PSYCHOLOGICAL RESEARCH IN POPULAR MEDIA CRITIQUE PAPER

ARTICLE

Parent-Adolescent Agreement About Adolescents’ Suicidal Thoughts Jason D. Jones, PhD, a Rhonda C. Boyd, PhD, a, b Monica E. Calkins, PhD, b Annisa Ahmed, BA, a Tyler M. Moore, PhD, b Ran Barzilay, MD, PhD, a, b Tami D. Benton, MD, a Raquel E. Gur, MD, PhDb

OBJECTIVES: To examine agreement between parent and adolescent reports of adolescents’ suicidal thoughts and explore demographic and clinical factors associated with agreement in a large community sample. METHODS: Participants included 5137 adolescents 11 to 17 years old (52.1% girls; 43.0% racial minority) and a collateral informant (97.2% parent or stepparent) from the Philadelphia Neurodevelopmental Cohort. Families were recruited from a large pediatric health care network. Adolescents and parents completed a clinical interview that included questions about adolescents’ lifetime suicidal thoughts. RESULTS: Agreement was moderate for thoughts of killing self (κ = 0.466) and low for thoughts of death or dying (κ = 0.171). Discrepancies stemmed from both parental unawareness of suicidal thoughts reported by adolescents and adolescent denial of suicidal thoughts reported by parents. Fifty percent of parents were unaware of adolescents’ thoughts of killing themselves, and 75.6% of parents were unaware of adolescents’ recurrent thoughts of death. Forty-eight percent of adolescents denied thoughts of killing themselves, and 67.5% of adolescents denied thoughts of death reported by parents. Several demographic (eg, age) and clinical (eg, treatment history) characteristics were associated with agreement. CONCLUSIONS: Early identification and intervention hinge on reliable and valid assessment of suicide risk. The high prevalence of parental unawareness and adolescent denial of suicidal thoughts found in this study suggests that many adolescents at risk for suicide may go undetected. These findings have important clinical implications for pediatric settings, including the need for a multi-informant approach to suicide screening and a personalized approach to assessment based on empirically derived risk factors for unawareness and denial.

abstract

NIH

aDepartment of Child and Adolescent Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and bDepartment of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Drs Jones and Boyd designed the current study, conducted the main analyses, and drafted the initial manuscript; Drs Gur and Calkins designed and conducted the parent study that provided the data for the current study, coordinated and supervised data collection and coding, and reviewed and revised the manuscript; Dr Moore assisted with data preparation, conducted supplemental analyses, and reviewed and revised the manuscript; Drs Barzilay and Benton assisted with study design, assisted with data interpretation, provided content expertise on youth suicide, and reviewed and revised the manuscript; Ms Ahmed assisted with data preparation and coding and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https:// doi. org/ 10. 1542/ peds. 2018- 1771

Accepted for publication Nov 8, 2018

PEDIATRICS Volume 143, number 2, February 2019:e20181771

WHAT’S KNOWN ON THIS SUBJECT: Previous research has documented discrepancies between parent and adolescent reports of adolescents’ suicidal thoughts. Much of this work has focused on small clinical or high- risk samples, with limited exploration of factors that might be associated with reporter agreement.

WHAT THIS STUDY ADDS: In the largest study to date, we found substantial reporter disagreements resulting from both parental unawareness and adolescent denial of suicidal thoughts in a community-based sample. We identified several correlates of reporter agreement. Implications for pediatric settings are discussed.

To cite: Jones JD, Boyd RC, Calkins ME, et al. Parent- Adolescent Agreement About Adolescents’ Suicidal Thoughts. Pediatrics. 2019;143(2):e20181771

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Adolescent suicide is a major public health concern. In the United States, suicide is the second leading cause of death among 10 to 24 year olds, 1 and rates of completed suicide among youth have continued to increase in recent years.2 In a nationwide survey, an alarming 18% of US high school students reported seriously considering suicide in the past year.3 Suicidal ideation is a risk factor for a future suicide attempt and a host of other negative outcomes, such as impaired functioning.4, 5 Thus, early identification and treatment of suicidal thoughts are critical, and the identification of at-risk youth is a key goal of suicide prevention initiatives.

Unfortunately, more than two-thirds of adolescents experiencing suicidal thoughts do not receive mental health services.6 A key contributor to this lack of service use may be that parents are unaware of their adolescents’ suicidal thoughts. Because most youth do not seek psychiatric treatment themselves, parents are “gatekeepers” for youths’ access to mental health services.7 If parents are not aware of suicidal thoughts, adolescents are less likely to receive the services they need.

Evidence suggests that agreement between parent and adolescent reports of adolescents’ suicidal thoughts is poor and that this lack of agreement stems largely from parental unawareness of adolescents’ suicidal thoughts.8, 9 However, researchers have also noted cases in which the parent reports suicidal thoughts that the adolescent denies.10, 11 Much of the previous research has been focused on small clinical samples, and there has been limited exploration of demographic or clinical characteristics associated with agreement. Our aim in the current study is to conduct the largest investigation to date of parent-adolescent agreement about adolescents’ suicidal thoughts and to explore correlates of agreement. Consistent with previous research, 8 – 11

we expected low to moderate agreement between reporters of adolescents’ suicidal thoughts and that disagreements would stem from both parental unawareness and adolescent denial. Given the limited and inconsistent findings about correlates of agreement in community samples, we did not make specific predictions about how the demographic and clinical characteristics would relate to agreement.

METHODS

Participants

The Philadelphia Neurodevelopmental Cohort (PNC)12 includes 9498 youth between the ages of 8 and 21 years recruited from a large pediatric health care network. Importantly, participants were not recruited from mental health treatment programs; thus, the PNC is a community-based sample not enriched for individuals seeking psychiatric help. Potential participants were excluded from the cohort if they were not proficient in English, had significant developmental delays, or had other physical or cognitive conditions that interfered with study participation. In this study, we focused on PNC participants between the ages of 11 and 17 years (n = 5137) for whom information about suicidal thoughts

was collected from both adolescents and a collateral informant. See Table 1 for sample demographics. Given that 97.2% of collaterals were parents or served in some type of caregiving capacity, we refer to the collateral informants as parents.

Procedures

After receiving a description of study procedures, adolescents and their guardians provided written assent and informed consent, respectively. The Institutional Review Boards of the University of Pennsylvania and Children’s Hospital of Philadelphia approved study procedures.

Measures

Psychopathology and Suicidal Thoughts

Adolescents and parents completed GOASSESS, 12 a computerized, structured clinical interview designed to screen for symptoms of major psychiatric disorders. Trained interviewers assessed adolescents’ treatment history as well as the prevalence, frequency and duration, and distress and impairment associated with symptoms of major domains of psychopathology. Psychometric evaluation of the factor structure of GOASSESS revealed an overall psychopathology factor score and 4 subfactor scores (T.M.M., M.E.C., T.D. Satterthwaite, et al., unpublished observations).12 In the current study, we used the overall psychopathology factor score as an

JONES et al2

TABLE 1 Sample Demographics

Demographic Characteristics

Age, mean (SD) 14.53 (1.98) Sex, % girls 52.1 Racial minority, % 43.0 African American 31.9 Mixed race 9.9 Asian American, Alaskan native, or Pacific Islander 1.2 Hispanic or Latino 6.0 SES z score, mean (SD), range 0.04 (0.98), −2.61 to 1.60 Collateral relationship, % Mother or mother figure 87.0 Father or father figure 10.2 Other 2.8

N = 5137. SES represents the standardized factor score derived from a factor analytic study of neighborhood-level census and crime data.13

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index of the severity of adolescents’ psychological difficulties. GOASSESS is based on the Kiddie Schedule for Affective Disorders and Schizophrenia and has been shown to be a valid screener of adolescent psychopathology in multiple studies.12, 14 – 17

During the GOASSESS interview, adolescents were asked about lifetime suicidal ideation: “Have you ever thought about killing yourself?” In addition, adolescents were asked about thoughts of death: “Have you ever thought a lot about death or dying?” Although not necessarily suicidal ideation, recurrent thoughts of death or dying are clinically meaningful when evaluating suicide risk, are associated with elevated distress, 18 and are included as a symptom of major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.19 In addition, previous studies in which reporter agreement about suicidal thoughts was examined have included questions about thoughts of death or dying.10, 20 – 24 Therefore, we considered it useful and important to also examine reporter agreement about thoughts of death or dying. Parents answered the same questions about their adolescents’ lifetime suicidal thoughts and thoughts of death. Responses to these 2 questions were coded dichotomously as yes (1) or no (0).

Interviewers were trained in a standardized protocol for responding to reports of suicidal thoughts. This included asking follow-up questions about current thoughts and consulting with a study clinician. If necessary, a doctoral-level clinician would conduct a formal suicide evaluation and safety check and make a determination about the appropriate course of action (eg, referral, emergency procedures). Any participant that requested a referral was provided with information about mental health resources.

Family History of Suicide

Parents were administered an abbreviated version of the Family Interview for Genetic Studies.25 Family history of suicide attempts or completions among first-degree biological relatives of the adolescent were coded from responses to open- ended screening questions.

Trauma Exposure

Eight items from the posttraumatic stress disorder section of the GOASSESS interview provided an index of trauma exposure. We created a 3-level categorical variable, reflecting assaultive trauma exposure, nonassaultive trauma exposure, or no trauma exposure.17

Mental Health Treatment History

During the GOASSESS interview, parents provided information about the adolescents’ history of mental health treatment, psychiatric hospitalizations, and psychoactive medication use.

Demographics

Demographic information was obtained during the interview. In addition, participants’ addresses were linked to census and crime data, enabling us to obtain neighborhood- level estimates of the adolescents’ socioeconomic status (SES).13

Analytic Plan

First, we examined agreement between adolescent and parent reports of adolescents’ suicidal thoughts. We used κ as our primary agreement index. In addition to κ, we calculated sensitivity and specificity estimates by using the adolescents’ responses as the standard for comparison. Second, we examined the directionality of disagreements by calculating the proportion of dyads in which (1) the adolescent reported suicidal thoughts the parent was unaware of (“parental unawareness”) and (2) the parent reported suicidal thoughts that the

adolescent denied (“adolescent denial”). Third, we performed logistic regressions to examine factors that might be associated with reporter disagreements. The first model included demographic characteristics. Given sex differences in the prevalence and developmental progression of suicidal thoughts across adolescence, 26 we included the age-by-sex interaction term in the model. The second model included clinical characteristics.

RESULTS

Missing Data

The amount of missing data were minimal (≤3.5%). Given that missing data were <5%27, 28 and because data from both parent and adolescent is required to evaluate agreement, listwise deletion was used. As a result, the sample size varies across analyses.

Prevalence of Suicidal Thoughts and Agreement Indices

We report endorsement of suicidal thoughts by reporter and agreement rates broken down by demographic characteristics in Tables 2 and 3. Landis and Koch29 recommended the following cutoffs for interpreting agreement on dichotomous data: ≤0.20 = slight, 0.21 to 0.40 = fair, and 0.41 to 0.60 = moderate. By using these commonly cited guidelines, reporter agreement on thoughts of killing self was moderate (κ = 0.466), whereas agreement on thoughts of death was slight (κ = 0.171). The sensitivity and specificity estimates indicate substantial parental unawareness of adolescents’ suicidal thoughts. When adolescents provided an affirmative response, 49.9% of parents were unaware of adolescents’ thoughts of killing themselves, and 75.6% of parents were unaware of thoughts of death. We also identified dyads in which the parent reported suicidal thoughts that the adolescent denied. When parents provided

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an affirmative response, 48.4% of adolescents denied thoughts of killing themselves and 67.5% of adolescents denied thoughts of death. Specificity was high for both thoughts of killing self (0.959) and thoughts of death (0.909).

Factors Associated With Agreement

Demographics

Age emerged as an important factor across all the models (Tables 4

and 5). Older adolescent age was associated with better agreement: decreased odds of parental unawareness and decreased odds of adolescent denial. In addition, for parental unawareness, the age- by-sex interaction was significant for both thoughts of killing self and thoughts of death. We examined the slopes for boys and girls to further explore these interactions (Figs 1 and 2). For thoughts of killing self,

neither slope was significant. For thoughts of death, the slope was negative and significant for girls (b = −0.28, P < .05) and positive and marginally significant for boys (b = 0.24, P = .057). This suggests that, for adolescent girls, parental unawareness of thoughts of death is high at younger ages and then decreases at older ages. The opposite pattern emerged for adolescent boys, with unawareness increasing slightly

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TABLE 2 Endorsement of Thoughts of Killing Self

Thoughts of Killing Self

Adolescent Yes Parent Yes Adolescent Yes; Parent No (Unawareness)

Parent Yes; Adolescent No (Denial)

N % N % N % N %

Whole sample 413 8.1 394 7.8 198 49.9 187 48.4 By age Less than the median 135 5.4 150 6.0 66 51.2 83 56.8 Greater than the median 278 10.8 244 9.6 132 49.3 104 43.3 By sex Boys 167 6.9 182 7.5 81 50.0 95 54.0 Girls 246 9.2 212 8.1 117 49.8 92 43.8 By race Racial minority 192 8.8 166 7.7 99 54.7 81 49.7 White 221 7.6 228 7.9 99 45.8 106 47.5 By ethnicity Hispanic or Latino 28 9.2 23 7.6 15 55.6 11 47.8 Non-Hispanic or Latino 385 8.0 371 7.8 183 49.5 176 48.5 By SES Less than the median 227 8.9 198 7.9 118 54.9 99 50.5 Greater than the median 186 7.3 196 7.8 80 44.0 88 46.3

Median age = 14.58; median SES z score = 0.40.

TABLE 3 Endorsement of Thoughts of Death or Dying

Thoughts of Death or Dying

Adolescent Yes Parent Yes Adolescent Yes; Parent No (Unawareness)

Parent Yes; Adolescent No (Denial)

N % N % N % N %

Whole sample 786 15.4 577 11.5 571 75.6 382 67.5 By age Less than the median 322 12.8 278 11.2 241 76.5 196 72.6 Greater than the median 464 17.9 299 11.9 330 75.0 186 62.8 By sex Boys 379 15.6 286 12.0 275 74.9 183 66.5 Girls 407 15.2 291 11.1 296 76.3 199 68.4 By race Racial minority 343 15.6 210 9.8 267 81.9 147 71.4 White 443 15.2 367 12.8 304 70.9 235 65.3 By ethnicity Hispanic or Latino 45 14.8 37 12.3 27 64.3 22 59.5 Non-Hispanic or Latino 741 15.4 540 11.5 544 76.3 360 68.1 By SES Less than the median 430 16.8 276 11.1 319 77.1 176 64.9 Greater than the median 356 14.0 301 12.0 252 73.9 206 69.8

Median age = 14.58; median SES z score = 0.40.

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in older boys. Race and ethnicity were associated with reporter discrepancies. The odds of parental unawareness and adolescent denial of thoughts of death were higher for racial minority adolescents relative to white adolescents. Hispanic or Latino ethnicity was associated with decreased odds of parental unawareness of thoughts of death. Finally, fathers were more likely to be unaware of adolescents’ thoughts of killing themselves than mothers.

Clinical Characteristics

Adolescents’ psychiatric treatment history (eg, psychotherapy) and family history of suicide were associated with decreased odds of parental unawareness (Tables 4 and 5). For adolescent denial, there was a large effect of psychopathology. More severe psychopathology was associated with decreased odds of adolescent denial of both thoughts of killing self and thoughts of death. In addition, a history of psychiatric hospitalization was associated with decreased odds of adolescent denial of thoughts of killing self.

DISCUSSION

Research to date has revealed substantial reporter discrepancies in the assessment of suicidal thoughts, 8, 9 indicating that a large number of adolescents at risk for suicide may go undetected in real-world health care settings. In general, this research has focused mostly on clinical or high-risk youth, the samples have been relatively small, and there has been limited exploration of factors associated with agreement. Therefore, our goal in the current study was to conduct the largest investigation to date of agreement between parent and adolescent reports of adolescents’ suicidal thoughts in a well-characterized, community-based sample and to identify demographic and clinical factors associated with agreement.

Disagreement, Unawareness, and Denial

Similar to previous research, rates of agreement in this study were low to moderate, 21, 30 with better agreement about thoughts of killing self than about thoughts of death. Alarmingly, ∼75% of parents were unaware of thoughts about death, and 50% of parents were unaware of thoughts about suicide that were reported by their adolescents. Interestingly, we also identified numerous dyads in which the parent reported suicidal thoughts that the adolescent did not endorse. Overall, there has been a paucity of research examining adolescents’ “denial” of suicidal thoughts endorsed by parents, and this study advances our understanding of this phenomenon.

Factors Associated With Agreement

Demographics

Adolescent age emerged as an important demographic factor: older

age was associated with decreased odds of both parental unawareness and adolescent denial. This indicates that younger adolescents may be more likely to go unnoticed and not receive services either because their parents are unaware of their suicidal thoughts or because they deny suicidal thoughts that their parents think they are having. It is also possible that younger adolescents have interpretative difficulties with questions about suicidal ideation and thoughts of death, resulting in low reporter agreement. If this is the case, extra attention may be warranted in research and clinical settings to ensure that younger adolescents fully understand questions about suicidal thoughts. These age findings are particularly noteworthy in light of recent evidence that deaths by suicide have increased among younger adolescents.31 We also found a significant age-by-sex interaction. Follow-up analyses revealed that

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TABLE 4 Logistic Regression Analyses of Factors Associated With Parental Unawareness

Thoughts of Death or Dying Thoughts of Killing Self

OR CI OR CI

Demographics Age 0.76* (0.59–0.99) 0.74** (0.55–1.01) Sex (girl = ref) 0.87 (0.61–1.24) 0.83 (0.53–1.30) Age × sex 1.70* (1.19–2.45) 1.63* (1.04–2.54) Race (white = ref) 2.48* (1.44–0.4.30) 1.44 (0.80–2.60) Hispanic (no = ref) 0.48* (0.24–0.95) 1.23 (0.54–2.80) SES 1.14 (0.87–1.49) 1.01 (0.75–1.37) Collateral relation (mother = ref) Father 1.68 (0.89–3.16) 2.91* (1.41–6.00) Other 1.50 (0.42–5.33) 0.81 (0.29–2.29)

χ2 (8) = 31.53*

χ2 (8) = 17.57*

n = 755 n = 397 Clinical factors Psychopathology severity 0.68 (0.42–1.11) 0.83 (0.43–1.58) Family history of suicide 0.50* (0.30–0.85) 0.63 (0.34–1.17) Psychoactive medications 0.73 (0.47–1.13) 0.49* (0.29–0.83) Psychotherapy 0.43* (0.27–0.67) 0.29* (0.15–0.58) Hospitalization 0.31* (0.17–0.57) 0.15* (0.07–0.32) Trauma exposure (no trauma = ref) Assaultive 1.24 (0.73–2.11) 0.99 (0.53–1.87) Nonassaultive 1.15 (0.75–1.76) 1.10 (0.63–1.93)

χ2 (7) = 70.29*

χ2 (7) = 97.61*

n = 730 n = 379

Higher scores indicate higher SES; n, sample size for each analysis. CI, 95% confidence interval; OR, odds ratio; ref, reference group. * P < .05; ** P = .059.

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parental unawareness of thoughts of death are decreased in older adolescent girls but increased in older boys. This interaction could reflect sex differences in the trajectory of depressive symptoms in which symptoms spike among midadolescent girls relative to boys.32 The surge in symptoms in girls may make thoughts of death more salient to their parents. The above findings suggest a need for age- and sex-specific strategies for facilitating adolescent disclosure and parental awareness of suicidal thoughts.

Parents of racial minority adolescents were more likely to be unaware of thoughts of death and to report thoughts of death that the adolescent denied. However, Hispanic parents were more aware of their adolescents’ thoughts of death. These results are consistent with a recent study that revealed greater

parent-adolescent discrepancies in reports of suicidal ideation among African American and Asian American families compared with European American and Hispanic Americans families.24 These findings, combined with results indicating that racial minorities are less likely to use health care services before a suicide attempt, 33 highlight the importance of taking racial and cultural differences into account when assessing suicide risk and implementing prevention programs.

Fathers were less aware of adolescents’ thoughts of killing themselves than mothers. These findings are consistent with research revealing that adolescents are less likely to disclose personal information to fathers than mothers34 and that fathers possess less “parental knowledge” about their adolescents than mothers.35, 36

Clinical Characteristics

In general, our findings suggest that a history of youth behavioral health treatment is associated with greater parental awareness of suicidal thoughts. For instance, parents were more likely to be aware of their adolescents’ thoughts of both death and killing self when the adolescents had a history of being in therapy or psychiatric hospitalization. Additionally, history of psychotropic medication usage was associated with increased parental awareness of adolescents’ thoughts of suicide. Given the cross-sectional design, it is not possible to definitively determine the direction of effects. It is possible that parents become aware of suicidal thoughts, which may lead them to seek treatment of their adolescents. Conversely, involvement in behavioral health care could uncover previously unknown suicidal thoughts or increase parents’ knowledge about and attention to adolescents’ suicidal thoughts.

Family history of suicide attempts or completions was associated with increased parental awareness of thoughts of death. To our knowledge, there has not been any previous research examining how family history of suicide relates to reporter agreement about suicidal thoughts. However, studies have examined the role of family history of mood disorders in reporter agreement about suicidal thoughts.9, 10, 24 The results of these studies have been mixed. Additional attention to family history of suicide is warranted to corroborate the present findings.

Regarding adolescent denial of suicidal thoughts, we found a large effect of adolescent psychopathology severity. Specifically, greater psychopathology was associated with less denial of both thoughts of death and thoughts of killing self. A study of a sample of adolescents who were hospitalized also revealed that youth with greater externalizing symptoms were less likely to deny

JONES et al6

TABLE 5 Logistic Regression Analyses of Factors Associated With Adolescent Denial

Thoughts of Death or Dying Thoughts of Killing Self

OR CI OR CI

Demographics Age 0.69* (0.53–0.89) 0.65* (0.48–0.88) Sex (girl = ref) 0.82 (0.57–1.19) 1.28 (0.83–1.95) Age × sex 1.31 (0.91–1.88) 1.50 (0.98–2.30) Race (white = ref) 1.85* (1.08–3.17) 1.17 (0.65–2.13) Hispanic (no = ref) 0.65 (0.32–1.31) 0.88 (0.36–2.12) SES 1.29 (0.99–1.69) 0.99 (0.73–1.33) Collateral relation

(mother = ref) Father 1.41 (0.71–2.79) 1.07 (0.45–2.52) Other 2.37 (0.66–8.53) 0.40 (0.10–1.57)

χ2 (8) = 20.56* χ2 (8) = 15.11* n = 566 n = 386

Clinical factors Psychopathology severity 0.08* (0.05–0.14) 0.08* (0.04–0.16) Family history of suicide 0.92 (0.50–1.67) 1.17 (0.64–2.16) Psychoactive medications 1.43 (0.88–2.33) 1.39 (0.82–2.34) Psychotherapy 1.24 (0.72–2.16) 0.69 (0.30–1.61) Hospitalization 0.75 (0.41–1.38) 0.35* (0.19–0.63) Trauma exposure (no

trauma = ref) Assaultive 0.93 (0.51–1.70) 0.76 (0.39–1.50) Nonassaultive 0.95 (0.59–1.52) 1.59 (0.90–2.80)

χ2 (7) = 129.94* χ2 (7) = 114.40*

n = 546 n = 376

CI, 95% confidence interval; OR, odds ratio; ref, reference group, higher scores indicate higher SES; n, sample size for each analysis. * P < .05; ** P = .057.

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suicidal ideation reported by a parent.9 Yet, in a large study of children who were maltreated, aggression and social withdrawal were associated with increased child denial of suicidal ideation reported by a parent.11 Differences in sample characteristics and the assessment of suicidal thoughts could account for the discrepant findings. In the present community-based sample of adolescents, it is possible that those adolescents with more severe psychological difficulties have been involved in behavioral health treatment and are more familiar with clinical assessment and, as a result,

are more comfortable disclosing suicidal thoughts than adolescents with less severe psychopathology.

Limitations

First, the PNC includes families presenting in pediatric settings in one geographic area. It is unclear whether the present findings would generalize to the larger population or to clinical samples. Second, to assess thousands of families in a short period of time, our assessment of suicidal thoughts was brief. In addition, the questions we asked were about lifetime suicidal thoughts and could be

susceptible to recall bias. Future research could include a more detailed, multimethod assessment that covers both current and lifetime suicidal thoughts as well as plans and attempts. Third, the prevalence of suicidal ideation reported in this study (8%) is lower than that reported in a national survey of youth (18%).3 This could possibly be due to our inclusion of younger adolescents (11–17 years), whereas the national survey was focused on high school students. Another possibility is that the mode of assessment used in this study (in-person interview)

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FIGURE 1 Age by sex interaction for parental unawareness of thoughts of killing self.

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affected the disclosure of suicidal thoughts. Research indicates that the prevalence of suicidal thoughts is higher in studies that use youth self-report questionnaires (as in the national survey) relative to face-to- face interviews.10 Fourth, thoughts of death or dying may encompass a wide range of youth ideation, some of which may not be related to suicide risk. Fifth, this study was focused on parent-adolescent agreement about adolescents’ suicidal thoughts. However, there are other individuals that adolescents might confide in, such as peers or other trusted adults.

Further examination of the role of nonparental figures is warranted and could reveal other important collateral informants that should be included in suicide screenings.

CONCLUSIONS

The findings from the current study have important clinical implications for pediatric settings, especially in light of growing endorsement of depression screening initiatives in pediatric primary care.37, 38 Given the high prevalence of parental unawareness and adolescent denial of suicidal thoughts found in this study,

it is possible that a large number of adolescents with suicide risk may not be detected by brief screens at routine check-ups. This highlights the urgent need for continued training of pediatric primary care physicians in the evaluation and management of suicidal ideation and the importance of collecting information from multiple informants and rectifying discrepant reports. In addition, the current study identified several demographic and clinical characteristics that may increase or decrease the risk of parental unawareness and adolescent denial of suicidal thoughts. Increasing awareness of these factors could

JONES et al8

FIGURE 2 Age by sex interaction for parental unawareness of thoughts of death or dying.

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aid clinicians in creating a more personalized approach to suicide risk assessment. The early identification and treatment of youth at risk for suicide depends on reliable and valid assessment of suicide risk. The present findings indicate the need for thorough, multi-informant screening of suicide risk in pediatric populations

that is informed by research on factors that might increase or decrease the reliability of assessments.

ACKNOWLEDGMENTS

We thank the participants of this study and all the members of the recruitment, assessment, and data teams whose individual

contributions collectively made this work possible.

PEDIATRICS Volume 143, number 2, February 2019 9

Address correspondence to Jason D. Jones, PhD, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 8th Floor, 2716 South St, Philadelphia, PA 19146. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Barzilay serves on the scientific board and reports stock ownership in Taliaz Health, unrelated to this work; the other authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by the National Institutes of Health (RC2 MH089983 and MH089924; K08MH079364; National Institute on Drug Abuse supplement to MH089983), the Dowshen Program for Neuroscience, and the Lifespan Brain Institute of Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine. Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3071.

ABBREVIATIONS

PNC:  Philadelphia Neurodevelopmental Cohort

SES:  socioeconomic status

REFERENCES

1. Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL; Centers for Disease Control and Prevention. Suicide trends among persons aged 10-24 years– United States, 1994-2012. MMWR Morb Mortal Wkly Rep. 2015;64(8):201–205

2. Drapeau CW, McIntosh JL. USA suicide 2016: official final data. Washington, DC: American Association of Suicidology; 2017. Available at: https:// www. suicidology. org/ Portals/ 14/ docs/ Resources/ FactSheets/ 2016/ 2016datapgsv1b. pdf? ver= 2018- 01- 15- 211057- 387. Accessed December 6, 2018

3. Kann L, McManus T, Harris WA, et al. Youth risk behavior surveillance - United States, 2015. MMWR Surveill Summ. 2016;65(6):1–174

4. Reinherz HZ, Tanner JL, Berger SR, Beardslee WR, Fitzmaurice GM. Adolescent suicidal ideation as predictive of psychopathology, suicidal behavior, and compromised functioning at age 30. Am J Psychiatry. 2006;163(7):1226–1232

5. Zhang X, Wu LT. Suicidal ideation and substance use among adolescents and young adults: a bidirectional relation? Drug Alcohol Depend. 2014;142:63–73

6. Husky MM, Olfson M, He JP, Nock MK, Swanson SA, Merikangas KR. Twelve- month suicidal symptoms and use of services among adolescents: results from the National Comorbidity Survey. Psychiatr Serv. 2012;63(10):989–996

7. Stiffman AR, Pescosolido B, Cabassa LJ. Building a model to understand youth service access: the gateway provider model. Ment Health Serv Res. 2004;6(4):189–198

8. Breton JJ, Tousignant M, Bergeron L, Berthiaume C. Informant-specific correlates of suicidal behavior in a community survey of 12- to 14-year- olds. J Am Acad Child Adolesc Psychiatry. 2002;41(6):723–730

9. Klaus NM, Mobilio A, King CA. Parent- adolescent agreement concerning adolescents’ suicidal thoughts and behaviors. J Clin Child Adolesc Psychol. 2009;38(2):245–255

10. Klimes-Dougan B. Screening for suicidal ideation in children and adolescents: methodological considerations. J Adolesc. 1998;21(4):435–444

11. Thompson R, Dubowitz H, English DJ, et al. Parents’ and teachers’ concordance with children’s

self-ratings of suicidality: findings from a high-risk sample. Suicide Life Threat Behav. 2006;36(2):167–181

12. Calkins ME, Merikangas KR, Moore TM, et al. The Philadelphia Neurodevelopmental Cohort: constructing a deep phenotyping collaborative. J Child Psychol Psychiatry. 2015;56(12):1356–1369

13. Moore TM, Martin IK, Gur OM, et al. Characterizing social environment’s association with neurocognition using census and crime data linked to the Philadelphia Neurodevelopmental Cohort. Psychol Med. 2016;46(3):599–610

14. Calkins ME, Moore TM, Satterthwaite TD, et al. Persistence of psychosis spectrum symptoms in the Philadelphia Neurodevelopmental Cohort: a prospective two-year follow-up. World Psychiatry. 2017;16(1):62–76

15. Barzilay R, Calkins ME, Moore TM, et al. Association between traumatic stress load, psychopathology, and cognition in the Philadelphia Neurodevelopmental Cohort [published online ahead of print April 15, 2018]. Psychol Med. doi: 10. 1017/ S0033291718000880

by guest on January 28, 2019www.aappublications.org/newsDownloaded from

16. White LK, Moore TM, Calkins ME, et al. An evaluation of the specificity of executive function impairment in developmental psychopathology. J Am Acad Child Adolesc Psychiatry. 2017;56(11):975–982.e3

17. Jones JD, Calkins ME, Scott JC, Bach EC, Gur RE. Cannabis use, polysubstance use, and psychosis spectrum symptoms in a community- based sample of U.S. youth. J Adolesc Health. 2017;60(6):653–659

18. Joo SH, Wang SM, Kim TW, et al. Factors associated with suicide completion: a comparison between suicide attempters and completers. Asia-Pac Psychiatry. 2016;8(1):80–86

19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Oxford, United Kingdom: Oxford University Press; 2013

20. Angold A, Weissman MM, John K, et al. Parent and child reports of depressive symptoms in children at low and high risk of depression. J Child Psychol Psychiatry. 1987;28(6):901–915

21. Velez CN, Cohen P. Suicidal behavior and ideation in a community sample of children: maternal and youth reports. J Am Acad Child Adolesc Psychiatry. 1988;27(3):349–356

22. Wagner JL, Smith G, Ferguson P. Self- efficacy for seizure management and youth depressive symptoms: caregiver and youth perspectives. Seizure. 2012;21(5):334–339

23. Lewis AJ, Bertino MD, Bailey CM, Skewes J, Lubman DI, Toumbourou JW. Depression and suicidal behavior in adolescents: a multi-informant and

multi-methods approach to diagnostic classification. Front Psychol. 2014;5:766

24. Kim J, Chan YF, McCauley E, Stoep AV. Parent-child discrepancies in reporting of child depression in ethnic groups. J Nurse Pract. 2016;12(6):374–380

25. Maxwell ME. Manual for the Family Interview for Genetic Studies. Bethesda, MD: Clinical Neurogenetics Branch, Intramural Research Program, National Institute for Mental Health; 1996

26. Boeninger DK, Masyn KE, Feldman BJ, Conger RD. Sex differences in developmental trends of suicide ideation, plans, and attempts among European American adolescents. Suicide Life Threat Behav. 2010;40(5):451–464

27. Graham JW. Missing data analysis: making it work in the real world. Annu Rev Psychol. 2009;60:549–576

28. Schafer JL. Multiple imputation: a primer. Stat Methods Med Res. 1999;8(1):3–15

29. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–174

30. Althoff RR, Rettew DC, Ayer LA, Hudziak JJ. Cross-informant agreement of the dysregulation profile of the child behavior checklist. Psychiatry Res. 2010;178(3):550–555

31. Curtin SC, Warner M, Hedegaard H. Increase in Suicide in the United States, 1999–2014. NCHS Data Brief, No 241. Hyattsville, MD: National Center for Health Statistics; 2016

32. Hankin BL, Young JF, Abela JRZ, et al. Depression from childhood into late

adolescence: influence of gender, development, genetic susceptibility, and peer stress. J Abnorm Psychol. 2015;124(4):803–816

33. Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. Med Care. 2015;53(5):430–435

34. Smetana JG, Metzger A, Gettman DC, Campione-Barr N. Disclosure and secrecy in adolescent- parent relationships. Child Dev. 2006;77(1):201–217

35. Jones JD, Ehrlich KB, Lejuez CW, Cassidy J. Parental knowledge of adolescent activities: links with parental attachment style and adolescent substance use. J Fam Psychol. 2015;29(2):191–200

36. Waizenhofer RN, Buchanan CM, Jackson-Newsom J. Mothers’ and fathers’ knowledge of adolescents’ daily activities: its sources and its links with adolescent adjustment. J Fam Psychol. 2004;18(2):348–360

37. Siu AL; US Preventive Services Task Force. Screening for depression in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2016;137(3):e20154467

38. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D; GLAD-PC Steering Group. Guidelines for adolescent depression in primary care (GLAD-PC): part I. Practice preparation, identification, assessment, and initial management. Pediatrics. 2018;141(3):e20174081

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