Correlates of Suicide-Related Behaviors among Children Ages Six to Twelve Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University By Molly S. Martinez, M.A. Graduate Program in Psychology The Ohio State University 2013 Dissertation Committee: Mary A. Fristad, PhD, Advisor Steven Beck, PhD Jennifer Cheavens, PhD Copyright by Molly S. Martinez 2013 Abstract Research has shown young children do contemplate and attempt suicide and are considered an under-studied population. Studies have identified risk factors for suicide-related behaviors among children across several domains; however, few studies have examined how risk factors from disparate domains interact to increase or decrease risk for suicide attempt in children. The Longitudinal Assessment of Manic Symptoms (LAMS) study (Findling et al., 2010; Horwitz et al., 2010) has collected a wealth of data on a child (ages 6 to 12) community mental health sample enriched for elevated symptoms of mania. Current or past suicidal acts were present for 57 (8.4%) of the 678 participants in the LAMS study for whom SRB status could be determined. For the current project, data from the LAMS study were analyzed in a multiple logistic regression model-building procedure. First, five independent domain-specific models (i.e., demographic variables, psychiatric family history, child psychopathology, psychosocial factors, and stressful life events) were constructed to better understand correlates of suicide-related behaviors among children in the sample. Subsequently, an integrated model of the combined influence of these factors was developed. ii Covariates that were highly associated with SRB in the domain-specific models were as follows: Demographic variables—age at baseline (OR=1.31) and having both biological parents as primary and secondary caregiver (OR=.51); Family history variables—having a parent attempt suicide (OR=2.71); Child psychopathology variables—suicidal ideation (OR=20.41), tobacco use (OR=3.98), and anhedonia (OR=2.01); Psychosocial varialbes—changing schools for reasons other than normal progression (OR=2.06), quality of parent-child relationship (OR=1.36), and ever having an academic tutor (OR=.30); Stressful life events— knowing someone who had recently tried to hurt him/herself (OR=3.24), mother or father recently remarrying (OR=3.23), ending a close friendship (OR=2.90), increased fighting with parents (OR=2.86), and having a friend who recently died (OR=.27). A comprehensive model that combined factors across all five domains resulted in a model that included three covariates: ever having experienced significant suicidal ideation (OR=31.27), parent report of the child’s mother or father recently remarrying (OR=1.87), and ever having an academic tutor (OR=.22). Understanding the complex interrelation of factors that coalesce to increase and/or decrease risk for SRB in children with the goal of establishing a developmentally sensitive biopsychosocial model of SRB is worthy of future research. iii Dedication Dedicated to my daughter, Cora. iv Acknowledgments This dissertation would not have been possible without the many families who participated in the LAMS study and the researchers dedicated to this project— thank you all. I would also like to thank my committee, for the time, effort, and patience provided during the process of drafting and completing this dissertation. Special thanks to Dr. Fristad, for your encouragement, understanding, and guidance and to Dr. Beck, who has been a role model, coach, and my greatest support throughout graduate school. I would like to acknowledge and thank the Lilly Foundation, which provided me with numerous scholarships over the past six years. The financial support was key to completing my course of study. Much love and gratitude goes to my family and friends who have believed in me, encouraged me, and commiserated with me over the years, and whom I know celebrate this accomplishment with me. I would especially like to thank my mother, Sandra, my stepfather, David, my sister, Amber, and brother-in-law, Fabio, for their constant faith, motivational ingenuity, and their readiness to renew my internal resources when they were depleted. Finally, and most profoundly, I would like to thank my husband, Manuel, without whose love, patience, understanding, support, and encouragement I may have never completed my first year of graduate school, much less this dissertation and doctoral degree. v Vita January 23, 1976…………………………….……...Born – Indianapolis, IN 1998……………………………………………...……....B.A., English, Indiana University 1999 – 2000………………………………...………....Behavioral Intervention Specialist Seabrook Elementary, Seabrook, NH 2004……………………………………………..……….M.A., English, Indiana University 2005…………………………………………..………….B.A., Psychology, Indiana University 2005 – 2006…………………………….……………..Research Study Coordinator Department of Psychiatry The Ohio State University 2006 – 2011…………………………………………...Graduate Research Associate Departments of Psychiatry & Psychology The Ohio State University 2008……………………………………………………...M.A., Psychology The Ohio State University 2011 – 2012…………………………………………...Graduate Teaching Associate Department of Psychology The Ohio State University 2012 – 2013…………………………………………..Internship, Clinincal Child Psychology Ann & Robert H. Lurie Children’s Hospital of Chicago vi PUBLICATIONS Martinez, M., & Fristad, M. (2013). Conversion from bipolar disorder not otherwise specified (BP-NOS) to bipolar I or II in youth with family history as a predictor of conversion, Journal of Affective Disorders, 148(2–3), 431-434. Snodgrass, M., & Vlachos-Weber, I. (2006). “Which one of us is truly crazy?”: Pop psychology and the discourse of sanity and normativity in The Simpsons. In A. Brown & C. Logan (Eds.), D’Oh: The Psychology of the Simpsons (pp. 37-48). Dallas, TX: Ben Bella Books. FIELDS OF STUDY Major field: Psychology Clinical Child & Adolescent Psychology Track vii Table of Contents Abstract ....................................................................................................................................... ii Dedication ................................................................................................................................. iv Acknowledgments ................................................................................................................... v Vita ............................................................................................................................................... vi Table of Contents ................................................................................................................. viii List of Tables ............................................................................................................................. x Introduction .............................................................................................................................. 1 Suicide Terminology ........................................................................................................................ 2 Historical Context of Research on Child and Adolescent Suicide ..................................... 5 Scope of the Problem ....................................................................................................................... 8 Developmental Considerations ................................................................................................. 11 Suicide Risk Assessment Scales for Young Children ........................................................... 18 Correlates and Risk Factors for Suicide-Related Behaviors in Children ..................... 22 Summary ............................................................................................................................................ 55 Study Aims and Hypotheses ........................................................................................................ 56 Method ..................................................................................................................................... 58 Screening and Enrollment Procedures ................................................................................... 59 Participants ...................................................................................................................................... 61 Instruments ...................................................................................................................................... 61 Rater Training and Reliability Procedures ............................................................................ 72 Statistical Analyses ........................................................................................................................ 73 Results ...................................................................................................................................... 80 Descriptive Statistics ..................................................................................................................... 80 Hypotheses 1 through 6 ................................................................................................................ 81 Hypothesis 1 ................................................................................................................................................... 82 Hypothesis 2 ..................................................................................................................................................