Posttraumatic stress disorder symptom clusters, suicidal ideation, and social support in a clinical adolescent sample.

Posttraumatic stress disorder (PTSD) is a risk factor for adolescent suicidal ideation (SI). This study explored the relation between PTSD symptom clusters and SI, and whether social support moderates this association, in a cross-sectional, adolescent, clinical sample (N = 125). We hypothesized that each cluster would be positively associated with SI severity and that social support would buffer these associations. Only the persistent avoidance cluster was significantly associated with SI severity. Further, social support moderated this association. Results highlight the positive association between persistent avoidance symptoms of PTSD and SI and suggest that bolstering social support serves a protective function.

Sexual Identity and its Association with Trajectories of Depressive Symptoms and Emotion Regulation Difficulties from Early to Middle Adolescence.

Few studies have examined how changes in sexual identity impact trajectories of depressive symptoms and emotion regulation difficulties. The current study addresses this gap in the literature by examining these associations over a three-year period in a community sample of adolescents (N = 177; Mage = 12.56; SD = 0.60; nmale = 95). Multilevel modeling revealed that youth who consistently held sexual minority identities from early to middle adolescence-but not youth with inconsistent sexual identity-demonstrated increases in depressive symptoms and emotion regulation difficulties relative to their heterosexual peers. Findings suggest that treatments that bolster emotion regulation abilities and address depressive symptoms may be of particular benefit to youth with consistent sexual minority identities from early to middle adolescence.

Adolescent depressed mood and difficulties with emotion regulation: Concurrent trajectories of change.

INTRODUCTION: Adolescent depression is a significant mental health concern. Emotion regulation difficulties have been associated with subsequent depressive symptoms, though different facets of emotion regulation are rarely compared. This study examined the degree to which trajectories of change in different facets of emotion regulation (goal-directed behavior, impulse control, and regulation strategies) and depressive symptoms were associated across twelve months in a clinical adolescent sample. METHODS: Participants included 110 adolescents from the US who were enrolled in a randomized trial that tested a cognitive-behavioral treatment for youth with co-occurring mental health and substance use concerns (Mage = 15.71 years; 57.3% male). Assessments were conducted at baseline, 3-, 6-, and 12-month follow-ups. Three separate bivariate latent basis growth curve analyses were conducted. Correlations between latent intercepts and latent slopes, as well as overall model fit, were examined. RESULTS: Impulse control and goal-directed behavior were each associated with depressive symptoms at baseline. Additionally, change in impulse control over time was significantly associated with change in depressive symptoms. However, the same was not true for goal-directed behavior. Overall fit indices for models of emotion regulation strategies were below acceptable levels and thus could not be interpreted. CONCLUSIONS: Findings from the present study indicate that adolescents' depressive symptoms appear to improve as their perceived ability to control impulses improves. These results suggest that addressing impulse control difficulties may be an important step in treating adolescent depression and co-occurring disorders.

Depression-related emotional problems mediate the relation between hopelessness and suicidal ideation severity.

OBJECTIVE: Cross-sectional research with adult samples suggests that hopelessness may indirectly affect suicidal ideation (SI) through overall depressive symptom severity. However, particular depressive symptom constellations, rather than overall symptoms, may underlie the association between hopelessness and SI. Yet, the cross-sectional nature of these studies precludes examination of the temporal associations among these constructs. METHODS: Using path analysis, the present study examined whether depression-related emotional problems mediate the relation between hopelessness and SI in a clinical sample of 110 adolescents over a 6-month period. The specificity of depression-related emotional problems as a mediator was also evaluated. RESULTS: After accounting for covariates, results supported the specificity of 3-month depression-related emotional problems as a mediator of the association between baseline levels of hopelessness and 6-month SI. CONCLUSION: Results suggest that treatment targeted specifically at hopelessness may help reduce depression-related emotional problems and lower SI, and ultimately, adolescent suicide risk.

Parent-adolescent relationship characteristics and adolescent cannabis use: A growth curve analysis.

Background: Adolescent cannabis misuse may be associated with serious academic, conduct, and health problems. Identifying factors associated with adolescent cannabis misuse over time may provide insight to address these factors in interventions. Parent-adolescent relationship characteristics (i.e., attachment, discipline) have been linked to adolescent cannabis misuse and may be important factors to study. Objectives: We investigated time-varying associations between parent-adolescent relationship domains and weekly adolescent-reported cannabis misuse. We hypothesized that during times when parents reported less positive aspects of their relationship with their adolescents, adolescents would report higher levels of cannabis misuse. Methods: Data were drawn from a community clinic treatment study for adolescents with substance use and co-occurring psychiatric disorders (n=110; average age=15.71; 57.3% male). Latent growth modeling with time-varying predictors (parent-adolescent relationship characteristics) was used to examine if the associations between adolescent cannabis misuse and relational frustration, discipline, and attachment varied across the study period (baseline, 3-, 6-, and 12-months). Results: Weekly cannabis misuse significantly increased over time, even after accounting for parental relationship characteristics. When parents rated higher levels of relational frustration relative to their average level of frustration, adolescents reported higher cannabis misuse at all study periods except 12-month follow-up. Conclusion: Results support the importance of considering how specific aspects of the parentadolescent relationship, in this case elevated parental frustration, are associated with adolescent cannabis misuse during treatment and after its completion. Findings suggest parental relationship frustration is a key factor to assess and address within individually tailored interventions for co-occurring cannabis misuse and psychiatric disorders.

Cannabis Use and Emotional Awareness Difficulties in Adolescents with Co-Occurring Substance Use and Psychiatric Disorders.

Background: Assessing predictors of cannabis use following adolescent substance use treatment may inform essential treatment elements to be emphasized before discharge. Adolescents with low emotional awareness may have limited resources for identifying and overcoming negative emotions, and therefore, use cannabis to regulate emotions. Purpose/objectives: The purpose of this study was to test the hypothesis that emotional awareness difficulties are associated with increased cannabis use across the transition out of substance use treatment. This hypothesis was investigated by applying an autoregressive random-intercept cross-lagged panel-modeling framework to test the fit of alternative models and inform hypotheses about directional associations between cannabis use and emotional awareness difficulties over time. Methods: Participants were 110 adolescents with co-occurring disorders and their families participating in an intensive home-based treatment trial. Adolescents reported on past 7-day cannabis use and difficulties in emotional awareness at baseline and three follow-up assessments across 12 months. Results: At baseline, 54% of the sample reported past-week cannabis use. A directional effect was supported such that difficulties with emotional awareness at 3 months' post-baseline, which corresponded to the approximate end of the treatment program, were associated with increased cannabis use at 6 months' post-baseline, controlling for the stability of cannabis use, and emotional awareness over time. Cannabis use, however, was not associated with subsequent difficulties in emotional awareness (i.e., effects in the opposite direction were not supported). Conclusions/Importance: Emotional awareness difficulties toward the end of a course of intensive outpatient treatment may be associated with increased cannabis use after the completion of treatment.

Alcohol misuse among adolescents with BPD symptoms: exploring the moderating role of reasons for drinking and perceived coping skills in a clinical adolescent sample.

BACKGROUND: Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. The current study explores factors that may impact risk for alcohol misuse among youth with BPD symptoms: using alcohol to self-medicate or to rebel and perceived coping skills. METHOD: A sample of 181 psychiatrically hospitalized adolescents (Mage  = 15.04 years, SD = 1.31 years; 71.8% female, 83.4% White) was recruited as part of a larger study from the northeastern United States. Assessments and diagnostic interviews were administered to adolescents. RESULTS: Use of alcohol for self-medication and perceived coping skills, but not using alcohol for rebellion, moderated the relationship between BPD symptoms and alcohol misuse. A significant positive relationship between BPD symptoms and alcohol frequency and/or problems was only found among adolescents who reported lower use of alcohol for self-medication purposes or higher perceived coping skills. CONCLUSIONS: Youth with more BPD symptoms are at high risk for alcohol misuse. Moderation effects for self-medication motives and perceived coping skills were counter to hypotheses; lower levels of self-medication motives contributed to greater alcohol problems, as did higher levels of perceived coping skills. Results suggest the importance of assessing how much youth are drinking or experiencing consequences, as well as why they are using alcohol. It is possible adolescents with more BPD symptoms may be reporting more coping skills, but actually exhibiting the phenomenon of apparent competence (i.e., present as 'in control', but actually experiencing extreme distress and lacking sufficient coping skills); collateral reports of adolescents' coping skills may provide a more objective measure of actual skill level. KEY PRACTITIONER MESSAGE: What is known? Adolescents who experience symptoms of borderline personality disorder (BPD) are at high risk for alcohol misuse, yet little is known about why these adolescents drink and what factors heighten or mitigate this risk. What is new? Adolescents who use alcohol to self-medicate or rebel are at high risk for alcohol problems, regardless of presence of BPD symptoms. Contrary to expectations, higher perceived coping skills strengthened the relation between BPD and alcohol misuse. Apparent competence (i.e., present as 'in control' but lack sufficient skills) may be at play. What is significant for clinical practice? Clinicians are encouraged to assess why adolescents are using alcohol and teach alternative coping strategies when self-medication and/or rebellion is an identified use. Clinicians are encouraged to collect collateral reports of adolescent's coping abilities rather than relying solely on self-report.

Family-focused cognitive behavioral treatment for depressed adolescents in suicidal crisis with co-occurring risk factors: a randomized trial.

BACKGROUND: Suicide is the second leading cause of death among adolescents. The purpose of this study was to test a family-focused outpatient cognitive behavioral treatment (F-CBT) protocol for depressed adolescents following psychiatric hospitalization for a suicide attempt or suicidal ideation, and who had a co-occurring risk factor (suicidal behavior prior to the index admission, nonsuicidal self-injury, and/or a substance use disorder), in a randomized Phase 2 efficacy trial. METHOD: One hundred forty-seven adolescents (mean age = 14.91 years; 76.2% female, 85.5% White) and their families, recruited primarily from an inpatient psychiatric hospitalization program, were randomly assigned to F-CBT or enhanced treatment-as-usual (E-TAU). A suicide attempt was the primary outcome variable. Depression, suicidal ideation, and nonsuicidal self-injury are also reported here. Assessments were completed at pretreatment as well as 6, 12, and 18-months postrandomization (Trial Registration ClinicalTrials.gov Identifier: NCT01732601). RESULTS: In the sample as a whole, rates of attempts decreased from 20% at 6 months to 9% at 12 months to 7% at 18 months. There was no evidence of a significant difference between treatment arms in rates of suicide attempts, major depressive disorder, suicidal ideation, or nonsuicidal self-injury at any of the postrandomization assessment points. CONCLUSIONS: Though F-CBT was associated with reductions in suicidality, depression, and nonsuicidal self-injury, E-TAU showed an equally strong effect. Greater frequency of F-CBT treatment sessions, particularly at the start of care, and alternative approaches to transitioning to care at 12 months, may be necessary when using F-CBT with this population.

Is the focus of community-based mental health treatment consistent with adolescent psychiatric diagnoses?

Most adolescents do not receive effective mental health services. This may stem in part from infrequent use of evidence-based and multi-informant diagnostic assessments to guide clinical care. The primary purpose of the present study was to examine whether adolescent mental health diagnoses and suicidality, derived via evidence-based diagnostic interviews and assessments, correspond with reported "reason for treatment" received by adolescents. Secondarily, we examined the potential association between socio-economic status and the match between youth diagnoses and reasons for treatment. The influence of parent-adolescent agreement on diagnoses and reasons for treatment on findings was also explored. Using chi-square analyses, a significant association was found between youth diagnoses of mood disorders, disruptive behavior disorders, and suicidality, respectively, and a focus of treatment on these conditions per combined parent-adolescent report. The same was not true for youth anxiety, attention-deficit hyperactivity, or substance abuse disorders. Results of exploratory analyses suggest that these results are driven by adolescent, but not parent report. With regard to socio-economic status, there was a trend for those with higher incomes to report a treatment focus consistent with youth diagnoses, per combined parent-adolescent report. Results suggest that focus of mental health treatment received by adolescents in standard community-based care may not uniformly address all current disorders. Efforts are needed to disseminate multi-informant evidence-based assessments to enhance the quality and effectiveness of care.

Mental Health Symptoms and Delinquency among Court-Involved Youth Referred for Treatment.

Youth involved in the justice system meet criteria for psychiatric disorders at much higher rates than youth in the general population and a large body of research has established a relationship between mental health problems and delinquency or recidivism. However, only limited research has examined the relationship between specific types of psychopathology and specific patterns or types of delinquency for justice-involved youth and only a single study has explored the relationship between psychopathology and delinquency among youth with psychiatric diagnoses receiving mental health treatment. We examined the relationship between severity of offending and internalizing and externalizing symptoms among court-involved, non-incarcerated youth referred for mental health treatment. Over half of youth and over two-thirds of parents reported youth symptomatology at the 93rd percentile or above for internalizing symptoms, externalizing symptoms, or both. We found that youth engaged in serious or violent delinquency are more likely to have externalizing problems but that internalizing symptoms were equally high across youth committing minor, moderate, and serious delinquent acts. Findings from this study support the need for future research exploring the nuances of relationships between psychiatric disorder and patterns of delinquency, which can provide helpful information to justice system stakeholders in identifying youth needs.

The role of family functioning in parenting practices of court-involved youth.

Court-involved youth engage in risky sex behaviors at higher rates than non-offending peers and are at particular risk for adverse sexual health outcomes. Parenting practices, such as parent-child sexual communication and parental monitoring, may protect court-involved youth from engaging in risky sexual behavior. Parent psychological distress and family dysfunction may, however, compromise parenting practices for court-involved youth. This study examined associations among parent mental health symptoms, family functioning, and parenting practices within 157 parent-youth dyads who were court-referred for mental health treatment. Results revealed that greater parent mental health symptoms were directly related to greater family dysfunction and indirectly associated with poorer parental monitoring through worse family functioning. Findings suggest that directly addressing parent mental health needs in family-based adolescent sexual health programming for court-involved youth may be effective in improving parent-child relationships and family processes that support long term sexual health outcomes for adolescents.

A brief peer gatekeeper suicide prevention training: Results of an open pilot trial.

OBJECTIVE: The purpose of the present study was to test a 1-hour peer suicide gatekeeper training for students from the broad college community in the context of an open pilot trial. METHOD: Two-hundred and thirty-one college students were recruited university-wide, Mage  = 20.7, 65.4% female, and completed a peer suicide prevention gatekeeping training program. Assessments were completed at pre-training and post-training as well as 3-month follow-up. RESULTS: This brief peer suicide gatekeeper training program was associated with increases in suicide prevention knowledge. It was also associated with an increase in the number of students who identified suicidal youth and made mental health referrals, as well as total number of referrals made, over the course of three months. Females reported greater improvement in suicide prevention skills and knowledge post-training than males. CONCLUSIONS: Offering peer suicide gatekeeper training to students from the general college population may hold promise in suicide prevention efforts.

Effects of Cognitive Distortions on the Link Between Dating Violence Exposure and Substance Problems in Clinically Hospitalized Youth.

PURPOSE: The purpose of the present study was to examine whether cognitive distortions (e.g., cognitive errors; negative views of self, world, and future) influence the association between dating violence and problematic substance use behaviors in a sample of psychiatrically hospitalized adolescents. METHOD: Participants included 155 adolescents, aged 13-17 years, who had initiated dating. Adolescents completed measures of dating violence, substance-related problems (alcohol and marijuana), and cognitive distortions. RESULTS: Logistic regressions were conducted to examine the direct and interactive effects of dating violence exposure and cognitive distortions on likelihood of recent problematic substance use. Results suggested a main effect of dating violence on problematic alcohol and other drug use as well as an interactive effect of dating violence and cognitive distortions. Specifically, the relationship between dating violence and odds of substance-related problems was higher among those with greater (vs. fewer) cognitive distortions. CONCLUSION: Study results suggest the need for careful screening of cognitive distortions among adolescent dating violence victims, particularly those in mental health treatment.

Dopamine D4 receptor VNTR polymorphism associated with greater risk for substance abuse among adolescents with disruptive behavior disorders: Preliminary results.

BACKGROUND AND OBJECTIVES: The variable number tandem repeats (VNTR) polymorphism of the dopamine D4 receptor gene (DRD4) has received considerable attention as a potential genetic contributor to addiction. However, is unclear whether the polymorphism is involved in developing general traits that lead to risky behavior or an intermediate phenotype more specific to substance use disorders. Association studies have produced equivocal results. To control for potential confounds, the present study examined whether the long variant of the DRD4 VNTR polymorphism (DRD4L) is associated with greater substance misuse in a homogenous clinical sample of youth with a disruptive behavior disorder (DBD). METHODS: Fifty-one psychiatrically hospitalized adolescents (mean age = 14.86 years) with a DBD diagnosis were recruited as part of a larger study. Participants provided saliva samples for genotyping procedures after completing a diagnostic interview and an assessment battery. RESULTS: The odds of a substance use disorder diagnosis were significantly greater among DRD4L than DRD4S carriers (OR = 5.20, 95%CI:1.42-19.04, p = .01). Relative to DRD4S homozygotes, DRD4L carriers also reported greater marijuana use (t = -2.68, p = .01) and hard drug use (t = -2.26, p = .03). DISCUSSION AND CONCLUSIONS: Although adolescents with DBDs are already at heightened risk for substance misuse, the present findings suggest that DRD4L further increases those odds. SCIENTIFIC SIGNIFICANCE: As differences persisted even among a psychiatrically homogenous sample of impulsive and risk-prone adolescents, the present findings suggest that DRD4L may be involved in the development of an intermediate phenotype specific to substance abuse (eg, cue-elicited craving).

The effect of parental monitoring on trajectories of disordered eating attitudes and behaviors among adolescents: An individual growth curve analysis.

The primary aim of the present study was to examine whether parental monitoring, as reported by adolescents and their parents, predicts more or less favorable trajectories of disordered eating behavior and attitudes over the course of one year in a sample of adolescent males and females. An additional aim was to explore whether these trajectories vary when study analyses are limited to females. Participants included 87 adolescents (mean age = 15.5 ± 1.4) in mental health treatment and their parents. Self-report measures included the Parental Monitoring Questionnaire, completed at baseline, and the Eating Attitudes Test-Dieting Subscale, completed at baseline as well as 6-month and 12-month follow-ups. Individual growth curve (IGC) analyses were used to examine change in disordered eating behavior and attitudes. Adolescents who reported lower parental monitoring showed trajectories characterized by increases in disordered eating attitudes and behaviors. The same pattern emerged when using parent report of monitoring, though only a trend was evident. When analyses were restricted to females, the main effect of parental and adolescent report of monitoring on disordered eating were equally strong. Results may suggest that parents who are less knowledgeable about their adolescents' daily lives, may be less aware of potential disordered eating attitudes and behaviors, and thus less likely to intervene. Findings could be used to inform family-based interventions for this population.

The effects of parental mental health and social-emotional coping on adolescent eating disorder attitudes and behaviors.

This study examined whether social-emotional coping skills moderate the association between parental mental health symptoms and adolescent disordered eating attitudes and behaviors in a clinical sample of adolescents with internalizing and/or externalizing symptoms. Fifty-nine adolescent-parent dyads (N = 118 total participants) recruited from a metropolitan area in the Northeastern United States completed assessments at baseline and 12-month follow-up. Generally, higher parental depression and anxiety were only found to be associated with greater disordered eating attitudes and behaviors among adolescents who reported poorer (versus stronger) emotional awareness/expression skills and less (versus greater) ability to regulate emotions. Results may suggest that adolescents who lack the ability to effectively recognize, express, and manage negative emotions that arise in the context of a challenging home environment may be at greater risk for engaging in maladaptive coping behaviors, such as disordered eating. Thus, bolstering adolescent social-emotional coping skills may help protect against adolescent disordered eating.

Negative cognitions as a moderator in the relationship between PTSD and substance use in a psychiatrically hospitalized adolescent sample.

Adolescents exposed to trauma are more likely to engage in alcohol and marijuana use compared to their nontrauma-exposed counterparts; however, little is known about factors that may moderate these associations. This study examined the potential moderating effect of cognitions relevant to exposure to trauma (i.e., negative view of self, world, and future) in the association between posttraumatic stress disorder (PTSD) diagnosis and substance use among a psychiatric inpatient sample of 188 adolescents. Findings were that PTSD diagnosis was not significantly associated with substance-use diagnoses, but was associated with substance-use symptoms, accounting for 2.9% and 9.6% of the variance in alcohol and marijuana symptoms, respectively. The association between PTSD diagnosis and substance use symptoms, however, was moderated by negative cognitions, with PTSD and high negative cognitions (but not low negative cognitions) being significantly positively associated with substance use symptoms. The relevant cognitions differed for alcohol symptoms and marijuana symptoms. Children and adolescents who experience trauma and PTSD may benefit from early interventions that focus on cognitive processes as one potential moderator in the development of posttrauma substance use.

Negative cognitive style and perceived social support mediate the relationship between aggression and NSSI in hospitalized adolescents.

Despite the well-documented association between aggression and NSSI among adolescents, relatively little research has been conducted on the mechanisms underlying this relationship. The purpose of this study was to investigate potential socio-cognitive mechanisms through which aggression and NSSI are related. Participants were 186 adolescents (ages 13-18) recruited from a psychiatric inpatient facility in the northeastern United States. According to teen report, 57.5% of the sample endorsed NSSI in the previous year. Mediation was tested using the modern bootstrapping technique described by Hayes, using 5000 resamples with replacement, including sex and depression diagnosis as covariates. Results demonstrated that greater negative self-talk, a more negative cognitive style, and lower perceived family support were all significant mediators of the relationship between aggression and greater frequency of NSSI, whereas perceived social support from friends was not a significant mediator. Limitations, clinical implications, and future research directions of the current research are discussed.

Concurrent trajectories of change in adolescent and maternal depressive symptoms in the TORDIA study.

Depression has a heightened prevalence in adolescence, with approximately 15 % of adolescents experiencing a major depressive episode by age 18. Depression in adolescence also poses a risk for future distress and impairment. Despite treatment advances, many adolescents relapse after initial remission. Family context may be an important factor in the developmental trajectory of adolescent depression, and thus in enhancing treatment. This study examined concurrent change over time in adolescent and maternal depressive symptoms in the context of the Treatment of Resistant Depression in Adolescents study. Participants were 334 adolescents (mean age: 16; SD: 1.6; 70 % female, 84 % Caucasian), and their mothers (n = 241). All adolescents were clinically depressed when they entered the study and had received previous selective serotonin reuptake inhibitor (SSRI) treatment. Adolescents received acute treatment for 12 weeks and additional treatment for 12 more weeks. Adolescent depression and suicidal ideation were assessed at 0, 6, 12, 24, 48 and 72 weeks, while maternal depressive symptoms were assessed at 0, 12, 24, 48 and 72 weeks. Latent basis growth curve analyses showed a significant correlation over 72 weeks between trajectories of maternal and adolescent depressive symptoms, supporting the hypothesis of concurrent patterns of change in these variables. The trajectories were correlated more strongly in a subsample that included only dyads in which mothers reported at least one depressive symptom at baseline. Results did not show a correlation between trajectories of maternal depressive symptoms and adolescent suicidal ideation. These findings suggest that adolescent and maternal depressive symptoms change in tandem, and that treatment for adolescent depression can benefit the wider family system. Notably, most mothers in this sample had subclinical depressive symptoms. Future research might explore these trajectories in dyads with more severely depressed mothers.

Barriers to Seeking Mental Health Services among Adolescents in Military Families.

Military families with adolescents experience high levels of stress associated with parental deployment, but many of these families do not seek or utilize mental health services. The current qualitative study was designed to better understand barriers to mental health treatment experienced by adolescents in military families. Focus groups and individual interviews were conducted with military adolescents (n = 13), military (non-enlisted) parents (n = 12), and mental health service providers who treat adolescents in military families (n = 20). Discussions primarily explored barriers to seeking treatment, with supplemental questions assessing the ideal elements of mental health services for this population. Seven barriers to engaging in mental health services were identified: four internal (confidentiality concerns, stigma, ethic of self-reliance, lack of perceived relevance) and three external (time and effort concerns, logistical concerns, financial concerns). Challenges engaging military adolescents in mental health services are discussed and several recommendations are offered for service providers attempting to work with this population.