Stressors and Child and Adolescent Psychopathology: Measurement Issues and Prospective Effects

This article reviews existing research on the association between stressors and symptoms of psychopathology in children and adolescents with a focus on measurement issues and prospective effects. The first half of the article focuses on the measurement of stressors, emphasizing checklists and interviews. Available measures of stressful experiences are reviewed and critiqued. Results of this review reveal both substantial progress (i.e., development of valid stressor assessment tools) and remaining problems (i.e., inconsistent measurement across studies). The second half of this article reviews studies that have tested for prospective associations between stressors and symptoms of psychopathology in children and adolescents. Studies that have examined the prospective effects of recent or prior stressors on current psychological symptoms, while controlling for prior psychological symptoms, are reviewed. Results overall suggest that stressors predict changes in rates of symptoms of psychopathology in children and adolescents over time. Results also suggest that symptoms of psychopathology predict changes in rates of stressors over time. Implications of these findings are that conclusive evidence now exists for the importance of stressors in the development of child and adolescent psychopathology.     

Stressors and child and adolescent psychopathology: evidence of moderating and mediating effects

This paper reviews studies that have tested for moderators or mediators of the relation between stressors and child and adolescent psychopathology. Many studies have tested for moderation, but results of research studying moderators have been inconclusive. There have been few theory-based studies and there have been few consistent findings. Far fewer studies have tested for mediation effects, but these studies have generally been theory-driven, have more often built upon one another in an incremental fashion, and have yielded consistent results. In particular, there is substantial evidence for the mediating role of family relationship in the relation between stressors and child and adolescent psychological symptoms. Future studies should integrate moderator and mediator research by testing for specific mediators in relation to particular moderating contexts, so that we can better understand the complex ways in which stressful life experiences affect the well-being of children and adolescents.     

Low Vagal Tone Magnifies the Association Between Psychosocial Stress Exposure and Internalizing Psychopathology in Adolescents

Vagal tone is a measure of cardiovascular function that facilitates adaptive responses to environmental challenge. Low vagal tone is associated with poor emotional and attentional regulation in children and has been conceptualized as a marker of sensitivity to stress. We investigated whether the associations of a wide range of psychosocial stressors with internalizing and externalizing psychopathology were magnified in adolescents with low vagal tone. Resting heart period data were collected from a diverse community sample of adolescents (ages 13–17; N = 168). Adolescents completed measures assessing internalizing and externalizing psychopathology and exposure to stressors occurring in family, peer, and community contexts. Respiratory sinus arrhythmia (RSA) was calculated from the interbeat interval time series. We estimated interactions between RSA and stress exposure in predicting internalizing and externalizing symptoms and evaluated whether interactions differed by gender. Exposure to psychosocial stressors was associated strongly with psychopathology. RSA was unrelated to internalizing or externalizing problems. Significant interactions were observed between RSA and child abuse, community violence, peer victimization, and traumatic events in predicting internalizing but not externalizing symptoms. Stressors were positively associated with internalizing symptoms in adolescents with low RSA but not in those with high RSA. Similar patterns were observed for anxiety and depression. These interactions were more consistently observed for male than female individuals. Low vagal tone is associated with internalizing psychopathology in adolescents exposed to high levels of stressors. Measurement of vagal tone in clinical settings might provide useful information about sensitivity to stress in child and adolescent clients.     

Empirically supported treatments of disease-related symptoms in pediatric psychology: asthma, diabetes, and cancer.

OBJECTIVE: To review empirical studies of psychological treatments for (1) reducing physical symptoms in children and adolescents with asthma, (2) improving glycemic control in children and adolescents with diabetes, and (3) reducing chemotherapy side effects in children and adolescents with cancer. METHODS: We identified peer-reviewed studies of effects of psychological treatments for asthma symptoms, diabetes symptoms, and side effects of cancer chemotherapy through computerized databases (i.e., PSYCHLIT and MEDLINE). Treatment approaches are evaluated with respect to meeting criteria for being "promising," "probably efficacious," or "well-established" based on the Chambless criteria (Chambless et al., 1996). RESULTS: Two well-established treatments (EMG biofeedback for children with emotionally triggered asthma and imagery with suggestion for children undergoing chemotherapy) and two probably efficacious treatments (relaxation for children with emotionally triggered asthma and distraction with relaxation for children undergoing chemotherapy) were identified. Additional research is needed to evaluate the efficacy of treatments for diabetes-related symptoms. CONCLUSIONS: Future research would be enhanced by identifying characteristics of children who are likely to respond to psychological treatment as an adjunctive strategy for symptom management and by clearly elucidating mechanisms of effect of various interventions.     

Major and minor life events as predictors of psychological distress: Further issues and findings

Current trends in research on stressful life events and disease have been to focus upon other psychosocial factors that may be associated with stress and illness relationships. Recently, the study of relatively minor life events or situations (e.g., daily hassles) has provided a promising alternative avenue of inquiry into basic stress measurement and the relationship of stress to disorder. While initial findings in this area of research appear encouraging, several methodological and procedural issues currently preclude definitive conclusions. The present paper outlines several of the most important limitations of existing research on this topic and provides further data taking these limitations into account for the role of minor life events as predictors of psychological distress. The results of the present prospective study indicate that undesirable minor events (e.g., hassles) significantly predict psychological symptoms, even once initial symptom status is controlled for statistically. Additionally, hassles were uniformly better predictors of subsequent psychological symptoms than were major life event categories; potentially important interactive effects (e.g., hassles x prior symptoms; hassles x prior major events) were also tested and their implications are discussed. Finally, basic associations between major and minor events were examined. The findings are discussed specifically in the context of recent advances in this area and more generally in relation to clarifying our understanding of psychosocial predictors of disorder.     

The Children's Somatization Inventory: further evidence for its reliability and validity in a pediatric and a community sample of Dutch children and adolescents

OBJECTIVE: To examine the psychometric properties of the Children's Somatization Inventory (CSI) in the Netherlands. METHOD: The CSI and a number of personality and psychopathology questionnaires were administered to Dutch schoolchildren (N = 479), children referred to a pediatric clinic (N = 63), and children's parents. RESULTS: Factor analysis yielded a number of factors that have also been found in previous research, viz., pain/weakness, gastrointestinal symptoms, and pseudoneurological symptoms. The reliability (internal consistency) of the CSI was satisfactory. Furthermore, support was obtained for the validity of the CSI. More specifically, the scale correlated in a theoretically meaningful way with child and parent reports of personality and psychopathology, and discriminated well between healthy and pediatric children. Finally, highly similar psychometric properties were obtained for the Parent version of the CSI (i.e., PCSI). CONCLUSION: The Dutch version of the CSI seems to be a reliable and valid self-report measure for assessing somatization symptoms in children and adolescents.     

Victims of war—Psychoendocrine evidence for the impact of traumatic stress on psychological well-being of adolescents growing up during the Israeli–Palestinian conflict

Violent conflicts are severe traumatic stressors with detrimental effects on physical and mental health, with children and adolescents being particularly at risk. For the hypothalamic–pituitary–adrenal (HPA) axis, characteristic patterns of dysregulation in trauma-exposed individuals have been shown. This study set out to investigate self-reported mental well-being in Palestinian adolescents growing up during the Israeli–Palestinian conflict. Hair cortisol concentrations (HCC) as a psychoendocrine marker for long-term HPA axis aberrations along with the potential protective factor sense of coherence (SoC; i.e., the global mindset to interpret the world and emerging stressors as comprehensible, manageable, and meaningful) were examined. Between 2014 and 2016, posttraumatic stress disorder (PTSD), depression, anxiety, HCC, and SoC were examined in 233 adolescents aged 11 to 16 from the West Bank. More than half of the participants reported trauma exposure, with 40% fulfilling the criteria of a preliminary PTSD diagnosis and a high prevalence of anxiety and depression. HCC was significantly elevated in the PTSD subgroup compared to the subgroup not exposed to any traumatic events (p = 0.046), with trauma-exposed individuals in between. HCC was further associated with typical sequelae of traumatic stress. Notably, SoC was inversely related to self-reported psychopathology, as well as to HCC in the trauma group. The results illustrate the situation of adolescents exposed to chronic traumatic stress and extend the literature on aberrant HPA axis functioning under such conditions. They also point out a central role of SoC, which may imply new strategies to aid individuals exposed to ongoing conflicts.     

School connectedness is an underemphasized parameter in adolescent mental health: results of a community prediction study.

There is limited prospective research on the relation between school connectedness (i.e., the extent to which students feel accepted, valued, respected, and included in the school) and mental health symptoms in adolescents. A sample of 2,022 students (999 boys and 1,023 girls) ages 12 to 14 years were measured at 2 time points (12 months apart) on school connectedness and mental health symptoms (general functioning, depression, and anxiety symptoms). School connectedness correlated extensively with concurrent mental health symptoms at both time points (between 38% and 55% covariation with depression, 26% to 46% with general functioning, and 9% and 16% for anxiety symptoms). Using hierarchical linear modeling, school connectedness also predicted depressive symptoms 1 year later for both boys and girls, anxiety symptoms for girls, and general functioning for boys, even after controlling for prior symptoms. The reverse, however, was not true: Prior mental health symptoms did not predict school connectedness 1 year later when controlling for prior school connectedness. Results suggest a stronger than previously reported association with school connectedness and adolescent depressive symptoms in particular and a predictive link from school connectedness to future mental health problems.     

Epidemiologic characteristics and sequelae of closed head‐injured children and adolescents: A review

This article reviews the epidemiology of head‐injured (HI) children and adolescents, including age and sex variables, etiology, and risk factors. Within this context, the psychophysiology (i.e., primary and secondary damage) and outcome and mortality as it exists in these children are described. In addition, motor and speech/language sequelae as well as cognitive and behavioral sequelae in closed head‐injured (CHI) children are reviewed along with findings based on neuropsychological assessment of this population. We concluded that although a pattern of cognitive sequelae, including visuospatial, vi‐suomotor, and memory deficits, are seen in children and adolescents, no apparent pattern of behavioral sequelae exists. More data comparing pre‐injury personality, behavior, and environment, and family influences is warranted before specific posttraumatic behavior can be evidenced.     

Contextual startle responses moderate the relation between behavioral inhibition and anxiety in middle childhood

Behavioral inhibition (BI), a temperament characterized in early childhood by wariness and avoidance of novelty, is a risk factor for anxiety disorders. An enhanced startle response has been observed in adolescents characterized with BI in childhood, particularly when they also manifest concurrent symptoms of anxiety. However, no prior study has examined relations among BI, startle responsivity, and anxiety in a prospective manner. Data for the present study were from a longitudinal study of infant temperament. Maternal reports and observations of BI were assessed at ages 2 and 3. At age 7, participants completed a startle procedure, while electromyography was collected, where participants viewed different colors on a screen that were associated with either the delivery of an aversive stimulus (i.e., puff of air to the larynx; threat cue) or the absence of the aversive stimulus (i.e., safety cue). Parental reports of child anxiety were collected when children were 7 and 9 years of age. Results revealed that startle responses at age 7 moderated the relation between early BI and 9‐year anxiety. These findings provide insight into one potential mechanism that may place behaviorally inhibited children at risk for anxiety.     

Complex Trauma in Children and Adolescents: Evidence‐Based Practice in Clinical Settings

Complex trauma (CT) results from exposure to severe stressors that occur within the caregiver system or with another presumably responsible adult, are repetitive, and begin in childhood or adolescence. As a result, many of these children and adolescents experience lifelong difficulties related to self‐regulation, relationships, psychological symptoms, alterations in attention and consciousness, self‐injury, identity, and cognitive distortions. The aims of this article include the following: (a) to examine several representative approaches identified as treatments for children and adolescents exposed to CT with respect to similarities and differences; (b) to examine representative evidence of model effectiveness; (c) to discuss how these approaches are and/or could be implemented in clinical practice; and (d) to suggest research designs that would facilitate greater translation of effective treatment into clinical settings.     

The relations among depression in fathers, children's psychopathology, and father-child conflict: a meta-analysis

Research on parental depression is beginning to recognize the importance of studying fathers in relation to maladaptive outcomes in their offspring. Paternal depression is hypothesized to correlate with internalizing and externalizing psychopathology in children and adolescents and to compromise adaptive parent-child relationships (e.g., increased conflict). In the present paper, meta-analytic procedures were applied to this literature to address the magnitude and direction of covariation between paternal depression and children's functioning. In addition, we tested whether variation in findings could be accounted for by study characteristics. Results indicated that paternal depression was significantly related to offspring internalizing and externalizing psychopathology and father-child conflict. Larger effects for internalizing symptoms were associated with the use of community samples and symptom rating scales of internalizing problems.     

Protection or Vulnerability? A Meta‐Analysis of the Relations Between the Positive and Negative Components of Self‐Compassion and Psychopathology

Self‐compassion is increasingly explored as a protective factor in relation to psychopathology. The Self‐Compassion Scale (SCS) and its Short Form variant (SCS‐SF) are the most widely used instruments for measuring this psychological construct, and previous studies have indeed shown that the total score of this scale is negatively associated with psychopathology. In this article, we point out that half of the items of the SCS and SCS‐SF are positive indicators of self‐compassion and directly refer to the three key components of self‐kindness, common humanity and mindfulness, while the other half of the items are negative indicators of the construct and reflect the precise opposite of the key components, namely self‐judgment, isolation and over‐identification. A meta‐analysis was conducted including 18 studies that reported on the positive and negative indicators of self‐compassion as indexed by the SCS/SCS‐SF and their relations to various types of psychopathology. Results showed that positive indicators of self‐compassion were negatively associated with psychopathology, which confirms their hypothesized protective influence. However, the negative indicators were positively linked to psychopathology, suggesting that these scales tap increased vulnerability to mental health problems. Moreover, tests comparing the strength of the relations between various SCS/SCS‐SF counterparts (i.e., self‐kindness versus self‐judgment, common humanity versus isolation and mindfulness versus over‐identification) and psychopathology showed that the negative indicators were significantly stronger linked to mental health problems than the positive indicators. This provides support for the idea that the use of a total self‐compassion score of the SCS or SCS‐SF, which typically includes the reversely scored negative subscales, will probably result in an inflated relationship with symptoms of psychopathology. Copyright © 2016 John Wiley & Sons, Ltd.     

Associations among depression, perceived self-efficacy, and immune function and health in preadolescent children

Experimental animal studies and adult research consistently show that stress exposure and/or psychological symptoms are associated with poorer health and immune functioning. The application to children is not yet clear, however, and we lack developmental models for studies in this area. The objective of this paper was to test the hypothesis that self-reported self-efficacy and depression, two markers of psychological well-being in children, would predict immunity and rate of illnesses. The data are based on a prospective study of 141 healthy, normally developing children aged 7-13 years who were recruited from an ambulatory pediatric setting. Children completed self-efficacy and depression measures and had blood obtained for IL-6 plasma levels and natural killer cell functional assays on three occasions, 6 months apart. Parents maintained weekly child illness diaries over 1 year using a thermometer to record fever. Parent psychiatric symptoms and income were used as covariates. Results indicated that, across the three occasions of measurement collected over the 1-year period, higher perceived self-efficacy was significantly associated with lower plasma interleukin 6 concentrations. There was no overall main effect of depressive symptoms on immune measures; however, for older girls, higher depression was associated with elevated natural killer cell cytotoxicity and an increased rate of total illnesses and febrile illnesses. The findings provide some of the first evidence that psychological processes are associated with immunity and health in a normally developing sample of preadolescents. Furthermore, the pattern of results suggests a modified model of a link between psychological well-being and immunological processes in children. These results build on and expand research on the notion of allostatic load and develop a groundwork for developmental studies in this area.     

The relationship between attachment strategies and psychopathology in adolescence

Aim: The majority of research investigating attachment and psychopathology has focused largely on children, and more recently adults. By comparison, few studies have considered the role of attachment on the development of psychopathology during adolescence. The scarcity of studies in this area is surprising given that adolescence is a critical period of psychological adjustment. This study investigates attachment patterns in adolescence and their relationship to symptomatology and interpersonal difficulties. Method: A two‐sample comparative design was employed so that a clinical group of adolescents were compared with a matched non‐clinical group, on attachment classifications (using a modified Separation Anxiety Test), reported interpersonal difficulties and clinical symptoms. Results: Significant differences were found between the clinical and non‐clinical groups on attachment classifications. Adolescents with ambivalent attachment patterns reported significantly more interpersonal difficulties and symptoms compared to young people classified as having secure and avoidant attachment classifications. The results are suggestive of specific differences in the way difficulties are reported. Conclusion: The findings are consistent with two strategies of affect regulation. It is proposed that a ‘hyperactivating’ strategy and a ‘deactivating’ strategy may be operating among those adolescents with ambivalent and avoidant attachment classifications, respectively. The implications of using self‐report measures in clinical work and for evidence‐based practice are discussed.     

Mental health issues among refugee children and adolescents

Each year, several thousand child refugees are resettled in Australia. These children have faced numerous stressors and are at increased risk for developing mental health problems including traumatic stress and a variety of emotional, behavioural, and educational difficulties. The diverse contexts in which refugee children may come into contact with mental health clinicians include school, child and adolescent mental health services, child protection services, and hospitals. This article summarises current knowledge regarding the mental health of refugee children and adolescents, distilling what is of particular relevance to Australian service providers. The stressors encountered by refugee children, psychological outcomes, appropriate interventions, and barriers to accessing services are discussed.     

Anxiety and depressive symptoms and anxiety sensitivity in youngsters with noncardiac chest pain and benign heart murmurs

OBJECTIVE: Chest pain in children and adolescents is rarely associated with cardiac disease. We sought to examine psychological symptoms in youngsters with medically unexplained chest pain. We hypothesized that children and adolescents with medically unexplained chest pain would have high rates of anxiety and depressive symptoms. METHODS: We assessed 65 youngsters with noncardiac chest pain (NCCP) and 45 comparison youngsters with benign heart murmurs using self-report measures of anxiety and depressive symptoms and anxiety sensitivity. RESULTS: Compared with the asymptomatic benign-murmur group, youngsters with NCCP had higher levels of some anxiety symptoms and anxiety sensitivity. Differences on depressive symptoms were not significant. CONCLUSIONS: Though preliminary, results suggest that youngsters with chest pain may experience increased levels of some psychological symptoms. Future studies of noncardiac chest pain in youngsters should include larger samples and comprehensive diagnostic assessments as well as long-term follow-up evaluations.     

Effectiveness of psychotherapy with children and adolescents.

This article reviews the outcome evidence of psychotherapy for children and adolescents. The questions that guide treatment research, conclusions about alternative treatments, and the impact on different types of problems are reviewed. Alternative treatments for children and adolescents have produced change across a diverse range of emotional and behavioral problems. Progress and advances in treatment research are illustrated by highlighting alternative treatments and factors that contribute to outcome in the treatment of conduct problem children. Although important advances can be readily identified in outcome research, the pace of progress has been thwarted by challenges of the subject matter (e.g., developmental issues, comorbidity, and the diverse parent, family, and other contextual factors in which child dysfunction is embedded) and deficiencies in current research (e.g., ambiguity in the characteristics of the samples, weak statistical power, departure of treatment conditions in research from those that characterize clinical work). Notwithstanding the recency of empirical attention to the topic, progress is evident in developing effective treatments for a wide range of problems.     

Comparison of psychopathology in the mothers of autistic and mentally retarded children

The aim of this study was to evaluate anxiety, depression, alexithymia, and general psychological symptoms in the mothers of autistic children in comparison with those in the mothers of mentally retarded children. Forty mothers of autistic children and 38 mothers of mentally retarded children were included in the study. After a clinical interview, psychometric tests were performed for depression, anxiety, alexithymia, and Symptom Distress Check List (SCL-90) for general psychological symptoms. Non-depression rates was 27.5% in the mothers of autistic children whereas the rate was 55.3% in the mothers of mentally retarded children. There was no difference regarding anxiety and alexithymia between the two groups. The psychopathology in the mothers of autistic children was more frequent than in those of mentally retarded children in all sub-scales of SCL-90 (somatization obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid thought, psychotism, and extra scale). The mothers of autistic children experienced more psychological distress than those of mentally retarded children. Our findings indicates that the assessment of autistic and mentally retarded children should include psychological assessment of their mothers.     

Internalizing symptoms and disorders in families of adolescents: a review of family systems literature

Internalizing symptoms and disorders are relatively common during adolescence and impact considerably on social and emotional functioning. Using a family systems framework, this paper reviews the current literature examining the impact of internalizing symptoms and disorders on the functioning of the family system, the spouse subsystem and the parent-child subsystem. Moreover, literature examining the relationship between parents' and adolescents' internalizing symptoms and disorders is reviewed. The reviewed research demonstrates that there exists an association between internalizing symptoms and disorders and poorer functioning at various levels of the family system. Longitudinal studies have generally reported that parent internalizing symptoms and disorders predict poorer functioning in the family system as well as internalizing symptoms and disorders in adolescents. However, few longitudinal studies have examined whether adolescent internalizing symptoms and disorders predict poorer family functioning and internalizing symptoms and disorders in parents. Those that have examined such effects report mixed results. On the basis of our review, we make recommendations about future research directions. In particular, it is argued that more research on the reciprocal effects of internalizing symptoms and disorders within families is needed to better understand the antecedents and consequences of these conditions for families of adolescents.