Attributional style in clinically depressed and conduct disordered adolescents

Developing a data-driven algorithm for guiding selection between cognitive behavioral therapy, fluoxetine, and combination treatment for adolescent depression

Treating adolescent depression effectively requires providing interventions that are optimally suited to patients' individual characteristics and needs. Therefore, we aim to develop an algorithm that matches patients with optimal treatment among cognitive-behavioral therapy (CBT), fluoxetine (FLX), and combination treatment (COMB). We leveraged data from a completed clinical trial, the Treatment for adolescents with depression study, where a wide range of demographic, clinical, and psychosocial measures were collected from adolescents diagnosed with major depressive disorder prior to treatment. Machine-learning techniques were employed to derive a model that predicts treatment response (week 12 children's depression rating scale-revised [CDRS-R]) to CBT, FLX, and COMB. The resulting model successfully identified subgroups of patients that respond preferentially to specific types of treatment. Specifically, our model identified a subgroup of patients (25%) that achieved on average a 16.9 point benefit on the CDRS-R from FLX compared to CBT. The model also identified a subgroup of patients (50%) that achieved an average benefit up to 19.0 points from COMB compared to CBT. Physical illness and disability were identified as overall predictors of response to treatment, regardless of treatment type, whereas baseline CDRS-R, psychosomatic symptoms, school missed, view of self, treatment expectations, and attention problems determined the patients' response to specific treatments. The model developed in this study provides a critical starting point for personalized treatment planning for adolescent depression.

Measuring anxiety as a treatment endpoint in youth with autism spectrum disorder

Despite the high rate of anxiety in individuals with autism spectrum disorder (ASD), measuring anxiety in ASD is fraught with uncertainty. This is due, in part, to incomplete consensus on the manifestations of anxiety in this population. Autism Speaks assembled a panel of experts to conduct a systematic review of available measures for anxiety in youth with ASD. To complete the review, the panel held monthly conference calls and two face-to-face meetings over a fourteen-month period. Thirty eight published studies were reviewed and ten assessment measures were examined: four were deemed appropriate for use in clinical trials, although with conditions; three were judged to be potentially appropriate, while three were considered not useful for clinical trials assessing anxiety. Despite recent advances, additional relevant, reliable and valid outcome measures are needed to evaluate treatments for anxiety in ASD.

Resiliency training in Indian children: a pilot investigation of the Penn Resiliency Program

This paper examines the effectiveness of the Penn Resiliency Program (PRP) in an urban Indian setting. The PRP is a program to prevent depression in early adolescence and has proved successful in changing children's attributional style of life events. While the program has been successful in preventing symptoms of depression in Western populations, the current study explored whether this program could be effective with an Indian sample. The aim of the current study was twofold; first, to study the attributional style of early adolescents in India and identify negative effects (if any) and second, to gain insights in using the PRP as a tool to change explanatory styles in Indian children. A total of 58 children participated in the study (Intervention group n = 29 and Control group n = 29). An Analysis of Covariance comparing post-test scores on Children's Attributional Style Questionnaire (CASQ) while controlling for baseline scores indicated that children in the intervention group exhibited a significant reduction in pessimistic explanatory style and an increase in optimistic orientation compared to children in the control group. This indicates that the program was effective in changing negative attribution styles among upper-class Indian school children. Future work may look into the longer impact of the program as well as further considerations into adapting the program for a middle class population.

Social Problem Solving and Aggression: The Role of Depression

The purpose of the present study was to examine direct and indirect relations among social problem-solving, depression, and aggression, as well as the mediating role of depression in the link between social problem-solving and aggression among Turkish youth. Data for the present study were collected from 413 adolescents. The participants’ age ranged from 14 to 17 with a mean of 15.74 years (SD = .97). Results indicated that social problem-solving was significantly and negatively associated with both depression and aggression. Also, depression significantly and positively associated with aggression and depression appears to act as a mediator in the relationship between social problem-solving and aggression. Findings suggest that social problem-solving and depression are important factors in understanding aggression among Turkish youth.

Predictors of hopelessness among clinically depressed youth

BACKGROUND

Factors that distinguish depressed individuals who become hopeless from those who do not are poorly understood.

METHOD

In this study, predictors of hopelessness were examined in a sample of 439 clinically depressed adolescents participating in the Treatment for Adolescents with Depression Study (TADS). The total score of the Beck Hopelessness Scale (BHS) was used to assess hopelessness at baseline. Multiple regression and logistic regression analyses were conducted to evaluate the extent to which variables were associated with hopelessness and determine which cluster of measures best predicted clinically significantly hopelessness.

RESULTS

Hopelessness was associated with greater depression severity, poor social problem-solving, cognitive distortions, and family conflict. View of self, view of the world, internal attributional style, need for social approval, positive problem-solving orientation, and family problems consistently emerged as the best predictors of hopelessness in depressed youth.

CONCLUSIONS

Cognitive and familial factors predict those depressed youth who have high levels of hopelessness.

Prevention of depression among Icelandic adolescents

Major depression and dysthymia are frequent, debilitating, and chronic disorders, whose highest rate of initial onset is during the late adolescent years. The effectiveness of a program designed to prevent an initial episode of major depression or dysthymia among adolescents was investigated. Participants were 171 fourteen-year-old "at risk" Icelandic adolescents who were randomly assigned to a prevention program or a treatment-as-usual assessment only control group. They were identified as "at risk" by reporting the presence of depressive symptoms or a negative attributional style. The program was based on a developmental psychosocial model of enhancement of resilience to factors associated with the occurrence of mood disorders. The results indicated that the prevention program resulted in a significantly lower rate of major depression and dysthymia than did the control group. The study demonstrated that school personnel in the school setting can implement such prevention programs.

Mood disorders in children and adolescents

Childhood mood disorders such as major depression, dysthymia, and bipolar disorder have been found to be highly prevalent among children and adolescents. The emotional and behavioral dysfunction associated with these mood disorders can cause impairments across areas of functioning, including academic and social arenas. This article reviews the course, possible causes, assessment, and treatment of this group of disorders in youth and concludes by examining the implications for nurses and other health care providers of youth with mood disorders.

Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth

Relapse rates for children and adolescents with major depressive disorder (MDD) range from 30% to 40% within 1 to 2 years after acute treatment. Although relapse rates are high, there have been relatively few studies on the prevention of relapse in youth. While acute phase pharmacotherapy has been shown to reduce symptoms rapidly in depressed youth, children and adolescents frequently report ongoing residual symptoms and often relapse following acute treatment. Recent adult trials have begun examining augmentation with psychosocial treatment after successful medication treatment to enhance medication response and prevent future relapse. This strategy has not yet been examined in youth with depression. Here we present initial efforts to develop a sequential, combination treatment strategy to promoting rapid remission and to prevent relapse in depressed youth. We describe efforts to adapt CBT to prevent relapse (RP-CBT) in youth who respond to pharmacotherapy. The goals of RP-CBT include: preventing relapse, increasing wellness, and developing skills to promote and sustain a healthy emotional lifestyle. We describe the rationale for, components of, and methods used to develop RP-CBT. The results from a small open series sample demonstrate feasibility and indicate that youth appear to tolerate RP-CBT well. A future test of the treatment in a randomized controlled trial is described.

Social neuroscience of child and adolescent depression

The social neuroscience of child and adolescent depression is inherently multidisciplinary. Depressive disorders beginning early in life can have serious developmental and functional consequences. Psychopathology research has described depression's defining clinical and contextual features, and intervention research has characterized its response to treatment and prevention programs. Neuroendocrine, electrophysiological, and neuroimaging studies have identified core neurobiological aspects of early-onset mood disorders. These areas are reviewed using a developmental social neuroscience perspective for integrating disparate observations. The paper introduces a dynamic adaptive systems framework, and it discusses hedonic capacity, stress sensitivity, ruminative self-focus, and attentional impairments as fundamental components of mood disorders.

Mediators of control beliefs, stressful life events, and adaptive behavior in school age children: the role of appraisal and social support

The authors examine the role of appraisal and social support as mediators of the relation between control beliefs and adaptive behavioral outcome. Using the responses from 297 children, ages 8 to 12 years old, the results suggest two significant mediational pathways. Social support was a mediator of the relation between unknown control for negative events and adaptive behavior and the relation between unknown control for positive events and adaptive behavior. Negative appraisal demonstrated no mediation relations. The role of social support and negative appraisal in the display of adaptive behavior and the implications for further model testing are discussed.

Positive emotionality at age 3 predicts cognitive styles in 7-year-old children

This study examined associations between temperament at age 3 and depressotypic cognitive styles at age 7 in a community sample of children. Sixty-four preschool aged children were assessed for positive emotionality (PE) and negative emotionality (NE) using a standardized battery of laboratory tasks and naturalistic home observations. At follow-up 4 years later, the children completed laboratory tasks designed to tap helplessness in social and problem-solving situations, positive and negative information-processing biases, and self-reports of attributional style. Lower PE at age 3 predicted greater helplessness in the interpersonal task and decreased positive schematic processing. There was little evidence for a relationship between NE and depressotypic cognitive styles. Our findings are consistent with the hypothesis that some portion of cognitive vulnerability to depression may stem from early-emerging differences in the expression of positive emotions.

Is There a Universal Positivity Bias in Attributions? A Meta-Analytic Review of Individual, Developmental, and Cultural Differences in the Self-Serving Attributional Bias

Researchers have suggested the presence of a self-serving attributional bias, with people making more internal, stable, and global attributions for positive events than for negative events. This study examined the magnitude, ubiquity, and adaptiveness of this bias. The authors conducted a meta-analysis of 266 studies, yielding 503 independent effect sizes. The average d was 0.96, indicating a large bias. The bias was present in nearly all samples. There were significant age differences, with children and older adults displaying the largest biases. Asian samples displayed significantly smaller biases (d = 0.30) than U.S. (d = 1.05) or Western (d = 0.70) samples. Psychopathology was associated with a significantly attenuated bias (d = 0.48) compared with samples without psychopathology (d = 1.28) and community samples (d = 1.08). The bias was smallest for samples with depression (0.21), anxiety (0.46), and attention-deficit/hyperactivity disorder (0.55). Findings confirm that the self-serving attributional bias is pervasive in the general population but demonstrates significant variability across age, culture, and psychopathology.

Helpless attributions and depression in adolescents: the roles of anxiety, event valence, and demographics

The relationship between helpless attributions and depression is well established. This study evaluated whether anxiety, event valence (positive or negative) and demographic variables (gender, age, socioeconomic status or race) influence this relationship. Results showed: (1) adolescents with anxiety and depression who were from lower socioeconomic backgrounds made less helpless attributions for negative events than did adolescents from higher socioeconomic backgrounds, (2) male adolescents with anxiety-only had helpless attribution styles that were similar to male adolescents with depression, but the same was not true for female adolescents, and (3) African-American adolescents showed less helpless attributions for negative events than did Caucasian adolescents. Results replicate past research showing that a helpless attribution style is associated with depression in adolescence, but suggest that this pattern may be influenced by demographic factors. Results also suggest that helpless attributions may be related to both anxiety and depression in males.

Examining cognitive models of externalizing and internalizing problems in subgroups of juvenile delinquents

Examined cognitive content and processes, from models of externalizing and internalizing problems, in incarcerated delinquents (N = 177). Four groups were defined by multiple criteria (with 41 youth not able to be classified): aggressive-internalizing (AI, n = 22); aggressive-noninternalizing (AN, n = 14); nonaggressive-internalizing (NI, n = 27); and nonaggressive-noninternalizing (NN, n = 73). Groups did not differ on self-centered and minimizing types of self-serving processing distortions, although the comorbid group endorsed more self-serving distortions of assuming the worst and blaming others than the NN group. Aggressive, in comparison to nonaggressive, delinquents reported more self-serving distortions in reference to overt behavior content. In contrast, self-debasing cognitive content was related to internalizing problems, as both the AI and NI groups had more negative beliefs about self than both the AN and NN groups, and more negative beliefs about the world and the future than the NN group. The AI group also had more negative beliefs about the world than the AN group. Self-debasing processing distortions were not specifically related to internalizing problems, as no differences emerged between the AN and NI groups; however, the AI group differed from the NN group on 3 of 4 types of these distortions. Both of the internalizing groups had a more negative attributional style than the NN group. Theoretical and treatment implications are highlighted.

Attenuation of frontal asymmetry in pediatric posttraumatic stress disorder

BACKGROUND

Volumetric imaging research has shown abnormal brain morphology in adults with posttraumatic stress disorder (PTSD) when compared with matched control subjects. In this article, we present brain imaging findings from a study of children with PTSD symptoms.

METHODS

Twenty-four children between the ages of 7 and 14 with a history of trauma and PTSD symptoms were assessed with the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA). The sample underwent magnetic resonance imaging in a 1.5 T scanner. Brain images were analyzed by raters blind to diagnostic status using well-standardized methods, and images were compared with age- and gender-matched healthy control subjects.

RESULTS

The clinical group demonstrated attenuation of frontal lobe asymmetry and smaller total brain and cerebral volumes when compared with the control group. There were no statistically significant differences in hippocampal volume between clinical and control subjects.

CONCLUSIONS

Frontal lobe abnormalities may occur as a result of PTSD in children or, alternatively, be a risk factor for the development of the syndrome in this age group. The implications of the findings and their consistency with previous research are discussed.

Reports of assent and permission in research with children: illustrations and suggestions

This study ascertained reports of assent (affirmative agreement) and permission (agreement by an adult fully capable of being informed) in 114 children's research articles in 1990 in Child Development (CD), Journal of Consulting and Clinical Psychology (JCCP), Journal of Pediatric Psychology, and Journal of Clinical Child Psychology. Of the research projects, 43% failed to specify permission, and 68.5% failed to specify assent. JCCP reported assent significantly more than CD. Assent was reported significantly more in research with older children than with younger children. This lack of sensitivity to assent and permission suggests that many authors, reviewers, and editors consider reporting assent and permission unessential. We recommend specifying assent and permission in all manuscripts, highlighting children's research issues in graduate training, and using specific safeguards when conducting research with children.

Five points and a lament about Range and Cotton's "Reports of assent and permission in research with children: illustrations and suggestions

This comment responds to an article by Range and Cotton (1995) on reporting of parental permission and child assent procedures in published articles for 4 psychology journals. Issue is taken with the assumptions, methodology, interpretations, and implications of listing researchers in the Range and Cotton article. There is no evidence researchers failed in their ethical obligations or that children were put at risk. Reporting permission/assent in publications is not an ethical requirement. Listing researchers as "failing" to do something not part of an ethical code is lamentable. Too many unfortunate implications and problems can be derived from Range and Cotton's analysis and conclusions.

The Children's Attributional Style Interview: developmental tests of cognitive diathesis-stress theories of depression

This paper presents an initial assessment of the Children's Attributional Style Interview (CASI), a newly designed measure for assessing attributional style in young children (age 5 and up). The CASI was used to conduct prospective tests of the reformulated helplessness and the integrated hopelessness/self-esteem theories of depression in a sample of 147 5-10-year-old children. For comparison, the same tests were also conducted with the Children's Attributional Style Questionnaire-Revised, a commonly used measure for assessing attributional style in older children (age 8 and up). The CASI evidenced support of the reformulated helplessness theory and partial support of the integrated hopelessness/self-esteem theory. The CASI also demonstrated good internal consistency. Thus, our findings provide initial support for the CASI as a methodologically sound measure of attributional style for children as young as 5 years old. Although preliminary, our findings also suggest possible developmental differences in how attributional style interacts with self-esteem and negative life stress. The CASI should prove to be a useful tool in furthering the understanding of the origins and development of attributional style in childhood, as well as its contribution to the understanding of the development and prevention of depressive symptomatology in children.

Screening for anxiety and depression in early adolescence

OBJECTIVE

To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths.

METHOD

Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions.

RESULTS

MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate.

CONCLUSIONS

The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Evaluation of cognitive diathesis-stress models in predicting major depressive disorder in adolescents

Diathesis-stress predictions regarding the onset of adolescent major depression and nonmood disorders were tested. Adolescents (N = 1,507) were assessed for dysfunctional attitudes and negative attributional style, as well as current depressive symptoms, current depressive and nondepressive diagnoses, and past and family histories of psychopathology. Approximately 1 year later, participants were reassessed on all measures. Analyses supported A. T. Beck's (1976) theory of depression (at the level of a trend) but not the hopelessness theory of depression. Findings were suggestive of a threshold view of vulnerability to depression; for those who experienced negative life events, depressive onset was related to dysfunctional attitudes but only when dysfunctional attitudes exceeded a certain level (low = intermediate < high). For participants who scored either very high or very low on both dysfunctional attitudes and negative attributional style, nonsignificant findings were obtained.

Validity of the Devereux Scales of Mental Disorders with adolescent psychiatric inpatients

Tested the validity of the Devereux Scales of Mental Disorders (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994) in a sample of 108 adolescent psychiatric inpatients. DSMD scales were compared to parent-report, interview-based, self-report and diagnostic measures. DSMD measures of conduct problems and delinquency were significantly associated with the predicted parent-report, interview-based, and diagnostic measures of conduct disorder and substance abuse and not with any measures of anxiety or depression. DSMD measures of anxiety and depression were related to other parent-report ratings of internalizing symptoms but had more limited convergent and discriminant validity. The DSMD was compared to the Child Behavior Checklist (CBCL; Achenbach, 1991) for diagnostic classification accuracy. The two measures were comparable in classifying oppositional or conduct disorder. The CBCL was superior for classification of major depression. The DSMD was superior for classification of substance abuse.

Coping and negative appraisal as mediators between control beliefs and psychological symptoms in children of divorce

Examined control beliefs of children of divorce as predictors of their coping, negative appraisals for stressful events, and mental health problems. We tested whether coping and negative appraisal for stressful events mediated the relations between multiple dimensions of control beliefs and mental health problems. Different dimensions of control beliefs were related to different aspects of coping and negative stress appraisal. Internal control beliefs for positive events were related to both active and avoidant coping. Unknown control beliefs for positive events were related to higher active coping and higher negative appraisal. Unknown control beliefs for negative events were related to higher avoidant coping. In addition, evidence for mediation was found such that the effect of unknown control beliefs for positive events on mental health problems was mediated by negative appraisal. Implications and directions for further research are discussed.

Preliminary examination of sex differences in depressive symptoms among adolescent psychiatric inpatients: the role of anxious symptoms and generalized negative affect

Assessed the emerging view that generalized negative affect and anxious symptoms are important in understanding sex differences in depressive symptoms. Sixty-three adolescent psychiatric inpatients (32 boys, 31 girls), ages 12 to 16 (M = 13.87, SD = 1.36), completed measures of positive and negative affect and anxious and depressive symptoms. Results demonstrated, as predicted, that depressive and anxious symptoms were more highly associated in adolescent girls than boys. Furthermore, girls with depressive symptoms were more likely to have comorbid anxious symptoms than boys with depressive symptoms. Sex differences were not found for adolescents with specific depressive symptoms and specific anxious symptoms (i.e., the absence of comorbidity). Our findings supported the possibility that sex differences in pure forms of depression are overestimated and that comorbid internalizing conditions may be more prevalent in adolescent girls than boys.

Age and gender differences in children's and adolescents' adaptation to sexual abuse

OBJECTIVE

How children manifest psychological distress following the discovery of sexual abuse requires a better understanding of individual differences in developmental capacities and vulnerabilities. This study examined how age at the time of the abuse discovery and gender of victim are related to psychological distress.

METHOD

One hundred and sixty-nine participants (96 children, 73 adolescents) were interviewed within 8 weeks of discovery of the abuse. Multivariate analyses were used to examine how age at discovery, and gender, with abuse characteristics as covariates, were related to shame, attribution style, depression, self-esteem, and traumatic events sequelae.

RESULTS

Adolescents compared to children report a higher level of depressive symptoms, negative reactions by others, and lower levels of self-esteem, social support, and sexual anxiety. Girls compared to boys report higher levels of intrusive thoughts, hyperarousal, sexual anxiety, personal vulnerability, and perceiving the world as a dangerous place and lower levels of eroticism.

CONCLUSIONS

These findings suggest the importance of considering individual differences in age and gender for understanding patterns of symptom expression. Treatment strategies need to reflect these individual differences in adjustment, such as targeting issues of sexual anxiety for girls and self-esteem for adolescents.

Psychological treatment of depression in children and adolescents. A review of treatment research

BACKGROUND

This paper reviews research on the psychological treatment of depression in children.

METHOD

Manual and computer literature searches were performed.

RESULTS

The most promising psychological interventions for depression in children are individual rather than family therapies. Cognitive--behavioural therapy seems to be an effective treatment for depressive symptoms and mild depressive disorders. It may also be a useful preventive intervention, though this remains to be conclusively demonstrated. There have been no systematic studies comparing psychological treatments with medication.

CONCLUSIONS

Studies comparing psychological treatments and medication are now required.

Low-end specificity of childhood measures of emotional distress: differential effects for depression and anxiety

This study examined the low-end specificity of self-report measures of anxious and depressed symptoms among a clinical sample of 96 child and adolescent psychiatric inpatients (54 boys, 42 girls; ages 8 to 16; M = 12.34, SD = 2.43). To our knowledge, the study is one of the first to examine the issue in a clinical sample, and the first to address this issue in children and adolescents. Participants completed the Children's Depression Inventory (CDI) and the Revised Children's Manifest Anxiety Scale (RCMAS). As predicted, CDI low-end participants obtained higher RCMAS Lie scale scores than depressed participants, suggesting a tendency to deny symptoms and to attempt to appear in a favorable light. In contrast, but also consistent with prediction, low-end RCMAS participants did not obtain higher Lie scale scores than anxious participants. Gender and age did not moderate the findings in any way. Thus, our results support hypotheses that defensiveness would affect a self-report measure of depression but not a self-report measure of anxiety. Recommendations for addressing low-end specificity problems in both research and clinical work are discussed.

Coping, Androgyny, and Attributional Style

To examine the impact of androgyny and attributional style on coping ability, a demographic questionnaire, the Zeitlin Coping Inventory, the Bem Sex-role Inventory and the Attributional Style Questionnaire were completed by 301 first-year students at the University of Stellenbosch. It was found that androgynous female subjects displayed significantly better coping abilities than female subjects with feminine, masculine, or undifferentiated sex-role orientations. No significant difference was found between coping abilities of androgynous and masculine male subjects, although both androgynous and masculine males showed significantly better coping abilities than males with feminine or undifferentiated sex-role orientations. Regarding a specific aspect of coping, namely flexibility of coping style, both male and female subjects with androgynous sex-role orientations displayed significantly more flexibility in their coping styles than subjects of any other sex-role type. Regarding attributional style, a significant positive correlation was found between good coping ability and an internal, stable, and global attributional style for positive events. A significant positive correlation was likewise found between good coping ability and an external, unstable, and specific attributional style for negative events. The conclusion was drawn that androgyny and an adaptive attributional style served as important coping resources.

Cognitive characteristics of adolescent suicide attempters

The present study examined the relationship among psychiatric diagnosis, depression, attributional style, and hopelessness among 69 adolescent suicide attempters and 40 psychiatrically hospitalized adolescent controls. Contrary to predictions, the suicide attempters were more likely than the nonsuicidal group to attribute good events to global causes. No differences in attributional style were found across the depressed versus nondepressed subjects. However, there was a modest relationship between depression and attributional style. Results suggest that maladaptive cognitive characteristics are present in adolescent clinical samples but may be less specific to suicide attempters than is often suggested.