INFORMATION TO USERS

This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer.

The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction.

In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion.

Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Each original is also photographed in one exposure and is included in reduced form at the back of the book.

Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6” x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact UMI directly to order. UMI A Bell & Howell Information Company 300 North Zeeb Road, Ann Arbor MI 48106-1346 USA 313/761-4700 800/521-0600

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ATTACHMENT STYLE, DEPRESSION AND LONELINESS

IN ADOLESCENT SUICIDE ATTEMPTERS

by

Kolleen M. Martin

submitted to the

Faculty of the College of Arts and Sciences

of The American University

in Partial Fulfillment of

the Requirements for the Degree

of Doctor of Philosophy

in

Psychology

Chair:■ • Alan.L. Berman. Ph.D. g ) r S 'I Vivian. Shavne. P h . D. AnthonVTzm H.SAhrens. Ph.D . £ Janiesinies vJ. Gray. Ph.D.

Dean liege

Date

1995

The American University

Washington, D.C. 20016

S he A E Z ic iii l iip j j vY

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 9706396

UMI Microform 9706396 Copyright 1996, by UMI Company. All rights reserved.

This microform edition is protected against unauthorized copying under Title 17, United States Code. UMI 300 North Zeeb Road Ann Arbor, MI 48103

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ATTACHMENT STYLE, DEPRESSION AND LONELINESS

IN ADOLESCENT SUICIDE ATTEMPTERS

by

Kolleen M. Martin

ABSTRACT

Attachment style, depression, loneliness and a variety of

pychosocial factors were examined in 31 adolescents who had

attempted suicide within the past year to determine if

depression played a mediating role between an insecure

attachment style and suicide attempts. This group was

compared to two control groups, clinical and normal, which

were matched for age, gender, SES and race. Loneliness was

expected to be associated with an insecure attachment style.

The mediating hypothesis was examined by regression and

logistic regression equations comparing attempters with both

control groups. Partial support was obtained for these

hypotheses. Attempters were more insecurely attached and

more depressed than normals, but not more than clinical

controls. Depression was found to mediate the effects of an

insecure attachment style on suicide attempts when comparing

attempters to normals, but not to clinical controls.

Loneliness scores were higher in individuals with an

insecure attachment style than those with a secure style in

ii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. each of the 3 group comparisons. Loneliness predicted

depression, but did not predict suicide attempts in any of

the comparisons. When comparing adolescent suicide

attempters to clinical controls, an insecure attachment

appears to be a general risk factor for both suicidality and

depression.

iii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS

I respectfully acknowledge the support of friends,

colleagues and family members, and the sacrifices made by my

children. The Chair, Alan Berman, Ph.D. has assisted in

understanding the usefulness of this project. Additionally,

committee members Vivian Shayne, Ph.D. and Anthony Ahrens,

Ph.D. have provided invaluable guidance and displayed

admirable patience with regard to the organization and

completion of this study.

iv

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS

ABSTRACT ...... ii

ACKNOWLEDGEMENTS...... iv

LIST OF TABLES...... vii

Chapter

1. INTRODUCTION...... 1

Risk factors...... 4

Current models...... 12

General model...... 14

2. METHOD...... 30

Subjects...... 30

Materials and procedures...... 34

3. RESULTS...... 40

4. DISCUSSION...... 57

APPENDICES ...... 77

A. Sources of participants...... 77

B. Group demographics...... 78

C. Characteristics of suicide attempts...... 79

D. Informed Consent To Participate...... 80

v

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. E. Parental Informed Consent...... 82

F. Family and Personal History Questionnaire.... 84

G. Beck Depression Inventory...... 87

H. UCLA Loneliness Scale (Version 3)...... 88

I. DAT and Lethality questions...... 90

J. Attachment Questionnaire...... 93

REFERENCES ...... 94

vi

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES

1. T test results and standard deviations for groups on

measures of depression, loneliness and attachment

style...... 39

2. Regression of depression on attachment...... 41

3. Logistic regression predicting suicide attempts 45

4. Regression of depression on attachment with all

clinical controls...... 46

5. Regression of depression on attachment and matching

variables with all clinical controls...... 47

6. Logistic regression with all clinical controls...... 47

7. Regression of depression on attachment combining

suicide attempters and matching clinical controls... 48

8. Logistic regression predicting suicide attempts from

attachment status and depression using attempters and

matching clinical controls...... 49

9. Mean loneliness scores and t tests by attachment

style...... 51

10. Multiple regression of depression on loneliness 52

11. Logistic regression predicting suicide attempts from

loneliness and depression...... 53

12. Family characteristics and psychotherapy history.... 54

vii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 13. Childhood experiences...... 55

14. Recent and lifetime suicide thoughts and behavior... 56

viii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 1

INTRODUCTION

Suicidal behavior in adolescents is a serious

mental health problem. Final mortality statistics for 1992

show that suicide was the third leading cause of death in

the 15-24 year age group (National Center for Health

Statistics [NCHS], 1994). This represents a rate of 13.0 per

100,000 and 4,693 actual deaths. Suicide statistics however

do not reflect the occurrence of serious suicidal ideation

and suicide attempts, the more common types of suicidal

behavior. Estimates of suicidal ideation and suicide

attempts among adolescents vary somewhat, but in general

offer an alarming picture of the number of adolescents who

have considered taking their own lives.

In a survey of 325 high school students, Smith and

Crawford (1986) found that 62.5% of the students reported

having had suicidal ideation but had not developed a plan,

and 8.4% stated they had made an attempt. Another survey of

urban high school students revealed a suicide attempt rate

of 9% (Harkavy-Friedman, Asnis, Boeck, & DiFiore, 1987).

Results from a survey of almost 600 9th and llth graders

indicated that 34% of students had been bothered by thoughts

of ending their lives in the past 12 months, and 9% had made

1

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2

an attempt to kill themselves (Kandel, Raveis & Davies,

1991). A larger study of over 3000 high school students

(Garrison, McKeown, Valois, & Vincent, 1993) found that 11%

of students reported having serious suicidal thoughts, while

7.5% indicated they had made an attempt. Andrews and

Lewinsohn (1992) reported a similar finding among 1700

adolescents of 7.1% for lifetime prevalence of suicide

attempts. Hence, the self-reported suicide attempt rate by

adolescents is approximately 8%. In terms of actual numbers,

Runyan and Gerken (1989) have estimated that as many as

500,000 make suicide attempts each year.

While these figures are of concern in their own

right, they are particularly of interest because of the

evidence for a continuum of suicidality from ideation to

attempts to completion (Brent, Perper, Goldstein, et al.

1988; Shaffer, Garland, Gould, Fisher & Trautman, 1988).

There are studies which suggest that a prior attempt may

constitute a risk factor for a future attempt, and possibly

a completion. For instance, in a study of 20 adolescent

suicide completions and a matched-pair control group,

Shafii, Carrigan, Whittinghill and Derrick (1985) found that

40% of those who completed suicide had made significantly

more prior attempts than the control group. Fifty-five

percent of the 20 victims had made more suicidal threats

compared to the control group prior to completion. A similar

case-control study of 67 completed youthful suicides (Brent,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3

Perper, Moritz, Allman, Friend, Roth, Schweers, Balach &

Baugher, 1993) reported significantly more prior suicidal

attempts in the completer group (28.5%) than the community

control group (1.5%). In fact, in this same study it was

shown that past suicidal ideation with a plan was as

strongly associated with completed suicide as was a past

attempt.

These findings are consistent with estimates that

from 26%-52% of attempters make repeated attempts (Mclntire

& Angle, 1980), and that 10-15% of suicide attempters

eventually commit suicide (Herjanic & Weiner, 1980).

Furthermore, there is evidence of a higher than expected

death rate among previous attempters than nonattempters,

mostly by suicide (Goldacre & Hawton, 1985; Otto, 1972;

Shaffer et al., 1988). Other similarities between attempters

and completers include similarly high rates of affective

disorder and family histories of affective disorder,

antisocial disorder and suicide (Brent et al., 1988).

These studies suggest that a significant number of

adolescents have engaged in life-threatening behavior and

that they are at higher risk for a suicide completion. From

the perspective of risk assessment, and more importantly,

intervention and prevention, the etiology and processes

associated with adolescent suicide attempts clearly deserve

more intensive examination.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4

Risk Factors

Recent investigations of adolescent suicidal

behavior have focused on the identification and integration

of risk factors to guide researchers toward a more

comprehensive understanding of the processes leading up to

an attempt.

Within the adolescent age group, studies have

yielded a variety of variables which place the adolescent at

risk for suicidal behavior. One significant factor is

gender, with almost six times as many boys completing

suicide as girls (21.9 versus 3.7 per 100,000; [NCHS,

1994]). In contrast, girls are three to four times more

likely to attempt suicide (Dubow, Kausch, Blum, & Reed, &

Bush, 1989; O'Carrol, 1987; Trautman & Shaffer, 1984).

The presence of psychiatric disorders ranks high

among the empirically derived risk factors for adolescent

suicidality. In a recent review of major psychiatric

disorders as risk factors for youth suicide, Kovacs and

Puig-Antich (1991) estimated that psychiatrically disordered

adolescents have a 200-fold higher risk for suicide than the

general adolescent population. The most freguently reported

diagnosis is depression and depressive symptoms (Andrews &

Lewinsohn, 1992; Brent et al., 1988; Carlson, 1983; Cole,

1989; Crumley, 1979; Friedman, Corn, Aronoff, Hurt, &

Clarkin, 1984a; Marks & Haller, 1977; Motto, 1984; Robbins &

Alessi, 1985). Bipolar disorder (Brent et al., 1988; Otto,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5

1972; Weiner, Weiner & Fishman, 1979) has also emerged as a

frequent diagnosis.

However, the nature of the association between

depression and suicide is not clear. A review of studies

linking depression to suicide in adolescents (Spirito,

Brown, Overholser, & Fritz, 1989) reveals that the rate of

depression varies widely among suicidal adolescents observed

in psychiatric settings, emergency rooms and general medical

units. In another study, the level of depression and

hopelessness was higher in adolescents who made

nonimpulsive, premeditated suicide attempts than in those

who made impulsive attempts (Brown, Overholser, Spirito &

Fritz, 1991), suggesting the level of intent is associated

with the level of depression. Investigating differences

within a group of adolescents with Major Depressive Disorder

(MDD), Myers, McCauley, Calderon, Mitchell, Burke, &

Schloredt (1991) reported that the suicidal group displayed

more conduct disorder diagnoses than their nonsuicidal

counterparts.

These findings imply, as have others (Brent,

Kalas, Edelbrock, Costello, Dulcan & Conover, 1986; Carlson

& Cantwell, 1982; Curran, 1987), that not every depressed

individual attempts suicide. Clearly, depression is not a

necessary or sufficient condition for suicidal behavior,

which has prompted investigators to search for a more

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6

precise understanding of the relationship between depression

and suicidal behavior.

A frequently observed variable among suicide

attempters, and related to depression, is anger (Cohen-

Sandler, Berman & King, 1982; Garfinkel, Froese, & Hood,

1982; Gispert, Wheeler, Marsh, & Davis, 1985; Khan, 1987;

Withers & Kaplan, 1987). Anger, exhibited as assaultiveness

or hostility, has been a frequently reported factor in

adolescent suicide attempts. In controlled studies suicidal

adolescents have produced higher scores on hostility

measures than nonattempters (Lehnert, Overholser, &

Spririto, 1994; Mclntire & Angle, 1973; Tishler, McKenry, &

Morgan, 1981). In a study of suicidal children, Cohen-

Sandler, Berman and King (1982) reported that depressed

affect and threatening others were the two factors that

distinguished the suicidal from nonsuicidal group. They

suggested that the increased losses suffered by this group

over time led to lowered self esteem and increased rage.

Conduct disorder is emerging as a frequent

diagnosis in suicidal adolescents (Schreiber & Johnson,

1986; Spirito et al., 1989). Comorbidity with depression is

high. Marriage, Fine, Moretti and Haley (1986) found in a

study of 60 children aged 8-17 that psychiatric ratings of

depressive symptoms were more severe in cases of conduct

disorder with depression than dysthymic disorder. The

authors suggest that these children will be more likely to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7

act on their feelings of depression. In a more direct

measure of suicidal risk, Apter, Bleich, Plutchik,

Mendelsohn & Tyano (1988) reported that suicidality scale

scores on the childhood version of the Schedule for

Affective Disorders and Schizophrenia (K-SADS) were higher

for adolescents diagnosed with conduct disorder (CD) than

major depressive disorder (MDD), even though the CD group

was less depressed than the MDD group. Comparing children

and adolescents with MDD and a psychiatric control group,

Myers and colleagues (1991) found that suicidality was best

predicted by comorbid conduct problems and depressive

thinking, as measured by the Children's Depression

Inventory. These findings suggest that for a group of

suicidal adolescents, aggression and antisocial behaviors

play as critical a role as does depressive affect, and that

comorbidity may heighten the risk for suicide. It is notable

that suicidal adolescents also tend to be impulsive (Arffa,

1983; Crumley, 1979; Hoberman & Garfinkel, 1988) which would

increase the likelihood that they would act on their

feelings, such as anger.

Another prominent risk factor among adolescent

suicide attempters is poor interpersonal relationships with

peers as well as family members (Crumley, 1979; Curran,

1987; Jacobs, 1971; Kandel et al., 1991; Teicher, 1973,

1979; Topol & Reznikoff, 1982). Suicide attempters report

being socially isolated (Rohn, Sarles, Kenny, Reynolds, &

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8

Heald, 1977) or having no friendships (Khan, 1987). Teicher

(1973) found that in addition to having few friendships, the

ones they did have were very close and intense.

Related to poor interpersonal relationships is

loneliness. Although it is also frequently linked with

depression, studies of loneliness indicate that, as a

construct, it is independent of depression (Weeks, Michela,

Peplau, & Bragg, 1980; Young, 1982). Studies have indicated

a link between loneliness and suicide attempts in

adolescents. For example, suicide is more prevalent in rural

compared to urban communities (Berman & Carroll, 1984), and

rural adolescents as a group, compared to other populations,

have been reported to be very lonely (Woodward & Frank,

1988). A recent study of suicidal behavior in adolescent

substance abusers found that suicide attempters reported

being significantly more lonely in their preteen/pre-

suicidal years than non attempters (Berman & Schwartz,

1990).

Studies of psychosocial risk factors have focused

primarily on the family. These studies report higher rates

of family violence (Hawton, Osborn, O'Grady, & Cole, 1982b;

Kosky, 1983; Withers & Kaplan, 1987), physical abuse (Green,

1978; Levin & Schonberg, 1987), family break-up

(Christoffel, Marcus, Sagerman & Bennett, 1988) and sexual

child abuse (Adams-Tucker, 1982; Deykin, Alpert, & McNamara,

1985; Green, 1978; Riggs, Alario, McHorney, DeChristopher, &

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9

Crombie, 1986) in the families of suicidal compared to

nonsuicidal adolescents.

Consistent with these findings are investigations

pointing to an increased incidence of psychiatric

disturbance in families of adolescent suicide attempters

(Berman & Carroll, 1984; Garfinkel et al., 1982). Drug and

alcohol abuse is frequently found among family members of

adolescent suicide attempters (Cohen-Sandier, Berman, &

King, 1982; Garfinkel et al., 1982; McKenry, Tishler, &

Kelly, 1983; Rohn et al., 1977), especially fathers (Tishler

& McKenry, 1982). In a review of these and other studies,

Spirito and colleagues (1989) note there are studies which

report no significant difference in the rate of family

psychiatric disorder in suicidal psychiatric inpatients

compared to non suicidal depressed inpatients (Carlson &

Cantwell, 1982; Friedman, Corn, Hurt, Fibel, Schulick, &

Swirsky, 1984b). Hence the relationship between family

history of psychiatric disturbance and adolescent suicide

behavior is presently unclear, although studies to date

imply family psychiatric histories may characterize

disturbed adolescents in general. Not surprisingly, studies

also demonstrate there is a high incidence of suicidal

behavior in other family members of adolescent suicide

attempters (Berman & Carroll, 1984; Garfinkel et al., 1982;

Jacobs, 1971; Kienhorst, Walters, Diekstra, & Otte, 1987;

Teicher, 1973).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10

In comparison to control groups, families of

suicidal adolescents have been found to suffer from

significant overall disturbed family functioning (Corder,

Shorr, & Corder, 1974; Khan, 1987; Taylor & Stansfield,

1984; Topol & Reznikoff, 1982).

Documentation of conflict between suicidal

adolescents and their parents (Cantor, 1976; Hawton,

O'Grady, Osborn, & Cole, 1982a) and serious communication

problems within the family (Curran, 1987; Hawton et al.,

1982a; Wenz, 1979) is substantial. Lukianowicz (1968)

described disturbed relations with parents as the "most

important extrinsic factor in the emotional disturbances" of

adolescents attempting suicide. Senseman (1969) reported

that a poor relationship with parents was the most frequent

reason given for attempted suicide.

Studies also show suicidal adolescents (Gispert,

Wheeler, Marsh, & Davis, 1985) and suicidal children (Cohen-

Sandler et al., 1982) have experienced more stressful life

events, and separations and losses (Jacobs, 1971; Jacobs &

Teicher, 1967; Morrison & Collier, 1969) over the course of

their lives than control group children. The argument has

been made that the decision to attempt suicide is strongly

linked to repeated exposure to these stressful events

(Jacobs, 1971; Smith & Crawford, 1986). Though as with

depression, not everyone who experiences multiple stressful

events becomes suicidal. Also, in a review of the literature

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 11

on stress and life events Paykel (1989) has noted that these

phenomena are more frequently associated with psychiatric

disordered adolescents in general, and more marked for early

loss of a parent by separation and divorce than by death.

The conclusion is that neither recent nor early environment

are sufficient causes by themselves, but may interact with

other personality variables, such as impulsive behavior.

Adolescents themselves report feeling more unhappy

in their families (Topol & Reznikoff, 1982) and feeling

rejected (Francis, 1976) or abandoned by their parents

(Sabbath, 1969). In a study by Hawton and colleagues (1982b)

parent/adolescent relationships were shown to relate to the

lethality of suicide attempts as well as the chronicity of

attempts. Low family support has been shown to predict

suicide attempts in a group of adolescents matched for level

of depression (Morano, Cisler & Lemerond, 1993).

These studies characterize adolescent suicide

attempters as depressed, possibly conduct disordered, with

poor interpersonal relationships, lonely and unable to

depend on their families for emotional support. A common

thread appears to be poor relatedness in general. While

these findings have pinpointed general risk factors, and are

undoubtedly of clinical usefulness, there is as yet no

comprehensive theory that explains how these empirical data

fit together. Hence, researchers and evaluators have

stressed the need for integration of these factors in the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 12

search for underlying dynamic processes (Jacobs, 1971;

Petzel & Riddle, 1981; Spirito et al.; 1989).

Current models

Jacobs (1971), using a case study approach with a

control group, examined 50 adolescent suicide attempters and

their parents. He hypothesized that adolescent suicide

attempts were the result of "progressive isolation from

meaningful relationships." His results suggested there was a

four stage process common to adolescents in these families-a

long standing history of problems, an escalation of problems

above and beyond those usually experienced in adolescence,

progressive failure of coping techniques, and lastly, a

chain reaction dissolution of remaining meaningful social

relationships immediately prior to the suicide attempt. The

core element was the social and emotional isolation

experienced by the suicidal adolescent.

Richman (1978; 1984; 1986) hypothesized that

suicidal behavior is the end point of long standing

emotional problems within the family, for which suicide

seemed to be the only resolution. He observed that

relationships in these families tended to alternate between

enmeshment and isolation. Again, there is an element of

social isolation and poor interpersonal relationships.

Rich & Bonner (1987; Bonner St Rich, 1987) found

evidence for a stress-vulnerability model for suicidal

ideation and behavior in their studies with college age

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 13

students. Preliminary findings from a multiple regression

analysis of self-report assessments of life stress, faulty

cognitions, loneliness, depression, hopelessness, family

cohesiveness, adaptive reasons for living, and suicidal

ideation and behavior indicated that suicidal behavior is

best predicted by l) loneliness, 2) irrational beliefs and

3) low adaptive reasons for living. Additionally, a factor

analysis of the initial variables revealed four factors: 1)

social/emotional alienation, 2) cognitive distortions, 3)

deficient adaptive intrapersonal and interpersonal

resources. While the first three factors appeared to be

"predispositional", the fourth factor, a combination of life

stress and hopelessness, seemed to become important as a

predictor situationally.

This set of studies demonstrates the significance

of a combination of loneliness and depressive thinking in

suicidal late adolescents. Of particular interest was the

component of deficient adaptive resources, which was

operationalized by combining the scores from measures of

reasons for living and family cohesiveness. The authors

suggested this component characterized individuals with few

beliefs or "attachments for staying alive." In other words,

they have difficulty identifying important beliefs and

values for staying alive. It is possible that these poor

attachments for staying alive may stem from general poor

relatedness, which over time would also result in loneliness

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 14

and depression. These results suggest that suicide attempts

in late adolescents are associated with poor attachments,

loneliness and depression, and that these factors are

"predispositional," or of a long standing nature.

A synthesis of these hypotheses regarding the

processes which eventually lead to suicide attempts in

adolescents paints the picture of families which, over a

long period of time, are not able to offer stable and

nurturing environments in which developing adolescents feel

relatively safe and supported, have dependable relationships

with parents, can learn to manage stress and anger

effectively, or succeed with the separation issues related

to emotional independence. Research on risk factors, as

noted above, characterizes the adolescent as exhibiting

depressive, and/or aggressive symptomatology, having few

meaningful relationships, being very lonely, and failing to

communicate distress to the family.

General model

All of the hypotheses which attempt to integrate

clinical observations and empirical data into a process

which eventually culminates in a suicide attempt by

adolescents include or imply depression, loneliness, and

poor interpersonal and familial functioning. Attachment

theory (Bowlby, 1969, 1973, 1980) offers one way to

understand how these risk factors may be related to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 15

depression and suicidal behavior. John Bowlby (1980) stated

"In most forms of depressive disorder, ...the principal

issue about which a person feels helpless is his ability to

make and maintain affectional bonds" (p. 247) . He explained

attachment as a biologically adaptive motivational system in

which a child seeks proximity to another (usually the

mother) for the instinctual purpose of protection and

survival. He suggested that infant attachment patterns could

be categorized as secure, or insecure. If the infant forms a

secure relationship with the attachment figure (most often

the mother), separation from this figure will elicit

appropriate but not excessive anxiety. However, if the

attachment has been characterized by apprehension and fear

that the attachment figure will be inconsistent,

inaccessible and/or unresponsive, then insecure attachment

behavior patterns will be exhibited (Bowlby, 1973). These

insecure patterns are generally characterized by excessive

clinging or excessive self-reliance, and serve the function

of maintaining proximity to the caregiver to avoid the

recurrence of an unbearable threat-loss of the attachment

figure (West & Sheldon-Keller, 1994).

Continuing studies of attachment behaviors in

children (Ainsworth, Blehar, Waters, & Wall, 1978; Main,

Kaplan & Cassidy, 1985) have further elaborated on these

patterns. Ainsworth and colleagues describe

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 16

anxious/ambivalent and avoidant patterns, while Main et al.

(1985) delineate preoccupied and dismissing patterns

. The anxious type of pattern is characterized by excessive

dependency and frequent seeking of interpersonal contact. In

contrast, the avoidant patterns are depicted as denying the

need for, or the importance of attachment relationships

(West & Sheldon-Keller, 1994).

These early child-caregiver relationships, or

attachment styles, are hypothesized to be of a robust and

enduring nature. Bowlby hypothesized that over time these

patterns of experience become internalized and develop

"internal working models" of relationships between the self

and others. In effect, the child develops

cognitive/affective expectations about the self as worthy of

care and attention (self-worth), and about the likelihood

that others will provide a sense of security and protection

when needed (Bowlby, 1973; 1988). As Main et al. (1985)

explain, it is "the-child-in-relation-to-the-attachment-

figure", rather than the attachment figure per se that is

internalized. The early experiences of the self-in-relation

to others leads to a consolidated sense of self and of the

other as they interact. These memories create general

expectations about future interactions and influence modes

of behavioral responses. These beliefs become core

components of personality. Patterns are reinforced by

experience with attachment events over childhood as the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 17

child continues to build a relationship with primary

caretakers (West & Sheldon-Keller, 1994) and into

adolescence when the caretaker becomes an "attachment figure

in reserve" (Weiss, 1991). There is evidence for the

maintenance of the attachment patterns formed in infancy

into childhood (Main & Cassidy, 1988), and into adulthood

(Hazan & Shaver, 1987). Additionally, it has been postulated

that patterns of response to separation, laid down in

childhood, continue into adolescence (Bios, 1967; Josselson,

1980) and adulthood (Behrends & Blatt, 1985; Weiss, 1982) .

Therefore it would seem logical that strengths or

disturbances in the pattern of early attachment with

significant caretakers would reappear during succeeding

separation experiences such as adolescence.

Attachment theory hypothesizes that there is a

link between psychopathology and insecure attachment

patterns, most notably depression and loneliness. Blatt and

Homann (1992) have suggested that John Bowlby's concept of

an internal working model of attachment plays a significant

role in understanding vulnerability to depression.

Specifically, they view the childhood antecedents of

depression to include an impairment of the internal working

model of a caregiving relationship. Lack of care and

support, and excessive control and criticism are associated

with depression. One way a disturbed mother-child

interaction may lead to later depression is the mother's

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18

failure to help the infant to regulate affect. Within this

context, depression can be described as a disturbance in

affect regulation.

In fact, there is a growing literature on

attachment as an organizational construct for both adaptive

psychological functioning (Armsden & Greenberg, 1987; Kobak

& Sceery, 1988) , as well as depressive symptoms in

adolescents. To test the supportive effects of attachment to

parents, Papini and Roggman (1992) measured attachment,

depression and anxiety at 3 separate times over an 18 month

period in a group of early adolescents. Correlational

results indicated that attachment to parents was

significantly and positively related to measures of self­

perceived competence, and significantly and negatively

correlated with feelings of depression and anxiety.

Armsden, McCauley, Greenberg, Burke, & Mitchell

(1990) examined security ofattachment to parents in four

groups of early adolescents (10-17 years of age): clinically

depressed, nondepressed psychiatric controls, nonpsychiatric

controls and adolescents with resolved depression. Depressed

adolescents reported less secure parent attachment than the

control groups, and attachment security of the adolescents

with resolved depression was equivalent to the

nonpsychiatric controls. Within the psychiatric groups,

security of attachment to parents was negatively correlated

with severity of depression. Less secure attachment to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 19

parents was also related to suicidal ideation. Kenny,

Moilanen, Lomax, & Brabeck (1993) investigated the

relationship between security of attachment to parents and

depressive symptoms in early adolescents using structural

equation modeling. They found evidence for the view of self,

as determined by the internal working model, to be the

mediating link between attachment security and depressive

symptoms.

There have been only two efforts, one direct and

one indirect, to link insecure attachment styles, depression

and suicidal behavior in adolescents, de Jong (1992)

examined attachment security and suicidality in three groups

of undergraduate students; one with a history of suicidality

(serious ideation/made plans and attempts), one reporting

current depression with a suicide severity score of 1 or 2

(only occasional or no suicidal ideation), and one normal

control group with suicide severity scores of 1 or 2. She

found that the suicidal group reported lower security of

attachment with parents than the other two groups.

Additionally, compared to the other groups, the suicidal

group reported that their parents (and mother) were less

emotionally available in childhood. The author concluded

that parents' emotional availability during childhood

heightened the adolescents' vulnerability to suicide. It is

uncertain how current attachment style may influence

childhood memories of attachment behaviors by parents.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 20

In a similar vein, Adam (1994) has proposed that

the link between attachment and suicide is the role of loss.

He proposes a vulnerability model in which insecure

attachment styles are risk factors across the life span. He

views adequate or inadequate parenting as a predisposing

factor, and current loss, rejection and disappointment as

precipitating factors for suicidal behavior. Early

attachment experiences produce vulnerability to suicidal

behavior through their effects on the attachment system,

mediated through the internal working models of self and

attachment figures. More specifically, when individuals with

an insecure attachment style encounter serious losses, they

are more inclined than those with a secure attachment to

view themselves as unworthy and unlikely to obtain the

desired support and nurturance from others that they need.

The effects of these internal working models, as noted

earlier, can be seen in personality differences involving

self-worth, affect regulation, and a capacity to form and

maintain relationships. He explains these as the keys to

understanding vulnerability or resilience to later

attachment stress. Secure attachment permits the capacity to

contain anxiety, mourn loss and cope with crises. In

contrast, insecure attachment styles increase the

vulnerability to react to loss or threatened loss with

immobilizing anxiety, destructive anger, hopelessness and

ego decompensation. Suicidal behavior is conceptualized as

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 21

an attachment crisis. When a significant attachment is

threatened, the response is acute distress with efforts to

avoid the loss, either by clinging or detached behavior. He

and colleagues have completed a controlled study of

adolescent suicide attempters, as yet unpublished, in which

he found evidence for a higher incidence of insecure

attachments with adolescent suicide attempters (personal

communication, 1994).

Adam's vulnerability model is also consistent with

Sroufe's (1988) conclusions that the child's understanding

of relationships is gained from internal working models of

self in relation to others, and represents a developmental

context that makes the emergence or absence of pathologies

more or less likely.

These studies suggest that insecure attachment

styles predispose individuals to depression which can lead

to suicidal behavior. For adolescents this is a particularly

compelling explanation in that the developmental tasks of

separation from the family and autonomous functioning may

leave those with insecure attachments without an adequate

sense of security to negotiate these separation related

tasks. Rephrased, the question is whether depression acts as

an intervening or mediating variable between an insecure

attachment and suicidal behavior.

To test this model, it is necessary to assess

secure and insecure attachment style in adolescents. At the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 22

time this study was conducted there was one attachment style

questionaire by Hazan and Shaver (1987) that had been

employed with older adolescents, but there were no available

measures providing classification of attachment styles

developed specifically for the adolescent age group. Most

studies of early and mid adolescents' attachments have

utilized the Inventory of Parent and Peer Attachment

(Armsden & Greenberg, 1987), a measure of degree of security

of attachment to parents or peers, which doesn't provide a

classification of attachment style. To investigate

attachment styles in adolescents it would be helpful to have

an additional measure of behavior which could be expected to

be correlated with an insecure attachment, as current

measures are relatively new and hence somewhat lacking in

reliability and validity data.

Recent theoretical and empirical studies of

loneliness, a construct frequently associated with social

isolation and lack of peer relationships, suggest this

construct may be similar to an insecure attachment style.

Specifically, people feeling socially isolated and unable to

find meaningful relationships would be expected to be higher

in insecurely than securely attached individuals. Kobak and

Sceery (1988) found that insecurely attached (avoidant)

college students were rated by their peers as the most

hostile compared to either anxiously or securely attached

individuals, and themselves reported more loneliness than

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 23

their secure counterparts. Weiss (1973) states that

loneliness is defined as a distressing affective and

motivational state resulting from the failure to satisfy

one's needs for social and emotional interchange with

others. Furthermore, "Loneliness appears always to be a

response to the absence of some particular type of

relationship, more accurately, a response to the absence of

some particular relational provision " (p. 17). This

provision may be a secure attachment. More to the

point, Weiss has suggested that loneliness is a direct

result of the functioning of the attachment system. In the

same vein, Peplau and Perlman (1979) have suggested that the

likelihood of an adolescent being lonely is increased by

personal characteristics that undermine either the

initiation, maintenance or quality of relationships.

Loneliness in college undergraduates has been linked to the

remembered quality of the parent-child relationship, degree

of family togetherness and quality of peer relationships

(Paloutzian & Ellison, 1982). Similarly, in an extensive

study of adolescents, Brennan and Auslander (1979) reported

loneliness was related to low self-esteem, perceptions of

inadequate parental nurturance and support, and alienation

from peers.

Friendships and general peer relationships play a

salient role in separating from earlier attachment figures

and developing extrafamilial attachments. These studies

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 24

suggest there may be an association between early

attachments to parental figures and later perceived

loneliness.

A review of the literature reporting loneliness in

adolescent suicide attempters reveals there are no studies

which assess loneliness on a standardized measure of this

construct. It may be for this reason that studies of social

adjustment have been reported to be conflictual. Berman and

Schwartz (1990) found that suicide attempters in an

adolescent drug abuse population reported being more lonely

in childhood than non attempters, but did not assess current

levels of loneliness. These results were obtained from a

questionnaire and need replication on a standardized measure

to assess present loneliness.

Research into the components of loneliness using

the Revised UCLA Loneliness Scale (Russell, Peplau &

Cutrona, 1980) and the Adolescent Experiences Questionnaire

has shown that among high school students, loneliness was

significantly predicted by a combination of social

alienation, lack of social facility and acceptance,

inferiority feelings and a lack of social integration,

(Goswick & Jones, 1982). Similar components were found to

predict loneliness in an undergraduate college population.

It was noted that high school experiences accounted for over

half the variance in current loneliness scores after a

period of as much as three years. This suggests that

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 25

patterns of experiences and behavior related to loneliness

in high school carry over to the college years. The authors

concluded that loneliness in both groups was associated with

unpleasant feelings and negative self perceptions, and

developed "as a consequence of disruptions in relationships

with significant others" ultimately resulting in inadequate

social skills. This finding may be interpreted to implicate

the role of attachment patterns in reported loneliness in

both high school and college in that early attachment

patterns are hypothesized to provide the prototype for

succeeding interpersonal relationships.

In an investigation of personality variables

associated with loneliness and the phenomenological aspects

of loneliness by adolescents, Moore and Schultz (1983) found

that scores on the UCLA. Loneliness Scale were correlated

with duration of loneliness, self-esteem, depression, state

and trait anxiety, and social anxiety. Loneliness was

experienced as boredom, emptiness and isolation.

In a study of younger adolescents the

relationships between chumship, altruistic behavior and

loneliness, Yarcheski and Mahon (1984) found that among 12-

14 year olds, the absence of a close chum relationship

(intimate interpersonal relationship with a person of the

same sex) was not predictive of being lonely. Unexpectedly,

the highest scores on the Revised UCLA Loneliness Scale were

obtained by adolecents with weak altruistic behavior and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 26

close chum relationships. Altruistic behavior was defined as

a willingness to share and help others in need of

assistance. The authors interpreted these findings as

indicating that lonely adolescents are locked into exclusive

one-to-one relationships, or "emotional oneness with a

partner", which effectively interfered with their ability to

form other interpersonal relationships. This is consistent

with Teicher's (1973) finding that suicidal adolescents have

few, but very close relationships. These results demonstrate

that loneliness is a complex phenomenon, and suggest that

lonely preadolescents are searching for more intense

relationships than their less lonely peers.

These findings imply that loneliness is related to

poor peer relationships in a particular way. Specifically,

there is a long standing history of difficulty initiating

and maintaining satisfactory interpersonal relationships

which is evident in preadolescence and persists into late

adolescence and young adulthood. When a friendship exists,

it is characterized as overly involved, and effectively

excludes the formation of multiple friendships. Furthermore,

loneliness is experienced as emptiness, isolation and

negative self perceptions. This affective pattern is

consistent with a history of poor and unsatisfactory early

attachments and suggests there may be a link between

loneliness and insecure attachment patterns.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 27

Studies have demonstrated that early caregiving

relationships influence children's later adjustment to peers

(Bretherton, 1985; George & Main, 1979). For the adolescent,

it is generally accepted that in the course of gradually

separating from the family, attachments and social

relationships will begin to shift beyond the family. It is

also expected that adolescents will experience a degree of

loneliness. Perhaps not surprisingly, adolescents are found

to be the loneliest of all age groups (Brennan, 1982;

Rubenstein & Shaver, 1980). There are indications that the

way in which late adolescents define and achieve separation

is associated with their psychological well-being and with

their perceived relationships with their mothers and fathers

(Moore, 1987). There is also support for the notion that the

shifting of attachment bonds away from parents and toward

peers is a critical antecedent of loneliness in adolescents

(Ostrov & Offer, 1978). Weiss (1973) states that

"adolescence...leads to extensive reorganization of the

affective system of attachment", and as this transformation

is uneven, there are periods when the adolescent will have

practically no attachments at all. Furthermore, Stierlin

(1974) has emphasized that the role of the parents is

crucial in the process of separation. He found that the role

played by parents varies from supportive, to attempts to

undermine the process by prolonging preadolescent

attachments, to premature rejection.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 28

Hence, there are strong indications that

loneliness and an insecure attachment style are

characterized in a similar manner. If this is the case, then

loneliness should be strongly associated with an insecure

attachment style.

Summarizing theoretical formulations and empirical

evidence, insecure attachments increase the vulnerability to

depression, as persuasively argued by Blatt and Homann

(1992). Depression is a well documented risk factor for

suicidal behavior. Adam (1994) has hypothesized that

insecure attachments increase vulnerability to suicidal

behavior, and de Jong (1992) demonstrated a higher incidence

of insecure attachments in suicidal late teens. These

studies suggest that the effects of an insecure attachment

style on suicidal behavior may be mediated by depression.

The purpose of this study is to test this model in

a sample of suicidal adolescents, making comparisons with

both a clinical and normal control group. Additionally, as

the measurement of insecure attachment in adolescents has

only recently begun, it would add validity to the assessment

if a theoretically associated variable could be shown to

correlate with insecure attachments. Loneliness is closely

related to an insecure attachment by its shared affective

experience of being unable to satisfy one's needs for

emotional closeness.

The hypotheses to be tested are as follows:

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 29

1) Depression will be a mediating variable between an

insecure attachment style and suicide attempts in

comparisons between a group of adolescent suicide attempters

and two control groups, one clinical and one normal.

Clinical controls will be obtained from community mental

health centers and Court supervised facilities. Diagnoses

will be reported where possible for attempters and clinical

controls as comorbid diagnoses may increase the risk for

suicidal behavior, de Jong's work combined attempters with

ideators and utilized an attachment to parents measure to

describe attachment. This study will extend current research

by including only adolescents who report having made an

actual attempt within the past year. Additionally, the

attachment measure will classify attachment style as secure

or insecure rather than degree of attachment to parents.

2) Loneliness will be positively correlated with an

insecure attachment style and suicide attempts, and will be

evaluated by a standardized measure. Loneliness has not been

previously reported in this population, or related to

attachment style.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 2

METHOD

Subjects

For the attempter and clinical control groups, 106

adolescents (13-19 years of age) were recruited from

participants in the out-patient services of 4 community

mental health centers, 4 Youth Shelters, 1 adolescent day

treatment program and 2 Court supervised residential

settings in the Northern Virginia area. Sources of the

participants are shown in Appendix A. There was a

significant difference in the sources of participants.

Approximately one-third of attempters and two-thirds of

clinical controls were obtained from Court supervised

residential placements, X2 (1, N = 62) = 6.46, p < .01.

Out-patient diagnoses at the mental health centers were made

according to DSM-III-R (American Psychiatric Association,

1987) and included depression, dysthymia, oppositional

defiant disorder and conduct disorder. Subjects from the

shelters and residential settings were not assigned

diagnoses, but were typically status offenders, runaways,

truants and adolescents viewed by Juvenile Court as Children

In Need of Supervision. For a normal control group, an

30

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 31

additional 89 students enrolled in peer helping and

psychology classes at a public high school were recruited.

No DSM-III-R diagnoses were available for the normal control

group. Although it was not possible to determine the precise

refusal rate, staff at the facilities who recruited

adolescents for this study indicated that few, perhaps five

percent of those approached, refused to participate.

Authorization was granted for this research by the

Human Subjects Committee in the Psychology Department of The

American University. Separate signed informed consents were

obtained from each subject and one parent.

Participants who endorsed a question asking if a

suicide attempt had been made within the past year (N = 31)

were placed in the attempter group. The attempt question is

one of three on the DAT scale (Allison, Hubbard, Ginzburg, &

Rachal, 1986). DAT is an acronym for the focus of each of

the three questions; depressed, attempted and thought. The

DAT is a three question measure of depression and suicidal

symptoms which was validated with the Beck Depression

Inventory and the NIMH Center for Epidemilogical Studies

depression scale (CES-D), both 21 item depression scales.

The DAT scale was developed as a screening measure for

suicidal behavior and depression in the Treatment Outcome

Prospective Study (TOPS), a national longitudinal study of

drug abusers. The 3 items ask if the subject has felt so

depressed that they couldn't get out of bed, thought about

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 32

committing suicide or attempted suicide, in any

predetermined time period. For the purposes of this study,

the time period was ”1 year". Only the third question was

scored as the basis for assignment to groups.

Lethality of attempts was measured for two

reasons. One was to increase the validity of a claim of a

suicide attempt. The second was to identify the attempters

as high or low-lethality. It is important to differentiate

between these subgroups of attempters because there is

emerging data to suggest these groups are different in terms

of their personality characteristics and their intent to die

(Berman & Jobes, 1991) . Lethality of the attempt was

determined by asking for further details of the attempt

incident. These responses permitted a rating of lethality to

be made using the Lethality of Suicide Attempt Rating Scale

(Smith, Conroy, & Ehler, 1984). The possible range of scores

is 0-10, with higher scores indicating increased lethality.

Only subjects reporting an attempt with a rating of 1 or

higher were included in the attempter group.

After the attempter group was formed, two matched

control groups were then created from the remaining clinical

and normal control groups. Clinical controls were defined by

having behavioral problems of sufficient severity to be in

one or more of several categories; engaged in out-patient

psychotherapy or a day treatment program, living in a

shelter temporarily due to conflict between parent and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 33

adolescent, being under Juvenile Court supervision due to

committing a crime, or being unable to live at home as a

result of severe behavioral problems such as violating

curfews and violence toward family members. All had access

to mental health counselors as a result of their placements.

Use of the term clinical controls for this group is used

broadly in that diagnoses were unavailable for many of the

participants, but their behavior, which had forced their

removal from their homes and/or school settings, clearly

places them outside normal limits and within a clinical

category.

Individuals were matched on gender and race, and

then as close as possible on age and socioeconomic status

(SES). When several matches were available, choices were

made alternately between choices at the top and bottom of

the list of participants. SES was determined by

Hollingshead's Four Factor Scale (Hollingshead, 1975). To

match for race, subjects are divided into Caucasian (N =

19), Black (N = 5) and Others (N = 7; Hispanic, Asian and

Other). Age was divided into three categories which ranged

from of 13-14, 15-16 and 17-19 years of age. It should be

noted that while there was no overall difference in age

grouping for matched controls or across groupings, F(2,90) =

1.189, p = 0.309, in the attempter group there were 8

subjects in the 13-14 year age group but only one in this

age group in the normal control group.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 34

General demographic information for the three

matched groups (N = 93) is summarized in Appendix B. Of the

attempters, 75% were female, 61% were Caucasian, and the

median age group was 15-16. The median SES level was II.

General characteristics of the attempts are described in

Appendix C. The mean lethality score for the attempters was

two, classifying these attempters as a low lethality sample.

The primary methods of suicide attempts were cutting, mostly

superficial, and overdoses of pills, and or, alcohol. Eight

received medical attention, six in an Emergency Room. Only

two were hospitalized. Seventeen told someone after the

attempt, and 17 received psychotherapy afterward, of which

ten reported it to be helpful.

Materials and Procedures

Questionnaires were administered by the author and

completed by subjects at the individual sites, either

individually or in small groups ranging from 3 to 8.

Eventual group membership for attempters and clinical

controls were unknown at the time of administration. The

completion time for the packet of questionnaires was

generally 15-25 minutes. The reading level of the

questionnaires was sixth grade. Two subjects stated they had

difficulty with reading, and the protocols were read to them

by the author.

Demographic information was obtained from the

Family and Personal Questionnaire, a form designed by the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35

author (see Appendix E). This form contained additional

questions regarding early attachment experiences and family

history. It included questions such as "During your

childhood did your mother/father often seem unconcerned,

hostile or rejecting toward you?", and "Were you often

lonely, sad or angry as a child?" Family history data

included questions about family substance abuse, suicide,

and mental illness. Additionally, there were questions

asking if and when subjects had psychotherapy, how long ago,

and if it was helpful.

Attachment style was determined by use of Hazan

and Shaver's (1987) attachment questionnaire. It provides

for classification of respondents into secure, anxious and

avoidant attachment styles. Anxious and avoidant styles are

two types of insecure attachment and are grouped together

for the purpose of this study. This measure was designed for

use with adults (Hazan & Shaver, 1990) but has been used in

with an older adolescent population (Pistole, 1989). This

measure categorizes attachment styles into secure and

insecure styles, unlike other measures of attachment in

adolescents which focus on degree of security rather than

style.

This questionnaire is based on Bowlby's attachment

theory, and appears to have adequate reliability and

validity (Lyddon, Bradford, & Nelson, 1993). Validity has

been established by the questionnaire's ability to predict

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 36

attachment style based on attachment theory when histories

of the way love is experienced, expectations concerning love

relationships and memories of childhood relationships with

parents were examined (Hazen & Shaver, 1987). With respect

to reliability, Pistole (1989) reported test-retest analysis

in which she found a contingency coefficient of 0.598

(maximum = 0.707) pointing to adequate consistency. The

original form was modified by adding the words

"girlfriends/boyfriends" and "like" in parentheses wherever

the words "love partners" and "love", respectively, appeared

in order to make it more age appropriate for younger

adolescents (see Appendix I). The questionnaire consists of

3 short paragraphs describing how individuals feel about

closeness to another in intimate relationships. Respondents

were asked to indicate which one of the three answer

alternatives best described them.

Loneliness was measured by the Revised UCLA

Loneliness Scale (Russell et al., 1980). It is a 20 item

measure designed to assess an individual's self-reported

experiences of loneliness by inquiring about the feeling

states which are believed to be related to loneliness, such

as social isolation, disturbed interpersonal relationships,

and feeling empty and restless. Underlying assumptions are

that there are common themes in the experience of loneliness

regardless of cause, that it is a unidimensional construct

and varies primarily in its experienced intensity (Russell,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 37

1982). The validity of the scale has been supported by

correlations with measures of depression, self-esteem,

anxiety and introversion-extraversion. Although these

personality variables account for 43% of the variance, when

the influence of these variables was controlled for,

loneliness scores continued to be related to the self­

labeling loneliness index (r=.79) demonstrating good

discriminant validity (Russell & Cutrona, 1980). Hence, it

is not confounded by social desirability, mood or other

personality variables such as negative affect or social risk

taking. Russell (1982) reported good reliability with a

coefficient alpha of .96 and test-retest correlation of .73

over a two month period. Other researchers have reported

similar reliability data (Knight, Chisholm, Marsh & Godfrey,

1988; Yarcheski & Mahon, 1984).

Current depression was measured by the Beck

Depression Inventory (Beck, Rush, Shaw, & Emery, 1979;

[BDI]). The BDI is a 21 item self-report questionnaire

developed to measure the intensity of depression by

assessing attitudes and symptoms frequently associated with

depression. Using the Schedule for Affective Disorders and

Schizophrenia for School-Age Children (K-SADS) as the

criterion validator, the BDI has been reported to adequately

distinguish adolescents with MDD from nondepressed

adolescents (Ambrosini, Metz, Bianchi, Rabinovich, & Undie,

1991). Likewise, concurrent validity measures with clinical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 38

ratings and the Hamilton Psychiatric Rating Scale for

Depression yielded mean correlations of 0.72 and 0.73

respectively.

The BDI has been used extensively with adolescents

and adults in a wide variety of clinical and nonclinical

populations (Steer, Beck & Garrison, 1986). Notably,

depression in adults as assessed by the BDI has been

positively correlated with suicidal behavior (Emery, Steer,

& Beck, 1981; Lester & Beck, 1975). Given its demonstrated

usefulness in suicidal and adolescent populations, the BDI

is an appropriate tool to assess depressive symptoms in

suicidal adolescents. While there are no standard cut-off

scores, the authors suggest scores of 0-9 are in the normal

range, 16-19 indicate mild-moderate depression, and scores

of 20 or more are in the moderate to severe depression

range. These guidelines are used in this study.

The suicide attempt was rated on the Lethality of

Suicide Rating Scale (Smith et al., 1984). It was designed

to bypass problems related to intent, such as minimizing

actual lethality due to stated intent. It is an interval

scale comprised of 11 points along a continuum which

measures the lethality of an attempt between no risk of

death and no risk of survival. Each point on the scale is

calculated on the basis of the actual

lethality of the method used, and is then modified by the

circumstances surrounding the attempt. Drug or chemical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 39

ingestions are evaluated in an extensive list that includes

lethal ranges of these substances by body weight categories.

Each scale point is explicitly defined in terms of these

variables, with 8 being considered "serious". Scores of 1-3

are considered of low lethality. While the reliability of

this scale would benefit from further reports of its utility

use as an assessment device, its objectivity and reliance on

quantitative data make it an appealing tool.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 3

RESULTS

Descriptive and inferential analyses were

conducted to examine the data. Table 1 presents mean scores

and standard deviations by group on the Beck Depression

Inventory (BDI), the UCLA Loneliness Scale and the Hazen and

Shaver attachment style questionnaire. The mean score on the

BDI for the attempter group was 19, which is at the upper

limit of the mild to moderate range of depression, while the

means for the clinical and normal control groups (15 and

10.6) were within the mild range.

In order to ascertain if differences obtained were

statistically significant, a series of t tests were carried

out and incorporated into Table 3. Attempters were more

depressed than the normal controls, t(60) = 3.12, p = .003,

but not than the clinical controls, t(60) = 1.57, £ = .12.

However, attempters were more lonely than their clinical

control counterparts, t(60) = 2.009, p < .05, but not than

the normal controls, t(60) = 1.61, p = .11.

Finally, the numbers of individuals describing

themselves as securely or insecurely attached are also

depicted in Table 3. Because attachment style is

categorical, a series of Pearson chi-square analyses were

40

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 41

conducted in this context. Significantly more attempters had

an insecure attachment style than normal controls, X2(l, N =

62) = 4.16, p = .04. However, the difference between the

attempters and clinical controls was nonsignificant, X2(l, N

= 62) = 0.62; n s .

TABLE 1

MEANS AND T TEST RESULTS FOR GROUPS ON MEASURES OF DEPRESSION, LONELINESS AND ATTACHMENT STYLE

ATTEMPTERS CLINICAL NORMAL N = 31 CONTROLS CONTROLS N = 31 N = 31

BDI MEAN = 19.03*** MEAN = 15.03 MEAN = 10.64b S.D. = 11.74 S.D. = 7.87 S.D. = 9.21 UCLA MEAN = 47.29** MEAN = 41.93b MEAN = 42.54 S.D. = 11.36 S.D. = 9.54 S.D. = 11.82 ATTACHMENT STYLE

INSECURE N = 21 (68%)** N = 18 (58%) N = 13 (42%)b ANXIOUS N = 12 (38%) N = 6 (19%) N = 6 (19%) AVOIDANT N = 9 (29%) N = 12 (39%) N = 7 (23%) SECURE N = 10 (32%) N = 13 (42%) N = 18 (58%)

Note. Statistics with *. significantly different from those with b. * E < .05. ** e < •01. Additional data analyses entailed the generation

of a series of multiple and logistic regression equations to

test the hypotheses regarding depression as a mediating

variable between attachment style and suicide attempts.

Baron and Kenny (1986) have argued that the appropriate test

for a mediational model is the examination of three

regression equations in which the following conditions must

be met: the independent variable must significantly affect

the mediator in the first equation; the independent variable

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 42

must significantly affect the dependent variable in the

second equation; and lastly, the mediator must significantly

affect the dependent variable, and the independent variable

should not, in the third equation. If these conditions hold,

then the effect of the independent variable on the dependent

variable must be less in the third equation than in the

second.

In this study, attachment style (hypothesis 1)

constituted the independent variable of interest, depression

(BDI score) was the mediating variable and a suicide attempt

(either yes or no) was the dependent variable. Depression

was a continuous variable while attachment style and suicide

attempts were measured as categorical variables. Regression

(Ordinary Least Squares) was used for the first equation.

But because attempter status, a categorical variable,

constituted the dependent variable of interest, logistic

regression, or Logit, was used for the second and third

equations. Reported chi-square values from Logit are Wald

chi-squares, and the -2 log likelihood chi-square g value

for the overall model was established as .05.

To test hypothesis 1, that the effects of an

insecure attachment style on suicide attempts are mediated

through depression, two sets of comparisons were made using

this series of 3 regression equations: one comparing the

attempter group to the clinical control group, and one

comparing the attempter group to the normal control group.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 43

The mediation hypothesis is the same for both group

comparisons.

As shown in Table 2, for comparisons of attempters

to either clinical controls, R2 =.172, F(l,60) = 12.47, p

<.001, or normal controls, R2 = .285, F(l,60) = 23.911, p <

.0001, an insecure attachment was found to be related to

increased depression.

TABLE 2

REGRESSION OF DEPRESSION ON ATTACHMENT

COEFFICIENT R: F RATIO

ATTEMPTERS VS -8.622 0.172 12.471*** CLINICAL CONTROLS ATTEMPTERS VS -12.015 0.285 23.911**** NORMAL CONTROLS

Note. *** e <.001. **** e <.0001.

In the second series of equations however, the

pattern of results varied as a function of control group

comparisons, as shown in Table 3. When comparing the

attempter to the clinical control group, an insecure

attachment style did not significantly predict membership in

the attempter group. However, when comparing attempters to

normal controls, an insecure attachment style did

significantly predict attempter status, X2(l, N = 62) =

4.06, p < .05 .

In the third equation series, both attachment and

depression were entered into the logistic regression

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 44

equations (Table 3). In the comparison between the attempter

and clinical control groups, neither depression, X2(l, N =

62) = 1.823, ns, nor attachment style X2(l, N = 62) = 0.02,

ns, significantly predicted which individuals would be in

the attempter group. However, with the attempter versus the

normal control group comparison, depression level did

predict attempter status, X2(l, N = 62) = 4.77, p < .05,

while attachment was no longer significant, X2(l, N = 62) =

0.29, ns.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 45

TABLE 3

LOGISTIC REGRESSION PREDICTING SUICIDE ATTEMPTS FROM ATTACHMENT STATUS AND DEPRESSION

GROUP PARAMETER PARAMETER WALD COMPARISONS ESTIMATE CHI-SQUARE

ATTEMPTERS VS ATTACHMENT -0.416 0.619 CLINICAL CONTROLS ATTEMPTERS VS ATTACHMENT -1.067 4.067* NORMAL CONTROLS ATTEMPTERS VS ATTACHMENT -0.878 0.022 CLINICAL DEPRESSION 0.395 1.823 CONTROLS ATTEMPTERS VS ATTACHMENT -0.340 0.296 NORMAL CONTROLS DEPRESSION 0.068 4.773*

Note. * g <.05. ** £ <.01

Additional analyses were performed comparing all

the clinical controls (N = 75) to the attempters (N = 31) to

increase the number of cases in the clinical group for

comparisons of the attempters and clinical controls.

Statistics are shown in Tables 4-6. Results obtained for the

first equation in the series again demonstrated that

attachment was a powerful predictor of depression status, R2

= .23, F(l, 104) = 32.91, p < .0001. Even when controlling

for the matching variables of age, gender, SES, and race,

attachment, t(l00) = 5.529, p < .0001, continued to predict

depression. It is noteworthy that in this sample, younger

subjects were more depressed than older subjects, t(100) =

2.22, p < .05.

In the second equation series, when gender was

statistically controlled, attachment style was not a

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. significant predictor of suicide attempt status, X2(l, N =

106) = 1.70, ns. Not surprisingly, gender was an important

matching variable (see Table 6). Therefore, even with the

added power of a larger clinical control group, attachment

style did not predict suicidality when comparing attempters

to clinical controls.

TABLE 4

REGRESSION OF DEPRESSION ON ATTACHMENT WITH ALL CLINICAL CONTROLS

GROUP COEFFICIENT R2 F RATIO COMPARISON

ATTEMPTERS VS -9.493 0.233 32.913*** ALL CLINICAL CONTROLS*

Note. * Total N = 106 (Attempters = 31, All Clinical Controls = 75). **** p < .0001

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 47

TABLE 5

REGRESSION OF DEPRESSION ON ATTACHMENT AND MATCHING VARIABLES WITH ALL CLINICAL CONTROLS

VARIABLECOEFFICIENT T

ATTACHMENT -9.643 -5.529**** AGE -2.489 -2.229* GENDER 2.499 1.461 RACE 0.544 0.830 SES .560 0.746

Note. * £ < .05. **** £ < .0001

TABLE 6

LOGISTIC REGRESSION WITH ALL CLINICAL CONTROLS PREDICTING SUICIDE ATTEMPTS FROM ATTACHMENT

GROUP PARAMETER PARAMETERWALD COMPARISON ESTIMATECHI-SQUARE

ATTEMPTERS VS ATTACHMENT -0.929 4.286* ALL CLINICAL CONTROLS ATTEMPTERS VS ATTACHMENT -0.620 1.703 ALL CLINICAL GENDER 1.310 7.253** CONTROLS

Note. * £ < .05. ** £ < .01

To investigate whether attachment style is

predictive of pathology in general rather than suicidality

in particular, separate analyses were performed combining

the original matched attempters with clinical controls, and

comparing them to the normal controls (see Tables 7 and 8).

In terms of the first equation series, attachment style

predicted depression status, R2 = .25; F(l,91) = 32.91, p <

.0001, and accounted for a slightly lower amount of the

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 48

variance than in the comparison between attempters and

normal controls, R2 = .29. In the second equation series,

attachment style predicted pathology status in the second

equation, X2(l, N = 93) = 3.61, p = .057, ns, only

marginally less than in the initial comparison with only the

matched attempters and normal controls X2(l, N = 62) = 4.06,

p < .05. As for the third equation series, depression

predicted pathology status X2(l, N = 93) = 4.91, p < .05, in

this comparison about as well as in the first comparison

X2(1, N = 62) = 4.77, p < .05. Here attachment style became

insignificant as a predictor of pathology status, as

hypothesized in a mediating model, when the effects of

depression were taken into account. These data show little

difference between the comparison of all clinical groups to

normals, and attempters to normals.

TABLE 7

REGRESSION OF DEPRESSION ON ATTACHMENT COMBINING SUICIDE ATTEMPTERS AND MATCHED CLINICAL CONTROLS

GROUP COEFFICIENT R2 F RATIO COMPARISON

ATTEMPTERS AND -10.558 .257 32.821**** CLINICAL CONTROLS VS NORMAL CONTROLS

Note. **** 2 < .0001

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 49

TABLE 8

LOGISTIC REGRESSION PREDICTING SUICIDE ATTEMPTS FROM ATTACHMENT STATUS AND DEPRESSION USING ATTEMPTERS AND MATCHED CLINICAL CONTROLS

GROUP PARAMETER PARAMETER WALD COMPARISON ESTIMATE CHI-SQUARE

ATTEMPTERS AND ATTACHMENT .853 3.613* CLINICAL CONTROLS VS NORMAL CONTROLS ATTEMPTERS AND ATTACHMENT 0.250 0.231 CLINICAL DEPRESSION -0.653 4.915* CONTROLS VS NORMAL CONTROLS

Note. * e = .057. * £ < .05.

To further explore the reasons for the lack of

significance in terms of the mediation model between the

attempter and clincial control groups, a review was

undertaken of the composition of the attempter and clinical

control groups. There were seven individuals in the clinical

control group who had made a suicide attempt within their

lifetimes, but not within the past year. The mediation

analysis was re-examined placing all attempters into the

attempter group, regardless of when the attempt occurred.

Results were not significant for the mediation analysis

once again. Although attachment style predicted depression,

R2 = 0.158, F (1,60) = 12.47, p <.001, attachment alone did

not predict suicide attempt status, X2(l, N = 62)= 1.27, ns.

Controlling for depression, neither attachment, X2(l, N =

62) = .55, ns, nor depression, X2(l, N = 62) = .471, ns

predicted suicide attempt status. These findings suggest

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 50

that the inclusion of lifetime attempters in the attempter

group did not differentiate the two groups on depression and

attachment style.

Lastly, as noted earlier in the breakdown of

sources of participants (Appendix A), there was a

significant difference in sources of attempters and clinical

controls. To explore if placement had an effect on the

results, the mediation analysis was tested with only

attempters (N = 10) and clinical controls (N = 20) from the

Court supervised residential placements. Results must be

viewed with caution because the small N violates the

assumption of 15 subjects per variable for regression

analysis. Attachment style predicted depression, R2 = 0.20,

F (1,28) = 8.63, p = .007, however, attachment alone did not

predict suicide attempt status, X2(l, N = 30) = 0.07, ns. In

the third equation, attachment was not a significant

predictor, X2(l, N = 30) = 1.96, ns, but higher levels of

depression did predict suicide attempt status, X2(l, N = 30)

= 6.67, p < .01. Thus, even controlling for the possible

effects of location, attachment did not distinguish between

these groups and depression continues to be a significant

variable in the prediction of suicide status.

To test the second hypothesis, that loneliness was

correlated with insecure attachment styles, loneliness

scores were examined for the different attachment styles. As

predicted and shown in Table 9, loneliness scores were

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 51

higher in individuals with insecure attachment styles within

the attempter group, t(29) = 3.36, £ < .002, the clinical

group, t (29) = 2.48, p < .01, and the normal control group,

t (29) = 3.54, £ < .001.

TABLE 9

MEAN LONELINESS SCORES AND T TESTS BY ATTACHMENT STYLE

ATTACHMENT ATTEMPTERS CLINICALNORMAL STYLE N= 31 CONTROLS CONTROLS N = 31 N = 31

INSECURE 51.38** 45.27** 50.70*** N = 21 N = 18 N = 13 SECURE 38.7 37.3 37.11 N = 10 N = 13 N = 18

Note. ** £ < .01. *** e < -001

To more closely examine the relationship of

loneliness and insecure attachment style to suicide,

loneliness was substituted for attachment style in the

series of equations previously described to test for

mediation. As shown in Table 10, loneliness was a good

predictor of depression for comparisons between both

attempters and clinical controls, R2 = .20, F(l,60) = 16.91,

E < .0001, and between attempters and normal controls, R2 =

.28, F (1,60) = 25.22, £ < -0001.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 52

TABLE 10

MULTIPLE REGRESSION OF DEPRESSION ON LONELINESS

COEFFICIENT R2 F RATIO

ATTEMPTERS VS 0.441 0.207 16.911**** CLINICAL CONTROLS ATTEMPTERS VS 0.523 0.284 25.221**** NORMAL CONTROLS

Note. **** g < .0001

For the second equation (Table 11), loneliness was

not quite significant as a predictor of suicide attempts for

the comparison of attempter to clinical control group, X2(l,

N = 62) = 3.65, p < .055, but was clearly in the

hypothesized direction. Loneliness performed more poorly as

a predictor in the comparison between the attempter and

normal control group X2(l, N = 62) = 2.47, ns. Again, this

was due to the slightly lower scores on the loneliness

measure for the normal compared to the clinical controls. It

is also noteworthy that the number of individuals in each

group (N = 31) was small. Perhaps larger groups may have

increased the significance of these statistics.

In the third equation (Table 11), entering both

loneliness and depression, loneliness had little predictive

value for suicide attempts in either comparison, as would be

expected in a mediation model. However, depression was a

significant predictor of suicide attempts only in the

comparison between the attempters and the normal control

group, X2(1, N = 62) = 5.66, e < .01, but not between

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 53

attempters and clinical controls, X2(l, N = 62) = .52, ns.

Hence, depression did not mediate the effects of loneliness

on suicide attempt status.

TABLE 11

LOGISTIC REGRESSION PREDICTING SUICIDE ATTEMPTS FROM LONELINESS AND DEPRESSION

GROUP PARAMETERS PARAMETER WALD COMPARISONS ESTIMATE CHI-SQUARE

ATTEMPTERS VS LONELINESS 0.050 3.657 CLINICAL CONTROLS ATTEMPTERS VS LONELINESS 0.036 2 .473 NORMAL CONTROLS ATTEMPTERS VS LONELINESS 0.040 1.944 CLINICAL DEPRESSION 0.021 0.524 CONTROLS ATTEMPTERS VS LONELINESS -0.001 0.003 NORMAL CONTROLS DEPRESSION -0.776 5.665**

Note. ** £ < .01

Data on family characteristics, childhood

experiences and therapeutic interventions gathered with

demographic information was also examined (Tables 12-13) . In

general, the attempter and clinical control groups had more

problems within their families, experienced poorer

relationships with parents and unhappiness in childhood and

had more psychotherapeutic intervention than the normal

control group. Pearson chi-square analyses were not

significant for comparisons between the attempter and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 54

clinical groups, with the exception of attempters having had

more psychotherapy within the past year (p < .04).

TABLE 12

FAMILY CHARACTERISTICS AND PSYCHOTHERAPY HISTORY

VARIABLES ATTEMPTERS CLINICAL NORMAL N = 31 CONTROLS CONTROLS N = 31 N = 31

Living with 9 (29%) 5 (16%) 18 (58%) both parents Family 14 (45%) 16 (51%) 7 (22%) substance abuse Parent 9 (29%) 4 (13%) 2 (6%) psychiatric illness Weekly use of 8 (25%) 7 (22%) 1 (3%) alcohol Weekly use of 8 (25%) 10 (32%) 2 (6%) drugs Substance abuse 10 (32%) 9 (29%) 1 (3%) treatment Psychotherapy 23 (75%) 20 (64%) 10 (32%) Within 21 (67%) 10 (32%) 4 (13%) year Within 1- 2 (6%) 11 (35%) 6 (19%) 5 years Was 15 (65%) 13 (65%) 5 (50%) helpful

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 55

TABLE 13

CHILDHOOD EXPERIENCES

VARIABLE ATTEMPTERS CLINICAL NORMAL N = 31 CONTROLS CONTROLS N = 31 N = 31

Parental Unconcern Mother 6 (19%) 10 (32%) 3 (9%) Father 13 (41%) 12 (38%) 6 (19%) Parental Rejection Mother 12 (38%) 10 (32%) 5 (16%) Father 13 (41%) 12 (38%) 2 (6%) Parental Hostility Mother 14 (45%) 12 (38%) 5 (16%) Father 13 (41%) 8 (25%) 2 (6%) Often lonely 14 (45%) 9 (29%) 8 (25%) Often angry 16 (51%) 10 (32%) 8 (25%) Often sad 19 (61%) 16 (51%) 7 (22%) Often had 2 29 (93%) 26 (83%) 28 (90%) friends Family 14 (45%) 18 (58%) 21 (67%) supportive

Data was also examined regarding recent and

lifetime suicidal ideation and behavior (Table 14).

Adolescents in the attempter group reported more suicidal

ideation within the past year (p < .0001), and in their

lifetimes (p < .001), than clinical controls. They also

reported having made more lifetime plans to commit suicide

(P < .001) than clinical controls. In addition, attempters

indicated they had made more lifetime suicide attempts (p <

.01) than clinical controls.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 56

TABLE 14

RECENT AND LIFETIME SUICIDAL THOUGHTS AND BEHAVIOR

VARIABLE ATTEMPTERS CLINICAL NORMAL N = 31 CONTROLS CONTROLS N = 31 N = 31

Suicidal 29 (94%)**** 11 (35%) 11 (35%) thoughts within past year Lifetime 28 (93%)**** 13 (41%)*** 9 (29%) thoughts of harming self Lifetime plan 26 (83%)*** 13 (41%) 9 (29%) to harm self Lifetime 22 (70%)** 7 (22%)** 1 (3%) attempts (not within past year)

Note. ** £ < .01. *** e < -001. **** £ < .0001.

Lastly, lethality of attempt and attachment style

were examined for possible differences between the two

styles of attachment. Lethality was divided into low (1 and

2 on the Lethality Rating Scale) and high ratings (3 and

higher). The Fisher exact test yielded a p < .38, indicating

no significant difference in this sample of attachment style

for between those participants with ratings of high and low

lethality.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 4

DISCUSSION

The results obtained provide partial support for

the first hypothesis regarding mediation. Specifically,

there is some evidence that the effect of an insecure

attachment style on suicide attempts is expressed, or

transmitted through, depression. Suicide attempters were

more insecure and more depressed than normals. This is

consistent with de Jong's (1992) evidence for lower security

of attachment to parents' in suicidal college students

compared to normals, and extends this finding to younger

adolescents. When comparing attempters to a matched group of

normal controls, the results demonstrated that attachment

style predicted depression, and suicide attempt status (an

attempt within the past year). However, when the effects of

depression were taken into consideration, as expected,

depression was a significant predictor and attachment style

was no longer related to suicide attempts.

Support for the mediation model was not replicated

in the comparison between attempters and clinical controls.

While attachment style predicted depression, attachment was

not able to perform as a predictor of suicide status. When

adding knowledge of depression to the equation, prediction

57

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 58

improved slightly, but was not significant. It is notable

that in this equation the predictive value of attachment

decreased, which was in the expected direction. These

results suggested the mediation model could have predictive

value in this comparison, but that possibly there was

insufficient power due to the small number of subjects.

An additional analysis comparing attempters to all

clinical controls, not only matched subjects, assisted in

exploring the question of power due to number of subjects.

Attachment style was again related to depressive status.

However, after controlling for the effects of gender and

age, two matching variables in the original matched sample,

attachment style did not predict suicide attempt status in

this larger clinical sample. Also, entering depression into

the equation did not improve prediction. Although not

statistically significant, the hypothesized relationship

between attachment and depression was again evident. Hence,

these results suggest that when comparing attempters to

clinical controls, an insecure attachment predicts

depression, as found in the attempter versus normal

comparison, but even with additional power, attachment style

is not a useful predictor for suicidal attempts. It appears

from these results that low power in the analyses was not

the primary reason for the lack of significance.

In this study attempters and the clinical controls

were not very different from one another on attachment style

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 59

and depression level. This lack of differentiation would

suggest that attachment style is predictive of depression in

general rather than suicidality specifically. This is

consistent with De Wilde and colleagues' (1993) failure to

identify any specific psychological factors including self­

esteem, state-trait anxiety, locus of control, competence,

and levels of family cohesion and conflict, amongst

adolescent suicide attempters that distinguished them from a

control group of depressed adolescents. Notably, there were

significant differences between normals and the clinical

groups (attempters and depressed).

To further explore differences between the larger

matched clinical sample, both attempters and clinical

controls, the clinical groups were combined and compared to

the normals in the mediation analyses. The results were

similar to the findings with the attempter versus normal

control comparison, in that attachment predicted depression

and depression acted as a mediator between an insecure

attachment and suicidality. This further suggests that an

insecure attachment predisposes individuals to pathology in

general, but is not specific to suicide attempters.

The empirical support for the mediation model in

the analyses of the attempter and combined clinical groups

versus the normals, and lack of significant results with the

attempter versus a larger clinical sample, illustrates the

difficulty of distinguishing attempters from clinical groups

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 60

in general. Results from this study for the mediation

hypothesis in the comparisons suggests that low lethality

attempters with a mild/moderate level of depression are not

significantly more depressed, and/or do not have a higher

incidence of insecure attachments, than the clinical

population in this study, which was characterized mainly by

oppositional behavior and criminal conduct.

These findings, that neither depression level nor

attachment style distinguish between the attempter and

clinical control group, raise the question of whether an

insecure attachment is a specific risk factor for

suicidality or psychopathology in general. Ingram's (1990)

proposal of a meta-construct model of descriptive

psychopathology provides a possible context in which to

understand these findings. This paradigm combines a

cognitive taxonomy and a partioning of variance analogy to

explain psychopathology. With the variance component, he

describes the expression of a given disorder as a function

of critical features (main effects), common features

(interactions) and error (individual differences). Critical

features are those which are unique to a given pathology,

such as depression or alcohol abuse, while common features,

such as self-focused attention, represent shared variance,

are present in a variety of disorders, and differentiate

adaptive from maladaptive functioning. Using the variance

portion of this model, an insecure attachment could be

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 61

viewed as a common, but not specific, psychopathological

feature for a variety of disorders, including suicidality.

The results from this study lend support to the role of an

insecure attachment style performing as a common feature in

that it predicts both suicidality and depression in

comparisons between normals and both clinical groups

(attempters and clinical controls). More precisely,

attachment style influences suicidality primarily through

its relationship to depression.

In all of the comparisons, attachment style

predicted depression, accounting for 17% of the variance in

the attempter and clinical control comparison, and 28% of

the variance between the attempters and normals. This

association was true even at a mild to moderate level of

depression (BDI = 19). This strong association provides

support for the vulnerability hypothesis postulated by

attachment theory (Bowlby, 1973) and Blatt and Homann

(1992), that an insecure attachment style lays the

groundwork for later depression. In a related manner, this

data is also consistent with the findings of Papini and

Roggman (1992), and Armsden and colleagues (199 0), that

depressive affect in adolescents is associated with low

security of attachment to parents.

The second hypothesis, that loneliness will be

correlated with an insecure attachment style and suicide

attempter status was also partially supported by the results

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 62

of regression equations. Loneliness scores were

significantly higher for those individuals with an insecure

attachment style than for those with a secure attachment

style in each of the three groups. This is a robust finding

and indicates there is a link between felt loneliness and

having an insecure attachment style. Given that the mean

loneliness scores between the three groups formed toy

pathology (attempters and clinical controls) or lack of it,

(high school population) were barely different statistically

and yet were clearly different when the groups were formed

by attachment style, suggests that loneliness is more

related conceptually to attachment style than to pathology

as defined by group membership in this study.

These findings provide indirect support for the

hypothesis that secure attachment to parents fosters more

self-esteem and emotional well-being (Armsden St Greenberg,

1987), and less social anxiety (Pappini, Roggman & Anderson,

1991) among adolescents. In older adolescents Blain and

collegues (1993) found that more securely attached

individuals reported higher levels of perceived social

support from parents and friends, and attachment to friends.

However, there is evidence that insecure attachment to

parents does not always extend to insecure attachments to

peers. Armsden and collegues (1990) found that depressed

children and adolescents' attachment to parents was less

secure, but not to peers when compared to psychiatric

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 63

controls. Likewise, de Jong (1992) reported that suicidal

late adolescents displayed the least secure attachment to

parents compared to depressed and control adolescents, but

were more similar to depressed adolescents in terms of

security of attachment to peers. Thus, how adolescents may

feel securely attached to peers but not to parents deserves

more study to understand how this division takes place.

Possibly, insecurely attached adolescents may attach to

others with insecure attachments who match their own

perceptions of themselves, and thereby gain a limited sense

of closeness and social support, however tenuous.

To examine the possibility that loneliness may

behave in a manner similar to an insecure attachment style,

loneliness was substituted for attachment in the series of

regression equations. Loneliness predicted depression in

both comparisons, not unexpected given the high correlation

between these two variables. However, loneliness did not

predict suicide attempt status in the attempter or clinical

control group comparison, although there was a strong trend.

Thus, loneliness does not predict suicide attempt status as

strongly as an insecure attachment style, although it

appears to be an important factor. This result extends

Berman and Schwartz's (1990) findings amongst adolescent

suicide attempters of higher incidences of remembered

loneliness in childhood, to include higher levels of current

loneliness.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 64

Although the failure of loneliness to predict

suicide attempts in the second equation invalidated the

mediation model, information obtained from predicting

suicide attempts from loneliness when controlling for the

effects of depression provided additional information about

this relationship. While the data are not statistically

significant and reflect only a trend, the data suggest that

after accounting for depression, suicide attempters in this

sample were more lonely than clinical controls. Therefore,

loneliness appears to behave in a similar but not altogether

identical fashion, to an insecure attachment style in this

regard.

In the normal versus attempter comparison, the

contribution of loneliness declined dramatically and

depression status became a very significant predictor of

suicide attempt status. This suggests that attempters

compared to normal controls are more different in their

levels of depression than they are in their levels of

loneliness. In contrast, in the attempter and clinical

control comparison, the contribution of loneliness declined

but depression added comparatively little to the

predictability of suicide attempt status. This pattern of

findings suggests that loneliness is a more important factor

when comparing attempters to clinical controls, but

depression carries more weight when comparing attempters and

normal controls. Analyses to investigate the possibility of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 65

a moderating effect from the interaction between depression

and loneliness on the prediction of suicide attempt status

were not significant, suggesting that being both depressed

and lonely did not increase the likelihood of making a

suicide attempt in this sample.

The additional questions regarding family

characteristics and childhood experiences did not reveal

significant differences between the attempter and clinical

control groups. However compared with normals and as

previously reported, attempters reported more difficulties

with disruptions to family life such as divorce (Cohen-

Sandler et al., 1982), family history of substance abuse,

suicide and psychiatric illness (Garfinkel et al, 1982).

This is consistent with reports of higher overall disturbed

family functioning in families of suicide attempters

compared to normals (Corder et al., 1974; Taylor &

Stansfield, 1984). The questions regarding childhood

experiences of parental unconcern, rejection and hostility,

and of general dysphoria, did not differentiate the

attempters from the clinical controls. Although the number

of individuals in each group was small (31) and limits

generalizability, there were patterns that distinguished

these two groups from the normal group. In general,

approximately one-third to one-half of subjects in the

attempter and clinical control groups reported feeling

disregarded by parents whereas only one-quarter or less of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 66

normals reported these feelings. Surprisingly, approximately

one-half of the attempter and clinical groups reported their

families as supportive, in spite of the reported dysphoria.

Two-thirds of the normals reported having supportive

families. Perhaps there is a desire on the part of those in

these groups to have had supportive families in spite of the

realities. At the same time it is plausible that for some of

the attempters, they do indeed perceive their families as

supportive but that other factors, such as level of

depressive affect, play a salient role in their motivation

to engage in suicidal behavior. This discrepancy suggests

there may a reporting bias toward social desirability.

Equally as likely is that because adolescents are separating

from their families and leaving behind whatever security was

available, it may be that for adolescents with insecure

attachments, there is a need to preserve the illusion of

secure attachments to family to assist them as they actually

separate.

Reports of prior therapeutic intervention were

investigated for several reasons. One is that a frequent

objective of psychotherapy is to improve satisfaction gained

from interpersonal relationships. Difficulty in

relationships could be viewed as related to an insecure

attachment style. The second reason was to determine if an

attachment related activity (psychotherapy) was perceived as

helpful. Indeed, two-thirds of the attempter and clinical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 67

control groups reported prior psychotherapy whereas only

one-third of normals did. This finding is consistent with an

earlier reports of higher levels of prior psychotherapy

(Brent et al., 1993; Garfinkel et al., 1982) in attempters.

Approximately one-half to two-thirds described psychotherapy

as helpful. Attempters' perceptions of psychotherapy have

not been reported previously. Thus, approximately half of

the attempters reported that they benefited from assistance

with a therapeutic intervention focused on improving

interpersonal relationships.

There were significant differences between

attempters and clinical controls in terms of recent and

lifetime suicidal thoughts and behavior. Attempters clearly

described more suicidal thoughts within the past year, and

lifetime thoughts, plans and attempts than clinical

controls. These results add support to Berman and Schwartz's

(1990) finding that adolescent suicide attempters report

histories of wishing to die stemming from childhood.

There are several limitations to the

generalizability of these results. First is the nature of

the characteristics of the obtained sample of attempters.

This group included adolescents who reported having made a

low lethality attempt within the past year. Only eight

obtained medical attention and six were taken to an

Emergency Room at a hospital. Seven in the clinical control

group had made a lifetime attempt not within the past year.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 68

However, even adding lifetime attempters to the attempter

group and re-analyzing the data did not significantly effect

the results. Therefore, these findings reflect only this

type of low lethality attempter, either within the past year

or lifetime, and cannot be presumed to characterize

attempters who have made more lethal attempts. The issue of

lethality carries added weight because it bears directly on

the intent of the suicide attempt. Berman and Jobes (1991)

have suggested that low lethality attempts are designed to

force change of an interpersonal nature, whereas higher

lethality attempts signal a serious wish to die. Hence, the

attempters in this study may have engaged in self­

destructive behavior to influence others' behavior toward

them, rather than actually intending to die. Questions

regarding intentionality of the attempters would have shed

more light on this question and enhanced accurate

categorization of the attempters.

Had the attempters in this study reported higher

lethality attempts, it is unclear what effect lethality

would have had on the mediation hypothesis. An investigation

of differences using regression analyses between high and

low lethality attempters in this sample, although with a

small N, indicated that lethality, measured as a categorical

variable, high and low, did not predict depression or

attachment. Were there to be an effect, it is probable that

the effect would be expressed by way of an association

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 69

between higher lethality and increased levels of depression,

particularly as depression is a highly significant risk

factor for completed adolescent suicides. However, there is

increasing evidence that adolescents displaying antisocial

behavior, such as conduct disordered youth, are at increased

risk for completed suicide, sometimes without comorbid

depression (Brent et al., 1993). As attachment style has not

been reported within an antisocial population, and higher

lethality attempters may not report high levels of

depression, it is at present not clear whether depression

mediates the effects on an insecure attachment style on

suicidal behavior within all subgroups. While it is

difficult to gain access to adolescents who have made high

lethality attempts, it is imperative continuing efforts be

made to study this group in order to improve risk

assessment.

Second, is the small number of matched subjects.

Although there was adequate statistical power (15 subjects

per variable), for the primary analyses, the small number of

subjects in some of the categories, particularly within the

normal group, curtailed comparisons of some of the

variables. It may also have contributed to several

differences between the sample and epidemiological surveys.

While 9-11% of normal controls reported prior suicidal

ideation which is consistent with earlier studies (Garrison

et al., 1993), lifetime attempts of 1% was substantially

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 70

lower than in the Garrison and collegues' study, 7.5%, and

the 9% reported by Kandel et al., 1991. The lack of

similarity for rate of prior suicidal ideation and attempts

between the attempter and clinical control groups is

puzzling, especially in light of the correspondence of their

depression levels. One possibility is that there may have

been unmeasured diagnostic differences. Perhaps the

attempters had comorbid diagnoses whereas the clinical

controls did not. Hence the broad definition of the clinical

control group makes the classification of this group

unclear.

There were also three methodological problems that

limited generalizability. One was the lack of information

regarding lifetime and recent stresses for the participants.

In terms of the mediation hypothesis, it would be important

to compare the amount of lifetime and recent stresses within

groups to determine if exposure to stress was significantly

higher in those with an insecure, compared to a secure,

attachment style. If there was more taxing of the attachment

system (by increased level of stress with minimal support

from caretakers) over time for attempters, possibly stress

could have moderated the relationship between an insecure

attachment style and depression. For example, if stress had

been low, there would have conceivably been less reason for

depression to develop. On the other hand, had stress been

high, depression would have been more likely to occur, which

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 71

may then have led to suicidality. This hypothesis does not

exclude the possibility that the mediation model may provide

an explanation for the data as well. It is possible that

those individuals with insecure attachment styles would be

more inclined to react to stress with feelings of

incompetance and eventually become depressed in comparison

to individuals with a secure attachment who may believe they

are more competant at solving problems. Thus, it is

plausible that both processes may occur. This possibility

warrants further reseach to highlight how and when each

process may take place.

A second methodological problem was the lack of

diagnoses for attempters and clinical controls. More

information about the nature of their emotional disturbances

over and above scores on the BDI would have provided a more

accurate mental health assessment of these adolescents.

Without this information, it is unclear if there were a

higher number of comorbid diagnoses in the attempter group

which would have increased their risk for suicidal behavior.

For instance, it is possible that more attempters than

clinical controls could have had diagnoses of both

depression and conduct disorder, and or borderline

personality disorder. The presence of unmeasured cormorbid

diagnoses clouds the mediation findings. For example, it is

not clear whether attachment exerts its effects on

suicidality through depression, or through depression in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 72

combination with other diagnoses. Use of a diagnostic

instrument such as the childhood version of the Schedule for

Affective Disorders and Schizophrenia (K-SADS) would have

served this purpose.

A third problem with the methodology was the

length of time between the attempt and the completion of the

measures in this study. The attempts could have been made a

week or a year beforehand, but depression was measured only

for the past week. This lag time makes it uncertain if, and

to what extent, the individual was depressed at the time of

the attempt. Although it is very likely that attempters were

depressed at the time of the attempt, the methodology used

in this study does not provide direct evidence for this

assumption. Therefore, it is unclear whether depression was

indeed a mediating variable at the time of the attempt. In a

a related manner, as it is unknown how soon after the

attempt the measures were completed, the question arises of

whether a suicide attempt is a dependent or independent

variable in this study. In other words, it is unknown if

having made an attempt somehow influenced depression or

attachment style status. Studies of events leading to

changes in attachment style in adolescents have not been

reported in the literature to date. In light of the multiple

experiences over time which are hypothesized to strengthen

an attachment style, it seems doubtful that a suicide

attempt would change a previously secure attachment style

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 73

into an insecure style. At the same time, an attempt may

increase depressive affect. Identification of when within

the past year the attempt was made would have provided more

clarification of the meaning of the data. Administering the

measures as soon as possible after the attempt would have

increased the validity of the findings.

Areas for further research would include use of an

expanded measurement of insecure attachment style. Because

depression is the most common diagnosis for attempters, and

attachment and depression are related, new measures such as

one by Bartholomew and Horowitz (1991) are promising in that

they define four attachment types (secure, fearful,

preoccupied and dismissing) based on the self in relation to

others. Specifically, their model focuses on esteem,

positive and negative, for others and for self. Each

attachment corresponds with one of four combinations. For

instance, the secure type would be characterized by a

positive view of self and of others, while the fearful type

would hold a negative view of self as well as others. In

terms of the mediation hypothesis, it may be that one or two

types of this categorization of attachment styles,

particularly the fearful type, may be related to suicidality

through depression while one or more of the others may not.

The fearful type is most consistent with depressive feelings

in that there would be low self-esteem and disbelief that

other people would be available and supportive. Use of this

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 74

type of measure with attempters would further clarify their

beliefs and expectations of others in interpersonal

relationships. This is important because suicide attempts

often follow interpersonal losses, and the intent of

adolescent suicidal behavior is frequently to force a change

in someone else's behavior (Berman & Jobes, 1991).

Potentially, this type of information, particularly how

suicide attempters view others, could be used to pinpoint

more focused psychotherapeutic interventions.

Results from this study also suggest it would be

useful to further explore the pathway from an insecure

attachment style to depression to suicidal behavior. If an

insecure attachment is a common, but not critical, feature

of suicidality, and not all insecurely attached adolescents

become depressed and go on to suicidal behavior,

clarification about how divisions in this process occur

would improve risk assessment. Studies comparing insecurely

attached adolescents who are depressed with those who are

not would be informative in this regard. For example, it may

be that suicidal adolescents have had less exposure than

their nonsuicidal counterparts, to protective factors over

their lifetimes such as opportunities for attachments other

than with nonsupportive parents. It might also be useful to

examine the different types of insecure attachments and

their association with depression. As suggested by Blatt and

Homann (1992), there is evidence that anxious and avoidant

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 75

insecure attachments may lead to depressive symptoms

centered on different issues. In their analysis an anxious

attachment style leads to a depression focused on issues of

dependency and loss, whereas the avoidant style leads to a

depression focused on self-criticism, and anger toward the

caregiver and the self. Assuming that anger toward self with

the avoidant type may be predictive of higher rates of self-

harm, it is plausible that this style may be more related to

suicidal behavior than the anxious style.

A final important area for additional inquiry

stems from the significantly more frequent lifetime

experiences of prior suicidal thoughts and plans amongst

attempters compared to clinical controls. While this

information was gathered as descriptive data and was

expected to be higher in the attempter group, it is

interesting that it occurred within groups which were

similar in levels of depression and incidence of insecure

attachments, but were slightly higher in reported

loneliness. Obviously the occurence of these thoughts was

not attributable to the measured variables, at least

directly. Although examination of the circumstances under

which these thoughts occurred would be retrospective, it may

provide information into the perceptions and cognitive

aspects of events that generate these thoughts.

Lastly, these findings indicate that only half of

attempters had psychotherapy subsequent to an attempt, and

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 76

that half of this group described it as helpful. Thus only a

quarter of attempters in this sample reported that the

obtained treatment was useful. It may be fruitful to study

those who are able to obtain, as well as report having

benefited, from treatment in terms of differences in

attachment style. It would be expected that people with

insecure attachment styles would be less likely to trust

others, such as therapists, and would thus not seek

psychotherapy for treatment of depression as readily as

those with secure attachments. The findings from this study

suggest that in terms of prevention of suicidal behavior,

one avenue worthy of future research is closer examination

of the pathways and processes by which an insecure

attachment style leads to depression.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX A

SOURCES OF PARTICIPANTS

Facility- Attempters Clinical Normal N = 31 Controls Controls N = 31 N = 31

Mental Health 7 5 0 Centers Youth Shelters/ 8 6 1 Group Homes Day Treatment 5 0 0 Court 10 20 0 Supervised Residential Placements Public High 1 0 30 School

77

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX B

GROUP DEMOGRAPHICS

ATTEMPTERSCLINICAL NORMAL N = 31 CONTROLCONTROL N = 31 N = 31

GENDER Male 8 8 9 Female 23 23 22 AGE 13-14 8 7 1 15-16 14 16 21 17-19 9 8 9 RACE Caucasian 19 19 18 Black 5 5 5 Asian 1 1 2 Hispanic 4 4 4 Other 2 2 2

78

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX C

CHARACTERISTICS OF SUICIDE ATTEMPTS

LETHALITY* 1 13 2 10 3 1 3.5 2 5 4 7 1

MEAN = 2 METHOD Cut Self 14 Overdose pills/alcohol 13 Electrocute self 1 Jump from building 1 Strangle self 1 Jump in front of truck 1 OBTAINED MEDICAL ATTENTION Stomach pumped 2 Stitches/bandages 3 Drank charcoal 1 Hospitalized for liver damage 2 TAKEN TO EMERGENCY ROOM 6 TOLD SOMEONE AFTER ATTEMPT 17 RECEIVED PSYCHOTHERAPY AFTER ATTEMPT 17 Described as helpful 10 Note. * N = 31

79

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX D

INFORMED CONSENT TO PARTICIPATE IN RESEARCH

You are being asked to participate in a research project investigating how adolescents describe and feel about themselves. This study is the dissertation of the main investigator, Kolleen Martin, M.A., a doctoral candidate in clinical psychology at The American University in Washington, D.C.

As a subject in this project you will be asked to complete several questionnaires which take approximately 20- 25 minutes to complete. Your answers will be confidential. The answer sheets are coded by number in order to preserve anonymity. Your name will not be on any of the questionnaires. This is done to protect your privacy and the confidentiality of information you give.

Please be aware that there are legal limits to confidentiality. Specifically, if there is evidence that a subject is in immediate danger of harming him/herself or others, there is a duty to disclose this information. The main investigator will consult with the subject and make an appropriate referral for assistance.

If while answering the questionnaires, you change your mind for any reason and decide that you do not want to participate, you are free to stop. This is entirely your choice. Just in case any of the questions about depression or self-harm elicit negative feelings, I will invite anyone with these reactions to talk with me afterwards.

If you are dissatisfied with the research activity, you may anonymously report your complaints to any of the persons listed on the attached sheet. Please separate the consent form and attached sheet so that you may take this sheet with you.

Your signature below indicates you understand the content of this informed consent form and agree to participate as a subject in this research. The signature of

80

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 81

one parent is also required on the attached second consent form if you are below the age of 18.

Name

Date

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX E

PARENTAL INFORMED CONSENT TO PARTICIPATE IN RESEARCH

Your teenager is being asked to participate in a research project investigating how adolescents describe, and feel about themselves. This study is the dissertation of the main investigator, Kolleen Martin, M.A., a doctoral candidate in clinical psychology at The American University in Washington, D.C.

As a subject in this project your teenager will be asked to complete several questionnaires which take approximately 20-25 minutes to complete. The answers will be confidential. The answer sheets are coded by number in order to preserve anonymity. Your teenager's name will not be on any of the questionnaires.

Please be aware that there are legal limits to confidentiality. Specifically, if there is evidence that a subject is in immediate danger of harming him/herself or others, there is a duty to disclose this information. The main investigator will consult with the subject and make an appropriate referral for assistance.

If while answering the questionnaires, your teenager changes his/her mind for any reason and decides they do not want to participate, they are free to stop. This is entirely their choice. Just in case any of the questions about depression or self-harm elicit negative feelings, I will invite anyone with these reactions to talk with me afterwards.

If you or your teenager are dissatisfied with the research activity, you may anonymously report your complaints to any of the persons listed on the attached sheet. Please separate the consent form and attached sheet so that you may take this sheet with you.

Your signature below indicates you understand the content of this informed consent form and agree to have your teenager participate as a subject in this research.

82

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 83

Parent Name

Date

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX F

NUMBER:

DATE:

FAMILY AND PERSONAL HISTORY QUESTIONNAIRE

Please answer the following questions to the best of your knowledge by checking yes (Y), no (N), or filling in the blank. Remember this information is confidential.

AGE: (13-14)______(15-16)______(17-19)

GENDER: Male Female

RACE: Caucasian Black______Asian_ Hispanic Other____

1. Are you currently living with both natural parents?

Y___

N la. If not, please indicate why not? Check only the one that applies.

abandonment___ divorce___ natural or accidental death___ suicide___ homicide

Which parent do you live with?

84

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 85

lb. Do you have contact with the parent you do not live with at least twice a month on a regular basis? Y N___

2. Have any of your relatives committed suicide?

Y 2a. If yes, how were they related to you?

N

3. Is there alcoholism or serious drug use in your immediate family?

Y 3a. If yes, which family member(s)? Mother , Father , Brother__ Sister___ N

4. Do either of your parents suffer from a serious psychiatric illness?

Y 4a. If yes, which parent______

4b. What is the illness?______

4c. If yes, was this parent hospitalized for this illness? Y N N

5. Have you ever had any type of counseling or psychotherapy for more than 6 sessions?

Y 5a. If yes, when______

5b. Was it helpful? Y N

5c. What type of psychotherapy was it? Individual Family Group N___

6. Before entering this treatment program, did you drink alcohol regularly, at least once a week?

Y N

7. Before entering this treatment program, did you use any illegal drug regularly, at least once a week?

Y N

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 86

8. When did you begin this treatment program?

This set of questions ask you about how you felt as a child. Answer with the first response that comes to mind. Remember this information is confidential

9. Do you believe that your mother, your father or both, often acted toward you in any of the following ways? Check only the box that applies. 'N', or no, means neither parent acted toward you in the described way.

Mother Father

unconcerned Y Y N rejecting Y___ Y___ N___ hostile Y___ Y___ N___

10. Did you often feel lonely in elementary school?

Y N___

11. Did your family move frequently? Y__ N__

12. Would you say you were often angry as a child?

Y N___

13. Were you often sad as a child? Y N

14. Did you usually have at least 2 friends at a time when you were a child? Y N___

15. Would you describe your family as close and supportive more times than not?

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX G

BECK INVENTORY

Marne. . D a te .

On this questionnaire are groups of statements. Please read each group of statements carefully. Then pick out the onestatement in each group which best describes the way you have beenPast feeling week. the DkCLUDwe Tooay•. Circle the number beside the statement you picked. If several statements in the group seem toapply equally well, circle each one.sure Be lo read all the statements in each croup before malring yourchoice. 1 01 I feetdo am sad. feel tad 12 01 I amhave less not interested lost interest in ocherin other people people. than I used to be 23 I am tadso sad all orthe unhappy time and that ( can't t can't snap stand out it.of it. 32 I1 havehaye lost mostall of ofmy my interest interest in inother other people. people. 2 011 am not I feelparticularly discouraged discouraged about the about future. the future. 13 01 I1 putmake ofT decisions making decisionsabout as wellmore as than I ever I used could. to 23 I feelt feel that I thehave future nothing a hopeless to look forwardand that to.things cannot 32 1I canlhave greatermake decisions difficulty at in all making anymore. decisions than before. improve. 14 0 1 don't feel I look any worse than I used to. 3 01 I fee! I have I faileddo not more feel likethan a the failure. avenge person. 21 I amfeel womedthat there that are I ampermanent looking changesold or unattractive. in my appearance 23 AsI feel I look I am back a complete on my life,failure all asI can a person. see u a lot of faiturei. 3 thatI believe make that me Ilook look unattractive. ugly. 4 01 I don'tget as enjoy much thingssatisfaction the way out I ofused things to as I used to 15 01 IIt cantakes work an extraabout effort as well to asget before. started at doing something 23 I don'tt am dissatisfiedget real satisfactionout or bored with of everything. anything anymore. 23 I havecan't todo push any workmyself at veryall. hard to do anything 5 01 I feel I don't guilty feel a goodparticularly part of guiltythe time Id 01 I don'tcan sleep sleep as as well well as as usual. I used to 32 I feel quiteguilty guiltyall of mostthe time. of the time 2 backI wake to upsleep 1*2 hours earlier than usual and find it hard to get 4 0 I don't feel I am being punished 3 backI wake to upsleep. several hours earlier than I used to and cannot get 21 1 expect to be I feel punished t may be punished. 17 0 I don *1 get more tired than usual 3 I feel I am being punished. 21 1I get tired morefrom doingeasily almostthan I usedanything. to 7 01 I1 amdon’t disappointed feel disappointed in myself in myself. 3 I am too tired to do anything. 32 I1 hateam disgusted myself. with myself. II 01 My appetite is notno worseas good than as usual.it used to be. I 0 1 dont feel I am any worse than anybody else 32 IMy have appetite no appetite it much at allworse anymore. now. 21 (I amblame critical myself of allmyself the time for my for weaknesses my faults. or mistakes. 19 0 I haven't lost much weight, if any. lately. 3 1 blame myself for everything bad that happens. 21 I have (oatlost more than 510 pounds. pounds, byI am eating purposely less. tryingv»« to lose weight • 0! I havedon't thoughts have any of thoughts killing myself,of killing but myself. 1 would not carry 3 1 have loti more than 15 pounds. 2 themI would out. like to kill myself. 21 0I I am womedno more aboutwomed physical about problemsmy health suchthan asusual. aches and 3 I would kill myself if I bad the chance. ramiias: very or upset womed stomach: about orphysical constipation, problems and it’s hard to It 01 I1 crydon moret cry nowany morethan Ithan used usual. to. 3 I amthink so of womed much else.about my physical problems that I cannot 32 I usedcry all to the be timeable tonow. cry. but now I onl CTy even though Idiiak about anything else. want to. 21 01 I amhave less not interested noticed any in sexrecent than change 1 used into my be. interest in sex II 0 1 am no more irritated now than I ever am 2 I am much less interested in vex now 21 I getfeel annoyedimtated orall imutcdthe time more now easily than I used in 3 I have lost interest in sex completely 3 me.I don't get imtated at all by the things that used to imtate Reproductionfrom: CENTER without FOR auth«vSexpreu>COGNITIVE THERAPY. written consent Room a not602. permitted 133 South Additional 36ch Street. copies Philadelphia. and/or permi\sion PA I9KU louse this scale mas be obtained « ft) 1 ln\ U o 87

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX H

UCLA LONELINESS SCALE (VERSION 3) C D m id W. It u n til A Csolyn Cutronx. 1914

Instructions

The following statements descnbe how people sometimes feel. For each statement, please indicate how often you feel the way described by wnung a number in the space provided. Here is an example:

How often do you feel happy?

If you never felt happy, you would respond ’never*; if you always feel happy, you would respond 'always*.

hSVER RARELY SOMETIMES ALWAYS

1 2 3 4

•1 . How often do you feel you are ’ in tune* w ith the people around you?

2 How often do you feel you lack compaiuonship?

3. How often do you feel there is no one you can ta n to?

4 . How often do you feel alone?

•5 . How often do you feel pan o f a group o f friends?

•6 . How often do you feel you have a lot m common with the people areund you?

7. How often do you feel you are no longs' dose to anyone?

8. How often do you feel your interests and ideas are not shared by those around you?

•9 . How often do you feel outgoing and friendly?

•10. How often do you feel dose to people?

U. How often do you feel left out?

12. How often do you fed your relationships with others are not meaningful?

88

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. B B S teB&X SOMETCSES ALWAYS

• 2 J 4

a How often do you t e l no one really knows you *e 0 ?

14. How often do you feel iiolaied bom others?

•is. How often do yco feel you a n find companionship when you'wm a?

•16. How often do you feel th at art people who really otdersund you?

17. How oftot do yoo feel dt> ?

It How often do you t e l people are arcutdyou but not w4h you?

•1 9 . How often do you t e l tim e a rt people you can talk to?

•2 0 . How often do you te l that are people you cat u n to?

Reproduced with permission of the copyright owner Further reproduction prohibited without permission APPENDIX I

DAT

Number:

Date:

1. In the past year, have you ever felt so depressed that you could not get out of bed in the morning?

Y N

2. In the past year, have you ever thought about committing suicide but did not act on this thought?

Y N

3. In the past year, have you attempted suicide?

Y If yes, go to page 2.

N If no, go to page 3.

90

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 91

Please answer the following questions to describe your attempt.

Check which of the following methods of attempt you used:

Overdose of alcohol or drugs

Other, please explain______

3a. If you took an overdose, how much of what substance or substances did you ingest?

3al. Approximately how much did you weigh at the time?

3b. If you physically hurt yourself, what exactly did you do?

3c. Did you require medical attention? Y N

3cl. If so, what was done?

3c2. Did this occur at a hospital Emergency Room? Y N___

3c3. Were you hospitalized? Y N___

3d. Did you tell anyone that you were going to hurt yourself before the attempt?

Y N If yes, relationship to you?______

3e. Did you tell anyone right after the attempt? Y___ N___

3f. After your attempt, did you obtain psychotherapy? Y N___

3fl. Overall, was it helpful? Y N (continue to next page)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 92

4. In your lifetime, have you ever given serious thought to harming yourself?

Y N

5. In your lifetime, have you ever thought of a way or plan to harm yourself?

Y N

6. Not including the past year, have you ever attempted suicide?

Y 6a. If yes, how old were you? ___

6b. Did you require medical attention? Y N___

6c. At the time, would you say were:

N depressed? Y___ N

lonely? Y___ N___

angry? Y___ N___

7. In your lifetime, have you attempted suicide more than once? Y N

If yes, how many times?

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. APPENDIX J

ATTACHMENT QUESTIONNAIRE

Number:

Date:

Please read through each of the three statements. Then place a check mark next to the numbered item that best describes you. Be sure to check only one statement.

1. I am somewhat uncomfortable being close to others; I find it difficult to trust them completely, difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, love partners (girlfriends/boyfriends) want me to be more intimate than I feel comfortable being.

2. I find that others are reluctant to get as close as I would like. I often worry that my partner (girlfriend/boyfriend) doesn't really love (like) me or won't want to stay with me. I want to get very close to my partner (girlfriend/boyfriend), and this sometimes scares people away.

3. I find it relatively easy to get close to others and am comfortable depending on them. I don't often worry about being abandoned or about someone getting too close to me.

93

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. REFERENCES

Adam, K.S. (1994) . Suicidal behavior and attachment: A developmental model. In Sperling, M.B. & Berman, W.H. (Eds.), Attachment in adults: Clinical and developmental perspectives (pp.275-298). New York: The Guildford Press.

Adams-Tucker, C. (1982). Proximate effects of sexual abuse in childhood: A report in twenty-eight children. American Journal of Psychiatry. 13 9. 1252-1256.

Ainsworth, M.D.S., Blehar, M.C., Waters, E.,& Wall, S. (1978). Patterns of attachments psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum.

Allison, M . , Hubbard, R.L., Ginzburg, H.M.,& Rachal, J.V. (1986). Validation of a three-item measure of depressive and suicidal symptoms. Hospital and Community Psychiatry. 37. 73-740.

Ambrosini, P.J., Metz, C., Bianchi, M.S., Rabinovich, H., & Undie, A. (1991). Concurrent validity and psychometric properties of the Beck Depression Inventory in outpatient adolescents. Journal of the American Academy of Child and Adolescent Psvchiatritv. 30. 51-57.

American Psychiatric Association (1987) , Diagnostic and Statistical Manual of Psychiatric Disorders. (3rd edition-revised^ (DSM-III-R). Washington, D.C.: American Psychiatric Association.

Andrews, J.A. & Lewinsohn, P.M. (1992). Suicidal attempts among older adolescents: Prevalence and co-occurrence with psychiatric disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 32. 655- 662 .

Apter, A., Bleich, A., Plutchik, R., Mendolsohn, D., & Tyano, S . (1988). Suicidal behavior, depression, and conduct disorder in hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 27. 696-699.

94

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 95

Armsden, G.C. & Greenberg, M.T. (1987). The inventory of parent and peer attachment: Individual differences and their relationship to psychological well-being in adolescence. Journal of Youth and Adolescence. 16. 427- 454.

Armsden, G.C., McCauley, E., Greenberg, M.T., Burke,m P.M. & Mitchell, J.R. (1990). Parent and peer attachment in early adolescent depression. Journal of Abnormal Child Psychology. 18. 863-697.

Arffa, S. (1983). Cognition and suicide: A methodological review. Suicide and Life-Threatening Behavior. 13. 109- 121.

Barron, R.M. & Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychology research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology. 51. 113- 1182.

Bartholomew, K. & Horowitz, L.M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology. 61. 226- 244.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.

Behrends, R.S. & Blatt, S.J. (1985). Internalization and psychological development throughout the life cycle. Psychoanalytic Study of the Child. 40. 11-39.

Berman, A. & Carroll, T. (1984). Adolescent suicide: A critical review. Death Studies. 8. 53-63.

Berman, A.L. & Jobes, D.A. (1991). Adolescent Suicide: Assessment and intervention. Washington, D.C.: American Psychological Association.

Berman, A. & Schwartz, R.H. (1990). Suicide attempts among adolescent drug users. American Journal of Diseases of Children. 144. 310-314.

Blain, M.D., Thompson, J.M. & Whiffen, V.E. (1993). Attachment and perceived social support in late adolescence: The interaction between working models of self and others. Journal of Adolescent Research. 8. 226-241.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 96

Blatt, S. J., & Homann, E. (1992). Parent-child interaction in the etiology of dependent and self-critical depression. Clinical Psychology Review. 12. 47-91.

Bios, P. (1967). The second individuation process of adolescence. Psychoanalytic Study of the Child. 22. 162-186.

Bonner, R.L. & Rich, A.R. (1987) Toward a predictive model of suicidal ideation and behavior: Some preliminary data in college students. Suicide and Life-Threatening Behavior. 17. 50-63.

Bowlby, J. (1969). Attachment and Loss: Vol. 1. Attachment. New York: Basic Books.

Bowlby, J. (1973). Attachment and Loss: Vol. 2. Separation. New York: Basic Books.

Bowlby, J. (1980). Attachment and Loss: Vol. 3. Loss, sadness and depression. New York: Basic Books.

Bowlby, J. (1988). A secure base. New York: Basic Books.

Brennan, T. (1982). Loneliness at adolescence. In L. Peplau, & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research, and therapy fpp. 269-290) . New York: John Wiley.

Brennan, T. & Auslander, N. (1979). Adolescent loneliness. Boulder, CO: Behavioral Research Institute.

Brent, D.A., Kalas, R., Edelbrock, C., Costello, A. J. , Dulcan, M.K., & Conover, N. (1986). Psychopathology and its relationship to suicidal ideation in childhood and adolescence. Journal of the American Academy of Child Psychiatry. 25. 666-673.

Brent, D.A., Perper, J.A., Goldstein, C.E., Kolko, D. J. , Allan, M.J., Allman, C.J. & Zelenak, J.P. (1988). Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Archives of General Psychiatry. 45. 581-588.

Brent, D.A., Perper, J.A., Moritz, G, Allman, C, Friend, A., Roth, C., Schweers, J., Balach, L., & Baugher, M. (1993). Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry. 32. 3, 521- 529.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 97

Bretherton, I. (1985). Attachment theory: Retrospect and prospect. In I. Bretherton, E. Waters (Eds.), Growing pains of attachment theory and research. Monographs of the Society for Research and Child Development. 50. (1- 2, Serial No. 209), 3-35.

Brown, L.K., Overholser, J, Spirito, A. & Fritz, G.K. (1991). The correlates of planning in adolescent suicide attempts. Journal of the Academy of Child and Adolescent Psychiatry. 30. 95-99.

Cantor, P.C. (1976). Personality characteristics found among youthful female suicide attempters. Journal of Abnormal Psychology. 85. 324-329.

Carlson,, G.A. (1983). Depression and suicidal behavior in children and adolescents. In D.P. Cantwell & G.A. Carlson, (Eds.) Affective Disorders In Childhood and Adolescence. New York: SP Medical and Scientific.

Carlson, G.A. & Cantwell, D. (1982). Suicidal behavior and depression in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 21. 361-368.

Christoffel, K.K., Marcus, D., Sagerman, S., & Bennett, S. (1988). Adolescent suicide and suicide attempts: A population study. Pediatric Emergency Care. 4. 32-40.

Cohen-Sandier, R., Berman, A. & King, R.A. (1982). Life stress and symptomatology: Determinants of suicidal behavior in children. Journal of the American Academy of Child and Adolescent Psvch iatrv. 21. 178-186.

Cole, D.A. (1989). Psychopathology of adolescent suicide: Hopelessness, coping beliefs, and depression. Journal of Abnormal Psychology. 98. 248-255.

Corder, B.F., Shorr, W . , Corder, R.F. (1974). A study of social and psychological characteristics of adolescent suicide attempters in an urban, disadvantaged area. Adolescence. 9. 1-16.

Crumley, F.E. (1979). Adolescent suicide attempts. Journal of the American Medical Association. 241. 2404-2407.

Curran, D.K. (1987). Adolescent Suicidal Behavior. Washington, D.C.: Hemisphere.

de Jong, M. (1992). Attachment, individuation, and risk of suicide in late adolescence. Journal of Youth and Adolescence. 21. 3, 357-373.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 98

De Wilde, E.J., Kienhorst, C., Diekstra, R., & Wolters, W. (1993). The specificity of psychological characteristics of adolescent suicide attempters. Journal of the American Academy of Child and Adolescent Psychiatry. 32. 51-59.

Deykin, E.Y., Alpert, J.J. & McNamara, J.J. (1985). A pilot study of effect of exposure to child abuse or neglect on adolescent suicidal behavior. American Journal of Psychiatry. 142. 1299-1303.

Dubow, E.F., Kausch, D.F., Blum, M.C., Reed, J. & Bush, E. (1989). Correlates of suicidal ideation and attempts in a community sample of junior high and high school students. Journal of Clinical Child Psychology. 18. 158-166.

Emery, G.D., Steer, R.A., & Beck, A.T. (1981). Depression, hopelessness, and suicidal intent among heroin addicts. International Journal of the Addictions. 16. 425-429.

Francis, C. (197 6). Adolescent suicide attempts. (Doctoral dissertation, California School of Professional Psychology,San Diego, 1976). Dissertation Abstracts International. 38, 4453B.

Friedman, R.C., Corn, R., Aronoff, M.S., Hurt, S.W., & Clarkin, J.F. (1984a). The seriously suicidal adolescent: Affective and character pathology. In R.S. Sudak, A.B. Ford and N.B. Rushforth (Eds.), Suicide in the young (pp. 209-226). Boston: John Wright, PSG, Inc.

Friedman, R.C., Corn, R. , Hurt, S.W., Fibel, B., Schulick, J., & Swirsky, S. (1984b). Family history of illness in the seriously suicidal adolescent: A life-cycle approach. American Journal of Orthopsychiatry. 54. 390- 397.

Garfinkel, B.D., Froese, A. & Hood, J. (1982). Suicide attempts in children and adolescents. American Journal of Psychiatry. 139. 1257-1261.

Garrison, C.Z., McKeown, R.E., Valois, R.F., & Vincent, M.L.(1993). Aggression, substance use, and suicidal behaviors in high school students. American Journal of Public Health. 83. 170-183.

George, C. & Main, M. (1979). Social interactions of young abused children: Approach, avoidance and aggression. Child Development. 50. 306-318.

Gispert, M . , Wheeler, K . , Marsh, L., & Davis, M.S. (1985).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 99

Suicidal adolescents: Factors in evaluation. Adolescence. 20. 753-762.

Goldaere, M. S Hawton, K. (1985). Repetition of self­ poisoning and subsequent death in adolescents who take overdoses. British Journal of Psychiatry. 146. 395-398.

Goswick, R.A., & Jones, W.H. (1982). Components of loneliness during adolescence. Journal of Youth and Adolescence. 11. 373-383.

Green, A.H. (1978), Self-destructive behavior in battered children. American Journal of Psychiatry. 13 5. 579-582.

Harkavy-Friedman, J.M., Asnis, G.M., Boeck, M. & DiFiore, J. (1987). Prevalence of specific suicidal behaviors in a high school sample. American Journal of Psychiatry. 144. 1203-1206.

Hawton, K . , O'Grady, J . , Osborn, M . , & Cole, D. (1982a). Adolescents who take overdoses: Their characteristics, problems and contacts with helping agencies. British Journal of Psychiatry. 140. 118-123.

Hawton, K . , Osborn, M . , O'Grady, J. , & Cole, D. (1982b). Classification of adolescents who take overdoses. British Journal of Psychiatry. 140. 124-131.

Hazan, C. & Shaver, P. (1987) . Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology. 52. 511-524.

Hazan, C. & Shaver, P.R. (1990). Love and work: An attachment-theoretical perspective. Journal of Personality and Social Psychology. 59. 270-280.

Herjanic, B. & Weiner, Z. (1980). Adolescent suicide. Advances in Behavioral Pediatrics. 1. 195-223.

Hoberman, H.M. & Garfinkel, B.D. (1988). Completed suicide in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 27. 689- 695.

Hollingshead, A.B. (1975). Four Factor Index of Social Status. New Haven, CN: Yale University, 1975.

Ingram, R. (1990) . Self-focused attention in clinical disorders: Review and a conceptual model. Psychological Bulletin. 107. 156-176.

Jacobs, J. (1971) . Adolescent Suicide. New York: Wiley

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 100

Interscience.

Jacobs, J., & Teicher, J.D. (1967). Broken homes and social isolation in attempted suicides of adolescents. International Journal of Social Psychiatry. 13, 138- 149.

Josselson, R. (1980). Ego development in adolescents. In J. Adelson (Ed.), Handbook of adolescent psychiatry, (pp. 188-210). New York: Wiley.

Kandel, D.B., Raveis, V.H., & Davies, M. (1991). Suicidal ideation in adolescence: Depression, substance use, and other risk factors. Journal of Youth and Adolescence. 20. 289-309.

Keinhorst, C.W.M., Wolters, W.H.G., Diskstr, R.F.W., & Otte, E. (1987). A study of the frequency of suicidal behavior in children aged 5-14. Journal of Clinical Psychology and Psychiatry. 2. 153-165.

Kenny, M.E., Moilanen, D.L., Lomax, R.,& Brabeck, M.M. (199 3). Contributions of parental attachments to view of self and depressive symptoms among early adolescents. Journal of Earlv Adolescence. 13. 408-430.

Khan, A.U. (1987). Heterogeneity of suicidal adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 26. 92-96.

Knight, R.G., Chisholm,B.J., Marsh, N.V. & Godfrey, H.P.D. (1988). Some normative, reliability, and factor analytic data for the Revised UCLA Loneliness Scale. Journal of Clinical Psychology. 44. 203-206.

Kobak, R.R. & Sceery, A. (1988). Attachment in late adolescence: Working models, affect regulation, and representation of self and others. Child Development. 59. 135-146.

Kosky, R. (1983) . Childhood suicidal behavior. Journal of Child Psychology and Psychiatry. 24. 457-468.

Kovacs, M. & Puig-Antich, J. (1991). "Major psychiatric disorders" as risk factors in youth suicide. In L. Davidson and M. Linnoila (Eds.), Risk factors for youth suicide (pp 127-143) . Hemisphere Publishing Corporation.

Lehnert, K.L., Overholser, J.C., & Spirito, A. (1994). Internalized and externalized anger in adolescent

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 101

suicide attempters. Journal of Adolescent Research. 9. 105-119.

Lester, D. & Beck, A.T. (1975). Suicidal intent, medical lethality of the suicide attempt, and components of depression. Journal of Clinical Psychology. 31. 11-12.

Levin, L., & Schonberg, K. (1987). Familial violence among adolescents who attempt suicide. Society of Adolescent Medicine. (Abstract, p.10).

Lukianowicz, N. (1968). Attempted suicide in children. Acta Scandinavia. 44, 415-435.

Lyddon, W.J., Bradford, E., & Nelson, J.P. (1993). Assessing adolescent and adult attachment: A review of current self-report measures. Journal of Counseling and Development. 71. 390-395.

Main, M. & Cassidy, J. (1988). Categories of response to reunion with the parent at age six: Predictable from infant attachment classification and stable over a one- month period. Developmental Psychology. 24. 415-426.

Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. In I. Bretherton and E. Waters (Eds.), Growing points of attachment theory and research. Monographs of the Society for Research in Child Development. 50 fl-2. Serial No. 209), 66-104.

Marks, P.A. & Haller, D.L. (1977). Now I lay me down for keeps: A study of adolescent suicide attempts. Journal of Clinical Psychology. 33. 390-400.

Marriage,K., Fine, S., Moretti, M . , & Haley, G. (1986). Relationship between depression and conduct disorder in children and adolescents. Journal of the American Academy of Child Psychiatry. 25. 687-691.

Mclntire, M. & Angle, C. (1973). Psychological "biopsy" in self-poisoning of children and adolescents. American Journal of Diseases of Children. 126. 42-46.

Mclntire, M. & Angle, C. (1980). Suicide Attempts in Children and Youth. Hagerstown, MD: Harper and Row.

McKenry, D., Tishler, C., & Kelly, C. (1983). The role of drugs in adolescent suicide attempts. Suicide and Life- Threatening Behavior. 13. 166-175.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 102

Morano, C.D., Cisler, R.A., & Lemerond, J. (1993). Risk factors for adolescent suicidal behavior: Loss, insufficient familial support and hopelessness. Adolescence. 28. Winter, 851-865.

Moore, D. (1987). Parent-Adolescent separation: The construction of adulthood by late adolescents. Developmental Psychology. 23. 298-307.

Moore, D., & Schultz, R.N. (1983). Loneliness at adolescence: Correlates, attributions, and coping. Journal of Youth and Adolescence. 12. 95-100.

Morrison, G.C., & Collier, J.G. (1969). Family treatment approaches to suicidal children and adolescents. Journal of the Academy of Child Psychiatry. 8. 140-153.

Motto, J.A. (1984). Suicide in male adolescents. In H.S. Sudak, A.B. Ford, & N.B. Rushforth (Eds.), Suicide in the young (pp. 227-244). Boston: John Wright PSG, Inc.

Myers, K., McCauley, E., Calderon, R. , Mitchell, J . , Burke, P., & Schloredt, K. (1991). Risks for suicidality in major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 30. 86-94.

National Center for Health Statistics (1994). Advance report of final mortality statistics, 1992. Monthly Vital Statistics Report. 4 3 (No. 6, Suppl., DHHS Publication No. PHS 95-1120). Hyattsville, MD: Public Health Service.

O'Carrol, P. (1987). Epidemiology of adolescent suicide. In I. Lann, and E. Moskcowita (Eds.) Strategies for studying suicide and suicidal behavior. Washington, D.C.: National Institute of Mental Health.

Ostrov, E.,& Offer, D. (1978). Loneliness and the adolescent. In S. Feinstein (Ed.), Adolescent psychology. Chicago: University of Chicago Press.

Otto, U. (1972). Suicidal acts by children and adolescents: A follow-up study. Acta Psychiatrica Scandinavia Supplement. 23 3. 5-123.

Paloutzian, R.F., & Ellison, C.W. (1982). Loneliness, spiritual well-being, and the quality of life. In L.A. Peplau, and D. Perlman (Eds.), Loneliness: A Sourcebook of Current Theory. Research, and Therapy. New York: Wiley-Interscience.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 103

Papini, D.R. & Roggman, L.A. (1992). Adolescent perceived attachment to parents in relation to competence, depression, and anxiety: A longitudinal study. Journal of Early Adolescence. 12. 420-440.

Pappini, D.R., Roggman, L.A. & Anderson, J. (1991). Early- adolescent perceptions of attachment to mother and father: A test of the emotional-distancing and buffering hypotheses. Journal of Early Adolescence. 11. 258-275.

Paykel, E.S. (1989). Stress and life events. In Alcohol, Drug Abuse, and Mental Health Administration, Report of the Secretary's Task Force on Youth Suicide: Volume 2. Risk factors for youth suicide (d p . 110-130). (DHHS Publication No. ADM 89-1622). Washington, D.C. Government Printing Office.

Peplau, L. A. and Perlman, F. (1979). Blueprint for a social psychological theory of loneliness. In M. Cooke, and G. Wilson (Eds.), Love and attraction. New York: Pergamon Press.

Petzel, S.V., & Riddle, M. (1981). Adolescent suicide: Psycho-social and cognitive aspects. In S.C. Feinstein, J.G. Looney, & A.Z. Sarosky (Eds.) Adolescent psychiatry. (Vol.9, pp. 343-398). Chicago: University of Chicago Press.

Pistole, M.C. (1989). Attachment in adult romantic relationships: Style of conflict resolution and relationship satisfaction. Journal of Social and Personal Relationships. 6. 505-510.

Rich, A.R., & Bonner, R.L. (1987). Concurrent validity of a stress-vulnerability model of suicidal ideation and behavior: A follow-up study. Suicide and Life- Threatening Behavior. 17. 265-270.

Richman,J. (1978). Symbiosis, empathy, suicidal behavior, and the family. Suicide and Life-Threatening Behavior. 8. 139-149.

Richman, J. (1984) . The family therapy of suicidal adolescents. In H. Sudak, A. Ford and N. Rushforth (Eds.), Suicide in the young. Littleton, MA: Wright PSG.

Richman, J. (1986). Family Therapy for Suicidal People. New York: Springer Publishing Company.

Riggs, S., Alario, A., McHorney, C., DeChristopher, J. &

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 104

Crombie, P. (1986). Abuse and health related risk taking behaviors in high school students who have attempted suicide. Journal of Developmental Behavioral Pediatrics. 205. 7. 205-206.

Robbins, D.R. & Alessi, N.E. (1985). Depressive symptoms and suicidal behavior in adolescents. American Journal of Psychiatry. 142, 588-592.

Rohn, R.D., Sarles, R.M., Kenny, T.J., Reynolds, B.J., & Heald, F.P. (1977). Adolescents who attempt suicide. The Journal of Pediatrics. 90. 626-638.

Rubenstein, C. , & Shaver, P. (1980). Loneliness in two northeastern cities. In J. Hartog and J. Audy (Eds.), The anatomy of loneliness. New York: International Universities Press.

Runyan, C., and Gerken, F. (1989). Epidemiology and prevention of adolescent injury. Journal of the American Medical Association. 262. 2273-2279.

Russell, D. (1982). The measurement of loneliness. In L. A. Peplau and D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research and therapy (pp. 81-104). New York: Wiley.

Russell, D., & Curtrona, L.A. (1980). The Revised UCLA Loneliness Scale: Concurrent and discriminative validity evidence. Journal of Personality and Social Psychology, 39. 472-480.

Russell, D. , Peplau, L.A., & Cutrona, C.E. (1980). The Revised UCLA Loneliness Scale: Concurrent and discriminant validity evidence. Journal of Personality and Social Psychology. 39. 472-480.

Sabbath, J.C. (1969). The suicidal adolescent-the expendable child. Journal of the American Academy of Child Psychiatry. 8. 272-289.

Schreiber, T.J. & Johnson, R.L. (1986). The evaluation and treatment of adolescent overdoses in an adolescent medical service. Journal of the National Medical Association. 78. 101-108.

Senseman, L.A. (1969). Attempted suicide in adolescents: A suicide prevention center in Rhode Island is in urgent need. Rhode Island Medical Journal. 52. 449-451.

Shaffer, D . , Garland, A., Gould, M . , Fisher, P. & Trautman, P. (1988). Preventing teenage suicide: A critical

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 105

review. Journal of the American Academy of Child and Adolescent Psychiatry. 27. 675-687.

Shafii, M., Carrigan, S., Whittinghill, J. & Derrick, A. (1985). Psychological autopsy of completed suicide in children and adolescents. American Journal of Psychiatry. 142. 1061-1064.

Smith, K. , Conroy, R.W., & Ehler, B.D. (1984). Lethality of suicide attempt rating scale. Suicide and Life- Threatening Behavior. 14. 215-242.

Smith, K. & Crawford, S. (1986). Suicidal behavior among "normal" high school students. Suicide and Life- Threatening Behavior. 16. 313-325.

Spirito, A., Brown, L., Overholser, J., & Fritz, G. (1989). Attempted suicide in adolescence: A review and critique of the literature. Clinical Psychology Review. 9. 335- 363 .

Sroufe, L.A. (1988) . The role of infant-caretaker attachment in development. In J.Belsky, & T.M. Nezworski, (Eds.), Clinical implications of attachment (pp. 18-38). Hillsdale, NJ: Lawrence Erlbaum Associates.

Steer, R.A., Beck, A.T., & Garrison, B. (1986). Applications of the Beck Depression Inventory. In N. Sartorius & T.A. Ban (Eds.), Assessment of depression (pp. 121- 142). Geneva, Switzerland: World Health Organization.

Stierlin, H. (1974). Separating Parents and Adolescents. New York: Harper and Row.

Taylor, E.A., and Stansfield, S.A. (1984). Children who poison themselves: I. A clinical comparison with psychiatric controls. British Journal of Psychiatry. 145. 127-132.

Teicher, J. (1973). A solution to the chronic problem of living: Adolescent attempted suicide. In J.C. Schoolar (Ed.), Current issues in adolescent psychiatry. New York: Bruner/Mazel.

Tishler, C.L., & McKenry, P.C. (1982). Parental negative self and adolescent suicide attempts. Journal of the American Academy of Child Psychiatry. 21. 404-408.

Tishler, C.L., McKenry, P.C., & Morgan, K.C. (1981). Adolescent suicide attempts: Some significant factors. Suicide and Life-Threatening Behavior. 11. 404-408.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 106

Topol, P. & Reznikoff, M. (1982). Perceived peer and family relationships, hopelessness, locus of control as factors in adolescent suicide attempts. Suicide and Life-Threatening Behavior. 12. 141-150.

Trautman, P.D. & Shaffer, D. (1984). Treatment of child and adolescent suicide attempters. In H.S. Sudak, A.B. Ford & N.B. Rushforth (Eds.), Suicide in the young (pp.307- 323). Boston, MA: John Wright PSG.

Weeks, P.G., Michela, J.L., Peplau, L.A., & Bragg, M.E. (1980). The relationship between loneliness and depression: A structural equation analysis. Journal of Personality and Social Psychology. 39. 1238-1244.

Weiss, R.S. (1973). Loneliness: The experience of emotional and social isolation. Cambridge, MA: MIT Press.

Weiss, R.S. (1982). Attachment in adult life. In C.M. Parkes and J. Stevenson-Hinde (Eds.), The place of attachment in human behavior. New York: Basic Books.

Weiss, R.S. (1991). The attachment bond in childhood and adulthood. In C.M. Parkes, P. Maris, & J. Stevenson- Hinde (Eds.), Attachment across the life cycle (pp.66- 76). New York: Routledge.

Weiner, A., Weiner, Z. & Fishman, R. (1979). Psychiatric in­ patients: Eight-to ten year follow-up. Archives of General Psychiatry. 36. 698-700.

Wenz, F.V. (1979). Sociological correlates of alienation among adolescent suicide attempts. Adolescence. 14. 19- 30.

West, M.L. & Sheldon-Keller, A. (1994). Patterns of relating. New York: Guilford Press.

Withers, L.E. & Kaplan, D.W. (1987). Adolescents who attempt suicide: A retrospective clinical chart review of hospitalized patients. Professional Psychology: Research and Practice. 18. 391-393.

Woodward, J.C. & Frank, B.D. (1988). Rural adolescent loneliness and coping strategies. Adolescence. 91. 559- 565.

Yarcheski, A, & Mahon, N.E. (1984). Chumship relationships, altruistic behavior and loneliness in early adolescents. Adolescence. 76. 913-923.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Young, J.E. (1982). Loneliness, depression and cognitive therapy: Theory and application. In L.A. Peplau and D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research and therapy. New York: Wiley.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.