Conjunctive moderator variables in vulnerability and resiliency research: life stress, social support and coping skills, and adolescent sport injuries

In life event research relating to vulnerability and resilience factors, single moderator variables have typically been the focus of study. Little is known about the ways in which moderator variables may interact with one another to increase vulnerability or resilience. We propose a distinction between conjunctive moderation, in which multiple moderators must co-occur in a specific combination or pattern to maximize a relation between a predictor and an outcome variable, and disjunctive moderation, in which any one of a number of moderators maximizes the predictor-criterion relation. Our results indicate that social support and psychological coping skills are statistically independent psychosocial resources and that they operate in a conjunctive manner to influence the relation between life stress and subsequent athletic injury in adolescents. Only athletes low in both coping skills and social support exhibited a significant stress-injury relation, and in that vulnerable subgroup, negative major life events accounted for up to 30% of the injury variance. Methodological considerations in the assessment of conjunctive moderator effects are discussed.     

Social problem‐solving skills as a mediator between executive function and long‐term social outcome following paediatric traumatic brain injury

There is debate regarding the relationship between executive function and social outcome following paediatric traumatic brain injury (TBI), due to inconsistent findings in the literature. It has been suggested that these contradictory results may reflect the absence of an established mechanism to explain this relationship. Yeates and colleagues (2004) proposed a possible model in which the maturity of social problem‐solving skills mediates the relationship between executive function and social outcome. The current study aimed to explore this model and determine whether social problem solving mediates the relationship between executive function and social outcome in a TBI population. The sample consisted of 36 adolescents and young adults who sustained a TBI between 8 and 12 years of age. They ranged between 16 and 22 years of age and were 7–10 years post‐injury. Findings indicated that a higher level of executive dysfunction was associated with less sophisticated social problem‐solving skills and poorer social outcome. Further, the maturity of social problem‐solving skills was found to mediate the relationship between executive function and social outcome in this group.     

Working memory outcomes following traumatic brain injury in children: A systematic review with meta-analysis

The aim of this review is to systematically examine the literature concerning multicomponent working memory (WM)—comprising a central executive (CE), two storage components (phonological loop, PL and visuo-spatial sketchpad, VSSP), and episodic buffer (EB)—in pediatric traumatic brain injury (TBI). Electronic searches were conducted of MEDLINE, PsychINFO and EMBASE up to October 2014 with the inclusion criteria of children and adolescents with TBI, and quantitative methods to assess at least one component of WM. Meta-analytic procedures calculated pooled effect sizes for WM outcomes. Of the studies examined, 27 met the inclusion criteria. Children with TBI exhibited deficits in the CE and PL, but not in the VSSP, and no study could be found which examined the EB. Qualitative analysis found that greater TBI severity was associated with poorer CE functioning in five out of nine studies. Differences in patterns of brain activation were evident in four out of five fMRI studies that examined WM in TBI children and controls. Deficits in CE were associated with poorer mathematical skills in the only study that examined relations between WM and academic deficits. Notwithstanding the heterogeneity of the studies reviewed, TBI places children at risk of WM deficits. Moreover, this meta-analysis suggests that various components of WM have differential vulnerability to pediatric TBI, with significant deficits found in the CE and PL, but not in the VSSP (although the VSSP has rarely been examined to date). Future studies should be theoretically driven, employ tasks assessing all components of the WM model and examine the functional ramifications (including academic outcomes) of WM deficits in this population.     

Type A personality, self-control, and vulnerability to stress

Type A behavior (hard-driving, competitive, time-urgent, hostile-irritable) has been linked to high stress levels and the risk of eventual cardiovascular problems (i.e., coronary heart disease, CHD). However, this pattern of behavior closely resembles the traditional masculine instrumental (goal-oriented) orientation, and, if kept within limits, may be viewed as adaptive in success-oriented, middle-class college students. Hypothetically then, Type A behavior may be displayed by a broad group of individuals, and only in those cases when it is allowed to reach extreme proportions is stress sufficient enough to confer risk. This article considers two lines of reasoning. Is greater self-control required for college women to be Type As, because it involves crossing into traditional male role behavior? Type A women displayed significantly better self-control then Type B women; the opposite result was disclosed for college men with Type As displaying poorer self-control than Type Bs. The question of whether risk-conferring Type A behavior would result from poorer self-control was answered in the affirmative. Self-control assumed moderator status; poorer self-control in both male and female Type As was associated with high levels of day-to-day stress relative to Type As with better self-control. Self-control did not influence stress level in Type Bs. This moderator effect suggests that only Type As who cannot contain their behavior within adaptive limits will be vulnerable to excessive stress and at risk for CHD.     

Asthma-specific cognitions,self-focused attention,and fear of negative evaluation in adolescents and young adults diagnosed with childhood-onset asthma

The present study examined the impact of asthma-specific thought intrusion (TI) and thought suppression (TS) on two cognitive-affective variables (self-focused attention and fear of negative evaluation) among adolescents and young adults (AYAs) diagnosed with childhood-onset asthma. Participants were 290 AYAs who completed assessment questionnaires and participated in a written exercise electronically. Asthma-TI and TS were reported by participants following participation in a writing assignment. Asthma-TI was associated with increased private, public, and social anxiety self-focused attention, and greater fear of negative evaluation. Interestingly, asthma-TS was not associated with these same outcome variables. Findings suggest illness-specific cognitions are associated with cognitive-affective variables and it may be important to assess for illness-specific intrusive thoughts following asthma-focused medical appointments. Additionally, findings suggest the importance of assessing asthma-TI and TS separately in order to better understand thoughts about health and psychological functioning.     

Secondary psychopathy,but not primary psychopathy,is associated with risky decision-making in noninstitutionalized young adults

Although risky decision-making has been posited to contribute to the maladaptive behavior of individuals with psychopathic tendencies, the performance of psychopathic groups on a common task of risky decision-making, the Iowa Gambling Task (IGT; Bechara, Damasio, Damasio, & Anderson, 1994), has been equivocal. Different aspects of psychopathy (personality traits, antisocial deviance) and/or moderating variables may help to explain these inconsistent findings. In a sample of college students (N = 129, age 18–27), we examined the relationship between primary and secondary psychopathic features and IGT performance. A measure of impulsivity was included to investigate its potential as a moderator. In a joint model including main effects and interactions between primary psychopathy, secondary psychopathy and impulsivity, only secondary psychopathy was significantly related to risky IGT performance, and this effect was not moderated by the other variables. This finding supports the growing literature suggesting that secondary psychopathy is a better predictor of decision-making problems than the primary psychopathic personality traits of lack of empathy and remorselessness.     

Impairments of attention following childhood traumatic brain injury.

Attentional deficits are commonly reported following traumatic brain injury (TBI) in adults, although the occurrence of such problems is less well documented in young children. This study aimed to investigate residual attentional abilities associated with TBI during childhood, by examining a number of aspects of attention including sustained, focussed, and divided attention, attentional shift, and response inhibition. Eighteen children with a history of TBI, aged between 8 and 14 years and 18 non-injured matched controls participated in the study. Results show that attentional skills may be differentially impaired after TBI, with children who have sustained moderate-to-severe TBI exhibiting significant deficits on the following attentional domains: sustain, focus, and response inhibition. These findings support the view that attentional impairments following pediatric TBI, while not global, may be more generalized than those reported for adult samples, perhaps reflecting the relative immaturity of attentional skills at the time of injury.     

Impairments of Attention Following Childhood Traumatic Brain Injury

Attentional deficits are commonly reported following traumatic brain injury (TBI) in adults, although the occurrence of such problems is less well documented in young children. This study aimed to investigate residual attentional abilities associated with TBI during childhood, by examining a number of aspects of attention including sustained, focussed, and divided attention, attentional shift, and response inhibition. Eighteen children with a history of TBI, aged between 8 and 14 years and 18 non-injured matched controls participated in the study. Results show that attentional skills may be differentially impaired after TBI, with children who have sustained moderate-to-severe TBI exhibiting significant deficits on the following attentional domains: sustain, focus, and response inhibition. These findings support the view that attentional impairments following pediatric TBI, while not global, may be more generalized than those reported for adult samples, perhaps reflecting the relative immaturity of attentional skills at the time of injury.     

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.     

Gender,instrumentality, and expressivity: Moderators of the relation between stress and psychological symptoms during adolescence

Examined the roles of gender, instrumentality, and expressivity as moderator of the relations between stressful events and psychological symptoms in samples of junior high (n = 93), senior high (n = 140), and college students (n = 145). Female adolescents in all three samples reported more overall negative events than did males. Females in the junior and senior high samples reported more negative interpersonal stresses than did males. However, there were no indications in any of the samples of a stronger relation between negative events and psychological symptoms for adolescent females than males. Further, there was little evidence that instrumentality or expressivity moderated the relations between negative events and psychological symptoms. In each sample, certain stresses were most strongly related to psychological symptoms: family stresses in the junior high, peer stresses in the senior high, and academic stresses in the college sample. Implications of the findings for developmental changes in stress during adolescence are discussed.     

Introduction to the Special Issue: Mechanisms of Action in Cognitive-Behavior Therapy

Research into mechanisms of treatment outcome in cognitive-behavior therapy (CBT), as work evaluating potential mechanisms through mediator and moderator analyses, has been increasing. In recognition of this growth in more refined analyses of functional components of treatment, this special issue highlights a diverse range of research-evaluating mechanisms, as well as mediators and moderators, of outcome. It is anticipated that the research described in these articles will stimulate additional investigations as well as provide important insights for clinicians in refining treatment programs.     

Cognitive reserve as a moderator of responsiveness to an online problem-solving intervention for adolescents with complicated mild-to-severe traumatic brain injury

Children and adolescents with traumatic brain injury (TBI) often experience behavior difficulties that may arise from problem-solving deficits and impaired self-regulation. However, little is known about the relationship of neurocognitive ability to post-TBI behavioral recovery. To address this question, we examined whether verbal intelligence, as estimated by Vocabulary scores from the Wechsler Abbreviated Scale of Intelligence, predicted improvements in behavior and executive functioning following a problem-solving intervention for adolescents with TBI. One hundred and thirty-two adolescents with complicated mild-to-severe TBI were randomly assigned to a six-month Web-based problem-solving intervention (CAPS; n = 65) or to an Internet resource comparison (IRC; n = 67) group. Vocabulary moderated the association between treatment group and improvements in metacognitive abilities. Examination of the mean estimates indicated that for those with lower Vocabulary scores, pre-intervention Metacognition Index scores from the Behavior Rating Inventory of Executive Function (BRIEF) did not differ between the groups, but post-intervention scores were significantly lower (more improved) for those in the CAPS group. These findings suggest that low verbal intelligence was associated with greater improvements in executive functioning following the CAPS intervention and that verbal intelligence may have an important role in response to intervention for TBI. Understanding predictors of responsiveness to interventions allows clinicians to tailor treatments to individuals, thus improving efficacy.     

Psychotherapy: Definitions, Mechanisms of Action, and Relationship to Etiological Models

In this paper, we define psychotherapy as a modality of treatment in which the therapist and patient(s) work together to ameliorate psychopathologic conditions and functional impairment through focus on the therapeutic relationship; the patient's attitudes, thoughts, affect, and behavior; and social context and development. The possible mechanisms of action and active ingredients of psychotherapy in children and adolescents are discussed, with an emphasis on the above-noted domains. The adult psychotherapy literature strongly supports the central roles of the therapeutic relationship and therapeutic empathy; this has been much less intensively explored in the child and adolescent psychotherapy literature. Similarly, there have been few studies examining the mediation of treatment effects by impact on specific domains. Ideally, treatment studies should gather data that can be informative about the impact of putative mediating and moderating psychosocial and biological variables on outcome and course. The results of such studies can aid further refinements in both theories of etiology and improvement in treatments for children and adolescents.     

Comprehensive Trail Making Test performance in children and adolescents with traumatic brain injury

The sensitivity of the Trail Making Test to brain damage has been well-established over many years, making it one of the most commonly used tests in clinical neuropsychological evaluations. The current study examined the validity of scores from a newer version of the Trail Making Test, the Comprehensive Trail Making Test (CTMT), in children and adolescents with traumatic brain injury (TBI). Participants included 242 children and adolescents, 121 with sustained TBI and 121 normal control participants, who were matched to the individuals with TBI on age and sex. Receiver operating characteristic analysis indicated that the CTMT composite index provided the best overall classification, with a correct classification rate of 79%. Differences between the TBI and control groups remained stable across age. These findings indicate that the CTMT is sensitive to TBI and overall demonstrates classification rates that are comparable with some other versions of the Trail Making Test. Whether the CTMT will exhibit similar classification accuracy in adults with TBI and for other neurological disorders awaits further investigation.     

Prevalence and Correlates of Depressive Symptoms Following Traumatic Brain Injuries in Children

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.     

Predictive validity of the Westmead Post-Traumatic Amnesia Scale for functional outcomes in school-aged children who sustained traumatic brain injury

The Westmead Post-Traumatic Amnesia Scale (WPTAS) is routinely used for the assessment of post-traumatic amnesia (PTA) in children who sustained traumatic brain injury (TBI). Yet, the WPTAS' predictive validity for functional outcomes is largely unknown. We aimed to determine whether PTA duration measured by the WPTAS (i) differentially predicts functional outcomes and (ii) contributes to predictions of outcomes beyond the Glasgow Coma Scale (GCS) in children who sustained TBI. Participants were children and adolescents with moderate-to-severe TBI (n = 55) aged 8–15 years. PTA duration was assessed with the WPTAS. Outcomes at the first outpatient follow-up were scored on the Kings Outcome Scale for Childhood Head Injury (KOSCHI) and the TBI Outcome Domain Scale-Extended (ODS-E). Longer PTA and lower GCS were both significantly correlated with worse (i) global outcomes: presence of disability on the KOSCHI and lower score on the ODS-E and (ii) select specific outcomes on the ODS-E: mobility, mood and cognition. PTA duration predicted cognitive outcome on the ODS-E independently, beyond GCS. Together, PTA duration and GCS, predicted the global KOSCHI outcome, as well as the ODS-E mobility and mood outcomes. Neither GCS nor PTA duration correlated with the ODS-E communication, impulsivity/disinhibition, headache, fatigue, sensory impairments or somatic complaints outcomes. PTA duration measured by the WPTAS is a significant unique predictor of functional cognitive outcomes in children who sustained moderate-to-severe TBI, and in combination with the GCS, a significant predictor of global, and several specific functional outcomes.     

Prevalence and correlates of depressive symptoms following traumatic brain injuries in children.

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.     

Resilience and Other Possible Outcomes After Mild Traumatic Brain Injury: a Systematic Review

The relation between resilience and mild traumatic brain injury (TBI) outcome has been theorized but empirical studies have been scarce. This systematic review aimed to describe the research in this area. Electronic databases (Medline, CINAHL, PsychINFO, SPORTdiscus, and PILOTS) were searched from inception to August 2015 for studies in which resilience was measured following TBI. The search terms included ‘TBI’ ‘concussion’ ‘postconcussion’ ‘resilience’ and ‘hardiness’. Inclusion criteria were peer reviewed original research reports published in English, human participants aged 18 years and over with brain injury, and an accepted definition of mild TBI. Hand searching of identified articles was also undertaken. Of the 71 studies identified, five studies were accepted for review. These studies were formally assessed for risk of bias by two independent reviewers. Each study carried a risk of bias, most commonly a detection bias, but none were excluded on this basis. A narrative interpretation of the findings was used because the studies reflected fundamental differences in the conceptualization of resilience. No studies employed a trajectory based approach to measure a resilient outcome. In most cases, the eligible studies assessed trait resilience with a scale and used it as a predictor of outcome (postconcussion symptoms). Three of these studies showed that greater trait resilience was associated with better mild TBI outcomes (fewer symptoms). Future research of the adult mild TBI response that predicts a resilient outcome is encouraged. These studies could yield empirical evidence for a resilient, and other possible mild TBI outcomes.     

A configural approach to the use of the strong vocational interest blank with student engineers

SVIB profiles of 1169 freshmen entering a college of engineering were grouped according to total occupational scale profile similarity into 28 code types. Mean scores or percentages for the individuals in each code type were compared to base rate values for income variables including ability, personality, and socioeconomic data and outcome variables including academic progress, choice of major, counsel-seeking behavior, and place of residence. The data for four code types were presented together with examples of how the results might be used by a counselor. The investigators concluded that SVIB profile types can be useful in acting as moderator variables to predict student characteristics, and that total profile analysis of the SVIB occupational scale merits further attention.