Adolescent Thoughts Research Articles

Gender Differences in Suicidal Ideation during the COVID-19 Pandemic among Iranian Adolescents and its Contributing Factors

Objective Suicidal thoughts in adolescents are common. The COVID-19 pandemic may have further led to an increase. This cross-sectional random sample “online” survey study was conducted in 2021 on 703 adolescents in Iran using the Beck Scale for Suicidal Ideation. Univariate, bivariate, and multinomial regression analysis, and Odds Ratio (OR) were reported. Results The prevalence of suicidal ideation in this sample was 28% and with higher rates in female participants (p = 0.01). It was more prevalent in 16 to 21 years old participants than adolescents with age of 16 and lower. Participants who were academically successful had less suicidal thoughts. Discussion Considering the high rate of suicidal ideation among adolescents, it is an emergency that requires effective intervention.

Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic.

Violence against adolescents is a pressing health problem with long-term implications for future physical and mental well-being, such as thoughts of self-harm, which have been associated with suicidal ideation and completion. However, much of the research has been conducted only in high-income countries. This study aimed to examine the correlation between violence against adolescents and self-harm thoughts in La Romana, Dominican Republic (DR). Cross-sectional survey data was collected at a community-based clinic from participants aged 13-20. Participants were recruited through the clinic's adolescent program and peer referral, and verbal consent was obtained. A survey solicited information about each participant's demographics, experiences with violence, and thoughts of harm to self or others. The survey was completed by 49 adolescents. The mean age was 16.78 (SD 2.34); 65% were female. We performed t-tests and Fisher's exact to investigate the relationship between demographics, reported violence experiences and having self-harm thoughts. About half (45%) had experienced physical violence, 76% had experienced emotional violence, and 12% had experienced sexual violence. The most common perpetrators of physical and emotional violence were classmates (12% and 24%), and the most common perpetrator of sexual violence was an ex-partner (4.1%). Ten participants (20.4%) had thought about harming themselves. Self-harm thoughts were significantly associated with being female (p = 0.025), employed (p = 0.05), and to a higher number of experiences of physical (0.029) and sexual violence (p = 0.023). The results of this study suggest a high prevalence of both violence and self-harm thoughts in adolescents in the DR. Interventions that address physical and sexual violence against adolescents may be particularly important. Particular attention should also be paid to screening for self-harm thoughts in female-identifying adolescents. Further research is needed to better understand the relationship between violence and self-harm thoughts in adolescents in the DR.

Substance Use, Internet Risk Behavior, and Depressive Symptoms as Predictors of Self-harm Thoughts in Adolescents: Insights from the 2019 ESPAD Survey in Croatia.

Self-harm has become a nonspecific symptom of mental distress that is most prevalent in the adolescent population. Since it is often a hidden problem, it is important to focus on preventing it. This study used the data from the Croatian leg of the European School Survey Project on Alcohol and Other Drugs to assess certain risk factors and possible protective factors for self-harm thoughts among 16-year-olds in Croatia. Using binary logistic regression, we identified that being female, having less family support and less parental knowledge of adolescents' activities, more frequent cannabis use, more compulsive Internet use and more frequent depressive symptoms significantly increased the likelihood of self-harm thoughts in this sample. Identifying factors that lead to thoughts of self-harm may open a potential space for self-harm prevention before those thoughts progress into behavior.

Exploring the Relationship between Perceived Parenting Style, Achievement Motivation, and Social Anxiety Thoughts in Adolescents

Exploring the Relationship between Perceived Parenting Style, Achievement Motivation, and Social Anxiety Thoughts in Adolescents

Network structure of emotional and behavioral problems, loneliness, and suicidal thoughts in adolescents at the school closure and reopening stage in China.

Public restriction and school closure policies during the pandemic may have long-term effects on adolescents' mental health, and adolescents' feelings and needs may change as the pandemic progresses. This study was conducted to explore the network structure and differences in emotional and behavioral problems (EBPs), loneliness, and suicidal thoughts in adolescents during different pandemic periods in China. Based on two cross-sectional studies conducted in Taizhou, China, during school closure (April 16 to May 14, 2020) and reopening (May 25 to July 10, 2021) using online questionnaire, a total of 14,726 adolescents (school closure: 6,587, school reopening: 8,139) were recruited. EBPs were evaluated based on the student version of the Strengths and Difficulties Questionnaire (SDQ). Loneliness and suicidal thoughts were measured by item 20 and item 9 of the Chinese version of the Children's Depression Inventory (CDI), respectively. Network analysis was used to estimate the network connections and properties between EBPs, loneliness, and suicidal thoughts. The prevalence of psychosocial problems significantly increased at the school reopening compared with the school closure: EBPs: 36.8% vs. 31.6%; loneliness: 40.3% vs. 33.9%; suicidal thoughts: 40.8% vs. 15.4%. Suicidal thoughts showed the closest connections with being unhappy and lonely. Being bullied was strongly connected with conduct problems of lying and stealing. The links between hyperactivity symptoms and the other domains of EBPs were stronger after the school reopened. Being unhappy and showing the hyperactivity symptoms of "nonpersistent, distractible, and fidgety" presented high network and bridge (increasing transference from one symptom domain to another) centrality. Loneliness showed high expected influence and bridge centrality. This study highlighted the high prevalence of EBPs, loneliness, and suicidal thoughts in Chinese adolescents. It also presented the network structure of these psychological problems over different pandemic stages. It is recommended that psychological support should be provided for adolescents, especially focusing on the central and bridge symptoms highlighted in this study.

Examining the relationship between risky sexual behavior and suicidal thoughts among unmarried adolescents in India

Addressing the problem of suicidal thoughts in adolescents requires understanding the associated risk factors. Multiple studies have shown that risky sexual behavior affected the adolescents’ psychological health that leads to their suicidal thoughts, behaviors and attempts. This study aimed to identify the association between various risky sexual behaviours and suicidal thoughts among unmarried adolescents in India. We used data collected from 4221 unmarried adolescent boys and 5987 unmarried adolescent girls aged 10–19 years, from the two rounds of the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey. Descriptive analysis was done to observe changes in the selected variables from wave-1 to wave-2. Random effect regression analysis was used to estimate the association of suicidal thoughts among unmarried adolescents with their risky sexual behaviours. The percentage of adolescent boys having suicidal thoughts increased from 1.35% in wave 1 to 2.19% in wave 2. Among adolescent girls, the percentage increased from 2.92% in wave 1 to 5.05% in wave 2. A proportion of 3.26% adolescent boys had more than one sexual partner during wave 1 whereas in wave 2, it rose to 8.71%, while in case of adolescent girls, the estimates only increased from 0.26% at wave 1 to 0.78% at wave 2. Nearly 4.55% boys and 1.37% girls had early sexual debut. Almost five percentage boys were sexually active at wave 1 whereas in wave 2, it rose to 13.56%, while among adolescent girls, the estimates decreased from 1.54% at wave 1 to 1.51% at wave 2. Contraceptive use increased over time among both adolescent boy and girls. Also, a large proportion of adolescent boys reported watching pornography (27.08% at waive 1 and 49.39% at wave 2) compared to adolescent girls (4.46% at wave 1 and 13.10% at wave 2). Adolescents who had more than one sexual partner [Coef: 0.04; p < 0.001], exposed to early sexual debut [Coef; 0.019; p < 0.01], sexually active [Coef: 0.058; p < 0.001] and reported watching pornography [Coef: 0.017; p < 0.001] were more likely to have suicidal thoughts. Adolescent boys and girls with risky sexual behaviors are likely to be at a higher risk of suicidal ideation, and thus, they should be treated with special care and attention by local healthcare practitioners.

Spontaneous Thought Characteristics are Differentially Related to Heightened Negative Affect vs. Blunted Positive Affect in Adolescents: An Experience Sampling Study.

Mind-wandering has been linked to negative affect and depressive symptoms in adolescents. However, mind-wandering is an extremely broad and heterogenous cognitive construct. Some features of spontaneous thought may be related to increased negative affect, whereas others may improve affect, or have no emotional influence. We used ecological momentary assessment (EMA) to investigate the characteristics of spontaneous thoughts in adolescents and their differential relations with moment-to-moment affect. One-hundred and sixteen adolescents (ages 13-18; Typical Mood (TM) = 58; Low Mood (LM) = 58) completed 5 days (2-3 times/day) of EMA (total 1,037 surveys) assessing current positive and negative affect (PA and NA) and dimensions of spontaneous thought. Multilevel models tested the relation between thought characteristics and affect. Relative to the TM group, LM adolescents had a higher frequency of mind-wandering (38% vs. 56%) and negatively-valanced thoughts during episodes of mind-wandering (21% vs. 37%). Negatively-valenced, self-referential and past-oriented thoughts were each associated with higher NA, even when controlling for plausible confounds (e.g., engagement in an unpleasant activity or social interaction, depressive symptom severity). In contrast, task-focused and positively-valenced thoughts were uniquely linked to higher PA. Characteristics of spontaneous thought - including temporal orientation, self-referential quality, and task-relatedness - were differentially related to NA vs. PA in adolescents. If replicated, these findings could inform more nuanced assessments of and targeted interventions for specific dimensions of mind-wandering contributing to high NA vs. blunted PA in teens.

중고등학생의 우울과 자살 생각의 관계에서 가족 결속력의 조절효과

The purpose of this study is to find an intervention plan to reduce suicidal thoughts in adolescents by examining the moderating effect of family cohesion in the relationship between depression and suicidal thoughts in middle and high school students. For this purpose, 500 middle and high school students residing in 10 cities and provinces across the country including Seoul were surveyed, and 399 of them were sampled and analyzed using SPSS 25.0 and PROCESS macro 4.0. The main findings are that first, depression showed a positive correlation with suicidal ideation, a negative correlation with family cohesion, and suicidal ideation showed a negative correlation with family cohesion. Second, the group with high family ties showed a relatively gentle increase in suicidal ideation due to depression, whereas the group with low family ties showed a steeper increase in suicidal ideation due to depression. In addition, the conditional effect of depression on suicidal ideation was significant in all three conditions of low, average, and high family cohesion. Therefore, family cohesion played a buffering role in the relationship between depression and suicidal ideation. Based on these results, a method to improve family cohesion was suggested as an intervention method to reduce the effect of depression on suicidal thoughts in middle and high school students.

The Persian Language Version of the Obsession With the COVID-19 Scale for Adolescents.

Objective: The worldwide pandemic of coronavirus disease (COVID-19) has caused significant public health burdens and psychological dysfunctions. In this challenging time, adolescents require special care. The Persian version of the Obsession with COVID-19 Scale (OCS) for adolescents was developed to screen for dysfunctional obsession associated with the coronavirus during the global pandemic. The structure and internal consistency of the OCS were established.Design and Measures: Although there are different language versions of the OCS, this is the first study to validate the psychometric properties of the OCS in Iranian adolescents. Seven hundred and nine students (369 girls) participated in the study. Demographic questions and the OCS were administered.Results: The findings provided support for the existence of a unidimensional structure that met the criteria for configural, metric, and full scalar invariance across gender (girls and boys), inhabitancy (urban and rural), and infection experience (infected and non-infected). The OCS is short and highly reliable measurement. However, further research is necessary to establish the validity of the scale in Iranian population.Conclusions: The development of such valid scales is an essential part of both research and practice during times of crisis, like a global pandemic. Diagnosis of pandemic related to obsessive thoughts in adolescents is needed as the COVID-19 pandemic is still ongoing and as experts point out, it can be expected that the effects of the pandemic will be observed in the coming years. The Persian version makes it possible to conduct international comparative research on the anxiety related to the COVID-19 pandemic.

Predicting short-term suicidal thoughts in adolescents using machine learning: developing decision tools to identify daily level risk after hospitalization.

Mobile technology offers unique opportunities for monitoring short-term suicide risk in daily life. In this study of suicidal adolescent inpatients, theoretically informed risk factors were assessed daily following discharge to predict near-term suicidal ideation and inform decision algorithms for identifying elevations in daily level risk, with implications for real-time suicide-focused interventions. Adolescents (N = 78; 67.9% female) completed brief surveys texted daily for 4 weeks after discharge (n = 1621 observations). Using multi-level classification and regression trees (CARTSs) with repeated 5-fold cross-validation, we tested (a) a simple prediction model incorporating previous-day scores for each of 10 risk factors, and (b) a more complex model incorporating, for each of these factors, a time-varying person-specific mean over prior days together with deviation from that mean. Models also incorporated missingness and contextual (study week, day of the week) indicators. The outcome was the presence/absence of next-day suicidal ideation. The best-performing model (cross-validated AUC = 0.86) was a complex model that included ideation duration, hopelessness, burdensomeness, and self-efficacy to refrain from suicidal action. An equivalent model that excluded ideation duration had acceptable overall performance (cross-validated AUC = 0.78). Models incorporating only previous-day scores, with and without ideation duration (cross-validated AUC of 0.82 and 0.75, respectively), showed relatively weaker performance. Results suggest that specific combinations of dynamic risk factors assessed in adolescents' daily life have promising utility in predicting next-day suicidal thoughts. Findings represent an important step in the development of decision tools identifying short-term risk as well as guiding timely interventions sensitive to proximal elevations in suicide risk in daily life.

The Mediating Role of Perceived Stress in the Relationship between Personality Traits and Negative Automatic Thoughts in Adolescents with Migraine

Background: The literature investigating adolescents with chronic headaches, particularly migraines, illustrated the crucial role played by a wide range of psychological problems. In addition, groundbreaking studies have shown that preexisting personality traits are important to accelerate the likelihood of migraine onset, maintenance, and outcome. This study aimed to investigate dimensions of perceived stress as a mediating role in relation to personality traits and negative automatics thought, in an adolescent with migraine. Materials & Methods: In this cross-sectional, descriptive study, the participants consisted of patients with chronic migraine referring to the two neurology clinics in Ahvaz City, Iran from 2019 to 2020. A diverse sample of patients (n =200) completed the Cohen’s Perceived Stress Scale, NEO Five-Factor Inventory (NEO-FFI), and Automatic Thoughts Questionnaire (ATQ-N). To analyze the obtained data SPSS V. 21 and Amos 18 were used. Results: Based on the standard path coefficients and the significance level, the relationship between personality traits and the negative dimension of perceived stress (β = -46, P≥ 0.001), personality traits and the positive dimension of perceived stress (β = 0.44, P≥ 0.001), The negative dimension of perceived stress to negative spontaneous thoughts (β = 0.45, P≥ 0.008), and The positive dimension of perceived stress to negative automatic thoughts is (β = -0.28, P≥ 0.004) were significant. Conclusion: According to the results, the indirect relationship between personality traits and n negative automatic thoughts was established and significant through the negative dimension of perceived stress. Moreover, the indirect relationship between personality traits and negative automatic thoughts was established and significant through the positive dimension of perceived stress.

The relationship between bullism, depression and suicidal thought in adolescents in albania

IntroductionThe effects of bullying can be both physical and emotional, and they can last for many years. Children that experience verbal and physical bullying are at a greater risk of developing depression later on in life, compared with children who did not.ObjectivesThis study aims to look into the relationship between bullying, depressive symptomatology and suicidal thoughts in adolescents of high schools in Lushnje.MethodsThree questionaires (the Beck Depression Inventory; the Bully/victim Behavior / Victim Behavior Questionnaire by Olweus; the Suicide Questionnaire) were circulated online and were completed by 400 adolescents from 2 high schools in a small city in Albania between September-November 2019. Data has been analysed using the Software Package for Social Sciences for Windows v. 22.0 (SPSS Inc. Chicago, IL).ResultsWe found significant positive correlation between bullying (victimization) and the level of depression (r (n = 400) =. 300, p≤.05), and significant positive correlation of bullying (cause) with level of depression (r (n = 400) =. 160, p≤.05) but lower than in victimes. The victims of bullying have higher levels of depression and vice versa. We found higher rate of depression in female adolescents with the average (M = 14.710, ds = 11.263) compared to boys with the average (M = 9.609, ds = 10.723). There is an important positive correlation of suicidal ideation with the level of depression (r (n = 400) =. 616, p≤.05).ConclusionsBeing either a bully or a victim of bullying seems to increase the chances of being affected by depression and suicidal thoughts

Parent and Adolescent Thoughts About Suicide Risk Screening in Pediatric Outpatient Settings

Suicide rates among adolescents in the United States continue to climb and many at-risk youths are undetected. Screening for suicidal thoughts has become the primary approach to identify those at risk, but no studies have assessed reactions to its deployment in pediatric outpatient settings. This mixed-method study assessed parents’ and adolescents’ thoughts about suicide risk screening in non-psychiatric, pediatric outpatient specialty settings. As part of a multi-site measurement validation study, adolescents (n = 269; ages 10–21) and parents (n = 246) at pediatric specialty clinics in the Midwest completed a survey regarding thoughts about suicide risk screening. Data were collected on tablet computers and transcribed verbatim. Three study team members independently coded transcripts of open-ended responses to identify major themes, and frequency data were analyzed using StataSE 15.1. Inter-rater agreement was substantial (Fleiss’ Kappa ranged 75–86%). Parents (55% 41–50 years of age, 20% male, 80% White) and adolescents (Mean age = 14.3, 50% male, 77% White) agreed medical providers should screen adolescents for suicide risk (93% and 88%, respectively). Majority of parents indicated that the pediatric outpatient setting is appropriate for suicide risk screening. Major themes included the important role of providers in identifying at-risk youth, the potential for screening to prevent suicides, and concerns about iatrogenic risk and misdiagnosis. Most parents and adolescents support screening for suicide risk in pediatric outpatient settings. Nevertheless, some have concerns about the screening process and implications. As suicide risk screening becomes standard practice in adolescent care, it’s critical to develop screening processes that maximize comfort and address concerns.

The relations between childhood maltreatment, shame, guilt, depression and suicidal ideation in inpatient adolescents

BackgroundPrevious studies demonstrated positive relations between various forms of maltreatment and suicidal ideation in youth; however, mechanisms underlying these relationships are not well understood. We propose that the experience of maltreatment in childhood may lead to high levels of generalized guilt and shame, resulting in an increase of depressive symptoms and suicidal thoughts in adolescents. The aim of the current study was to test our model of relations between these constructs using path analysis. Methods112 inpatient adolescents aged 12-17 years completed the Childhood Trauma Questionnaire to measure various types of maltreatment, the Personal Feelings Questionnaire to evaluate generalized guilt and shame, the Beck Depression Inventory-II to assess depressive symptoms, and the Columbia-Suicide Severity Rating Scale to assess suicidal ideation. ResultsFindings partly confirmed the theoretical model. Indirect positive effects of sexual and emotional abuse, as well as emotional and physical neglect on suicidal ideation via generalized self-conscious emotion and/or depression were demonstrated. In contrast to our predictions, indirect negative effects of physical abuse on suicidal thoughts via generalized guilt and shame and depression were found. LimitationsSample characterized by predominately Caucasian inpatient adolescents from financially stable and well-educated environments, over-reliance on self-report measures and the lack of a longitudinal design were main limitations of the study. ConclusionsThe study provides novel information on the potential mechanisms underlying the association between childhood maltreatment and suicidal ideation in adolescents. Generalized guilt and/or shame could be possible targets for interventions for victims of some forms of maltreatment to reduce depressive symptoms and suicidal ideation.

Suicidal Ideation in Adolescence: A Perspective View on the Role of the Ventromedial Prefrontal Cortex.

Suicide in adolescence is a worldwide issue, and it continues to present a serious problem in terms of its prevention. Among the various aspects of suicide, a very interesting area of research is represented by suicidal ideation. Recently, neuroimaging-based methods have made it possible to study the cognitive processes involved in several social situations and clinical conditions. This theoretical perspective article with an interdisciplinary approach integrates evidence from developmental psychology and social neuroscience with the aim of investigating the role of the brain area responsible for regulating negative emotions during the cognitive processes of suicidal ideation: the ventromedial prefrontal cortex. By highlighting the role of brain areas in the few studies published so far, it is possible to develop perspectives of considerable impact. Studying and understanding the role of brain areas involved in suicidal thoughts in adolescents could facilitate the creation of new perspectives on prevention programs and interventions.

The relationship between profiles and transitions of internalizing and externalizing symptoms in children and suicidal thoughts in early adolescence.

Adolescence is a high-risk period for the onset of suicidal thoughts and behaviors. Identification of preceding patterns of internalizing and externalizing symptoms that are associated with subsequent suicidal thoughts may offer a better understanding of how to prevent adolescent suicide. Data from the National Longitudinal Survey of Children and Youth, a prospective population-based Canadian cohort, contained Child Behavior Checklist items which were used to examine profiles and transitions of internalizing and externalizing symptoms in children, aged 6-11 years (n = 8266). The association between these profiles/transitions and suicidal thoughts in adolescents was examined using multivariate logistic regression modeling. Latent profile analyses identified four measurement invariant profiles of internalizing and externalizing symptoms at ages 6/7 and 10/11: (1) low on all symptoms, (2) moderate on all symptoms, (3) high on all symptoms, and (4) high on hyperactivity/inattention and internalizing. Recurrent (homotypic or heterotypic) and increasing symptoms from 6/7 to 10/11 were associated with suicidal thoughts in adolescence, compared to those with stable low symptoms. Those with decreasing symptoms from 6/7 to 10/11 were not at increased risk of suicidal thought in adolescence. While patterns of recurrent symptoms were associated with suicidal thoughts, a similar association was observed between profiles at age 10/11 years and suicidal thoughts. This suggests that the recent assessments of mental health symptoms in children may be as sufficient a predictor of adolescent suicidal thought as transition profiles.

Paranoid Thoughts in Adolescents with Social Anxiety Disorder

Recently, social anxiety disorder (SAD) and paranoia have been demonstrated to be closely related. However, data were primarily drawn from adult community samples or patients with schizophrenia. The present study used a cross-sectional design to evaluate a sample of adolescents with SAD (n=30, mean age 15.3±0.9years) compared with an age- and sex-matched group of healthy controls (n=26, mean age 15.9±1.6years). The SAD group displayed more frequent and intense paranoid thoughts than the control group (t=4.16, p<0.001). The level of paranoid thoughts was significantly predicted by the degree of social phobia, even after adjusting for sex and other anxiety disorders, although adjusting for depression slightly reduced the extent and significance of the prediction. A lack of awareness about the association between SAD and paranoia may lead to incorrect diagnoses (e.g. misdiagnosis of psychotic disorders), or it may negatively influence the (psycho)therapeutic process and patient outcomes.

1370 – Adolescents’ mental health evaluation in ukraine using adapted seyle protocol

Modern situation n Ukraine is charachterized by rapid growth of socio-economic inequality. To evaluate mental health, psychosocial problems and suicidality in adolescents aged 14-17 years with regards to socio-economic factors of the families. To evaluate role of socio-economic enaquality as a factor impairing adolescents’ mental health. Components of SEYLE protocol were adapted to local regulations and were used to measure wide range of psycho- social factors characterizing adolescents’ mental health. 250 children aged 14-17 representing different types of schools (from elite gymnasiums to municipal boarding-schools) were questioned. It was found that main psychosocial problems of adolescents were in the domains of sleep disturbances, internet addiction, unhealthy life styles including smoking, alcohol and risky behaviours. Both negative and positive characteristics have a tendency to clastering. Suicidal thoughts are admitted by 30% of children with a slight prevalence in girls. One of the strong predictors of negative life styles and mental health problems is the answer to the question if a child have ever seen a parent being drunk. There was a marked association between mental health problems and socio-economic status of the family. Poorer economic status of the family was associated with higher level of depression, feeling of stress, loneliness, psychosomatic symptoms and suicidal thoughts in adolescents. Socio-economic status of the families, parents life styles, internet abuse and fatigue play an important role in adolescents suicidality. Children are very susceptible to the stress in parents caused by socio-economic circumstances.

P.7.03 Brain-derived neurotrophic factor gene val66met polymorphism, smoking and suicide-related thoughts in adolescents

P.7.03 Brain-derived neurotrophic factor gene val66met polymorphism, smoking and suicide-related thoughts in adolescents

Investigating the causal relationship between Self Beliefs and Automatic Thoughts in Adolescents\ Success Aspiration

The study investigated the correlation between self beliefs and automatic thoughts in adolescents\' success aspirations in Lagos, Nigeria. A sample of 180 students randomly selected from nine secondary schools comprising of 90 males and 90 females was used. Questionnaire was employed to generate data for the study. This study also investigated the current state of the influence of gender schema on adolescents\' success aspiration. Data collected were analyzed with the use of ANCOVA and Pearson correlation coefficient. Results obtained indicated a significant effect of self defeating beliefs and negative automatic thoughts in success aspiration as a result of poor success expectancy. Keywords : Self belief, Automatic thought, Gender schema, Success expectancy International Journal of Educational Research Vol. 4 (1) 2008: pp. 37-46