Adapting Brief CBT-I for Depressed Adolescents: A Case Illustration of the Sleeping Better Program

Disturbed sleep is a common symptom of depression in adolescents, but this symptom is not often targeted in psychological therapies for depression. Although the causal relationship between sleep and depression is unclear, there is increasing evidence that in adults, Cognitive Behavioral Therapy for Insomnia (CBT-I) improves sleep problems and reduces symptoms of depression; however, there has been little investigation of using this approach with adolescents. This article describes the adaptation of brief CBT-I for adolescents with depression. A single case study is reported to illustrate the use of the Sleeping Better program. Adaptations for adolescents include increased emphasis on engagement of the young person and the inclusion of parents in treatment. The treatment program was acceptable to the adolescent and parent, and treatment outcome, as indicated by sleep diaries and standardized measures of depression and anxiety, was positive. Further evaluation of the Sleeping Better program is needed to establish if it is an effective low-intensity intervention for sleep problems in adolescents who have depression or anxiety.     

Strategies included in cognitive behavioral therapy programs to treat internalized disorders: a systematic review

This review aimed to identify the strategies used in programs based on cognitive behavioral therapy (CBT) to prevent and treat symptoms of anxiety, depression, and internalized behaviors of children and adolescents. Based on an online search (ERIC, PsycInfo, Virtuose UQAM, and Google Scholar), 61 studies describing different cognitive behavioral programs were selected. Results showed that 40 strategies were implemented in at least one program. However, none of the strategies were systematically present in all programs, and only few were reported in more than 50% of the studies. Cognitive restructuring and problem-solving were the most popular strategies to treat depressive symptoms, whereas anxiety programs also generally included relaxation and exposure. Furthermore, six strategies were identified in a single anxiety program, whereas nine strategies were implemented in only one depression program. These results suggest that in anxiety and depression programs designed for children and adolescents, the label “CBT” encompasses a wide variety of programs with only few similar strategies. Such findings highlight the need to define a common basis for CBT programs, in order to better reflect CBT theory and to identify the effectiveness of the strategies included in these programs.     

Association between anxiety and depression in children and adolescents with anxiety disorders

The relationship between anxiety and depression was examined in a sample of 106 children and adolescents referred to an outpatient anxiety disorder clinic for children. Twenty-eight percent of patients with DSM-III diagnoses of anxiety disorders displayed a concurrent major depression. Children with anxiety disorders plus major depression were found (1) to be older, (2) to demonstrate more severe anxiety symptomatology, and (3) to be diagnosed with different rates of certain anxiety-disorder subtypes, when compared to anxious patients without major depression. Nondepressed anxious children and adolescents did not differ from a psychopathological control group in severity of either anxiety or depression symptoms.     

The Adolescent Mattering Experience: Gender Variations in Perceived Mattering,Anxiety, and Depression

Individuals who perceive that they matter to others are likely to experience lower anxiety and depression levels. The effects of young adolescents' perceived mattering on their anxiety and depression levels were examined. Results indicated that female adolescents reported lower anxiety levels but greater depression levels than did male adolescents, perceived mattering was inversely related to adolescents' anxiety and depression levels, and the associations between mattering and anxiety and between mattering and depression varied by gender.     

Aerobic exercise in the psychological treatment of adolescents.

A small group of psychiatrically institutionalized adolescents (16 boys, 11 girls) were assigned to a three-day-per-week running/aerobic exercise program or a regular physical activity class. The complete program continued over 9 weeks, with 11 subjects remaining throughout the program. Dependent measures of body-mass index, timed performance on a one-mile run, resting, exercise, and recovery heart rates, and measures of depression, mood-states, and self-efficacy were assessed pre-, mid-, and post-9-wk. treatment and at a 4-wk. follow-up. Improvements in depression, anxiety, hostility, confused thinking, and fatigue were shown in treated girls, with increases in vigor and self-efficacy for all treated subjects.     

Aerobic physical activity effects on psychological well-being in low-income Hispanic children

Psychological well-being has been generally associated with vigorous aerobic activity and structured aerobic activity in adolescents and children. Low-income children are at greater risk than the general population for experiencing high environmental stress and increased mental health problems. This study investigated the effects of a structured physical fitness program on psychological well-being in low-income Hispanic children. A total of 66, 33 girls, 33 boys, in Grade 4 were randomly assigned to either an Aerobic intensity (n = 34) or a Control intensity physical activity program (n = 32) for 6 wk. Psychological well-being was defined as scores on trait anxiety, depression, and self-esteem, measured, respectively, by the Trait Anxiety Inventory, Beck Depression Inventory, and Rosenberg Self-esteem scale. Analysis showed the children in the Aerobic intensity program significantly (p < .05) improved their cardiovascular fitness as measured by the PWC170 test. After the program was over, the children in this Aerobic group reported significantly (p < .05) less depression. The main effect for self-esteem reflected the Aerobic group's greater self-reported self-esteem. No differences were found on trait anxiety. The effects on depression and self-esteem may only be attributed to the cardiovascular improvement given the higher intensity physical activity program because causation was not assessed here.     

Parental Behaviors During Family Interactions Predict Changes in Depression and Anxiety Symptoms During Adolescence

This study investigated the prospective, longitudinal relations between parental behaviors observed during parent-adolescent interactions, and the development of depression and anxiety symptoms in a community-based sample of 194 adolescents. Positive and negative parental behaviors were examined, with negative behaviors operationalized to distinguish between observed parental expressions of aggression and dysphoria. Results showed that higher levels of parental aggression prospectively predicted higher levels of both depression and anxiety symptoms in adolescents over two-and-a-half years, whereas higher levels of positive parental behaviors prospectively predicted lower levels of depression symptoms only. Parental dysphoric behavior was not related to changes in either symptom dimension. These results suggest that patterns of parental behaviors may be differentially associated with depressive versus anxious outcomes in adolescents, and highlight the potential role for family-focused prevention or treatment interventions aimed at reducing an escalation of depression and anxiety symptoms in adolescence.     

Do extraversion and neuroticism moderate the association between bullying victimization and internalizing symptoms? A three-wave longitudinal study

The current study examined the moderating roles of neuroticism and extraversion in victims of bullying. According to a stress-diathesis model, we hypothesized that adolescents with high levels of neuroticism and low levels of extraversion would react to victimization with increased symptoms of depression and social anxiety. A sample of 1440 adolescents (648 girls and 792 boys; ages between 13- and 17-years-old) completed measures of extraversion and neuroticism at time 1, as well as measures of bullying victimization, depressive symptoms and social anxiety symptoms at time 1, time 2, and time 3 (in intervals of six months). The results of multilevel analyses for longitudinal data indicated that there was a weak association between bullying victimization and social anxiety symptoms for the adolescents who scored high on extraversion. In addition, the adolescents with high levels of extraversion presented a greater reduction in depressive symptoms over time than adolescents with low levels. Although neuroticism predicted both depression and social anxiety, no significant interactions were evident between neuroticism and bullying victimization. Regarding gender differences, the association between bullying victimization and social anxiety was stronger for boys than for girls, whereas the association between neuroticism and depression was stronger for girls.     

The moderating role of emotional stability in the relationship between exposure to violence and anxiety and depression

This study investigated the associations among exposure to violence, emotional stability, and psychological symptoms. The moderating role of emotional stability in the relationship between exposure to violence and anxiety and depression was examined in a sample of 482 high school students in Hong Kong. Results showed that both witnessing violence and low levels of emotional stability were positively associated with symptoms of anxiety and depression. Low levels of emotional stability exacerbated the relation between witnessing violence and symptoms of anxiety and depression; the opposite pattern was found among adolescents with high levels of emotional stability. This study sheds light on the role of emotional stability in ameliorating the detrimental effects of witnessing violence on symptoms of anxiety and depression among adolescents. Findings of this study also have implications for the development of emotionally healthy personalities.     

The Development of Adolescent Generalized Anxiety and Depressive Symptoms in the Context of Adolescent Mood Variability and Parent-Adolescent Negative Interactions

This study explored the influence of adolescent mood variability on the symptom development of generalized anxiety and depression in the context of parent-adolescent negative interactions. Participants were 456 adolescents (55.7 % male) from a community sample, who were followed from age 13 to 16 years. During 4 annual assessments, adolescents reported on their generalized anxiety and depressive symptoms, and both parents and adolescents on levels of negative interactions with each other. Within each study year, adolescents rated their daily mood states during 5 consecutive days for 3 times per year (total of 9 weeks). The absolute differences between mood states on consecutive days were summed to construct a mood variability score. Results showed that high levels of adolescent mood variability predicted increases in generalized anxiety and depressive symptoms across the studied period. No influence of negative interactions on anxiety and depression development was found, but positive predictive links from mood variability to negative interactions at age 14 and 15 appeared. The study underscores the role of adolescent mood variability in the development of symptoms of generalized anxiety and depression during adolescence, but found little evidence for an influence of parent-adolescent negative interactions on internalizing problem development.     

Predictors of suicide ideation and depression in Hong Kong adolescents: perceptions of academic and family climates

The unique dimensions of perceptions of school and family contributing to depression and suicide ideation in Hong Kong adolescents were examined in two studies. In Study 1, among 327 Hong Kong Chinese female students ages 13-18, 47% reported some suicide ideation. Suicide ideation was significantly associated with depression, test anxiety, academic self-concept, and adolescents' perceived parental dissatisfaction with academic performance. The correlation between test anxiety and depression was especially high (r = .51). Study 2 examined how three different aspects of perceived family relationship were associated with depression and suicide ideation. Among 371 Hong Kong Chinese adolescents ages 14-20, 52.6% reported suicide ideation. Low levels of family cohesion and support and high levels of parent-adolescent conflict were positively related to depression and suicide ideation in both genders. Across both studies, depression mediated associations between academic- and family-related variables and suicide ideation. Findings underscore the importance of both academic and family climate in understanding depression and suicide ideation among Chinese adolescents.     

A case series of attention modification in clinically anxious youths

Research in the last fifteen years suggests that anxious individuals selectively attend towards threatening information. Attention modification interventions for internalizing adults have been developed to target cognition at this basic level; these programs have demonstrated initial efficacy in attention bias and anxiety symptom reduction. To date, there have been no published studies of attention modification in youths with clinical levels of anxiety. The current case series examined the initial efficacy of a four-week (12 sessions) attention modification program (AMP) designed to train attention away from threat in 16 children and adolescents (ages 10 to 17) diagnosed with DSM-IV anxiety disorders. Overall, youths experienced a significant decrease in anxiety and depression symptoms, and 12 of 16 youths no longer met criteria for any anxiety diagnosis at post-treatment. AMP was feasible with youths, and all youths and parents deemed the program acceptable. These findings provide support for further research on the use of cognitive bias modification interventions with clinically anxious youths.     

Intolerance of Uncertainty–Focused Treatment for Adolescents With Excessive Worry: A Pilot Feasibility Study

Bouts of excessive worry are common across the lifespan, increasing in frequency and complexity during adolescence and adulthood, and are found in several psychiatric disorders, particularly the anxiety disorders. There are evidence-based treatments for adolescents with anxiety disorders but psychological treatments designed specifically to target excessive worrying in adolescents are rare. Intolerance of uncertainty (IU), a cognitive predisposition described as a fear of the unknown, is highly associated with worry among adolescents. This study investigated the feasibility, acceptability, and preliminary efficacy of IU-focused cognitive behavioral therapy (IU-CBT) for adolescents with excessive worry. Twelve participants (aged 13–17 years) with excessive worry, irrespective of psychiatric diagnosis, were provided weekly face-to-face sessions, primarily including therapist and self-guided exposure to situations involving uncertainty. Sessions were supplemented with an internet-delivered educational program for parents, designed to teach parents about worry, IU and helpful parental behaviors. The main outcome measure was the Penn-State Worry Questionnaire for Children (PSWQ-C). The treatment was well tolerated with no dropouts and families reporting being satisfied with the treatment. Participants were able to grasp the notion of IU and its relationship to worry and avoidance. Significant reductions were observed for self-reported worry, anxiety, depression, IU, and parent-reported worry, as were significant increases in global functioning. Based on a clinician rating, 58.3% were categorized as much or very much improved at posttreatment, rising to 66% at 3-month follow-up. Participants with generalized anxiety disorder (GAD) benefitted more from treatment than those with social anxiety disorder. The findings suggest that this IU-focused psychological intervention is acceptable and feasible to adolescents with excessive worry but may be most effective for those with GAD.     

Irrational Beliefs and Emotionality in Adolescents with and without Bronchial Asthma

Asthmatic adolescents (N = 129) between the ages of 12 and 18 were assembled into three groups on the basis of severity of illness and were compared with each other and with a fourth group of 74 healthy, nonasthmatic adolescents. Differences in selective cognitive (irrational beliefs) and emotional (anxiety, depression, and hostility) characteristics were examined. Multivariate analysis indicated that irrational beliefs in the importance of approval and the lack of control of emotions, along with self-reported anxiety, depression, or hostility, were strongly associated with disease severity. Whereas adolescents with mild asthma closely resembled the physically healthy comparison group, adolescents with moderate and severe asthma exhibited a cognitive-emotional complex that can be described as maladaptive or dysfunctional. Implications of these results for the treatment of asthma are discussed.     

Latent class analysis of anxiety and depressive symptoms of the Youth Self-Report in a general population sample of young adolescents

This study examined whether distinct groups of young adolescents with mainly anxiety or mainly depression could be identified in a general population sample. Latent class analysis was used on self-report ratings of DSM-IV symptoms of anxiety and depressive disorders, because it was hypothesized that these ratings provide a bigger chance to identify distinct groups than parent ratings of symptoms that are poorly associated with DSM-IV. Results from exploratory and confirmatory latent class analysis showed that only very small numbers of young adolescents had mainly anxiety or mainly depressive symptoms. Instead, a five-group model fitted the data best. These five groups contained young adolescents who either had a high, intermediate, or low probability to have comorbid symptoms of anxiety and depression. It was concluded that symptoms of DSM-IV anxiety and depressive disorders co-occur in young adolescents, and that latent class analysis on items that capture also severe symptoms like suicidal thoughts are needed to derive groups with specific comorbidity patterns in a general population sample.     

School absenteeism and mental health among sexual minority youth and heterosexual youth

Adolescent school absenteeism is associated with negative outcomes such as conduct disorders, substance abuse, and dropping out of school. Mental health factors, such as depression and anxiety, have been found to be associated with increased absenteeism from school. Sexual minority youth (youth who are attracted to the same sex or endorse a gay, lesbian, or bisexual identity) are a group at risk for increased absenteeism due to fear, avoidance, and higher rates of depression and anxiety than their heterosexual peers. The present study used longitudinal data to compare sexual minority youth and heterosexual youth on excused and unexcused absences from school and to evaluate differences in the relations between depression and anxiety symptoms and school absences among sexual minority youth and heterosexual youth. A total of 108 14- to 19-years-old adolescents (71% female and 26% sexual minority) completed self-report measures of excused and unexcused absences and depression and anxiety symptoms. Compared to heterosexual youth, sexual minority youth reported more excused and unexcused absences and more depression and anxiety symptoms. Sexual minority status significantly moderated the effects of depression and anxiety symptoms on unexcused absences such that depression and anxiety symptoms were stronger predictors of unexcused absences for sexual minority youth than for heterosexual youth. The results demonstrate that sexual minority status and mental health are important factors to consider when assessing school absenteeism and when developing interventions to prevent or reduce school absenteeism among adolescents.     

Gender differences in subjective well-being, self-esteem and psychosocial functioning in adolescents with symptoms of anxiety and depression: findings from the Nord-Trøndelag Health Study

Derdikman‐Eiron, R., Indredavik, M. S., Bratberg, G. H., Taraldsen, G., Bakken, I. J. & Colton, M. (2011). Gender differences in subjective well‐being, self‐esteem and psychosocial functioning in adolescents with symptoms of anxiety and depression: Findings from the Nord‐Trøndelag health study. Scandinavian Journal of Psychology52, 261–267. Gender differences in the prevalence of symptoms of anxiety and depression during adolescence are well documented. However, little attention has been given to differences in subjective well‐being, self‐esteem and psychosocial functioning between boys and girls with symptoms of anxiety and depression. The aim of this study was to investigate gender differences in the associations between such symptoms and subjective well‐being, self‐esteem, school functioning and social relations in adolescents. Data were taken from a major population‐based Norwegian study, the Nord‐Trøndelag Health study (HUNT), in which 8984 (91% of all invited) adolescents, aged 13–19 years, completed an extensive self‐report questionnaire. Although prevalence rates of symptoms of anxiety and depression were higher in girls than in boys, a significant interaction between gender and symptoms of anxiety and depression was found in respect of each of the following outcome variables: subjective well‐being, self‐esteem, academic problems, frequency of meeting friends and the feeling of not having enough friends. These interactions indicate that the associations between symptoms of anxiety and depression and lower subjective well‐being and self‐esteem, more academic problems in school and lower social functioning were stronger for boys than for girls. Our findings may contribute to an earlier assessment and more efficient treatment of male adolescent anxiety and depression.     

Biases in attention and interpretation in adolescents with varying levels of anxiety and depression

ABSTRACT

This is the first study to investigate multiple cognitive biases in adolescence simultaneously, to examine whether anxiety and depression are associated with biases in attention and interpretation, and whether these biases are able to predict unique variance in self-reported levels of anxiety and depression. A total of 681 adolescents performed a Dot Probe Task (DPT), an Emotional Visual Search Task (EVST), and an Interpretation Recognition Task. Attention and interpretation biases were significantly correlated with anxiety. Mixed results were reported with regard to depression: evidence was found for an interpretation bias, and for an attention bias as measured with the EVST but not with the DPT. Furthermore, interpretation and attention biases predicted unique variance in anxiety and depression scores. These results indicate that attention and interpretation biases are unique processes in anxiety and depression. They also suggest that anxiety and depression are partly based on similar underlying cognitive mechanisms.     

The Role of Life Stress and Social Support in the Adjustment of Sexually Victimized Pregnant and Parenting Minority Adolescents

Associations among sexual victimization and the psychosocial functioning of African American and Latina pregnant and parenting adolescents were examined. Forty-seven (17.7%) of the 265 participants reported histories of sexual victimization, most of which was unwanted sexual intercourse. The victimized adolescents reported higher levels of depression, anxiety, and life stress and, although the two groups reported no differences in their levels of social support, support was found to be differentially related to depression and anxiety in the two groups. In particular, victims derived benefits from social support at low levels of stress, but social support provided no protection against depression and anxiety at average or high levels of stress. For nonvictims, social support provided no benefits at low levels of stress, but protected against depression and anxiety at moderate levels of stress and against depression at high levels of stress. Implications of these findings for research, theory, and intervention are discussed.     

Anxiety and depression as correlates of self-reported behavioural inhibition in normal adolescents

In a previous study, Muris, Merckelbach, Wessel, and Van de Ven [Psychopathological correlates of self-reported behavioural inhibition in normal children. Behav. Res. Ther. 37 (1999) 575-584] found that children who defined themselves as high on behavioural inhibition displayed elevated levels of psychopathological symptoms compared to children who defined themselves as low or middle on behavioural inhibition. The present study further examined the relationship between self-reported behavioural inhibition and anxiety disorders and depression symptoms in a large sample of adolescents aged 12-18 years (N=968). Adolescents completed a measure of behavioural inhibition and questionnaires of anxiety and depression. Results indicated that adolescents who classified themselves as high on behavioural inhibition had higher scores of anxiety and depression than adolescents who classified themselves as low or middle on behavioural inhibition. Structural equations modelling was employed to test hypothetical models on the role of behavioural inhibition in childhood anxiety and depression. It was found that a pathway in which behavioural inhibition results in anxiety, which in turn leads to depression, provided the best fit for the data.