Assessing Aspects of Social Relationships in Youth Across Middle Childhood and Adolescence: The NIH Toolbox Pediatric Social Relationship Scales.

OBJECTIVE: Social relationships are a critical context for children's socioemotional development and their quality is closely linked with concurrent and future physical and emotional wellbeing. However, brief self-report measures of social relationship quality that translate across middle childhood, adolescence, and adulthood are lacking, limiting the ability to assess the impact of social relationships on health outcomes over time. To address this gap, this article describes the development and testing of the National Institutes of Health (NIH) Toolbox Pediatric Social Relationship Scales, which were developed in parallel with the previously-reported Adult Social Relationship Scales. METHODS: Item sets were selected from the NIH Toolbox adult self-report item banks in the domains of social support, companionship, and social distress, and adapted for use in preadolescent (ages 8-11 years) and adolescent (ages 12-18 years) cohorts. Items were tested across a U.S. community sample of 1,038 youth ages 8-18 years. Classical test and item response theory approaches were used to identify items for inclusion in brief unidimensional scales. Concurrent validity was assessed by comparing resultant scales to established pediatric social relationship instruments. RESULTS: Internal reliability and concurrent validity were established for five unique scales, with 5-7 items each: Emotional Support, Friendship, Loneliness, Perceived Rejection, and Perceived Hostility. CONCLUSIONS: These brief scales represent developmentally appropriate and valid instruments for assessing the quality of youth social relationships across childhood and adolescence. In conjunction with previously published adult scales, they provide an opportunity for prospective assessment of social relationships across the developmental spectrum.

Emotion assessment using the NIH Toolbox.

One of the goals of the NIH Toolbox for Assessment of Neurological and Behavioral Function was to identify or develop brief measures of emotion for use in prospective epidemiologic and clinical research. Emotional health has significant links to physical health and exerts a powerful effect on perceptions of life quality. Based on an extensive literature review and expert input, the Emotion team identified 4 central subdomains: Negative Affect, Psychological Well-Being, Stress and Self-Efficacy, and Social Relationships. A subsequent psychometric review identified several existing self-report and proxy measures of these subdomains with measurement characteristics that met the NIH Toolbox criteria. In cases where adequate measures did not exist, robust item banks were developed to assess concepts of interest. A population-weighted sample was recruited by an online survey panel to provide initial item calibration and measure validation data. Participants aged 8 to 85 years completed self-report measures whereas parents/guardians responded for children aged 3 to 12 years. Data were analyzed using a combination of classic test theory and item response theory methods, yielding efficient measures of emotional health concepts. An overview of the development of the NIH Toolbox Emotion battery is presented along with preliminary results. Norming activities led to further refinement of the battery, thus enhancing the robustness of emotional health measurement for researchers using the NIH Toolbox.

Assessing social support, companionship, and distress: National Institute of Health (NIH) Toolbox Adult Social Relationship Scales.

OBJECTIVE: The quality of our daily social interactions-including perceptions of support, feelings of loneliness, and distress stemming from negative social exchanges-influence physical health and well-being. Despite the importance of social relationships, brief yet precise unidimensional scales that assess key aspects of social relationship quality are lacking. As part of the National Institute of Health (NIH) Toolbox for the Assessment of Neurological and Behavioral Function, we developed brief self-report scales designed to assess aspects of social support, companionship, and social distress across age cohorts. This article details the development and psychometric testing of the adult NIH Toolbox Social Relationship scales. METHODS: Social relationship concepts were selected, and item sets were developed and revised based on expert feedback and literature review. Items were then tested across a community-dwelling U.S. Internet panel sample of adults aged 18 and above (N = 692) using traditional (classic) psychometric methods and item response theory approaches to identify items for inclusion in 5-8 item unidimensional scales. Finally, concurrent validity of the newly developed scales was evaluated with respect to their interrelationships with classic social relationship validation instruments. RESULTS: Results provide support for the internal reliability and concurrent validity of resulting self-report scales assessing Emotional Support, Instrumental Support, Friendship, Loneliness, Perceived Rejection, and Perceived Hostility. CONCLUSION: These brief social relationship scales provide the pragmatic utility and enhanced precision needed to promote future epidemiological and social neuroscience research on the impact of social relationships on physical and emotional health outcomes.

Assessment of self-reported negative affect in the NIH Toolbox.

We report on the selection of self-report measures for inclusion in the NIH Toolbox that are suitable for assessing the full range of negative affect including sadness, fear, and anger. The Toolbox is intended to serve as a "core battery" of assessment tools for cognition, sensation, motor function, and emotional health that will help to overcome the lack of consistency in measures used across epidemiological, observational, and intervention studies. A secondary goal of the NIH Toolbox is the identification of measures that are flexible, efficient, and precise, an agenda best fulfilled by the use of item banks calibrated with models from item response theory (IRT) and suitable for adaptive testing. Results from a sample of 1763 respondents supported use of the adult and pediatric item banks for emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) as a starting point for capturing the full range of negative affect in healthy individuals. Content coverage for the adult Toolbox was also enhanced by the development of a scale for somatic arousal using items from the Mood and Anxiety Symptom Questionnaire (MASQ) and scales for hostility and physical aggression using items from the Buss-Perry Aggression Questionnaire (BPAQ).

Describing depression: congruence between patient experiences and clinical assessments.

OBJECTIVES: Efforts to describe depression have relied on top-down methods in which theory and clinical experience define depression but may not reflect the individuals' experiences with depression. We assessed the degree of overlap between academic descriptions of depression and patient-reported symptoms as conceptualized in the Patient-Reported Outcomes Measurement Information System(®) (PROMIS(®)). By extension, this work assesses the degree of overlap between current clinical descriptions of depression and patient-reported symptoms. DESIGN: In this content analysis study, four focus groups were conducted across two sites to elicit symptoms and the experience of depression from depressed and medically ill patients. METHODS: Depressed and medically ill patients were asked to describe symptoms that characterize depression. Data were transcribed and then coded using an a priori list of 43 facets of depression derived from extant depression measures. RESULTS: Participants described 93% of the symptoms from the a priori list, supporting the validity of current depression measures. Interpersonal difficulties were underscored as was anger. In general, results from the focus groups did not require the generation of new items for depression and supported the content validity of the PROMIS hierarchical framework and item pool created originally. CONCLUSIONS: This work supports the validity of current depression assessment, but suggests further investigation of interpersonal functioning and anger may add to the depth and breadth of depression assessment.

Content validity in the PROMIS social-health domain: a qualitative analysis of focus-group data.

PURPOSE: Our aim was to assess the content validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) social health item banks by comparing a prespecified conceptual model with concepts that focus-group participants identified as important social-health-related outcomes. These data will inform the process of improving health-related quality-of-life measures. METHODS: Twenty-five patients with a range of social limitations due to chronic health conditions were recruited at two sites; four focus groups were conducted. Raters independently classified participants' statements using a hierarchical, nested schema that included health-related outcomes, role performance, role satisfaction, family/friends, work, and leisure. RESULTS: Key themes that emerged were fulfilling both family and work responsibilities and the distinction between activities done out of responsibility versus enjoyment. Although focus-group participants identified volunteerism and pet ownership as important social-health-related concepts, these were not in our original conceptual model. The concept of satisfaction was often found to overlap with the concept of performance. CONCLUSION: Our conceptual model appears comprehensive but is being further refined to more appropriately (a) distinguish between responsibilities versus discretionary activities, and (b) situate the outcome of satisfaction as it relates to impairment in social and other domains of health.

Sudden gains in interpersonal psychotherapy for depression.

Sudden, precipitous improvements in depressive symptom severity have been identified as occurring among unipolar depressed individuals. These "sudden gains" have been associated with superior acute treatment outcome in several treatment modalities, including cognitive therapy. A better understanding of sudden gains may provide insight into the mechanisms of action in these and other psychotherapies. One efficacious therapy that has been overlooked in sudden gains research is interpersonal psychotherapy (IPT; Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). Comprehensive guide to interpersonal psychotherapy. New York: Basic Books). The present research examined the rates and concomitant features of sudden, precipitous improvements in depressive symptomotology among 185 women receiving IPT for recurrent depression. Sudden gains, defined using extant criteria for the Beck Depression Inventory, were assessed over 12 weeks of acute IPT treatment for depression and occurred for 33.5% of the sample. Sudden gains were not associated with diagnostic and demographic characteristics or with differential likelihood of achieving depression remission with IPT monotherapy during active treatment. Further, those with sudden gains were no more likely to maintain their recovery through maintenance treatment. The lack of impact of sudden gains on eventual outcome is discussed in terms of potentially disparate emphases and mechanisms of change between IPT and cognitive-behavioral therapy (CBT).

The relationship between beliefs about depression and coping strategies: gender differences.

OBJECTIVE: Leventhal's common-sense model of illness representation provides a conceptual framework for exploring the relationship between beliefs about depressive illness and use of coping strategies. We explored this relationship among depressed patients both across genders and in terms of gender differences. DESIGN: Depressed primary care patients prescribed antidepressants provided self-report measures of beliefs about depression, emotional reaction to depression, beliefs about medications and coping strategies used. Baseline data from a longitudinal study is presented. METHOD: Primary data analyses were conducted using canonical correlation analysis, a multivariate statistical method akin to principal component and regression analyses. It allows for parsimonious description of the association between two multivariate sets of variables (in this case, beliefs about depression and coping strategies) by identifying pairs of linear combinations that account for the majority of the between association from the two sets of variables. RESULTS: The sample consisted of 189 depressed primary care patients (70.4% female). Results indicated that emotional reaction to depression is a major factor in determining coping strategies. Greater emotional reaction to depression was associated with maladaptive coping for men and women, while women showed additional relationships between greater perceived control over depression and more adaptive coping techniques as well as between perception of consequences of depression and problem solving. CONCLUSIONS: The present research provides preliminary evidence that beliefs about depression are related to coping styles. Further, men and women may differ in the way in which their perceptions about depression influence coping styles adopted.

Non-treatment-related sudden gains in depression: the role of self-evaluation.

A number of studies have demonstrated that recovery from depression is often marked by precipitous improvements during the course of treatment. The present research examined sudden gains occurring outside of the context of treatment in a sample of college students with current major depressive disorder (n=60), and tested whether variables pertaining to cognitive style, hope, self-evaluation, and life events would be associated with these gains. Results indicated that 60% of the sample experienced sudden gains, with over half of those sudden gains reversing before the end of the 9-week observation period. Sudden gainers were significantly less depressed at the end of the observation period but were no more likely to have achieved remission compared to non-sudden gainers. Although changes in cognitive style did not precede sudden gains, individuals with sudden gains had significantly higher self-esteem at baseline compared to non-sudden gainers. Furthermore, decreases in the frequency of social comparison occurred in the week prior to sudden gains. These results suggest that sudden gains do occur outside of the context of treatment and that self-evaluation processes may play an important role in recovery from depression.

A prospective investigation of the impact of attachment style on stress generation among clinically depressed individuals.

The present study sought to determine if attachment style contributed to the generation of stressful life events among clinically depressed individuals during the course of treatment. Participants (N=68) were interviewed about life stressors experienced during a 3-month treatment protocol using a contextual approach (Life Events and Difficulties Schedule; [Brown, G. W., & Harris, T. O. (1978). Social origins of depression: A study of psychiatric disorder in women. New York: Free Press]). Results suggested interactive effects between severity of depression and attachment style on stress associated with future sociotropic and dependent life events. Mildly depressed individuals who reported a dismissing attachment style (higher levels of avoidant attachment and lower levels of anxious attachment) or preoccupied style (lower levels of avoidant attachment and higher levels of anxious attachment) experienced higher levels of stress associated with sociotropic events. Likewise, a dismissing attachment style predicted stress associated with dependent events among mildly depressed individuals. These effects were not present among our more severely depressed participants.

Sudden gains in cognitive behavioral treatment for depression: when do they occur and do they matter?

Despite the use of efficacious treatments for depression, individuals differ in both the degree to which they recover and the rate at which recovery occurs. Tang and colleagues found that depressed patients who had sudden improvements in their symptomatology not only maintained these gains, but also enjoyed more improvement and higher rates of recovery than those without sudden gains (J. Consulting Clin. Psychol. 67(6) (1999) 894; J. Consulting Clin. Psychol. 70(2) (2002) 444). Our study examined the role of sudden gains in a cognitive-behavioral group treatment for depression. Results indicated that 41.9% of patients experienced sudden gains. Furthermore, sudden gains occurring in the first third of treatment appear to have special importance. Participants enjoying early sudden gains had significantly larger changes in depressive symptom scores over the course of treatment than those without sudden gains and were marginally more likely to be treatment responders compared to those without early sudden gains. In contrast to Tang and DeRubeis (J. Consulting Clin. Psychol. 67(6) (1999) 894), however, sudden gains were not associated with cognitive changes.