Reducing youth internalizing symptoms: effects of a family-based preventive intervention on parental guilt induction and youth cognitive style

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Parent-Child Role Confusion: Exploring the Role of Family Processes in the Context of Parental Depression

OBJECTIVE

Parent-child role confusion has been shown to influence developmental outcomes for children whose parents have a history of depression; however, more research is needed to understand the pathways by which parental depression increases risk of role confusion. The current study aimed to extend previous literature by evaluating how different family processes (e.g., interparental conflict, guilt induction, family cohesion, and positive parenting practices) contribute to the development of emotional role confusion in families with a history of parental depression.

METHOD

The sample was comprised of 90 parent-child dyads (parent Mage = 42, 90% female, 83.3% White; child Mage = 11.51, 51.1% female, 75.6% White) participating in the control group of a randomized controlled trial. All parents had a history of depression. A longitudinal path analysis was conducted to evaluate prospective associations in the multiple mediator model.

RESULTS

Findings from the current study suggest that parental depressive symptoms are not directly related to the development of parent-child emotional role confusion, but are instead indirectly related through increased interparental conflict observed by youth. Although not identified as significant mediators, guilt induction and positive parenting practices emerged as predictors of emotional role confusion. Lastly, family cohesion did not appear to influence the development of role confusion.

CONCLUSION

Findings suggest that parenting behaviors and coparenting relationship quality play important roles in the development of parent-child emotional role confusion, with interparental conflict emerging as the strongest predictor in families with a history of parental depression.

A positive parenting program to enhance positive affect in children of previously depressed mothers

Children of mothers with a history of depression are at heightened risk for developing depression and other maladaptive outcomes. Deficits in parenting are one putative mechanism underlying this transmission of risk from mother to child. The present study evaluated whether a brief intervention with mothers with a history of depression produced greater use of positive parenting behaviors and an increase in observed positive affect in their 8- to 10-year-old children. Mothers with a history of depression (n = 65) were randomly assigned to either a positive parenting intervention or an attention control intervention condition. In addition, a comparison group of 66 mothers with no history of depression was evaluated one time. Results revealed significant increases in positive parenting behaviors (e.g., active listening, praise) immediately postintervention in mothers randomized to the positive parenting intervention as compared to those in the attention control condition. Children of mothers in the positive parenting intervention showed increases in positive affect as compared to children of mothers in the attention control intervention. Increases in mothers' active listening and smiling/laughing significantly predicted increases in children's positive affect. The intervention did not increase the rate of children's moment-by-moment positive affect contingent on mothers' positive parenting behaviors. This study showed the short-term effectiveness of a brief parenting intervention for enhancing interactions between mothers with a history of depression and their children by directly targeting mothers' positive parenting and, indirectly, children's expressions of positive affect. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"That's Not What I Heard!": Adolescent Internalizing, Negative Perceptions of Maternal Communication, and Felt Shame and Guilt

Adolescents with internalizing problems are more prone to feelings of guilt and shame, experience more guilt-induction, and report more negative parenting, but little is known about the way these processes are associated nor the extent to which they occur within real-time parent-adolescent interactions. The current study sought to clarify these links by investigating whether negatively biased perceptions of maternal communication mediate links between adolescent internalizing symptoms and their feelings of guilt, shame, and guilt-induction during real-time mother-adolescent discussions. One hundred twenty-three mother-adolescent dyads participated in the study. These dyads were moderately diverse in both race/ethnicity (53% White, 29% Black, 12% Hispanic) and family income (26% earned less than $30,000/year, 22% earned more than $100,000/year) and included adolescents who ranged in age from 12 to 17 (Mage = 13.99) and were approximately half female (54%). Mothers and adolescents engaged in lab discussions about issues of conflict and guilt and rated mothers' positive and negative communication during the tasks; observers rated these same behaviors. Adolescents also reported on their general internalizing symptoms prior to the discussions and feelings of guilt, shame, and experienced guilt induction following each discussion task. Structural equation models, parceling out shared and unique perceptions of maternal communication behaviors, showed that adolescents with more internalizing symptoms reported greater feelings of shame and perceived maternal guilt-induction following the discussion, and that these associations were mediated by adolescents' unique perceptions of more maternal negativity. These findings highlight the potential role of cognitive biases in perpetuating established associations among adolescent internalizing symptoms, shame, and parental guilt-induction.

Nonsuicidal Self-Injury and Suicidal Behaviors in Girls: The Case for Targeted Prevention in Preadolescence

Non-suicidal self-injury (NSSI) affects 15-20% of adolescents-disproportionately girls-and is a strong predictor of eventual suicide attempts and suicide. Many girls now initiate NSSI before age 10. These early-starters exhibit greater frequency of NSSI, use more diverse methods, and are hospitalized more often, yet there are no empirically supported prevention programs for preadolescents. Obstacles to prevention include ascertaining who is sufficiently vulnerable and specifying mechanistic intervention targets. Recent research indicates that (1) preadolescent girls with ADHD who are also maltreated are at alarming risk for NSSI and suicide attempts by adolescence, and (2) the conjoint effects of these vulnerabilities are sufficiently potent for targeted prevention. Research also indicates that existing interventions are effective in altering child- and family-level mechanisms of NSSI. These interventions alter neurobiological markers of vulnerability, which can be used as proximal efficacy signals of prevention response, without waiting for NSSI and suicide attempts to emerge.

Potential Mediators in Parenting and Family Intervention: Quality of Mediation Analyses

Parenting and family interventions have repeatedly shown effectiveness in preventing and treating a range of youth outcomes. Accordingly, investigators in this area have conducted a number of studies using statistical mediation to examine some of the potential mechanisms of action by which these interventions work. This review examined from a methodological perspective in what ways and how well the family-based intervention studies tested statistical mediation. A systematic search identified 73 published outcome studies that tested mediation for family-based interventions across a wide range of child and adolescent outcomes (i.e., externalizing, internalizing, and substance-abuse problems; high-risk sexual activity; and academic achievement), for putative mediators pertaining to positive and negative parenting, family functioning, youth beliefs and coping skills, and peer relationships. Taken as a whole, the studies used designs that adequately addressed temporal precedence. The majority of studies used the product of coefficients approach to mediation, which is preferred, and less limiting than the causal steps approach. Statistical significance testing did not always make use of the most recently developed approaches, which would better accommodate small sample sizes and more complex functions. Specific recommendations are offered for future mediation studies in this area with respect to full longitudinal design, mediation approach, significance testing method, documentation and reporting of statistics, testing of multiple mediators, and control for Type I error.

Cognitive behavioural therapy (CBT), third-wave CBT and interpersonal therapy (IPT) based interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people. It has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health. This is an update of a Cochrane review that was last updated in 2011.

OBJECTIVES

To determine whether evidence-based psychological interventions (including cognitive behavioural therapy (CBT), interpersonal therapy (IPT) and third wave CBT)) are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

We searched the specialised register of the Cochrane Common Mental Disorders Group (CCMDCTR to 11 September 2015), which includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We searched conference abstracts and reference lists of included trials and reviews, and contacted experts in the field.

SELECTION CRITERIA

We included randomised controlled trials of an evidence-based psychological prevention programme compared with any comparison control for young people aged 5 to 19 years, who did not currently meet diagnostic criteria for depression.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trials for inclusion and rated their risk of bias. We adjusted sample sizes to take account of cluster designs and multiple comparisons. We contacted trial authors for additional information where needed. We assessed the quality of evidence for the primary outcomes using GRADE.

MAIN RESULTS

We included 83 trials in this review. The majority of trials (67) were carried out in school settings with eight in colleges or universities, four in clinical settings, three in the community and four in mixed settings. Twenty-nine trials were carried out in unselected populations and 53 in targeted populations.For the primary outcome of depression diagnosis at medium-term follow-up (up to 12 months), there were 32 trials with 5965 participants and the risk of having a diagnosis of depression was reduced for participants receiving an intervention compared to those receiving no intervention (risk difference (RD) -0.03, 95% confidence interval (CI) -0.05 to -0.01; P value = 0.01). We rated this evidence as moderate quality according to the GRADE criteria. There were 70 trials (73 trial arms) with 13,829 participants that contributed to the analysis for the primary outcome of depression symptoms (self-rated) at the post-intervention time point, with results showing a small but statistically significant effect (standardised mean difference (SMD) -0.21, 95% CI -0.27 to -0.15; P value < 0.0001). This effect persisted to the short-term assessment point (up to three months) (SMD -0.31, 95% CI -0.45 to -0.17; P value < 0.0001; 16 studies; 1558 participants) and medium-term (4 to 12 months) assessment point (SMD -0.12, 95% CI -0.18 to -0.05; P value = 0.0002; 53 studies; 11,913 participants); however, the effect was no longer evident at the long-term follow-up. We rated this evidence as low to moderate quality according to the GRADE criteria.The evidence from this review is unclear with regard to whether the type of population modified the overall effects; there was statistically significant moderation of the overall effect for depression symptoms (P value = 0.0002), but not for depressive disorder (P value = 0.08). For trials implemented in universal populations there was no effect for depression diagnosis (RD -0.01, 95% CI -0.03 to 0.01) and a small effect for depression symptoms (SMD -0.11, 95% CI -0.17 to -0.05). For trials implemented in targeted populations there was a statistically significantly beneficial effect of intervention (depression diagnosis RD -0.04, 95% CI -0.07 to -0.01; depression symptoms SMD -0.32, 95% CI -0.42 to -0.23). Of note were the lack of attention placebo-controlled trials in targeted populations (none for depression diagnosis and four for depression symptoms). Among trials implemented in universal populations a number used an attention placebo comparison in which the intervention consistently showed no effect.

AUTHORS' CONCLUSIONS

Overall the results show small positive benefits of depression prevention, for both the primary outcomes of self-rated depressive symptoms post-intervention and depression diagnosis up to 12 months (but not beyond). Estimates of numbers needed to treat to benefit (NNTB = 11) compare well with other public health interventions. However, the evidence was of moderate to low quality using the GRADE framework and the results were heterogeneous. Prevention programmes delivered to universal populations showed a sobering lack of effect when compared with an attention placebo control. Interventions delivered to targeted populations, particularly those selected on the basis of depression symptoms, had larger effect sizes, but these seldom used an attention placebo comparison and there are practical difficulties inherent in the implementation of targeted programmes. We conclude that there is still not enough evidence to support the implementation of depression prevention programmes.Future research should focus on current gaps in our knowledge. Given the relative lack of evidence for universal interventions compared with attention placebo controls and the poor results from well-conducted effectiveness trials of universal interventions, in our opinion any future such trials should test a depression prevention programme in an indicated targeted population using a credible attention placebo comparison group. Depressive disorder as the primary outcome should be measured over the longer term, as well as clinician-rated depression. Such a trial should consider scalability as well as the potential for the intervention to do harm.

Child Temperamental Flexibility Moderates the Relation between Positive Parenting and Adolescent Adjustment

Temperamental flexibility and lower positive parenting are associated with internalizing and externalizing problems; however, youth varying in flexibility may be differentially affected by positive parenting in the prediction of symptoms. We examined whether children's flexibility moderated prospective relations between maternal and paternal positive parenting and youth internalizing and externalizing symptoms during adolescence. Participants (N =775, 71% male) and their caregivers completed measures when youth were 10-12 and 12-14 years old. Father positive parenting interacted with child flexibility to predict father-reported internalizing and externalizing problems. Consistent with the diathesis-stress model, children lower in flexibility experienced greater symptoms than children higher in flexibility in lower positive parenting contexts. Among children lower in flexibility, lower paternal positive parenting was associated with greater internalizing and externalizing symptoms compared to higher paternal positive parenting. However, among youth higher in flexibility, symptom levels were similar regardless of whether youth experienced lower or higher paternal positive parenting.

Seesaw Discipline: The Interactive Effect of Harsh and Lax Discipline on Youth Psychological Adjustment

Although extant research documents the negative consequences of harsh and lax discipline for youth, little empirical attention has been devoted to understanding the impact when parents utilize both strategies. As such, the current study was designed to explore the interaction of harsh and lax discipline on youth internalizing and externalizing symptoms in three developmental periods (early childhood, middle childhood, and adolescence). Participants were 615 parents (55 % female) and one of their 3-to-17 year old children (45 % female). Parents provided reports of their harsh and lax parenting tactics as well as offspring internalizing and externalizing symptoms. Multiple linear regression analyses were utilized to examine the relations between the interaction of harsh and lax parenting on youth symptoms. The interaction between harsh and lax discipline was significantly related to youth internalizing, but not externalizing, problems in the both the young and middle childhood samples and marginally significant in the adolescence sample: Seesaw discipline - a novel construct indicative of high levels of both harsh and lax discipline - was associated with the highest levels of youth internalizing problems. Parents who engage in seesaw parenting have children and adolescents who are more likely to evidence internalizing symptoms. Such findings may inform prevention and intervention efforts that target dysfunctional discipline.