Differentiating Adolescent Self-Injury from Adolescent Depression: Possible Implications for Borderline Personality Development

Self-inflicted injury (SII) in adolescence marks heightened risk for suicide attempts, completed suicide, and adult psychopathology. Although several studies have revealed elevated rates of depression among adolescents who self injure, no one has compared adolescent self injury with adolescent depression on biological, self-, and informant-report markers of vulnerability and risk. Such a comparison may have important implications for treatment, prevention, and developmental models of self injury and borderline personality disorder. We used a multi-method, multi-informant approach to examine how adolescent SII differs from adolescent depression. Self-injuring, depressed, and typical adolescent females (n = 25 per group) and their mothers completed measures of psychopathology and emotion regulation, among others. In addition, we assessed electrodermal responding (EDR), a peripheral biomarker of trait impulsivity. Participants in the SII group (a) scored higher than depressed adolescents on measures of both externalizing psychopathology and emotion dysregulation, and (b) exhibited attenuated EDR, similar to patterns observed among impulsive, externalizing males. Self-injuring adolescents also scored higher on measures of borderline pathology. These findings reveal a coherent pattern of differences between self-injuring and depressed adolescent girls, consistent with theories that SII differs from depression in etiology and developmental course.     

Review of a Parent’s Influence on Pediatric Procedural Distress and Recovery

Understanding how parents influence their child’s medical procedures can inform future work to reduce pediatric procedural distress and improve recovery outcomes. Following a pediatric injury or illness diagnosis, the associated medical procedures can be potentially traumatic events that are often painful and distressing and can lead to the child experiencing long-term physical and psychological problems. Children under 6 years old are particularly at risk of illness or injury, yet their pain-related distress during medical procedures is often difficult to manage because of their young developmental level. Parents can also experience ongoing psychological distress following a child’s injury or illness diagnosis. The parent and parenting behavior is one of many risk factors for increased pediatric procedural distress. The impact of parents on pediatric procedural distress is an important yet not well-understood phenomenon. There is some evidence to indicate parents influence their child through their own psychological distress and through parenting behavior. This paper has three purposes: (1) review current empirical research on parent-related risk factors for distressing pediatric medical procedures, and longer-term recovery outcomes; (2) consider and develop existing theories to present a new model for understanding the parent–child distress relationship during medical procedures; and (3) review and make recommendations regarding current assessment tools and developing parenting behavior interventions for reducing pediatric procedural distress.     

Role of Body Dissatisfaction in Developmental Psychopathology Among the Adolescents with Obesity: A Matched Case Control Study

Body-image is a significant component of self-image, and problems with the same are associated with several behavioural and psychological disorders. Adolescents, who otherwise more concerned about their body-image than any other age group, are at a higher risk for various psychological problems due to obesity. But much of our understanding in this regard comes from studies on the adults. In this backdrop, this study aims to examine the role of body dissatisfaction in developmental psychopathology among adolescents with obesity. Participants were 32 adolescents with obesity and 32 with normal weight, aged 11–16 years and school-going. Both groups were matched for age, gender and academic levels on one-to-one basis. Those with a body mass index (BMI) ≥ 30 kg/m² were considered obese, and those with a BMI < 25 kg/m² were considered as normal weight. All the participants were assessed using standard scales of body-image and developmental psychopathology. Results indicated that both obesity and poor body-image correlated with psychopathology in specific domains, but neither of them predicted psychopathology. This study suggests that body-image and obesity are risk factors but not predictors of psychopathology. However, psychosocial interventions are indicated to address the issues of body satisfaction and self-image in adolescents with obesity.     

Cognitive Behavior Therapy for Anxious Adolescents: Developmental Influences on Treatment Design and Delivery

Anxiety disorders in adolescence are common and disruptive, pointing to a need for effective treatments for this age group. Cognitive behavior therapy (CBT) is one of the most popular interventions for adolescent anxiety, and there is empirical support for its application. However, a significant proportion of adolescent clients continue to report anxiety symptoms post-treatment. This paper underscores the need to attend to the unique developmental characteristics of the adolescent period when designing and delivering treatment, in an effort to enhance treatment effectiveness. Informed by the literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review the ‘why’ and the ‘how’ of developmentally appropriate CBT for anxious adolescents. ‘Why’ it is important to consider developmental factors in designing and delivering CBT for anxious adolescents is addressed by examining the age-related findings of treatment outcome studies and exploring the influence of developmental factors, including cognitive capacities, on engagement in CBT. ‘How’ clinicians can developmentally tailor CBT for anxious adolescents in six key domains of treatment design and delivery is illustrated with suggestions drawn from both clinically and research-oriented literature. Finally, recommendations are made for research into developmentally appropriate CBT for anxious adolescents.     

Perfectionism in Pediatric Anxiety and Depressive Disorders

Although perfectionism has been identified as a factor in many psychiatric disorders across the life span, it is relatively understudied in pediatric anxiety and depressive disorders. Furthermore, there exists little cohesion among previous research, restricting the conclusions that can be made across studies. In this review, research associating perfectionism with pediatric anxiety and depression is examined and a framework is presented synthesizing research to date. We focus on detailing the current understanding of how perfectionism develops and interacts with other developmental features characteristic of anxiety and depression in children and potential pathways that result in anxiety and depressive disorders. This includes: how perfectionism is measured in children, comparisons with relevant adult literature, the development of perfectionism in children and adolescents, mediators and moderators of the link between perfectionism and anxiety and depression, and the role of perfectionism in treatment and prevention of these disorders. We also present research detailing perfectionism across cultures. Findings from these studies are beginning to implicate perfectionism as an underlying process that may contribute broadly to the development of anxiety and depression in a pediatric population. Throughout the review, difficulties, limitations, and gaps in the current understanding are presented while offering suggestions for future research.     

Stopping the Nonadherence Cycle: The Clinical and Theoretical Basis for Dialectical Behavior Therapy Adapted for Adolescents With Chronic Medical Illness (DBT-CMI)

Most adolescents with chronic illness do not adhere to their regimen. A novel transdiagnostic adaptation of dialectical behavior therapy (dialectical behavior therapy for chronic medical conditions; DBT-CMI) is presented to improve medical adherence in adolescents. The authors describe the approach of DBT-CMI and the model’s conceptualization of nonadherence, with specific focus on the core concepts of non-adherence across illness in adolescence.DBT-CMI has been piloted in two disease groups with preliminary benefit. DBT-CMI lends itself theoretically as a transdiagnostic approach due to specific skills that target core concepts of nonadherence in adolescence. Future research is warranted on the applicability of DBT-CMI across other pediatric medical conditions to replicate findings and examine long-term outcomes.     

Feelings Matter: Depression Severity and Emotion Regulation in HIV/STI Risk-Related Sexual Behaviors

Human immunodeficiency virus (HIV)/sexually transmitted infection (STI) prevention models may not address psychological complexities among adolescents with mental illnesses. This study examined contextual factors related to HIV/STI risk among heterosexually active Black adolescents with mental illnesses to inform the development of targeted HIV/STI prevention strategies. Black adolescent males and females (aged 14–17) were recruited from outpatient mental health programs in Philadelphia, PA to complete a computer-assisted personalized interview on sociodemographics, sexual behaviors, and emotion regulation (N?=?53). Two sample t-tests, Wilcoxon Rank Sum tests and regression modeling were used to examine differences in the study measures by gender and relationship status. Reports of sexual partner concurrency were high—both while already in a sexual relationship (67.3%) and multiple sexual partners in the same day (42.3%). Boys reported significantly more risk behaviors than girls. Sadness dysregulation predicted currently being in a relationship, older age at first oral sex, fewer vaginal sexual partners and fewer unprotected oral sexual encounters. Coping difficulties predicted a greater number of vaginal and oral sexual partners, and a lower age at first vaginal sex. Increasing depression severity was related to older age at first vaginal sex, fewer vaginal sexual partners and fewer unprotected oral sexual encounters in the past 3 months. This formative work suggests that coping mechanisms should be addressed in HIV/STI prevention research through the inclusion of activities targeted toward emotion regulation and decreasing sexual risk behaviors. Psycho-education and skills building may mitigate the psychopathology that contributes to HIV/STI risk in the target demographic.     

Distress tolerance and early adolescent externalizing and internalizing symptoms: The moderating role of gender and ethnicity

A large body of research has examined the development of internalizing and externalizing symptoms in childhood and early adolescence. Notably, there is significant concomitant impairment associated with early adolescent symptomatology, as well as association of these symptoms with future development of psychopathology, poor physical health, self-destructive thoughts and behaviors, criminal behavior, and HIV risk behaviors. Drawing on negative reinforcement theory, the current study sought to examine the potential role of distress tolerance, defined as the ability to persist in goal-directed activity while experiencing emotional distress, as a potential mechanism that may underlie both internalizing and externalizing symptoms among 231 Caucasian and African American youth (M age = 10.9 years; 45.5% female; 54.5% Caucasian ethnicity). A series of regressions resulted in significant moderated relationships, such that low distress tolerance conferred increased risk for alcohol use among Caucasians, delinquent behavior among African Americans, and internalizing symptoms among females. Clinical implications, including the potential role of negative reinforcement models in early intervention with young adolescents, are discussed.     

Novel Insights into Longstanding Theories of Bidirectional Parent–Child Influences: Introduction to the Special Section

Although bidirectional parent and child influences have been incorporated in theoretical models pertaining to the development of internalizing and externalizing behaviors in youth, studies have historically focused on the socializing influence that parents have on their children. This has left several important research questions unanswered about the nature of bidirectional parent-child relations across development, including how these bidirectional effects are related to different types of child and adolescent psychopathology. The goal of this special section is to examine some longstanding issues regarding the nature of bidirectional parent-child effects across time using a diverse array of longitudinal datasets. The results from these studies emphasize the importance of considering bidirectional effects in developmental psychopathology research, particularly the often overlooked influence that children and adolescents have on their parents' behavior and emotional well-being. Following these empirical articles, an expert in the field provides a scholarly commentary designed to outline the progress that has been made in understanding bidirectional parent-child effects across development as well as to propose fruitful areas for future research.     

Internal and External Validity of Self-Report and Parent-Report Measures of Sluggish Cognitive Tempo in South Korean Adolescents

This study evaluated the internal and external validity of self-report and parent-report measures of sluggish cognitive tempo (SCT) in South Korean adolescents. Adolescents (N =?469, ages 13–17 years; 50.2% boys) completed self-report measures of SCT and attention-deficit/hyperactivity disorder inattention (ADHD-IN) in addition to measures of internalizing and externalizing psychopathology, social problems, and grades. Parents rated adolescents on SCT, ADHD-IN, internalizing and externalizing psychopathology, and social problems. Using adolescent self-report, 11 of 15 SCT symptoms showed convergent and discriminant validity with ADHD-IN. Using parent-report, all 15 SCT symptoms showed convergent and discriminant validity with ADHD-IN. For within source analyses, SCT showed unique and stronger associations than ADHD-IN with internalizing psychopathology whereas ADHD-IN showed unique and stronger associations than SCT with externalizing psychopathology. SCT and ADHD-IN showed similar unique associations with social problems, whereas ADHD-IN was more strongly related than SCT to grades. Across source analyses also supported the differential unique associations of SCT and ADHD-IN with internalizing and externalizing psychopathologies. This study provides initial evidence for the internal and external validity of SCT with South Korean adolescents, extending support for the transcultural validity of SCT to the important developmental period of adolescence.

     

Growing Up Can Be Painful: A Case Report of the Bat Mitzvah and Chronic Pain

Among a subgroup of adolescents with chronic pain syndromes, anxiety about “growing up” appears common and may be exacerbated by developmental transitions. Using the bat mitzvah ceremony as one example of a developmental rite of passage, we present two cases in which adolescent girls facing this transition developed new chronic musculoskeletal pain syndromes or experienced recurrences of pain symptoms. In both cases, the transition to adulthood, symbolized by the bat mitzvah, was associated with anxiety in adolescents who were unusually focused on the negative aspects of becoming independent adults. The aims of this case report are (1) to highlight the role of developmental transitions as a possible factor in the biopsychosocial model of pediatric pain; (2) to illustrate how to address emotional and cognitive responses to these transitions in the context of cognitive-behavioral treatment for pain; and (3) to suggest systematic approaches to investigating this clinically-observed phenomenon in future research.     

The Teaching and Learning of Psychotherapy by Rudolf Ekstein and R. S. Wallerstein

The homogeneous group has been the most common form of group therapy for chronically physically ill children and adolescents. The goals of these groups have included the provision of peer support, adaptation to the realities of physical illness, and acceptance of and cooperation with the medical management of the disease. The refinement of the theory of developmental ego psychology suggests that the heterogeneous group has potential for aiding the emotional maturation of the chronically physically ill. This paper presents examples of groups of latency-age children, early adolescents, and middle adolescents that included chronically physically ill with physically healthy peers. The groups were planned under the assumption that despite external differences, children and adolescents of a similar age identify with peers in terms of normal age-specific developmental needs and conflicts.     

The Role of Temperament in the Etiology of Child Psychopathology

A substantial proportion of children and adolescents come to suffer from psychological disorders. This article focuses on the temperament factors that are involved in the pathogenesis of child psychopathology. It is argued that besides the reactive temperament factor of emotionality/neuroticism, the regulative process of effortful control also plays an important role in the etiology and maintenance of internalizing and externalizing problems in youths. More specifically, vulnerability to child psychopathology is determined by a temperament that is characterized by high levels of emotionality/neuroticism and low levels of effortful control. Models are hypothesized in which reactive and regulative temperament factors either have interactive or additive effects on the development of psychological disorders in children, and conceptualized in terms of a developmental psychopathology perspective. Directions for future research and clinical implications of this temperamental view on psychopathology are discussed.     

Characteristics of Suicidality Among Adolescents

The identification of high-risk adolescent suicide attempters in a population of depressed and suicidal adolescents is of crucial importance. This retrospective study examined characteristics of suicidality (recent and lifetime, active and passive) and psychopathology (depression, aggression, impulsivity, stressful life events, SCL-90 dimensions) among four groups of depressed adolescent outpatients: (1) suicide attempters who required medical treatment (n = 84), (2) suicide attempters who did not require medical treatment (n = 57), (3) suicidal ideators who had never made a suicide attempt (n = 40), and (4) nonsuicidal patients (n = 44). Results indicate that the nonsuicidal group could be differentiated from the three suicidal groups on the basis of suicidality and psychopathology, and that the three suicidal groups could be differentiated from one another on the basis of suicidality but not psychopathology. These findings are discussed in terms of the usefulness of certain self-report measures of suicidality for identifying suicidal adolescents and for differentiating among them. Furthermore, the findings suggest that psychopathological factors do not determine which suicidal adolescents make a medically dangerous suicide attempt and which do not.     

Perinatally acquired HIV infection: Long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.     

The Bender-Gestalt Psychopathology Scale: Failure to Infer Validity in a School-Aged Sample

The concurrent validity of Hutt's (1977) empirical psychopathology scale of the Bender Visual-Motor Gestalt Test was evaluated among three groups of younger school-aged children within the 7-to-10- year age range (M = 109.1): adjustment disordered, conduct disordered, and nonclinical controls (n = 40/group). Excellent interscorer reliability was achieved with approximately 2 hr of self-study of the scoring manual. Although the conduct-disordered group was significantly more immature on Koppitz' Developmental Scoring System, there were no significant differences among groups on the psychopathology scale when visual-motor development was covaried (M = 50.5). This was an unexpected result, given Hutt's initial validation study among school-aged children. The psychopathology scale was not inferred to be valid among adolescents in the only known concurrent validation study. Pending supportive validation research, the psychopathology scale should not be employed in the clinical assessment of younger school-aged children.     

Heuristic and analytic processes in mental models for conditionals: An integrative developmental theory

This article presents a developmental dual-process theory of the understanding of conditionals that integrates Evans’ heuristic–analytic theory within the revised mental model theory of conditional proposed by Barrouillet, Gauffroy, and Lecas (2008). According to this theory, the interpretation of a conditional sentence is driven by unconscious and implicit heuristic processes that provide individuals with an initial representation that captures its meaning by representing the cases that make it true. This initial model can be enriched with additional models (a process named fleshing out within the mental model theory) through the intervention of conscious and demanding analytic processes. Being optional, these processes construct representations of cases that are only compatible with the conditional, leaving its truth-value indeterminate when they occur. Because heuristic processes are relatively immune to developmental changes, while analytic processes strongly develop with age, the initial model remains stable through development whereas the number of additional models that can be constructed increases steadily. Thus, the dual-process mental model theory predicts in which cases conditionals will be deemed true, indeterminate, or false and how these cases evolve with age. These predictions were verified in children, adolescents and adults who were asked to evaluate the truth value and the probability of several types of conditionals. The results reveal a variety of developmental trajectories in the way different conditionals are interpreted, which can all be accounted for by our revised mental model theory.     

Commentary: Conceptual and Methodological Challenges to the Study of Emotion Regulation and Psychopathology

In this commentary, I argue that although emotion regulation and its role in psychopathology has been the focus of considerable psychological research with both children and adults, fundamental questions remain about how these phenomena are linked. I pose four challenges to the study of emotion regulation and psychopathology that have yet to be fully met, either empirically or conceptually. I note that a multi-level developmental approach that places emotion regulation within the context of both the larger self-regulatory system and the social relationships within which regulation occurs may be useful in understanding the emergence and maintenance of early behavioral patterns that evolve into disorders of psychological functioning.