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. Author manuscript; available in PMC: 2025 Aug 25.
Published in final edited form as: Clin Child Psychol Psychiatry. 2021 Mar 9;26(3):795–809. doi: 10.1177/1359104521996762

Assessing change in suicidal ideation intensity for youth in treatment for pediatric bipolar disorder

Meredith A Gruhn 1, Amy West 2, Elissa Hamlat 3, Sally Weinstein 1
PMCID: PMC12371758  NIHMSID: NIHMS2060017  PMID: 33715470

Abstract

Objective:

Suicidal ideation (SI) is significantly higher for youth with pediatric bipolar disorder (PBD), yet clinical correlates of suicidality remain poorly understood in this population. The current study investigates how change in risk factors for SI relate to change in SI intensity over a 6-month period of treatment.

Method:

Children ages 9 to 13 (N = 71; 41% female; 54% Caucasian; Mean age = 9.17) engaged in one of two psychotherapy treatment conditions and completed assessments of SI risk factors and psychopathology symptoms at baseline (pre-treatment), 4 and 8 weeks (during treatment), 12 weeks (post-treatment), and 39 weeks (follow-up assessment at 6 months post-treatment). Children also completed assessments of SI intensity at baseline, post-treatment (12 weeks), and 6 months post-treatment.

Results:

Mixed-effects regression models indicate that increases in health-related quality of life in the family, mobilization of the family to acquire/accept help for PBD, and child self-concept were associated with decreased SI intensity over time.

Conclusions:

Findings highlight the importance of family and child level factors in influencing longitudinal change in SI intensity in youth with PBD. Clinical implications and future directions are discussed.

Keywords: Suicide, pediatric bipolar disorder, family, parenting, self-concept, coping, suicidal ideation, intervention

Pediatric bipolar disorder (PBD) represents one of the most substantial risk factors for suicide in children and adolescents, with up to 50% of youth with PBD attempting suicide by the age of 18 compared to approximately 4% in the general population (Algorta et al., 2011; Goldstein et al., 2012; Lewinsohn et al., 2003; Nock et al., 2013). More than a third of adolescents with suicidal ideation (SI; i.e. thinking about or planning suicide) go on to make an attempt (Nock et al., 2013); thus, investigating change in SI over the course of treatment represents an important research target to inform and bolster suicide prevention efforts in this population. Although significant decreases in SI following psychosocial interventions have been observed in youth at risk for suicide (see Calear et al., 2016 for a review), little is known about the specific components of treatment that relate to change in SI longitudinally, particularly in pre-adolescents with PBD.

The majority of effective psychosocial interventions for PBD elicit family involvement, including child- and family-focused cognitive-behavioral therapy, multifamily group therapy, family skills training, cognitive or dialectical behavior therapy, and family-focused therapy (Fristad et al., 2009; Goldstein et al., 2007; Weinstein et al., 2013). Preliminary evidence suggests that suicidality may decrease as a function of these interventions despite not being a primary treatment target (Goldstein et al., 2015; Weinstein et al., 2018). SI risk factors commonly addressed in PBD treatment that could be partly responsible for observed changes in SI can be classified as static (i.e. relatively stable), or dynamic (i.e. changeable) (Bouch & Marshall, 2003). While static predictors of SI in youth with PBD, which include female sex, older age, early illness onset, mixed episodes, trauma history, and family history of suicidality (Hauser et al., 2013), provide valuable clinical information, dynamic factors (e.g. coping skills, family functioning; Heru & Ryan, 2004; Houck et al., 2016) represent constructs more readily changed through intervention. The current study is therefore focused on dynamic risk factors for SI that are common components of PBD interventions in order to increase the clinical utility of findings.

Given the emphasis on family/parental involvement in PBD treatment, assessing SI risk-factors that at the family-, parent-, and child-levels provides key information on how each aspect of therapeutic intervention may impact suicidality for children with this disorder. Hypotheses on SI risk factors that may be most strongly related to SI at each level can be drawn from the broader literature on youth suicidality, as this research question has been minimally examined in PBD. At the family-level, active help-seeking and engagement in PBD treatment, family cohesion, and perceived overall family functioning/quality of life (e.g. level of conflict, communication) have been linked to SI in adolescents with psychiatric disorders (Machell et al., 2016). Further, these variables show promise for improvement in family-based interventions which, in turn, corresponds to decreased SI in youth. For example, the Resourceful Adolescent Parent Program, a family-based treatment for adolescents at high-risk for depression (RAP-P; Shochet, 1998; Shochet et al., 2001), has led to significant reductions in SI that are largely mediated by changes in family functioning (Pineda & Dadds, 2013). At the parent-level, parents’ awareness and understanding of their child’s mental health symptoms as well as their capacity to adaptively respond/cope are significant predictors of SI in offspring (Czyz et al., 2018; Hammerton et al., 2016; Hauser et al., 2013). Most family-based interventions include psychoeducation and coping skills training for parents that lead to improvement in parent’s knowledge, self-efficacy, and ability to cope with their child’s symptoms (e.g. Cohen & Mannarino, 2008; Kircanski et al., 2011; Schnyder et al., 2015), but whether these improvements are directly related to improvement in children’s SI is currently unknown (Ridge et al., 2016; Zalsman et al., 2016). Parental depression is also a major risk factor for suicidality in offspring (Sarkar et al., 2010; Spirito et al., 2006). Although not a direct treatment target for PBD, past studies indicate that improvement in parent depressive symptoms may be a byproduct of family-based interventions that could decrease child internalizing symptoms through non-genetic pathways (e.g. modeling, household stress, negative self-talk; (Compas et al., 2009; Jaser et al., 2008), rendering the question of whether change in parent depressive symptoms is related to change in SI for youth with PBD. At the child-level, poor self-concept, emotion dysregulation, and impaired ability to cope with stress have been consistently linked to suicidality in youth (Wild et al., 2004; Wolff et al., 2018), and there is some evidence that therapy-related improvements in self-esteem and coping are linked to SI reduction (Kuhlberg et al., 2010).

The current study investigates how changes in SI risk factors at the family-, parent-, and child-levels are related to changes in SI in children engaged in treatment for PBD. Increases in family cohesion, quality of life, and mobilizing family to acquire/accept help for the child’s disorder were expected to relate to decreased SI intensity for children at the family level. At the parent-level, increased knowledge of PBD, increased ability to cope with PBD, and decreased depressive symptoms were expected to relate to decreased child SI intensity over time. Last, a negative association between children’s coping skills and self-concept was hypothesized to emerge, such that increased coping and self-concept would be related to decreased SI intensity at the child-level. These hypotheses were examined for participants engaged in one of two treatment conditions, with the goal of investigating SI risk factors that are common across treatment modalities. Our prior work examined changes in SI prevalence and intensity over time in youth ages 7 to 13 with PBD participating in a randomized clinical trial (RCT) comparing a manualized child and family-focused cognitive-behavioral therapy (CFF-CBT) group program targeting the symptoms and psychosocial impairment of PBD to treatment as usual for PBD (individual therapy + family therapy) (Weinstein et al., 2018). We found that all youth demonstrated significant reductions in SI across the treatment period and at a 6-month follow-up, with no differences by condition, suggesting that change in suicidality may be prompted by change in the dynamic family, parent, and/or child risk factors that were inherent in both conditions. Building on this work, as well as past research highlighting relatively equal SI reductions across varied treatment formats (Calear et al., 2016), supporting the premise of examining change in SI risk factors and SI intensity for all participants without an emphasis on treatment condition comparisons.

Methods

Study participants

Participants included 71 youth recruited from a large midwestern urban academic medical center to participate in a psychosocial RCT for PBD (for details and consolidated standards of reporting trials diagram, see West et al., 2014). Children ages 7 to 13 with a current diagnosis of bipolar spectrum disorder who were medically stabilized were eligible to participate in the study. Exclusion criteria included youth with an IQ below 70 on the Kaufman Brief Intelligence Scale-Second Edition (KBIT; Kaufman & Kaufman, 2004), active psychosis, active substance abuse or dependence, significantly impairing neurological or medical problems, and/or current severe suicidality with intent or plan requiring immediate hospitalization, as measured by the Columbia Suicide Severity Rating Scale (Posner et al., 2011), although no youth were excluded for this reason.

Procedure

Eligibility of participants was assessed by trained raters, including licensed clinical psychologists and doctoral students. Children provided written informed assent and parents provided written informed consent prior to study participation. Following the consenting process, parents were interviewed using the WASH-U-KSADS, with portions of the Kiddie-SADS-Present and Lifetime Version, to define children’s mood episodes (Geller et al., 1996). Semi-structured interviews were reviewed during study meetings with clinicians specialized in PBD for final diagnosis determination. Youth meeting DSM-IV-TR diagnostic criteria for a bipolar spectrum disorder I, II, or not otherwise specified (Bell, 1994) completed the baseline assessment and were then randomized to treatment condition using Research Randomizer software (Urbaniak & Plous, 1997).

Psychosocial intervention.

Youth and their parents participated in one of two psychotherapy conditions: (1) manualized CFF-CBT (n = 35) in a specialty mood disorders clinic or (2) unstructured psychotherapy treatment-as-usual (TAU; n = 36) in a general child psychiatry clinic. Families in both conditions received 12 weekly 60- to 90-minute sessions and up to six monthly booster sessions. CFF-CBT study therapists included 23 clinical psychology predoctoral and postdoctoral trainees who received an initial 3-hour CFF-CBT training and weekly expert supervision by the treatment developers. CFF-CBT sessions included parent, child, and family group sessions, which were designed to target PBD symptoms and associated psychosocial impairments in preadolescent youth (for additional details see West et al., 2014).

TAU was a dose-matched family-based treatment provided by pre- and postdoctoral psychology trainees, psychiatry fellows, and social work interns (n = 25) who received training on PBD prevalence, symptoms, course, and associated impairments, enhancing this program compared with typical TAU. TAU therapists also received ongoing weekly supervision from licensed child-focused clinicians following routine clinic procedures. Content and structure of sessions in this condition were not manipulated; therapists and supervisors were instructed to follow their routine clinical practice for child/family-focused treatment. Youth in TAU attended more sessions than is typical of community treatment for suicidal youth (e.g. four or fewer sessions; Spirito et al., 2002). Treatment was provided by clinicians in a competitive academic medical center utilizing evidence-based treatment methods, with high satisfaction ratings from families. Studies examining SI prevention suggest that the provision of a non-programmatic but high quality, well-received, supervised treatment is effective in addressing pediatric SI at this stage of severity (Weinstein et al., 2018).

All participants received medication management with non-study providers in the specialty mood disorders clinic. Medication changes were tracked at each session, but medication was not manipulated for the study. Medication changes during the course of the study did not differ between CFF-CBT (23%, n = 15 reported a medication change during the course of the study) and TAU (23%, n = 15), χ2 = 0.05, n = 66, p = .82.

Assessments of psychopathology symptoms and SI risk factors occurred at baseline (pre-treatment); 4 and 8 weeks (during treatment); 12 weeks (posttreatment); and 39 weeks (follow-up assessment at 6-months posttreatment). Assessments of SI intensity occurred at baseline, 12 weeks (posttreatment), and 39 weeks (follow-up assessment at 6-months posttreatment).

Measures

Demographics.

Child age, sex, race/ethnicity, and family income were assessed via the Conners–March Developmental Questionnaire (Conners & March, 1994).

Psychopathology.

The WASH-U-KSADS (Geller et al., 1996), a semi structured interview specifically designed to assess PBD, was used to make a PBD diagnosis based on DSM-IV criteria (APA, 1994). Research assistants were trained to administer the interview and demonstrated adequate interrater reliability (k > 0.74).

The Children’s Depression Rating Scale–Revised (CDRS-R; Poznanski et al., 1984) is a clinician-rated instrument for measuring depression in children. Scores are summed across 17 items rated on a 5-point Likert scale. The CDRS-R demonstrated strong internal reliability in this sample (α = 0.84; intraclass correlation = 0.78).

The Child Mania Rating Scale (CMRS; Pavuluri et al., 2006) was used to assess child mania symptoms via parent-report. Scores on the CMRS are calculated by summing across 21 items, each rated on a Likert scale ranging from 0 (never) to 3 (very often), and scores ⩾ 20 are considered clinically significant. The CMRS demonstrates strong psychometric properties, concurrent validity with the YMRS, and sensitivity to symptom change across treatment (Pavuluri et al., 2006; West et al., 2011). Reliability in this sample was strong (α = .90).

Family factors.

The family scale of the KINDL Questionnaire for Measuring Health-Related Quality of Life in Children (KINDL; Ravens-Sieberer & Bullinger, 1998) was used to measure children’s self-reported quality of life within the family unit. This scale includes 4 items on a 5-point Likert scale, and has demonstrated good internal consistency in the general population (α = .81) and this sample (α = .75). The cohesion scale of the Family Adaptability and Cohesion Evaluation Scale II-Cohesion and Rigid scales (FACES; Olson, 2011; α = .78) was used to assess cohesion within the family, which includes 7 items on a 5-point Likert scales assessing family involvement, closeness, and support via parent-report. The Family Crisis Oriented Personal Evaluation Scales (FCOPES; McCubbin et al., 1987; α = .84), a 39-item questionnaire on a 5-point Likert-scale, was used to measure families’ ability to engage in effective problem solving and cope with hardships. The mobilizing family to acquire/accept help subscale was used in this study to assess parent-reported support-seeking efforts by the family. Internal consistency for this subscale is adequate in the general population (α = .71) and this sample (α = .77).

Parent factors.

Parents’ current depressive symptoms were assessed with the Beck Depression Inventory—II (BDI–II), a standardized and widely used self-report checklist of depressive symptoms with adequate internal consistency and validity in distinguishing severity of MDD (Beck et al., 1996; Steer et al., 2001). Internal consistency in the current sample was α = .93.

The Coping Health Inventory for Parents (CHIP; McCubbin et al., 1983) is a self-report measure that assesses parents’ perceptions of their ability to manage family life in the context of caring for a child who is severely and/or chronically ill. This measure includes three subscales of coping: (1) maintaining family integration, cooperation, and an optimistic definition of the situation; (2) maintaining social support, self-esteem and psychological stability; and (3) understanding the medical situation through communication with other parents and consultation with medical staff. All responses are rated on a Likert scale ranging from 0 (not helpful) to 3 (extremely helpful). Scores from the subscales were summed to create a total coping score, which demonstrated excellent internal consistency (α = .93).

The Therapy Outcome Parents Scale (TOPS; West et al., 2009) measures parents’ knowledge of their child’s illness and ability to cope with caring for a child with bipolar disorder. Parents rate 20 items on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Responses are summed to create a total score, with higher scores indicating greater perceptions of knowledge and self-efficacy. Examples of items include: “I feel confident in my ability to spot the early warning signs of ‘out of control’ behavior in my child” and “I encourage the use of positive self-statements in my child and try to discourage negative thoughts.” This measure demonstrates good internal consistency (α = .86–.90) and predictive validity as a treatment outcome measure for children in PBD and their parents (West et al., 2009). Internal consistency in the current sample is α = .83.

Child factors.

The Youth Coping Index (YCI; McCubbin & Thompson, 1991) was used to measure personal development, problem solving, and stress management in youth. The YCI is a 31-item measure that has demonstrated strong internal consistency, stability, and predictive validity for positive adaptation (McCubbin & Thompson, 1991); sample α = 82. Self-esteem was measured with the Piers-Harris Self-Concept Scale (PHSCS-2; Piers, 2002). The PHSCS-2 is a 60-item scale with well-established reliability and validity that assesses attitudes about physical appearance, intellectual and school status, behavior, satisfaction with self, and popularity. Reliability in this sample was excellent (α = .90).

SI intensity.

Current and lifetime SI was assessed via the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011), a semi-structured interview appropriate for ages 6 and up. In line with past work (Weinstein et al., 2015), current SI was defined as occurring within the past month. The Suicide Ideation Intensity Index is comprised of five items assessing the frequency, duration, controllability, deterrents, and reasons for suicidal thoughts on 5-point scales. The C-SSRS has shown good sensitivity and specificity for suicidal thoughts across multiple studies (Posner et al., 2011). Reliability in this sample was strong (α = .88).

Analytic approach

All analyses were carried out in SPSS Version 24. Means, standard deviations, and bivariate correlations were calculated for key study variables. Mixed-effects regression models (MRMs; Laird & Ware, 1982) were estimated to test study hypotheses using the SPSS MIXED command. Mixed models are robust to the data dependency that occurs with repeated assessments of individuals over time and efficient in handling missing data by using all available data for a given participant to estimate group trends at each time point. Further, MRMs simultaneously account for both an individual’s mean SI intensity and mean level of each SI risk factor across time (i.e. between-subject effects) as well as the difference between an individual’s mean and current level of SI intensity and SI risk factor at each assessment wave (i.e. within-subject effects).

Separate MRMs were conducted to test family-, parent-, and child-level SI risk factors (Table 3). Treatment (TAU [0], CFF-CBT [1]), assessment wave (baseline, 4, 8, 12, and 39 weeks for SI risk factor; baseline, 12, and 39 weeks for SI intensity), child age, and child sex were controlled for in all models. Given the strong association between SI and psychopathology (Pelkonen & Marttunen, 2003), child mania and depression symptoms were also controlled for in each MRM to ensure that significant findings were attributable to family-, parent-, or child-level risk factors over-and-above the effect of symptoms. Each dynamic SI risk factor and the corresponding assessment wave*risk factor interaction were entered into separate models to assess change trajectories (i.e. slopes) from baseline to 4-, 8-, 12-week, and 6-month assessments. Models included all randomized participants to provide the most conservative test of hypotheses. Participants who dropped out of the study were contacted for follow-up assessments and were included in the analyses if available (n = 8).

Table 3.

Interaction effects from mixed effects regression models on change in SI intensity.

Estimate SE t (df)
Family models
Quality of life × wave .03 .01 2.82** (142)
Cohesion × wave .02 .04 .53 (138)
Acquiring/accepting help × wave .15 .06 2.55** (141)
Parent models
Depression symptoms × wave −.01 .02 −.51 (131)
Coping skills × wave −.00 .01 −.32 (142)
Knowledge of illness × wave .04 .02 2.07 (139)
Child models
Coping skills × wave .00 .01 .15 (140)
Self-concept × wave .06 .02 3.08** (103)
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Note.

*

p < .05.

**

p < .01.

Results

Demographic and clinical factors

Mean age of the sample was 9.17 years (SD = 1.60, range 7–13); 41% were female; 54% were Caucasian, 30% African American, 10% Hispanic, 4% American Indian or Alaskan Native, 1% Native American or Pacific Islander, and 1% Other. Table 1 lists the descriptive statistics for each predictor domain. There were no differences in age (t(58.63) = 0.31, p = 0.76), gender (χ2(1) = 0.68, p = .41), or race (χ2(5) = 5.18, p = .40) across treatment conditions.

Table 1.

Descriptive statistics.

Baseline Week 4 Week 8 Week 12 6 Months
Mean SD Mean SD Mean SD Mean SD Mean SD
Family-level dynamic factors
Quality of life 3.74 .74 3.73 .79 3.99 .62 3.93 .75 3.90 .69
Cohesion 28.37 4.57 27.80 4.65 28.42 4.69 29.95 3.89 28.97 4.54
Acquiring/accepting help 15.35 3.35 15.48 3.08 14.82 3.41 14.88 3.15 15.11 3.32
Parent-level dynamic factors
Depression symptoms 10.41 9.94 – – – – 8.00 7.40 8.50 11.17
Coping skills 81.87 26.18 83.39 25.66 82.96 22.53 82.53 25.24 82.52 28.62
Knowledge of child’s illness 70.68 10.96 74.73 9.07 75.40 10.06 79.28 9.58 77.67 10.39
Child-level dynamic factors
Coping skills 96.21 17.14 102.87 15.09 100.84 15.99 101.16 17.31 96.35 17.20
Self-concept 43.23 10.23 46.40 9.62 48.18 7.40 49.76 8.28 48.45 9.34
Outcome
Suicidal ideation intensity 4.28 6.18 – – – – .40 1.89 .27 1.37
Control variables
Child mania symptoms 23.21 10.37 22.12 8.41 18.44 10.55 18.72 11.40 16.30 11.37
Child depression symptoms 41.51 11.38 33.50 8.49 33.75 10.78 30.88 10.15 32.18 8.97
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Sixty-two percent (n = 44) of the sample was diagnosed with bipolar NOS, 32% (n = 23) with Bipolar I and 6% (n = 4) with Bipolar II. Index mood episodes included: 32% (n = 22) mixed, 25% (n = 17) manic, 23% (n = 16) unspecified, 16% (n = 11) depressed, and 4% (n = 3) hypomanic. At baseline, current SI was prevalent: 41% (n = 29) endorsed any ideation, and 31% (n = 22) endorsed active forms of ideation. There were no differences in baseline, post-treatment, or follow-up SI intensity across treatment groups.

Treatment effects

Overall attrition by the follow-up assessment did not differ by condition (n = 10 in CFF-CBT, n = 19 in control; χ2 = 2.51, ns). A series of t and χ2 tests were examined whether SI intensity and SI intensity risk mechanisms differed by treatment condition to inform whether analyses needed to account for group differences when collapsing across treatment type. Findings indicated equivalence across conditions, except for child mania symptoms. Youth in CFF-CBT demonstrated lower mania symptoms versus TAU (t = 2.90, p = .01). Paired sample t-tests demonstrated that SI intensity at 6 months was significantly lower than at baseline (t = 5.26, p = .00) across treatment conditions, suggesting that both treatments were effective in reducing SI intensity over time. Table 1 displays descriptive statistics for all measures by timepoint.

SI intensity

Family-level dynamic risk factors were not correlated with one another at baseline. At 6 months, the FACES was significantly positively correlated with the KINDL (r = .40, p < .01) and F-COPES (r = .37, p < .05), indicating that higher levels of parent-reported family cohesion were related to higher mobilization of the family to acquire/accept help and greater child-reported family coping 6 months post-baseline. Bivariate-level analyses also highlight significant negative correlations between the FCOPES and C-SSRS at baseline (r = −.36, p < .01), indicating that higher mobilization of the family to acquire/accept help was related to lower child SI intensity at baseline (see Table 2).

Table 2.

Bivariate correlations of dynamic SI risk factors and SI intensity.

1 2 3 4 5 6 7 8 9 10 11 12.
1. Family QoL – .40* .23 .03 .00 .43* .04 −.18 −.07 −.08 −.18 .09
2. Family cohesion .12 – .37* −.33 .32 .46** .04 .12 −.13 −.08 −.41* −.22
3. Acquiring/accepting help .13 .19 – −.06 .52** .44* .05 −.08 −.17 −.07 −.10 −.05
4. Parent depression symptoms −.19 −.19 −.11 – −.01 −.14 .23 .24 −.01 .02 .02 .19
5. Parent coping .10 .21 .31** −.07 – .30 .17 −.06 −.16 −.02 .02 −.29
6. Parent’s knowledge of child’s illness .37** .20 .31** −.33** .20 – .46** −.15 .14 −.12 −.08 −.18
7. Child coping .15 .12 .12 .13 −.04 −.02 – .18 .03 .03 −.24 −.20
8. Child self-concept .20 .00 .00 −.14 −.09 −.10 .27* — .04 −.07 −.44* −.05
9. Child SI intensity −.09 −.06 −.36** .28* −.05 −.17 −.02 −.39** – .22 .32 −.03
10. Child mania symptoms −.22 .05 .04 .25* .01 −.09 .28* −.11 .16 – .22 −.07
11. Child depression symptoms −.05 .16 .19 .04 .18 .18 −.10 −.59** .27* .07 – .07
12. Child age .16 −.19 .03 .01 −.27* .06 −.13 .00 −.02 −.11 −.07 —
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Note.

*

p < .05.

**

p < .01.

Variables at baseline below diagonal; variables at 6 months above diagonal. SI = suicidal ideation; QoL = quality of life.

MRMs demonstrated significant main and interaction effects for family quality of life (KINDL: t = −2.77, p < .01; KINDL × WAVE: t = 2.68, p > .01) and acquiring/accepting help (FCOPES main effect: t = −3.47, p < .001), FCOPES × WAVE: t = 2.55, p < .02) in relation to SI intensity. Main effects suggest that poorer child-reported quality of life and parent-reported help seeking were each related to higher SI intensity. Interaction effects demonstrate significantly higher rates of SI intensity for youth with low family quality of life and help-seeking behaviors at the start of treatment (t = −2.41, p = .02), but demonstrate a significant reduction in SI intensity as these variables improve over the course of treatment (t = −3.25, p = .002). No significant main or interaction effect emerged for family cohesion (FACES), suggesting parent-reported levels of family involvement, closeness, and support were unrelated to change in SI intensity in this sample (see Table 3).

At the parent-level, bivariate correlation analyses among dynamic factors (i.e. parental depression, coping, and competence/self-efficacy) highlight significant negative associations between baseline BDI-II and TOPS at baseline (r = −.33, p < .01), indicating that higher depression symptoms in parents were related to decreased knowledge of their child’s illness and ability to cope with caring for a child with PBD at baseline. Parent depression symptoms were also related to child SI intensity at baseline (r = .28, p < .05) such that a higher symptom score was linked to greater SI intensity in offspring (see Table 2). MRMs, which were conducted to further examine the link between change in parent-level variables and change in SI intensity in youth, yielded no significant main or interaction effects (see Table 3).

At the child-level, coping skills and self-concept were significantly positively correlated at baseline (r = .27, p < .05), indicating that higher endorsements of personal development, problem solving, and stress management on the YCI were related to higher ratings of self-concept (e.g. attitudes about physical appearance, intellectual and school status, behavior, satisfaction with self, and popularity). A significant correlation also emerged between self-concept and SI at baseline, such that greater self-concept was linked to lower SI intensity cross-sectionally at baseline (r = −.39, p < .01; see Table 2). MRMs of child-level dynamic factors yielded a significant main effect (t = −2.34, p = .02) and interaction effect (t = 2.07, p = .04) of child self-concept, indicating that greater endorsement of self-concept in children was linked to decreased SI intensity when examined statically and over the course of treatment. No significant relations between youth coping (YCI) and SI intensity emerged in correlation or regression analyses.1

Of note, gender, age, and depression and mania symptom ratings were included as covariates in all models. Results indicate that depression and mania symptoms were consistent predictors of suicidal ideation intensity in each MRM model, while age and gender were unrelated to SI intensity.

Discussion

The current study is the first to investigate how change in dynamic, modifiable risk factors for suicidality influences change in SI intensity for youth with PBD over the course of treatment. Past findings suggest that SI may improve across treatment modalities (e.g. CFF-CBT, child/family psychotherapy) despite differences in symptom outcomes (Weinstein et al., 2018). Thus, we identified several key treatment components at the family-, parent-, and child-levels to better understand how improvements in each domain may impact SI among preadolescents with PBD. Results suggest that treatment targets pertaining to the family unit as well as directly to the child may be particularly pertinent to SI improvement.

At the family-level, improvement in family quality of life (QoL) was significantly related to reductions in SI intensity over time. This finding is in line with prior indications that that youth with severe SI report lower QoL than youth with passive or absent SI (Weinstein et al., 2014) and suggests that that change in the child’s perceptions of QoL during/after treatment may contribute to change in SI. Increased satisfaction with family QoL may protect against SI risk through many interrelated processes, such as higher engagement in positive family activities and increased support from the family to address suicidal thoughts. This finding is also consistent with suicide prevention research in non-PBD samples (e.g. Shpigel et al., 2012), suggesting that treatment mechanisms predicting SI improvement in the general population may be similarly effective for youth with PBD.

Increased efforts to problem-solve and acquire/accept help were also significantly related to decreased SI intensity in youth at the family-level. This measure assesses parent-reported help-seeking efforts through informal (e.g. from others who have faced “the same or similar problems”) and formal (e.g. professional counseling) avenues, and may relate to child SI improvement through direct engagement in treatment or through secondary pathways (e.g. improved efficacy to discuss suicide within the family).

The third family-level factor, family cohesion, was not significantly related to SI intensity over time. Although distinct constructs, this parent-reported measure (FACES) includes items similar to the child-reported QoL items on the KINDL (e.g. FACES: “Family members feel very close to each other”; KINDL: “I got on well with my parents”) and measures were significantly correlated post-treatment. Thus, one possible explanation for the discrepancy between this pattern of significance (i.e. non-significant association between family cohesion and child SI intensity and significant association between family quality of life and child SI intensity) is that the child’s perception of family functioning/quality of life could supersede parent-perception in impacting SI intensity change. However, further research is needed to confirm this theory.

No significant findings emerged predicting child SI intensity at the parent-level, including parent’s depression symptoms, coping, and knowledge of child’s illness. Given past findings that have demonstrated benefits of improvements in parent mental health and parents’ knowledge of child mental health symptoms on child symptoms and functioning (e.g. Hauser et al., 2013), it will be important for future research to further disentangle relations between parent-level risk factors and child SI in populations with PBD.

At the child-level, increased self-concept over time was significantly related to decreased SI intensity—a finding consistent with past work citing significant relations between self-concept and SI in both the general population (Wild et al., 2004; Wolff et al., 2018) and youth with PBD (Goldstein et al., 2012; Weinstein et al., 2015). Youth dissatisfied with their view of themselves might engage in SI as in response to negative cognitive biases, suggesting that challenging deleterious self-focused thinking patterns may be vital to address in treatment. Although not a primary hypothesis of the study, it is also important to note that depression and mania symptoms were significantly related to SI intensity in all MRM models, supporting past findings that SI intensity is highly related to mood disorder symptoms (Goldstein et al., 2012).

Contrary to hypotheses, changes in youth coping over the course of treatment were unrelated to SI intensity. The coping measure used in the present study includes subscales assessing spiritual and personal development, positive appraisal and problem-solving, and incendiary communication and tension management. Thus, it is possible that change in other coping strategies not measured in this study (e.g. distraction) may impact SI change. Given the relatively young age of the current sample (M = 9.21 years), a second possibility is that changes in the family environment and the child’s self-concept may be more important for SI reduction/prevention at this developmental timepoint. Coping may become increasingly important as cognitive regions continue to mature and youth can engage in more complex thinking. Future studies should continue to incorporate measures of coping to understand (a) which specific strategies are generally targeted in PBD treatment, (b) how changes in these strategies impact SI, and (c) how coping-SI associations evolve across adolescent development.

Results highlight several possible treatment targets to reduce SI in PBD, particularly at the family- and child-levels, which should be interpreted within the study’s limitations. First, the content of TAU sessions was not measured, negating our ability to account for specific intervention strategies responsible for observed changes. A careful assessment of the treatment components included in each modality would allow for a more thorough understanding of the role of treatment type on the association between SI risk factor change and SI intensity. Additionally, investigating the impact of SI risk factors uniquely addressed in each treatment as potential moderators of the association between treatment condition and SI intensity represents an important target for future work. Second, it should be acknowledged that variables not measured in this study (e.g. changes in the school environment, social connectedness, sleep) have been associated with youth suicide (e.g. Bilsen, 2018; Im et al., 2017; Stone et al., 2015) and could have influenced SI intensity change longitudinally. Future investigations of SI change in youth with PBD should consider additional factors that may alter or contribute to treatment-related mechanisms of change. Third, the current sample is representative of youth with PBD in outpatient treatment, but results may not generalize to all individuals with PBD (e.g. inpatient populations), nor to can results be applied to other forms of self-harm or suicidal behaviors (e.g. suicide attempts).

Despite limitations, findings offer promising evidence for suicide prevention research and clinical work. Family QoL, the family’s efforts to acquire and accept help for children’s PBD, and child self-concept may be particularly important treatment targets in reducing SI intensity for youth with PBD. Specifically, parent/family interventions targeting QoL improvement (e.g. engaging in parent-child communication training; planning/scheduling pleasurable family activities), the provision of PBD treatment education (e.g. how to find and utilize applicable resources and networks), and promoting positive child self-concept (e.g. emphasizing strengths; correcting negative self-schema via cognitive or dialectical behavior therapy; increasing parents use of praise) may serve to reduce mortality in this high-risk population.

Supplementary Material

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Supplemental material

Supplemental material for this article is available online.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the National Institutes of Mental Health (NIMH) under Grant K23 MH079935 and the American Foundation for Suicide Prevention under Grant YIG-1-140-11.

Biographies

Author biographies

Meredith A Gruhn was a predoctoral internship at the University of Illinois at Chicago (UIC) at the time of this project and is currently a postdoctoral fellow at the University of North Carolina at Chapel Hill (UNC).

Amy West is Associate Professor of Clinical Pediatrics and Associate Training Director for Psychology in the Division of General Pediatrics at Children’s Hospital Los Angeles (CHLA) and USC.

Elissa Hamlat is a postdoctoral Scholar at the UCSF Weill Institute for Neurosciences.

Sally Weinstein is Associate Professor of Clinical Psychology in Psychiatry and a clinical psychologist at UIC.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

1.

Supplementary analyses were conducted to examine the impact of family-, parent-, and child-level SI risk factors preceding SI intensity, with risk factors measured at baseline only (Supplemental Table 1) as well as 4-, 8-, and 12-weeks post baseline (Supplemental Table 2) longitudinally predicting 6-month SI intensity. The pattern of significance observed in the primary analyses remained consistent, suggesting that family quality of life, mobilizing the family to acquire help, and child self-esteem are related to child SI intensity when temporal precedence is established.

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