Psychopathology and Its Relationship to Suicidal Ideation inChildhood and Adolescence

DAVID A. BRENT, M.D., ROBERT KALAS, M.S.W., CRAIG EDELBROCK, PH.D.,ANTHONY .J. COSTELLO, M.D., MINA K. DULCAN, M.D., AND NOELLE CONOVER, B.S.

A sample of 231 children referred for psychiatric treatment were assessed with astructured diagnostic instrument, the National Institute of Mental Health DiagnosticInterview Schedule for Children (DISC). A hierarchy of suicidal ideation from nonspecificideation to suicidal behavior was empirically derived. Both the symptoms and syndrome ofdepression were correlated with the severity of suicidality, but there was considerableoverlap between categories. Parents and their children showed low agreement, but highinternal consistency for ratings of suicidality. The continuity between suicidal ideation andsuicidal behavior is explored. These findings are compared to those ofothers in the literature,and implications for further research are discussed.

Journal of the American Academy of Child Psychiatry, 25, 5:666-673, 1986.

Suicide and suicidal behavior among youths haveincreased to epidemic proportions in recent years(Frederick, 1978; Shaffer and Fisher, 1981; Weissman,1974). Attempted suicide is one of most common emer­gencies in child psychiatric practice (Mattsson et aI.,1969; Pfeffer et aI., 1979, 1980, 1982). In spite of effortsto characterize suicidal children and adolescents, thediagnostic features of this group remain unclear (Shaf­fer, 1982). More importantly, the antecedents of sui­cidal behavior in youth have not been delineated,making prediction and prevention of suicide untenable(Eisenberg, 1980). There is evidence that both thosewho attempt (Brent, 1983; Hawton et aI., 1982a; Pfef­fer et aI., 1979, 1980, 1982) and those who completesuicide (Shaffer, 1974) have a history of suicidal idea­tion and hopelessness, which, through mechanisms

Receit'ed (Jct. 1.5, 19H·/; revised Mar. 27, 19H.5; accepted April 16,HIH.5.

lJal'id A. Hn·nt. M.n.. is Assistant Professor, Child I'sychiatry.W"stern Psychiatrie Institute and Clinic. Rohert Kala.,. M. S. W .. isSenior Social Worker. C"nter for Children and Families. WesternI'sychiatric Institute and Clinic; Craiji f:delhrock. Ph.lJ.. is AssociateI'rofessor. Child Psychiatry, (!nit'ersity of Massaehusett., School ofMedicine; Anthony J. Costello. M.lJ.. is lJirector and Professor. Child/'.,ychiatry, (!nil'ersity of Massachusetts School of Medicine; MinaK. lJu/c'an, M.n.. is Associate Professor and lJirector, Child Psychia­try, Emory (!nil"'rsity; Noelh· Conover, H.S., is Systems Analyst,w""t"rn I'.,ychiatric Institute and Clinic.

This worli /I'as partially supported hy NIMH Traininji (;rant 2T:J2MH 1.59169-06 (/). H.J. the W. T. (;rant Foundation (C. KJ. andMIMH Contract RFP-lJH-HI-0027 (A .•J. C.J. The comments of twoanonymous revie/l"'r" Il'ere helpful.

I'resented at the :Jlst Annual Medinji of the American Academyof Child Psychiatry. Toronto, (Jntario. (Jctoher, 19H-/.

Reprints may he requested from lJQl,id Hrl'Tlt. M.n.. :JHII (J'HaraSt .. Pittshurjih, I'A 1.521:J. lJr. Hrent is Assistant Professor of ChildI'sychiatry and Post-doctoral Felloll'. Psychiatric EpidemiolojiY at th,'W"stern I'sychiatric Institute and Clinic.

0002-71:IR/R6/2"O,,-066(; $02.00/0 'C' 19RH by the American Acad­emy of Child Psychiatry.

unknown, develops into self-destructive activityamong a few.

Previous studies have shown that the severity ofsuicidal ideation is correlated with depressive symp­tomatology in children and adolescents (Carlson andCantwell, 1982; Pfeffer et aI., 1979, 1980, 1982, 1984).However, some believe that suicidal behavior is theculmination of progressively more severe suicidal idea­tion (Pfeffer et aI., 1979), whereas others view suchbehavior as discontinuous from suicidal ideation(Carlson and Cantwell, 1982; Hawton et aI., 1982a;Shaffer, 1982). This discrepancy might be explainedby the existence of two different populations of suici­dal attempters: a dysphoric, hopeless group, whoseattempts are planned and of high intent, and animpulsive, externalizing group whose attempts are ofvariable intent (Brent, 1983; Paykel and Rassaby1978). Studies such as Pfeffer's may have drawn pri­marily from the former group, and that of Carlson andCantwell, from the latter. The present study has arelatively large sample size, an empirically derivedhierarchy of suicidal ideation, and minimization ofinformation and criterion variance through the use ofa structured diagnostic interview. All these featuresare novel to this area of research.

In this study, the following questions will be ad­dressed: (1) is there evidence for a hierarchy of suicidalideation? (2) do children with differing degrees ofsuicidal ideation differ as to symptom scores andDSM-III diagnoses? and (3) what is the relative valueof parent and child reports in the assessment of sui­cidal ideation in this age group?

Method

Sample. During 1982-1983, all children and adoles­cents referred for assessment at Western Psychiatric

666

PSYCHOPATHOLOGY AND SUICIDE 667

TABLE 1

Suicidality Scale (SS)

Severity QuestionItem-Total

Correlation"Percent

Affirmative

Nonspecific

Specific

Attempts

Do you feel your family would be better off without you?When you are upset, do you think about death and dying?

Do you feel hopeless?Have you thought about killing yourself?Do you ever feel that life is not worth living?

Have you ever tried to kill yourself?More than once?

0.740.64

0.460.780.61

0.640.61

4038

33:3128

147

" All correlations significant at p < 0.001.

TABLE 2

Means of Symptom Scores on DISC-C and DISC-P by Child'sReport of Suicidalitv: Results of Analysis of Variance"'·

TABLE 3

Mean.~ of Symptom Scores on DISC-C and DISC-P by Parent'sReport of Suicidality: Results of Analysis of Variance"'·

and a follow-up interview 10-21 days later. A prelim­inary examination of the data showed that suicidalideation as measured by the DISC could be assessed

"Broken line indicates that differences between means are notsignificant, after correction by Duncan's multiple range test.

• Brackets indicate significant difference between nonadjacentcells.

'C = score on DISC-C.d I' = score on DISC-I'.

Variable None )INOnSPeCifiC I,specific) ~AttemPtP (3, 227) (N = 103) (N = 41) (N = (7) N = 20)

Sex: P = 1.57 1.31 I 1.24I

I.:l7,

1.50I II I I

Age: P' = 4.84 11.06 I 11.12 12.70 I 1:3.00

Attentional ProblemsI I tr I

P = 1.35 C' 16.75 I 14.90I 15.30 12.95I I

P = 1.6:J I'd 20.21 : 22.90 I 21.78 I 17.00I

Conduct Problems I I I

F = 1.82 C 13.42 ~ 14.34 I 16.22 I 11.75I

P = 1.74 I' 16.29 I 18.89 I 19.67 I 17.25

Depression (Affective) I I IIP = 2.16 C 8.11 I 8.46 I 9.G4 I 10.20

P 10.27 T 13.05 I j,').8fi I 16.40I I

Depression (Cognitive)I I II I IP = 2.143 C fi.67 I 6.00 I 6.21 I 8.00

P'" = 19.80 P 3.69 1 5.66 I 7.82 I 6.40I

Depression (intensity) I

~I I

P" = 5.40 C 1.86 I 2.32 I 2.:J4

P'" = 1:1.88 p I.I:J I 2.51 I 3.00I I 2.50I I I

Depression (Vegetative I

P = 0.426 C ,').31 I5.20

I 5.5,,) I fi.9,')I I

P'" = 5.6fi I' fi.20 I 6.024 I 7.01 I 7.25I

Depression (Total) I I

2:J.75 IP = 2.67 C 20.96I

21.98I

28.00I I

P'" = 29.68 I' 20.29 I 27.24 I 34.24 I :12.00

Substance Abuse I I II I

!P= O.G2 C 0.29 I 0.39 I 0.fi4 0.60

P= 0.60 I' 0.10 I 0.24 1 0.:J6 I 0.10

1.77

i.90

i.G1

1.1 :1

1.6fi

1.29

1.6"

I.fi2

1.10

empt=:31)

I.:l6

1.34

1.00

8B1

8.1:1

8.48

Institute and Clinic were invited to participate in astudy of the National Institute of Mental HealthDiagnostic Interview Schedule for Children (DISC)(Costello et al., 1982). Two hundred and thirty-oneparent-child pairs completed the initial assessment

Variable None Nonspecific Specific AttP (:J, 227) (N = 81) (N= 39) (N= 80) (N

- -I I

Sex: P = 1.4R 1.26 1.31 I 1.41 II

Age: P = :1.00 11.59 I 12.6.') I 12.fi4 1:I I II I

Attentional Problems:P" = ,').47 C' 12.70 16.92 16.98 1

P = 1.10 I'd I I I

22.39 I 21.46 I 19.91 I 1

Conduct Problems: I II I

P= 9.72 C 10.06 16.14 I 16.97 I 11

P= 2.87 I' 16.40 21.87 17.74 I 11

Depression (Affective)II

P = 21.20 C 6.05 8.69 10.59 I 1

P = 1.09fi I' 12.:JO 12.79 I 1:1.46 I 1,I I

Depression (Cognitive) I IP'" = 13.14 C 4.20 6.41 I 7.0fiI I

,--P = 1.048 I' 4B9 fi.64 ,').7:l I I

-- --- --

Depression (intensity)P'" = I:J.62 C 1.28 2.21 2.7:l

P= 4.:19 I' 1.89 I 1.75 I 1.84I I

Depression (Total)P = 27.20 C 1".49 22.fi1 26.4(i :1

P = 1.62 I' 24.74 I 26.1:JI

27.49 I 2~I

I I ISubstance Abuse I I I

P= 2.16 C 0.22 I 0.41 I 0.,,:1 I (

P= O.4:J1 P 0.2,,) I 0.21 I 0.:1:1 I (.1 I I

"Broken line indicates that differences between means are notsignificant, after correction by Duncan's multiple range test.

• Brackets indicate significant difference bet ween nonadjacentcells.

'C = score on DISC-C.d I' = score on DISC-I'., p < (Ull. " P < 0.001. '" P < 0.0001.

668 BRENT ET AL.

Diagnosis

TABLE 4

Percent of Children Meeting DSM-lll Diagnoses in Different Categories of Suicidal Ideation by Degree of Suicidal Ideation on DISC-C

None Nonspecific Specific Attempt(N = 81) (N = 39) (N = 80) (N = 31)

Conduct DisorderCo 54.3 53.8 49.2 67.8pb 53.3 53.8 61.3 48.1

Attention Deficit DisorderC 7.4 12.8 41.3 22.6P 27.2 46.2 16.3 46.2

Alcohol AhuseC'" 3.7 2.6 6.3 6.5P 2.5 2.6 6.3 0.0

Separation Anxiety DisorderC 28.3 35.9 15.1 35.5P 24.7 12.9 36.3 19.3

Overanxious DisorderC···· 3.7 7.7 10.1 19.4P 11.1 10.2 8.8 19.3

Avoidant DisorderC 8.6 7.8 5.1 16.2P 2.4 2.6 0.0 3.2

AgoraphohiaC 23.5 25.7 17.5 29.0P 19.8 17.9 33.8 19.4

Social PhohiaC 17.3 33.4 15.8 32.3P 19.7 7.7 :l8.8 25.5

Simple PhohiaC 49.4 69.2 35.0 64.5P 40.7 :18.5 60.:3 35.5

Major Depressive EpisodeC···· 8.6 15.4 16.3 25.8p 8.6 2.6 21.3 9.7

Bipolar DisorderC 0.0 0.0 0.0 0.0P 1.2 0.0 0.0 3.2

Dysthymiac···· 18.5 :18.5 ,'>2.6 80.7P 56.9 48.7 65.0 64.5

CyclothymiaC 3.7 17.9 7.5 12.9P 8.6 5.1 10.0 12.9

o C = child report.h P = parent report.)('test for trend significant at: • p < 0.0,'>, •• P < 0.01, ••• P < 0.001, and •••• p < 0.0001.

reliably (r > 0.60; P < 0.001), thereby warrantingfurther study of this phenomenon with the DISC.Because suicidal ideation could be reliably assessedand the test-retest characteristics of this domain forthis subsample were known, this group was chosen forfurther study. The patients ranged in age from 6 to18, with a mean age of 12.96. Approximately two­thirds were male, slightly over 50% were white, andan equivalent proportion were lower class.

Instrument. The DISC is a highly structured diag­nostic interview, similar in purpose to the Diagnostic

Interview Schedule (DIS), developed for epidemiologicstudies of adult psychopathology (Robins et aI., 1981).There are parallel parent (DISC-P) and child (DISC­C) versions, both of which yield computer-generatedDSM-III diagnoses as well as quantitative symptomscores in 27 symptom areas (Costello et aI., 1984). Thecontent, development, and reliability of this intervieware discussed in two more general papers on the DISC(Costello et aI., 1985a, 1985b). Psychometric proper­ties of the DISC have been described elsewhere (Cos­tello et aI., 1982, 1985; Edelbrock and Costello, 1984;

PSYCHOPATHOLOGY AND SUICIDE

TABLE 5

669

Percent of Children Meetin# DSM-III Dia#noses in Different Categories of Suicidal Ideation by Degree of Suicidal Ideation on DISC-P

DiagnosisNone Nonspecific Specific Attempt

(N = 103) (N = 41) (N = 67) (N = 20)

Conduct DisorderC" 4.9 43.7 55.3 65.0ph 49.5 51.3 56.7 65.0

Attention Deficit DisorderC 15.5 10.7 13.4 10.0P 40.8 56.1 44.8 35.0

Alcohol AbuseC 3.9 4.9 7.5 0.0P 1.9 2.4 7.5 0.0

Separation AnxietyC 35.9 34.2 29.9 30.0P 14.6 31.7 16.4 20.0

Overanxious DisorderC 8.8 4.8 4.5 25.0P 2.9 14.7 22.4 15.0

Avoidant DisorderC 6.8 14.6 7.5 20.0P 2.9 0.0 6.0 5.0

AgoraphobiaC :12.1 26.9 25.4 20.0P 14.6 22.0 17.4 35.0

Social PhobiaC 28.2 26.8 29.9 40.0P 12.6 19.5 20.7 25.0

Simple PhobiaC 65.0 56.1 52.2 50.0P :12.0 51.2 :34.3 50.0

DepressionC' 11.6 14.6 20.9 :30.0P' 1.0 7.3 25.4 15.0

Bipolar DisorderC 0.0 0.0 0.0 0.0P 0.0 0.0 1.5 5.0

------~

DysthymiaC :l(i.4 48.8 5:1.8 70.0P**** 2,').2 62.5 77.7 75.0

CyclothymiaC 10.7 7.:1 9.0 10.0P 1.0 14.6 16.4 5.0

"C = child report.h P = parent report.X2 test for trend significant at: • p < 0.05, •• p < (Ull, ••• P < 0.001, and •••• p < 0.0001.

TABLE 6

Results of Regression of Suicidality Scale (Child Rl'port) onIJcmo#raphic Variables and Symptom Smres"

TABLE 7

Results of Rl'gression of Suicidality Scale (Parent Report) onDemographic and Symptom Variables"

T Significance T SignificanceVariable~----

Depression-C (vegetative)Depression-C (affective)Conduct-CDepression-P (intensity)

"R 2 = 0.42.

Beta

0.:174 ± .0720.192 ± .04:,0.050 ± .018

0.18 ± .074

1i.194.462.812.47

<0.0001<0.0001

0.00,')0.01

Variable

Depression-P (affective)Depression-P (intensity)Attentional problems-P

"R 2 = 0.29.

Beta

0.219 ± 0.0:3 7.200.197 ± 0.080 2.,'):3

-0.027 ± 0.014 -1.98

<0.00010.010.05

670 BRENT ET AL.

TABLE 8

Pprcpnta/4e of DSM-1l1 Dia/4noses on IJISC-P and DISC-C a" a Function of Parent-Child Concordance on Severity of Suicidal Ideation

Parent -Child Concordance Separation Simple ConductDepression Dysthymia

for Suicidal Ideation Anxiety Phobia Disorder

Child» Parent (N = 27)C 3:~.3** 77.8* 33.3 81.5* 48.1

P :U 29.6 11.1 29.6 63.0

Parent» Child (N = 21)C 14.3 :~:~.3* 28.6 42.9 42.9

P 14.:~ 81.0 23.8 :~3.3 57.1-----

Child = Parent (N = 63)C 17.5 :1l.7 31.7 54.0 58.7

P 9.5 44.4 17.1) 42.9 52.4----------------- ----------------

* p < 0.05 relative to concordance for conduct disorder. ** p < 0.01 relative to concordance for conduct disorder.

Edelbrock et aI., 1984) and can be summarized asfollows: (l) interrater reliability is high; (2) test-retestreliability is high for the DISC-P across all age ranges.For the DISC-C, test-retest reliability was higher inadolescents than in younger children, but the entireage range showed a decline in symptom scores uponre-interview; (3) parent-child agreement was highestacross all age ranges for patients with conduct disor­der, but increased with age across a wide range ofsymptoms; and (4) high discriminant and concurrentvalidity have been demonstrated.

Symptom scores were generated in the areas ofsuicidal ideation, components of depression (vegeta­tive, affective, cognitive, intensity, total), conductproblems, attentional difficulties, and substance abusefrom questions given in the DISC-C and DISC-P,based on criteria of DSM-III. The sum of items per­taining to a particular symptom complex constituteda symptom score. The items for suicidal ideation weredeleted from the depression scores. The particularquestions pertaining to suicidal ideation are noted inTable 1. DSM-III diagnoses reported in this paper arederived from computer algorithms.

Results

The disparity in test-retest reliability across agegroups necessitated separate data analyses for chil­dren aged 6-9, 10-13, and 14-18. However, becauseconsistent results were obtained across age groups, theresults are reported on the entire sample.

Evidence for a Hierarchy of Suicidal Ideation. AGuttman scale was constructed from the questionspertaining to suicidal ideation and is depicted in Table1. Since each question could be answered 0, 1, or 2,the range for the scale was 0-14. Subjects who en­dorsed items of greater severity were likely to respondpositively to less severe items as well (coefficient ofreproducibility = 0.83), as is typical of Guttman scales

(Nie et aI., 1975). Furthermore, correlation betweentotal score on the suicidality scale (SS) and the rankof the most severe item endorsed was high (r = 0.84,p < 0.001). The scale showed high internal consist­ency, as all item-total correlations were greater thanr = 0.60, with the exception of hopelessness (r = 0.46,p < 0.01). However, hopelessness was included becauseof its well-known importance as a correlate of suicidalideation and intent (Beck, et aI., 1975; Kazdin et aI.,1983a). The levels of suicidal ideation were chosen onboth statistical and clinical grounds. These findingsappear to confirm the existence of a hierarchy ofsuicidal ideation in this age group: none, nonspecific(e.g., thoughts of death without intent), specific (e.g.,with suicidal intent), and actual suicidal activity.

Suicidal ideation was classified on the basis of themost severe item endorsed for almost all data analyses,with the exception of multiple regression of symptomscores on SS (e.g., the sum of all suicidal items en­dorsed). Because of the high correlation between thetwo measures of suicidality (r = 0.84, p < 0.001), theywere felt to be nearly equivalent. However, classifica­tion of suicidal ideation on the basis of the most severeitem endorsed was felt to more closely simulate theclinical approach, and also does not assume that sui­cidal ideation and suicidal behavior are continuousphenomena.

Relationship between Severity of Suicidal Ideationand Nosologic Characteristics of the Child. The rela­tionship between symptom scores and severity of sui­cidal ideation was examined by use of analysis ofvariance rather than by Pearson's r, because the lattertest assumes that the relationship between severity ofideation and symptom scores is linear. Duncan's mul­tiple range test was employed to correct for post-hoccomparisons.

There was a tendency for almost all symptoms toincrease with the severity of suicidal ideation, but

PSYCHOPATHOLOGY AND SUICIDE 671

these effects were frequently seen between nonadja­cent groups (e.g., significant differences were foundbetween those with nonspecific ideation and thosewho had made suicide attempts, but not between thosewith specific vs. nonspecific suicidal ideation) (seeTable 2). Variables which were significantly differentbetween all groups were: child's report of vegetativesigns of depression (F (3, 227) = 19.80, P < 0.0001),affective signs of depression (F (2, 227) = 21.20, P <0.0001), total score for depression (F (3, 227) = 27.20,P < 0.0001), and parent's report of the intensity ofdepressive symptomatology (F (3, 227) = 4.39, P <0.005). When parental report of suicidality was em­ployed as the classification variable, similar findingsemerged (see Table 3): parental report of affective (F(3, 227) = 25.68, P < 0.0001), cognitive (F (3, 227) =19.80, P < 0.0001), intensity (F (3, 227) = 13.88, P <0.0001), and combined components of depression score(F (3, 227) = 29.08, P < 0.0001), as well as the child'sreport of the intensity of depression (F (3,227) = 5.40,P < 0.001) were the variables most sensitive to groupdifferences.

Discriminant function analysis was utilized in orderto learn which variables most effectively distinguishedbetween those patients with specific suicidal ideation(e.g., with intent, but without activity), and those whohad actually attempted suicide (by the child's report).Variables which discriminated between these twogroups included: intensity (parent and child), vegeta­tive (child), and cognitive aspects (parent and child)of depression, as well as parental report of substanceabuse. Classification accuracy was 74.8%, but overtwo-thirds of the attempters were misclassified, sug­gesting considerable overlap between the two groupsif only psychiatric symptomatology is utilized for cat­egorization. Discriminant function analysis by parentreport of suicidal behavior yielded similar results withrespect to discriminating variables and classificationaccuracy.

The frequency of DSM-III diagnoses in childrenwith different levels of suicidal ideation was compared.The child's report of the severity of suicidal ideation(see Table 4) was associated with increased frequencyof child-generated diagnoses of alcohol abuse(x~(trend) = 14.01, df = 1, p = 0.0002), overanxiousdisorder (x~(trend) = 24.94, df = 1, P < 0.0001),depression (x~(trend) = 21.65, df = 1, p < 0.0001), anddysthymic disorder (x~(trend) = 39.70, df = 1, P <0.0001). No such trends were observed for the parent­generated diagnoses. When the groups were classifiedon the basis of the parental report of their child'sseverity of suicidal ideation (see Table 5), diagnoseswhich were commoner as the severity of suicidal idea­tion increases were: depression (parent: x~(trend) =

5.74, df = 1, P = 0.02; child: x2(trend) = 5.16, df = 1,P = 0.02), and dysthymic disorder (parent: x~(trend)

= 46.41, df = 1, P < 0.0001).When compared to those without suicidal ideation

(on the DISC-P), those with thoughts of suicide ofany severity were more likely to show conduct disorder(child's report: x2 = 59.31, df = 1, P < 0.0001). Thehigh rate of affective and other types of disorders seenin children with more severe levels of suicidal ideationis addressed in the discussion below, and in fact, isnot a spurious finding. Out of 40 x2 tests, 10 weresignificant, 5 times as many as would be expected bychance alone (at p = 0.05).

Relative Contribution of Parent and Child Informa­tion to the Evaluation of Suicidality. Correlation be­tween children and parent reports of suicidality in­creased with age: for children 6-9, r = 0.034, p = 0.39,for 10-13, r = 0.22, P = 0.02, and for 14-18-year-olds,r = 0.32, p = 0.02.

In general, the parent and child reports of suicidalitywere poorly correlated with one another, but wereinternally consistent. That is, severity of suicidalitywas associated with marked increases in symptoms ofanxiety and affect within informant, but with onlymodest increases in the anxiety and affective symp­toms reported by the complementary informant. Mul­tiple regression of child and parent information on thechild's report of suicidality (as measured by the SS)explained 42% of the total variance, with the parent'sreport contributing only 2% (see Table 6). A corre­sponding regression analysis of the same independentvariables on parental report of suicidality (as meas­ured by the SS) explained 29% of the variance, withinformation from the child contributing virtuallynothing to the regression equation (see Table 7).

Altogether, 83 parent-child pairs were in concord­ance for the degree of the child's suicidal ideation,while 67 parents reported more ideation than did theirchildren, and 81 children reported more ideation thandid their parents (McNemar's test, x~ = 1.13, df = 1,NS). These groups did not differ with respect to age(F (2,228) = 1.74, NS) or sex (x~ = 2.78, df = 2, NS).An examination of Table 8 reveals the relationshipbetween concordance for suicidal ideation and forselected psychiatric syndromes. Since parents (P) andchildren (C) in all categories (C » P, C = P, C « P)showed a similar degree of concordance for conductdisorder, the concordance for diagnoses between par­ent and child was compared relative to the concor­dance for the diagnosis of conduct disorder.

When the child reported more severe suicidal idea­tion than the parent, this was reflected in a similardiscordance over a wide array of internalizing disor­ders (depression, Fisher's exact test, p = 0.01; dys-

672 BRENT ET AL.

thymic disorder, x~ = 3.99, df = 1, P < 0.05; simplephobia x~ = 4.38, df = 1, P < 0.05). On the other hand,when the parent reported more severe ideation thanthe child, this discordance was seen only for the di­agnosis of dysthymic disorder, although the differencewas not statistically significant (x~ = 0.92, df = 1,NS).

The attending psychiatrist's case summary was re­viewed in those cases in which the parent and childreport of suicidality were markedly discordant (N =48, three cases unavailable for review). Clinically sig­nificant suicidal ideation was noted in the case sum­maries in a similar proportion of the two discordantgroups (child » parent, N = 25; 52% significantideation; parent » child, N = 20; 45% significantideation; x~ = 0.25, df = 1, NS). This supports theview that when the clinician is faced with discordantreports of suicidality, the more severe report shouldreceive the greater weight.

Discussion

Limitations. While this study has strengths associ­ated with a structured clinical interview, it is none­theless limited in several ways: (1) those subjects withsuicidal behavior in the past may not have had thepsychiatric symptoms reported on the DISC at thetime of their suicide attempt, (2) the sample consistsentirely of a psychiatrically referred sample willing toparticipate in a research study, and (3) the study wascross-sectional. Each of these limitations will be dis­cussed in turn.

A chart review of the 31 patients who had engagedin suicidal behavior revealed that 77% had engaged insuicidal behavior in the context of the psychiatricreferral, whereas in 10%, the attempt appeared toantedate the episode, and in 13%, it was impossible todelineate the relationship between the attempt andthe episode. Reanalyses including only the 77% aboutwhom definite information was available did not alterany of these findings. This is actually consistent withevidence that those who have engaged in suicidalbehavior continue to differ in certain ways from psy­chiatric controls, regardless of when the attempt oc­curred (Hawton et aI., 1978).

The sample in this study was unusual insofar as itwas drawn from one urban referral center, familieshad to agree to participate in the project, and the sexdistribution was heavily skewed toward male children.All these factors may have contributed to our findingthat suicidal ideation and activity are continuous,since serious, planned suicidal behavior is most likelyto occur in male subjects with psychiatric difficulties(Brent, 1983; Garfinkel et aI., 1982; Mattsson et aI.,1969; Shaffer, 1974). Families willing to participate inthe study may have been more organized than those

of nonparticipants. As a result, external precipitantsmay not have contributed significantly to suicidalityin this cohort relative to psychiatric disorders intrinsicto the child.

Finally, this study is cross-sectional, so that hy­potheses about the progression of suicidal ideationdrawn from the results of the Guttman scaling requireconfirmation by longitudinal follow-up.

Commentary. The Guttman scale reported above(Table 1) suggests a model for the development ofsuicidal behavior, beginning with nonspecific suicidalideation, progressing to hopelessness and suicidal in­tent, and finally culminating in suicidal activity. Thisscale supports the view that suicidal behavior andsuicidal ideation are continuous manifestations of thesame phenomenon, a view consistent with the findingsof Pfeffer (1979, 1980, 1982, 1984) and Paykel et al.(1974), and contradictory with the results of others(Carlson and Cantwell, 1982; Hawton et aI., 1982a).Perhaps, as suggested earlier, this study, and those ofPfeffer et a1. (1979, 1980, 1982), drew from a morepsychiatrically disturbed population in whom a suicideattempt was a manifestation of a psychiatric illness,rather than a maladaptive and impulsive coping re­sponse to stressful circumstances. Since the latter typeof suicide attempter is less likely to follow throughwith referral for psychiatric treatment, the sample inthe present study probably underrepresents this im­pulsive and less psychiatrically disturbed group (Haw­ton et aI., 1982b).

The content of the SS suggests that hopelessnessseems to occupy a position intermediate between non­specific and specific suicidal ideation, which is con­sistent with the work of others (Beck et aI., 1975;Kazdin et aI., 1983a). Interventions aimed at the ame­lioration of hopelessness may also prevent suicidalbehavior in some patients (Beck et aI., 1975)

Our analyses show that suicidal ideation and behav­ior appear to be related to a broad range of psycho­pathology, consonant with the view that suicidalityper se is not related to any particular syndrome (Shaf­fer, 1982). However, the various components of de­pression were the most significant correlates of suici­dal ideation and behavior. Our findings, as notedabove, are closer to Pfeffer's than to Carlson andCantwell's insofar as those with a history of suicideattempts were more likely to show both the symptomsand the syndrome of depression. Either depressionplays a larger role in youthful suicidal behavior thanheretofore realized, or these findings may be attrib­utable to the characteristics of this psychiatricallyreferred sample. The fact that problems of attention,conduct, and anxiety also correlate with suicidalitysuggests that factors other than dysphoria, such as

PSYCHOPATHOLOGY AND SUICIDE 673

impulsivity and impaired social skills, may also con­tribute to suicidal behavior in children and adoles­cents.

Our findings that child and parent reports of suici­dality tend to have greater internal consistency thanin comparison with one another is similar to theresults of Kazdin et al. (l983b, 1983c) with respect toratings of childhood depression. It seems unlikely thateither parent or child would falsify a report of suicidalideation (an assumption bolstered by the internalconsistency of both the parent and child reports), andtherefore, on clinical grounds, the more serious reportshould probably receive the greater weight.

Although this study suggests that suicidal ideationand behavior are continuous phenomena, at least in apsychiatrically referred population, an importantquestion remains. That is, to what extent do thosepatients who score high on the SS resemble completedsuicides? Patients who scored high on the SS werelikely to show signs of depression, anxiety and conductdisturbance, and to have made at least one suicideattempt. It is difficult to draw many conclusions aboutdemographic correlates because the majority of thesubjects were male, but high scorers were likely to beolder. This profile, albeit incomplete, is certainly con­sistent with what is known about youthful suicidecompleters (Shaffer, 1974). A more definitive answerto this question must await work which either pro­spectively follows "high-risk" youth in order to learnwhat were the correlates of suicide, or comparativelyassesses suicide completers and matched psychiatriccontrols.

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