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STRESS, SELF-ESTEEM, AND SUICIDAL IDEATION IN LATE ADOLESCENTS Victor R. Wilbum and Delores E. Smith

ABSTRACT

The relationships among stress, self-esteem, and suicidal ideation in late adolescents were examined in a group of college students. Multiple regression analysis indicated that both stress and self-esteem were significantly related to suicidal ideation; low self-esteem and stressful life events significantly predicted suicidal ideation. The hypothesis that self-esteem would moderate the effects of life stressors on suicidal ideation was supported at the .06 level. A significant minority of the sample indicated having thoughts severe enough to be classified as clinical suicidal ideation. In general, participants who had experienced negative life events in the 6 to 12 months prior to participating in the study had lower self-esteem than those who had similar stresses within the prior six months. However, the opposite was true for clinical suicidal ideators; those who experienced negative life stressors recently had lower selfesteem than those who experienced negative life events six months to a year in the past. Adolescent svdcide is a worldwide problem, but it is of particular

concern in highly industrialized nations such as the United States (Conner, Duberstein, Conwell, Seidlitz, & Caine, 2001); Kurtz & Derevensky, 1993). The suicide rate in the United States has tripled since 1960, making it the third leading cause of death among adolescents and the second leading cause of death among the college-age population (National Mental Health Association, 1997). Although it is estimated that approximately 14 adolescents in the United States commit suicide each day, the actual number is two to three times higher (American Psychiatric Association, 1996; 1998). Understandably, these aleirming statistics have stimulated great concern in the public at large and have led social scientists to warn of an impending rise in the number of suicides and suicidal attempts among adolescents (Berman & Jobes, 1994; Griffiths, Farley, & Fraser, 1986; Watt & Sharp, 2002). Much of the research literature appears to be focused on suicide per se. However, professionals are increasingly paying attention to

Reprint requests to Victor R. Wilbum, 215 Schrank Hall South, University of Akron, Akron, OH 44325-6103; email: [email protected]

ADOLESCENCE, Vol. 40, No. 157, Spring 2005 Libra Publishers, Inc., 3089C Clairemont Dr., PMB 383, San Diego, CA 92117

the antecedent behaviors. According to Bush and Pargament (1995), suicidal behavior is often preceded by thoughts, threats, and unsuccessful attempts at suicide. Similarly, Cole, Protinsky, and Cross (1992) noted that suicide was the completed process of a continuum that began with suicidal ideation, followed by an attempt at suicide, andfinallycompleted suicide. Suicidal ideation is a preoccupation with intrusive thoughts of ending one's own life (Cole, Protinsky, & Cross, 1992; Harter, Marold, & Whitesell, 1992) while suicide is the completed act of taking ones life (National Mental Health Association, 2002). Because of this progression from thought to action, it is fitting that researchers explore the notion of suicidal ideation in greater depth. The current study examined the phenomenological relationship among stress, self-esteem, and suicidal ideation in adolescents. Much of the research to date has focused on the associations of stress and self-esteem to actual suicide but not to ideation. Moreover, the majority of studies have examined the relationships in clinical populations. Thus, we know little about the associations of these processes in nonclinical populations. The present study investigated the relationship among cumulative negative life experiences (stress), self-esteem, and suicidal ideation in a nonclinical population of college students. Selye (1974) defined stress as a response of the hioman body to any stimulus that disrupts the individual's homeostasis. Because these responses are unavoidable, individuals are faced with the constant urge to maintain internal balance. Accordingly, any experience that affects one's homeostasis is considered to be stress (Rice, 1992). Social scientists have expanded Hans Selye's notion of physiological stress to include social, cognitive, and psychological or mental stress. MuUis, Youngs, MuUis, and Rathge (1993) proposed that stress is a function of an individual's appraisal of a life stressor and therefore, a cognitive process. Similarly, Lazarus (1993) contended that the extent to which individuals experience stress is determined by their subjective evaluations of their experiences. Therefore, if individuals appraise an event as traumatic, they vsdll experience more stress from the experience than will individuals who appraise the event as nonsignificant. Researchers (e.g., Bartle-Haring, Rosen, & Stith, 2002; Ferrer-Wreder, Lorente, Kurtines, Briones, Bussell, Berman, & Arrufat, 2002) have noted the importance of reducing stress by helping youth develop positive perceptions of the self in order to avoid catastrophic socioemotional outcomes such as suicidal behavior. Indeed, exposure to stress by youth has been linked to severe emotional and psychological problems (Bartle-Haring, Rosen, & Stith, 2002; Gonzales, Tein, Sandier, & Friedman, 2001), a known precursor to suicide (Teen suicide, 1998).

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Stress and Suicidality The search for identity, a naturally stressful demand on youth can be overwhelming to some adolescents and predispose them to thoughts of suicide (Teen suicide, 1998). Hence, the high incidence of adolescent suicide is assumed to be indicative of societal stress in the lives of young people (Griffiths, Farley, & Fraser, 1986; Turner, Kaplan, Zayas, & Ross, 2002). Several studies (e.g., Adams, Overholser, & Spirito, 1994; Clum & Febbraro, 1994; Peck, 1989; Simonds, McMahon, & Armstrong, 1991) have found that suicide attempts among adolescents do tend to increase as stress levels increase. Academic pressure, workrelated problems, interpersonal difficulties, death of loved ones, illnesses, and loss of relationships have been found to be significant stressors on young people (Butler, Novy, Gagan, & Gates, 1994; Kurtz & Derevensky, 1993; Mullis, Youngs, Mullis, & Rathge, 1993). Petzel and Riddle (1981) maintained that a poor or an overachieved academic performance can serve as a precursor to stress, subsequent depression, and suicidality. Henry, Stephenson, Hanson, and Heirgett (1993) reported that serious suicide attempts seem to be higher among students who experience considerable academic success and less serious suicide attempts more indicative of students who are failing at school. Those researchers argued that academically successful students experience greater amounts of stress than do their less successful peers because more successful students feel more pressure to maintain their level of performance. This pressure may cause them to increase the lethality of their suicidal intent. However, students who have consistently exhibited a pattern of academic failure may simply engage in risk-taking behaviors (e.g., criminal acts, risky sexual activity) that predispose them to suicidality. On the other hand, Petzel and Riddle (1981) observed that the majority of suicidal students in both high school and college are receiving passing scores in their academic classes, an indication that academic performance is not the only significant factor that contributes to the occurrence of suicide. Self-esteem Self-esteem, the evaluations individuals make about the self (Harter et al., 1992), is shaped by individuals' appraisals of how they are perceived by significEint others (Sullivan, 1953). Therefore, the quality of feedback received from the environment significantly affects ones functioning. As such, negative feedback about the self, is detrimental to the self-esteem (Sullivan, 1953). Thus, it would be logical to assume that self-esteem is a powerful resource for combatting the effects of stress and suicidal ideation.

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Researchfindingshave indicated an inverse correlation between life stressors and self-esteem (Abramson, Metalsky, & Alloy, 1989; Garber, Robinson, & Valentiner, 1997; Kliewer & Sandier, 1992). Specifically a negative self-esteem predisposes adolescents to depression and other psychiatric difficulty (Garber, Robinson, & Valentiner, 1997; He5Tnan, Dweck, & Cain, 1992). Therefore, it is conceivable that positive selfesteem enhances one's ability to cope effectively with stress because individuals with poor coping mechanisms are more vulnerable to environmental stressors (Simonds, McMahon, & Armstrong, 1991). In this study, the association between adolescent stress, self-esteem, and suicidal ideation was examined. As noted earlier, in the past the focus of this type of research has been on clinical samples (i.e., people diagnosed as suffering from psychiatric illnesses) (Adams, Overholser, & Spirito, 1994; Asamow, 1992; Bush & Pargament, 1995). In many cases, participants are solicitedfromgroups who are undergoing treatment as a result of a recent suicidal episode. It is important to examine suicidality in nonclinical groups because of the growing number of attempts and completions at suicide among adolescents in the general population (Teen Suicide, 1998).

METHOD

Participants Data were collected from 88 students at a human sciences college in a large land-grant university in the southern region of the United States. The sample consisted of 79 females (90%) and 9 males (10%) ranging in age from 18 to 34 years (M = 21 years; SD = 1.73) and mostly Caucasian (90%).

Procedure

Volunteer participants were informed about the purpose of the study and of their rights and expectations. They were then presented with a survey package consisting of three questionnaires (The Life Experiences Survey, the Rosenberg Self-esteem Scale, and the Suicidal Ideation Questionnaire), and a letter explaining the nature of the study. A referral sheet containing a list of local organizations that provided counseling services was also included. Students who chose to participate were instructed to complete the questionnaires as honestly and thoroughly as possible, and to ensure anonymity, to provide no identifying marks on the surveys. Finally, they were instructed to return the completed surveys to a designated place, instead of to a person, in the following class period. 36

Measures The Suicidal Ideation Questionnaire (SIQ) (Reynolds, 1987). The SIQ is a self-administered 25-item measure designed to assess an individual's preoccupation with thoughts of suicide. The measure, set on a 6-point Likert-type scale, requires individuals to indicate the frequency with which they have suicidal thoughts selecting from the following choices: I never had this thought (0); I had this thought hefore but not in the past month (1); Almost once a m.onth (2); Couple of times a month (3); About once a week (4); Couple of times a week (5); Almost every day (6). The responses are summed to determine possible scores ranging from 0 to 150, with higher scores indicating a greater disposition for suicidal ideation. The SIQ also determines whether the individual thinks about suicide to the degree that clinical intervention is indicated. For example, a participant who obtains a cumulative score of 24 or greater on the SIQ is considered a candidate for further psychological evaluation and intervention. To this end, the SIQ includes five thoughts that serve as indicators of clinical suicidality: (I thought about killing myself; I thought about how I would kill myself; I thought about when I would kill myself; I thought that if I had the chance I would Mil myself; 1 thought about ways people kill themselves. If a participant reported experiencing any of the five thoughts at least a couple of times per week, this would serve as an indication that further psychological evaluation and intervention should occur, regardless of the SIQ total score. The instrument is well known in the social sciences and has been foimd to have a high internal consistency reliability (coefficient alpha = .96) and a moderate to high level of test-retest reliability (r = .86). The instrument correlates highly with the Heimilton Depression Rating Scale (r = .92) (Reynolds, 1987). Life Experiences Survey (LES) (Sarason, Johnson, & Siegel, 1978). The LES is a 60-item instrument designed to measure stressful life events and the importance of life experiences across time of experience. For each event, respondents indicate whether the event occurred within the last six months (1 to six months) or within the last 6 to 12 months; the stressful outcomes are designated as acute and chronic, respectively. The LES assesses the type of appraisal of the life experiences (positive, negative, or total) and evaluates the individual's response patterns. The measure is set on a 7-point Likert-type scale anchored by - 3 (extremely negative) and 3 (extremely positive). The rating of (0) on the scale indicates that the participant appraises the life experience as having no impact. Because positive life experiences do not cause the t3T)e of stress that can potentially lead to thoughts about suicide, only negative life experiences were used in the analysis

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for the present study. The test-retest reliability for the negative life changes on the life experiences survey have been reported to be .56 and .88 (p < .001), respectively (Sarason, Johnson, & Siegel, 1978). In addition, the measure shows significant correlations with other wellestablished psychological measures such as the Beck Depression Inventory, Internal-External Locus of control Scale, Holmes and Rahe Scale, and State-Trait Anxiety Inventory. Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965). The RSES is a 10-item instrument designed to assess adolescents' global feelings of self-worth. The instrument is set on a 4-point Likert-type scale with response choices ranging from "strongly agree" (1) "strongly disagree" (4). The measure possesses good reliability (.85) and confirmed face and convergent validity have been reported. The RSES has been purported to be the standard against which new self-esteem measures are evaluated (Robinson, Shaver, & Wrightsman, 1991).

RESULTS

Pearson's product-moment correlation was computed to determine the linear relationships among suicidal ideation, negative stress, and self-esteem. The intercorrelations showed significance between suicidal ideation and self-esteem (r = -42, p < .001), suicidal ideation and negative stress (r = .33, p < .002), and negative stress and selfesteem (r = -.35, p < .001) (Table 1). These correlations indicated that as self-esteem increased, stress and suicidal thoughts decreased; as stress increased, suicidal thoughts increased. A significant minority of the sample (12%) indicated that they were clinical suicidal ideators. A stepwise multiple regression analysis was performed to examine the extent to which negative Ufe stressors and self-esteem contributed to the variability on suicidal ideation. The minimal requirement for the variables to be entered into a regression equation was p = .05. Results indicated that negative stress and self-esteem were significant predictors of suicidal ideation; together they explained 22% of the variation in suicidal ideation (R^ = .22, p < .001). Simple linear regressions were also conducted to determine whether self-esteem and negative stress were independently predictive of suicidal ideation. Self-esteem and negative stress each accounted for 11% of the predictability on suicidal ideation (Table 2). However, when the degree of shared explainability between the independent variables (stress and self-esteem) was controlled, negative stress added only 3% of the explainability of suicidal ideation. Therefore, self-esteem appeared to be a stronger predictor of suicidal ideation than did stress. Further, the

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Table 1 Correlations Among Predictor and Criterion Variables Life Stressors Life Stressors Self-esteem Suicidal Ideation Self-esteem -.35** Suicidal Ideation .33* -.42*** -

Note. Standard beta = .21 for life stressors and .35 for self-esteem. *p < .01, **p < .001, ***p < .0001 Table 2 Results of Stepwise Regression for Prediction of Suicidal Ideation Predictor Variable Life Stressors Self-esteem Interaction Partial R^ .108 .108 .190 F 10.3 11.5 7.7 df 1 2 3 P .0019 .0011 .6525

study examined whether self-esteem moderated the effects of perceived negative stress on suicidal ideation. Regression analysis revealed a nonsignificant interactional effect (Table 2), indicating that self-esteem did not seem to moderate the effect of stress on suicidal ideation. Data distinguished between life stressors that occurred within the last six months (acute stress) and those that occurred prior to the last six months (chronic stress). T-tests indicated a significant difference it = 2.61, p < .01) in the mean number of acute and chronic stressful life events. Mean scores between were (M = 1.9; SD = 2.40; M = 2.81; SD = 2.6), respectively. 39

The correlations between self-esteem and acute and chronic negative stressors were examined to determine if lower self-esteem related differently to the two t3T)es of stressors. Significant negative relationships were found between self-esteem and both t5T)es of stressors (r = .29, p < .01 and r = .22, p < .05), respectively. The association between suicidal ideation and acute and chronic stress were also assessed. No significant correlation was found between acute stress and suicidal ideation but there was a significant correlation between chronic stress and suicidal ideation (r = .21, p < .05). However, when the data were adjusted to determine the correlational relationship between stress and clinical suicidal ideators, a significant effect (r = .25, p = .05) was found between acute stress and clinical suicidal ideators, but no relationship was found between chronic stress and clinical ideators. This suggested that individuals who experience more acute stressful events were more likely to experience clinical suicidal ideation than were those who experienced chronic stressors.

DISCUSSION

The purpose of this study was to determine the relationships among stress, self-esteem, and suicidal ideation. Majorfindingsare as follows: (a) negative stress and self-esteem significantly predicted suicidal ideation, (b) self-esteem did not moderate the effects of negative stress on suicidal ideation, and (c) 12% of the sample were clinical suicidal ideators. A significant degree of covariance between self-esteem and negative life experiences in the prediction of suicidal ideation was found; but self-esteem explained a greater degree of variability of suicidal ideation than did stress. However, little is known regarding the participants' coping styles and other available resources. This study could be improved by including variables such as the quality of an individual's coping strategies and the availability of external resources to deal with life processes. It is quite possible that factors such as coping strategies and social support systems could alleviate stress and hence, thwart the feelings of hopelessness that could lead to thoughts of suicide. For example, past research has established a link between adolescents' stress and family support, and between family support and self-esteem. The stress adolescents experience when their support from family is perceived to be low can significantly lower their self-esteem and increase the level of stress and risk of suicide. Researchers have found that adolescents who perceived their family as uncaring, distant, and

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controlling had a higher likelihood of committing suicide (Turner, Kaplan, Zayas, & Ross, 2002). Furthermore, Olvera (2001) reported a significant relationship between family problems and suicidal ideation. Therefore, it is logical to assume that family support would be a powerful resource for combatting stress and ultimately thoughts of suicide. In addition, clearer results could be attained by implementing a lifestressor instrument that addresses issues more specific to negative life experiences among adolescents. For example, the instrument might incorporate items that related to negative stressors based on academic achievement, economic resource availability, social and interpersonal relationships, and family and life transitions. In such an instrument, individuals would be asked to identify which items have a negative impact on them and the extent to which they have been affected. Chronic life experiences had a stronger negative effect on self-esteem than did acute stress. However, when clinically suicidal ideation was controlled for, acute stress was more detrimental for those falling into the category of clinical suicidal ideation. One explanation for the finding could be that acute stress is more powerful than chronic stress; it is not until individuals experience stressful life events for more than six months that self-esteem becomes taxed. The fact that this hypothesis (adolescents who are low suicidal ideators will perceive life experiences more acutely) was confirmed when looking at the clinical suicidal ideators, is an indication that self-esteem may very well serve as a buffer between life stressors and suicidal ideation, especially when looking at the clinical suicidal ideators. Further research is needed to confirm this view. This seems to suggest that self-esteem is an important factor for helping persons deal with life stressors. In addition, self-esteem can become extremely taxed over long periods of dealing with a life stressor which may impede the ability to cope with a particular stressor. However, the strong correlation among low self-esteem, negative life stressors within a period of six months, and clinical suicidal ideation might be an indication that this hjnpothesis has validity with some individuals. Future studies should explore the relationship with a larger sample that falls into the category of clinical suicidal ideation. This study failed to support the hypothesis that positive selfesteem would moderate the effects of negative life stress during adolescence. However, it should be noted that the failure to support this hypothesis could be attributed to the fact that other variables, not assessed in this study, may affect the relationship. For example, feelings of hopelessness or poor quality of family and peer support also can be .factors in the relationship between self-esteem and life stressors. 41

Methodological issues may also play a role in this finding. The global nature of the self-esteem instrument used here may not be able to delineate discrete domains of self-esteem. A multidimensional self-esteem measure might be more powerful in assessing distinct relationships. For example, individuals might report relatively high academic self-esteem and a low measure of esteem related to perceptions of interpersonal or physical self. By incorporating multiple dimensions in examining self-esteem development, researchers can obtain a greater understanding of adolescents. Furthermore, 90% of the sample consisted of white females; therefore, generalization beyond this population is limited. This unequal gender distribution prevented us from examining whether females were more likely than males to experience more thoughts of suicide. Several studies (Berman & Jobes, 1994; Adams, Overholser, & Spirito, 1994; Teen Suicide, 1998) have noted distinct differences in the occurrence of suicidal behaviors, stress levels, and self-esteem. Also, Gibbs (1988) noted that suicide is an increasing problem among minority youth. However, other researchers (Bloch, 1999; Hoberman & Garfinkel, 1988) have noted that suicide statistics continue to reflect a preponderance of older adolescents who are Caucasian. Future studies should incorporate a more representative sample with respect to gender and race. A noteworthy point is that 12% of the individuals who reported thoughts of suicide could be classified as clinical suicidal ideators. This finding C£in serve to prompt both professionals and parents to be more cognizant of the emotional development of adolescents. Parents can strive to be more supportive and less critical of their children when they are under stress. Also, parents are in the unique position of helping adolescents build self-esteem and improve problem-solving and coping skills; in turn, this can help them deal with negative life stressors and reduce the occurrence of intrusive thoughts about suicide. Practitioners can provide more counseling services and alternative therapeutic interventions for students, especially when they detect unusual life strains--particularly in the college academic environment. It should also be noted that 86% of the sample reported that they had experienced thoughts of suicide at some time in their lives, but not to the point where special attention (counseling, medication, or hospitalization) might be needed, 13 percent in = 11) of whom could be classified as clinical suicide ideators. However, 14% (n = 12) reported that they had never experienced thoughts of suicide. Thus, the proportion of clinical suicidal ideators in this study is similar to the proportion who had never experienced thoughts of suicide. However, it

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is troubling that the majority of participants did report having suicidal thoughts. It is unclear whether this finding could be an indication that these individuals may eventually need intervention or whether thinking about suicide is a common occurrence in the lives of young people. Further research is necessary to better understand the factors that serve as catalysts in the transition from suicidal thoughts to suicidal acts. Future researchers could improve upon this study through qualitative research. It might be beneficial to conduct interviews with individuals who have never experienced suicidal thoughts, those who have clinically significant thoughts of suicide, and those who experience some thoughts but not to the point of acting on them. Individuals who have never experienced suicidal thoughts would serve as an appropriate baseline for comparing types of stressors, styles of coping, and the importance of self-esteem on suicidality. In addition, future studies should expand their investigation to adolescents and their family members.

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Clum, G. A., & Febbraro, G. A. (1994). Stress, social support, and problemsolving appraisal/skills: Prediction of suicide severity within a college sample. Journal of Psychopathology and Behavioral Assessment, 16(1), 69-83. Conner, K. R., Duberstein, P. R., Conwell, Y., Seidlitz, L., & Caine, E. D. (2001). Psychological vulnerability to completed suicide: A review of empirical studies. Suicide and Life-Threatening Behavior, 31(4), 353-385. Ferrer-Wreder, L., Lorente, C. C , Kurtines, W., Briones, E., Russell, J., Berman, S., & Amifat, O. (2002). Promoting identity development in marginalized youth. Journal of Adolescent Research, 17(2), 168-187. Garber, J., Robinson, N., & Valentiner, D. (1997). The relation betweren parenting and adolescent depression: Self-worth as a mediator. Journal of Adolescent Research, 12(1), 12-33. Gonzalez, N. A., Tein, J., Sandier, I. N., & Friedman, R. J. (2001). On the limits of coping: Interaction betweren stress and coping for inner-city adolescents. Journal of Adolescent Research, 16(4), 372-395. Griffiths, J. K., Farley, O. W., & Fraser, M. W. (1986). Indices of adolescent suicide. Journal of Independent Social Work, 1(1), 49-63. Harter, S., Marold, C , & Whitesell, N. (1992). Model of psychosocial risk factors leading to suicidal ideation in young adolescents. Development and Psychopathology, 4, 167-188. Henry, C , Stephenson, A., Hanson, M., & Hargett, W. (1993). Adolescent suicide and families: An ecological approach. Adolescence, 2S(110), 291-308. Heyman, G., Dweck, C , & Cain, K. (1992). Young children's vulnerability to sellF-blame and helplessness: Relationship to beliefs about goodness. Child Development, 63, 401-415. Hoberman, H. M., & Garfinkel, B. D. (1988). Completed suicide in children and adolescents. American Academy of Child and Adolescent Psychiatry, 27, 689-695. Lazarus, R. (1993). Why we should think of stress as a subset of emotions. Handbook of stress: Theoretical and clinical aspects (2nd ed.). New York: Free Press. Kliewer, W., & Sandier, L (1992). Locus of control and self-eteem as moderators o^ stressor symptom relations in children and adolescents. Journal f of Abnormal Child Psychology, 20(4), 240-248. Kurtz, L., & Derevensky, J. L. (1993). Stress and coping in adolescents: The effects of family configuration, and eivviroMaent otv suicidality. Can-adian Journal of School Psychology, 9(2), 204-216. Mullis, R. L., Youngs, G. A., Mullis, A. K., & Rathge, R. W. (1993). Adolescent stress: Issues of measurement. Adolescence, 2S(110), 267-279. National Mental Association (1997). Suicide. Retrieved November 19, 2002, from http://www.Nmha.org/infoctr/factsheets/82.cfm. Olvera, R. (2001). Suicidal ideation in Hispanic and mixed-ancestry adolescents. Suicide and Life-Threatening Behavior, 31(4), 416--427. Peck, D. L. (1989). Teenage suicide expressions: Echoes from the past. International Quarterly of Community Health Education, 10(1), 53-64. Petzel, S. V., & Riddle, M. (1981). Adolescent suicide: Psychosocial and cognitive aspects. Adolescent Psychiatry, 9, 342-398. Reynalds, W. (1991). Suicidal Ideation Questionnaire. Odessa, FL: Psychological Assessment Resources, Inc. 44

Rice, P. L. (1992). Stress and health. Pacific Grove, CA: Brooks/Cole. Robinson, J., Shaver, P., & Wrightsman, L. (1991). Measures of personality and social psychological attitudes. San Diego, CA: Academic Press. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Sarason, I. G., Johnson, J. H., & Siegel, J. M. (1978). Assessing the impact of life changes: Development of the life experiences survey. Journal of Consulting and Clinical Psychology, 46(5), 932-946. Selye, H. (1974). Stress without distress. New York: Lippincott and Crowell, Publishers. Simonds, J. F., McMahon, T., & Armstrong, D. (1991). Assessing the impact of life changes: Development of the life experiences survey. Journal of Consulting and Clinical Psychology, 46(5), 932-946. Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: W. W. Norton. Teen Suicide. (1998). American Psychiatric Association. Http://www.psych.org/ public_info/teen. cfin Turner, S. G., Kaplan, C. P., Zayas, L., & Ross, R. E. (2002). Suicide attempts by adolescent Latinas: An exploratory study of individual and family correlates. Child and Adolescent Social Work Journal, 19(5), 357-374. Watt, T. T., & Sharp, S. F. (2002). Race difference in strains associated with suicidal behavior among adolescents. Youth & Society, 34(2), 232-255.

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