1 SOC SCI 172AW American Culture Fall 2021 Short Literature Review First Draft Due: Friday November 12th by 11:59PM PST on Canvas Final Revision Due: Sunday December 5th by 11:59PM PST on Canvas For the third and final assignment, students are individually responsible for writing a short literature review on the topic of Youth Suicide. This review must be a minimum of 1,500 words, including a title page, abstract, and reference page. APA formatted is required! This assignment is worth 35% of your final grade. Later in the quarter, each student will pick from one of six sub-topics. After the sub-topic has been assigned, each student will write a literature review using three articles (all on the same sub-topic) posted on the course website. You may not use any other articles or sources. The sub-topics are as follows: • LGBT Youth and Suicide • Minority Youth and Suicide • Family Factors and Youth Suicide • Bullying and Youth Suicide • Youth Offenders/Homeless Youth and Suicide • Prevention of Youth Suicide For this literature review, it is important for students to show their knowledge about the research topic. This literature review is different from an annotated bibliography, which is a listing of articles with descriptions. A critical review is not a string of summaries, it is a synthesized review. In other words, students do not simply write a short review of each research study, but tie the research studies together into a “story” or “conversation.”. This process requires some insight and interpretation, not evaluation. Keep in mind that personal opinions are not included in a literature review. Report what is relevant to your study and ignore what is not. This means you need to read the abstract, the introduction and conclusion of your articles. And, for long articles, focus on the parts that relate to your topic. **At the end of the literature review, you will also need to write a two-paragraph summary of what you have learned about the topic from the three articles. This includes critique and reflection about the “story,” not the individual articles.** Avoid long quotes in your review, and paraphrase whenever possible. Maximum quotes = 2 short quotes (less than 40 words each). 2 Do not quote/cite secondary sources in the readings Correct APA formatting is also required – double-spaced, 12 pt Times New Roman font, 1 inch margins all around, APA in-text citations and a reference page. Run spelling and grammar checks and doublecheck your APA formatting. Be sure to CITE your sources throughout the review. Grading Rubric Short Literature Reviews will be graded according to the following criteria: 1. Content and Development (Total points: 60) a. Paper adequately synthesizes the key ideas and conclusions from the three articles and puts them in conversation with one another: 60 Points 2. Mechanics and Style (Total points: 40) a. APA rules of spelling, grammar, usage, and punctuation are followed: 30 Points b. Sentences are complete, clear, and concise, and the tone is appropriate to the content and assignment: 10 Points 100 points total Journal of Adolescent Health 51 (2012) 93–95 www.jahonline.org Adolescent health brief Bullying and Suicidal Behaviors Among Urban High School Youth Lisa Hepburn, Ph.D.a,b, Deborah Azrael, Ph.D.a,b, Beth Molnar, Sc.D.a,c, and Matthew Miller, M.D., Sc.D.a,b,* a Harvard Youth Violence Prevention Center, Harvard School of Public Health, Boston, Massachusetts Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts c Department of Society, Human Development and Health, Harvard School of Public Health, Boston, Massachusetts b Article history: Received May 11, 2011; Accepted December 7, 2011 Keywords: Bullying; Suicidal ideation; Suicide; Adolescence See Editorial p. 3 A B S T R A C T Purpose: To determine whether involvement in bullying as a perpetrator, victim, or both victim and perpetrator (victim-perpetrator) was associated with a higher risk of suicidal ideation or suicide attempts among a multiethnic urban high school population in the United States. Methods: In 2008, a total of 1,838 youth in 9th–12th grades attending public high school in Boston, MA, completed an in-school, self-reported survey of health-related behaviors. Logistic regression was used to evaluate the relationship between bullying behaviors and self-reported suicidal ideation and suicide attempts within the 12 months preceding the survey. Results: Students who reported having been involved in bullying as a perpetrator, victim, or victim-perpetrator were more likely than those who had not been involved in bullying to report having seriously considered or attempted suicide within the past year. When age, race/ethnicity, and gender were controlled, students who were victim-perpetrators of bullying were at highest risk for both suicidal ideation and suicide attempt. Conclusions: Urban youth who have been bullied as well as those who have bullied others are at increased risk of suicidal ideation and suicide attempts. 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. An association between bullying and suicidal ideation and suicide attempts has been observed among adolescents both outside the United States and among suburban U.S. populations [1– 4]. The highest risk for self-harming behavior has been observed among youth who are both victims of bullying and bully others [1]. In the present study, we examine whether there is an association between bullying and suicidal ideation and suicide attempts, in particular * Address correspondence to: Matthew Miller, M.D., Sc.D., Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Kresge 3rd floor, Boston, MA 01225. E-mail address: mmiller@hsph.harvard.edu (M. Miller). The primary investigators and all authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. IMPLICATIONS AND CONTRIBUTION Urban youth face a host of risk factors for adverse health behaviors including poverty, crime and violence. Involvement in bullying, particularly for those who are both victims and perpetrators, presents another risk factor that must be accounted for when planning interventions to reduce harmful behavior among urban U.S. populations. among victim-perpetrators, within a multiethnic population of urban high school youth with a high proportion of immigrant youth or youth from immigrant families. Methods Data were obtained from the 2008 Boston Youth Survey, a biennial in-school survey of a random sample of traditional high school students in Boston Public Schools [5]. Twenty-one of 31 invited schools participated (69%) in the study. Seventy-one percent of students selected completed the survey; 85% of those who did not were absent from school on the day of survey administration. Bullying victimization was measured with five questions about “other kids, including those in your school or neighborhood . . . (but not) people in your family . . . or someone you were 1054-139X/$ - see front matter 䉷 2012 Society for Adolescent Health and Medicine. All rights reserved. doi:10.1016/j.jadohealth.2011.12.014 94 L. Hepburn et al. / Journal of Adolescent Health 51 (2012) 93–95 neither a victim nor a perpetrator of bullying, (2) perpetrator of bullying only, (3) victim of bullying only, or (4) victim and perpetrator of bullying. Three models with interaction terms were tested to evaluate whether the effect of bullying on the risk of suicide varied by gender, nativity, or language spoken at home. Models were adjusted for grade, race, and gender. or are dating”: In the past 30 days, has someone or a group of people repeatedly hurt you or made you feel bad by . . . (a) teasing, picking on, or making fun of you?; (b) sending you mean e-mails, text messages, or posting something about you on the Internet?; (c) spreading rumors or lies about you?; (d) making unwanted sexual comments or gestures?; and (e) stealing your things? Bullying perpetration was assessed with two questions: In the past 30 days, how many times have you . . . (1) picked on someone by chasing them, grabbing their hair or clothes, or making them do something they didn’t want to do? (2) told lies or spread rumors about someone, or tried to make sure that other kids disliked him/her? Responses were collapsed into never versus any. Victim-perpetrators were those who answered affirmatively to at least one bullying victimization question and one perpetration question. Suicidal behavior was measured with the following question: In the past 12 months, have you . . . (a) seriously considered attempting suicide, and (b) actually attempted suicide. Two independent variables were created. Depressive symptoms were measured using an adapted version of the Modified Depression Scale [6]. Sociodemographic variables assessed included gender, age, grade in school, U.S.- or foreign-born, primary language spoken at home (to represent non-native born households), Hispanic ethnicity, and race. Bivariate associations between the two dependent variables (seriously considering and attempting suicide), sociodemographic characteristics, and bullying behavior were assessed using Pearson ␹2 statistics. Logistic regression models with robust standard errors adjusted for clustering by school were used to evaluate the association between bullying behaviors and suicidal ideation and suicide attempts. Respondents were divided into mutually exclusive categories of: (1) Results The demographic composition of the sample did not differ from that of Boston public high schools in terms of sex, nativity, race, ethnicity, or age [5]. Thirty-one percent of students were born outside the United States, and 43% of students’ primary household language was not English. Involvement with bullying did not vary significantly by race or ethnicity (␹2 ⫽ 19.8, p ⬍ .07) or primary household language (␹2 ⫽ 6.8, p ⬍ .08). Youth who were born outside of the United States were more likely to be victims of bullying than youth born in the United States (␹2 ⫽ 14.7, p ⫽ .002). Twelve percent (n ⫽ 201) of students reported that they had seriously considered suicide in the past 12 months, and 4.4% (n ⫽ 69) reported a suicide attempt in the same period. Youth who reported being bullied were more likely to have considered suicide, compared with those who had not, as were those who had bullied others and those who had been both bullied and had bullied others (Table 1). Multivariate models found that involvement in bullying as a perpetrator, victim, or victimperpetrator increased the risk of seriously considering suicide, and that being a victim or victim-perpetrator was also associated with higher risk of suicide attempts (Table 2). The models with interaction terms included found that the effect of bullying on suicidal ideation and suicide attempts did not vary by immigrant status (individual or household) or by gender. Each typology of bullying Table 1 Association between bullying behaviors and suicidal ideation and suicide attempts Bullying involvement Bullying victimization Any None Type of victimization Teasing Electronic Rumors/lies Sexual harassment Property theft Bullying perpetration Any None Type of perpetration Directb Indirectb Bullying participation None Perpetration only Victimization only Perpetration and victimization Total sample N ⫽ 1,833 Suicide attempts N ⫽ 69 % Yes Number ␹2 No % Number % p Number Yes % No Number % ␹2 p Number 14 59 732 1,101 17.2 8.3 118 81 82.8 91.7 569 898 30.4 ⬍.001 7.4 1.6 51 16 92.6 98.4 636 963 35 ⬍.001 18 8 22 17 14 311 137 388 293 240 20.1 26 21.3 21.4 22.3 58 32 76 59 50 79.9 74 78.7 78.6 77.7 230 91 280 217 174 21.9a 25.0a 37.8a 27.4a 26.1a ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 9 13.8 9.8 9.4 8.9 26 17 35 26 20 91 86.2 90.2 90.6 91.1 262 105 321 250 204 21.8a 33.5a 38.1a 24.0a 15.5a ⬍.001 ⬍.001 ⬍.001 ⬍.001 ⬍.001 20 80 353 1,506 19.8 10 64 134 80.2 90 260 1,201 23.4 ⬍.001 9 2.9 29 39 91 97.1 296 1,296 24 ⬍.001 12 14 212 254 21.8 19.5 42 46 78.2 80.5 151 190 19.8 15 ⬍.001 0.001 9.8 16.5 19 39 90.2 83.5 174 216 21.6a 11.1a ⬍.001 ⬍.001 51 8 29 12 891 133 512 214 7.8 11.3 13.9 25.1 66 14 67 50 92.2 88.7 86.1 74.9 777 110 416 149 48.2 ⬍.001 1.7 1.6 5 13.6 14 2 24 27 98.3 98.4 95 86.4 829 123 459 149 61.1 ⬍.001 ␹2: Pearson ␹2 test performed to examine differences between those who attempted suicide or seriously considered suicide and those who did not. a Binary variables, comparison with “None” in each case. b Direct perpetration includes chasing, grabbing hair and clothes, making them do things they did not want to do; indirect perpetration includes telling lies, spreading rumors, and trying to make other kids dislike him/her. L. Hepburn et al. / Journal of Adolescent Health 51 (2012) 93–95 Table 2 Logistic regression models for bullying categories and suicidal ideation and suicide attempts Bullying behavior Considered suicide OR (95% CI) Attempted suicide OR (95% CI) None Perpetrator Victim Victim-perpetrator 1.00 1.49 (1.07–2.09) 1.69 (1.11–2.58) 3.78 (2.86–4.99) 1.00 .99 (.20–4.88) 2.90 (1.58–5.36) 9.32 (4.91–17.73) Adjusted for gender, race, and grade in school (standard errors adjusted for clustering by school). OR ⫽ odds ratio; CI ⫽ confidence interval. remained significantly associated with suicide attempts in models that included depressive symptomology (Table 2). Discussion In addition to common stressors related to adolescence, youth who are racial or ethnic minorities, including those who are foreign-born or born to immigrant families, face additional stressors related to cultural assimilation and may be at higher risk for bullying victimization [7]. Although we observed that immigrant youth were at greater risk of being victims of bullying, there were no differences in the effect of bullying on suicidal ideation or suicide attempts among youth who were immigrants or from immigrant families. We did not observe any differential effect by gender, in contrast to the findings by Kim et al [8] among Korean youth. Our study suggests that the association between bullying and the risk for seriously considering or attempting suicide remains consistently strong even after taking into account race, ethnicity, immigrant status, and gender. Victim-perpetrators have again demonstrated the highest risk for self-harming behavior, supporting the findings in more homogeneous populations [2], that this group deserves special attention. Our study may not be generalizable to nonurban populations, nor did we ask about several potentially important confounders (previous suicide attempts, aggressive-impulsive and disruptive behavior, parental divorce) [9] or about frequency of victimiza- 95 tion. We also did not ask about physical bullying victimization, a behavior often difficult to distinguish from more normative peer fighting. As a result, we may be underreporting bullying victimization. Health professionals who work with urban and immigrant youth should evaluate adolescents’ involvement in bullying when addressing the risk of self-harming behavior within this population. Acknowledgments The Boston Youth Survey 2008 (BYS) was funded by a grant from the CDC/NCIPC (U49CE00740) to the Harvard Youth Violence Prevention Center (David Hemenway, Principal Investigator). BYS was conducted in collaboration with the City of Boston and Mayor Thomas M. Menino. The survey would not have been possible without the participation of the faculty, staff, administrators, and students of Boston Public Schools. The authors also acknowledge the work of Renee Johnson, Daria Fanelli, Alicia Savannah, Angela Browne, and Dan Dao. References [1] Kim YS, Leventhal B. Bullying and suicide. A review. Int J Adolesc Med Health 2008;20:133–54. [2] Klomek AB, Marrocco F, Kleinman M, et al. Bullying, depression, and suicidality in adolescents. J Am Acad Child Adolesc Psychiatry 2007;46:40 –9. [3] Kaltiala-Heino R, RimpelÅ M, Marttunen M, et al. Bullying, depression, and suicidal ideation in Finnish adolescents: School survey. BMJ 1999;319:348 –51. [4] Liang H, Flisher AJ, Lombard CJ. Bullying, violence, and risk behavior in South African school students. Child Abus Negl 2007;31:161–71. [5] Rothman EF, Johnson RM, Azrael D, et al. Perpetration of physical assault against dating partners, peers, and siblings among a locally representative sample of high school students in Boston, Massachusetts. Archive of pediatric and adolescent medicine Arch Pediatr Adolesc Med 2010;164:1118 –24. [6] Dahlberg LL, Toal SB, Swahn M, Behrens CB. Measuring Violence-Related Attitudes, Behaviors, and Influences Among Youths: A Compendium of Assessment Tools, 2nd ed., Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2005. [7] Yu SM, Huang ZJ, Schwalberg RH, et al. Acculturation and the health and well-being of U.S. Immigrant adolescents. J Adolesc Health 2003;33:479 – 88. [8] Kim YS, Koh YJ, Leventhal B. School bullying and suicidal risk in Korean middle school students. Pediatrics 2005;115:357– 63. [9] Cash SJ, Bridge JA. Epidemiology of youth suicide and suicidal behavior. Curr Opin Pediatr 2009;21:613–9. Journal of Adolescent Health 53 (2013) S43eS50 www.jahonline.org Original article Acutely Suicidal Adolescents Who Engage in Bullying Behavior: 1-Year Trajectories Cheryl A. King, Ph.D. a, b, *, Adam Horwitz a, b, Johnny Berona a, b, and Qingmei Jiang, M.S. c a b c Department of Psychiatry, University of Michigan Depression Center, Ann Arbor, Michigan Department of Psychology, University of Michigan Depression Center, Ann Arbor, Michigan Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan Article history: Received June 8, 2012; Accepted September 30, 2012 Keywords: Bully; Suicide; Suicidal ideation; Aggression; Psychiatric hospitalization; Longitudinal A B S T R A C T Purpose: Prospective longitudinal research is needed to examine associations between bullying behaviors and trajectories of suicidal ideation and behavior and overall functional impairment. The specific aims of the present study are to: (1) characterize differences in baseline functioning between acutely suicidal adolescents who are classified into bullying perpetrator and non-bully groups and (2) examine the 1-year trajectories of these two groups of adolescents. Method: Participants were 433 psychiatrically hospitalized suicidal adolescents (72% female), ages 13 to 17 years. Participants reported suicidal ideation, depression, anxiety, substance use, adaptive functioning, and bullying behavior. Six items from the Youth Self-Report were used to classify adolescents into bullying perpetrator (n ¼ 54) and non-bully (n ¼ 379) groups. Follow-up assessments were conducted at 6 weeks, 3 months, 6 months, and 12 months. Results: At hospitalization, adolescents in the bully group reported significantly higher levels of suicidal ideation, substance use, and functional impairment. Suicidal ideation differences remitted at six weeks. The elevated functional impairment of the bullying perpetrator group persisted across the 12-month period. Conclusion: Adolescents who met bullying perpetrator group criteria were characterized by more severe suicidal ideation and higher levels of proximal risk factors for suicide. Bullying behavior was not stable over time but was associated with elevated suicide risk when present. These findings highlight the importance of specifically assessing for and targeting bullying behavior at multiple time points when treating suicidal adolescents. Ó 2013 Society for Adolescent Health and Medicine. Open access under CC BY-NC-ND license. We thank Sanjeev Venkataraman, M.D., and Paul Quinlan, M.D., for administrative and risk management support; Anne Kramer, M.S.W., A.C.S.W., Barbara Hanna, Ph.D., and Lois Weisse, R.N., for project management; and Jean Pletcher and Kiel Opperman for administrative and research assistance. We also thank our research staff, participating inpatient staff, and the families who took part in this study. This research was supported by NIMH awards to Dr. Cheryl King (R01 MH63881, 5K24MH077705) and a clinical and translational research award to the University of Michigan (UL1RR024986). The authors declare no conflicts of interest. Publication of this article was supported by the Centers for Disease Control and Prevention. The opinions or views expressed in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. * Address correspondence to: Cheryl A. King, Ph.D., ABPP, Department of Psychiatry, Rachel Upjohn Building, 4250 Plymouth Road, University of Michigan, Ann Arbor, MI 48109. E-mail address: kingca@umich.edu (C.A. King). Suicide is the second leading cause of death among adolescents ages 13 to 17 [1]. Moreover, 6.3% of high school students have attempted suicide at least once and 13.8% report suicidal ideation during the previous year [2]. Individual risk factors include depression, hopelessness, substance abuse, and family history of mental illness [3]. Social and interpersonal risk factors for suicidal behavior among adolescents include peer victimization, physical and sexual abuse, having a socially stigmatized social identity, and perceptions of limited social support [4]. Bully perpetration (bullying others) is also a risk factor for suicidal ideation and behavior among adolescents [5]. Among sixth- to tenth-grade U.S. students, 13.0% bully others, 10.6% are 1054-139X Ó 2013 Society for Adolescent Health and Medicine. Open access under CC BY-NC-ND license. http://dx.doi.org/10.1016/j.jadohealth.2012.09.016 S44 C.A. King et al. / Journal of Adolescent Health 53 (2013) S43eS50 victims of bullying, and 6.3% report being both a bully and a victim (“bully-victims”) [6]. Among Finnish adolescents, depression and severe suicidal ideation were strongly associated with bullying perpetration or being bullied [7]. Bully-victims may exhibit greater rates of depression and suicidal behavior than those who are solely victims or perpetrators [e.g., 7,8]. Research involving psychiatrically hospitalized adolescents provides an opportunity to assess future trajectories for a highrisk group. This population is at a high risk for suicide attempts [9], particularly during the first year following hospitalization [10]. Aggressive and bullying behaviors have received less attention in this population than internalizing psychopathology. Kerr et al. [11] found that disruptive and aggressive behaviors did not have a main effect on adolescent suicidal behavior after hospitalization. However, internalizing symptoms were more predictive of subsequent suicidal behavior among aggressive youth, suggesting an interaction between aggressive behaviors and internalizing psychopathology. Goldston and colleagues [12] found that up to 13 years after hospitalization, co-occurring major depressive disorder and conduct disorder was the only unique pattern of comorbidity that elevated risk for suicide attempts. Prinstein et al. [13] found that externalizing and disruptive behaviors were not predictive of later attempts after hospitalization. Further research is needed to clarify the relation between aggressive behaviors and suicide. A transactional developmental model of risk for suicidal behavior suggests that bullying perpetration would exacerbate this risk, possibly via reciprocal influences on self-schema and interpersonal relationships [14]. The bullying may lead to heightened social conflict, impair interpersonal relationships, and reduce opportunities for involvement in positive social activities. In a downward spiral, this could create heightened emotional distress and ultimately lead to a more negative self-concept. To our knowledge, only one study has examined the relation between bullying others and suicidal behavior among psychiatrically hospitalized youth [15]. Female bully perpetrators had a threefold increase risk of suicide attempt compared to nonbullying girls. This association was not found among the boys; however, the study may have been underpowered to detect such a relationship because significantly more girls than boys reported both bullying behavior and suicide attempts. Further, in the absence of longitudinal data for psychiatrically hospitalized samples, it is unknown whether bullying will predict future suicidal thoughts and behavior. The few studies that examine bullying longitudinally are community- or population-based samples in which the base rates of suicidal ideation and behavior are low (for a review, see [16]). For instance, Klomek and colleagues [17] found that bullying behaviors and victimization had differential effects by gender. Bullying behavior and victimization was associated with suicide attempts and completions in adulthood but not after controlling for the effects of conduct disorder and depression, whereas frequent victimization contributed to attempted and completed suicide above and beyond conduct disorder and depression. Additional prospective longitudinal research is needed to explore further the ways in which bullying impacts trajectories of suicidal ideation and behavior and overall functioning, particularly for clinical samples at elevated risk for suicidal behavior. The specific aims of the present study are twofold: (1) to describe whether bully perpetrators differ from non-bullying adolescents at the time of hospitalization for severe suicidal ideation and/or behavior; and (2) to examine the 1-year trajectories of acutely suicidal adolescents who are classified into bullying perpetrator and non-bully groups. This study improves on past research by providing a prospective longitudinal examination of the trajectories of adolescent “bully-perpetrators” and “non-bullies” at the time of their acute suicide risk. Data were unavailable to focus on peer victimization in this study. It is hypothesized that psychiatrically hospitalized adolescents who engage in bullying behaviors will exhibit more suicidal behavior and ideation, higher levels of depression, and lower levels of adaptive functioning at baseline and over a 1-year period as compared to non-bullying psychiatrically hospitalized adolescents. Methods Participants Participants in the present study were 433 suicidal adolescents (310 females, 123 males), ages 13 to 17 years (M ¼ 15.6 years, SD ¼ 1.3), who were psychiatrically hospitalized between 2002 and 2005. Participants were primarily white (85.9%). The distribution of other racial/ethnic groups was: black (7.6%), American Indian (2.3%), Asian American (1.2%), and other (3.0%). Annual income for families ranged from less than $15,000 (5%) to more than $100,000 per year (16%), with the median income in the range of $40,000 to $59,000 per year. This study used data from the Youth-Nominated Support Team-II study, a randomized controlled intervention trial for suicidal adolescents following hospitalization [18]. Inclusion in the parent study was determined by parent or adolescent report of an adolescent suicide attempt during the past month, or suicidal ideation characterized by persistence or a specific plan, as reported on the Diagnostic Interview Schedule for Children, version IV DISC-IV [19]. Exclusion criteria included: severe cognitive impairment, direct transfer to a medical unit or residential placement, residence more than 1 hour drive from the hospital, and no legal guardian available. Thirteen adolescents were excluded from the present study because they did not complete the Youth Self Report (YSR) [20], which was used to classify adolescents into bully-perpetrator and non-bully groups. Measures The Suicidal Ideation QuestionnairedJunior (SIQ-JR) [21] is a 15-item self-report measure that assesses a range of suicidal thoughts on a 7-point time-referential scale ranging from “I never had this thought” to “almost every day.” It has excellent test-retest reliability [21] and was predictive of suicidal thoughts and attempts 6 months after hospitalization in an adolescent inpatient sample [9]. In this sample, the SIQ-JR had an internal consistency of .92. The Children’s Depression Rating ScaledRevised (CDRS-R) [22] is a semistructured interview that assesses depressive symptoms for the previous 2 weeks. The CDRS-R has demonstrated strong validity and reliability in studies with adolescents [23]. Inter-interviewer reliability for total scores, which were established prior to study onset and at 1-year intervals, was very high (mean alpha across raters was .98). The Beck Hopelessness Scale (BHS) [24] is a 20-item self-report true/false questionnaire that assesses negative attitudes about the future (e.g., “I don’t expect to get what I really want,” “My future seems dark to me”). The BHS has demonstrated strong C.A. King et al. / Journal of Adolescent Health 53 (2013) S43eS50 psychometric properties in adolescent samples [e.g., 25] and had an internal consistency of .91 in this sample. The Multidimensional Anxiety Scale for Children (MASC) [26] is a 39-item self-report scale designed to assess a broad spectrum of anxiety symptoms. The internal consistency coefficient for the total score, which was used in this study, was .73. The Personal Experiences Screen Questionnaire (PESQ) [27] is a self-report measure used to screen for adolescent abuse of alcohol or other substances. The PESQ Problem Severity scale has demonstrated adequate reliability and validity for identifying problem substance usage [27]. The Problem Severity scale in this sample had an internal consistency of .94. The Child and Adolescent Functional Assessment Scale (CAFAS) [28] is administered to parents and assesses their child’s functional impairment across a spectrum of settings (e.g., school, home, community). The CAFAS has established strong inter-rater reliability as well as construct and concurrent validity [29]. Interrater reliability for CAFAS subscales in this study were high (alpha range of .83e.98). The Youth Self Report (YSR) [20] is a 119-item questionnaire that assesses a broad range of behavior problems and was assessed at baseline. Six items pertaining to bullying behavior (I tease others a lot; I physically attack people; I am mean to others; I destroy things belonging to others; I threaten to hurt people; I get in many fights) were selected from the larger inventory. Items were scored on a 0 to 2 scale (0 ¼ not true; 1 ¼ sometimes true; 2 ¼ very true). Bully-perpetrators were categorically defined as having a score of 6 or higher on these six items. This 6-item scale had an internal consistency of .77. Procedures Detailed study procedures are described elsewhere [17]. Briefly, Institutional Review Board approval was attained. Participants were recruited from either a university or private psychiatric hospital in a Midwestern region of the United States. Parent/guardian written informed consent and adolescent informed assent were obtained. Baseline assessments were conducted within 1 week of hospitalization (7% completed following discharge). Adolescents were randomized to either a social support intervention (Youth-Nominated Support Team Intervention-Version II [YST-II]) or treatment-as-usual [18]. There were no differences in treatment assignment between the bully-perpetration and non-bully groups. Follow-up assessments for the SIQ-JR, CDRS-R, and BHS took place after 6 weeks, 3 months, 6 months, and 12 months. Follow-up assessments for the MASC, PESQ, and CAFAS took place after 3 and 12 months. The follow-up assessment for the YSR took place after 12 months. Data analysis Baseline demographic and clinical characteristics of bullyperpetrator and non-bully groups were compared using chisquare and t-tests. The SIQ-JR, BHS, CDRS-R, CAFAS, MASC, and PESQ repeated scores over time were treated as correlated outcome values in mixed regression models. The aim of these analyses was to describe the trends in these scores across assessment points during the 12-month study period. Mixed regression models enabled subjects with incomplete data across time to be included, which increases statistical power. Such models are often also less biased than complete-case analysis because the smaller number of subjects in complete case S45 analyses may be less representative of the larger population of interest [30]. Since all clinical outcome scores showed nonlinear trends over time, segmented or pairwise linear regression models were chosen over polynomial regression models because of better global fit without losing local fit. All baseline scores were centered. Coded time; hospital; treatment group; five baseline clinical scores; sex, age, and race; multiple suicide attempts; and bully group were included as fixed effects in the initial model. The subject effects were modeled as random effects so that each subject had his/her own intercept and slope. An unstructured covariance matrix of random coefficients was specified. Bully-perpetrator versus non-bully and the coded time variable, including any time interaction terms with bully, if at least one was significant, were included in final reduced models. Other main effects were kept in the final model at the alpha ¼ .05 significance level. Results Baseline comparisons of bully-perpetrator and non-bully groups Demographics. There were no differences in sex, race, maternal level of education, and proportion of families receiving public assistance between bully-perpetrator and non-bully groups (Table 1). The bully-perpetrator group was significantly younger (mean: 15.2, SD: 1.2) than the non-bully group (mean: 15.6, SD: 1.3). Clinical characteristics. As displayed in Table 2, the bullyperpetrator group had significantly higher baseline scores than the non-bully group for suicidal ideation (SIQ-JR), substance abuse (PESQ), and overall functional impairment (CAFAS Total). In terms of specific domains of functioning, Fisher exact tests indicated the subscale scores of bully-perpetrator and nonbully groups were distributed differently in the domains of: home (p ¼ .02), school/work (p ¼ .04), and behavior toward others (p ¼ .0003). A greater proportion of adolescents in the bully-perpetrator group were at the most severe levels of these subscales. There were no differences between groups for suicide attempt history, depression severity, hopelessness, anxiety, and functional impairment specifically related to moods/emotions. Table 1 Demographic characteristics of bully perpetrators and non-bullies Demographic Sex M F Race Black White Other Mother education Some high school High school Some college Some graduate Family public assistance No Yes Bully perpetrators % Non-bullies % (n ¼ 54) (n ¼ 379) 31.5 68.5 28.0 72.0 28.4 71.5 13.2 83.0 3.8 6.0 86.1 7.9 6.9 85.8 7.4 9.6 36.5 28.9 25.0 9.5 20.3 38.4 31.8 9.5 22.4 37.2 30.9 82.7 17.3 89.7 10.3 88.8 11.2 There were no significant p values at 95% confidence. Overall % (N ¼ 433) S46 C.A. King et al. / Journal of Adolescent Health 53 (2013) S43eS50 Table 2 Baseline clinical characteristics of bully perpetrators and non-bullies Measure Construct SIQ-JR CDRS-R CAFAS Total BHS total PESQ e Problem Severity MASC Suicide Attempt Hx None One Multiple Suicidal ideation 53.50 (18.8) 45.31 (21.6)
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