Coping After Divorce

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UNIVERSITY OF CALIFORNIA
Los Angeles
Adolescents’ Coping After Parental Divorce:
Depression, High-Risk Behaviors, and Suicidality
A dissertation submitted in partial satisfaction of the
requirements for the degree Doctor of Philosophy
in Nursing
by
Helene Seeman
1997
UMI Number: 9725984
UMI Microform 9725984

Copyright 1997, by UMI Company. All rights reserved.
This microform edition is protected against unauthorized

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UMI
300 North Zeeb Road
Ann Arbor, MI 48103
The dissertation o f Helene Seeman is approved.
Anne K. Wuerker
Colleen Keenan
Dennis P. Cantwell
ij-ca
i? /
Mary Ann Lewis, Committee Chair
University of California. Los Angeles
1997
DEDICATION
This dissertation is dedicated, first and foremost, to my wonderful husband and best
friend, Otto, without whose unshakable faith in me, unflagging support, and unbelievable
patience, it would not have been possible; to my precious children, Carolyn and David,
and their spouses, whose pride in me is exceeded by my immeasurable pride in them; to
my beloved baby sister, Shelley Pincus Dylan Busby, and her family, who were always by
my side in spirit; and to my friend and partner-in-crime, Marylynn Gibson Aguirre, who
somehow got my motor restarted each time it stalled. Finally, this is dedicated to the
memory o f my loving parents, Tillie and Sid Pincus, and my father-in-law Jack Seeman,
who would have said that they had never for a minute doubted it, or me, had they lived to
see this.
TABLE OF CONTENTS
Chapter Page
I. THE PROBLEM
Introduction 1
Aims of the study 3
Research questions 4
Hypotheses 5
Outline of remaining chapters 9
II. THEORETICAL FRAMEWORK
Theoretical framework 10
HI. REVIEW OF THE LITERATURE
Introduction 13
Psychological morbidity after parental divorce 13
Depression 19
Masked depression 20
Depression and high-risk behaviors 21
High-risk behaviors and suicide 24
Suicide 26
IV. METHODOLOGY
Design 32
Sample 32
Sample selection criteria 33
Chapter PaSe
Instruments 34
Demographic Data Questionnaire 36
Kidcope 36
Reynolds Adolescent Depression Scale 39
Youth Risk Behavior Survey 41
Definitions of terms 44
Data collection 50
Pilot study 50
V. RESULTS
Introduction 52
Data analysis 52
Characteristics of the sample 54
Tests of hypotheses
Hypothesis 1 62
Hypothesis 2 66
Hypothesis 3 69
Hypothesis 4 72
Hypothesis 5 75
Multivariate analyses 77
VI. SUMMARY
Introduction 86
Chapter Page
Discussion of limitations of the study 92
Implications for nursing 95
Recommendations for future research 96
APPENDICES
A Questionnaire A: Demographic Data Questionnaire 99
B Questionnaire B: Kidcope 107
C Questionnaire C: Reynolds Adolescent Depression Scale 110
D Questionnaire D: Youth Risk Behavior Survey 113
E Frequency distributions for questionnaire responses
by total sample 118
F Agreement to Participate; Informed Consent 126
G Scripts 133
REFERENCES 144
LIST OF FIGURES AND TABLES
Figure Page
1. Hypothesized associations 8
2. Psychodynamic Model of Adolescent Suicidaiity 12
Tables
1. Suicide rates for persons 15-19 years of age 29
2. Constructs of instruments 35
3. Variables 48
4. Mean ages for the total sample 55
5. Frequency distributions and likelihood ratio x2s
for questionnaire responses 59
6. Bivariate associations between coping, depression,
high-risk behaviors, and suicidaiity; with relative risk 65
7. Mean group differences for coping style and depression 66
8. Bivariate associations between depression and high-risk
behaviors, with relative risk 68
9. Mean differences in depression scores, by engagement
in high-risk behaviors 69
10. Bivariate associations between suicidal ideation and
high-risk behaviors, with relative risk 71
Table Page
11. Bivariate associations between suicide attempt(s) and
high-risk behaviors, with relative risk 72
12. Bivariate associations between depression and
suicidaiity, with relative risk 74
13. Mean differences in depression scores by suicidaiity 75
14. Bivariate associations between hospitalization status and
coping, depression, high-risk behaviors, and suicidaiity,
with relative risk 77
15. Logistic regression coefficients for depression 79
16. Classification tables for depression 79
17. Logistic regression coefficients for depression,
with suicide attempt(s) omitted from the model 80
18. Logistic regression coefficients for depression,
with suicidal ideation omitted from the model 81
19. Logistic regression coefficients for substance abuse 82
20. Classification table for substance abuse 82
21. Logistic regression coefficients for suicidal ideation 84
22. Classification tables for suicidal ideation 84
23. Logistic regression coefficients for suicide attempt(s) 85
24. Classification tables for suicide attempt(s) 85
ACKNOWLEDGEMENTS
Many individuals have been instrumental in contributing to the completion of this
dissertation. I would like to acknowledge them at this time.
First, I would like to express my appreciation to the members o f my doctoral
committee, Drs. Dennis Cantwell, Anne Wuerker, and Colleen Keenan, for sharing their
time, experience, and knowledge to assist me in this work. I particularly wish to thank my
Chair, Dr. Mary Ann Lewis, for her guidance through each step of the research process.
I would like to express my deep appreciation and gratitude to Dr. Lynn Brecht,
who has graciously provided assistance and shared her expertise in every aspect of
statistical analysis. Her generous and nonjudgmental support has been an invaluable
resource in conducting and reporting this research.
Finally, I would like to thank Laura Zelman, R.N., for her unselfish assistance in
gaining access to appropriate subjects and collecting the data necessary to complete this
study.
VITA
November 18, 1942 Bom; Bronx, New York
1964 B.S., Nursing

Hunter College
New York, New York
1990 M.N. (Nursing)

University of California, Los Angeles
Los Angeles, California
1991-1995 Audrienne Moseley Doctoral Scholar

Doctoral program in nursing
University of California, Los Angeles
1978-1988 Charge Nurse, Adolescent Unit

Northridge Hospital
Northridge, California
1988-1996 Charge Nurse, Adolescent Unit

Pine Grove Hospital
Canoga Park, California
1996- Assistant Professor o f Nursing

Los Angeles Southwest Community College
ABSTRACT OF THE DISSERTATION
Adolescents’ Coping After Parental Divorce:
Depression, High-Risk Behaviors, and Suicidaiity
by
Helene Seeman
Doctor of Philosophy in Nursing
University of California, Los Angeles, 1997
Professor Mary Ann Lewis, Chair
Problem: Divorce rates in the United States are high. Extensive research reports the
negative effects on the children involved. These effects may be depression and/or
engagement in high-risk behaviors such as unprotected sex, substance abuse, cigarette
smoking, and truancy. The most grave manifestation of these negative effects may be the
increasing incidence of child and adolescent suicide. The child or adolescent’s typical
coping style may contribute to such maladaptive responses to the divorce.
Purpose: To examine the associations between an adolescent’s coping style and
depression, engagement in high-risk behaviors, and suicidaiity.
Design: A non-experimental, cross-sectional research design; data collected at one point in
time.
Sample: Eighty adolescents 14- 17 years of age, whose parents had divorced within the
previous one to four years. Forty subjects had not been hospitalized for psychiatric
treatment since the divorce; forty subjects had been hospitalized for psychiatric treatment.
Method: Coping style was assessed using the Kidcope; depression was assessed using the
Reynolds Adolescent Depression Scale (RADS); engagement in high-risk behaviors and
suicidaiity were both determined by completion o f the Youth Risk Behavior Survey
(YRBS). Sociodemographic data was collected.
Results: A strong association was found between a negative/avoidant coping style and
depression, truancy, and suicidaiity. Negative copers were 20 times as likely as
positive/approach copers to be depressed, over three times as likely to have been truant,
five times as likely to have had suicidal ideation, and over four times as likely to have
made at least one suicide attempt since the divorce. Depression was significantly
associated with the high-risk behaviors, and a strong association was found between
depression and suicidaiity. These relationships were most significant among the
hospitalized adolescents, who were also more likely to have family members who had
attempted and/or committed suicide, and to have friends who had been hospitalized for
treatment of depression. They were also more likely to report physical abuse between
their parents.
Conclusions: This study reinforces the need for further research directed towards
developing interventions which would facilitate adolescents’ employment of adaptive
coping strategies.
Chapter 1
The Problem
Introduction
The rate of divorce in the United States has been steadily increasing for as long as
such records have been kept; the rate currently approaches 50% of marriages (Anable,
1991). This is at least double the rate for the 1970s and three times that of the 1960s
(Hetherington, 1979; Long & Forehand, 1987). Predictions about the number of children
bom in the United States in the 1980s who will experience parental divorce before their
18th birthdays range from 30% (Long & Forehand) to 40% (Cherlin et al., 1991). Some
have labeled these predictions as underestimates (Emery, 1982; Kalter, 1977).
Schwartzberg estimated, in 1980, that more than 10,000,000 American children live in
fatherless homes.
As the divorce rate has increased, so has the level of attention paid by researchers
to the impact of divorce on children. While some contend that parental divorce does not
routinely have a detrimental effect on children (Abelsohn & Saayman, 1991; Austin &
Martin, 1992; Baron & MacGillivray, 1992; Berman & Nesbitt, 1981; Cherlin et al., 1991;
Hetherington, 1979, 1993; Kienhorst et al., 1993; Offer & Schonert-ReichL, 1992; Parish,
1981; Reinhard, 1977; Slater, Stewart, and Linn, 1983; Sorosky, 1977; Tousignant,
Bastien, & Hamel, 1993), most agree that divorce is a powerful traumatic event in a child's
psychosocial development (Aro & Palosaari, 1992; Clark, 1992; Fendrich, Warner, &
Weissman, 1990; Frost & Pakiz, 1990; Hetherington, 1993; Irion, Coon, & Blanchard-
Fields, 1988; Kienhorst et al.; Parish, 1981; Plunkett, Schaefer, Kalter. Okla, & Schreier,
1986; Puskar & Lamb, 1991; Rae-Grant & Robson, 1988; Sandler, Reynolds, Kliewer, &
Ramirez, 1992; Scholte, 1992; Schwartzberg, 1980; Wallerstein, 1984, 1989; Wallerstein
& Blakeslee, 1989; Young, 1980). In a review of records as long ago as 1977, Kalter
found children of divorce referred for outpatient psychiatric treatment at twice the rate of
their occurrence in the general population. Today, some contend that the effect of divorce
on children is the major issue feeing United States society (Long & Forehand, 1987;
Wallerstein, 1987).
In light of this, it is important to understand the process that transpires with
children who adapt poorly after their parents divorce. These factors, however, have
largely been addressed in comparing children from divorced families with children in intact
families. Relatively little research focuses on those adolescents who survive their parents'
divorce without dire affective or behavioral consequences in relation to those who do not.
Environmental events can certainly be seen as stressful stimuli. One such event is
any major change which could be extremely disruptive or cataclysmic. This may be
particularly true if the environmental stressor is perceived as outside the individual’s
control, as with one’s parents decision to divorce. In addition, a disastrous occurrence
such as parental divorce will probably evolve as a chronic, rather than acute, stressor. It is
also vital to understand that there are a number of important events and processes
associated with divorce which might certainly effect both the adolescent’s ability to cope
effectively and the outcomes measured in this study, i.e., depression, engagement in high-
risk behaviors, and suicidaiity. These events may include a lowered socioeconomic status.
having to relocate and/or having to change schools and thus lose friends, or being
abandoned by a parent.
Clearly, divorces will continue to occur in families with children, and the rate may
well increase. Thus, factors mediating childrens' adaptive coping with their parents
divorce is a critical area for further study.
Aims of the Study
Underlying this study was the assumption that the differences in adolescents’
cognitive, emotional, and behavioral responses to the stress of their parents’ divorce can
be seen as the result of the particular coping strategies they choose. Adolescents in Group
I, who had not been hospitalized for psychiatric treatment since their parents’ divorce and
who were demonstrating adaptive responses and behaviors were presumed to be using
positive/approach coping strategies, such as social support, since they were drawn from
social groups such as scout troops and religious institutions. The subjects in Group II,
drawn from a hospitalized population, were manifesting maladaptive responses and
behaviors, such as truancy and substance abuse, which demonstrate more frequent use of
negative/avoidant coping strategies such as distraction, withdrawal, and negative
emotional regulation to cope with such stressors as parental divorce. The specific aims of
this study, therefore, were:
For adolescents who have not been hospitalized for psychiatric treatment since
their parents’ divorce (Group I) and those who have been hospitalized for treatment since
their parents’ divorce (Group II):
1) to examine the association between coping strategy and depression,
engagement in high-risk behaviors, and suicidaiity.
2) to examine the association between depression and engagement in
high-risk behaviors.
3) to examine the association between engagement in high-risk behaviors and
suicidaiity.
4) to examine the association between depression and suicidaiity.
5) to examine differences in the characteristics of adolescents in both groups.
Research Questions
1) For adolescents whose parents have divorced within the past one to three year(s) who
have not been hospitalized for psychiatric treatment since their parents’ divorce; and
those who have been hospitalized for psychiatric treatment since their parents’ divorce:
A) What is the association between coping strategy and depression?
B) What is the association between coping strategy and engagement in high-risk
behaviors?
C) What is the association between coping strategy, and suicidaiity?
D) What is the association between depression and engagement in high-risk
behaviors?
E) What is the association between engagement in high-risk behaviors and
suicidaiity?
F) What is the association between depression and suicidaiity?
2) What are the characteristics and coping strategies o f adolescents who have not been
hospitalized for psychiatric treatment since their parents’ divorce compared to those who
have been hospitalized since the divorce?
Hypotheses
For adolescents who have not been hospitalized for psychiatric treatment since their
parents’ divorce (Group I) and who have been hospitalized for psychiatric treatment since
their parents’ divorce (Group II):
Aim 1:
H,: There will be a statistically significant association between coping strategy and
1) depression;
2) engagement in unprotected sex;
3) substance abuse;
4) cigarette smoking;
5) truancy;
6) suicidaiity.
Aim 2:
H2: There will be a statistically significant association between depression and
engagement in high-risk behaviors, i.e.,
1) engagement in unprotected sex;
2) substance abuse;
3) cigarette smoking;
4) truancy.
Aim 3:
H3: There will be a statistically significant association between suicidaiity and
engagement in high-risk behaviors, i.e.,
1) suicidal ideation and:
a) engagement in unprotected sex;
b) substance abuse;
c) cigarette smoking;
d) truancy;
2) suicide attempt(s) and:
a) engagement in unprotected sex;
b) substance abuse;
c) cigarette smoking;
d) truancy.
Aim 4:
H4: There will be a statistically significant association between depression and
suicidaiity, i.e.,
1) suicidal ideation:
2) suicide attempt(s).
Aim 5:
Hs: There will be a statistically significant difference in hospitalization status
(nonhospitalzed: Group I; hospitalized: Group II) associated with coping
style, depression, engagement in high-risk behaviors, and suicidaiity.
Figure 1 illustrates the hypothesized associations addressed by the study.
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Outline o f Remaining Chapters
Chapter 2 deals with the theoretical framework on which the study was based. The
review o f the literature in Chapter 3 focuses on the relationships among and between
factors including stressful events such as parental divorce, coping strategies and strategies,
and outcomes such as depression, engagement in high-risk behaviors, and suicidaiity.
Chapter 4 addresses the research design, sample selection criteria, methodology,
procedure, measurement instruments, and definitions of terms used. Data collection
procedures and results of the pilot study are also addressed. Data analyses are presented
in Chapter 5. The final chapter summarizes the findings and includes discussion of the
limitations o f the study, the implications for nursing, and recommendations for future
research.
Chapter 2
Theoretical Framework
To provide a reasonable way to explain the development and pathogenesis of
suicidaiity in adolescents, Sulik and Garfinkel (1992), suggest a multifactorial approach to
the evaluation of suicide risk. The authors identify four groups o f possible antecedents to
suicidaiity: stressful events, vulnerability, psychopathology, and self-destructive behaviors,
and suggest several possible models. The role of stressful or traumatic events would be
emphasized in a psychodynamic model. In assessing the suicide risk for an adolescent
within this framework, one must be cognizant of the need to gather information on
significant events in the adolescent’s history before this point in time, his or her social
skills and available support, and any comorbid psychopathology. This conceptualization
envisions the loss of a parental figure, in this instance through divorce, as a chronic
stressor which effects a child’s cognitive, social, and emotional development. Past events
in the child’s life, as well as his present developmental stage, can be seen in the model as
strongly influencing the child’s current feelings, cognitions, and behaviors. This influence
will result in a vulnerability to mood or behavioral morbidity. The degree o f vulnerability
to affective or behavioral pathology is seen as dependent on various personal factors, one
of which is the adequacy of the adolescent’s coping strategies. If the coping defenses of
the adolescent are inadequate - if for example, he or she employs an avoidant coping
strategy such as social withdrawal - symptoms of depression are quite likely to occur.
This depression could manifest itself as hopelessness or anhedonia, and might co-occur
with such self-destructive and high-risk behaviors as substance abuse or unprotected
sexual activity. Finally, this depression and risk-taking are likely to be strongly associated
with suicidality. A possible conceptualization of such a model is shown in Figure 2.
Figure 2
PSYCHODYNAMIC MODEL OF ADOLESCENT SU1C1DALITY
SUICIDALITY
. Ideation
. Attcmpt(s)
STRESSFUL w VU LNERABIIJT Y_ PSYCHOLOGICAL

EVENT FACTORS MORBIDITY
Divorce . Inefleclivc coping strategics . Depression

• negative coping
- avoidance coping
SELF-DESTRUCTIVE
BEHAVIORS
High-risk behaviors:
- unprotected sex
• substance abuse
- cigarette smoking
- truancy
Chapter 3
Review of the Literature
Introduction
This literature review focuses on research which examines psychological morbidity
in adolescents associated with parental divorce, with particular emphasis on depression
and suicidality. Suicide is appropriately seen as the ultimate negative outcome for
adolescents with some manifestation of psychological morbidity. The review also examines
these adolescents’ engagement in high-risk behaviors and the relationship of these
behaviors to depression and suicidality. Statistics for these variables are be presented.
While suicide within the adolescent population is still seen as an unusual event, the
statistics may be considered alarming. Research addressing factors which may mediate the
effects o f marital disruption on the child is discussed, as are coping styles or strategies
which may influence effective adaptation to the divorce . Finally, limitations or
weaknesses in these studies are considered as they were influential in the planning and
design of this study.
Psychological Morbidity After Parental Divorce
A research study by Frost and Pakiz (1990), part of a 10-year research project on
the effects of elapsed time since marital disruption on children’s functioning, specifically
addresses this issue. Subjects were 192 ninth and tenth graders who had been followed
since kindergarten. Measurements included adolescent self-reports of antisocial behavior,
using the Life Events Scale, two subscales of the Youth Self-Report, and selected items
from the Diagnostic Interview Schedule for Children. Emotional functioning was
measured with the Children’s Depression Inventory and parents’ check-list responses on
all or part of several inventories. Analyses of covariance, loglinear analyses, and chi-
square statistical methods were used to analyze the data. Significant relationships were
found between divorce and adolescent self-reports of behaviors including cigarette
smoking, marijuana smoking, and involvement with alcohol and other drugs. The more
recent the marital disruption, the higher the reported antisocial behaviors and adverse
emotional effects, especially depression in girls, but all adolescents from disrupted
families differed from those in intact families. While this longitudinal study has the
advantage of frequently being able to compare child variables before and after divorce or
separation, it suffers from the most common shortcoming of research studies in this
domain, that of comparing divorced and intact families, with attention focused on those
children who experience psychological morbidity after the divorce, rather than scrutinize
those who may survive the divorce without significant affective and/or behavioral
disorder. The benefit of comparisons of divorced with divorced is to further the
knowledge of the sequelae o f divorce by examining the effects of other personality
variables, such as the adolescent’s coping repertoire, which were probably in place before
the parents’ separation and divorce.
A pattern which seems to persist over time is that adolescent boys who come to
psychiatric treatment from divorced homes tend to be more aggressive, resentful, and
assaultive than are boys from intact homes who are in treatment; adolescent girls from
divorced or separated homes who are in psychiatric treatment engage in significantly more
sexual acting out than do same-age girls from intact homes (Beer & Beer, 1993; Kalter.
1977; Schoettle & Cantwell, 1980; Sorosky, 1977).
While the great majority of research supports the impression of divorce as a
powerful negative event in a child’s life, there is some research suggesting otherwise.
AbeIsohn and Saayman (1991) examined the relationship of three family-based clinical
dimensions (cohesion, adaptability, and generational hierarchy) with adolescent adjustment
to parental separation. The subjects were 45 adolescents from 30 mother-custody families
in which the parents had permanently separated within the last 18 months. Nineteen
families were labeled aided, i.e., they had applied to a child guidance clinic for child-
focused family help in negotiating the divorce process. Eleven families were considered
unaided, i.e., they met the same inclusion criteria, but had not applied for help. Individual
family member’s perception o f the family across the dimensions of cohesion and
adaptability were assessed with the Family Adaptability and Cohesion Evaluation Scale
(FACES). The postseparation generational hierarchy construct was measured with the
Postseparation Generational Hierarchy Questionnaire (GHQ). Adolescent adjustment was
measured with the Child Behavior Checklist (CBCL). Findings included a significant
negative correlation between Deviance from Mean scores on cohesion and the CBCL
social competency scale and positive correlations between Deviance from Mean scores on
adaptability and CBCL internalizing scores, and between increased adolescent access to
mother’s distressed affect and CBCL social competency scores, in both the aided and
unaided groups. While aided adolescents were more distressed than the unaided group,
the great majority of all adolescent subjects could not be classified within the CBCL's
clinical range. The authors suggest that divorce should be seen as a stressor, rather than a
disaster, for most adolescents. They acknowledge, however, the limitations of this study,
beginning with its small sample size. In addition, each measure was from a single point of
view (mother’s or adolescent’s), the focus was entirely on the structure of the custodial
home, and the design includes no subject or family history.
Another study, (Austin & Martin, 1992), explored the relationship of educational
level, marital status of parents, number of children in family, and family stability, to the
social, emotional, and academic development of college-bound students. The sample
consisted o f 52 tenth grade public high school students in college-preparatory classes.
Social, emotional, and academic development were gauged with the Measures of
Psychosocial Development (MPD), the School Environment Preference Survey (SEPS),
and the Study Attitudes and Methods Survey (SAMS). Demographic data including age,
grade point average, parents’ marital status, and family mobility were also collected.
Multivariate analyses of variance found a significant main effect o f parents’ marital status
for academic interest, alienation toward authority, ego integrity, and study methods, i.e.,
children of divorce had significantly higher scores on ego integrity, acceptance of
authority, and academic interest, but had worse study habits, than children from intact
families. In addition, children who had changed schools at least once, which may occur
with divorce, had higher levels of autonomy, initiative, and resolution of initiative versus
guilt. While the results of the study indicate that children of divorce may be better
adjusted in many areas than children o f intact families, the small sample size and absence
o f a control group should lead to caution in generalizing from this research. The authors
recommend that the data should probably be considered descriptive of this group of
students, rather than causal for children of divorce as a whole.
Two prospective longitudinal studies, in Great Britain and the United States, were
employed by Cherlin et al. in 1991 to investigate the effects o f divorce on children.
Children age seven in Britain and ages seven to 11 in the U.S. who were in two-parent
families at an initial interview were followed through a second interview four years later,
at ages 11 and 11 to 16, respectively. At both time points, in Britain, parents and teachers
rated the children’s behavior problems, using adaptations of the Rutter Home Behaviour
Scale (RHBS) and the Bristol Social Adjustment Guide (BSAG). British children also
completed reading and mathematics tests. In the U.S. sample, a parent was asked
questions about the child’s behavior problems which were similar to those on the adapted
RHBS. Children whose parents divorced or separated between the two time points were
compared to children whose families remained intact. Parent-rated behavior problems was
the only outcome that could plausibly be compared in the two groups. In the British
study, boys and girls whose parents had divorced between interviews showed more
behavior problems at age 11 than those whose families remained intact. The magnitude of
the difference was modest but statistically significant. In the U.S., the boys results were
similar to those of the British boys. For girls, however, there was little difference between
those from divorced and those from intact families. Interestingly, when both behavior
problems before the divorce and amount of marital conflict before the divorce were
controlled for, the effect of divorce fell to levels that were no longer statistically significant
among subject boys in the U.S. and in Great Britain. While the study seems to suggest
that divorce effects can be predicted by conditions which existed before the divorce, it
does not allow for differentiation between families that were generally dysfunctional and
those that may have been functioning well until the marital conflict reached a level that
lead to separation and divorce. In addition, results may be markedly different with older
children, as in the present study.
Some research reports describe the association between parents' divorce and an
adolescent's subsequent increased anger (Rae-Grant & Robson, 1988; Wallerstein & Kelly,
1976), deteriorating school performance (Allison & Furstenburg, 1989; Frost & Pakiz,
1990; Irion et al., 1988; McCombs & Forehand, 1989; Neighbors, Forehand, &
Armistead, 1992; Rae-Grant & Robson; Schoettle & Cantwell, 1980; Slater et al., 1983;
Wallerstein & Kelly), or school phobia (Agras, 1979), substance abuse (Frost & Pakiz;
Irion et al; Rae-Grant & Robson; Reynolds & Rob, 1988; Schoettle & Cantwell; Slater;
Steidl, Horowitz, Overton, & Rosenstein, 1992), sexual acting out (Rae-Grant & Robson;
Reynolds & Rob; Schoettle & Cantwell; Schwartzberg, 1980; Slater), and neuroendocrine
changes (Gerra, et al., 1993).
A study looking at children’s lack of well-being in three areas - problem
behaviors, psychological distress, and academic performance - was conducted with a
probability sample of 1,197 subjects nationwide (Allison & Furstenburg, 1989), using
parent, teacher, and student self-reports. In all the analyses, children from intact families
are compared with children who had experienced the dissolution of their parents’
marriage. Bivariate comparisons and regression analyses showed that those adolescents
whose parents’ marriage dissolved were significantly worse off than those from intact
families, with respect to measurement of problem behaviors, school performance, and
psychological distress; this held true for the parent’s, teacher’s, and the student’s own
reports. While the proportion o f variation in outcome measurement which could be
attributed to divorce never exceeded 3%, the authors’ attributed this to their selection of
possibly unreliable or invalid outcome measures, with low estimates of internal
consistency. Another possible weakness of this study might be that it does not account for
the affective or behavioral condition of the subjects before their parents’ divorce. Further,
it, like most others, compares children of divorced with children of intact homes .
Depression
An association between parent’s divorce and the occurrence of outright
depression in the adolescent is also noted in the literature (Adams, Overholser, & Lehnert,
1994; Anable, 1991; Aro & Palosaari, 1992; Blumenthal, 1990; Brubeck & Beer, 1992;
deWilde, Kienhorst, Diekstra, & Wolters, 1992; Eggert Thompson, Herting, & Nicholas,
1994; Morano, Cisler, & Lemerond, 1993; Rae-Grant & Robson, 1988; Shaffer, 1974;
Schwartzberg). A 1992 study of adolescents aged 14 to 19 years, conducted by Brubeck
and Beer, examined several variables of real concern - depression, self-esteem, suicide
ideation, death anxiety, and grade point average (GPA) - looking for any association with
the marital status of students’ parents. One hundred thirty-one high school students in
grades nine to twelve completed the Beck Depression Inventory, Coopersmith Self-
Esteem Inventory: short form, Death Anxiety Scale, and the first 11 questions of the Beck
Scale of Suicidal Ideation (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961).
Demographic data, including marital status of parents, was collected. Grade point
average, on a four-point scale, was obtained from school files. Descriptive statistics were
used to analyze scores on the suicidal ideation, depression, self-esteem, death anxiety,
GPA, and age for students of divorced and nondivorced parents. Analyses of variance
were then performed to examine the possible influence o f different variables. A number of
the results were significant: on self-esteem and GPA the children of divorced parents
scored lower than children of nondivorced parents; on depression, children of divorced
parents scored higher than those o f nondivorced parents. Pearson correlations also
yielded results o f interest: high scores on depression tended to be associated with high
suicide ideation scores; students high on depression and suicide ideation also had lower
GPAs. The authors conclude that divorce is clearly associated with undesirable scores on
several measures. Since this study has the added value o f examining young people in
various stages o f adolescent development, it would be very helpful to see it replicated with
divergent and more readily generalized samples.
Masked Depression
It is important to note that many theoreticians and clinicians have maintained, over
time, that anger, antisocial acts, high-risk behaviors, and poor school performance may be
real symptoms, although they are masked, of clinical depression in children, or defenses
used by the child to resist depression (Bailey, 1992; Christ, Adler, Isacofif, & Gershansky,
1981; Cytryn, & McKnew, 1972; Glaser, 1967; Grueling & DeBlassie, 1980; Hollon,
1970; Lesse, 1974. 1979; Rosenstein, Horowitz, Steidl, & Overton, 1992; Sadler, 1991).
This point of view is contested by others, who see these “masking" symptoms as possible
prodromal manifestations of depressive illness, or incomplete forms of the illness (Strober,
Green, & Carlson, 1981), or as comorbid conditions which may overshadow true
depression (Carlson & Cantwell, 1980).
Depression and High-Risk Behaviors
The relationship between depression and the high-risk behaviors o f interest in this
study is frequently noted in the literature. With regard to one of them, Bailey notes:
“substance abuse may be a manifestation of psychopathology, an effect of
psychopathology, or unrelated to psychopathology” (1989, p. 155). Depression is
considered by some to predate the substance abuse, as do other behavioral and personality
factors (Bailey, 1989, 1992). In a sample of incarcerated juvenile offenders, 74% gave as
their main reason for using drugs, the attempt to ameliorate sadness and depression. The
comorbidity of substance abuse with other psychiatric disorders is consistently noted.
Substance abuse is implicated in the pathogenesis of psychiatric illnesses, including
affective disorders, anxiety disorders, and the many behavior disorders. The presence of
these conditions, are seen as vulnerability factors for the risk of substance abuse disorder.
(Bailey; Bukstein, Brent, & Kaminer, 1989; Neighbors, Kempton, & Forehand, 1992).
In a review of the records of 84 adolescents hospitalized with comorbid substance
abuse, Horowitz et al., (1992) found 1) coexisting conduct disorder and substance abuse
(21%); 2) coexisting affective disorder and substance abuse (40%); and, 3) coexisting
conduct and affective disorders and substance abuse (50%). In addition, these researchers
found substance abuse consistently associated with a pattern of maladaptive behaviors
related to cognitive (i.e., poor judgment), affective (i.e., sadness, mood swings), and
behavioral disregulation (i.e., heightened risk-taking).
Disinterest in school, truancy, and school failure have been linked with depression
in several studies, whether because of the adolescent’s inability to concentrate, fatigue, or
other o f the symptoms of depression. (American Academy of Pediatrics, 1988; Kovacs,
1983; Mellencamp, 1981; Sadler, 1991).
Depression as a risk factor for truancy and other school-related problems opens
the door to conceptualizing it as a, perhaps indirect, predisposing factor for other high-
risk behaviors. The Centers for Disease Control analyzed data from the Youth Risk
Behavior Survey afler its 1992-1993 administration to a national sample. Using a
multistage cluster probability design, a representative nonclinical national sample was
selected, and questionnaires were completed by 10,645 (77.2%) 12 to 19 year olds who
had not yet completed high school. Among respondents, 91% were in school and 9%
were out of school (i.e., not attending school at all). Out of school adolescents were
significantly more likely than in school adolescents to report having smoked cigarettes in
the past 30 days (33.7% versus 20.4%), ever having smoked cigarettes (57.7% versus
50.9%), having used alcohol (62.9% versus 55.2%), having used marijuana ( 31.4%
versus 15.9%), having used cocaine (7.1% versus 2.1%), ever having had sexual
intercourse (70.1% versus 45.4%), or having had four or more sexual partners (36.4%
versus 14%).
Positive associations between depression and cigarette smoking have also been
discussed in the literature (Reynolds & Rob, 1988; Sussman et al., 1993; Way, Stauber,
Nakkula, & London, 1994).
Unprotected sexual activity is o f grave concern when HTV infection or infection
with another sexually transmitted disease is at epidemic proportions among young people
(Moscicki, Millstein, Broering, & Irwin, Jr., 1993). To add to the concern, the Centers for
Disease Control (1992) has noted a recent change in the primary mode of transmission of
HTV in adolescents from transfusion to various sexual and substance abuse behaviors.
Sadler (1991) discusses adolescent sexual activity related to depression, and sees it as an
attempt to escape from depression, or to have the baby they hope will help them achieve
love and wholeness.
In a 1993 survey, DiClemente and Ponton conducted structured interviews with
76 adolescents admitted to an inpatient adolescent psychiatric service. Although the
authors do not sort the patients by diagnosis, it is to be expected from the large number of
studies with clinical populations that the most frequent admitting diagnosis is an affective
disorder. The authors compared the inpatient responses to the replies to the same
questionnaire obtained by the Centers for Disease Control in a school-based survey and
calculated prevalence ratios to quantify the differences. The psychiatrically hospitalized
adolescents were 1.9 times as likely as their school-based peers to report not using
condoms during their last sexual encounter, while being 1.8 times as likely to be sexually
active. Since the Centers for Disease Control report that of all sexually active United
States adolescents, only 47% o f females and 25% of males report regular condom use, the
extrapolated figures for depressed adolescents is likely to be worse.
Finally, it must be noted that adolescents who engage in any one of the high-risk
behaviors are most likely to engage in others as well. They are also more likely than their
peers to be depressed (Bailey, 1989, 1992; Centers for Disease Control, 1994, March 4;
Millstein et aL, 1992; Moscicki, 1993; Reynolds & Rob, 1988; Richter, Valois, McKeown,
& Vincent, 1993; Way, Stauber, Nakkula, & London, 1994; Windle, 1990).
High-Risk Behaviors and Suicide
A significant association between adolescents’ engagement in the various high-risk
behaviors and suicidality has been considered in research literature.
A modified, 11-item version of the National Adolescent Student Health Survey
(American School Health Association, 1989) was administered to a convenience sample
drawn from eighth to lOth-graders in six Alabama public school districts - two rural
(n=769), two moderate size communities (n=1,666), and two metropolitan areas
(n=l,368) (Adcock, Nagy, & Simpson, 1991). Four of the items inquired about the
students’ stress, depression, and attempts at suicide. The remaining seven items addressed
what the investigators considered possible danger signs for potential suicide, such as
sexual activity and alcohol consumption.
Significant differences for suicidal ideation and attempts were found between
“participants”, i.e., those students engaging in both sexual activity and alcohol use in the
previous month, and “abstainers”, those who had engaged in neither. Across all genders
and ethnicities, participants were almost three times as likely to have attempted suicide as
abstainers (25% versus 9%). All comparisons were significant at the p=.00l level.
Garrison, McKeown, Valois, and Vincent (1993) administered the Youth Risk
Behavior Survey (Centers for Disease Control, 1990) to 3,764 South Carolina public high
school students to analyze the frequency and correlates o f suicidal behaviors. Almost 25%
of the students reported behaviors ranging from serious thoughts of suicide (11%), to
specific suicide plans (6.4%), to suicide attempts that did not require medical attention
(5.9%), to attempts which did require medical care (1.6%).
While female gender was the most consistent predictor of suicidality, odds ratios
(ORs) for cigarette smoking were elevated across all categories of suicidal behaviors and
increased in magnitude with the severity of the behavior reported, i.e., OR =1.06 for
cigarette use and suicidal thoughts, to OR =1.66 for cigarette use and attempts requiring
medical care. Alcohol use was significantly associated with suicide plans (OR =1.22) and
attempts not requiring medical care (OR =1.31). Illicit drug use was significantly
associated with suicide attempts which required medical care (OR =2.88). The magnitude
of the odds ratios increased with the use o f potentially more dangerous drugs in
combination with the more severe suicidal behaviors. For example, for the effect for
suicide attempts requiring medical care and: intravenous drugs, OR =6.91; cocaine, OR
=3.63; LSD, PCP, methamphetamines and heroin, OR =2.54; marijuana, OR = 2.35; and
frequency of alcohol intake, OR =2.10.
An extensive written questionnaire, which included a shortened, 16-item, Beck
Depression Inventory and a validated self-administered list of multiple choice questions
about current mood state, drug use, suicidal behaviors, etc., was administered to 340 13 to
19 year old drug users over a four month period of time (Berman & Schwartz. 1990).
This resulted in 298 usable completed questionnaires. Sixty percent of the subjects
reported using an intoxicant at least once daily. Sixty-seven percent reported the
occurrence of suicidal ideation during the years of drug use; 30% reported at least one
suicide attempt; 25% had made multiple attempts. Only 22% of the attempters reported
having made any suicide attempts before they initiated drug use.
When compared with non-drug using, age and gender matched, “normative”
controls, results were startling. Drug user/suicide attempters differed significantly from
controls on 24 of the 32 items on the questionnaire, including school truancy, illegal
activities, parental conflict, etc. Substance abusers were three times as likely as controls
to make a suicide attempt; both the wish to hurt oneself and actual attempts increased
significantly after the initiation of substance abuse.
Other studies support findings o f relationships between the various high-risk
behaviors, such as substance abuse, cigarette smoking, truancy, unprotected sexual
activity, risk-taking and suicidality. (Blumenthal, 1990; Downey, 1991; Eggert et al.,
1994; Grossman, 1992; Lowry et al., 1994; Pritchard, Cotton, & Cox, 1992; Richter,
1993; Rockett, Spirito, Fritz, Riggs, & Bond, 1991; Runeson, 1990).
Suicide
Even as the incidence of depression in adolescents increases (Klerman &
Weissman, 1989; Puskar & Lamb, 1991), a growing body o f evidence supports the
association between depression and suicidal ideation and behaviors in adolescents (Berman
& Schwartz, 1990; Blumenthal. 1990; Brent et al.. 1991; Carlson & Cantwell. 1982; de
Wilde, Kienhorst, Diekstra, & Wolters, 1992; Eggert et al., 1994; Fowler, Rich,& Young,
1986; Hanna, 1992; Holinger, 1990; Kelly, 1991; Marton, Connolly, Kutcber, &
Korenblum, 1993; Morano,1993; Pallikkathayil & Flood, 1991; Range & Antonelli, 1990;
Runeson, 1989; Shaffi, Carrigan, Wittinghill, & Derrick, 1985), as well as the relationship
between the high risk behaviors which may serve as masking symptoms of depression in
adolescents and adolescent suicide (Adcock et al., 1991; Bailey, 1989, 1992; Berman &
Schwartz, 1990; Blumenthal, 1990; de Wilde; Grossman, 1992; Grunbaum & Basen-
Engquist, 1993; Horowitz et al., 1992; Neighbors, 1992; Newcomb, Maddahian, &
Bentler, 1986; Orr, Beiter, & Ingersoll, 1991; Reynolds & Rob, 1988; Sulik & Garfinkel,
1992; Way, Stauber, Nakkula, & London, 1994).
The association between substance abuse and suicide in people under age 30 was
explored in a study conducted in 1986. After extensive review of clinical records and
postmortem toxicologic data, and the performance o f psychological autopsies on 133
youth suicides, 88 of the young people were assigned principal diagnoses o f substance
abuse, or of substance abuse plus another disorder. This large group was not diagnosed
with major depression alone. The researchers also found that the substance abuse had been
present for at least nine years before the completed suicide, and that multiple substance
abuse was the norm (Fowler, Rich, & Young). The same researchers then compared
those 133 youth suicides with 150 completed suicides of people aged 30 and over. After
assigning DSM diagnoses to the older subjects, the researchers reported that their major
finding was the unexpectedly high number of substance abusers in the total sample.
Despite this finding, the young people comprised a significantly larger proportion of those
with substance abuse as a primary diagnosis, while there were a higher number o f the
older sample whose primary diagnosis was depression (Rich, Young, & Fowler, 1986).
The data on risk factors for suicidality in adolescents assum e critical importance
when one considers the striking increase in both attempted and completed child and
adolescent suicides in the past 40 years. A national survey of more than 11,000 eighth and
10th grade students in the United States disclosed that one in five of the girls, and one in
10 of the boys, had made at least one actual suicide attempt (Blumenthal, 1988). In a
1993 study of American teenagers, 60% reported knowing at least one other teen who had
attempted suicide; six percent reported having made an attempt themselves (Ackerman,
1993). It must be remembered when examining these figures that the actual rates may be
greatly underestimated since nonserious suicide attempts may not be reported at all and
the figures may also omit injuries from single-car automobile "accidents", "accidental"
drug overdoses, or “accidental” gunshots, which are not classified as suicides or suicide
attempts, but perhaps should be (Blumenthal, 1990; Centers for Disease Control, 1992,
October; Grossman, 1992; Holinger, 1990; Millstein et al., 1992; Pallikkathayil & Flood,
1991; Puskar & Lamb, 1991). This proviso notwithstanding, the statistics for both
children and adolescents remain alarming. Among 15-19 year olds, the estimated range
for suicide attempts is 8 - 18% of that population (Adcock et al., 1991). Puskar and Lamb
(1991) propose that there are a half million serious suicide attempts per year in this age
group.
As Table 1 shows, the suicide rate for 15-19 year old males has increased more
than 500% since 1950. and the total for both genders has more than quadrupled. The
actual yearly number of completed suicides of 15-19 year olds has increased from
approximately 250 in 1933, to more than 2000 in 1987, to almost 6000 in 1991 (Puskar,
Hoover, & Miewald, 1992).
Table 1. Suicide rates* for persons 15-19 years of age, by gender: United States,
1950,1960, 1970, 1980, 1990
Year
A?e(vrs)/Gender 1950 1960 1970 1980 1990
15-19
Male 3.5 5.6 8.8 13.8 18.1
Female 1.8 1.6 2.9 3.0 3.7
Total 2.7 3.6 5.9 8.5 11.1
*Per 100,000 persons Source: CDC
The Centers for Disease Control (CDC, 1991) reports that a survey they
conducted in 1990 among ninth to twelfth-graders disclosed that 27.3% had thought
seriously about suicide, 16.3% had made a suicide plan, 8.3% had made an actual attempt,
and 2% had made a suicide attempt that required medical attention in the previous 12
months.
Perhaps most alarming are reports of a steadily decreasing age at first suicide
attempt over the past 20 years, with approximately 12,000 five - 14 year olds hospitalized
every year after suicide attempts (Blumenthal, 1990; Conrad, 1994). Between 1960 and
1987, the rate for completed suicides o f children under 14 years of age doubled, and since
1933 suicides o f children aged five to nine years have averaged one - five per year, while
those of 10 to 14 year olds averaged 50 - 200 per year (Blumenthal: Holinger. 1990).
Many psychiatrists and health officials position suicide as the third leading cause of death
among five to 14 year olds (Greene, 1994). A survey of 123 elementary school (grades K
to six) counselors revealed that in one school year they had had contact with 187 children
who were considering suicide, 26 who had made actual attempts, and one who had
succeeded in committing suicide. Depression was the most commonly occurring factor for
these children and parental divorce was the issue of most concern to them (Nelson &
Crawford, 1990). Greene submits that family problems, including separation and divorce,
are among the factors which can have a profound influence on suicide probability (1994).
Along with increasing suicide rates among adolescents, there is also concern about
their engagement in high-risk behaviors which may also be related to adolescent morbidity.
These include illicit drug use and abuse (Eggert et al., 1994; MacDonald, 1984; Millstein
et al., 1992), unprotected sex which may result in pregnancy or infection with a sexually
transmitted disease (Eggert et al.; Millstein et al., Orr, 1991), risk-taking and injuries
(Smith, Ptacek, & Smoll, 1992), and cigarette smoking (Sussman et al., 1993).
Social science researchers have reported the positive associations between
increasing divorce rates and increasing numbers of children in psychological distress.
Factors which might influence this association have been addressed by researchers,
primarily when comparing children from divorced families with children from intact
families. These factors may include issues o f interparental conflict (Anable, 1991; Emery,
1982; Forehand, Thomas, & Wierson, 1990; Hetherington, 1979; Long & Forehand,
1987; Long, Forehand, Fauber, & Brody, 1987; Merskey & Swart, 1989; Neighbors,
Forehand, & McVicar, 1993; Parish, 1993; Piatt et al., 1993; Porter & O'Leary. 1980;
Rae-Grant & Robson, 1988; Sandler et al., 1992; Sorosky, 1977; Swart & Merskey, 1989;
Thomas & Forehand, 1993), issues of loss or abandonment, real or felt, by one or both
parents (Anable; Baron & MacGillivray, 1989; Fauber, Forehand, Thomas, & Wierson,
1990; Forehand et al., 1991; Hetherington, 1979; Lefkowitz & Tesiny, 1984; Merskey &
Swart, 1989; Poznanski, Krahenbuhl, & Zrull, 1976; Rae-Grant & Robson; Reynolds &
Rob, 1988; Scholte, 1992; Schwartzberg, 1980; Sorosky; Thomas & Forehand;
Tousignant et al., 1993; Wallerstein & Kelly, 1976), reduced socioeconomic status and
concomitant increased stress in the custodial parent (Abelson & Saayman, 1991;
Hetherington; Schwartzberg; Slater et al., 1983), and individual coping strategies and
styles (Armistead et al., 1990; Asamow, Carlson, & Guthrie, 1987; Farber, Felner, &
Primavera, 1985; Irion & Blanchard-Fields, 1987; Johnson & Pandina, 1991; Kienhorst et
al., 1993; Kliewer & Sandler, 1993; Sandler et al., 1992; Schwartzberg; Sorosky). An
anomalous trend in the state of California has been reported. It was the only one of the 50
states which showed a consistent decline in adolescent suicide between 1970 and 1990.
There was a 32% decline for California as a whole, and a greater than 50% decline in Los
Angeles and San Francisco. Initial investigation revealed no clear explanation for the
decrease, but it should be noted that California was also the only state to have reduced
divorce rates in the same time period (Males, 1994).Given the increasing numbers of
children and adolescents who are at risk for, and who do, commit suicide before the age of
19, it is imperative that research be conducted to implement appropriate and efficacious
interventions for this population.
Chapter 4
Methodology and Design
Design
This study used a non-experimental cross-sectional research design with data
collected at one point in time for purposes o f description, comparison, and correlation.
(Tabachnik & Fidell, 1992). The target population was adolescents between 14 and 17
years o f age whose parents had divorced within the past one to four year(s) and had not
remarried each other.
Sample
For comparing coping strategies in the two groups or assessing bivariate
relationships among the predictor and/or outcome variables, a total sample of 80 subjects
(Group I: n = 40; Group II: n = 40) permitted detection of a medium effect size of .35 in
examining associations using likelihood ratio x2s with a power of .93 at a = .05 (Cohen,
1988). The sample size was well within the suggested 5 - 2 0 subjects/ variable in a
statistical equation (Tabachnik & Fidell, 1992).
A convenience sample of 80 adolescents was selected. Flyers asking for
appropriate study volunteers were posted and distributed at the selected sites. Potential
participants were informed that subjects who completed the study would receive $20.00
gift certificates for a local record store. The subjects who met sample selection criteria
and who had not been hospitalized for treatment of depression, engagement in high-risk
behaviors such as substance abuse, or suicidality since their parents' divorce were
Reproduced with permission o f the copyright owner. Further reproduction prohibited without permission.
recruited from randomly selected local public and private high schools, scout troops, and
religious institutions. The subjects who met sample selection criteria who had been
hospitalized for treatment o f depression, engagement in high-risk behaviors such as
substance abuse, or suicidality since their parents’ divorce were recruited from randomly
chosen inpatient adolescent psychiatric treatment units in the Los Angeles area. While the
first 80 nonhospitalized subjects who met sample selection criteria participated in and
completed the study, four of the hospitalized potential subjects refused to participate.
Three could, or would, give no reason for the refusal. The fourth hospitalized adolescent
said that she would not take the risk that any information she imparted would not be
shared with her family or doctor, and thus possibly affect these relationships and the length
o f her hospital stay. The four adolescents who refused to participate met sample selection
criteria and were demographically similar to those subjects who did participate. Clearly,
it is possible that they were afraid to trust the researcher’s assurances of confidentiality.
The battery of tests was administered to hospitalized subjects within five days of their
admission to the hospital in order to avoid confounding the study with coping skills
subjects may have acquired since admission or effects of psychotropic medications, such
as antidepressants, subjects may have begun to take.
Sample Selection Criteria
The adolescents who participated in this study met the following criteria:
1) Age between 14 years 0 months and 17 years 11 months;
2) English-speaking;
3) No treatment for mental, affective, or behavioral disorder prior to the
separation and divorce, by self-report;
4) No evidence of thought disorder, by medical history;
5) IQ at least within normal range, as evidenced by school placement;
6) No deaths, significant losses, or medical conditions which could effect
adaptation since parents' separation and divorce, by self-report;
7) Not on any psychotropic medications at time o f study.
8) Parents separated and subsequently divorced between one and four years prior
to time of study and not remarried to each other.
Instruments
The scripts to be used for initial contacts and for administration of the instruments
can also be found in the Appendix. Constructs of the four instruments used in this study
are shown in Table 2. A copy of each can be found in the appendices.
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Table 2
Snicidulily
The Demographic Data Questionnaire (DDQ) (Appendix A) was used to collect
demographic data as well as data related to the intervening and extraneous variables. The
intervening variables in this study are of particular interest as the subjects’ social-structural
and cultural settings are quite likely to have an impact on both the independent variable,
coping, and on all three dependent variables: depression, high-risk behaviors, and
suicidality.
While it was not possible to collect data on all the behaviors and beliefs of every
one o f the subjects as well as their social-structural and cultural setting, i.e., ethnic,
community, or national, contextual beliefs about violence, suicide, divorce, and
relationships must be considered when study results are evaluated.
The Kidcope ('Spirito. Stark, & Williams, 1988) (Appendix B), a measure of
cognitive and behavioral coping strategies, was administered to assess coping strategy. It
is a brief, 10-item scale designed to assess cognitive and behavioral coping strategies used
by children and adolescents. In addition, scales for the frequency of use and the efficacy of
each coping strategy used by a subject are an integral part of the instrument. The
questionnaire can be completed in 20 minutes or less. The three primary scales are: A)
coping strategy, B) frequency o f use, and C) efficacy of the chosen strategy. Rather than
analyze each coping strategy separately, the authors have determined through analyses of
their own studies that the questionnaire items can be grouped into two subscales of coping
strategies: 1) positive/approach coping and 2) negative/avoidance coping. It should be
noted that while items 7A and 7B both address emotional regulation, 7A (“I yelled,
screamed, or hit something”) would be a negative/avoidance strategy, while 7B ("I tried to
calm myself by talking to myself, praying, taking a walk, or just trying to relax”) would be
a positive/approach strategy (Spirito, Hart, Overholser, & Halverson, 1990; Spirito,
Overholser, & Hart, 1991; Spirito, Overholser, & Stark, 1989; Spirito, Stark, Grace, &
Stamoulis, 1991; Spirito, Stark, & Vye, 1994; Stark, Spirito, Williams, & Geuvremont,
1989).
In developing the Kidcope, Spirito and associates (1988) distributed the ten items
between the two styles of coping their research had generated. The first,
positive/approach coping, is seen as the more adaptive, productive, and functional. It
includes, for example, problem solving. The other strategy, negative/avoidance coping,
has a maladaptive connotation. It includes self-criticism and social withdrawal.
The factor subscales and the variables in each are:
Scale A: Coping strategy
Subscale 1. Positive/approach coping. This includes cognitions, emotions, and
behaviors associated with active management o f a stressor. The strategies in this subscale
are cognitive restructuring (trying to reframe the stressor as a more positive occurrence);
problem-solving (seeking ways to actively resolve the trouble); positive emotional
regulation (seeking functional means to relieve emotional pressure); social support
(turning to others for help).
Subscale 2.: Negative/avoidance coping. This includes cognitions, emotions, and
behaviors associated with blocking information which would help in dealing with the
stressor or using harmful or self-defeating means of addressing the issues. The strategies
in this subscale are distraction (either denial or attempts at denial); self-criticism (blaming
self and taking no action); blaming others (and remaining inactive); negative emotional
regulation (releasing emotional pressure in useless or deleterious ways, such as screaming
or hitting walls); wishful thinking (a way to deny and remain immobile); resignation
(passive acceptance).
Scale B: Frequency
Asks “How often did you do this?” on a four-point Likert scale ranging from “not
at all” to “almost all the time”.
Scale C: Efficacy
Asks “How helpful was it?” about a chosen strategy, on a five-point Likert scale
ranging from “not at all” to “very much”.
The Kidcope is an appropriate instrument for this study, since the literature has
shown that suicidal children and adolescents either generate fewer positive coping
strategies than nonsuicidal subjects (Asamow et al., 1987; Asamow & Guthrie, 1988), or
are more likely to use avoidant coping methods like isolation or substance abuse (Cohen-
Sandler, Berman, & King, 1982). Spirito et al., (1989) have found that social withdrawal
may be the negative/avoidance strategy most often associated with adolescent suicide.
Since Spirito et al., (1988) conceptualized coping as a process rather than a stable
personality trait, they expected low to moderate test-retest reliability correlations over
time. In their psychometric testing they obtained moderate (r =.41) to fairly high (r =.83)
correlations on frequency ratings over short (three to seven day) periods. Efficacy ratings
varied much more. Over a 10-week period, as expected, reliability correlations were
considerably lower (r =15 to r =.43).
Concurrent validity for the Kidcope was assessed through comparisons with
standardized coping measurement instruments, the Coping Strategies Inventory (CSI) and
the Adolescent Coping Orientation for Problem Experiences Inventory (ACOPE).
Correlations with the CSI were predictably moderate to high (r =.33 to r =.77), since
several CSI subscales are very similar to Kidcope items. Validation with the ACOPE was
less strong (r = -.08 to r =.62), ostensibly because ACOPE factors are less congruent with
Kidcope factors.
The researchers predicted that the coping strategies that respondents felt were
most effective would be the ones they used most frequently. In fact, using a sample of
609 adolescents who completed the Kidcope, in every instance the highest correlations
were found between the frequency and efficacy of each coping strategy.
The Reynolds Adolescent Depression Scale fRADST (Reynolds, 1986) (Appendix
C), is a 30-item self-report scale intended to evaluate the severity of depressive symptoms
in children 12 to 18 years old. It is readable at the third-grade level Answers are on a
four-point Likert-style scale, ranging from 1 (“almost never”) to 4 (“most of the time”).
The items were written to address symptomatology of major depression and dysthymic
disorder as described in the Diagnostic and Statistical Manual of Mental Disorders-III
(DSM-III) (American Psychiatric Association, 1980). The diagnostic criteria for both
major depression and dysthymic disorders remain essentially unchanged in the fourth and
most recent edition of the DSM (American Psychiatric Association, 1994), so the RADS
continues to be an appropriate instrument. Somatic, motivational, cognitive, mood, and
vegetative aspects of depression are included, but there are no discrete subscales. Possible
scores on the RADS range from 30 to 120; a score of 77 is recommendeded as a cutoff to
delineate a clinically significant level of depression.
The RADS’ test manual documents relatively robust normative data from studies
involving thousands of adolescent subjects, yielding similar mean scores (Dailey,
Bolocofsky, Alcorn & Baker, 1992; Reynolds & Miller, 1989; Schonert-Reichl, 1994).
The author reports high reliability statistics which support homogeneity of item
content with samples ranging from 62 to 2120 subjects (range .91 to .96). A sample o f 76
adolescents aged 12 to 18 years with a diagnosis of conduct disorder yielded an internal
consistency reliability score of .88 for the RADS (Nieminen & Matson, 1989). Reynolds
(1987) reports a 12-week test-retest reliability coefficient of .79 with a sample of 415 high
school students.
A number of studies have established the construct validity of the RADS against
other depression scales and related constructs. These include the Center for
Epidemiological Studies - Depression Scale (CES-D) (Radioff, 1977) (r = .71); the Zung
Self-Rating Depression Scale (Zung, 1965) (r = .89); Kovacs’ (1981) Childrens’
Depression Inventory (CDI) (Brown, Overholser, Spirito, & Fritz, 1991) (r = .64); (Kahn,
Kehle, & Jenson, 1987) (r = .75); (Matson & Nieminen, 1987) (r = .62); (Shain, Naylor,
& Alessi, 1990) (r .87); the Differential Emotions Scale - IV (DES) (Blumberg & Izard.
1986) (r = .72). In addition, Shain et al. (1991) found significant differences between the
RADS scores of adolescents with major depression (mean score = 85.5) and normal
controls (mean score = 45.5).
The RADS cutoff score has been validated in a number of studies. Using the
RADS cutoff score of 77 and a Hamilton Depression Rating Scale (HDRS) (Hamilton,
1960) cutoff score of 15 as criteria, Carey, Kelley, and Carey (1991) found that 78.1% of
32 psychiatrically hospitalized adolescents were correctly categorized. With a more
conservative HDRS cutoff score o f 20, Reynolds (1987) reported a correct classification
o f 89.2% of 111 adolescent subjects.
The Centers for Disease Control's Youth Risk Behavior Survey fYRBS: 1990)
(Appendix D), was used to ascertain engagement in high-risk behaviors and suicidality.
The survey came into being in 1988 when the Centers for Disease Control (CDC) began
reviewing the leading causes of mortality and morbidity among one to 24-year-old
Americans. The researchers found that nearly all the contributing behaviors could be
collapsed into six areas: 1) those resulting in intentional or unintentional injury; 2) tobacco
use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unwanted
pregnancies and sexually transmitted diseases, including the human immunodeficiency
virus; 5) dietary behaviors; and 6) physical inactivity. Almost 70% of all deaths and a
considerable amount of acute and chronic morbidity in this age group result from motor
vehicle crashes (31%), other unintentional injuries (14%), homicide (13%), and suicide
(10%). The CDC further found that alcohol and other drug use is very strongly associated
with the above four mortality and morbidity causes. The Centers’ conclusion, therefore,
was that the majority of the health and social problems o f one to 24-year-olds could be
seen to be caused by a relatively small number of preventable behaviors.
Federal agencies responsible for monitoring the incidence and prevalence of
behaviors in the she categories above appointed a panel chairperson to a YRBS steering
committee. In August, 1989, the committee held a two-day workshop to begin the
process o f delineating, prioritizing, and devising questions to measure the behaviors of
interest. After a number of meetings, surveys, and revisions, a version o f the questionnaire
was given to the Questionnaire Design Research Laboratory at the National Center for
Health Statistics. The survey was then subjected to four waves of laboratory and field
testing with high school students. In October, 1990, the core questionnaire was
completed. It is self-administered, contains 75 multiple choice questions, and is readable
at the seventh grade level.
The system currently includes national school-based surveys, state and local
school-based surveys, and a national household-based survey. The national school-based
survey has been and will be conducted biennially, in odd-numbered years, this entire
decade, using a probability sample o f ninth to twelfth graders in public and private high
schools. In 1991, the final version of the YRBS was administered to a national sample of
12,272 adolescents.
Beginning in 1990, the CDC offered each state and local department of education
the YRBS questionnaire plus fiscal and technical assistance to conduct the survey.
Although using the exact same questionnaire would enhance comparability across sites.
the questionnaire is designed so that questions may be added, deleted, or modified without
seriously compromising validity.
To collect data on youth who do not attend school, the CDC and the Bureau of
the Census incorporated a YRBS in the 1992 National Health Interview Survey.
Finally, the YRBS was designed to comprehensively examine interrelationships
among categorical risk behaviors. It focuses on behaviors, rather than on attitudes or
knowledge. Many of the behaviors measured are associated not only with poor health
outcomes, but also with negative social outcomes. The system is not designed to evaluate
intervention outcomes or to train teachers.
Because the survey is based on self-reports o f possibly controversial behaviors,
these behaviors may well be underreported or overreported. Establishing criterion-related
validity for some responses may therefore be problematic. The survey was carefully
planned to assure the utmost confidentiality and anonymity, and the CDC reports that data
collected to date seems to demonstrate trends consistent with data from other such
surveys. In addition, a test-retest reliability study of the YRBS was conducted on two
occasions 14 days apart, with a sample of 1,679 students in grades seven through twelve.
(Brener, Collins, Kann, Warren, & Williams, 1995). No significant differences were found
between the prevalence estimates at time one and time two. A kappa statistic was
computed for each of 53 questionnaire items. The investigators used the following labels
for kappa values: <0%, poor; 0-20%, slight; 21-40%, fair; 41-60%, moderate; 61-80%,
substantial; and 81-100%, almost perfect. Kappas for 72% of the 53 items were
substantial or higher. More than 90% of the items could be labeled moderate or higher.
The CDC experts and Brener et al. acknowledge the difficulty of examining the validity of
self-report surveys of health and behavior practices. There are really no “standards” for
condom use, cocaine use, etc. All suggest a search for new and innovative psychometric
methods of establishing the reliability and validity o f measures such as these.
Definition of Terms
Divorce.: For the purposes of this study, divorce means that the parents have
moved to separate residences, and have subsequently divorced legally, at least one, but not
more than four, year(s) before the time of the study. The parents may be remarried, but
not to each other.
Coping.: A cognitive-phenomenological theory o f stress and coping was used in
this study (Folkman, 1984, 1992; Folkman & Lazarus, 1985; Lazarus, 1993).
Psychological stress is defined as “a particular relationship between the person and the
environment that is appraised by the person as taxing or exceeding his or her resources
and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 19). Divorce is here
conceptualized as such a stressor for the adolescents in this study. Coping, then, is
defined as “constantly changing cognitive and behavioral efforts to manage specific
external and/or internal demands that are appraised as taxing or exceeding the resources of
the person” (p. 141). It is important to understand that “coping” is not synonymous with
“mastery”. There are many stressors that cannot possibly be mastered, and “effective
coping under these conditions is that which allows the person to tolerate, minimize,
accept, or ignore what cannot be mastered” (Lazarus & Folkman. 1984, p. 140).
Positive/approach coping is thus seen as more effective or adaptive, and includes, for
example, cognitive restructuring and seeking social support. Negative and avoidance
coping strategies, such as self-criticism and social withdrawal, have a maladaptive
connotation.
Depression.: The most current Diagnostic and Statistical manual of Mental
Disorders (DSM-IV), (American Psychiatric Association, 1994), provides a description of
major depression which was the source for the definition of depression used in this
research. At least one of the symptoms must include depressed mood for most of the day,
nearly every day (in children or adolescents this can manifest itself as irritable mood)
AND/OR loss of interest or pleasure in all or almost all daily activities (anhedonia), plus
three or four o f the rest: significant weight loss or gain, or decrease or increase in appetite;
insomnia or hypersomnia nearly every day; objective; psychomotor agitation or
retardation nearly every day; fatigue or loss of energy nearly every day; feelings of
worthlessness or excessive or inappropriate guilt; decreased ability to concentrate, or
indecisiveness; recurrent thoughts of death, recurrent suicidal ideation, a suicidal plan, or a
suicide attempt. These symptoms must have been present for at least two consecutive
weeks, must represent a change from previous functioning, must not be due to effects
from drug abuse, medication, or a disease process, and are not accounted for by
bereavement.
The Reynolds Adolescent Depression Scale (RADS) yields a raw score ranging
from 30 to 120. The scale employs a cutoff score of 77 to define a clinically relevant level
of depression and that was the depression criterion used for this study. In addition, for
those hypotheses using depression as a predictor or outcome variable, the mean of the
actual RADS score was computed and used to further reinforce the findings.
High-risk behaviors.: These are behaviors which can be seen as potentially
damaging to an adolescent developmentally, affectively, cognitively, physiologically, or in
any combination o f those factors. The definitions of the specific behaviors in this study
are: Unprotected sex'. The adolescent and/or his or her partner did not use any
contraceptive method to prevent infection with a sexually transmitted disease and/or
pregnancy the last time he or she had sexual intercourse.
Substance abuse: The subject had ingested alcohol, marijuana, any form of
cocaine, steroids, or any other illegal drug, such as LSD, PCP, methamphetamines, heroin,
etc., or used an inhalant such as glue, paint, or liquid paper to get high at some time in the
previous 30 days.
Cigarette smoking'. The subject had smoked a cigarette or cigarettes at some time
in the previous 30 days.
Truancy'. The subject “ditched”, or was truant from, school at some time in the last
30 days.
Suicidality: Two levels of suicidality were specifically addressed in the study:
Ideation: Since the parents’ divorce, had the adolescent seriously
considered attempting suicide and/or made a plan for how he or she would
commit suicide;
Attempt: Since the parents’ divorce, had the adolescent actually attempted
suicide.
The independent and dependent variables addressed by the study and the methods
used to collect data on them can be seen in Table 3. Also shown are the intervening and
extraneous variables of interest.
Table 3. Variables.
variable Definition Instrument Source o f data
Independent
Coping style: The predominant Kidcope Self-report
-Positive/approach coping style o f the
-Negative subject, per the
/Avoidance Kidcope result.
Dependent
Depression A raw total RADS Reynolds Self-report
score o f 77 or Adolescent
higher Depression Scale
(RADS)
High-risk behaviors The subject and/or Youth Risk Self-report

- Unprotected sex his/her partner used Behavior Survey
no contraception the (YRBS)
last time he or she
had sexual
intercourse.
-Substance abuse The subject has

ingested alcohol,
marijuana, any form
of cocaine, steroids,
or any other illegal
drug, such as LSD,
PCP,amphetamines,
heroin, etc., or used
an inhalant such as
glue, paint, or liquid
paper to get high at
some time in the
past 30 days.
- Cigarette smoking The subject has

smoked a cigarette
or cigarettes in the
past 30 days.
- T ruancy The subject ditched

or was truant from
school at some time
in the last 30 days.
Table 3, cont?d.
Variable________________ Definition________________ instrument______________ Source o f data
Dependent,cont’d
Suicidality
• Ideation Since the parents’ Youth Risk Self-report
divorce, has the Behavior Survey
subject seriously (YRBS)
considered attempting
suicide and/or made a
plan for how he or she
would commit suicide.
- Attempt Since the parents’

divorce has the
adolescent actually
attempted suicide.
Intervening
Primary caretaker Demographic Data Self-report

Any sibling(s) Questionnaire
Parental conflict: (DDQ)
pre-and post-divorce
Parent(s) remarriage
Residing with step
parent
Extraneous
Subject’s gender Demographic Data Self-report

Subject’s ethnicity Questionnaire
Subject’s age within (DDQ)
14-17 year range
Data Collection
Prior to undertaking data collection, permission to conduct the study was obtained
from the University o f California, Los Angeles’ Human Subjects Protection Committee.
Permission was also obtained from the sites from which subjects were recruited. Potential
subjects who responded to recruitment efforts at the sites, and their parent(s) or legal
guardian(s), were familiarized with and asked to sign an informed consent to participate in
the study. Those who consented to take part in the study were then screened for sample
selection criteria. Individuals who met the criteria were assigned code numbers and an
appointment was made for them to complete the test battery. Each subject was contacted
one day before the scheduled interview time to confirm the appointment. At the appointed
time they completed the demographic data questionnaire, through which information on
intervening and extraneous variables was gathered and recorded, and then the other
instruments. A time period of approximately one to one-and-a-half hours was allowed for
each interview.
Pilot Study
A pilot study was conducted with the first eight subjects who met Group I (n = 4)
and Group II (n = 4) criteria. The purpose o f the pilot was to determine the feasibility o f
the study, to obtain information for improving the project, and to minimize the possibilities
o f unforeseen problems arising during the study itself. Since interviews were scheduled
and questionnaires administered, the pilot study also served to assess whether respondents
were able to understand the questions and directions, or if they might find specific
questions in some way objectionable (Polit & Hungler, 1987).
When the data from the pilot were collected and examined, it was determined that:
1. major revisions would not be necessary;
2. it was possible to secure the cooperation of subjects;
3. the projected cost of the study was reasonable;
4. respondents were able to understand the questions and directions;
5. the questions were not felt to be objectionable.
Chapter 5
Results
Introduction
This study has identified and described selected factors that have an impact on the
adaptiveness of adolescents’ coping after their parents’ divorce. The Psychodynamic
Model o f Adolescent Suicidality provided the conceptual framework for this study. It was
anticipated that there would be significant associations and interrelationships between the
adolescents’ coping styles, depression, engagement in high-risk behaviors, and suicidality.
It was further expected that there would be a significant difference in these variables
between the nonhospitalized and the hospitalized groups. The ultimate goal of a study
such as this is, of course, to contribute to knowledge leading to the development of
interventions which help to prevent the tragedy of childhood suicide, and aid in
determining at which point such interventions would be most effective.
Data Analysis
Table 3, on page 49, outlines the operational definitions o f the variables for which
data were collected and analyzed in this study.
Descriptive statistics such as frequency distributions, means, and standard
deviations were used to summarize gender, grade in school, ethnicity, current age, and
age at the time of the divorce in the total sample and in each group. The significance of
the differences in mean ages between the groups was examined with /-tests, used to
analyze the data. Frequency distributions were also used to describe the responses to the
Demographic Data Questionnaire in the total sample and both groups. Significant
differences in responses by group were examined with likelihood ratio yc analyses.
Descriptive statistics were also used to examine and compare the data collected
about depression, using the RADS as both a categorical and a continuous variable.
Bivariate relationships in the hypotheses were tested using likelihood ratio x2s with
phi (<p) coefficients, and odds (relative risk) ratios. Phi correlation coefficients were
calculated to describe the degree of association between the outcome variables of coping
strategy and depression, engagement in unprotected sex, substance abuse, cigarette
smoking, truancy, and suicidality (Aim I); between depression and engagement in high-
risk behaviors (Aim 2); between engagement in high-risk behaviors and suicidality (Aim
3); between depression and suicidality (Aim 4), and between these characteristics in the
two groups (Aim 5).
The cp coefficient is a nonparametric measure o f degree of association which is free
from the influence of total sample size. Used with dichotomous nominal level data, it is
interpretable as a correlation coefficient, i.e., values close to zero indicate little if any
association, values close to 1 indicate almost perfect predictability (Jaeger, 1990).
Relative risk was computed since, in studies with an equivalent number of subjects
in each group, relative risk can be interpreted as an odds ratio. Odds or relative risk ratios
are employed to facilitate interpretation of the findings and their significance, and thus as a
measure of the degree of association between an antecedent factor and an outcome event.
These ratios are appropriate for use with dichotomous nominal predictor and outcome
variables; they are the number of observations that had the event divided by the number
that did not have the event, i.e.,
Number of observations with event

Relative risk = _______________________________________
or odds ratio
Number of observations without the event
If the probability of an event is small, relative risk ratios have a value that is very
close to the probability o f the event (Fleiss, 1981).
Finally, if any pairwise associations between the variables were found to be
significant, logistic regression coefficients were performed for multivariate analyses. While
these regressions do not establish a causal ordering o f the elements in the model, they
further clarify the roles played in the model by these elements.
Results
Characteristics of the sample
A total of 80 subjects participated in the study. Their characteristics are presented
in the tables below. As shown in Table 4, the average current age o f the subjects was 16
years (SD=1.05), while their average age at the time of their parents’ divorce was 13 years
(SD=1.24).
Table 4. Mean ages for the total sample.
M SD
Current age (in years) 16.0 1.05

Age at time o f divorce (in years) 13.3 1.24
The frequency distribution in Appendix E provides a description of the
characteristics o f the total sample. Most o f the subjects were female (66%) and Caucasian
(44%). The majority o f the adolescents in the study currently live with their mothers
(68%), most of whom have not remarried (53%). In their immediate families, defined as
parents, siblings, grandparents, aunts, or uncles, more than half of the young people had a
family member who had been treated for depression (51%). Many had immediate family
members who had abused and/or been addicted to drugs (48%) and who had attempted
suicide (41%).
The adolescents in the study reported a number of situations indicative of conflict
between their parents. Three-quarters of the children perceived their parents as angry at
each other both before and after the divorce (73%), and 64 percent saw them as having
been verbally abusive toward each other. Almost one third also reported that there had
been physical abuse between their parents before and/or after the divorce (30%).
A trend was also noted among the friends o f adolescents in the study. Almost half
o f their friends had been treated for depression (49%). Substance abuse seemed a
significant problem, with a majority of the young people reporting that they have friends
who abused drugs (64%), and many more who smoke cigarettes on a regular basis (80%).
Most of the children in the sample had friends who had attempted (49%), or actually
completed (14%), suicide. This last finding exceeds the 8% to 11% completed suicides
reported by the CDC (1994, April 22).
The YRBS shows a clear pattern with regard to adolescent sexual behaviors, in
that a large majority of the total sample reported being sexually active (62%), which
corresponds closely with the CDC’s figures of 45% to 70%, with a significant number
having had their first sexual experience at age 12 or younger (9%). In fact, while only
about one tenth of the young people became sexually active at age 16 or older (11%),
many more reported becoming sexually active at age 13 or younger (23%). Further, of
those who were sexually active, forty percent had used alcohol or another illicit drug
before engaging in sex. Three quarters o f the children who participated in the study had
smoked at least one cigarette before age 16 (75%), with 57% of those having done so at
12 years of age or younger. Almost half of the teenagers in the study (48%) had smoked
cigarettes at least one day of the previous thirty, which is a significantly higher number
than CDC (1994, March 4) estimates of 20% to 40%, and most o f those who had smoked
on at least one day, had smoked every day of the preceding month (68%).
The perception of adolescents as a population at high-risk for substance abuse
seems to be supported by the data from this study. Almost nine-tenths of the young
subjects had drunk alcohol before age 16 (89%).This is much higher than the CDC figures
o f 55% to 63% (1994, March 4), with 71% having had more than a sip o f alcohol before
they were 12 years old. Almost three quarters of the adolescents had also first
experimented with marijuana before age 17 (71%).This is a notably larger percentage than
that reported by the CDC, which ranged from 16% to 31%, and 20% of the teens in this
study had done so before they reached age 12. Further, one third of the subjects reported
having used cocaine (34%). This, too, is a larger number than that suggested by the CDC,
which was 2% to 7%.
Frequency distributions were calculated for both groups’ responses to the DDQ.
The demographic data were then analyzed to discern any differences between
nonhospitalized subjects (Group I) and hospitalized subjects (Group II). T-test analyses
were performed to determine if there was significant difference in current ages and age at
time o f divorce, and none were found. Likelihood ratio x2s were then calculated to detect
any significant differences between Group I and Group II nominal level demographic
variables, such as with whom the adolescent resided at the time of the study, whether or
not the parent(s) had remarried, whether the subject was living with a stepparent or has
siblings, and whether the subjects believed that their parents were angry at each other
before and after the divorce. As shown in Table 5, the groups were homogeneous in
terms of demographic questionnaire data. Significant differences between the groups were
found, however, on certain variables. In response to a question asking whether anyone in
their immediate families had ever attempted suicide, more than half of the hospitalized
subjects (Group II) responded “yes” (58%), while only 25% of the nonhospitalized
subjects did so (LR =9.5, p=.0\). Asked whether anyone in their immediate families had
committed suicide, 35%ofthe hospitalized subjects said “yes”, while 10% of the
nonhospitalized subjects responded positively (LR=8.10, p=.Q2). Seventy percent of the
hospitalized sample had friends who had been hospitalized or treated for depression, but
only 27.5% of the nonhospitalized sample replied affirmatively (Z./?=l5.23,p=.000).
Finally, a significant difference between the groups was found in response to whether
either or both of the subjects’ parents had ever physically abused the other. Forty-two
point five percent of the hospitalized adolescents reported that such abuse had occurred,
while just 17.5% of the nonhospitalized adolescents did so (LR-6.22, p=.04).
Table 5. Frequency distributions and likelihood ratio x2s for questionnaire responses.
Nonhospitalized Hospitalized
(n=40) (n=40)
Variable JL S i - n % Likelihood ratio y-
What is your sex? 0.50

Female 28 70.0 25 62.5
Male 12 30.0 15 37.5
In what grade are you? 1.40

8th 2 5.0 3 7.5
9th 7 17.5 9 22.5
10th 13 32.5 9 22.5
11th 11 27.5 13 32.5
12th 7 17.5 6 15.0
Do you describe yourself as: 3.40

White or Caucasian 18 45.0 17 42.5
Black or African American 7 17.5 7 17.5
Hispanic or Latino 8 20.0 6 15.0
Asian or Pacific Islander 3 7.5 2 5.0
Native American or 0 0 2 5.0
American Indian
Other 3 7.5 2 5.0
No response I 2.5 4 10.0
With whom do you live now? 9.46

Mother 25 62.5 29 72.5
Father 5 12.5 8 20.0
Other relative(s) 4 10.0 3 7.5
Other nonrelative(s) 6 15.0 0 0
Have either of your parents

gotten married again?
Mother 1.80
Yes 22 55.0 16 40.0
No 18 45.0 24 60.0
Father 0.31
Yes 18 45.0 16 40.0
No 21 52.5 24 60.0
No response 2.5 0 0
Are you presently living with 1.70

a stepparent?
Yes 15 37.5 10 25.0
No 24 60.0 30 75.0
No response 2.5 0 0
Table 5. cont’d.
Ouestion n % n % Likelihood ratio y:
Do you have any sisters or 1.90

brothers?
Yes 29 72.5 34 85.0
No 11 27.5 6 15.0
Do you consider your parents’ 0.65

divorce an important event in
your life?
Yes 24 60.0 24 60.0
No 12 30.0 14 35.0
Don’t know 4 10.0 2 5.0
Has anvone in vour immediate 4.60

familv ever been hospitalized or
treated for depression?
Yes 16 40.0 25 62.5
No 15 37.5 11 27.5
Don’t know 9 22.5 4 10.0

familv ever smoked cigarettes
regularly?
Yes 30 75.0 30 75.0
No 9 22.5 9 22.5
Don’t know 1 2.5 1 2.5

familv ever abused or been addicted to drues?
Yes 17 42.5 21 52.5
No 15 37.5 14 35.0
Don’t know 7 17.5 4 10.0
No response 1 2.5 1 2.5
Has anvone in vour immediate 9.5**

familv ever attempted suicide?
Yes 10 25.0 23 57.5
No 11 27.5 8 20.0
Don’t know 19 47.5 9 22.5
* p i .05 * * p s . 0 i * * * p s.0 0 i
Table S. cont'd.
Ouestion n % n % Likelihood ratio y:
Has anvone in vour immediate 8.10*

familv ever committed suicide?
Yes 4 10.0 14 35.0
No 23 57.5 19 47.5
Don’t know 13 32.5 7 17.5
Have anv o f vour friends been 15.23***
hospitalized or treated for
depression?
Yes 11 27.5 28 70.0
No 26 65.0 10 25.0
Don’t know 3 7.5 2 5.0
Have anv o f vour friends smoked 2.20

cigarettes regularly?
Yes 30 75.0 34 85.0
No 9 22.5 4 10.0
Don’t know 1 2.5 1 2.5
No response 0 0 I 2.5
Have anv o f vour friends abused 2.80

or been addicted to drugs?
Yes 23 57.5 28 70.0
No 16 40.0 II 27.5
Don’t know 1 2.5 0 0
No response 0 0 1 2.5
Have anv o f vour friends 0.59

attempted suicide?
Yes 8 20.0 31 77.5
No 28 70.0 6 15.0
Don’t know 3 7.5 3 7.5
No response 1 2.5 0 0
Have anv o f vour friends 4.16

committed suicide?
Yes 3 7.5 8 20.0
No 36 90.0 29 72.5
Don’t know 1 2.5 3 7.5
* p s.05 **pz. 01 ***pa.Q01
Table 5, cont'd.
Ouestion n % n % Likelihood ratio y2
Do either or both o f your 2.00

parents often seem to be
angry at the other?
Yes 28 70.0 30 75.0
No 11 27.5 7 17.5
Don’t know 1 2.5 3 7.5
Has either or both o f your 5.10

parents ever verballv abused
the other by cursing, name-
calling, threatening, and so on?
Yes 24 60.0 27 67.5
No 15 37.5 I 30.0
Don’t know I 2.5 1 2.5
Has either or both o f your 6.22*

oarents ever phvsicallv abused
the other by slapping, shoving,
punching, using a weapon, and
so on?
Yes 7 17.5 17 42.5
No 26 65.0 19 47.5
Don’t know 7 17.5 4 10.0
* p <..05 **ps.01 ***/>£.001
Tests of hypotheses
Results for the five hypotheses tested are discussed below and shown in Tables 6-
14. For adolescents who have not been hospitalized for psychiatric treatment since their
parents’ divorce (Group I) and those who have been hospitalized for psychiatric treatment
since the divorce (Group II):
Hypothesis 1: There will be a statistically significant association between coping strategy
and depression, engagement in unprotected sex, substance abuse, cigarette smoking,
truancy, and suicidality.
The hypothesis was partially supported in that adolescents who typically used a
negative/avoidance coping style were more likely to be depressed and suicidal, regardless
of hospitalization status than those who used positive/approach coping strategies. In
addition, there were indications that some o f the negative copers were more likely to
engage in some of the high-risk behaviors.
As shown in Table 6, for the total sample, a strong association was found between
negative/avoidance coping and depression (<p=.60, p=.000). Even among nonhospitalized
subjects, there was a significant and robust association between the two (<p=.46, p=.007).
The relationship was stronger for the hospitalized subjects (<p=.75, p=.000). Among
hospitalized subjects, a weak but statistically significant association was discerned between
negative/avoidance coping and the non-use of protection against pregnancy at the
subjects’ last sexual experience (tp=.39; p=.05). A significantly strong association was
found between negative coping and substance abuse in the nonhospitalized group. There
were no significant associations found between coping style and cigarette smoking in the
last 30 days among all subjects, regardless o f hospitalization status. In the total sample, a
weak association, providing modest evidence against H^, was found between negative
coping and truancy in the last 30 days (<p=.29; p=.01). Negative copers in the
nonhospitalized sample were even more likely to have been truant (<p=.44, p=.009). Weak
associations which provide strong evidence against the null hypothesis were also found
between negative coping and adolescents’ suicidality since the divorce, both in ideation
(<p=.39; / t=.000) and attempt(s) (<p=.33; p=.004). Finally, in the total sample of both
hospitalized and nonhospitalized adolescents who completed usable instruments, more
subjects used negative/avoidance coping (46%) than used positive/ approach coping
(44%), although the difference did not reach statistical significance.
Relative risk estimates were then calculated on statistically significant associations.
Among all the adolescent subjects in the study, those who used negative coping were 20
times as likely to be depressed as those who used positive coping. The negative copers in
the nonhospitalized group were almost eight times as likely to be depressed. The
hospitalized negative copers were 100 times as likely to be depressed as the small number
of hospitalized positive copers. Negative copers, as a group, were more than three times
as likely as positive copers to have been truant in the last 30 days, five times as likely to
have had suicidal ideation since their parents divorced, and more than four times as likely
as positive copers to have made one or more suicide attempts since the divorce.
Nonhospitalized adolescents who utilized negative coping strategies were almost four
times as likely to have abused substances in the previous thirty days, and 12‘/2 times as
likely to have been truant from school as the positive copers. Among hospitalized
subjects, the adolescents who used negative coping strategies were over 14 times as likely
as their positive-coping counterparts to have experienced suicidal ideation and nine times
as likely to have made a suicide attempt.
Table 6. Bivariate associations between coping, depression, high-risk behaviors,
and suicidality, with relative risk estimates.
Relative Confidence
Variable Negative cooing risk interval
Depression
All subjects .61*** 20.00 (13.10, 28.66)
Nonhospitalized subjects .46** 7.69 (5.18, 10.40)
Hospitalized subjects .74*** 98.98 (54.97, 108.27)
Unprotected sex (STDs)
All subjects .15
Nonhospitalized subjects 21
Hospitalized subjects .11
Unprotected sex (pregnancy)
All subjects .21
Nonhospitalized subjects .22
Substance abuse
All subjects .22
Cigarette smoking
All subjects .22
Truancy
All subjects .29** 3.57 (2.79, 5.29)
Suicidality (ideation)
All subjects .39*** 5.26 (3.18, 7.28)
Hospitalized subjects .58*** 14.29 (9.32,18.18)
Suicidality (attempts])
All subjects .33** 4.55 (2.14, 6.52)
Hospitalized subjects .48** 9.09 (7.66, 14.00)
*P £.. 05 **ps.0t ***ps.001
Table 7 confirms that when the association between coping style and depression is
calculated with the RADS computed as a continuous variable, the findings rem ain almost
the same as those found with the RADS as a dichotomous variable, i.e., negative/
avoidance coping is strongly associated with depression. While the association continues
to be strongest for the hospitalized sample, there is still a robust relationship between
actual RADS score and depression in the total sample and a statistically significant
association even in the nonhospitalized sample.
Table 7. Mean group differences for coping style and depression.
Variable N Mean RADS score SD r-value
All subjects
Positive/approach coping 35 65.88 16.98 - 6.54***
Negative/avoidance coping 37 89.57 13.69 (df=70)
Nonhospitalized
Positive/approach coping 27 62.56 15.53 3.49*
Negative/avoidance coping 9 74.11 11.78 (df=34)
Hospitalized
Positive/approach coping 8 77.00 17.90 - 3.59***
Negative/avoidance coping 28 94.54 10.17 (d£=34)
*ps.05 **ps.01 ***pz. 001
Hypothesis 2 : There will be a statistically significant association between depression and
engagement in high-risk behaviors, i.e., engagement in unprotected sex, substance abuse,
cigarette smoking, and truancy.
This hypothesis, too, was partially supported. Among all the adolescents in this
study the relationship between depression and high-risk behaviors was strong. As can be
seen in Table 8, statistically significant associations were found in the total sample
between depression and some variables, i.e, engagement in unprotected sex for sexually
transmitted diseases (<p=.27; p=.01) and pregnancy at last sexual engagement (cp=.24;
p=.03). Associations were also found in the total sample between depression and
substance use in the previous 30 days (<p=.28; p=.01); cigarette smoking in the last 30
days (cp=.33; /?=.003), and truancy in the past 30 days (<p=.35; />=.001).
Relative risk estimates were computed for significant factors. In this case, subjects
who were clinically depressed were assessed for risk of various outcomes. Adolescents
who were depressed were found to be close to four times as likely to have engaged in sex
without protection against sexually transmitted diseases and five times as likely not to
have used protection against pregnancy at their last sexual encounter. Depressed subjects
were more than three times as likely to have abused drugs, almost four times as likely to
have smoked cigarettes, and five times as likely to have been truant as their non-depressed
peers in the study.
Table 8. Bivariate associations between depression and high-risk behaviors, with
relative risk estimates.
Relative Confidence
Depression risk interval

All subjects 21** 3.80 (1.23, 11.6)
Hospitalized subjects 22
All subjects 24* 4.90 (0.99, 23.84)
Substance abuse
All subjects .28** 330 (1.26, 8.69)
Cigarette smoking
All subjects 22** 3.95 (1.55, 10.11)
Nonhospitaiized subjects .25
Truancy
All subjects 35*** 5.05 (1.76,14.52)
* p i .05 **ps .01 ***/?s.00l
When the association between depression and high-risk behaviors was calculated
with the RADS as a continuous variable, results were the same. As shown in Table 9,
using either method of assessing depression, a large number o f adolescents, regardless of
hospitalization status, were significantly depressed. In treating the RADS as a categorical
variable with a score of 77 as the cut-point for clinically significant depression, 45 percent
were found to be depressed. Using the actual RADS score as a continuous variable, the
median score for the entire sample was 83 points.
Table 9. Mean differences in depression scores by engagement in high-risk behaviors.
Variable N Mean RADS score SD r-value
Ail?,shiest?
Yes 22 87.00 14.04 2.70**
No 57 74.53 19.80 (df=77)
Yes 12 89.92 11.51 3.32*
No 67 75.85 19.47 (df=77)
Substance abuse
Yes 53 82.23 15.41 2.71**
No 27 70.44 23.29 (df=78)
Cigarettes
Yes 40 84.63 15.08 2.38**
No 40 71.86 20.77 (df=78)
Truancy
Yes 29 86.83 13.45 2.50**
No 51 73.37 20.26 (df=78)
05 **ps .01 ***/>s.00l
Hypothesis 3: There will be a statistically significant association between suicidality
(ideation and/or attempt[s]) and engagement in high-risk behaviors since parental divorce.
This hypothesis was only modestly supported. As a group, teenagers in the study
who had suicidal ideation were more likely to be cigarette smokers, and this was also true
for the nonhospitalized adolescents. There was no clear association, however, between
suicidal ideation and the other high-risk behaviors. For all the adolescents who had made
suicide attempts after their parents divorced, the only significant factors were that they
were more likely to have engaged in sexual activity without using birth control, and to
have smoked cigarettes. Among the nonhospitalized young people who had reported
attempting suicide, the only associated risk behaviors were substance abuse and cigarette
smoking. Table 10 shows that for all subjects, a weak association was found between
suicidal ideation and cigarette smoking in the last 30 days (<p=.35; /?=.001). A moderate
association, providing strong evidence against Ho, was found among nonhospitalized
subjects between suicidal ideation and recent cigarette smoking (cp=.42; p=.007).
With regard to suicide attempt(s), the only associations found were in the total
sample, between history of attempts and unprotected sex (pregnancy) at time of last sexual
experience (<p=.28; p=.01)), and cigarette smoking in the past 30 days (<p=.31; p=.005).
The only other associations were found between active suicidality and two other variables
in the nonhospitalized sample, but not in the hospitalized sample. These associations
were between a suicide attempt or attempts since the divorce and substance use in the
previous 30 days (<p=.30; /?=.02), and between suicidality and cigarette smoking in the
previous 30 days ((p=.35; p=.02). This is shown in Table 11.
The relative risk of a subject in the total sample who was experiencing suicidal
ideation having smoked a cigarette in the last 30 days was over four times as great as that
of a non-suicidal subject. A nonhospitalized subject who was experiencing suicidal
ideation was slightly more than five times as likely to have smoked a cigarette in the last
30 days. The risk of smoking for a subject who had attempted suicide since his or her
parents’ divorce was four times that of an adolescent subject who hasn’t made a suicide
attempt. A nonhospitalized subject who had made at least one suicide attempt was slightly
less than four times as likely to have used an illicit substance in the past 30 days as a
nonsuicidal subject who was not hospitalized. Further, a subject who had tried to kill
himself at least once was almost five times as likely as a non-suicidal subject to have used
no protection against pregnancy the last time he or she engaged in sexual intercourse.
Table 10. Bivariate associations between suicidal ideation and high-risk behaviors, with
relative risk estimates.
Suicidal Relative Confidence

ideation risk interval
Unprotected sex ( STDs)

All subjects .15
All subjects .20
Substance abuse
All subjects .12
Cigarette smoking
All subjects 35*** 4.33 (1.67,11.07)
Nonhospitalized subjects .42** 5.20 (1.32,20.54)
Truancy
All subjects .14
*p s.05 ***ps.00l
Table 11. Bivariate associations between suicide attempt(s) and high-risk behaviors,
with relative risk estimates.
Suicide Relative Confidence

a tte m p ts). . risk interval
Unprotected sex ( STDs)
All subjects .21
All subjects .2 8 * * 4.70 (1.27, 17.41)
Substance abuse
All subjects .14
Nonhospitalized subjects JO * 3.75 (0.83, 16.99)
Cigarette smoking
All subjects J l* * 4.00 (1.48, 10.79)
Nonhospitalized subjects J5 *
Truancy
All subjects .21
*p<. .05 **p&.01 ***ps.001
Hypothesis 4: There will be a statistically significant association between depression and
suicidal ideation and/or attempt(s).
Not surprisingly, among all the subjects in the study, regardless of hospitalization
status, teens who were depressed were very likely to have had thought of suicide or to
have attempted suicide. The surprising finding was that while this remained true for
nonhospitalized adolescents, the relationship between depression and suicide was much
smaller for hospitalized adolescents. Relatively strong associations were found between
the presence of clinical depression and suicidality in all subjects, as shown in Table 12.
For depression and suicidal ideation in the total group, the <p value was .62 at a p of .000;
for suicide attempt(s), the <p was .49, and p=.000. Depressed nonhospitalized subjects,
too, were likely to experience suicidal ideation (<p=.55; p=.000) and to have made a
suicide attempt or attempts (<p=.35; p=.02). Unexpectedly, however, while there was a
significant association between depression and suicidal ideation among hospitalized
subjects (<p=.32; p=.05), the association between depression and suicide attempt(s) among
the hospitalized adolescents did not approach statistical significance.
Estimates for the relative risk that subjects in the total sample who were clinically
depressed would experience suicidal ideation or have made at least one suicide attempt
since their parents’ divorce are shown in Table 18. Those who were depressed were more
than 19 times as likely to have had thoughts of suicide as those who did not meet the
study’s criteria for depression. These subjects, furthermore, were about 13 times as likely
to have made a suicide attempt. Nonhospitalized adolescents who met depression criteria
were almost nine times as likely to experience suicidal ideation and only a little more than
six times as likely to have made a suicide attempt as their hospitalized study peers.
Among the hospitalized adolescents, not surprisingly, those who were clinically depressed
were more than 53 times as likely to have experienced suicidal ideation since their parents’
divorce as the nondepressed patients.
Table 12. Bivariate associations between depression and suicidality. with relative risk
estimates.
Relative Confidence
Variable Depression risk interval
Suicidal ideation
All subjects .62*** 19.33 (6.17,60.63)
Nonhospitalized subjects .55*** 8.67 (2.00,37.37)
Hospitalized subjects .32* 53 23 (7.93,358.78)
Suicide attempt(s)
All subjects 49*** 13.33 (3.56,49.99)
Nonhospitalized subjects 35* 6.25 (1.14,34.12)
*ps.O5 **p i . 01 ***/>s.00l
The association between depression and suicidality remained strong regardless of
which method was used to quantify depression. The unexpected finding that depression
was associated much more strongly with suicidal ideation than with suicide attempt(s) was
also reconfirmed when the actual score on the RADS was used. This is shown in Table 13.
Table 13. Mean differences in depression scores by suicidality.
Variable 1V Mean RADS score SD r-value
All subjects
Suicidal ideation
Yes 42 89.95 14.32 2.21***
No 38 65.32 15.08 (df=78)
Suicide attempt
Yes 28 91.75 12.06 2.28***
No 52 70.98 18.34 (df=78)
Nonhospitalized
Suicidal ideation
Yes 10 7930 15.85 3.49***
No 30 61.57 13.27 (df=38)
Suicide attempt
Yes 4 85.50 9.04 2.83**
No 36 63.83 14.92 (df=38)
Hospitalized
Suicidal ideation
Yes 32 93.28 12.26 2.81**
No 8 7936 13.69 (df=38}
Suicide attempt
Yes 24 92.79 12.33 1.32
No 16 87.06 15.05 (df=38)
*ps.05 **p<;.01 ***ps.001
Hypothesis 5: There will be a statistically significant difference in hospitalization status of
subjects associated with coping style, depression, engagement in high-risk behaviors, and
suicidality.
With regard to the total sample, frequency distributions indicated that more than
half of the adolescents were significantly depressed. When depression was examined as a
categorical variable, with a RADS score of 77 points or higher signifying clinical
depression, more than 56 percent (n=45) of all the adolescents in the study were
depressed. When RADS scores were considered as a continuous variable, the results were
the same, with a mean RADS score for the entire adolescent sample of 78.25 (SD=19.14).
Findings on the differences between the groups could not be considered
unexpected. The teenagers who were hospitalized for psychiatric treatment were much
more likely to have used negative/avoidance coping, to be depressed, to have engaged in
risky behaviors, and to have attempted suicide at least once than were the nonhospitalized
teens. The only area in which there was no difference in hospitalization status was
whether or not the adolescents had had thoughts of suicide. As shown in Table 14,
associations were found demonstrating that the hospitalized adolescents were significantly
more likely to use negative/avoidance coping strategies (<p=.53, p=.000), to be clinically
depressed (<p=.58; p=.000), to have engaged in sex the last time without using protection
against sexually transmitted diseases (cp=.35; p=.002) or pregnancy (<p=.29; p=.01); to
have used substances of abuse within the last 30 days (<p=.24; p=.03), to have smoked at
least one cigarette in the last 30 days (q>=.45; p=.000), to have been truant in the last 30
days ((p=.29; p=.01), to have experienced suicidal ideation (cp=.55,p=.000) and to have
made at least one suicide attempt since the divorce (<p=.52; p=.000).
The relative risk factors are estimates o f the odds o f a subject in the hospitalized
group experiencing the other factors specified. Members o f the hospitalized group were
about 16 times as likely as the nonhospitalized subjects to use negative coping strategies.
Compared to nonhospitalized subjects, the hospitalized teenagers were about 15 times as
likely to meet criteria for clinical depression, about 54 times as less likely to engage in sex
without using protection against sexually transmitted diseases and more than 65 times as
likely not to have used birth control, and were a little more than eight times as likely to
have abused drugs. Hospitalized subjects were more than 69 times as likely to have
smoked at least one cigarette in the last 30 days, over 34 times as likely to have been
truant, and about 14 times as likely to have made at least one suicide attempt since the
divorce.
Table 14. Bivariate associations between hospitalization status and coping, depression,
high-risk behaviors, and suicidality, with relative risk estimates.
Association with Relative Confidence

Hospitalization status risk interval
Negative coping .53*** 15.94 (13.53,31.21)

Depression .58*** 14.93 (11.61,20.30)
Unprotected sex (STDs) .35** 54.05 (38.40, 57.20)
Unprotected sex (pregnancy) 29** 65.36 (51.93,75.11)
Substance abuse .24* 28.17 (16.27,38.42)
Cigarette smoking .45*** 69.44 (56.11,76.33)
Truancy .29** 34.48 (20.59,44.96)
Suicidal ideation .02
Suicide attempts) .52*** 14.29 (10.22, 24.93)
*P<..05 **Ps.01 ***P s.001
Multivariate analyses
After the hypothesis testing addressed the pairwise relationships in the study, a
more comprehensive perspective was needed as a way to further examine the proposed
theoretical model. Logistic regressions were conducted in order to accomplish this end.
First, as the literature does not support a clear cut causal ordering, the elements of the
model were considered as predictor and outcome variables. Significant clinical depression
was found in the majority o f the adolescents subjects who participated in the study, both
nonhospitalized and hospitalized. Substance abuse was chosen as the representative high-
risk behavior variable for several reasons. First, the majority of the published research
which was reviewed for this study reported a clear association between substance abuse
and suicide. In addition, depression and most of the other high-risk behaviors in this
study, as well as those in other research, were found to be associated with substance abuse
at some level. Finally, suicidal ideation and suicide attempt(s) were used as outcome
variables because the alarmingly increased incidence of childhood and adolescent suicide
over the past few decades has made it an important public health issue. Most of the
current related research describes associations between suicidality and depression, coping,
and risky behaviors.
As can be seen in Table 15, two variables were significant in predicting
depression. Logistic regressions indicated that those with negative/avoidance coping
styles had over 14 times as much chance of being depressed as did those with
positive/approach coping styles, and those who experienced suicidal ideation were about
22 times as likely to be depressed as those who did not experience suicidal ideation.
Although coping style and several other factors had been associated with depression in
bivariate analyses, only a negative coping style and suicidal ideation were significantly
associated when logistic regression was calculated with depression as the outcome
variable when all factors were included.
Table 15. Logistic regression coefficients for depression.1
Variable B S.E. Wald. df=l p Exd (B)
Negative coping 2.63 0.85 9.60 .001*** 14.29

Unprotected sex, STDs 1.74 1.47 1.41 235 5.71
Unprotected sex, preg. 0.78 1.93 0.16 .685 2.19
Substance abuse -036 1.02 0.13 .724 0.68
Cigarettes 0.13 0.88 0.02 .885 1.13
Truancy 1.73 1.04 2.76 .097 5.66
Suicidal ideation 3.08 1.06 8.50 .004** 21.70
Suicide attem pts) -0.17 1.11 0.02 .880 0.85
*ps.05 **Ps. 01 ***P s.001

* Model chi-square=52.22, df=8, p=.0Q0
As shown in Table 16, of 39 subjects observed to be clinically depressed, the
model correctly predicted 35 (90%); of 31 subjects observed not clinically depressed, the
model correctly predicted 28 (90%), providing an overall rate for correct predictions of
90%.
Table 16. Classification table for depression.
Predicted
Percent correct
Observed Yes No
Yes 15 4 89.74%
No 1 28 90.32%
Overall 90.00%
Because, when pairwise relationships were examined, depression was found to be
strongly associated with both suicidal ideation and with suicide attempt(s), further
analysis was done to explore the potential overlap of these predictors. As can be seen in
the logistic regression model in Table 15, with both suicidal ideation and suicide
attempt(s) in the equation, ideation carried that prediction. The association between
depression and suicide attempt(s) was not significant. Tables 17 and 18 show that when
suicide attempt(s) were removed from the multivariate model, ideation remained
significantly associated with depression. With or without suicide attempt(s) in the model,
people with suicidal ideation were about 20 to 22 times as likely to be depressed as those
who did not have suicidal ideation. The association of depression and suicide attempt(s)
did not reach statistical significance even when suicidal ideation was removed from the
equation.
Table 17. Logistic regression coefficients for depression, with suicide attempt(s)
omitted from the modei. *
Variable B S.A. Wald. df=l D ExpfBl
Negative coping 2.62 0.85 9.60 . 002 ** 14.29

Unprotected sex, STDs 1.73 1.45 1.41 .236 5.61
Substance abuse -0.36 1.02 0.13 .727 0.70
Cigarettes 0.11 0.87 0.02 .902 1.11
Truancy 1.71 1.02 2.78 .095 5.51
Suicidal ideation 2.99 0.89 11.21 . 001 *** 19.97
*ps. 05 **p=s.01 ***p=s.001

* Model chi-square=52.20, df=7, p=.000
Table 18. Logistic regression coefficients for depression, with suicidal ideation omitted
from the model.a
Variable B S.A. Wald. df=l p Exp(B)
Negative coping 2.58 0.72 12.76 , 000*** 12.50

Substance abuse -0.16 0.84 0.04 .849 0.85
Cigarettes 1.51 0.84 0.66 .416 1.85
Truancy 1.02 0.81 1.58 .209 2.77
Suicide attempt(s) I.5I 3.45 1.77 .071 4.54
*pz. 05 **ps.01 ***ps.001

* Model chi-square=40.76, df=7, /?=.000
Of further interest was the difference between multivariate and bivariate results for
the relationships between depression and the high-risk behaviors. Statistically significant
bivariate associations were found between depression and unprotected sex for STDs and
pregnancy, substance abuse, cigarette smoking, and truancy. When all the variables were
included in regression equations, however, the results were somewhat different. In the
model with depression as the dependent variable, shown previously in Table 15, there
were no significant associations between depression and any of the predictor variables for
high-risk behaviors.
In predicting substance abuse, truancy was found to be significant when other
variables were controlled for. As shown in Table 19, adolescents who were truant were
almost nine times as likely to engage in substance abuse as the adolescents who were not
truant.
Table 19. Logistic regression coefficients for substance abuse.1
Variable B S.A. Wald. df=l P ExpfBl
Negative coping .48 .73 .44 .506 1.62

Depression .25 .89 .08 .775 1.29
Unprotected sex, preg. .16 1.60 .01 .918 1.18
Cigarettes 1.04 .70 2.22 .136 2.84
Truancy 2.16 .80 7.23 .007** 8.65
u>
©
1
Suicidal ideation .92 .00 .971 .97

Suicide attempts) -1.16 .96 1.46 .227 .31
V *.05 **p i .01 ***ps.00l

'M odel chi-square=22.74, df=8,p=.004
Table 20 demonstrates that of 45 subjects observed to have abused substances in
the previous 30 days, the model correctly predicted 35 (78%); of the 25 subjects who did
not engage in substance abuse, the model correctly predicted 18 (72%), for an overall
successful prediction rate of 76%.
Table 20. Classification table for substance abuse.
Predi&gd
Percent correct
Observed____________ Yes No
Yes 35 10 77.78%
No 7 18 72.00%
Overall 75.71%
Finally, the various elements that might be considered to be associated with
suicidality were examined. Table 21 illustrates multivariate relationships with suicidal
ideation. Depression was one of the two significant factors which could be considered
predictive o f suicidal ideation. The odds o f a depressed adolescent having had suicidal
ideation were more than 25 times as great as those of an adolescent who was not
depressed. The other significant variable was a history of one or more suicide attempts
made by the adolescent since his or her parents divorced. Adolescents who had made at
least one suicide attempt were almost 64 times as likely to be experiencing suicidal
ideation as were adolescents who had not made a suicide attempt.
Although bivariate comparisons between the factors indicated that
negative/avoidance coping, depression, cigarette smoking, and unprotected sex were each
associated with suicidality, logistic regression results differed in that significant
relationships were only found between depression and suicidal ideation and between
suicidal ideation and suicide attempt(s), controlling for other factors in the equation. In
this model, adolescents experiencing depression were 25 times as likely to have had
thoughts of suicide since their parents’ divorce.
Table 21. Logistic regression coefficients for suicidal ideation/
Variable B S.A. Wald. df=l P ExpfB)
Negative coping .15 .98 .02 .880 1.16

Depression 3.23 1.09 8.80 .003** 25.16
Unprotected sex, STDs -.40 1.02 .16 .693 .67
Unprotected sex, preg. .01 1.62 .00 .995 .99
Substance abuse -.15 1.05 .02 .886 .86
Cigarettes 1.61 .96 2.79 .095 5.01
Truancy -1.96 1.24 2.50 .114 .14
Suicide attempts) 4.15 1.33 9.73 .002** 63.60
*/>s.05 **ps.Q\ 001

1 Model chi-square=51.79, df=8, p=.000
Of 35 subjects observed to have experienced suicidal ideation since their parents
divorced, the model correctly predicted 29 (83%); of the 35 subjects who did not
experience suicidal ideation, the model correctly predicted 29 (83%), for an overall
successful prediction rate of 83%. This is shown in Table 22.
Table 22. Classification table for suicidal ideation.
Predicted
Percent correct
Observed Yes No
Yes 29 6 82.86%
No 6 29 82.86%
Overall 82.86%
Although previous bivariate calculations indicated a strong association between
several of the variables and suicide attempt(s), in the multivariate model illustrated in
Table 23 the only association of note is that between suicidal ideation and suicide
attempt(s). Those subjects who had experienced suicidal ideation since their parents
divorced were about 38 times as likely to have attempted suicide as those who reported
that they had not experienced suicidal ideation.
Table 23. Logistic regression for suicide attempt(s).a
Variable B S.A. Wald. df=l D ExpfBf
Kidcope .60 .77 .61 .434 1.82

Depression .07 1.02 .00 .948 1.07
Unprotected sex, STDs -.10 1.01 .01 .925 .91
Unprotected sex, preg. 1.10 1.41 .61 .434 3.02
Substance abuse -.62 .86 .51 .477 .54
Cigarettes .70 .76 .87 .352 2.02
Truancy .91 .85 1.16 281 2.50
Suicidal ideation 3.65 1.17 9.74 .002** 38.34
*ps.05 **p^.01 ***ps.001

*Model chi-square=37.73, df=8, p=.000
Table 24 shows that, of 23 subjects observed to have attempted suicide since their
parents divorced, the model correctly predicted 19 (83%); of the 47 subjects who did not
make a suicide attempt, the model correctly predicted 39 (83%), for an overall successful
prediction rate of 83%.
Table 24. Classification table for suicide attempt(s).
Predicted
Observed Yes No
Yes 19 4 82.61%
No 8 39 82.98%
Overall 82.86%
Chapter 6
Summary
Introduction
The purpose of this study was to help explain why some adolescents seem to do
well emotionally, cognitively, and behaviorally after their parents divorce, while others
seem to react in maladaptive ways. From evaluating the findings in this research, it is clear
that adolescents, as a group, are a highly vulnerable and at-risk population. Taken as a
whole, the group of young people in the study seemed to be in significant distress
following parental divorce. A greater percentage were found to use negative and
maladaptive coping strategies than used positive strategies for successful coping. More
than half of the total sample were significantly depressed. These children were sexually
active and engaged in unprotected sex, used or abused alcohol and other street drugs,
smoked cigarettes, and had been truant from school at rates exceeding those of the general
population of adolescents, and had begun these activities at younger ages. Many of these
young people had experienced suicidal ideation and had made suicide attempts, with some
having made many attempts.
There were also many disquieting findings relating to the friends and family of
children in the study. More than half reported that their parents were verbally, if not also
physically, abusive to each other. Most had immediate family members who had been
treated for depression, and a large group had family members who had abused drugs
and/or attempted suicide. With regard to their friends, the information given by the
adolescents in the study was also disturbing. The largest group had friends who had been
treated for depression, and the majority disclosed that substance abuse among friends was
an issue. Most tragically, a significant number of the children not only had friends who
had attempted suicide, but had a very great number who had succeeded in committing
suicide. While the literature on the subject of adolescent suicide supports the predictive
power o f a history of suicide among friends and family, the number of adolescents in the
study who reported such data was significantly great even for those who had never made a
suicide attempt.
The hospitalized subjects were more likely to have an immediate family member
who had attempted or committed suicide, to have a friend who had been hospitalized or
otherwise treated for depression, or to have parents who were physically abusive to each
other. It was surprising, however, that there were no significant differences between
hospitalized and nonhospitalized adolescents with regard to whether their parents had
remarried, whether they lived with a stepparent, whether their parents seemed angry at, or
were verbally abusive to, each other before and after the divorce, whether the child
considered the divorce an important event in his or her life, and whether any immediate
family member had been hospitalized or treated for depression or abused drugs. Perhaps
even more unexpectedly, there were no significant differences between psychiatrically
hospitalized and nonhospitalized subjects with respect to whether they had friends who
had ever smoked cigarettes, abused or been addicted to drugs, or had attempted or
committed suicide.
Associations predicted in the hypotheses were also less robust than anticipated.
The connection between coping style and the various negative behaviors or outcomes, for
example, were fewer in number than expected. It was only in the relationship between a
negative/avoidant coping style and depression, as well as in failure to use protection
against pregnancy at the last sexual encounter that significant associations were found in
the hospitalized group. The literature would have led one to expect that the coping style
used by the subjects might have predicted a larger association with factors such as
substance abuse, cigarette smoking, truancy, and suicidality in adolescents hospitalized for
psychiatric treatment since their parents’ divorce.
While there were significant associations in the total sample (n=80), between
depression and high-risk behaviors such as unprotected sex, substance use, cigarette
smoking, and truancy, these associations had been predicted to be even more robust
among depressed adolescents in psychiatric hospitals. This did not prove to be the case.
Based on the literature, it was also hypothesized that there would be significant
associations between suicidality and engagement in high-risk behaviors; that is, that
subjects who had experienced suicidal ideation or had made at least one suicide attempt
since their parents divorce were more likely to engage in the risky behaviors. It was
further presumed that suicidal adolescents were more likely to be found in the hospitalized
population. The findings were almost precisely the opposite o f expectations. For all
subjects, significant associations were only found between suicidal ideation and cigarette
smoking, and, for suicide attempt(s), with sex without protection from pregnancy and with
cigarette smoking. Not a single significant association was found between suicidality and
the majority of the high-risk behaviors. Most notably, significant associations were found
between suicidal ideation and cigarette smoking in the past 30 days, between suicide
attempt(s) and both substance use and cigarette smoking in the past 30 days, and with a
history o f truancy, but these were found only in the nonhospitalized sample.
For the fourth hypothesis, the truly surprising finding was that, while the expected
strong associations were found between depression and suicidality in all subjects, and even
in nonhospitalized subjects, the only hypothesized association which did not achieve
statistical significance was that between depression and suicide attempt(s) since the
divorce among the hospitalized adolescents. That relationship, however, was significant
for nonhospitalized adolescents.
Some predictable associations were, indeed, found in testing H5. Not surprisingly,
adolescents in the hospitalized group were more likely to use negative/avoidance coping
strategies, to suffer from clinical depression, to engage in sex without using protection
against sexually transmitted diseases, to have used illicit substances, smoked a cigarette,
and/or been truant from school within the past 30 days, and to have made at least one
suicide attempt since the divorce. What was surprising, however, was that there were no
significant associations between hospitalization status and suicidal ideation since the
divorce, or in whether or not the subject had made a plan for suicide.
There are several possible explanations for the lack of strikingly significant
differences in some variables between the hospitalized and nonhospitalized samples. All
the subjects were, after all, adolescents, and this is a developmental stage that is normally
conflict-laden and difficult to negotiate. Further, not only were all the subjects adolescents,
but they had all fairly recently experienced their parents’ divorce. Another factor to be
considered is that the two samples were notably homogeneous for most demographic
variables, so it might not be completely surprising that their responses were so similar.
It should also be noted that engagement in high-risk behaviors such as unprotected
sex, substance abuse, cigarette smoking, and truancy are considered by most authorities to
have reached epidemic proportions among all adolescents in the United States. In
addition, anger, and even verbal abuse, are not exceptional occurrences between divorcing
parents. It should probably not be too surprising, therefore, that there was so little
difference between groups for these variables.
Logistic regressions were performed to further examine the specific roles of the
multiple predictor variables. In finding, for example, that negative copers in this study
were far more likely to be depressed than were positive copers, the regression reinforced
the findings when coping and depression had been analyzed as bivariates; the regressions
showed that those findings remained consistent even with the inclusion of other variables.
When both suicidal ideation and suicide attempts were in the equation, ideation carried the
prediction of depression; even when suicidal ideation was removed from the equation,
suicide attempt(s) did not reach statistical significance as a predictive variable. When
suicide attempt(s) were deleted, suicidal ideation was even more strongly predictive of
depression. One possibility for these findings might be the difficulty in separating
suicidality into conceptually distinct elements. Suicidal ideation and attempts were found
to be very closely associated as concepts, and it is difficult to rationalize the presence of
one without the other. Further, it is hard to explain the absence of an association between
suicide attempts and depression or coping in a regression equation. It is possible that
potential depressed subjects who experienced suicidal ideation and made suicide attempts
were not well represented because their suicide attempts were often successful. The fact
that so few variables which were significant in bivariate comparisons with depression were
predictive in logistic regressions does suggest that other possible predictors need to be
considered. The ultimate goal of research such as this is to contribute to development of
interventions to decrease the numbers of adolescent suicide. To that end, any possible
variables associated with depression, high-risk behaviors, and suicidality need to be
examined for predictive potential.
Some variables which might have affected findings of significant group differences
were not addressed at all in this study. These include such areas as family structure,
including the ordinal position of the subject and factors of social and/or family structure,
such as the involvement of adults other than the parents in the child’s life, and whether
there were profound changes in socioeconomic status after the divorce.
It is tempting to explain any differences between the groups in maladaptive
responses by recognizing that the adolescents who were in the hospital had been placed
either because they were insightful enough to ask for such help, or because their parents
were sensitive and informed enough to have sought the help for them, and this is clearly a
possibility. This is a potential explanation for the stronger association between suicidal
ideation and some o f the high-risk behaviors in the nonhospitalized sample. The significant
difference between the groups in the presence of clinical depression might conflict with
this viewpoint. Following this reasoning, one would think that acting-out adolescents who
were not receiving any psychiatric help would be more depressed than those who were
being treated. This was not the case. The hospitalized teens were, in fact, significantly
more likely to have used dysfunctional coping strategies. They were also significantly
more likely to be clinically depressed on admission, and more likely to have responded
positively to questions about some of the elements often associated with depression, such
as a family history o f suicidality and a personal history o f suicide attempts. The
nonhospitalized adolescents who were clinically depressed, however, were more likely to
have made a suicide attempt or attempts than the depressed teens who were receiving
hospital treatment.
Finally, the findings on the various hypotheses when the RADS was used as a
continuous linear measurement of depression were virtually identical to the data collected
using the RADS as a simple categorical variable. This serves to confirm that the cut-off
score for depression recommended by the RADS’ authors is a valid measure of depression
when used as a dichotomous nominal variable. It seems obvious that further research will
need to be conducted to determine whether the results of this study were aberrant or
would be replicated in similar or varied populations.
Discussion of the Limitations o f the Study
Convenience sampling limits generalizability through selection bias, in that only
adolescents whose families have health insurance or the ability to pay out-of-pocket were
included in the hospitalized sample. Furthermore, subjects in this group may have lived in
families involved enough, or psychologically perceptive enough, to seek psychiatric
treatment when problems emerged. In contrast, membership in the nonhospitalized group
did not insure that these adolescents had adapted effectively to their parents' divorce. By
including subjects who were readily available, and who volunteered for the study, there
was the potential for non-homogeneity o f the subjects. Further, since the subjects
volunteered to be in the study, they do not adequately represent all adolescents whose
parents have divorced. The threat o f non-homogeneity was minimized by the researcher’s
screening of the interested subjects for eligibility with regard to the sample selection
criteria, to assure that the subjects possessed the attributes under investigation. Moreover,
/-tests were performed to uncover any significant differences in demographic variables, as
well as in other intervening and extraneous variables.
Another limitation resulting from the sampling method was that the subjects were
all very similar, both with regard to demographic data and in many of their responses. It
seems, therefore, that the sampling technique did not allow for diversity in selection of
subjects, but does contribute to implications for future research.
While the researcher needs to trust that subjects were honest in their responses,
there does exist the possibility of a Hawthorne effect. Some of the subjects could have
answered the questions as they felt they were expected to answer; others may have sought
to dramatize the extent of their experiences, difficulties, or suffering. In addition to this,
another limitation to the study is the absence of data verification. Not only could the
subjects’ responses to questions about themselves not be confirmed, but the material they
provided about friends and family members was also not validated. Confirmation of study
information would fortify the value of this research.
Post-divorce changes such as decreased socioeconomic status, home relocation
and attendance at a new school with loss of friends and support system, existence of
parental conflict pre- and post-divorce, abandonment by one or both parents; and so on.
may account for a significant portion o f variance.
Time limitations necessitated the collection o f data at only one point in time. This
might be a serious limitation of the study, in that it could be argued that it is the change in
coping strategies over time that should be considered clinically significant.
Social-structural and cultural factors such as beliefs of the family, community,
ethnic group, peer group, religion, etc. toward such things as divorce, coping, suicide,
depression, substance abuse, sexual activity, cigarette smoking, and school attendance
may have a substantial effect on outcomes.
Concurrent or pre-existing psychiatric disorders which may be undiagnosed,
unsuspected, and/or untreated may influence the adequacy of the adolescent’s coping as
well as the outcome measures of depression, engagement in high-risk behaviors, and
suicidality. Conditions such as anxiety or panic disorder, the attention-defick disorders,
obsessive-compulsive disorders, and the personality disorders would, ideally, be accounted
for in a more extensive study than this dissertation.
Although a power analysis was conducted and assured that the sample size in this
study was adequate, future studies in the area of adolescents’ coping with divorce would,
ideally, use an even larger sample. The sample used here, however, was at least as large
as that in other studies of this type.
Finally, the refinement of the conceptualization of coping must be pursued, as a
universally accepted definition of adaptive coping remains elusive. Although defined for
the purposes of this research, coping clearly has different meanings across the literature.
Implications for Nursing
As the number of divorces in the United States continues to increase, and the
number o f childhood suicides remains unacceptably high, nurses will continue to be in
direct contact with adolescents in psychological difficulty. This is especially meaningful in
that the data on the total study sample of children of divorced parents exposes a
population of adolescents in this country who seem to be perilously at risk for disastrous
behaviors. Nurses are in an excellent position to assist young people to cope with their
parents’ divorces, particularly with the growing number of psychiatric nurses in advanced
practice who work in inpatient and outpatient settings as educators, researchers, and
psychotherapists. At a clinical level, assessment of habitual coping mechanisms can
monitor the effects of traumatic events on the functioning of adolescents. These
assessments might lead to screening programs to identify high-risk youth who might
benefit from nursing interventions designed to maximize overall adaptive outcomes. In a
case such as this, these interventions might focus on strengthening and expanding the
adolescent’s coping repertoire by teaching problem-solving skills, providing supportive
individual therapy, or facilitating group therapy with other children whose parents are
divorcing, and helping the adolescent to identify a potential support system. Stress
management and relaxation techniques can also be taught. This research has attempted to
contribute to the foundation of nursing’s understanding of factors which may affect
adolescents’ coping strategies.
Recommendations for Future Research
The limitations of this research, as discussed above, suggest the need for far more
investigation in this truly critical area. First, more representative sampling might have
captured more subtle differences and associations than were found in this study. It is also
a distinct possibility that the instruments used were not sensitive enough to detect more
subtle differences in the two groups with a total sample size such as this. Also, drawing
subjects from a more socioeconomically diverse population would certainly expand
knowledge. More cultural, religious, and social diversity, as well as a sample with more
differences in the areas of family and social structure, would also provide for a richer
foundation. For example, including a question regarding the subjects’ birth order might
provide important data for analysis and comparison.
A study which also accounts for post-divorce changes, such as those in
socioeconomic status, residence, neighborhood, school, and availability of social support
system, would be very valuable. Other potential changes after the divorce include changes
in one or both parent’s emotional or mental status, separation from siblings, real or
perceived abandonment by one or both parents, and so on. Pertinent factors need to be
determined and accounted for in future studies.
The issue of parental conflict was only touched on in this research. Future
research could greatly expand our knowledge base by addressing specific issues, such as
the particular kind of parental conflict in each family affected, i.e., financial or child-
rearing differences, overt vs covert hostility, scapegoating, etc. Also to be addressed is
the issue of how the adolescent perceives the conflict and its meaning to him or her.
As there are so many rapid developmental changes in adolescence, and as there
may be notable maturational differences even among adolescents of very similar ages, a
longitudinal study might help to make childhood trauma studies such as this more clinically
relevant. A more extensive study might also more directly address the possibility of
undiscovered concurrent or pre-existing psychiatric disorders in subjects selected. This
might be accomplished with the use o f a semi-structured diagnostic interview instrument
such as the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS)
(Chambers & Puig-Antich, 1986). The difficulty presented in using the KSADS for this
research was that it is relevant to a “non-well” population and was problematic for use
with the supposedly well-adapted nonhospitalized subjects. It would have been helpful to
have modified the KSADS as necessary so that it could be administered to all the
adolescents in the study, whether in the hospitalized or nonhospitalized sample. This
would have provided much more information which might have helped to account for
some o f the differences, as well as the similarities, between subjects. Using instruments
which gather objective data, i.e., interviews with, or questionnaires completed by, parents
and teachers, rather than relying on the purely subjective, self-reported data gathered in
this study, would certainly enrich our understanding of the subjects and their
circumstances.
With a long-range goal of developing nursing interventions which might prevent at
least some of the many adolescent suicides, researchers need to address ways to identify
and measure the specific variables that are involved. Many of the risk behavior variables,
i.e., sex without protection against STDs and/or pregnancy and the suicidality constructs.
suicidal ideation and attempt(s), are so closely intertwined that it is difficult to tell which
specific variable predicts the negative outcomes. Research which might refine the
measurement of such variables would be extremely helpful.
It is apparent that future research must occur which would contribute to clearer
definitions of concepts such as coping, adolescent depression, high-risk behaviors, and
intrafamily conflict, as well as to the refinement of instruments used to measure these
complex concepts. Qualitative inquiries could help to capture the essential meaning of
their parents’ divorce to the teenagers. Finally, data collection methods for adolescent
coping must be valid, replicable, and sufficiently sensitive to yield meaningful results.
APPENDIX A:
QUESTIONNAIRE A:
DEMOGRAPHIC DATA QUESTIONNAIRE
QUESTIONNAIRE A
INSTRUCTIONS: Please read each item carefully. Please fill in the blanks when you are
asked to do so. For the rest of the questions, please circle the letter next to the number
that most closely describes you.
1. How old are you? (Please fill in the blanks).
_______ years and_________months
2. What is your sex?
a. Female
b. Male
3. In what grade are you?
a. 8th grade
b. 9th grade
c. 10th grade
d. 11th grade
e. 12th grade
4. Do you describe yourself as:
a. White or Caucasian
b. Black or African-American
c. Hispanic or Latino
d. Asian or Pacific Islander
e. Native American or American Indian
f. Other
5. How old were you the last time your parents separated/divorced?
_________ yearsand__________ months
6. With whom do you live now?
a. Mother
b. Father
c. Other relative(s)
d. Other non-relative(s)
7. Have either of your parents gotten married again?
Mother:
a. Yes
b. No
Father:
a. Yes
b. No
8. Are you presently living with a step-parent?
a. Yes
b. No
9. Do you have any sisters or brothers?
a. Yes
Number of sisters__
Number of brothers _
b. No
10. Do you consider your parents’ divorce an important event in your life?
a. Yes
b. No
c. Don’
The next ten questions ask about your immediate family and your friends.
Immediate family means: parents, sisters, brothers, grandparents, aunts, and
uncles.
11. Has anyone in your immediate family ever been hospitalized or treated for
depression?
a. Yes
b. No
c. Don’t know
12. Has anyone in your immediate family ever smoked cigarettes regularly?
a. Yes
b. No
c. Don’t know
13. Has anyone in your immediate family ever abused or been addicted to drugs?
a. Yes
b. No
c. Don’t know
14. Has anyone in your immediate family ever attempted suicide?
a. Yes
b. No
c. Don’t know
15. Has anyone in your immediate family ever committed suicide?
a. Yes
b. No
c. Don’t know
16. Have any of your friends been hospitalized or treated for depression?
a. Yes
b. No
c. Don’t know
17. Have any of your friends smoked cigarettes regularly?
a. Yes
b. No
c. Don’t know
18. Have any o f your friends abused or been addicted to alcohol or drugs?
a. Yes
b. No
c. Don’t know
19. Have any of your friends attempted suicide?
a. Yes
b. No
c. Don’t know
20. Have any of your friends committed suicide?
a. Yes
b. No
c. Don’t know
The next three questions ask about your parents’ relationship before and after their
divorce.
21. Do either or both of your parents often seem to be angry at the other?
a. Yes
b. No
c. Don’
22. Has either or both of your parents ever verbally abused the other by
cursing, name-calling, threatening, and so on?
a. Yes
b. No
c. Don’t know
23. Has either or both of your parents ever physically abused the other by
slapping, shoving, punching, using a weapon, and so on.?
a. Yes
b. No
c. Don’t know
Thank you so much for your help !!
APPENDIX B:
QUESTIONNAIRE B:
KIDCOPE
Questionnaire B
INSTRUCTIONS: Please read each item and circle which phrase applies (if any). Then
answer both questions to the right of each item, circling the best answer.
How often did you do this? How much did it help?

To handle the last
Not Some A lot Almost Not A Some- Pretty Very
thing that really
at times o f the all the at little times much much
stressed me out or all time time all
upset me:
1) I thought about something 0 1 2 3 0 1 2 3 4
else; tried to forget it; and/or went
and did something like watch TV
or play a game to get it o ff my
mind.
2) I stayed away from people;

kept my feelings to myself, and 0 1 2 3 0 1 2 3 4
just handled the situation on
my own.
3) I tried to see the good side of

things and/or concentrated on 0 1 2 3 0 1 2 3 4
something good that could
come out of the situation.
4) I realized I brought the

problem on myself and blamed 0 1 2 3 0 1 2 3 4
myself for causing it.
5) I realized that someone else

caused the problem and blamed 0 1 2 3 0 1 2 3 4
them for making me go through
this.
6) I thought of ways to solve the

problem; talked to others to get 0 1 2 3 0 1 2 3 4
more facts and information
about the problem and/or tried
to actually solve the problem.
7 A) I talked about how I was

feeling; yelled, screamed, or hit 0 1 2 3 0 1 2 3 4
something.
B) I tried to calm myself by

talking to myself, praying, q | 2 0 1 2 3 4
taking a walk, or just trying to
relax.
How often did you do this? How much did it help?
Not Some- A lot Almost Not A Some- Pretty Very

at times of the all the at little times much much
all time time all
8) I kept thinking and wishing

this had never happened; and/or 0 1 2 3 0 1 2 3 4
that I could change what had
happened.
9) I turned to my family, friends,

or other adults to help me feel 0 1 2 3 0 1 2 3 4
better.
10) I just accepted the problem

because 1 knew I couldn’t do 0 1 2 3 0 1 2 3 4
anything about it.
APPENDIX C:
QUESTIONNAIRE C:
REYNOLDS ADOLESCENT DEPRESSION SCALE (RADS)
Questionnaire C
INSTRUCTIONS: Listed below are some sentences about how you feel. Read each sentence and decide
how often you feel this way: almost never, hardly ever, sometimes, or most o f the time. Circle the number
under the answer that best describes how you really feel. Remember, there are no wrong answers. Just choose
the answer that tells how you usually feel.
ALMOST HARDLY SOME- MOST OF

NEVER EVER TIMES THE TIME
1) I feel happy...........................................
2) I worry about school.............................
3) I feel lonely...........................................
4) I feel that my parents don’t like me.....
5) 1 feel important.....................................
6) I feel like hiding from people...............
7) I feel sad................................................
8) I feel like crying....................................
9) I feel that no one cares about me.........
10) I feel like having fun with other kids..
11)1 feel sick............................................
12) I feel loved..........................................
13) I feel like running away......................
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
ALMOST HARDLY SOME- MOST OF
NEVER F.VER TIMES THE TIME
14) I feel like hurting myself............... 1 2 3 4
15) I feel that other kids don’t like me. 1 2 3 4
16) I feel upset..................................... 1 2 3 4
17) I feel life is unfair.......................... 1 2 3 4
18) I feel tired...................................... 1 2 3 4
19) I feel I am bad............................... 1 2 3 4
20) I feel I am no good........................ 1 2 3 4
21)1 feel sorry for myself.................... 1 2 3 4
22) I feel mad about things................. 1 2 3 4
23) I feel like talking to other kids..... 1 2 3 4
24) I have trouble sleeping................. 1 2 3 4
25) I feel like having fun..................... 1 2 3 4
26) I feel worried................................ 1 2 3 4
27) I get stomach aches...................... 1 2 3 4
28) I feel bored................................... 1 2 3 4
29) I like eating meals........................ 1 2 3 4
30) I feel like nothing helps anymore. 1 2 3 4
APPENDIX D :
QUESTIONNAIRE D:
YOUTH RISK BEHAVIOR SURVEY (YRBS)
Questionnaire D
[NSTRUCTIONS: Please circle the letter next to the answer that best describes you. Please be sure to answer
every question to the best of your ability.
The first four questions ask about sexual The next two questions ask about
behavior. drinking alcoboL This includes drinking
beer, wine, wine coolers, and liquor such
I. How old were you the first time you had as rum, gin, vodka, or whiskey. For these
sexual intercourse? questions, drinking alcohol does not
include drinking a few sips of wine for
a. I have never had sexual religious purposes.
intercourse.
b. 12 years old or younger. 5. How old were you when you had your
c. 13 years old. first drink o f alcohol other than a few
d. 14 years old. sips?
e. 15 years old.
f. 16 years old. a. I have never had a drink of
g- 17 years old. alcohol other than a few sips.
b. 8 years old or younger.
2. The last time you had sexual intercourse, c. 9 or 10 years old.
did you or your partner use a condom? d. 11 or 12 years old.
e. 13 or 14 years old.
a. I have never had sexual f. 15 or 16 years old.
intercourse. g- 17 years old.
b. Yes
c. No
6. During the past 30 days, on how many
3. The last time you had sexual intercourse, days did you have at least one drink of
what method did you or your partner use alcohol?
to prevent pregnancy? (Select only
one response). a. 0 days
b. 1 or 2 days.
a. I have never had sexual c. 3 to 5 days.
intercourse. d. 6 to 9 days.
b. No method was used to e. 10 to 19 days.
prevent pregnancy. f. 20 to 29 days.
c. Birth control pills. g- All 30 days.
d. Condoms.
e. Withdrawal. The next ten questions are about the use of
f. Some other method. m arijuana and other drugs.
g- Not sure.
7. How old were you when you tried
4. Did you drink alcohol or use drugs before m arijuana for the first time?
you had sexual intercourse the last time?
a. I have never tried marijuana.
a. I have never had sexual b. 8 years old or younger.
intercourse. c. 9 or 10 years old.
b. Yes. d. 11 or 12 years old.
c. No. e. 13 or 14 years old.
f. 15 or 16 years old.
g. 17 years old.
8. During the past 30 days, how many 12. During the past 30 days, how many
times did you use m arijuana ? times have you sniffed glue, breathed
the contents of aerosol spray cans, or
a. 0 times. inhaled any paint or sprays to get high?
b. 1 or 2 times.
c. 3 to 9 times. a. 0 times.
d. 10 to 19 times. b. 1 or 2 times.
e. 20 to 39 times. c. 3 to 9 times.
f. 40 or more times. d. 10 to 19 times.
e. 20 to 39 times.
f. 40 or more times.
9. How old were you when you tried any
form of cocaine, including powder, 13. How old were you when you took
crack, or freebase, for the first time? steroid pills or shots without a doctor’s
prescription?
a. I have never tried cocaine.
b. 8 years old or younger. a. I have never taken steroids.
c. 9 or 10 years old. b. 8 years old or younger.
d. 11 or 12 years old. c. 9 or 10 years old.
e. 13 or 14 years old. d. 11 or 12 years old.
f. 15 or 16 years old. e. 13 or 14 years old.
g- 17 years old. f. 15 or 16 years old.
g- 17 years old.
10. During the past 30 days, how many

times did you use any form of cocaine, 14. During the past 30 days, how many
including powder, crack, or freebase? times have you taken steroid pills or
shots without a doctor’s prescription?
a. 0 times.
b. 1 or 2 times. a. 0 times.
c. 3 to 9 times. b. 1 or 2 times.
d. 10 to 19 times. c. 3 to 9 times.
e. 20 to 39 times. d. 10 to 19 times.
f. 40 or more times. e. 20 to 39 times.
f. 40 or more times.
11. How old were you the first time you 15. How old were you the first time you
sniffed glue, or breathed the contents used any other type of illegal drug, such
o f aerosol spray cans, or inhaled any as LSD, PCP, Ecstasy, mushrooms,
paint or sprays to get high? nitrous oxide, ice, speed, or heroin?
a. I have never tried any of the a. I have never used any illegal
inhalants mentioned above. drugs.
b. 8 years old or younger. b. 8 years old or younger.
c. 9 or 10 years old. c. 9 or 10 years old.
d. 11 or 12 years old. d. 11or 12 years old.
e. 13 or 14 years old. e. 13 or 14 years old.
f. 15 or 16 years old. f. 15 or 16 years old.
g- 17 years old. g. 17 years old.
16. During the past 30 days, how many times The next two questions are about school
have you used any othertype o f illegal attendance.
drug, such as LSD, PCP, Ecstasy,
mushrooms, nitrous oxide, ice, speed, or 20. In what grade were you the first time
heroin? you ditched, or were truant from,
school?
a. 0 times.
b. I or 2 times. a. I have never been truant from
c. 3 to 9 times. school.
d. 10 to 19 times. b. 7th grade or earlier.
e. 20 to 39 times. c. 8th grade.
f. 40 or more times. d. 9th grade.
e. 10th grade.
f. 11th grade.
g. 12th grade.
The next three questions ask about
tobacco use.
21. During the past 30 school days, on how
17. Have you ever tried cigarette many days did you ditch, or were you
smoking, even one or two puffs? truant from, school?
a. Yes a. 0 days.
b. No. b. 1 or 2 days.
c. 3 to 5 days.
d. 6 to 9 days.
18. How old were you when you smoked e. 10 to 19 days.
a whole cigarette for the first time? f. 20 to 29 days.
g- all 30 school days.
a. I have never smoked a whole
cigarette.
b. 8 years old or younger. Sometimes people feel so depressed and
c. 9 or 10 years old. hopeless about the future that they may
d. 11 or 12 years old. consider attem pting suicide, that is, taking
e. 13 or 14 years old. some action to end their own lives. The next
f. 15 or 16 years old. four questions ask about suicide.
g- 17 years old.
22. Since your parents’ divorce, did you
ever seriously consider attempting
During the past 30 days, on how many suicide?
days did you smoke cigarettes?
a. Yes.
a. 0 days. b. No.
b. 1 or 2 days.
c. 3 to 5 days. 23. Since your parents’ divorce, did you
d. 6 to 9 days. make a plan about how you would
e. 10 to 19 days. commit suicide?
f. 20 to 29 days.
g- all 30 days. a. Yes
b. No.
24. Since your parents* divorce, how
many times did you actually attempt
suicide?
a. 0 times
b. I time.
c. 2 or 3 times.
d. 4 or 5 times.
e. 6 or more times.
25. If you have attempted suicide since your

parents’ divorce, did any attempt result
in an injury, poisoning, or overdose that
had to be treated by a doctor or nurse?
a. I did notattempt suicide.

b. Yes.
c. No.
APPENDIX E:
FREQUENCY DISTRIBUTIONS FOR QUESTIONNAIRE RESPONSES
BY THE TOTAL SAMPLE
Frequency distributions for questionnaire responses by total sample
Question_____________________________________________ N______________________ %
What is your sex?

Female 53 663
Male 27 33.8
In what grade are you?

8th 5 6.3
9th 16 20.0
10th 22 27.5
11th 24 30.0
12th 13 16.3
Do you describe yourself as:

White or Caucasian 35 43.8
Black or African American 14 17.5
Hispanic or Latino 14 17.5
Asian or Pacific Islander 5 6.3
Native American orAmerican Indian 2 2.5
Other 5 6.3
No response 5 6.3
With whom do you live now?

Mother 54 67.5
Father 13 16.3
Other relative(s) 7 8.8
Other nonrelative(s) 6 7.5
Have either of your parents gotten

married again?
Mother
Yes 38 47.5
No 42 52.5
Father
Yes 34 42.5
No 45 56.3
No response 1 1.3
Are you presently living with a

stepparent?
Yes 25 31.3
No 54 67.5
No response 1 1.3
Question N %
Do you have any sisters or brothers?

Yes 63 78.8
No 17 213
Do you consider your parents divorce

an important event in your life?
Yes 48 60.0
No 26 32.5
Don’t know 6 7.5
Has anyone in your immediate family

ever been hospitalized or treated for
depression?
Yes 41 51.3
No 26 32.5
Don’t know 13 16.3

ever smoked cigarettes regularly?
Yes 60 75.0
No 18 22.5
Don’t know 7 2.5

ever abused or been addicted to drugs?
Yes 38 47.5
No 29 36.3
No response 7 2.5

ever attempted suicide?
Yes 33 41.3
No 19 23.8

ever committed suicide?
Yes 18 22.5
No 42 52.5
Question_____________________________________ N________________________ %
Have any o f your friends been

hospitalized or treated for
depression?
Yes 39 48.8
No 36 45.0
Don’t know 5 6.3
Have any o f your friends smoked

cigarettes regularly?
Yes 64 80.0
No 13 16.3
Don’t know 2 2.5
No response 1 1-3
Have any of your friends abused or

been addicted to drugs?
Yes 51 63.8
No 27 33.8
Don’t know 1 1-3
No response 1 1-3
Have any o f your friends attempted

suicide?
Yes 39 48.8
No 34 42.5
Don’t know 6 7.5
No response 1 1-3
Have any o f your friends committed

suicide?
Yes 11 13.8
No 65 81.3
Don’t know 4 5.0
Do either or both o f your parents

often seem angry at the other?
Yes 58 72.5
No 18 22.5
Don’t know 4 5.0
Question___________________________________________________ N %
Has either or both of your parents

ever abused the other by cursing,
name-calling, threatening, and so on?
Yes 51 63.8
No 27 33.8
Don’t know 2 2.5
Has either or both of your parents ever

physically abused the other by slapping,
shoving, punching, using a weapon, and
so on?
Yes 24 30.0
No 45 56.3
How old were you the first time you had

sexual intercourse?
1 have never has sexual intercourse 30 37.5
12 years or younger 7 8.8
13 years old 11 13.8
16 years or older 9 11.3
Did you drink alcohol or use drugs

before you had sexual intercourse the
last time
I have never had sexual intercourse 29 36.3
Yes 20 25.0
No 29 36J
No response 2 2.4
How old were you when you had your

first drink o f alcohol, other than a few
sips?
I have never had a drink o f alcohol 9 11.3
8 years old or younger 9 11.3
9 or 10 years old 15 18.8
II or 12 years old 15 18.8
13 or 14 years old 23 28.8
17 years old 0 0
Question___________________________________________________ N ________________________ %
How old were you when you smoked

marijuana for the first time?
i have never tried marijuana 23 28.8
13 or 14 years old 28 35.0
15 to 16 years old 17 213
17 years old 1 1.3
How old were you when you tried

any form o f cocaine for the first time?
I have never tried cocaine 53 66.3
8 years old or younger 0 0
9 to 10 years old 0 0
II to 12 years old 1 1.3
13 to 14 years old 13 16.3
15 to 16 years old 12 15.0
17 years old 1 1.3
How old were you the first time you

sniffed glue, breathed the contents o f
aerosol spray cans, or inhaled any
paint, gasses, or sprays to get high?
I have never tried any o f the 65
inhalants mentioned above
8 years old or younger 0 0
9 to 10 years old 3 3.8
II to 12 years old 0 0
17 years old 0 0
Question N %
How old were you the first time you

used any other illegal drug (LSD,
PCP, Ecstasy, mushrooms, nitrous
oxide, ice, speed, heroin, etc.)
I have never used any other 37 46.3
illegal drugs.
8 years old or younger 0
9 to 10 years old 0
II to 12 years old 25
13 to 14 years old 5.0
15 to 16 years old 10.0
17 years old 0
How old were you when you

smoked a whole cigarette for
the first time?
I have never smoked a 20 25.0
whole cigarette
I I to 12 years old 19 23.8
13 to 14 years old 23 28.8
17 years old 0 0
During the past 30 days, on

how many days did you smoke
cigarettes?
0 days 42 52.5
l o r 2 days 4 5.0
3 to 5 days 3 3.8
6 to 9 days 1 1.3
10 to 19 days 3 3.8
20 to 29 days 1 1.3
All 30 days 26 32.5
Question_______________________ N %
In what grade were you the first

time you ditched, or were truant
from, school?
I have never been truant 34 42.5
7th grade or earlier 10 12.5
8th grade 11 13.8
9th grade 17 21.3
1Oth grade 6 7.5
11th grade 1 13
12th grade 1 1.3
Since your parents’ divorce, did

you ever seriously think of
committing suicide?
Yes 42 52.5
No 38 47.5
Since your parents’ divorce, how

many times did you actually
attempt suicide?
0 times 52 65.0
1 time 10 12.5
2 or 3 times 9 11.3
4 or 5 times 6 7.5
6 or more times 3 3.8
APPENDIX F
AGREEMENT TO PARTICIPATE
INFORMED CONSENT
AGREEMENT TO PARTICIPATE
Date of preparation: August, 1995

Page 1 o f 3
Adolescents’ Coping After Their Parents Divorce:
I hereby allow Helene Seeman, MN, RN, a doctoral student at the UCLA
School o f Nursing to include me in a research study which will help people to better
understand how adolescents deal with their parents’ divorce and the reasons why they
might have emotional problems or mood changes, or start taking part in different activities
after the divorce.
I have been asked to take part in this study because I am a teenager between 14
and 17 years of age whose parents separated and divorced between one and four years
ago. About 100 adolescents will take part in the study; 50 will be picked from young
people who are in the hospital being treated for emotional problems or self-destructive
behaviors, the other 50 are not now in hospitals.
I understand that if I agree to participate in this study, I will be asked to fill out
four check-off questionnaires about how I deal with different things, and about my feelings
and activities. These questionnaires have been explained to me by Helene Seeman, MN,
RN. Filling in all of the questionnaires will take about one-and-a-half hours.
I understand that all information will be kept strictly private. It will not be shared
with anyone, including parents, doctors, or teachers. The only exception to this
confidentiality is if the researcher is given information indicating something that is a
danger to me. Code numbers instead of names will be used on all of the questionnaires.
An unlabeled book listing the number assigned to each name will be kept under lock and
key where only the researcher can look at it. The book and all questionnaires will be
destroyed as soon as the study is completed.
I understand that taking part in this study may involve the following risks or
discomfort:
a) I may feel nervous, sad, or embarrassed from talking about the divorce and my feelings
and activities; and b) I may feel that my privacy has been invaded. If I have any problems
like this, the researcher is a nurse and therapist, and she has had extensive experience
providing support to and dealing with emotionally upset teenagers. If it seems necessary,
Ms. Seeman has a list of therapists for more intense counselling.
Page 2 o f 3
I understand that if I am in the group of hospitalized adolescents my doctor will be

asked if he/she thinks there is any reason I shouldn’t participate in the study. Regardless of
the doctor’s agreement, however, the decision about whether or not I do participate is
entirely up to my parent(s) and me.
I understand that my doctor will be told if I become very emotionally upset when
I’m filling out the questionnaires.
I understand that I may feel relieved at being able to talk about my feelings about
the divorce and it may also make me feel good to know that I am helping people
understand better the reasons why children may have a hard time handling their parents
getting divorced and why they may get depressed, do risky things, or become suicidal.
I understand that Helene Seeman, RN, MN, and her faculty sponsor, Dr. MaryAnn
Lewis, will answer any questions I may have at any time concerning details o f the study.
They can be reached at (310) 825-8464, at the UCLA School of Nursing, 10833 LeConte
Avenue, Los Angeles, CA 90095.1 understand that if any part of this study is changed, I
will be told and will be asked again for my assent.
I understand that my participation in the study is completely voluntary and will not
have any effect on my treatment here in the hospital. I have the right to refuse to answer
any question that I don’t want to answer and I may withdraw from this study at any time
without penalty.
I understand that if I have any further questions about my rights as a research

participant, I may call or write the office of the Vice Chancellor-Research Programs, 2138
Murphy Hall, UCLA, Los Angeles, CA 90095-1405, (310) 825-8714.
I understand that I will get a $20.00 gift certificate to Wherehouse Records for
taking part in this study. If I decide to withdraw before the study is completed, I will
receive the following:
If I have completed 3 questionnaires, a $15.00 gift certificate;
If I have completed 2 questionnaires, a $10.00 gift certificate;
If I have completed 1 questionnaire, a $5.00 gift certificate.
If I start the study and my participation is ended through no fault of mine, I will receive a
$20.00 gift certificate.
Page 3 o f 3
I want to participate in the study and I have received a copy of this form.
Subject is a minor (age ):
Subject’s signature___________________________________________
Date___________________
Researcher’s signature________________________________________
Date____________________
INFORMED CONSENT
Date of preparation: August, 1995

Page 1 o f3
Adolescents’ Coping After Their Parents Divorce:
I hereby authorize Helene Seeman, MN, RN, a doctoral candidate in the UCLA
School o f Nursing to include___________________________ _ my child/ward, in a
research study which will help to better understand how adolescents deal with their
parents’ divorce and the reasons why they might have emotional problems or mood
changes, or start to take part in different activities after the divorce.
My child/ward has been asked to participate in this study because my child/ward is

an adolescent between 14 and 17 years of age whose parents separated and divorced
between one and four years ago. About 100 adolescents will take part in the study, of
which 50 are currently hospitalized for treatment of emotional problems or self-destructive
behaviors and 50 are not in hospitals.
I understand that my child/ward’s participation in this study is completely

voluntary and will have no effect on my child/ward’s treatment in the hospital.
I understand that if my child/ward agrees to participate in this study, my

child/ward will be asked to complete four questionnaires about how my child/ward deals
with things, and my child/ward’s feelings and activities. These questionnaires have been
explained to me by Helene Seeman, MN, RN. Completing the questionnaires will take
approximately one-and-a-half hours.
I understand that all information will be kept confidential. My child/ward’s

responses will not be shared with anyone, including parents, doctors, or teachers. The
only exception to this confidentiality is if the researcher is given information indicating
something that is a danger to my child/ward. Code numbers rather than individual names
will be used on all of the questionnaires. An unlabeled book listing the number assigned to
each name will be kept under lock and key where only the researcher will have access to
it. The book and all questionnaires will be destroyed as soon as the study is completed.
I understand that taking part in this study may involve the following risks or
discomfort: a) anxiety, sadness, or embarrassment from talking about the divorce and my
child/ward’s feelings and activities; and b) feeling that my child/ward’s privacy is invaded.
These risks may be lessened since the nurse-researcher is highly experienced in providing
Page 2 o f 3
supportive counseling and dealing with emotionally distressed adolescents. Should it

prove necessary, a pool of appropriate referrals for more intensive counselling is
available.
I understand that if my child/ward is in the hospitalized adolescent group,

agreement from my child/ward’s primary doctor will be obtained for my child/ward to be
included in the study. Regardless of this agreement, however, the decision about whether
or not to participate rests solely with my child/ward and me. Should my child/ward
experience any emotional distress, I understand that the primary doctor will be informed of
this.
I understand that the possible benefits of taking part in the study for my child/ward
may include relief at being able to talk about my child/ward’s feelings about the divorce
and gratification at knowing that my child/ward is helping people get a better
understanding of the reasons why children may have a hard time handling their parents
getting divorced and why they may get depressed, do risky things, or become suicidal.
I understand that Helene Seeman, RN, MN and her faculty sponsor, Dr. MaryAnn
Lewis, will answer any questions I may have at any time concerning details of the study.
They can be reached at (310) 825-8464, at the UCLA School of Nursing, 10833 LeConte
Avenue, Los Angeles, CA 90095.1 understand that if the study design or the use o f the
information is to be changed, I will be so informed and my consent reobtained.
I understand that my child/ward has the right to refuse to answer any question that
my child/ward may not wish to answer.
I understand that I may refuse to participate or may withdraw my child/ward from

this study at any time without negative consequences.
Circumstances may arise which might cause the investigator to terminate my

child/ward’s participation before completion of the study.
I also understand that no information which identifies my child/ward will be

released without my separate consent except as specifically required by law.
Page 3 o f 3
I understand that if I have any questions, comments, or concerns about the study
or the informed consent process, I may write or call the office of the Vice Chancellor-
Research Programs, 2138 Murphy Hall, UCLA, Los Angeles, CA 90095-1405, (310) 825-
8714.
I understand that my child/ward will receive a $20.00 gift certificate to

Wherehouse Records for participation in this study. I further understand that if my
child/ward decides to withdraw before the study is completed my child/ward will receive
the following:
For completing 3 questionnaires, a $15.00 gift certificate;
For completing 2 questionnaires, a $10.00 gift certificate;
For completing 1 questionnaire, a $5.00 gift certificate.
I understand that if my child/ward’s participation is ended through no fault of my
child/ward’s, my child/ward will receive a $20.00 gift certificate.
In signing this consent form I acknowledge that I have received a copy of this form.
Subject’s name_________________________________________________________
Subject is a minor (age ):
Mother__________________________________________ D ate________________
F ather__________________________________________ Date________________
Guardian_________________________________________D ate________________
Witness_________________________________________ Date.
APPENDIX G:
SCRIPTS
SCRIPT: Initial contact with parent of nonhospitalized child
Hi. My name is Helene Seeman. Am I calling at a bad time? (Thank you so much for
calling.) I am a nurse and a Clinical Specialist in Child and Adolescent Mental Health
from the UCLA School of Nursing. I’m studying for a doctoral degree in nursing. As you
know from the flyer, my study looks at the ways teenagers cope with their parents
divorce. I’m especially interested in whether they become depressed or suicidal and
whether they have begun engaging in behaviors such as cigarette smoking, unprotected
sex, drug abuse, or truancy since the divorce. Because divorce is so common these days,
this study would improve our understanding of how to help kids deal with divorce. All the
answers to the questionnaires will be completely confidential and no names will be written
on them.
If you and your child or ward are willing to participate in this study you will both be asked
to read and sign a consent form describing the project. After this, your child (ward) will
be asked to complete four questionnaires. One questionnaire asks for information about
the child’s age, sex, ethnicity, family relationships, and friends. The other questionnaires
ask about coping styles, depression, suicidality, and risky behaviors. That will take about
an hour-and-a-half. When the questionnaires are completed your child (ward) will receive
a $20.00 gift certificate to Wherehouse Records as my way of thanking him (her).
If you would like it, I’ll be glad to send you a copy of the results o f the study when it’s
finished.
Do you think you would be interested in allowing your child (ward) to participate in this
study?
IF YES: Thank you so much! I will be contacting you in the next few days to arrange an
appointment time for the survey. You will need to come with your child (ward) so that
you can be further informed about the study and so you can sign a consent form. If you
have any questions before we meet, you can call me at (310) 825-8476.
IF NO: Thank you so much for your time. If you change your mind, I can be reached at
(310) 825-8476.
SCRIPT: Initial contact with nonhospitalized child
Hi. My name is Helene Seeman. I’m a nurse, and I work with children and adolescents
in a psychiatric hospital and in outpatient therapy. I’m also going to school at UCLA,
and, as you know from the flyer, I’m doing a study about the ways kids deal with their
parents’ divorce. I’m especially interested in whether they become depressed or suicidal
or begin doing such risky things as abusing drugs, having unsafe sex, smoking cigarettes,
or ditching school. I’m sure you know that lots of kids don’t deal well with their parents’
divorce and we hope that we can find ways to help them. It’s important for you to know
that everything you fill out will be completely confidential. You’re name won’t be written
on any of the questionnaires or anywhere else. If you’re interested, I’ll be glad to send
you a copy of the results of the study when its done.
If you are willing to participate in the study you and your parent will be asked to read and
sign a consent form that’ll tell you more about the study. Then you’ll be asked to fill out
four questionnaires. One questionnaire asks about things like your age, sex, grade in
school, and relationships with family and friends. The other questionnaires are about how
you usually deal with problems, and about things like depression, feeling like hurting or
killing yourself, and risky behaviors. This should take about 1 1/2 hours. While we need
your parent or guardian’s consent for you to be in the study, none of your answers to
questions will be shared with them. When you’re all done you’ll get a $20 gift certificate
to Wherehouse Records as my way of saying thank you.
Do you think you’d be interested in taking part in this study?
IF YES: Thank you so much! In order for you to take the survey, I’ll need to speak to
your parent or guardian. Since you’re a minor, I’ll need their consent, too, for you to
participate. Pretty soon I’ll be calling you and your parents to set up a time and place for
you to do the questionnaires. You’ll both need to come in so you can both sign the
consent form before you get started on the questionnaires. If you have any questions, you
can reach me at (310) 825-8476.
IF NO: Thanks so much for talking with me. If you should change your mind about being
in the study, you can reach me at (310) 825-8476.
SCRIPT: Initial contact with parent of hospitalized child
H i I’m Helene Seeman. I’m a nurse and a Clinical Specialist in Child and Adolescent
Mental Health here. I’m also studying for a doctoral degree at the UCLA School o f
Nursing. My research looks at the way teenagers cope with their parents’ divorce. I’m
especially interested in whether they become depressed or suicidal and whether they have
begun engaging in such behaviors as cigarette smoking, unprotected sex, drug abuse, or
truancy since the divorce. Because divorce is so common these days, this study would
improve our understanding of how to help kids deal with divorce. All the answers to the
questions will be completely confidential and no names will be written on them. Also,
whether or not your child or ward takes part in the study is totally up to you both and
there are no negative repercussions if you or he/she don’t want to take part. While your
consent and the consent of your child’s psychiatrist are needed for your child/ward to
participate in the study, none of his/her answers will be communicated to you.
If you and your child or ward are willing to participate in this study you will both be asked
to read and sign a consent form describing the project further. After this, your child
(ward) will be asked to complete four questionnaires, two of which your child/ward would
have been asked to fill out even if he/she were not in the study, as part of the hospital’s
regular admission process. One questionnaire asks for information about your child’s age,
sex, ethnicity, family relationships, and friends. The other questionnaires ask about coping
styles, depression, suicidality, and risky behaviors. That will take about an hour-and-a-half
. When the questionnaires are completed your child/ward will receive a $20.00 gift
certificate to Wherehouse Records as my way o f thanking him/her.
If you would like it, I’ll be glad to send you a copy of the results of the study when it’s
finished.
Do you think you would be interested in allowing your child/ward to participate in this
study?
IF YES: Thank you so much! Very soon I’ll explain more about the study to you and
your child/ward and ask you to sign a consent form. Then I’ll set up a time for your child
to do the questionnaires. If you have any questions, you can speak to me here at the
hospital or you can let one of the staff know that you need to talk to me.
IF NO: Thank you so much for your time. Should you change your mind, you can let me
know here at the hospital or you can let one of the staff know that you wish to talk to me.
SCRIPT: Initial contact with hospitalized child
Hi. I’m Helene Seeman. I’m a nurse on the Adolescent Unit here. I’m also going to
school at UCLA and I’m doing a study for school about the ways kids deal with their
parents’ divorce. I’m especially interested in whether they become depressed or suicidal
after the divorce, or whether they start doing such risky things as abusing drugs, having
unsafe sex, smoking cigarettes, or ditching school after the divorce. I’m sure you know
that lots of kids don’t deal well with their parents’ divorce and we hope that we can find
ways to help them. Its important for you to know that everything you fill out will be
completely confidential. You’re name won’t be written on the questionnaires or anything
else. Also, whether or not you take part in the study is totally up to you and there are no
negative repercussions if you decide you don’t want to take part.
If you’re willing to participate in the study, you and your parent or guardian will be asked
to read and sign a consent from that will explain more about the study. Then you’ll be
asked to fill out four questionnaires, two of which you’d be asked to fill out even if you
weren’t in the study as part of being admitted to the hospital. One questionnaire asks
about things like your age, sex, grade in school, and your relationships with family and
friends. The other questionnaires are about how you usually deal with problems, and
about things like depression, feeling like hurting or killing yourself, and about risky
behaviors. This should take about 1 1/2 hours. While we have to have consent from your
parent or guardian and your psychiatrist for you to take part in this study, absolutely none
of the information will be shared with them. When you’re all done you’ll get a $20.00
gift certificate to Wherehouse Records as my way o f saying thank you.
Do you think you’d be interested in taking part in this study?
IF YES: Thank you so much! Pretty soon you and your parents or guardian will be asked
to sign that consent form I mentioned and we’ll set up a time and place for you to do the
questionnaires. If you have any questions, you can speak to me here at the hospital or you
can let one of the other staff members know that you need to talk to me.
IF NO: Thank you so much for talking with me! If you should change your mind about
being in the study, you can speak to me here at the hospital or you can let one of the other
staff members know that you need to talk to me.
SCRIPT: At time of instrument administration
Hi. Thank you so much for agreeing to do this! There are four short questionnaires for
you to fill out. I’ll give them to you one at a time and I’ll tell you how each one is filled
out when I give it to you. This shouldn’t take very long.
Don’t write you’re name on any of the questionnaires. All the answers will be kept
private and no one will know what you write. Completing this survey is voluntary. Please
answer all the questions based on how you really feel and what you really do.
For each question, please circle the best answer. Unless you’re specifically asked not to,
answer every question on each form. If you’re not sure of an answer just circle the best or
closest answer.
THANK YOU VERY MUCH FOR YOUR HELP!!!!
BEFORE QUESTIONNAIRE A
The questions that ask about your background will only be used to describe the types of
teenagers taking this survey. No names will ever be reported. Please remember not to
write your name anywhere on this form.
To answer the questions, please fill in the blanks where you are asked to do so.
For the rest of the questions, please circle the answer that comes closest to describing
your own situation.
B E F O R E QUESTIONNAIRE B
Think o f the last thing that really stressed you out or upset you, such as a fight with a
friend or a parent, failing a test, meeting someone new, etc. This form asks questions
about how you handled that. Circle only those things you really did. Then circle your
responses to two questions about each o f the items you have chosen. There are no right
or wrong answers.
Remember not to write your name anywhere on the form.
BEFORE QUESTIONNAIRE C
This form has a number of sentences that people use to describe their feelings. Please read
each sentence and decide how often you feel the way the sentence describes. Just
remember to answer the way you really feel.
Remember not to write your name anywhere on the form.
BEFORE QUESTIONNAIRE D
This survey asks about physical and emotional health behaviors and what things you do
that might effect your health. The information you give will only be used to develop
better health skills for young people like yourself. Please circle the number next to the
statement that best describes you and what you do. There are no correct or incorrect
answers, so please be as honest as possible.
Again, do not write your name anywhere on the form. It is important to us that we
guarantee your confidentiality.
References
Abelsohn, D., & Saayman, G.S. (1991). Adolescent adjustment to parental

divorce: An investigation from the perspective of basic dimensions of structural family
therapy theory. Family Process. 30f21. 177-191.
Ackerman, G.L. (1993). A congressional view o f youth suicide. American
Psychologist. 48(21. 183-184.
Adams, D.M., Overholser, J.C., & Spirito, A. (1994). Stressful life events
associated with adolescent suicide attempts. Canadian Journal of Psychiatry. 39(11. 43-
48.
Adcock, A.G., Nagy, S., & Simpson, J.A. (1991). Selected risk factors in
adolescent suicide attempts. Adolescence. 26(1041. 817-828.
Allison, P.D., & Furstenburg, F.F. (1989). How marital dissolution affects
children: Variations by age and sex. Developmental Psychology. 25. 540-549.
American Academy of Pediatrics. (1988). Substance abuse: A guide for health
professionals. Elk Grove Village: EL.
American Psychiatric Association (1980). Diagnostic and statistical m anual o f
m ental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.). Washington, DC: Author.
American School Health Association. (1989). The National Adolescent Student
Health Survey: A report on the health of America’s youth. Oakland, CA:Third Party
Publishing Co.
Anable, K.E. (1991). Children of divorce: Ways to heal the wounds. Clinical Nurse
Specialist. 5(31. 133-137.
Armistead, L., McCombs, A., Forehand, R.. Wierson, M., Long, N.. & Fauber. R.
(1990). Coping with divorce: A study of young adolescents. Journal of Clinical Child
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Coping After Divorce

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INFORMATION TO USERS

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Adolescents’ Coping After Parental Divorce:

Depression, High-Risk Behaviors, and Suicidality

A dissertation submitted in partial satisfaction of the

requirements for the degree Doctor of Philosophy

UMI Microform 9725984

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Mary Ann Lewis, Committee Chair

University of California. Los Angeles

and their spouses, whose pride in me is exceeded by my immeasurable pride in them; to

Aims of the study 3

Outline of remaining chapters 9

II. THEORETICAL FRAMEWORK

HI. REVIEW OF THE LITERATURE

Psychological morbidity after parental divorce 13

Depression and high-risk behaviors 21

High-risk behaviors and suicide 24

Sample selection criteria 33

Demographic Data Questionnaire 36

Reynolds Adolescent Depression Scale 39

Youth Risk Behavior Survey 41

Characteristics of the sample 54

Discussion of limitations of the study 92

Implications for nursing 95

Recommendations for future research 96

A Questionnaire A: Demographic Data Questionnaire 99

B Questionnaire B: Kidcope 107

C Questionnaire C: Reynolds Adolescent Depression Scale 110

D Questionnaire D: Youth Risk Behavior Survey 113

E Frequency distributions for questionnaire responses

by total sample 118

F Agreement to Participate; Informed Consent 126

2. Psychodynamic Model of Adolescent Suicidaiity 12

1. Suicide rates for persons 15-19 years of age 29

4. Mean ages for the total sample 55

5. Frequency distributions and likelihood ratio x2s

for questionnaire responses 59

6. Bivariate associations between coping, depression,

high-risk behaviors, and suicidaiity; with relative risk 65

7. Mean group differences for coping style and depression 66

8. Bivariate associations between depression and high-risk

behaviors, with relative risk 68

9. Mean differences in depression scores, by engagement

10. Bivariate associations between suicidal ideation and

high-risk behaviors, with relative risk 71

11. Bivariate associations between suicide attempt(s) and

high-risk behaviors, with relative risk 72

12. Bivariate associations between depression and

suicidaiity, with relative risk 74

13. Mean differences in depression scores by suicidaiity 75

14. Bivariate associations between hospitalization status and

coping, depression, high-risk behaviors, and suicidaiity,

with relative risk 77

15. Logistic regression coefficients for depression 79

16. Classification tables for depression 79

17. Logistic regression coefficients for depression,

with suicide attempt(s) omitted from the model 80

18. Logistic regression coefficients for depression,

with suicidal ideation omitted from the model 81

19. Logistic regression coefficients for substance abuse 82

20. Classification table for substance abuse 82