The Depression Prevention Initiative: Impact on Adolescent Internalizing and Externalizing Symptoms in a Randomized Trial

This randomized controlled trial examined the longitudinal effects of two school-based indicated depression prevention programs on adolescents’ internalizing and externalizing symptoms, as measured by adolescents, their parents, and their teachers. One hundred eighty-six adolescents participated in this study. The average age was 14.01 (SD = 1.22) years, and the sample was 66.7% female. One third of the sample belonged to a racial minority. Youth received either Interpersonal Psychotherapy–Adolescent Skills Training or group counseling. Symptoms were assessed using adolescent, parent, and teacher reports on the Achenbach System of Empirically Based Assessment at baseline, postintervention, and 6-month follow-up. Adolescents reported the most robust effects in favor of Interpersonal Psychotherapy–Adolescent Skills Training. Adolescents in Interpersonal Psychotherapy–Adolescent Skills Training reported significantly greater reductions in internalizing symptoms through the 6-month follow-up and significantly greater reductions in externalizing symptoms during the intervention as compared to group counseling. Less robust effects were found when examining parent and teacher reports, although there was evidence of significant within-group change in parent- and teacher-reported internalizing symptoms for both interventions and significant between-group differences in teacher-reported externalizing symptoms. This study provides additional evidence supporting the efficacy of Interpersonal Psychotherapy–Adolescent Skills Training as a depression prevention program for adolescents. Interpersonal Psychotherapy–Adolescent Skills Training appears to have fast-acting effects on broadband internalizing and externalizing symptoms as reported by adolescents. This suggests that Interpersonal Psychotherapy–Adolescent Skills Training may serve as a transdiagnostic preventive intervention. Moreover, given the disparate reports of adolescents, parents, and teachers, this study demonstrates the significance of collecting information from multiple sources when possible.     

Co-activation of SAM and HPA responses to acute stress: A review of the literature and test of differential associations with preadolescents’ internalizing and externalizing

Understanding co-activation patterns of the hypothalamic-pituitary-adrenal axis (HPA) and sympathetic adrenal medullary (SAM) during early adolescence may illuminate risk for development of internalizing and externalizing problems. The present study advances empirical work on the topic by examining SAM-HPA co-activation during both the reactivity and recovery phases of the stress response following acute stress exposure. Fourth and fifth grade boys and girls (N = 149) provided cortisol and alpha-amylase via saliva at seven times throughout a 95-min assessment in which they were administered the modified Trier Social Stress Test. Parents reported on adolescents’ life stress, pubertal development, medication use, and externalizing problems. Adolescents reported their own internalizing symptoms. Multiple linear regressions tested both direct and interactive effects of SAM and HPA reactivity and recovery on internalizing and externalizing problems. Results from these analyses showed that whereas SAM and HPA reactivity interacted to predict internalizing symptoms, it was their interaction during the recovery phase that predicted externalizing. Concurrent high SAM and HPA reactivity scores predicted high levels of internalizing and concurrently low SAM and HPA recovery scores predicted high levels of externalizing. Implications of the findings for further study and clinical application are discussed.     

Perceived discrimination and youths' adjustment: sleep as a moderator

Adolescents' sleep duration was examined as a moderator of the association between perceived discrimination and internalizing (anxiety, depression) and externalizing symptoms. Participants were 252 adolescents (mean: 15.79 years; 66% European American, 34% African American) who reported on their perceived discrimination (racial and general) and adjustment. Sleep duration was measured using actigraphy. Moderation effects were evident. The lowest levels of internalizing symptoms were observed for adolescents with longer sleep duration in conjunction with lower levels of perceived racial discrimination. Further, general perceived discrimination was associated more strongly with externalizing behaviours for youth with shorter versus longer sleep. Findings highlight the importance of sleep as a bioregulatory system that can ameliorate or exacerbate the effects of discrimination on youths' adjustment.     

Effect of Co-Occurrence on the Referability of Internalizing and Externalizing Problem Behavior in Adolescents

Assessed the effect of co-occurring versus not co-occurring internalizing and externalizing behavior problems on the reasons parents reported for clinical referral of their adolescent child. Reasons for referral were coded for 181 inpatient adolescents, and parent ratings of internalizing and externalizing behavior were obtained for a general population sample of 500 adolescents. Parents concurrently reported internalizing and externalizing behavior as reasons for referral less frequently (p < .0001) than would be expected given the correlation between these two domains in the general population sample. This suggests that the presence of externalizing problems may decrease parents' concern or awareness of internalizing problems, the presence of internalizing problems may decrease parents' concern or awareness of externalizing problems, or both Implications for the clinical referral of adolescents and for informal parental efforts at helping their children with externalizing and internalizing problems are discussed.     

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.     

Latent change score modeling of psychophysiological data: an empirical instantiation using electrodermal responding

We examined latent change score (LCS) modeling as an approach to the analysis of children's skin conductance level (SCL) throughout a stressful task-a simulated interadult argument-as it relates to externalizing and internalizing symptoms. LCS is an extension of traditional multilevel modeling (MLM), which allows estimation of proportional growth terms. Children (age 6-12 years; N=150) were from two-parent families. Mothers reported on children's internalizing and externalizing symptoms. Results indicated that the LCS models outperformed the traditional MLM. The use of LCS yielded important novel information regarding profile and pattern of responding for various children and is likely to advance understanding of relations between children's physiological responses and psychopathology symptoms.     

Pathways from family economic conditions to adolescents' distress: Supportive parenting,stressors outside the family,and deviant peers

Economic hardship is a stressor that affects large numbers of children and their families. This study estimated a model that included pathways linking economic conditions to the internalizing and externalizing symptoms of a multiethnic sample of urban adolescents. Similar to other prominent models, this model included parental distress and parenting as key constructs, but the expanded ecological model also included stressors outside the family and adolescents' associations with deviant peers as possible explanatory factors. Data from 300 adolescents and their parents were consistent with a model that showed linkages between economic conditions, parental depressive symptoms, supportive parenting, and internalizing symptoms. Stressors outside the family were associated with deviant peer affiliations which, in turn, predicted internalizing and externalizing symptoms. The implications of these findings for understanding economic conditions' influence on adolescents' mental health are discussed. © 2002 John Wiley & Sons, Inc.     

Longitudinal links among parenting, self-presentations to peers, and the development of externalizing and internalizing symptoms in African American siblings

A longitudinal model that linked involved-supportive parenting and siblings' ability-camouflaging self-presentations to peers with the development of externalizing and internalizing symptoms was tested with 152 pairs of first- and second-born African American siblings (mean ages 12.7 years and 10.2 years at the first wave of data collection). Three waves of data were collected at 1-year intervals. Teachers assessed siblings' externalizing symptoms, internalizing symptoms, and academic competence; siblings reported their own self-presentations and desire for peer acceptance; and mothers and siblings provided multiinformant assessments of involved-supportive parenting. Involved-supportive parenting at Wave 1 was linked with peer-directed self-presentations at Wave 2. Wave 2 self-presentations were linked indirectly with changes from Wave 1 to Wave 3 in externalizing and internalizing symptoms through their association with academic competence.     

An attachment-based intervention for parents of adolescents at risk: mechanisms of change

Mechanisms that account for treatment effects are poorly understood. The current study examined processes that may underlie treatment outcomes of an attachment-based intervention (Connect) for parents of pre-teens and teens with serious behavior problems. Parents (N = 540) in a non-randomized trial reported on their teen’s functioning prior to and following treatment. Results confirmed significant decreases in parents’ reports of teens’ externalizing and internalizing symptoms, replicating prior evaluations of this program. Reductions in parents’ reports of teen attachment avoidance were associated with decreases in externalizing symptoms, while reductions in parents’ reports of teen attachment anxiety were associated with decreases in internalizing symptoms. Parents’ reports of improved teen affect regulation were also associated with decreases in both internalizing and externalizing symptoms. Results were comparable across gender and for parents of teens with pre-treatment externalizing symptoms in the clinical versus sub-clinical range. A model of therapeutic change in attachment-based parenting programs is discussed.     

Can Mother–Daughter Communication Buffer Adolescent Risk for Mental Health Problems Associated With Maternal Depressive Symptoms?

The current study sought to test whether higher quality mother–daughter communication would buffer associations between maternal depressive symptoms and girls’ internalizing and externalizing psychopathology symptoms among urban African American girls across a 12-month period. One hundred ninety-four treatment-seeking urban African American adolescent girls, ages 12–16, and their mothers participated in the study. Every 6 months (for up to 3 assessments), daughters reported on their internalizing and externalizing symptoms, mothers reported on their depressive symptoms, and both mothers and daughters reported on the quality of their dyadic communication. Daughters additionally reported on the extent to which they felt accepted by their mothers at each assessment. Results of multilevel modeling revealed that quality of communication significantly interacted with maternal depressive symptoms to predict externalizing and internalizing symptoms in daughters, such that the risk associated with maternal depressive symptoms was fully buffered for daughters in high-quality communication dyads. Secondary analyses demonstrated that these patterns of results were not accounted for by higher levels of social status or maternal acceptance. Drawing on a vulnerable and understudied population of urban African American adolescent girls, this work suggests that family communication may contribute to important intergenerational psychopathology transmission processes, above and beyond more general features of the family environment.     

Psychological adjustment of children and adolescents with chronic arthritis: a meta-analytic review

OBJECTIVE: To review studies of psychological adjustment among children and adolescents with chronic arthritis to determine whether they are at more risk for development of adjustment problems than controls. METHODS: We used meta-analytic techniques to review 21 studies reporting overall adjustment problems, internalizing symptoms, externalizing symptoms, or self-concept among youths with arthritis. RESULTS: Youths with arthritis displayed increased risk for overall adjustment problems and internalizing symptoms, but not for externalizing symptoms or poor self-concept. Risk was greater in studies making comparisons to study controls rather than to norms and in studies including mixed disease samples (arthritis plus other rheumatic diseases) rather than samples of youths with arthritis only. CONCLUSIONS: Results suggest the importance of assessing for internalizing problems among youths with chronic arthritis. Future research may benefit from inclusion of child self-report of adjustment problems, diagnostic specificity in reporting results, and use of adjustment measures without somatic items.     

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.     

Associations Between Marital Conflict and Adolescent Conflict Appraisals,Stress Physiology,and Mental Health

The goal of the current study was to examine conflict appraisals and diurnal cortisol production as mediators of the robust association between marital conflict and adolescent adjustment problems. Parents reported their marital conflict and were observed engaging in a marital conflict discussion; they also reported adolescent internalizing and externalizing behaviors. Adolescents (n = 105, 52% female, 10–17 years of age) appraised their parents’ marital conflict and reported their internalizing and externalizing behaviors. After the laboratory visit, adolescents provided four saliva samples on each of 2 consecutive days to assess diurnal cortisol production. More-negative marital conflict predicted more self-blame for parental conflict, which in turn predicted less robust decreases in cortisol across the day. Further, this flattened cortisol production pattern mediated the relationship between greater self-blame for parental conflict and adolescents’ elevated internalizing behaviors. Feeling responsible for parental conflict appears to be particularly damaging in terms of physiological regulation and adjustment, and may therefore be a particularly useful intervention target.     

Family processes that shape the impact of interparental conflict on adolescents

This study draws on the family systems concepts of triangulation and wholism to investigate how interparental conflict may affect adolescents' psychological adjustment. An ethnically and socioeconomically diverse sample (N = 388) of 14- to 18-year-olds completed measures of interparental conflict, family relationships, internalizing problems, and externalizing problems. We found that triangulation into parental disagreements mediated the association between parental conflict and both internalizing and externalizing problems. Adolescents exposed to more frequent, intense, and poorly resolved conflict were more likely to feel triangulated, but this association was moderated by the nature of the alliances they had with their parents. Specifically, at low levels of interparental conflict, adolescents who had substantially stronger alliances with one parent than the other reported greater triangulation than those with more balanced alliances. At high levels of conflict, these groups reported similar degrees of triangulation. We also found that supportive parent-child relationships reduced adolescents' appraisals of threat and self-blame for interparental conflict, while more empathic relationships with siblings increased these appraisals. Finally, close relationships with fathers acted as a protective factor that reduced symptoms of maladjustment.     

Exposure to Community Violence and the Trajectory of Internalizing and Externalizing Symptoms in a Sample of Low-Income Urban Youth

This study examined trajectories of psychopathology in a sample of low-income urban youth and tested exposure to community violence as a predictor of these trajectories. Self-report and parent-report survey measures of psychological problems and exposure to community violence were collected annually over 3 years from a sample of 364 fifth- to ninth-grade low-income urban youth (64% female; 95% youth of color). Linear growth models showed that youth experienced declines in both internalizing and externalizing symptoms across adolescence. Exposure to community violence was more strongly associated with externalizing symptoms than with internalizing symptoms but predicted declines in both types of symptoms. Results also indicated that youth reported more internalizing and externalizing symptoms than their parents reported for them. Exposure to community violence may explain unique trajectories of mental health problems among low-income urban youth. In addition, youth efforts to adopt a tough façade in the face of community violence could lead to higher rates of externalizing problems relative to internalizing problems, whereas desensitization processes may better explain reductions in both types of symptoms over time. Finally, youth report may be more valid than parent report in the context of urban poverty.     

Bias in Self-Perceptions and Internalizing and Externalizing Problems in Adjustment During Early Adolescence: A Prospective Investigation

We investigated bias in self-perceptions of competence (relative to parent ratings) for family, school, and peer domains as predictors of adjustment problems among 139 young adolescents over a 1-year period using a prospective design. Regressions examined measures of bias at Time 1 (T1) as predictors of ratings of internalizing and externalizing problems at Time 2 (T2), controlling for T1 adjustment ratings. For the family domain, curvilinear trends were found. Follow-up analyses revealed that for this domain both negative bias (self-perceptions less favorable than parent ratings) and positive bias (self-perceptions more favorable than parent ratings) predicted greater internalizing and externalizing problems as rated by youth, parents, and teachers. For the peer domain, higher scores on the measure of bias predicted greater internalizing and externalizing problems as rated by teachers. These findings are consistent with the view that accuracy in self-perceptions of competence can have important implications across multiple domains of development.     

Bias in self-perceptions and internalizing and externalizing problems in adjustment during early adolescence: a prospective investigation.

We investigated bias in self-perceptions of competence (relative to parent ratings) for family, school, and peer domains as predictors of adjustment problems among 139 young adolescents over a 1-year period using a prospective design. Regressions examined measures of bias at Time 1 (T1) as predictors of ratings of internalizing and externalizing problems at Time 2 (T2), controlling for T1 adjustment ratings. For the family domain, curvilinear trends were found. Follow-up analyses revealed that for this domain both negative bias (self-perceptions less favorable than parent ratings) and positive bias (self-perceptions more favorable than parent ratings) predicted greater internalizing and externalizing problems as rated by youth, parents, and teachers. For the peer domain, higher scores on the measure of bias predicted greater internalizing and externalizing problems as rated by teachers. These findings are consistent with the view that accuracy in self-perceptions of competence can have important implications across multiple domains of development.     

Relations of effortful control, reactive undercontrol, and anger to Chinese children's adjustment

The purpose of the study was to examine the zero-order and unique relations of effortful attentional and behavioral regulation, reactive impulsivity, and anger/frustration to Chinese first and second graders' internalizing and externalizing symptoms, as well as the prediction of adjustment from the interaction of anger/frustration and effortful control or impulsivity. A parent and teacher reported on children's anger/frustration, effortful control, and impulsivity. Parents reported on children's internalizing symptoms, and teachers and peers reported on children's externalizing symptoms. Children were classified as relatively high on externalizing (or comorbid), internalizing, or nondisordered. High impulsivity and teacher-reported anger/frustration, and low effortful control, were associated with externalizing problems, whereas low effortful control and high parent-reported anger were predictive of internalizing problems. Unique prediction from effortful and reactive control was obtained and these predictors (especially when reported by teachers) often interacted with anger/frustration when predicting problem behavior classification.     

Adrenocortical activity in at-risk and normally developing adolescents: individual differences in salivary cortisol basal levels, diurnal variation, and responses to social challenges

The purpose of this study was to examine adrenocortical activity (basal, diurnal variation, and responses to social stressors) in adolescents at risk for psychopathology. Salivary cortisol levels were examined in normally developing and at-risk youth with internalizing and externalizing symptoms ranging from subclinical to clinical levels. Adolescents showed expected patterns of diurnal variation, with high early morning cortisol levels and a pattern of decline throughout the day. Females showed higher midday and late afternoon levels than males, and these patterns interacted with risk status. Internalizing problems sometimes were associated with gradual rather than steep declines in basal cortisol production. Both immediate and delayed cortisol reactivity to a social performance stressor were associated with internalizing symptoms. There was no evidence of relations between externalizing problems and underarousal of the hypothalamic-pituitary-adrenal (HPA) system. These and other results suggest that gender is an important moderating factor linking psychopathology. development, and context with HPA axis functioning in adolescence.     

Presence of a Sibling as a Potential Buffer Following Parental Divorce: An Examination of Young Adolescents

Examined whether the presence of a sibling may buffer young adolescents from adverse influences of parental divorce. Subjects were 79 adolescents from intact families, 77 from divorced families, their mothers, and their social studies teachers. Independent variables included adolescent gender, parental marital status, and sibling group (i.e., no siblings, one older sibling only, or one younger sibling only). Dependent measures were externalizing behaviors as reported by the adolescent's teacher and internalizing behaviors as reported by the teacher and the adolescent. Results indicated a significant interaction between marital status and sibling group; specifically, adolescents with no siblings from divorced families were reported by teachers as demonstrating more externalizing problems than all other groups.