Laboratory and performance-based measures of depression in children and adolescents

Using Wearable Digital Devices to Screen Children for Mental Health Conditions: Ethical Promises and Challenges

In response to a burgeoning pediatric mental health epidemic, recent guidelines have instructed pediatricians to regularly screen their patients for mental health disorders with consistency and standardization. Yet, gold-standard screening surveys to evaluate mental health problems in children typically rely solely on reports given by caregivers, who tend to unintentionally under-report, and in some cases over-report, child symptomology. Digital phenotype screening tools (DPSTs), currently being developed in research settings, may help overcome reporting bias by providing objective measures of physiology and behavior to supplement child mental health screening. Prior to their implementation in pediatric practice, however, the ethical dimensions of DPSTs should be explored. Herein, we consider some promises and challenges of DPSTs under three broad categories: accuracy and bias, privacy, and accessibility and implementation. We find that DPSTs have demonstrated accuracy, may eliminate concerns regarding under- and over-reporting, and may be more accessible than gold-standard surveys. However, we also find that if DPSTs are not responsibly developed and deployed, they may be biased, raise privacy concerns, and be cost-prohibitive. To counteract these potential shortcomings, we identify ways to support the responsible and ethical development of DPSTs for clinical practice to improve mental health screening in children.

A Lifespan Development Theory of Insecure Attachment and Internalizing Symptoms: Integrating Meta-Analytic Evidence via a Testable Evolutionary Mis/Match Hypothesis

Attachment scholars have long argued that insecure attachment patterns are associated with vulnerability to internalizing symptoms, such as depression and anxiety symptoms. However, accumulating evidence from the past four decades, summarized in four large meta-analyses evaluating the link between insecure attachment subtypes and internalizing symptoms, provide divergent evidence for this claim. This divergent evidence may be accounted for, at least in part, by the developmental period under examination. Specifically, children with histories of deactivating (i.e., insecure/avoidant) but not hyperactivating (i.e., insecure/resistant) attachment patterns in infancy and early childhood showed elevated internalizing symptoms. In contrast, adolescents and adults with hyperactivating (i.e., insecure/preoccupied) but not deactivating (i.e., insecure/dismissing) attachment classifications showed elevated internalizing symptoms. In this paper, we summarize findings from four large meta-analyses and highlight the divergent meta-analytic findings that emerge across different developmental periods. We first present several potential methodological issues that may have contributed to these divergent findings. Then, we leverage clinical, developmental, and evolutionary perspectives to propose a testable lifespan development theory of attachment and internalizing symptoms that integrates findings across meta-analyses. According to this theory, subtypes of insecure attachment patterns may be differentially linked to internalizing symptoms depending on their mis/match with the developmentally appropriate orientation tendency toward caregivers (in childhood) or away from them (i.e., toward greater independence in post-childhood). Lastly, we offer future research directions to test this theory.

Rapid detection of internalizing diagnosis in young children enabled by wearable sensors and machine learning

There is a critical need for fast, inexpensive, objective, and accurate screening tools for childhood psychopathology. Perhaps most compelling is in the case of internalizing disorders, like anxiety and depression, where unobservable symptoms cause children to go unassessed-suffering in silence because they never exhibiting the disruptive behaviors that would lead to a referral for diagnostic assessment. If left untreated these disorders are associated with long-term negative outcomes including substance abuse and increased risk for suicide. This paper presents a new approach for identifying children with internalizing disorders using an instrumented 90-second mood induction task. Participant motion during the task is monitored using a commercially available wearable sensor. We show that machine learning can be used to differentiate children with an internalizing diagnosis from controls with 81% accuracy (67% sensitivity, 88% specificity). We provide a detailed description of the modeling methodology used to arrive at these results and explore further the predictive ability of each temporal phase of the mood induction task. Kinematical measures most discriminative of internalizing diagnosis are analyzed in detail, showing affected children exhibit significantly more avoidance of ambiguous threat. Performance of the proposed approach is compared to clinical thresholds on parent-reported child symptoms which differentiate children with an internalizing diagnosis from controls with slightly lower accuracy (.68-.75 vs. .81), slightly higher specificity (.88-1.00 vs. .88), and lower sensitivity (.00-.42 vs. .67) than the proposed, instrumented method. These results point toward the future use of this approach for screening children for internalizing disorders so that interventions can be deployed when they have the highest chance for long-term success.

Rapid Anxiety and Depression Diagnosis in Young Children Enabled by Wearable Sensors and Machine Learning

This paper presents a new approach for diagnosing anxiety and depression in young children. Currently, diagnosis requires hours of structured clinical interviews and standardized questionnaires spread over days or weeks. We propose the use of a 90-second fear induction task during which time participant motion is monitoring using a commercially available wearable sensor. Machine learning and data extracted from the most clinically feasible 20-second phase of the task are used to predict diagnosis in a sample of children with and without an internalizing diagnosis. We examine the performance of a variety of feature sets and modeling approaches to identify the best performing logistic regression that provides a diagnostic accuracy of 80%. This accuracy is comparable to existing diagnostic techniques, but at a small fraction of the time and cost currently required. These results point toward the future use of this approach in a clinical setting for diagnosing children with internalizing disorders.

Wearable sensors detect childhood internalizing disorders during mood induction task

There is a significant need to develop objective measures for identifying children under the age of 8 who have anxiety and depression. If left untreated, early internalizing symptoms can lead to adolescent and adult internalizing disorders as well as comorbidity which can yield significant health problems later in life including increased risk for suicide. To this end, we propose the use of an instrumented fear induction task for identifying children with internalizing disorders, and demonstrate its efficacy in a sample of 63 children between the ages of 3 and 7. In so doing, we extract objective measures that capture the full six degree-of-freedom movement of a child using data from a belt-worn inertial measurement unit (IMU) and relate them to behavioral fear codes, parent-reported child symptoms and clinician-rated child internalizing diagnoses. We find that IMU motion data, but not behavioral codes, are associated with parent-reported child symptoms and clinician-reported child internalizing diagnosis in this sample. These results demonstrate that IMU motion data are sensitive to behaviors indicative of child psychopathology. Moreover, the proposed IMU-based approach has increased feasibility of collection and processing compared to behavioral codes, and therefore should be explored further in future studies.

Getting What You Expect: Negative Social Expectations in Early Adolescence Predict Hostile Romantic Partnerships and Friendships Into Adulthood

Adolescents' negative expectations of their peers were examined as predictors of their future selection of hostile partners, in a community sample of 184 adolescents followed from ages 13 to 24. Utilizing observational data, close friend- and self-reports, adolescents with more negative expectations at age 13 were found to be more likely to form relationships with observably hostile romantic partners and friends with hostile attitudes by age 18 even after accounting for baseline levels of friend hostile attitudes at age 13 and adolescents' own hostile behavior and attitudes. Furthermore, the presence of friends with hostile attitudes at age 18 in turn predicted higher levels of adult friend hostile attitudes at age 24. Results suggest the presence of a considerable degree of continuity from negative expectations to hostile partnerships from adolescence well into adulthood.

Movements Indicate Threat Response Phases in Children at Risk for Anxiety

Temporal phases of threat response, including potential threat (anxiety), acute threat (startle, fear), and post-threat response modulation, have been identified as the underlying markers of anxiety disorders. Objective measures of response during these phases may help identify children at risk for anxiety; however, the complexity of current assessment techniques prevent their adoption in many research and clinical contexts. We propose an alternative technology, an inertial measurement unit (IMU), that enables noninvasive measurement of the movements associated with threat response, and test its ability to detect threat response phases in young children at a heightened risk for developing anxiety. We quantified the motion of 18 children (3-7 years old) during an anxiety-/fear-provoking behavioral task using an IMU. Specifically, measurements from a single IMU secured to the child's waist were used to extract root-mean-square acceleration and angular velocity in the horizontal and vertical directions, and tilt and yaw range of motion during each threat response phase. IMU measurements detected expected differences in child motion by threat phase. Additionally, potential threat motion was positively correlated to familial anxiety risk, startle range of motion was positively correlated with child internalizing symptoms, and response modulation motion was negatively correlated to familial anxiety risk. Results suggest differential theory-driven threat response phases and support previous literature connecting maternal child risk to anxiety with behavioral measures using more feasible objective methods. This is the first study demonstrating the utility of an IMU for characterizing the motion of young children to mark the phases of threat response modulation. The technique provides a novel and objective measure of threat response for mental health researchers.

The serotonin transporter linked polymorphic region and brain-derived neurotrophic factor valine to methionine at position 66 polymorphisms and maternal history of depression: associations with cognitive vulnerability to depression in childhood

Preliminary work indicates that cognitive vulnerability to depression may be associated with variants of the serotonin transporter promoter polymorphism (5-HTTLPR) and the valine to methionine at position 66 (val66met) polymorphism of the brain-derived neurotrophic factor (BDNF) gene; however, existing reports come from small samples. The present study sought to replicate and extend this research in a sample of 375 community-dwelling children and their parents. Following a negative mood induction, children completed a self-referent encoding task tapping memory for positive and negative self-descriptive traits. Consistent with previous work, we found that children with at least one short variant of the 5-HTTLPR had enhanced memory for negative self-descriptive traits. The BDNF val66met polymorphism had no main effect but was moderated by maternal depression, such that children with a BDNF methionine allele had a heightened memory for negative self-descriptive traits when mothers had experienced depression during children's lifetimes; in contrast, children with a methionine allele had low recall of negative traits when mothers had no depression history. The findings provide further support for the notion that the 5-HTTLPR is associated with cognitive markers of depression vulnerability and that the BDNF methionine allele moderates children's sensitivity to contextual factors.

5-HTTLPR polymorphism modulates neural mechanisms of negative self-reflection

Cognitive distortion in depression is characterized by enhanced negative thoughts about both environment and oneself. Carriers of a risk allele for depression, that is, the short (s) allele of the serotonin transporter promoter polymorphism (5-HTTLPR), exhibit amygdala hyperresponsiveness to negative environmental stimuli relative to homozygous long variant (l/l). However, the neural correlates of negative self-schema in s allele carriers remain unknown. Using functional MRI, we scanned individuals with s/s or l/l genotype of the 5-HTTLPR during reflection on their own personality traits or a friend's personality traits. We found that relative to l/l carriers, s/s carriers showed stronger distressed feelings and greater activity in the dorsal anterior cingulate (dACC)/dorsal medial prefrontal cortex (dmPFC) and the right anterior insula (AI) during negative self-reflection. The 5-HTTLPR effect on the distressed feelings was mediated by the AI/inferior frontal (IF) activity during negative self-reflection. The dACC/dmPFC activity explained 20% of the variation in harm-avoidance tendency in s/s but not l/l carriers. The genotype effects on distress and brain activity were not observed during reflection on a friend's negative traits. Our findings reveal that 5-HTTLPR polymorphism modulates distressed feelings and brain activities associated with negative self-schema and suggest a potential neurogenetic susceptibility mechanism for depression.

Longitudinal dynamics of depressogenic personality and attachment dimensions in adolescence: an examination of associations with changes in depressive symptoms

Depressogenic personality and attachment are two major factors related to the development of adolescents' depressive symptoms. However, no previous longitudinal studies have examined simultaneously both vulnerability factors in relationship to depressive symptoms. The present study examined associations between intra-individual change in adolescents' depressogenic personality orientations (i.e., sociotropy and autonomy), dimensions of mother-adolescent attachment (i.e., anxiety and avoidance), and depressive symptoms. The sample of the present research consisted of 289 high school students (mean age = 12.51 years at Time 1, 66% female) participating in a 3-wave cohort-sequential design. Latent growth curve modeling revealed no significant intra-individual change in depressogenic personality orientations but significant changes in dimensions of attachment and symptoms of depression. Initial levels of sociotropy were not related significantly to changes in attachment dimensions and depressive symptoms. High initial levels of autonomy were associated with increases in attachment anxiety, attachment avoidance, and depressive symptoms. In addition, results suggested that the association between initial levels of autonomy and increases in depressive symptoms was mediated by increases in attachment anxiety and avoidance. The discussion focuses on the status of depressogenic personality and attachment as risk factors for depression.

Selective Information-Processing in Depressed Children and Adolescents: Is There a Difference in Processing of Self-Referent and Other-Referent Information?

In this study, selective memory-processing of self-referent and other-referent information in depressed children was examined. A control group (N = 50) and a depressed group (N = 22) were given two intentional self-referent encoding tasks, in which participants were presented with positive and negative adjectives. In the first experiment, participants were given self-referent and structural instructions. The second experiment included a self-referent instruction and an other-referent instruction. The encoding tasks were followed by a recall task. The results of the first experiment supported the selective processing hypothesis for self-referent information in depressed children and adolescents. However, the recall ratios of positive and negative information after focusing on self and others in the second experiment revealed that depressed children diverted their attention away from negative self-referent information and displayed memory-processing similar to nondepressed children.

The Role of Depressogenic Personality and Attachment in the Intergenerational Similarity of Depressive Symptoms: A Study With Early Adolescents and Their Mothers

Parental depression has been identified as a risk factor for psychopathology in children, and for child depression in particular. Increasingly, research is addressing the underlying psychological processes that may explain the intergenerational similarity of depressive symptoms. In the present study, we aim to investigate the role of two theoretically relevant vulnerability factors in this intergenerational similarity, that is, (a) dimensions of depressogenic personality (i.e., sociotropy and autonomy) and (b) dimensions of attachment (i.e., anxiety and avoidance). Results in a sample of early adolescents and their mothers show significant intergenerational similarity in both sets of vulnerabilities. Moreover, the intergenerational similarity of both vulnerability factors was found to account for the association between mothers’ and children’s depressive symptoms. Within each generation there were also meaningful and specific associations between dimensions of depressogenic personality and dimensions of attachment, with sociotropy being primarily related to anxiety and with autonomy being primarily related to avoidance.

Factor structure and psychometric properties of the Modified Scale for Suicidal Ideation among suicidal youth

BACKGROUND

Although suicidal behaviors occur at a high rate in adolescence, relatively few interview-based measures are available to assess suicidal ideation among youth. Existing interview measures are limited by a paucity of empirical study, a failure to conform to standard suicide nomenclature, or a lengthy administration time. This study presents data on the psychometric properties and factor structure of the brief, layperson-administered Modified Scale for Suicidal Ideation (MSSI) among suicidal youth.

METHODS

The MSSI was administered to an inpatient sample of 102 suicidal youth aged 13-17 years. Additional interview and self-report measures were administered to examine the convergent validity of the MSSI.

RESULTS

Consistent with previous findings among suicidal adults, the MSSI displayed good internal consistency and expected patterns of convergent validity. Principal component analysis revealed a bidimensional structure, with factors corresponding to (1) Desire and Ideation and (2) Plans and Preparations. Each factor displayed acceptable internal consistency and expected patterns of convergent validity via associations with hopelessness, depressive symptoms, impulsivity, and a self-report measure of suicidal behaviors. The Plans and Preparations factor significantly associated with the presence of a current suicide attempt and with greater suicide intent among attempters, whereas the Desire and Ideation factor did not.

CONCLUSIONS

The MSSI appears to be a reliable and valid instrument to assess suicidal ideation among distressed youth. Clinicians are encouraged to pay particular attention to responses on the Plans and Preparations factor given its stronger association with suicide attempt and more serious suicide intent.

Depression as a longitudinal outcome and antecedent of preadolescents' peer relationships and peer-relevant cognition

Using longitudinal data and structural modeling, we investigated bidirectional associations among preadolescents' peer relationships, peer-relevant cognition, and depressive symptoms. Depression was expected to be an outcome and precursor of peer-relevant cognition, and cognition was expected to be an outcome and precursor of being more or less liked by classmates (peer likeability). We also examined whether cognition mediated the association between peer likeability and depression. Participants were 308 students (mean age = 11.0, SD = 0.9) who participated twice during a school year. A third assessment was completed with Grade 5 to 6 students 1 year after the second assessment. The model with bidirectional paths had a good fit to the data, but the most parsimonious model was an "effects" model showing that preadolescents with more depressive symptoms had less positive peer-relevant cognition at later assessments, and that those with more positive peer-relevant cognition were more liked by their peers over time. There were no age differences, some gender differences, and no support for cognition as a moderator of the association between depression and peer likeability.

Early-emerging cognitive vulnerability to depression and the serotonin transporter promoter region polymorphism

BACKGROUND

Serotonin transporter promoter (5-HTTLPR) genotype appears to increase risk for depression in the context of stressful life events. However, the effects of this genotype on measures of stress sensitivity are poorly understood. Therefore, this study examined whether 5-HTTLPR genotype was associated with negative information processing biases in early childhood.

METHOD

Thirty-nine unselected seven-year-old children completed a negative mood induction procedure and a Self-Referent Encoding Task designed to measure positive and negative schematic processing. Children were also genotyped for the 5-HTTLPR gene.

RESULTS

Children who were homozygous for the short allele of the 5-HTTLPR gene showed greater negative schematic processing following a negative mood prime than those with other genotypes. 5-HTTLPR genotype was not significantly associated with positive schematic processing.

LIMITATIONS

The sample size for this study was small. We did not analyze more recently reported variants of the 5-HTTLPR long alleles.

CONCLUSIONS

5-HTTLPR genotype is associated with negative information processing styles following a negative mood prime in a non-clinical sample of young children. Such cognitive styles are thought to be activated in response to stressful life events, leading to depressive symptoms; thus, cognitive styles may index the "stress-sensitivity" conferred by this genotype.

Empirical evidence of cognitive vulnerability for depression among children and adolescents: a cognitive science and developmental perspective

We summarize and integrate research on cognitive vulnerability to depression among children and adolescents. We first review prospective longitudinal studies of the most researched cognitive vulnerability factors (attributional style, dysfunctional attitudes, and self-perception) and depression among youth. We next review research on information processing biases in youth. We propose that the integration of these two literatures will result in a more adequate test of cognitive vulnerability models. Last, we outline a program of research addressing methodological, statistical, and scientific limitations in the cognitive vulnerability literature.

Toward guidelines for evidence-based assessment of depression in children and adolescents

We aim to provide a starting point toward the development of an evidence-based assessment of depression in children and adolescents. We begin by discussing issues relevant to the diagnosis and classification of child and adolescent depression. Next, we review the prevalence, selected clinical correlates, course, and treatment of juvenile depression. Along with some general considerations in assessment, we discuss specific approaches to assessing depression in youth (i.e., interviews, rating scales) and briefly summarize evidence on the reliability and validity of a few selected instruments. In addition, we touch on the assessment of several other constructs that are important in a comprehensive evaluation of depression (i.e., social functioning, life stress, and family history of psychopathology). Last, we highlight areas in which further research is necessary and conclude with some broad recommendations for clinical practice given the current state of the knowledge.

Altered emotional processing in pediatric anxiety, depression, and comorbid anxiety-depression

The goal of this study was to examine some of the mechanisms underlying emotion regulation in childhood affective disorders by examining the impact of distracting emotional information during performance on a working memory task ("Emotional n-back" or E-n-back). The sample included 75 children (38 girls and 37 boys) between 8 and 16 years of age meeting criteria for: Anxiety disorder (ANX, n = 17), Major depressive disorder (MDD, n = 16), Comorbid anxiety and depression (CAD, n = 24), or Low-risk normal control (LRNC, n = 18). Results showed that the MDD and CAD groups had significantly longer reaction times on negative emotional backgrounds compared to neutral backgrounds, whereas the LRNC group had significantly longer reaction times on positive backgrounds. These results suggest altered processing of emotional information particularly associated with depression. Because the E-n-back task engages higher-order cognitive processes, these results suggest that these alterations in processing emotional information also interfere with the cognitive processes that govern how attentional resources are allocated. Further, research is needed to replicate this study and delineate underlying neural mechanisms.

Research on information-processing factors in child and adolescent psychopathology: a critical commentary

Provides a critical commentary on the state-of-the-art of research on information-processing (I-P) factors in clinical child and adolescent psychology. The articles in this special section amply demonstrate the value of the I-P paradigm as a heuristic framework for conceptualizing and studying the role(s) of cognitive factors in the etiology and maintenance of child and adolescent psychopathology. However, the current status of such research also reflects a number of limitations that warrant consideration if the potential value of the I-P paradigm is to be fully realized. Specifically, understanding the role(s) played by such factors is impeded by a variety of insufficiently addressed methodological and psychometric issues, as well as by insufficiently articulated theories regarding such factors. These issues are particularly challenging for child and adolescent psychopathology researchers because of the complexities added by development. The value of I-P theories of childhood and adolescent psychopathology will be considerably enhanced if these issues are more fully considered in future research.

Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems

OBJECTIVE

The objective of the study was to examine specificity, order of appearance, and developmental changes in the relationships between sleep problems and behavioral problems in children.

METHOD

Four hundred ninety children were selected from a large-scale longitudinal study of children growing up in adoptive and nonadoptive (biological) families in Colorado. Parental ratings of children's sleep and behavioral problems on the Child Behavior Checklist were obtained from ages 4 to 15 years.

RESULTS

Sleep problems decreased from age 4 years to mid-adolescence, but there was modest stability of individual differences across this age range (r = 0.29). Regression analyses indicated that sleep problems at age 4 predicted behavioral/emotional problems in mid-adolescence after accounting for child sex, adoptive status, and stability of behavioral/emotional problems. Finally, the correlation between sleep problems and depression/anxiety increased significantly during this age period from r = 0.39 at age 4 years to r = 0.52 at mid-adolescence.

CONCLUSIONS

Early sleep problems may forecast behavioral/emotional problems, and there may be important developmental change in the overlap between sleep problems and behavioral/emotional problems.