Self-concept and ego development in deaf adolescents: a comparative study.

Self-concept and ego development, two intertwined aspects of self-indicating well-being and social-cognitive maturation, respectively, were examined in a representative sample of deaf adolescents of normal intelligence (N = 68), using translated and adapted versions of Harter's (1988, Manual for the self-perception profile for adolescents. Denver, CO: University of Denver) multidimensional measure of self-concept and Loevinger's (1998, Technical foundations for measuring ego development. Mahwah, NJ: Lawrence Erlbaum) measure of ego development. Compared to hearing norm groups, deaf adolescents showed lower levels of self-perceived social acceptance, close friendships and ego development and higher physical appearance. Hierarchical multiple regression analyses controlling for sociodemographic variables showed positive associations of global self-worth with support for signing during childhood and quality of parent-child communication and of ego development with attending a regular school. Cluster analysis identified three social competence profiles: uniformly low competence, uniformly high competence, and low social acceptance with high physical appearance. Cluster membership was associated with school type, ego development, and (past) neurological disorder. The results are discussed in reference to interventions aimed at the well-being of deaf youth.

Self-concept and psychopathology in deaf adolescents: preliminary support for moderating effects of deafness-related characteristics and peer problems.

BACKGROUND: High rates of psychopathology were found amongst deaf adolescents, but little is known about the psychosocial risk factors. This study investigated whether (1) less severe deafness and/or acquired or otherwise complicated deafness, and (2) having mainly contacts with hearing people, each represent chronic stressful conditions that moderate the associations between self-esteem and emotional problems. In addition, the moderating effect of observed peer rejection on the association between social acceptance and behavioural problems was explored. METHOD: Deaf adolescents of normal intelligence (N = 68) completed the Self Perception Profile for Adolescents. Psychopathology was assessed using a semi-structured interview with adolescents and reports by parents, teachers and expert ratings. Data on moderator variables were collected from school records, parental and teachers' reports. RESULTS: Emotional mental health problems were negatively associated with self-esteem and positively with peer rejection. The association between self-esteem and emotional problems was moderated by the deafness variable less severe deafness or acquired or otherwise complicated deafness. Behavioural mental health problems were positively associated with social acceptance and peer rejection but negatively with the amount of involvement with hearing people. Peer rejection moderated the association between social acceptance and behavioural problems. CONCLUSIONS: The findings emphasise the importance of considering self-concept dimensions, peer problems and deafness- and context-related characteristics when assessing and treating deaf adolescents.

Confirmatory factor analysis and factorial invariance analysis of the adolescent self-report Strengths and Difficulties Questionnaire: how important are method effects and minor factors?

OBJECTIVES. This study examined the factor structure of the self-report Strengths and Difficulties Questionnaire, paying special attention to the number of factors and to negative effects of reverse-worded items and minor factors within the subscales on model fit. Furthermore, factorial invariance across gender, age, level of education, and ethnicity was investigated. DESIGN. Data were obtained from the Youth Health Monitor Rotterdam, a community-based health surveillance system. METHODS. The sample consisted of 11,881 pupils of 11-16 years old. Next to the original five-factor model, a factor model with the number of factors based on parallel analysis and scree test was investigated. Confirmatory factor analysis for ordered-categorical measures was applied to examine the goodness-of-fit and factorial invariance of the factor models. RESULTS. After allowing reverse-worded items to cross-load on the prosocial behaviour factor and adding error correlations, a good fit to the data was found for the original five-factor model (emotional symptoms, conduct problems, hyperactivity-inattention, peer problems, prosocial behaviour) and a model with four factors (emotional symptoms and peer problems, conduct problems, hyperactivity-inattention, prosocial behaviour). Factorial invariance across gender, age, level of education, and ethnicity was found for the final five- and four-factor model, except for the prosocial factor of the four-factor model that showed partial invariance across gender. Conclusions. While support was found for both models, the final five-factor model is theoretically more plausible and gained additional support as the original scales emotional problems and peer problems showed different relations with gender, educational level, and ethnicity.

Stepped care cognitive behavioural therapy for children with anxiety disorders: a new treatment approach.

BACKGROUND: The current nonrandomized clinical trial explored changes over time in children with an anxiety disorder during stepped care, manual-based cognitive behaviour therapy (CBT). METHODS: Clinically anxious children (8-12 years, n = 133) and their parents participated in child focused CBT (10 sessions). If assessments indicated additional treatment was necessary, participants could step up to a second and possibly third treatment phase (each 5 sessions) including more parental involvement. RESULTS: After the first treatment phase 45% of the Intention-To-Treat sample was free of any anxiety disorder; after the second and third phase an additional 17% and 11% respectively. In total, 74% of the children no longer met criteria for any anxiety disorder following treatment. Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases, as well as child reported anxiety sensitivity and negative affect. Children participating in more treatment showed significant improvements during additional treatment phases, indicating that late change occurred for the subgroup that had not changed during the first phase. CONCLUSIONS: Stepped care offers a standardized, assessment based, yet tailored treatment approach for children with anxiety disorders. A more intensive treatment is offered when initial CBT is insufficient, providing children additional opportunities to reach the desired outcome.

CBT for childhood anxiety disorders: differential changes in selective attention between treatment responders and non-responders.

BACKGROUND: This study examined whether treatment response to stepped-care cognitive-behavioural treatment (CBT) is associated with changes in threat-related selective attention and its specific components in a large clinical sample of anxiety-disordered children. METHODS: Ninety-one children with an anxiety disorder were included in the present study. Children received a standardized stepped-care CBT. Three treatment response groups were distinguished: initial responders (anxiety disorder free after phase one: child-focused CBT), secondary responders (anxiety disorder free after phase two: child-parent-focused CBT), and treatment non-responders. Treatment response was determined using a semi-structured clinical interview. Children performed a pictorial dot-probe task before and after stepped-care CBT (i.e., before phase one and after phase two CBT). RESULTS: Changes in selective attention to severely threatening pictures, but not to mildly threatening pictures, were significantly associated with treatment success. At pre-treatment assessment, initial responders selectively attended away from severely threatening pictures, whereas secondary responders selectively attended toward severely threatening pictures. After stepped-care CBT, initial and secondary responders did not show any selectivity in the attentional processing of severely threatening pictures. Treatment non-responders did not show any changes in selective attention due to CBT. CONCLUSIONS: Initial and secondary treatment responders showed a reduction of their predisposition to selectively attend away or toward severely threatening pictures, respectively. Treatment non-responders did not show any changes in selective attention. The pictorial dot-probe task can be considered a potentially valuable tool in assigning children to appropriate treatment formats as well as for monitoring changes in selective attention during the course of CBT.

Psychometric qualities of the Dutch version of the Pediatric Inventory for Parents (PIP): a multi-center study.

OBJECTIVES: Diagnosis and treatment of childhood cancer are continuous stressors in the lives of the entire family involved. Disease-related tools for the assessment of parental stress and adaptation are scarce. For that reason, the Pediatric Inventory for Parents (PIP), a disease-related measure, was translated into Dutch and its psychometric qualities were determined to prove its value. METHODS: The PIP and three other measures (State-Trait Anxiety Inventory, General Health Questionnaire and Parenting Stress Index, Short Form) were administered to 174 parents of 107 children diagnosed with cancer in three university medical centers in the Netherlands. RESULTS: Internal consistency (Crohnbach's alpha=0.94 and 0.95) and test-retest reliability (Pearson's r between 0.67 and 0.87) of the Dutch PIP total scales are satisfactory. Validity was illustrated by a high correlation between PIP-scores and anxiety and general stress. Confirmatory factor analysis showed acceptable fit to the data for the original four-factor and the one-factor models; the four-factor model showed slightly better fit. CONCLUSION: The PIP can be used in clinical practice to assess disease-related parental stress. Further psychometric testing is highly recommended.

No differences between group versus individual treatment of childhood anxiety disorders in a randomised clinical trial.

BACKGROUND: The present study compares an individual versus a group format in the delivery of manualised cognitive-behavioural therapy (FRIENDS) for children with anxiety disorders. Clinically referred children (aged 8 to 12) diagnosed with Separation Anxiety Disorder (n = 52), Generalised Anxiety Disorder (n = 37), Social Phobia (n = 22) or Specific Phobia (n = 16) were randomly assigned to individual (n = 65) or group (n = 62) treatment. METHOD: Analyses were conducted separately for the intent-to-treat sample and the sample of children who completed treatment. Analyses included chi-square comparisons and regression analyses with treatment format as a predictor. RESULTS: Forty-eight percent of the children in the individual versus 41% in the group treatment were free of any anxiety disorder at post-treatment; 62% versus 54% were free of their primary anxiety disorder. Regression analyses showed no significant difference in outcome between individual and group treatment. CONCLUSIONS: Children improved in both conditions. Choice between treatments could be based on pragmatic considerations such as therapeutic resources, referral rates, and the preference of the parents and the child.

A comparison of four scoring methods based on the parent-rated Strengths and Difficulties Questionnaire as used in the Dutch preventive child health care system.

BACKGROUND: Validated questionnaires can support the identification of psychosocial problems by the Preventive Child Health Care (PCH) system. This study assesses the validity and added value of four scoring methods used with the Strengths and Difficulties Questionnaire (SDQ) for the identification of psychosocial problems among children aged 7-12 by the PCH. METHODS: We included 711 (of 814) children (response: 87%) aged 7-12 undergoing routine health assessments in nine PCH services across the Netherlands. Child health professionals interviewed and examined children and parents. Prior to the interview, parents completed the SDQ and the Child Behaviour Checklist (CBCL), which were not shown to the professionals. The CBCL and data about the child's current treatment status were used as criteria for the validity of the SDQ. We used four SDQ scoring approaches: an elevated SDQ Total Difficulties Score (TDS), parent-defined difficulties, an elevated score for emotional symptoms, conduct problems or hyperactivity in combination with a high impairment score, and a combined score: an elevated score for any of these three methods. RESULTS: The Cohen's Kappa ranged from 0.33 to 0.64 for the four scoring methods with the CBCL scores and treatment status, generally indicating a moderate to good agreement. All four methods added significantly to the identification of problems by the PCH. Classification based on the TDS yielded results similar to more complicated methods. CONCLUSION: The SDQ is a valid tool for the identification of psychosocial problems by PCH. As a first step, the use of a simple classification based on the SDQ TDS is recommended.

Parenting and parental anxiety and depression as predictors of treatment outcome for childhood anxiety disorders: has the role of fathers been underestimated?

A substantial percentage of children with anxiety disorders do not respond adequately to Cognitive Behavioral Therapy (CBT). Examination of parental factors related to treatment outcome could contribute to a further understanding of treatment outcome responses. This study investigated the predictive value of paternal and maternal emotional warmth, rejection, overprotection, anxiety, and depression for CBT outcome in clinic-referred anxious children (ages 8-12). Levels of maternal emotional warmth, paternal rejection and anxiety, and depressive symptoms predicted treatment success and failure. A higher level of maternal emotional warmth was associated with a less favorable treatment outcome. Higher levels of paternal rejection, anxiety, and depressive symptoms were consistently associated with a less favorable treatment outcome.

Translation and cross-cultural adaptation of assessment instruments used in psychological research with children and families.

With the increased globalization of psychology and related fields, having reliable and valid measures that can be used in a number of languages and cultures is critical. Few guidelines or standards have been established in psychology for the translation and cultural adaptation of instruments. Usually little is reported in research publications about the translation and adaptation process thus making it difficult for journal readers and reviewers to adequately evaluate the equivalency and quality of an instrument. In this study, issues related to the translation and adaptation of assessment instruments for use in other cultures and/or languages are addressed. Existing literature on translation is reviewed and examples from the clinical child and family psychology field are given to illustrate relevant issues. Suggestions are made for avoiding common translation errors.

Characteristics of children and adolescents in the Dutch national in- and outpatient mental health service for deaf and hard of hearing youth over a period of 15 years.

In this study socio-demographic, deafness-related and diagnostic characteristics of hearing impaired children and adolescents referred to a national mental health service for deaf and hard of hearing children and adolescents were examined. Socio-demographic and diagnostic characteristics were compared to corresponding characteristics of hearing referred peers with identified mental health problems. The difference in characteristics between them and hearing referred peers with identified mental health problems was analyzed. A total of 389 deaf and hard of hearing and 3361 hearing children and adolescents was extracted from a database, all first referrals of patients of a center for child and adolescent psychiatry over a 15-year period. With deaf and hard of hearing patients we found higher rates of environmental stress, as indicated by conditions such as more one parent families (38.6% versus 25.8%), and more parents with a low educational level (44.2% versus 31.1%). Moreover, deaf and hard of hearing patients were older at their first referral (10.8 versus 9.4 years) and had higher rates of pervasive developmental disorders (23.7% versus 12.3%) and mental retardation (20.3% versus 3.9%). Within the target group of deaf and hard of hearing patients, most patients were deaf (68.9%; 22.3% was severely hard of hearing), relatively few (13.7%) had a non-syndromal hereditary hearing impairment, and more (21.3%) had a disabling physical health condition, especially those with a pervasive developmental disorder (42.6%). These findings illustrate both the complexity of the problems of deaf and hard of hearing children and adolescents referred to specialist mental health services, and the need for preventive interventions aimed at early recognition.

Persistence of anxiety disorders and concomitant changes in cortisol.

In a clinical sample of 116 children and adolescents we studied the relation between the course of an anxiety disorder during treatment and the concomitant changes in cortisol levels. Assessments at baseline, after three months, and at one-year follow-up were performed with the Anxiety Disorders Interview Schedule. When we compared cortisol levels at baseline and one-year follow-up, persistence of the anxiety disorder was associated with both increased daytime cortisol production (F=3.2, p=0.04) and a trend towards a decreased cortisol morning rise (F=2.4, p=0.09). At one-year follow-up daytime cortisol production was lowest in the early remitters (109.7±29.2 h mmol/l), higher in the late remitters (121.0±40.0 h mmol/l) and highest in the non-remitters (131.1±48.9 h mmol/l). Early remitters had the highest cortisol morning rise (1.1±1.5 h mmol/l), followed by the late remitters (0.8±1.8 h mmol/l), the non-remitters had the lowest cortisol morning rise (0.07±1.7 h mmol/l). Persistence of an anxiety disorder may thus lead to changes in HPA-axis functioning, underscoring the importance adequate treatment of anxiety disorders.

The relation of severity and comorbidity to treatment outcome with Cognitive Behavioral Therapy for childhood anxiety disorders.

The present study investigated the impact of comorbidity over and above the impact of symptom severity on treatment outcome of Cognitive Behavioral Therapy for children with anxiety disorders. Children (aged 8-12, n = 124) diagnosed with an anxiety disorder were treated with a short-term CBT protocol. Severity was assessed with a composite measure of parent-reported behavior problems. Two approaches to comorbidity were examined; "total comorbidity" which differentiated anxiety disordered children with (n = 69) or without (n = 55) a co-occurring disorder and "non-anxiety comorbidity' which differentiated anxious children with (n = 22) or without a non-anxiety comorbid disorder (n = 102). Treatment outcome was assessed in terms of Recovery, represented by post-treatment diagnostic status, and Reliable Change, a score reflecting changes in pre- to post-treatment symptom levels. Severity contributed to the prediction of (no) Recovery and (more) Reliable Change in parent-reported internalizing and externalizing symptoms and self-reported depressive symptoms. Total and non-anxiety comorbidity added to the prediction of diagnostic recovery. Non-anxiety comorbidity added to the prediction of Reliable Change in parent reported measures by acting as a suppressor variable. Non-anxiety comorbidity operated as a strong predictor that explained all of the variance associated with severity for self-reported depressive symptoms. The results support the need for further research on mechanisms by which treatment gains in children with higher symptom severity and non-anxiety comorbidity can be achieved.

Examining the relation between the therapeutic alliance, treatment adherence, and outcome of cognitive behavioral therapy for children with anxiety disorders.

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.

Threat-related selective attention predicts treatment success in childhood anxiety disorders.

OBJECTIVE: The present study examined whether threat-related selective attention was predictive of treatment success in children with anxiety disorders and whether age moderated this association. Specific components of selective attention were examined in treatment responders and nonresponders. METHOD: Participants consisted of 131 children with anxiety disorders (aged 8-16 years), who received standardized cognitive-behavioral therapy. At pretreatment, a pictorial dot-probe task was administered to assess selective attention. Both at pretreatment and posttreatment, diagnostic status of the children was evaluated with a semistructured clinical interview (the Anxiety Disorders Interview Schedule for Children). RESULTS: Selective attention for severely threatening pictures at pretreatment assessment was predictive of treatment success. Examination of the specific components of selective attention revealed that nonresponders showed difficulties to disengage their attention away from severe threat. Treatment responders showed a tendency not to engage their attention toward severe threat. Age was not associated with selective attention and treatment success. CONCLUSIONS: Threat-related selective attention is a significant predictor of treatment success in children with anxiety disorders. Clinically anxious children with difficulties disengaging their attention away from severe threat profit less from cognitive-behavioral therapy. For these children, additional training focused on learning to disengage attention away from anxiety-arousing stimuli may be beneficial.

Prevalence and correlates of psychopathology in a sample of deaf adolescents.

AIMS: To examine prevalence and correlates of psychopathology in deaf adolescents using a multi-method multi-informant approach. METHODS: Data for the study came from checklist assessments by parents (Child Behavior Checklist (CBCL)) and teachers (Teacher's Report Form (TRF)) of 70 deaf adolescents aged 13 to 21 years, from semi-structured clinical interviews of the adolescents (Semi-structured Clinical Interview for Children and Adolescents (SCICA)), and from expert ratings of dossier data. RESULTS: The percentages of Total Problems scores in the borderline clinical range in this population as found with the CBCL, TRF and SCICA are 28%, 32% and 49-63% respectively. Expert dossier ratings identified psychiatric caseness in 49% and DSM-classifications in 46% of the adolescents (primary classifications: emotional disorder 27%, behavioral disorder 11%, other disorder 7%). Cross-informant agreement between single ratings and expert dossier ratings was better than agreement between single ratings. Logistic regression analyses revealed that low IQ, a signing mode of communication and a history of three or more physical disorders were associated with psychiatric caseness. CONCLUSIONS: Findings suggest a high prevalence of psychopathology in the population studied and argue for a special focus on the early detection of significant emotional and behavioral problems as well as a multi-informant approach to the assessment of disorder in deaf children and adolescents. The correlational findings support the view that it is not deafness per se that contributes to psychiatric problems.

Dutch version of the Strengths and Difficulties Questionnaire (SDQ).

A Dutch translation of the Strengths and Difficulties Questionnaire (SDQ) was made. In the first wave of data collection, self-report data of 11- to 16-yearolds (N = 970) were collected on the SDQ and other measures of psychopathology. In the second wave of data collection, extended versions of the SDQ were completed by 11- to 16-year-olds (N = 268), by parents of 8- to 16-year-olds (N = 300) and by teachers of 8- to 12-year-olds (N = 208); in addition, the Child Behaviour Checklist (CBCL) was completed by the parents and the Youth Self Report (YSR) by the 11- to 16-year-olds. The results reveal that the internal consistency of the teacher SDQ is good; and the parent and self-report SDQ are generally acceptable and comparable with the internal consistencies of CBCL/YSR. The mean inter-informant product-moment correlations of the SDQ scales were satisfactory (parent-teacher 0.38; teacher-self-report 0.27; parent-self-report 0.35) and comparable with the mean inter-informant correlations of the CBCL and YSR (0.34). The inter-informant rank correlations of the impact questions were also satisfactory (mean parent-teacher 0.48; mean parent-self-report 0.24). Concurrent validity with the other measures of psychopathology used in the present study was good.

The Dutch Childhood Anxiety Sensitivity Index: psychometric properties and factor structure.

Examined the reliability, validity, and factor structure of the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991) in a Dutch sample. Five hundred forty-four Dutch schoolchildren between 8 and 16 years of age completed Dutch translations of the CASI; the State-Trait Anxiety Inventory for Children (Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973); and the Fear Survey Schedule for Children-Revised (Ollendick, 1983). The Dutch CASI was found to have adequate internal consistency for use with children as well as adolescents. Results reveal that the CASI predicted fear beyond a measure of trait anxiety in this Dutch sample. Both exploratory and confirmatory factor analyses comparing different models were undertaken. The model with 3 first-order factors found in previous studies showed an acceptable fit in this cross-validation sample. Loadings on the 3 factors (Physical Concerns, Mental Concerns, and Publicly Observable Concerns) did not differ between children and adolescents. Results are compared with previous research on the CASI. Directions for future research are discussed.

A developmental analysis of self-reported fears in late childhood through mid-adolescence: social-evaluative fears on the rise?

BACKGROUND: The frequently reported decline in the overall frequency and intensity of fears during late childhood and adolescence may mask different developmental patterns for two broad subclasses of fears: fears concerning physical danger and fears concerning social evaluation. It was investigated if physical fears decrease between late childhood and mid-adolescence, while social-evaluative fears increase during this period. It was also studied if changes in both sets of fears are more strongly related to socio-cognitive maturity than to age, which itself is only a proxy measure of maturity. METHODS: A non-clinical sample of 882 children and adolescents (ages 8-18) was recruited for study. Fears were assessed using the Ollendick Fear Survey Schedule for Children-Revised (FSSC-R). A Principal Components Analysis (PCA) was conducted to study the factor structure of the Failure and Criticism subscale of the FSSC-R. Level of development was assessed using the Sentence Completion Test for Youth (SCT-Y), a measure of socio-cognitive maturity that is based on Loevinger's model, and measure, of ego development. RESULTS: The PCA of the Failure and Criticism subscale revealed three factors: Social Evaluation, Achievement Evaluation, and Punishment. As predicted, the significant decrease of overall fearfulness obscured two contradictory developmental patterns: (a) fears of physical danger and punishment decreased with age, whereas (b) fears of social and achievement evaluation increased with age. Hierarchical regression analyses showed that the age effect for social-evaluative fears was explained entirely on the basis of developmental differences in socio-cognitive maturity (controlling for verbal ability). In contrast, age was a better predictor of the decrease of physical and punishment fears (although socio-cognitive maturity still added to the predictive value of age). CONCLUSION: The expression of social evaluation fears during adolescence appears not atypical and might be a corollary of socio-cognitive maturation. At the same time, the natural presence of those fears during adolescence appears to constitute a vulnerability for developing a social anxiety disorder.