-
0.35
diction of SI, such that negative word endorsement was only a
0.3 significant predictor of SI among girls. This finding suggests
Probability of SI

0.25 that the presence of a negative self-schema may be a particu-

0.2 Girls larly important risk factor for the development of SI in fe-
Boys males. No other interactions between sex and cognitive vul-
0.15
nerabilities emerged in the current sample. The finding that
0.1 the preferential endorsement of negative adjectives as self-
0.05 referent is a significant predictor of prospective SI is in line
0 with Wenzel and Beck’s (2008) cognitive model of suicide.
Low SRET High SRET Specifically, in this model of suicide, as the frequency, inten-
Fig. 1 Gender moderates the relationship between SRET Neg words and sity, and duration of information processing biases increase,
SI one is at greater risk of experiencing suicidal cognitions. The
 J Abnorm Child Psychol

greater number of negative words attributed to oneself might self-referent recall and SI was nonsignificant. It is possible that
signify a higher likelihood that one possesses a negative self- the use of a clinical sample with higher rates of depression and
schema, which causes biases in the interpretation and SI would be necessary in order for these relationships to reach
encoding of environmental stimuli. Given that the SRET re- significance, and thus, further research is warranted.
quired adolescents to quickly decide whether or not a negative A significant body of research supports the role of rumina-
adjective was self-referent, it is possible that this task may tap tion as a robust prospective predictor of SI in late adolescent
into automatic self-associations to a greater degree than to and adult samples (Morrison and O’Connor 2008). Although
explicit self-beliefs. Whereas explicit self-beliefs are theorized rumination served as a significant independent predictor of SI
to signify one’s carefully weighted assessment of the truth of over follow-up in our sample, it is somewhat surprising that it
alternative ideas, automatic self-associations are theorized to was not predictive beyond the effect of the other cognitive
more truthfully reflect how closely two constructs (such as the factors in our study. It is possible that high levels of shared
self and negative characteristics) are linked in one’s memory variance between the constructs of rumination and negative
(Gawronski and Bodenhausen 2006). Automatic self- inferential style led to their loss of significance when entered
associations may be more reflective of deep-seated self- into a model simultaneously along with the remaining risk and
schemas, as they are hypothesized to be less affected by social protective factors of interest. Rather, our results suggest that a
desirability biases and introspection deficits (Greenwald and response style characterized by the tendency to distract one-
Farnham 2000). Beck’s theory indicates that the deeper-seated self and engage in problem-solving when faced with negative
the negative self-schemas, the more likely they are to have a affect is a more potent predictor of prospective SI. Our find-
dysfunctional effect on information processing biases, and ings complement Abela et al’s. (2007) report that a response
therefore, the greater likelihood that they may lead to suicidal style characterized by distraction and problem-solving pre-
cognitions (Beck 1976, 1987). dicted decreases in depressive symptoms over time among
It is intriguing that negative adjective endorsement on the adolescents, therefore operating as a protective factor. The
SRET emerged as the only cognitive variable to significantly response styles theory (Nolen-Hoeksema 1991) suggests that
interact with sex in predicting SI, as sex differences have not responding to negative mood by first engaging in distraction
typically been reported in previous SRET research within the to lower arousal and subsequently engaging in problem-
depression literature. However, to our knowledge, the current solving to resolve the issue that induced the low mood may
study is the first to examine SRET performance as a predictor of be an effective way to reduce negative affect. In an extension
SI, finding that the possession of a negative self-schema is a of this theory, our current results suggest that utilizing distrac-
particular risk factor for SI in girls but not boys. It is possible tion and problem-solving techniques also may lessen the like-
that negative self-concept predicts SI more strongly among girls lihood that adolescents consider suicide as a means of
due to a stronger internalization of negative views; indeed, it responding to or regulating depressed mood. Given that this
has been shown that women engage in a greater degree of self- measure of distraction/problem-solving has not been exam-
focus compared to men (Ingram et al. 1988). In keeping with ined in relation to SI in prior studies, this finding highlights
this idea, if girls attend to and identify more strongly with this this response style as a potentially important protective factor
negative self-schema than boys, they may be more likely to against the onset of SI, and future research will be needed to
adopt a hopeless or defeatist attitude and in turn, engage in SI. replicate and extend these findings.
A previous study of the relationship between self-esteem and SI
in adolescence somewhat supported this concept, demonstrat-
ing that girls displayed both higher rates of SI and lower self- Clinical Implications
esteem; however, no significant interaction was reported
(Overholser et al. 1995). Future research should aim to further Future research should probe whether quantifying information
examine this relationship between negative self-concept and SI, processing biases using the SRET might be a feasible way to
and potential differences that may exist between sexes. assess non-clinical adolescent samples for suicide risk, while
Beck’s theory of depression (1987) hypothesized that neg- avoiding the inherent biases associated with self-report mea-
ative self-schemas cause individuals to encode negative infor- sures of sensitive information. The present findings addition-
mation more deeply than positive information. Therefore, ally suggest that targeting maladaptive self-schemas in thera-
consistent with Wenzel and Beck’s (2008) cognitive model py (e.g., with cognitive therapy; Wenzel et al. 2009) may be
of suicide, individuals at risk for SI may be better able to re- worthwhile among young adolescents, and particularly among
trieve negative information than positive information. girls, as self-concept is still developing and may be relatively
However, contrary to hypotheses, the current study did not find more malleable at this stage of development than in later ad-
strong support for this hypothesis. Although increased negative olescence (Abela and Hankin 2008; Kroger et al. 2010).
self-referent recall on the SRET trended toward significance as Furthermore, our results suggest that assessing the use of
a predictor of SI, the relationship between decreased positive adaptive response styles to negative affect (problem-solving
J Abnorm Child Psychol

and distraction) also may be important in quantifying suicide predict trajectories of SI over time. Specifically, multi-wave
risk, and may represent a point of intervention clinically. For data collection could allow researchers to perform mediation
those who already employ distraction and problem-solving in analyses to identify potential mechanisms that underlie the
response to depressive affect, building upon these skills may relationships between our study’s cognitive factors and risk
enhance resiliency. For those who do not utilize these skills at for or protection against SI. In addition, given the low base
all, teaching problem-solving strategies and the distress toler- rate of SI in our community sample of early adolescents, our
ance skill of distraction may be very helpful in preventing study only examined a combined measure of suicidal ideation
future SI. These strategies have been successfully implement- with and without plans, which limited our ability to differen-
ed within treatments such as dialectical behavioral therapy for tiate whether certain cognitive factors more strongly predict
adolescents (DBT-A; Miller et al. 2006). Numerous treatments those at greater risk with suicidal plans versus those without
also have been developed to reduce the use of rumination, plans. Therefore, future research would benefit from separate
including mindfulness-based cognitive therapy (Segal et al. examination of adolescents with and without suicidal plans. In
2012), rumination-focused cognitive behavioral therapy addition, given the low base rate of MDD in our sample, the
(Watkins et al. 2011), emotion regulation therapy (Mennin present study was unable to longitudinally examine the rela-
and Fresco 2014), and cognitive control training (Siegle tionship between MDD and SI across the study period, which
et al. 2007). These treatments originally were developed for would be important to demonstrate the unique prediction of
adults, but ideally could be extended to adolescents to help cognitive factors to MDD versus SI over time. Additionally, in
prevent the onset or recurrence of SI. 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
Study Strengths and Limitations due to minimal power. Future studies should examine this
study’s cognitive factors as predictors of suicidal behaviors
Although we arguably examined not only empirically among community sampled young adolescents.
established cognitive predictors (i.e., negative inferential style Nevertheless, given that SI is a strong predictor of future sui-
and rumination), but also cognitive predictors that have re- cide attempts (e.g., Beck et al. 1999; Brown et al. 2000;
ceived less empirical attention in the field (i.e., self-referent Lewinsohn et al. 1994; Myers et al. 1991), understanding
information processing and distraction/problem-solving in re- factors that precede the onset of SI may be important in atten-
sponse to negative affect), we did not exhaustively cover all uating suicide risk.
potentially important cognitive variables that may predict SI. The current study’s prospective design and 2 year follow-
For example, examining cognitive variables such as autobio- up period beginning at early adolescence (ages 12 to 13)
graphical memory (e.g., Arie et al. 2008; Williams and allowed us to uniquely predict SI in early adolescence, a sen-
Broadbent 1986) and cognitive flexibility (e.g., Miranda sitive period prior to the sharp emergence of psychopathology
et al. 2012, 2013) might further enhance predictive models (Hankin et al. 1998; Kessler et al. 2001). Prospective studies
of SI among young adolescents and should be investigated of SI among community samples of young adolescents are
in tandem with the cognitive variables examined in the current relatively rare, with those that exist being primarily reliant
study. Wenzel and Beck’s (2008) model of suicidal behavior on self-report measures of SI. Therefore, an important strength
purports that maladaptive cognitive processes serve to in- of this study was its use of a combined indicator of SI incor-
crease the chance of activating a suicide schema, such as porating both interviewer-administered and self-report mea-
hopelessness, which may trigger cognitive processes associat- sures and both mother and adolescent report. Nevertheless,
ed with suicidal acts (i.e., selective attention to suicide- as with most methods of measuring SI, the measures used in
relevant environmental cues and attentional fixation). Future the present study likely are imperfect. For example, only SI
research should explore how both the maladaptive and adap- occurring in the prior 2 weeks is captured by responses on the
tive cognitive processes supported in the current study influ- CDI. Although the K-SADS covers a longer period of follow-
ence the activation of suicide schemas and cognitive processes up, due to demand characteristics, adolescents may be more
associated with suicidal acts to build empirical evidence for reluctant to disclose the occurrence of SI to interviewers on
this model. the K-SADS than they are on self-report measures. Future
Although our study covered approximately 2 years of fol- studies might use multiple modes (e.g., interview, self-report)
low-up, future studies may consider extending the follow-up that cover the same period of follow-up, as well as implicit
period to examine how these cognitive factors may differen- measures of SI, to assess SI more completely. However, this is
tially impact SI among early, middle, and late adolescents. the first study that we know of that examines a computerized
Future work that includes more follow-up assessments, par- self-referent encoding task and the distraction and problem-
ticularly among high-risk samples in which base rates of SI are solving subscale of the Children’s Response Style
higher, could use other statistical approaches to model and Questionnaire (Abela et al. 2007) as predictors of SI. Early
 J Abnorm Child Psychol

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