Emerging Risk of Adolescent Depression and Suicide Detected Through Pediatric Primary Care Screening.

OBJECTIVE: The goal of the current study was to document patterns of stability and change in adolescent depression and suicide risk detected via universal depression screening in pediatric primary care and to determine who may go on to experience emerging risk. METHODS: Retrospective electronic health record information (sociodemographic data and depression screening results for 2 timepoints) was extracted for adolescents aged 12-17 who attended well-visits between November 15, 2017, and February 1, 2020, in a large pediatric primary care network. A total of 27,335 adolescents with 2 completed depression screeners were included in the current study. RESULTS: While most adolescents remained at low risk for depression and suicide across the 2 timepoints, others experienced emerging risk (i.e., low risk at time 1 but elevated risk at time 2), decreasing risk (i.e., high risk at time 1 but low risk at time 2) or stable high risk for depression or suicide. Odds of experiencing emerging depression and suicide risk were higher among adolescents who were female (compared to males), Black (compared to White), and had Medicaid insurance (compared to private insurance). Odds of experiencing emerging depression risk were also higher among older adolescents (compared to younger adolescents) as well as adolescents who identified as Hispanic/Latino (compared to non-Hispanic/Latino). CONCLUSIONS: Findings can inform symptom monitoring and opportunities for prevention in primary care.

Developmental trajectories of adolescent internalizing symptoms and parental responses to distress.

Parents' responses to their children's negative emotions are a central aspect of emotion socialization that have well-established associations with the development of psychopathology. Yet research is lacking on potential bidirectional associations between parental responses and youth symptoms that may unfold over time. Further, additional research is needed on sociocultural factors that may be related to the trajectories of these constructs. In this study, we examined associations between trajectories of parental responses to negative emotions and adolescent internalizing symptoms and the potential role of youth sex and racial identity. Adolescents and caregivers (N = 256) completed six assessments that spanned adolescent ages 13-18 years. Multivariate growth models revealed that adolescents with higher internalizing symptoms at baseline experienced increasingly non-supportive parental responses over time (punitive and distress responses). By contrast, parental responses did not predict initial levels of or changes in internalizing symptoms. Parents of Black youth reported higher minimization and emotion-focused responses and lower distress responses compared to parents of White youth. We found minimal evidence for sex differences in parental responses. Internalizing symptoms in early adolescence had enduring effects on parental responses to distress, suggesting that adolescents may play an active role in shaping their emotion socialization developmental context.

Parent-youth convergence (and divergence) in reports about pediatric quality of life.

PURPOSE: Researchers and service providers typically assess pediatric Health-Related Quality of Life (HRQOL) by collecting independent reports from parents and youth. An emerging body of work indicates that patterns of parent-youth reports yield information germane to understanding youth outcomes. We identified patterns of HRQOL among youth and their parents seeking mental health treatment and examined links between agreement patterns and mental and physical health functioning. METHODS: Participants included 227 youth (mean age = 14.40 years, SD = 2.42; 63% female) and parent dyads presenting at a mood disorders clinic between 2013 and 2020. We assessed HRQOL using parallel youth and parent forms of the Pediatric Quality of Life Inventory Generic Core Scales. We also assessed youth clinical correlates of depression, suicidal ideation, and impairment, as well as health information via electronic health record (e.g., psychotropic medication usage, BMI). RESULTS: Latent class analysis showed three parent-youth reporting patterns: Low-Low (LL), High-High (HH), and Parent Low-Youth High (PL-YH). Relative to youth in the HH group, youth in the LL and PL-YH groups reported significantly greater depressive symptoms and had higher rates of suicidal ideation and psychotropic medication use. In addition, youth in the LL group reported significantly greater levels of impairment. CONCLUSIONS: Parent-youth patterns of HRQOL reporting can reveal clinically meaningful information and indicate poorer functioning for certain groups (LL, PL-YH) of youth. These findings have implications for improving accuracy of risk assessments that leverage HRQOL data.

Personalized Depression Prevention Reduces Dependent Stressors Among Adolescents: Results from a Randomized Controlled Trial.

OBJECTIVE: Depression and stressors both increase during adolescence. The stress generation model posits that depression symptoms and associated impairment contribute to the generation of dependent stressors. Adolescent depression prevention programs have been shown to reduce the risk of depression. Recently, risk-informed personalization approaches have been adopted to enhance the efficacy of depression prevention, and preliminary evidence supports the beneficial effects of personalized prevention on depression symptoms. Given the close association between depression and stress, we examined the hypothesis that personalized depression prevention programs would reduce adolescents' experience of dependent stressors (interpersonal and non-interpersonal) over longitudinal follow-up. METHOD: The present study included 204 adolescents (56% girls, 29% racial minority) who were randomized to receive either a cognitive-behavioral or an interpersonal prevention program. Youth were categorized as high or low on cognitive and interpersonal risk using a previously established risk classification system. Half of the adolescents received a prevention program that matched their risk profile (e.g., high cognitive risk randomized to cognitive-behavioral prevention); half received a mismatched program (e.g., high interpersonal risk randomized to cognitive-behavioral prevention). Exposure to dependent and independent stressors was assessed repeatedly over an 18-month follow-up period. RESULTS: Matched adolescents reported fewer dependent stressors during the post-intervention follow-up period (d = .46, p = .002) and from baseline through 18-months post-intervention (d = .35, p = .02) compared to mismatched youth. As expected, there were no differences between matched and mismatched youth on the experience of independent stressors. CONCLUSIONS: These findings further highlight the potential of personalized approaches to depression prevention and demonstrate benefits that go beyond depression symptom reduction.

Depression Prevention in Pediatric Primary Care: Implementation and Outcomes of Interpersonal Psychotherapy-Adolescent Skills Training.

This study evaluated the fidelity, feasibility, acceptability, and preliminary outcomes of a depression prevention program, interpersonal psychotherapy-adolescent skills training (IPT-AST), in urban pediatric primary care (PC) with a sample of primarily Black youth. Twenty-two adolescents with elevated depressive symptoms participated in this open clinical trial. Adolescents were identified through a screening questionnaire completed at well visits. Ratings of IPT-AST fidelity and session attendance were recorded. Youth and caregivers reported on their attitudes toward the intervention and completed measures of adolescents' symptoms and functioning pre- and post-intervention. Results demonstrated high levels of fidelity, attendance, and acceptability, despite some difficulties with recruitment. Adolescents and caregivers reported significant improvements in functioning. There were marginally significant reductions in self-reported depression, anxiety, and total mental health symptoms. Caregivers reported a significant decrease in total mental health symptoms. Findings provide preliminary information regarding the implementation and effects of IPT-AST when delivered in PC.

Risk and Resilience Measures Related to Psychopathology in Youth.

Childhood adversity places youth at risk for multiple negative outcomes. The current study aimed to understand how a constellation of risk and resilience factors influenced mental health outcomes as a function of adversities: socioeconomic status (SES) and traumatic stressful events (TSEs). Specifically, we examined outcomes related to psychosis and mood disorders, as well as global clinical functioning. The current study is a longitudinal follow up of 140 participants from the Philadelphia Neurodevelopmental Cohort (PNC) assessed for adversities at Time 1 (Mean age: 14.11 years) and risk, resilience, and clinical outcomes at Time 2 (mean age: 21.54 years). In the context of TSE, a limited set of predictors emerged as important; a more diverse set of moderators emerged in the context of SES. Across adversities, social support was a unique predictor of psychosis spectrum diagnoses and global functioning; emotion dysregulation was an important predictor for mood diagnoses. The current findings underscore the importance of understanding effects of childhood adversity on maladaptive outcomes within a resilience framework.

Attachment and attitudes toward children: effects of security priming in parents and non-parents.

The present two-study investigation is the first to examine whether experimentally boosting attachment security (security priming) affects attitudes in the parenting domain for both parents and non-parents. Mothers (n = 72) and childless undergraduates (n = 82) were randomly assigned to a neutral or a secure prime condition and then completed measures of implicit attitudes (a child-focused version of the Go/No-Go Association Task) and explicit attitudes (self-reported) toward children. Following the priming manipulation, mothers in the secure prime condition had more positive implicit attitudes toward their child compared to mothers in the neutral prime condition. Security priming also increased mothers' positive explicit attitudes toward their children, but only among mothers who scored high on self-reported attachment-related avoidance. No priming effects emerged among non-parents. These results provide the first evidence for a causal link between parental attachment security and parental attitudes toward children.

Pathways linking attachment and depressive symptoms for Black and White adolescents: do race and neighborhood racism matter?

Decades of evidence demonstrate that insecure attachment is associated with increased risk for depressive symptoms. Yet research has focused on predominantly White samples, with little attention to whether developmental pathways vary by social-contextual factors like racial identity and neighborhood racism. This study examines whether longitudinal links between attachment style and depressive symptoms differ for White and Black American adolescents or by exposure to neighborhood racism (N = 171, Mage at Time 1 = 14 years). Multigroup measured variable path analyses controlling for gender and household income revealed that attachment avoidance predicted relative increases in depressive symptoms for White adolescents, but not for Black adolescents. Links between attachment style and depressive symptoms did not differ based on exposure to neighborhood racism. Experiences of neighborhood racism were associated with greater attachment avoidance but not anxiety. Results highlight the importance of examining attachment in different socioecological contexts to illuminate the unique pathways characterizing Black youth development.

The Depression Prevention Initiative: Trauma as a Moderator of Prevention Outcomes.

Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST) is an evidence-based indicated depression prevention program that has been shown to reduce depression symptoms. Research is needed to identify moderators of IPT-AST's effects. Although trauma history has emerged as a moderator of depression treatment outcomes, the impact of trauma on short- and long-term outcomes in the context of preventive interventions for adolescent depression is unknown. This study examines the impact of trauma on prevention outcomes in a school-based randomized controlled trial (RCT) in which 186 adolescents (mean age = 14.01 years, SD = 1.22; 67% female) were randomly assigned to IPT-AST delivered by research staff or group counseling (GC) provided by school counselors. Trauma history significantly moderated intervention outcomes during the active phase of the intervention, but not during long-term follow-up. During the active phase, youth in IPT-AST with low or no trauma exposure experienced significantly greater reductions in depression symptoms than youth in GC with low or no trauma exposure, but there were no significant differences in rates of change between the two interventions for youth with high or any trauma exposure. These findings highlight the importance of assessing trauma and investigating whether these interventions can be tailored or supplemented to enhance the effects for youth with trauma exposure.

Association between family history of suicide attempt and neurocognitive functioning in community youth.

BACKGROUND: Suicidal behavior is highly familial. Neurocognitive deficits have been proposed as an endophenotype for suicide risk that may contribute to the familial transmission of suicide. Yet, there is a lack of research on the neurocognitive functioning of first-degree biological relatives of suicide attempters. The aim of the present study is to conduct the largest investigation to date of neurocognitive functioning in community youth with a family history of a fatal or nonfatal suicide attempt (FH). METHODS: Participants aged 8-21 years from the Philadelphia Neurodevelopmental Cohort completed detailed clinical and neurocognitive evaluations. A subsample of 501 participants with a FH was matched to a comparison group of 3,006 participants without a family history of suicide attempt (no-FH) on age, sex, race, and lifetime depression. RESULTS: After adjusting for multiple comparisons and including relevant clinical and demographic covariates, youth with a FH had significantly lower executive function factor scores (F[1,3432] = 6.63, p = .010) and performed worse on individual tests of attention (F[1,3382] = 7.08, p = .008) and language reasoning (F[1,3387] = 5.12, p = .024) than no-FH youth. CONCLUSIONS: Youth with a FH show small differences in executive function, attention, and language reasoning compared to youth without a FH. Further research is warranted to investigate neurocognitive functioning as an endophenotype for suicide risk. Implications for the prevention and treatment of suicidal behaviors are discussed.

The Depression Prevention Initiative: Mediators of Interpersonal Psychotherapy-Adolescent Skills Training.

Several adolescent depression prevention programs have demonstrated effects on depressive symptoms and overall functioning. Yet, despite an increasing emphasis on elucidating mechanisms of change in interventions, few studies have identified mediators of these preventive interventions. In this study, we examined interpersonal mediators of Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST), an evidence-based depression prevention program. The Depression Prevention Initiative is a school-based randomized controlled trial in which 186 adolescents (M age = 14.01, SD = 1.22; 66.7% female; 32.2% racial minority) were assigned to receive either IPT-AST (n = 95) or Group Counseling (GC) (n = 91). We examined whether change in interpersonal conflict, social support, or social functioning from baseline to midintervention mediated the effects of IPT-AST on depressive symptoms and overall functioning at postintervention. At postintervention, youth in IPT-AST had lower depressive symptoms (d = -.31) and higher overall functioning scores (d = .32) than youth in GC. Improvements in adolescent romantic functioning, reductions in peer conflict, and improvements in a factor score reflecting mother-adolescent conflict and difficulties in family functioning emerged as significant mediators. However, the effects of the intervention on change in the mediators were not statistically significant. These findings add to the sparse literature on mediators of psychosocial interventions, provide partial support for the theoretical mechanisms underlying change in IPT-AST, and highlight important directions for future prevention and intervention research.

Mothers' Attachment Style as a Predictor of Breastfeeding and Room-Sharing Practices.

OBJECTIVE: To prospectively assess breastfeeding and room-sharing practices during the infant's first 6 months and investigate whether mothers' own adult attachment style predicts the initiation and course of these recommended parenting behaviors. METHOD: This study included 193 mother-infant dyads living in the Netherlands. Diary methodology was used to generate 27 weekly measures of breastfeeding and room-sharing during the infant's first 6 months. Multilevel mixed effects models were used to examine trajectories of breastfeeding and room-sharing and to test whether mothers' own adult attachment style predicted the initiation and course of these behaviors, adjusting for covariates. RESULTS: Most (86%) mothers initiated breastfeeding immediately after birth and the rates of breastfeeding declined steadily over the 6 months (b = -2.47, SE = 0.19, p < .001). Mothers with higher attachment avoidance showed faster decreases in breastfeeding than less avoidant mothers (b = -1.07, SE = 0.21, p < .001). Sixty-four percent of mothers engaged in room-sharing after birth which also decreased steadily over the 6 months (b = -3.51, SE = 0.21, p < .001). Mothers' attachment style did not predict the initiation or course of room-sharing. CONCLUSIONS: Given the major implications of breastfeeding and room-sharing for infants' health, safety, and development, the pediatrics community has issued clear guidelines encouraging these behaviors. Yet many new parents do not adhere to the recommended practices. This study identifies mothers' adult attachment style as a predictor of breastfeeding over time that could be incorporated into interventions for parents.

Neurocognitive functioning in community youth with suicidal ideation: gender and pubertal effects.

BACKGROUND: Although there are extensive data on clinical psychopathology in youth with suicidal ideation, data are lacking regarding their neurocognitive function. AIMS: To characterise the cognitive profile of youth with suicidal ideation in a community sample and evaluate gender differences and pubertal status effects. METHOD: Participants (N = 6151, age 11-21 years, 54.9% females) from the Philadelphia Neurodevelopmental Cohort, a non-help-seeking community sample, underwent detailed clinical evaluation. Cognitive phenotyping included executive functioning, episodic memory, complex reasoning and social cognitive functioning. We compared participants with suicidal ideation (N = 672) and without suicidal ideation (N = 5479). Regression models were employed to evaluate differences in cognitive performance and functional level, with gender and pubertal status as independent variables. Models controlled for lifetime depression or general psychopathology, and for covariates including age and socioeconomic status. RESULTS: Youth with suicidal ideation showed greater psychopathology, poorer level of function but better overall neurocognitive performance. Greater functional impairment was observed in females with suicidal ideation (suicidal ideation × gender interaction, t = 3.091, P = 0.002). Greater neurocognition was associated with suicidal ideation post-puberty (suicidal ideation × puberty interaction, t = 3.057, P = 0.002). Exploratory analyses of specific neurocognitive domains showed that suicidal ideation-associated cognitive superiority was more prominent in post-pubertal males compared with females (Cohen's d = 0.32 and d = 0.11, respectively) across all cognitive domains. CONCLUSIONS: Suicidal ideation was associated with poorer functioning yet better cognitive performance, especially in post-pubertal males, as measured by a comprehensive cognitive battery. Findings point to gender and pubertal-status specificity in the relationship between suicidal ideation, cognition and function in youth. DECLARATION OF INTEREST: R.B. serves on the scientific board and reports stock ownership in 'Taliaz Health', with no conflict of interest relevant to this work. M.A.O. receives royalties for the commercial use of the Columbia-Suicide Severity Rating Scale from the Research Foundation for Mental Hygiene. Her family owns stock in Bristol-Myers Squibb. All other authors declare no potential conflict of interest.

Association between traumatic stress load, psychopathology, and cognition in the Philadelphia Neurodevelopmental Cohort.

BACKGROUND: Traumatic stressors during childhood and adolescence are associated with psychopathology, mostly studied in the context of post-traumatic stress disorder (PTSD) and depression. We investigated broader associations of traumatic stress exposure with psychopathology and cognition in a youth community sample. METHODS: The Philadelphia Neurodevelopmental Cohort (N = 9498) is an investigation of clinical and neurobehavioral phenotypes in a diverse (56% Caucasian, 33% African American, 11% other) US youth community population (aged 8-21). Participants were ascertained through children's hospital pediatric (not psychiatric) healthcare network in 2009-2011. Structured psychiatric evaluation included screening for lifetime exposure to traumatic stressors, and a neurocognitive battery was administered. RESULTS: Exposure rate to traumatic stressful events was high (none, N = 5204; one, N = 2182; two, N = 1092; three or more, N = 830). Higher stress load was associated with increased psychopathology across all clinical domains evaluated: mood/anxiety (standardized ß = .378); psychosis spectrum (ß = .360); externalizing behaviors (ß = .311); and fear (ß = .256) (controlling for covariates, all p < 0.001). Associations remained significant controlling for lifetime PTSD and depression. Exposure to high-stress load was robustly associated with suicidal ideation and cannabis use (odds ratio compared with non-exposed 5.3 and 3.2, respectively, both p < 0.001). Among youths who experienced traumatic stress (N = 4104), history of assaultive trauma was associated with greater psychopathology and, in males, vulnerability to psychosis and externalizing symptoms. Stress load was negatively associated with performance on executive functioning, complex reasoning, and social cognition. CONCLUSIONS: Traumatic stress exposure in community non-psychiatric help-seeking youth is substantial, and is associated with more severe psychopathology and neurocognitive deficits across domains, beyond PTSD and depression.

Long-Term Effects from a School-Based Trial Comparing Interpersonal Psychotherapy-Adolescent Skills Training to Group Counseling.

Adolescence represents a vulnerable developmental period for depression and an opportune time for prevention efforts. In this study, 186 adolescents with elevated depressive symptoms (M age = 14.01, SD = 1.22; 66.7% female; 32.2% racial minority) were randomized to receive either Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST; n = 95) delivered by research clinicians or group counseling (GC; n = 91) delivered by school counselors. We previously reported the short-term outcomes of this school-based randomized controlled trial: IPT-AST youth experienced significantly greater improvements in depressive symptoms and overall functioning through 6-month follow-up. Here, we present the long-term outcomes through 24 months postintervention. We examined differences in rates of change in depressive symptoms and overall functioning and differences in rates of depression diagnoses. Youth in both conditions showed significant improvements in depressive symptoms and overall functioning from baseline to 24-month follow-up, demonstrating the efficacy of school-based depression prevention programs. However, the two groups did not differ in overall rates of change or in rates of depression diagnoses from baseline to 24-month follow-up. Although IPT-AST demonstrated advantages over GC in the short term, these effects dissipated over long-term follow-up. Specifically, from 6- to 24-month follow-up, GC youth showed continued decreases in depressive symptoms, whereas IPT-AST youth showed a nonsignificant increase in symptoms. GC youth remained relatively stable in overall functioning, whereas IPT-AST youth experienced a small but statistically significant worsening in functioning. This study highlights the potential of school-based depression prevention efforts and the need for further research.

Stability of Attachment Style in Adolescence: An Empirical Test of Alternative Developmental Processes.

Few studies have examined stability and change in attachment during adolescence. This 5-year longitudinal study (a) examined whether prototype or revisionist developmental dynamics better characterized patterns of stability and change in adolescent attachment (at T1, N = 176; Mage  = 14.0 years, SD = 0.9), (b) tested potential moderators of prototype-like attachment stability, and (c) compared attachment stability in adolescence to stability in adulthood. The results supported the prototype model, which assumes that there is a stable, enduring factor underlying stability and change in attachment. Exploratory moderation analyses revealed that family conflict, parental separation or divorce, minority status, and male sex might undermine the prototype-like stability of adolescent attachment. Stability of attachment was lower in adolescence relative to adulthood.

Perceptions of parental secure base support in African American adolescents and young adults: A preliminary study of predictive links to adult C-reactive protein.

Within the field of relationship science there is increasing interest in the connections between close relationships and physical health. In the present study, we examined whether adolescents' (~12 years old) and young adults' (~20 years old) perceptions of their parents as a secure base prospectively predict C-reactive protein (CRP), a commonly used marker of inflammatory activity, at age 32 in a well-characterized sample of African Americans. We utilized existing data collected as part of the Maryland Adolescent Development in Context Study (MADICS) to construct measures of perceptions of parental secure base support (SBS), general parental support, and peer support in early adolescence and early adulthood. In the present study, SBS was operationalized as the perceived ability to depend on parents in times of need. Fifty-nine African American MADICS participants who reported on perceived support in early adolescence and early adulthood participated in a follow-up home visit at age 32 during which serum CRP was measured via a blood draw. After controlling for inflammation-related confounds (e.g., tobacco use, body mass index), adolescents' perceptions of parental SBS, but not peer support or general parental support, predicted lower CRP values at age 32 (b = -.92, SE = .34, p < .05). None of the support variables in early adulthood predicted CRP at 32 years. This study adds to a growing literature on relationships and health-related outcomes and provides the first evidence for a link between parental SBS in adolescence and a marker of inflammatory activity in adulthood.

Parents' self-reported attachment styles: a review of links with parenting behaviors, emotions, and cognitions.

For decades, attachment scholars have been investigating how parents' adult attachment orientations relate to the ways in which they parent. Traditionally, this research has been conducted by developmental and clinical psychologists who typically employ the Adult Attachment Interview (AAI) to measure adult attachment. However, dating back to the mid-1990s, social and personality psychologists have been investigating how self-reported adult attachment styles relate to various facets of parenting. The literature on self-reported attachment and parenting has received less attention than AAI research on the same topic and, to date, there is no comprehensive review of this literature. In this article, we review more than 60 studies of the links between self-reported attachment styles and parenting, integrate the findings to reach general conclusions, discuss unresolved questions, and suggest future directions. Finally, we discuss the potential benefits to the study of parenting of collaborations among researchers from the developmental and social attachment research traditions.

Attachment-related biases in adolescents' memory.

Attachment theorists propose that individuals' internal working models influence their social information processing. This study explored links between attachment representations and social information processing by examining adolescents' (n = 189; Mage  = 16.5 years) attachment-related memory biases. Participants completed laboratory tasks assessing memory for (a) emotionally salient childhood events, (b) adjectives describing their parents, and (c) generalized parent-related characteristics not specific to their own parents. As expected, dismissing attachment (assessed using the Adult Attachment Interview) was linked across tasks to a deactivating strategy in which memory for emotional childhood events and attachment-relevant stimuli was reduced. In contrast, evidence that preoccupied attachment was linked to a hyperactivating strategy in which memory was heightened emerged only in relation to emotional childhood events.

Parental attachment style: examination of links with parent secure base provision and adolescent secure base use.

The secure base construct represents one of attachment theory's most important contributions to our understanding of parent-child relationships and child development. The present study represents the first examination of how parents' self-reported attachment styles relate to parental secure base provision and adolescent (mean age = 16.6 years, SE = .59) secure base use during an observed parent-adolescent interaction. Further, the present study is the first to examine how fathers', as well as mothers', attachment styles relate to observed behavior in a parent-child interaction. At the bivariate level, maternal avoidance, but not anxiety, was negatively associated with observed adolescent secure base use. In addition, path analysis revealed that maternal avoidance was indirectly related to less adolescent secure base use through mothers' self-reported hostile behavior toward their adolescents and through adolescents' less positive perceptions of their mothers. Further, paternal anxiety, but not avoidance, was indirectly related to less adolescent secure base use through fathers' self-reported hostile behavior toward their adolescents. No significant findings emerged in relation to parental secure base provision. We discuss these results in the context of attachment theory and suggest directions for future research.