156

Developmental

Psychopathology

events, depressed youth are less able' to generate effective solutions to interpersonal problems. Consistent with this hypothesis, depressed children have
poorer social skills (Bell-Dolan, Reaven, & Peterson,
1993) and they are less often chosen as playmates
or workmates by other ~hildren (R~d~IRh, Hammen.
& Burge, 1994).
Are depressed children the victims or the initiators of negative social relationshipf? An ingenious
study by Altmann and Gotlib (19881 investigated the
social behavior of depressed school-age children by
observing them in a natural setting: at play during
recess. The authors found that depressed children
initiated play and made overtures for social contact
et least as much as did nondepressed children, and
were approached by other children just as often. Yet,
depressed children ended up spending most of their
time alone .. By carefully observing the sequential
exchanges between children, the researchers discovered the reason for this. Depressed children were
more likely to respond to their peers with what
was termed "negative/aggressive"
behavior: hitting,
name-calling, being verbally or physically abusive.
These observations fit well with the model de,
veloped by Patterson and. Capaldi (1990), in which
peer relations are posited to play the role of mediators of depression. According to this model, a negative family environment leads children prone to depression to enter school with low self-esteem; poor
interpersonal skills, aggressiveness, and a negative
cognitive style. They are less able to perceive constructive solutions to social problems' andale more
likely to be rejected by peers because of the way
they behave. Peer rejection, in turn, increases their
negative view of self and thus their depression.
In order to test this model, Capaldi (1991, 1992)
differentiated four groups of boys depending on
whether they demonstrated aggression, depressed
mood, both aggression and depression, or neither.
Boys were followed over a two-year period. from
grades 6 to . While depression and adjustment
problems t ded to abate over time in the depressed
group, no such improvement occurred in the. two
other'
bed groups. While, in general; aggressive behavior was more stable than depressed
mood, condu t problems increased the risk of subsequen
having a depressive mood. In fact, ag-

gression in grade 6 predicted depressed mood in

grade 8, while earlier depression did not predict
later conduct problems.
Capaldi conceptualizes the process leading from
aggression to depression as follows. (See Figure
7.3.) Aggression and noxious behavior. alienates parents, peers, and teachers, resulting in more interpersonal conflict and rejection. Further, a~agreSSiOn
leads to oppositional behavior in the cl sroom,
which leads to learning deficits and poor kill development. Both of these factors result in profound
failure experiences in the social and academic
realms. Failure and rejection, in turn, produce low
self-esteer;z. The impact of peer rejection. low academic skills, and low self-esteem is associated with
increasingly serious deficits in adolescence, ultimately resulting in depression.

The Organic Context

Evidence that organic factors play an important etiological role in depression has emerged in studies of
_adult populations, while research evidence in regard
to children is slight. (Our presentation follows Hammen .and Rudolph, 1996. unless otherwise noted.)
Familial concordance rates provide evidence for
agenetic component in depression. Children, adolescents, and adults who have close relatives with
depression are at considerable risk for developing
depression themselves. In fact, having a depressed
parent is the single best predictor of whether a child
. will become depressed.
However, simply demonstrating a correlation between parent and child depression fails to disentangle the relative influence of heredity and environ-
ment. For this, twin and adoption studies are needed.
One study of adolescents compared monozygotic and
dizygotic twins, biological siblings, half-siblings,
and biologically unrelated step-siblings and found
significant genetic influences at lower levels of depression but significant environmental influences at
high levels of depression (Rendeet 81., 1993). Another study investigated a large sample of monozygotic and dizygotic twin pairs agedS to 16 years
(Thapar & McGuffin, 1996). While environmental
factors seemed to best account for depression in
childhood, evidence for a genetic component was
strong in adolescence. In sum, while data support th~
-.'

,
I

,
I-

I-

Chapter

Figure

7.3

Soun:e: Adapted

Mediators

from Patterson

Disorders in the Depressive Spectrum

and Child and Adolescent

Suicide

157

of the .Effects of Child and Family. Factors on Depression.

and Capaldi.

1990

theory of a genetic component to depression in adults

andadolescents, other factors also playa major role
in the etiology of depression in children.
Research with adults indicates a neuroendocrine
imbalance as an etiological agent;' particularly hypersecretion of the hormone cortisol. This is not surprising since hormone production regulates mood,
appetite, and arousal. all of which are adverselyaffected by depression. However, little evidence exists for the role of cortisol in child depression.
Depression is also associated with low levels
of the neurotransmitter serotonin. Antidepressant
medications that act to increase serotonin _availability. including tricyclics such as imipramine and
the new generation -of selective serotonin reuptake
inhibitors (SSRIs). such as Prozac, have been proven
effective in combating depression in adults. Again.

however. evidence in support of this mechanism

in children is mixed at best. In many controlled
studies. antidepressant medications have not been
effective in combating child depression. Fisher
and Fisher (1996) reviewed thirteen double-blind
placebo-controlled studies published between 1965
and 1994 and found only two cases in whicli antidepressants relieved depression better than placebos. In fact, some studies seemed to shoW"that the
placebo was more effective! Similar null findings
are reported in an exhaustive review by SommersFlanagan and Sommers-Flanagan (1996).
Much of the research these investigators reviewed was based on -the older type of antidepressants rather than the new SSRIs. which may
be both more effective and safer. Recent studies
focusing on the efficacy of SSRIs in child and

158

Developmental

Psychopathology

Cognitive
representations
seff, others

of

, Faroily'-'-~_
e,xp~rie~
T"-

~I

Ufe
stress

~--~--~~-.------"

l~erjiersonal
"., ..

..

,. ~C'C?",petence
,

Figure

7.4

Hammen's

:';

Multifactorial

Transactional

Model of Child and Adolescent Depression.

Source: Hammen and Rudolph. 1996

adolescent depression are somewhat more promising (DeVane & Sallee, i996). However, effect
sizes are ,still small, and in some studies results
emerged only for ratings of global improvement
and not for symptoms of depression (Emslie, Kennard, & Kowatch, i995).
In summary, research on child depression, while
limited, suggests that organic theories of etiology
derived from studies of adults cannot be applied as
easily to children. Further, without prospective data
demonstrating that biological indicators predate the
onset of depression, there remains some question as
to whether these are the cause or result of depression, Ultimately, the picture is likely to be a complex and transactional one. Experiences and mood
act on biology, and, in turn, biology reciprocally affect cognitions, emotions, and memory (Post &
Weiss, 1997).

Integrative Developmental Model

A comprehensi e developmental psychopathology
model of depression has been put forward by Hammen (1991, i992; Hammen & Rudolph, 1996) and
is presented ir; Figure 7.4. The case study that was
presemed in 'X J also illustrates the elements of
r

While acknowledging that there are many pathways to depression, Hammen's model places dysfunctional cognitions at the forefront. First, how- ,
ever, the stage for the development of these negative
cognitions is set by family factors, such as a depressed parent, insecure attachment, and insensitive
.or.rejecting caregiving. Adverse interpersonal experiences contribute to the child's development of negative schemata: of the self as unworthy, others as
undependable and uncaring, and relationships as
hurtful or unpredictable. The depressive cognitive
style also involves the belief that others' judgments
provide the basis for one's self-worth, as well as a
tendency to selectively attend to only negative
events and feedback about oneself.
Further, Hammen highlights the fact that the relationships among affect, cognition, and behavior
are dynamic and transactional. For example, negative cognitive styles lead to problems in interpersonal functioning, which act both as vulnerabilities
to depression and as stressors-m-theirown right. The
negative attributions of depressed children interfere
with the development of adequate coping and social
skills, and they respond to interpersonal 'problems
through ineffective strategies such as withdrawal or
acquiescence. These strategies not only fail to resolve interpersonal problems but even exacerbate
,

l
I
I

Chapter 7

-:

Disorders in the Depressive Spectrum and Child and Adolescent Suicide

159

them.:.increasing experiences of victimization, rejecDevelopmental influences also enter into the piction, and isolation. Therefore, the negative cognitive
ture in a number of ways. First, difficulties that ocstyles and poor interpersonal problem-solving skills
cur earlier in development may have particularly
associated with depression further disrupt social
deleterious effects, diverting children to a deviant
relationships, .undermine ihe child's. competence,
pathway from which it is difficult to retrace their
induce stress.rand confirm the child's negative besteps. Once on a deviant trajectory, children become
liefs about the self ana the world.
increasingly less able to make up for failures to deAs development proceeds, these cognitive and in- " velop early stage-salient competencies. Accumuterpersonal vulnerabilities increase the ;elihOOd that
lated stress may also alter the biological processes
individuals will respond with depressio when faced
underlying depression, especially in young chilwith stress during development.Hamme's model dedren, whose systems are not yet fully matured. Secscribes three aspects to the role of stress in depresond, cognitive development can influence depression. First, as described above, individuals vulnerable
sion. As we have seen, young children's thinking
to depression may actually generatesome of their own
tends to be undifferentiated and extreme, constressors. In this way they contribute to the aversivetributing to an "all pr nothing" kind of reasoning.
ness of their social environments, as well as consoliA negative cognitive style formed at an early age,
dating their negative perspectiveson the world. An iltherefore, may be particularly difficult to change
lustration of this kind of process later in development
once consolidated. Third, the organizational view
is "assortative mating," the tendency of individuals to
of development argues that the connections among
choose partners who mirror or act on their vulneracognition, affect, behavior, and contextual factors
strengthen over time. Thus, over the life course, debilities.For example, Hammen and colleagues find
pressivepatterns are integrated into the self system,
that depressed women are more likely than others to
marry men with a diagnosable psychopathology,and,
become increasingly stable, and require lower
in turn, to experience marital problems and divorce
thresholds for activation.
Hammen's model is relatively new, and it is in
which contribute further to their depression.
Second, the association between stress and "dethe nature of research in developmental psypression is mediated by the individual's cognitive
chopathology that decades must pass before we have
data available that fully test a given model by tracstyle and interpretation of the meaning of stressful
events. While life stress increases the likelihood of . ing pathways of development from infancy to adulthood. Therefore, it is too early. to say whether this
psychopathology in general, it is the tendency to in-.
. terpret negative events 'as disconfirmationsof one's
is an accurate account of the developmental psychopathology of depression. To date, parts of the
self-worth that leads to depression in particular:
model have held up to empirical scrutiny. Rudolph,
Third, certain groups of children are at high risk
Hammen, and Burge (1994) demonstrated links bebecause they are exposed to the specific kinds. of
tween child depression and negative cognitions _
stressors that increase depression. These include
about self and other, negative representations of
maltreated children, those whose parents are emotionally disturbed, those in families with high levfamily and peer relationships, biases in social inels of interparental conflict, or those who live in sitformation processing, and poor interpersonal skills.
uations of chronic adversity that diminish the entire
However, in a study of adults, Hammen and eelleagues (1995) found that, while attachment-related
family'S morale and sense of well-being.
negative cognitions and life stress predicted depresBiological factors can comeinto play at any point
in the cycle. For example, individual differences in
sion one year later, the results were not specific to
temperament may contribute to problems' in chilsymptoms of depression. Therefore. it may be that
Hammen's model actually represents a general
dren's relationships with parents and others: Biologmodel for the development of psychopathology, one
ical factors can affect children's ability to cope with
stressful circumstances, as well as increasing their . that can be appliedjo the understanding of depression but is not specific to it.
vulnerability to depression as a reaction to stress.

160

Developmental

Psychopathology

Intervention

PhaJ"acotherapy
CAs noted above, while some studies indicate that ~he
new antidepressants
(SSRIs) reduce depressive
symptoms in children, results are mixed. Undesir-'
able side effects also occur, including restlessness
and irritability, insomnia, gastrointestinal discomfort, mania, and psychoticreactiom'[
(De VanJ &
Sallee, 1996). There are advocates fOr their continued use, who cite the low rates. of serious side effects and the devastating consequences of untreated
depression (Kye & Ryan, 1995). However, others
are strongly opposed, arguing that their use is unethical given that their effectiveness is not supported
by the existing research (Pellegrino, 1996).
Despite questions about the effectiveness of antidepressants with children, JPey are being prescribed at arr increasing rate:fin 1996, U.S. physicians wrote 735,000 prescriptions for SSRIs for
children ages 6 to 18, a rise of 80 percent in only
two years (Clay, 1997). Prozac now comes in peppermint flavor especially designed for children')
As with adult depression, fOJ:child depression the
usual recommendation (if not the usual practice) is
to use antidepressant medic'Jon only as an adjunct
to other forms of treatment.[Many factors thatcontribute to depression-stressful
life circumstances, .
poor parent-child relationships, family conflict and
dissolution, low self-esteem, arid negative cognitive
biases, for example=-cannot
be' changed by psychopharmacologj)and
can be better addressed by.
psychotherapy with .the individual child or the family (Dujovne, Barnard, & Rapoff, 1995).

Psychodynamic Psychotherapy
Psychodynamic
treatments for depression focus.
broadly on problems in underlying personality organizarion, tracing these back to the negative childhood experiences from which depression emerges ',
(The goals of therapy are to decrease.self-criticism
and negative self-representations
and to help the
child to develop more adaptive defense mechanisms
in order to be able to continue on a healthy course
of emotional developmentjwith
younger c~dr~n,
the therapist may use playas a means of bringing

d>.

these issues into the therapy room, with the focus

shifting to d{scussion as children become more cognitively mature (Speier et al., 1995).
Psychodynamic approaches rarely provide outcome studies beyond individual case reports. However, Fonagy an~ Target (1996) investigated the
effectiveness of aldevelop~entally oriented psychoanalytic approach with children. (This is described in
more detail in Chapter 17.) Results showed that the
treatment was effective, particularly for in~malizing
problems such as depression asd anxiety. ounger
children (i.e., under II years) responded
st. However, the treatment was no quick cure; the best results
were found when treatment sessions took place 4 to
5 times per week over a period of two years.

Cognitive Behavior,!l Therapy

An example of a cognitive-behavioral
approach is
the Coping with Depression Course for Adolescence
(Lewinsohn et al., 1996), a downward extension of
a treatment program originally designed for adults.
This intervention includes role playing to teach interpersonal and problem-solving techniques, cognitive restructuring to decrease maladaptive cognitions such
"Nothing ever turns out right for me,"
and self-reinforcement techniqueyStudieS
of the effectiveness. of this approach show that, for the 80
percent of adolescents who improve, treatment gains
are lasting. Cognitive behavioral therapies for child
depression are the most extensively researched, and,
o:,erail, findings concerning their effectiveness are
. very positive (see Marcotte, 1997, and SouthamGerow et aI., 1997, for reviews).

as

Family Therapy
A comprehensive review by Dujovne, Barnard, &
Rapoff (1995) examines the relative effectiveness
of a number of different treatments for childhood
depression.
They conclude that rc~IY-fOcuSed
.. treatments (family therapies) .warrant pnmary consideration, given the roles of the family sitwition.
parent-child

relationships,

and parent depression in

. the developm~nt of.de?ress~ve sp~c~m disorders.

Consistent With this, \Lewmsohn s group (1996)
found that the effectiveness of their cognitivebehavioral intervention for depressed children was
enhanced by the addition of interventions with the

II-

Chapter 7

Disorders in tDe Depressive Spectrum and Child and Adolescent Suioce

infant'S attention, thus increasing the level of muparents. Group sessions are held in which parents
tual interest and engagement. Results suggest that
are given the opportunity to discuss issues related
each specific coaching strategy improved the interto depression and to .learn the same infrpersonal
actional behavior of the type of depressed mother
communication and conflict resolution skills being
taught to their children.]
.
for whom .it ~.as de~elopey
Arr effective multifaceted approach to treating
_
J
,
child depression in the family c9ntext is described
Child and Adolescent Suicide
by Stark and associates (l996).l{nterventions with
the child include the use of individual and group
therapy in order to increase positive mood and exDefinitions and pretalence
pectations, restructure maladaptive schemata, and
cbs we begin our discussion of suicide, we must im- enhance social skills. Interventions aimed at the
mediatelydistinguish among three categories: suicilarger system include parent training and family
therapy in order to reduce the environmental stresses.
dalthoughts, suicide attempts, and completed suicide.
that contribute to the development of depression. _JOur review' follo~ ~~land and Zigler, 1993, ~x~ _.
Further, consultation with teachers is provided to
cept where noted.) SUlczdal thoughts,~nce considered-to be rare in childhood, are in fact disconcertpromote and reinforce children's use of adaptive
ingly prevalent. Studies of U.S. high school students
coping strategies during the school
have found that 63 percent experienced suicidal
. Prevention"
thoughts, while 54 percent of college students had
c~nsidered suicide at least once in their Iives)
~ Efforts to prevent the development of childhood de(!)Suicide atte.0lZEGpicaily involve using a slowpression have focused on those most at riskacting method under circumstances in which disnamely, children of depressed mothers. For examcovery is possible. The act is most often in reacple, Gelfand and colleagues (1996) developed an intion to an interpersonal conflict or significanttervention program for depressed mothers and their
stressor. Although the attempt 'is unsuccessfu9 it:-'
infants. Home visits were made by trained nurses
may nevertheless be serialS, serving as "practice"
whose goals were to increase depressed mothers'
parenting efficacy as well as,to foster more positive
for a futur.elethal attempt~pproxirnately, 7.per~ent . _
mother-infant interactions)Mothers who particiof U,S. high school students. attempt SUICIdeIn a
pated improved in reported depression and per- . given year (Centers for Disease: Control, 1995), and
there are reports of repeated and apparently serious~'~'
ceived stress, and both their own arid their infants'
attempts at suicide ~ng
preschopler~Rosenthal
overall adjustment improved. Children of mothers
who participated were also less avoidant in their at& Rosenthal, I984).(further, while as many as 10
percent of college students report having made a
tachment than other children; however, they were
alsp more resistant.
.
suicide attempt, only 2 percent of those had sought
medical or psychological help)Therefore, our sta(An intriguing study by Malphurs and colleagues
tistics on the prevalence of suicide attempts may be
(1996) targeted another at-risk sample, depressed
underestimates.
teenage mothers. Mothers were observed interact(j)Coppleted suicide, while, rare,is a significant
ing with their infants and were differentiated in
problem among adole~uicide
is the third
terms of whether they demonstrated a withdrawn or
leading cause of death among 15- to 19-year~old
an intrusive parenting style. Specific types of interadolescents in the United States, in line behind acventions were designed t-;;tieIp counter these probcidents and hornicidesl (Garland & Zigler, 1993).
lematic patterns) For example, intrusive mothers
were coached ~ imitate their children's behavior, (Further, suicide among the young is increasing at an. 'IV' cQ.S
alarming rate, with rates rising much more dramatthus giving children more opportunities to initiate
ically than in the general populationjwhile suicide
and influence the flow of the interaction. In conin the general population has increased 17 percent
trast, withdrawn mothers were coached to keep their

daY;)

';

r .

161

d.

[)eolejelplTlenta

162

sychopa ology

20
18
16
5uidde rate per
100,000 in pop~

14
. 12.
10
8
6
4
2

O~-r----r----.----r----.----~---.----.----.----'-1960--62 63-65

Figure

7.5

Source: Garland

66-68

69-71

72-74

75--77 71h'10. 8,.,83

-e-

White males

-0-

NonWhite males

___

WhIte females

-{}-

Nonwhite females

84--86. 87-M

U.S. Youth Suicide Rates for 1S- to 19-Year-Olds by Race and Gender.

and Zigler. 1993

since the 1960s, among adolescents it has increased

200 percent, to 11.3 per 100,000. (See Figure 7.5.)
Rates for younger children are lower: In 1991, the
suicide rate for .children aged 5 to 14 was 0.5 per
100,000. A protective factor for younger children
may be that they have.more, ..difficulty. accessing
lethal means; consequently, there are 14.4 attempts
for every completed suicide in'lO- to ll-year-olds
(Pfeffer et al., 1994). Most suicides (70 percent) OCcur in the horne. Firearms are the most frequent
method used b~ both males and females (59 per-.
cent), followed by hanging for males and drug ingestion for females.
tIn all age groups, females are more likely than
males to attempt suicide, while males are more likely
to succeed. Females attempt suicide at least three
times as often as males do, whereas males ~omp1ete
suicide about four times as often as females) The ex- .
planation for this appears to lie in the choice of
method. In contrast to male suicides, two-thirds of
whom die by self-inflicted gunshot wounds;the typical young female attempter ingests drugs at home.
The latter case is called low-lethality behavior because of the length of time needed for the method to
take effect and the likelihood that someone will find
the attempter before it is too late to resuscitate. It
should not be assumed, however, that young womenr
are less serious about wanting to die. Females are

more likely to have an aversion to violent methods,

and sometimes young people's understanding of
how deadly a drug can be is simply inaccurate. Further, these statistics often come from mental health
clinics and ignore one very important group incar.~
.males.lf W~ illcl.I.Ided...waks In.juvaUk
detention facilities in these statistics, the gender
differences in suicide attempts might not be so great.

Etiology

The Intrapetsonal Context

Psychological characteristics distinguish some adolescent suicides, the majority of whom have a diagnosable psychopathology (Beautrais, Joyce, &
Mulder, 1996). For example,(83 percent of youths
with suicidal ideation show signs of depression. The
.relationship between sllifide and depression is a significant but complex onf. Most depressed youths are
.:not suicidal. Further, while Harrington 'and co1leagues' (1994) longitudinal research
that
_childhood -depression is a strong predictor. of attempted suicide in adulthood, the key seems to be
the association between childhood depression and
adult depression. In other words, depressed children
who grow up to be nondepressed adults are not at
risk for suicide.

s~s

i -

I
I

Chapter

Disorders-in the Depressive Spectrum

and Child and Adolescent

Suicide

163

There are other significant predictors of youth

The link between conduct disorder and suicide may
suicide besides depression. Clues to these can be
also be strongest for boys, with the combination of
found in a study of 3,000 suicidal youths attending
depression and conduct problems particularly toxic.
a free medical clinic (Ado links, 1987). Feeling (f Capaldi (l9?2)
found that, among boys who
states preceding theirsuicide
attempts were anger
showed a combination of depression and aggresfirst, followed by loneliness, worry about the future,
sion, school failure, poor relationships with parents
remorse orsharne,
and hopelessness. The reasons
and peers, and low self-esteem resulted in suicidal
youths gave for attempting suicide were; ill order,
ideation two years later)
However, it is important to recognize that suicirelief from an intolerable state of mind or escape )
from. an impossible situation, making people undal adolescents are a diverse group. Some may exderstand how desperate they feel, making someone
hibit no apparent problems or disorders. They may
appear to be "model" youth who keep their anxiety,
sorry or getting back at someone, trying to influence someone or change someone's mind, showing
perfectionism, and feelings of failure to themselves.
how much they loved someone or finding out
The Interpersonal Context:
whether someone really loved them, and seeking
Family
Influences
help. Many had been preoccupied with thoughts of
The family context is also important, although a sigdeath for an extended period of time, but only
nificant weakness of many family studies is that they
around half of the adolescents said they actually
wanted the attempt to succeed. Typically, despite the
are retrospective rather than prospective, (Here we
long, gestation period of suicidal thoughts, the acfollow the review by Wagner, 1997. unless otherwise noted.) Assessing suicide only after it is attual attempt was made with little-premeditation.
tempted does not provide convincing evidence that .
These data have two important implications.
First, impulsivity is implicated in suicide. Impulfamily-factors lead up to suicide.
sivity may be seen in many ways, including low
A number of studies have confirmed the exis- .:
tence of a significant degree of family dysfunction
frustration tolerance and lack of planning, poor
self-control, disciplinary problems, poor academic
and adverse childhood experiences among suicide
performance, and risk-taking behavior. Substance
attempters) (Beautrais, Joyce, & Mulder, 1996).
Prospective studies show that suicidal ideation and
abuse is found in 15 to 33 percent of suicide compIeters, with suicidal thoughts increasing after the
suicide attempts are predicted by low levels of paronset of substance use. Substance abuse may play"
ent warmth, communicativeness,
support, and emoa: role in increasing impulsivity, clouding judgment,
tional responsiveness. and high levels of violence,
vand disinhibiting self-destructive behavior. Other
disapproval, harsh discipline; abuse, and general
family conflict. Retrospective studies show that atdisorders of impulse control. including eating distempters and their parents describe the family as
orders, are also related to an increased risk for suihaving lower cohesion, less support. and poorer
cide (Berman & Jobes, 1991).
adaptability to change. Suicide attempters also are
Secondly, ~nger and aggression emerge as an
more likely to report feeling that they are unwanted ..
important part of the suicide constellation) About
.70 percent of suicidal youth exhibit conduct.disoror burdensome to their families. There is a signifi.rler and antisocial
behavior (Berman & Jobes,
cantly high level of psychopathology 'among family
1991). Childhood conduct disorder also has been'
members, particularly suicide and depression.
Perceived lack of support from parents also has
shown to predict adult suicidality independently of
depression (Harrington et al., 1994). Achenbach
been implicated as a significant predictor of adolescent suicidal thinking (Harter & Marold, 1994).
and colleagues' (1995b) six-year longitudinal study
Further, Harter and Whitesell (1996) found that
also shows that suicidal ideation is predicted, not
the depressed youths exhibiting the least suicidal .
by depression, but by earlier signs of externalizing
ideation were those who perceived themselves to
disorders: for boys, intbe.form
of aggressiveness,
and for girls, in the form. of delinquent behavior.
have more positive relationships" with parents and

164

Developmental

Psychopathology

more parent support. Thus supportive parent-child

relationships IDf-yprovide a buffer against suicidality in at-risk children.
.
Finally, exposure to the suicidal behavior of
another person in the family or immediate social
network is more 'Common in suicidal adolescents
than in controls. This has been referred to as a contagion effect: Children who are exposed to suicidal
behavior, especially in family members or peers,
are more likely to attempt it themselves. Such exposure should be regarded as accelerating the risk
factors already present rather than being a sufficient
cause of suicide.

The Interpersonal Context:

Peer Relations
Perceived (Jackof peer supportJ(HfI1er & Marold,
1994) and~or social adjustmenj (Pfeffer et al.,
1994) have been identified as risk factors. Suicidal
youth are more likely than others to feel ignored
and rejected by peers. They also report having
fewer friends and are concerned that their friendships are contingent-that they must behave a certain way in order to be accepted by agemates. Perceived social failures, rejection, humiliation.' and
romantic disappointments
are common precipitants of youth suicide.

The Superordinate Context

Socioeconomic disadvantage has also been associated with suicide (Beautrais, Joyce, & Mulder, 1996),
with children growing up in poverty being at greater
risk for suicidal fu.oqghts, attemp~, and completi~ns.

~~"( ..s~U~
""'1

trt

~~

"'.t)"",,-~

~~\

.s~~~

'> ~

showing that childhood suicide attempts are a strong

predictor of spbsequent attempts and completions.
For example, \';ix to eight years after their first attempt, suicidal children were six times more likely
than other children to have made another suicide
_attempY:Pfeffer
et,al:, 1994). Most subse~~~nt attempts occurred Within two years of the initial a~- .
tempt, and over half of those who continued to be
4uicidal made multiple attempts. Therefore, suicide
attempts in children should not be dismissed as mere
attention-getting behavior, since those who engage
in them are at risk for more serious attempts and
possible completions in the future.
Among(adolescent
suicide atternpters, Adolinks
(1987) found that the majority improved within one
month. However, about one-third subsequently experienced major difficulties in the form of increased
psychological and physical disorders, interpersonal
problems, and increased criminal behavior. One in
ten repeated the attempt, with boys succeeding more ;
often than girls, The risk for future disturbances was
particularly strong ill teenage males)

Integrative Developmental Models

A classic reconstructive account is provided by Jacobs (1971), who investigated fifty 14~ to 16-yearolds who attempted suicide: A control sample of
thirty-one subjects, matched for age, race, sex, and
level of mother's education was obtained from a 10- '
cal high schooL Through an intensive, multi-technique investigation, Jacobs was able to reconstruct
a five-step model of the factors leading up to suicidal attempts:

Developmental Course

1. Long-standing history of problems from early

childhood. Such problems included parental di- .

The question often arises as to whether youn/children who attempt suicide are really trying to. kill
themselves, and therefore whether their attempts
warrant serious concern or presage future suicidal- .
ifY:Doubt about whether they really intend to die is
supported by cognitive-developmental
research on
children's limited understanding of the concept of
death, as weU as studies showing that suicidal children have a .limited understanding of the permanency of death (Cuddy-Casey & Orvaschel, 1997).
However, ~ngitudinal
research is consistent in

vorce, death of a family member, serious illness,

parental alcoholism. and school failure, Subsequent research has shown that it is ahigb level
- of intrafamilial conflict along with a lack of support for the child that is the riskfactor, not a par, . ticular family consteUation such
divorce or
single parenthood (Weiner, 1992).
2. Acceleration of problems in adolescence. Far
more important than earlier childhood problems
was the frequency of distressing events occur;
ring within the last five years for the suicidal

c.' .. '

as

Chapter 7

Disorders in the Depressive Spectrum

youths; for example, 45 percent had dealt with divorce in the previous five years as compared
to only 6 percent of the control group. Terrni-\
nation of a serious romance was also much
- higher among the suicidal group, as were arrests
and jail sentences.
3. Progressive failure to cope and isolation from
meaningful social relationships. The suicidal and
control groups were equally rebellious in terms
of becoming disobedient, sassy, and defiant.
However, the coping strategies of suicidal adolescents were characterized much more by withdrawal behavior, such as avoiding others and engaging in long periods of silence (see also Spirito
et al., 1996). The isolation in regard to parents
was particularly striking. For example, while 70
percent of all suicide attempts took place in the
home, only 20 percent of those who reported the
attempt had informed their parents about it. In
one instance an adolescent telephoned a friend
who lived miles away, and he, in turn, telephoned
the parents who were in the next room.
4. Dissolution of social relationships. In the days
and weeks preceding ~e attempt, suicidal adolescents experienced th~rea1cing off of social relationships, leading to the feeling of hopelessness.
5. Justification of the suicidal act, giving the adolescent permission to make the q,ttempt.This justification was reconstructed from 112 suicide
notes of adolescents and adults attempting and
completing suicide. The notes contain certain recurring themes; for example, the problems are
seen as long-standing and unsolvable, so death
seems like the only solution. The authors of such
notes also state that they know-what they are doing, are sorry for their act, and beg indulgence.
The motif of isolation and subsequent hopelessness is prevalent.

r_

Another comprehensive account of the development of suicidal ideation is offered b1Earter (Harter, Marold, & Whitesell, 1992; Harteree Marold,
1991, 1994), who integrates her own research with
that of others. Her model reconstructs the successive steps that ultimately eventuate in suicidal
ideation in a nonnative sample of 12- to IS-yearolds. (See Figure 7.6.)

and Child and Adolescent

Suicide

165

Immediately preceding and highly related to suicidal ideation is what Harter calls the depression
composite, which is made up of three interrelated
variables: low global self-worth, negative affect, and
hopelessness. The first two are highly correlatedthe lower the perceived self-worth, the greater the
feelings of negative mocd,
_ J ,
Moreover, the depressive composite is rooted
both in the adolescents' feelings of incompetence
and in their lack of support froln family and
friends. These two variables of. competence and
support are, in turn, related in a special way. In
regard to competence, physical appearance, peer
likability, and athletic ability are related to peer
support, while scholarly achievement and behavioral conduct are related to parental support. Finally, adolescents identify more strongly with
peer-related competencies, with the others being
regarded as more important to parents than to
themselves.
Analyses of the data revealed that peer-related
competencies and support were more strongly
related to the depressive composite than were
parental-related competencies and support, perhaps because the former are more closely connected with the adolescents' own self-concept.
However, parental support was important in differentiating the adolescents who were only depressed from those who were depressed and had
suicidal ideation. Further, the quality of support
was crucial, Regardless of the level, if adolescents
perceived they were acting only to please parents
or peers, their self-esteem decreased and depression and. hopelessness increased. On the other.
hand, uncoriditional support helped adolescents
minimize the depressive composite.
In regard to the question of which came first, lowered self-worth or depression, the data indicate that
causation can go in either direction. Some adolescents
become depressed when they experience .lowered
self-worth, while others become depressed over other
occurrences such as rejection or conflict, which in
turn lower self-worth.
To answer the question, Why adolescence? Harter and colleagues (1997) marshal a number of findings concerning this period. IIi adolescence, selfawareness, self-consciousness, intiospection, and

166

Developmental

Psychopathology

Competence/Adequacy
plus
~opefrn,!ess (If Important) fon
PIiYSl~~P~~RAN(_E.
PEER LlKfJ'.BIUTY

" c'
1

ATHLETIC CdMPETENCE :.

Levelof plus
Hopelessness about;
D.epresslon Composite:
."7'

P~ER SUP.PORT

-Level cif plus' .

:'~~I.e~sness

:."

SEu:--WORTH
AFFECT
,GENERAL HOPELESSNES.S

SUIOOAl

. loiAffON -

about

PARENT SUPP.ORT

-t:ompe&lielMequ~cY plus
-Ho~ele'mie~ (If Important) for:

~~~~i'&;~p~c~
-liEHAVIOlto\L.CONDUq,
~.~- .... ~~;; :.:.;:' ~
-,:

Figure

7.6

Risk Factors for Adolescent Suicidal Ideation.

Source: Harter. Marold. and Whitesell,

1992

preoccupation with self-image increase dramatically,

while self-esteem becomes more vulnerable. Peer
support becomes significantly more salient, although
adolescents still struggle to remain connected with
parents. For the first time, the adolescent can grasp
the full cognitive meaning of hopelessness, while affectively there is an increase in depressive symptomatology. Suicidal ideation is viewed as an effort to
cope with or escape from the painful cognitions and
affects of the depressive. composite.

Intervention
frhe vast majority of suicidal adolescents provide
clues as to their imminent behavior; one study found
that 83 percent of completers told others of their suicidal intentions in the week prior to their death. (Our
presentation
follows Berman and Jobes, 1991.)
Most of the time such threats are made to family
members or friends, who do not take them seriously,

try to deny them, or do not understand their irnpprtance. Friends, for example, might regard reporting
the threats as a betrayal of trust. Thus, not only do'
adolescents themselves not seek professional help,
but those in whom they confide tend to delay or re. sist getting help. Consequently, an important goal
of prevention is to educate parents and peers concerning risk signs.
Once an adolescent comes for professional help,
'the immediate therapeutic-task is to protect the youth
from self-harm through crisis intervention. This
might involve restricting access to the means of commitring suicide, such as removing a gun from the
house or pills from the medicine cabinet; a "no sui- -.
cide contract" in which the adolescent agrees not to
hurt himself or herself for an explicit time-limited
period; decreasing isolation by hav[;gsympathetic
family members or friends with the adolescent at all
timeszgiving medication to reduce agitation or de- .
pression; or, in extreme cases, hospitalization.

.'

Chapter

Disorders in the Depressive Spectrum

Suicide Prevention

Turning again to Garland and Zigler's (1993) review, we find that two of the most commonly used
suicide prevention efforts-suicide hot lines and
media campaigns=-are only minimally effective.
Communities with suicide hot lines have slightly re- duced suicide rates; however, hot lines tend to be
utilized by only one segment of the population, Cau- .
casian females. Even less helpful, well-meaning eftorts to call media attention to the problem of suicide among teenagers may have the reverse effect.
Several studies have shown increased suicide rates
following television or newspaper coverage of suicide, particularly among teenagers.
School-based suicide prevention programs are
extremely popular, with the number of schools implementing them increasing 200 percent in recent -,
years. Goals of these programs are to raise awareness of the problem of adolescent suicide, train participants to identify those at risk, and educate youth
about community resources .available to thern.:
However, a number of problems have been identified with school-based suicide prevention efforts.
For one thing, they may never reach the populations most at risk because incarcerated youths, runaways, and school dropouts will never attend the
classes. Even when students do attend the pro.grains, there are questions as to their-benefits. The
programs tend to exaggerate the prevalence of
teenage suicide, while. at the same time de-ernphasizing the fact that most adolescents who attempt
suicide are emotionally disturbed. Thus, they ignore
evidence for th"e contagion effect and encourage
youth to identify with the case studies presented.
By trying not to stigmatize suicide. these programs
may inadvertently normalize suicidal behavior and
reduce social taboos against it.

and Child and Adolescent

Suicide

Large-scale, well-controlled studies provide some

basis for these concerns. For example. one study of
300 teenagers showed that attending a suicide prevention program slightly increased knowledge
about suicide but was not effective in changing attitudes about it. Boys in particular tended to change .. -in the undesirable-direction: more of them reported
increased hopelessness and maladaptive coping after expc\sure to the suicide program (Overholser et
al., 198;). Another study of 1,000 youths found no
positive effects on.attitudes toward suicide. In fact,
participation in the program was associated with a
small number of students responding that they now .
thought suicide was a plausible solution to their
problems. The students most at risk for suicide to
begin with (those who had made previous attempts)
were the most likely to find the program distressing (Shaffer et al., 1991).
If suicide prevention programs are not the solution,
what mightbe? While suicide is rare, Garland and
Zigler (1993) point out, the stressors and life problems that may lead some youth to it are not. Therefore, successful prevention programs might be aimed
toward such risk factors for suicide as substance abuse,
impulsive behavior, depression, lack of social support,
family discord, poor interpersonal problem-solving
skills, social isolation, and low self-esteem.
Recall that in Chapter 5 we dealt with the issue of
control in the toddler-preschool period--control of
excessive negativism and control of the bodily functions of eating and urination. We will now return to
this theme of control, exploring its manifestation in:
the middle childhood period. We will examine two
extremes: excessive control, which is an important element in anxiety disorders, and inadequate self-control, which lies at the heart of conduct disorders.

167

..