Handbook of Depression in Adolescents

Susan Nolen-Hoeksema, Lori M. Hilt, Susan Nolen-Hoeksema, Lori M. Hilt

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415648202
• eBook ISBN: 9781136675850
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Depressive disorders are among the most common types of psychopathology in the United States.  Adolescent-onset depressive disorders represent particularly insidious conditions because of their strong association with chronic and recurrent emotional problems in adulthood. This handbook offers authoritative reviews of research on the nature, ca

Section IV

PSYCHOSOCIAL FACTORS

Chapter Twelve

Stress Exposure and Stress Generation in Adolescent Depression

CONSTANCE HAMMEN

CONTENTS

Methodological Considerations

Stressor Assessment

Self-Report Checklists

Interview Methods of Stressor Assessment

General Criticisms of Stressor Assessment Methods

Additional Methodological Notes

Stress Exposure and Depressive Reactions to Stress

Adolescence and Exposure to Stress

Gender Differences in Stress Exposure

Depression Reactivity and Sensitivity to Stress

Gender Differences in Depressive Reactions to Stress

Stress Sensitization and Related Concepts

Stress Generation and Depression

Definitions and Empirical Evidence

Correlates and Predictors of Stress Generation

Models of the Stress-Depression Relationship

Conclusions and Future Directions

References

The current volume’s focus on depression in adolescence is an acknowledgment of the distinctiveness of this age group in terms of epidemiological, etiological, course, and treatment considerations. The high rates of onset of depressive disorder and the emergence of dramatic gender differences in adolescence raise intriguing questions about the developmental psychopathology of depression, and foretell crucial clinical concerns about the impact and course of depressive disorders with adolescent onset. Indeed, it could be claimed that studies of adolescent depression are central to understanding unipolar depression in its most frequent and typical forms. One reason is that adolescence is one of the most common periods of onset of depression in recent birth cohorts, with high rates of recurrence even in community samples (e.g., Andrade et al., 2003; Kessler et al., 2003;Lewinsohn, Rohde, Klein, & Seeley, 1999). A second is that compared to adolescent depression, those with childhood onset and later adult onset are likely different disorders with unique etiological and course features (e.g., Blazer, 2003; Weissman et al., 1999).

The purpose of the current chapter is to examine the role of stress in adolescent depression as a predictor of onset of depressive disorders and symptoms, as well as stress as a consequence of depression and characteristics of the depressed person and his or her environment (and such stress in turn may precipitate further depression). The research on stressful life events and their impact in adolescence is voluminous, spanning investigations of discrete stressors, such as a traumatic event or natural disaster, teen pregnancy, parental divorce, sexual assault, community violence, poverty, as well as studies of recent cumulative negative events. The current chapter will focus only on the latter—cumulative negative events—to limit the coverage and because such research forms the basis of most contemporary models and empirical tests of etiological mechanisms of depression and of explanations of gender differences. Also, excellent recent reviews of the wider range of stressors, both discrete and aggregated, in both child and adolescent samples covering psychopathology broadly, are available and generally draw similar conclusions about the stress-symptom relationship (e.g., Grant et al., 2003; Grant et al., 2006).

Most models of the origins of adolescent depression are either implicitly or explicitly diathesis-stress models, in which stressors play a necessary role, moderated or mediated by biological, socioemotional, and cognitive variables. Therefore, many of the chapters in Sections III and IV of this book will also present theory and research involving stressors. Consequently, the current chapter attempts to avoid duplication, and will present selective coverage of diathesis-stress models predicting depression.

Finally, the chapter attempts to emphasize issues that move beyond the basic observation that stress triggers depression. Thus, it notes certain methodological issues and addresses the measurement of stress, discusses whether adolescence is truly associated with increasing exposure to stress, reviews research on changing sensitivity to stressors, and explores evidence and mechanisms of stress generation. There is also discussion of gender differences in several topics: exposure to stressors, depressive reactions, specific sensitivity to interpersonal events, and the generation of stress.

METHODOLOGICAL CONSIDERATIONS

Stressor Assessment

Although research may examine depression in relation to a single specific stressor or situation (e.g., teen pregnancy, witnessing violence), considerable research examines occurrence of varied and multiple episodic (acute) stressful life events. While studies of adult depression have increasingly adopted interview methods of assessing stressors, with exceptions, most research on adolescent depression has used self-report checklists. Each of these approaches has advantages and limitations, which are elaborated below. Relatively few methods of evaluating ongoing, chronic stress have been developed, and pertinent issues are discussed.

Self-Report Checklists

A number of different checklists of negative life events have been reported. A review of methods for assessing life events in relation to youth psychopathology reported at least 11 such lists (Grant, Compas, Thurm, McMahon, & Gipson, 2004). Some of the more commonly used include the Adolescent Perceived Events Scale (APES; Compas, Davis, Forsythe, & Wagner, 1987) which covers both negative and positive experiences rated by the youth on valence (+3 extremely good to −3 extremely bad); the Life Events Questionnaire (LEQ; Coddington, 1972) originally developed for children but adapted for adolescents; and the Junior High Life Experiences Study (JHLES; Swearingen & Cohen, 1985), also covering positive and negative events. It is common for these instruments to be adapted by adding content relevant to the participant group, shortened to include only negative events, or only major events. A number of research groups have developed their own checklists, often borrowing items from these or similar instruments or generating items relevant to specific samples (e.g., Adolescent Stress Questionnaire; Byrne, Byrne, & Reinhart, 1995; Byrne & Mazanov, 2002; the Adolescent Life Change Event Scale; Waaktaar, Borge, Fundingsrud, Christie, & Torgersen, 2004; Yeaworth, York, Hussey, Ingle, & Goodwin, 1980). Scoring is variable across instruments, sometimes based on simple counts of event occurrence in the previous specified time frame, or sums of valence scores rated by youth for subjective impact. Recent research has established relatively sound psychometric properties of life event checklists, including test-retest reliability and concurrent validity (Grant et al., 2004). Some checklists target daily hassles, minor and daily events often highly subjective in nature—for example “schoolwork too hard” or “not enough fun things to do” (e.g., Everyday Life Events Scale [ELESC], Jose, Cafasso, and D’Anna [1994]; school-related [academic and peer] hassles questionnaire; Robinson, Garber, and Hilsman [1995]).

The advantages of checklists are evident. They are associated with low cost due to ease of administration and scoring. They are flexible and can be adapted for coverage of specific populations, and may be easily used in screening situations to detect potential needs for intervention. Disadvantages include reliance on idiosyncratic interpretation of the meaning of an item (e.g., “health problem of family member,” “problems with classmates”) as well as individual decisions about whether an event’s occurrence rises to the threshold level for reporting (“brother or sister leaving home” [for how long?]), failure to include occurrence of personally significant events if rare or not represented on the questionnaire, and lack of dates of events’ occurrence. Caution is also warranted about the content investigators choose to include on checklists. For example, Meadows, Brown, and Elder (2006), in the national Add Health study found that males scored higher on the stress index than females at all three waves of data, but they attributed the differences to the fact that the 12-item checklist contained more items likely to be experienced by males rather than representative of all stressors (e.g., expulsion from school, victim of violence, first involvement with law enforcement).

Conceptual criticisms may also be raised when events’ scoring is based on subjective appraisal of negativity, as such research (appraisals of stress predicting depression) may involve tautology due to the effects of emotional state on perceptions.

Notably, checklists provide no information about the context in which stressful life events occur, or how multiple events may be related to each other—all of which may affect the significance, duration, and consequences of the events. The use of different checklists, administered to adolescents of different ages, also makes it difficult to compare across samples, or to draw conclusions about normative aspects of stress experiences among adolescents (e.g., Grant et al., 2004). Lack of standard widely used measures also limits understanding of stress-depression mechanisms, the clarity of which requires greater precision in measurement of objective aspects of stress exposure.

Interview Methods of Stressor Assessment

Several research groups have reported on stress-depression relationships based on methods of contextual threat assessment for adolescents, adapted from methods originally applied to adults (e.g., Brown & Harris, 1978). In this approach the interviewer elicits information from the participant (or in the case of children and younger adolescents, from both a parent and the child) concerning not only event occurrence, but also the date of occurrence and facts of the circumstances in which the event occurred. Contextual details include information about the event’s features, but also about whether it was expected, what the consequences were, resources available, whether the person had prior experience with similar events, and the like. The idea is to obtain as much information as needed to distinguish how the same event might have different meaning and impact from one person to another depending on circumstances — for example, death of a grandmother might have largely different significance if she was the primary caretaker of a child or a geographically distant and rarely seen relative. In some life event assessment methods, the interviewer later presents to a rating team a narrative of the factual information blinded as to the person’s actual reaction to the event. The rating team is also blind as to the participant’s psychiatric status or history, and rates the severity of the event, according to the principle of scoring “objective impact” as how a typical person would experience the same event under the same circumstances. Raters may be guided by a written dictionary of scoring for similar items accumulated across usage of the procedure in comparable populations. Typically, raters also make judgments, from the contextual information, about the extent to which the event’s occurrence is at least in part dependent upon or independent of the characteristics or behaviors of the person (“fateful”).

Most of the existing stressor interviews for adolescents are based to some extent on the Life Events and Difficulties Schedule (LEDS; Brown & Harris, 1978). For example, the Pittsburgh group adapted the LEDS for American adolescents (Duggal et al., 2000; Williamson et al., 1998), and Garber, Keiley, and Martin (2002) used the Life Events Interview for Adolescents (LEIA) adapted from the LEDS and from the UCLA Life Stress Interview. The UCLA Life Stress Interview (Hammen, Adrian, Gordon, Jaenicke, & Hiroto, 1987) was based on the contextual threat approach, but is briefer and less time-intensive than the LEDS, and includes assessment of both chronic role-related stress (e.g., academic, romantic, friendship, family, and other domains) as well as episodic life events. The UCLA Life Stress Interview was initially developed for adults but has been adapted for use with children and adolescents (e.g., Adrian & Hammen, 1993; Hammen & Brennan, 2001; Hammen, Rudolph, Weisz, Rao, & Burge, 1999; Rudolph & Hammen, 1999). Rudolph and colleagues have further adapted the UCLA interview for younger adolescents (e.g., Rudolph & Flynn, 2007). Other context-based interview assessments include the Psychosocial Assessment of Childhood Experiences (PACE; Sandberg, McGuinness, Hillary, & Rutter, 1998; Sandberg, Rutter, Giles, & Owen, 1993) and methods developed by Goodyer and colleagues (e.g., Goodyer & Altham, 1991). Research has generally supported the reliability and validity of interview measures of stressors (reviewed in Grant et al., 2004).

Disadvantages of the contextual threat-based interview assessments include their expense: they are time-consuming to administer, require interview experience and training, and the scoring procedures may be laborintensive especially if independent raters are used to evaluate magnitude of “objective” threat. The focus on objective severity of the event’s impact has also been criticized for its neglect of “subjective” appraisal which, it is argued, reflects the individual’s actual perception and experience of the event (e.g., Lazarus & Folkman, 1984). Moreover, it has been noted that “context” information that is elicited and folded into the threat ratings may itself consist of risk factors that account for some of the association between the purported event and depression—such as whether the event was expected or the availability of resources (Kessler, 1997; Mazure, 1998). Nevertheless, interview-based approaches and contextual threat scoring are commonly recommended because of the superior quality of information obtained, the precision in evaluation of timing of event occurrence in relation to symptom changes, and the potentially more complete coverage of stressors. Several studies have generally indicated that questionnaires may pick up items too minor to be rated as events in the interview, or that the instruments may each pick up something not noted by the other, but the two methods appear to be similarly predictive of depression (Lewinsohn, Rohde, & Gau, 2003; Zimmerman, Pfohl, & Stangl, 1986). In a small study comparing administration of the LEDS interview and the Life Events Checklist (Johnson & McCutcheon, 1980) in a clinical sample of youth with recent major depression and a non-ill comparison, Duggal et al. (2000) found that only about one-third of events considered by the interview to be severe and likely to have provoked the depression were identified on the checklist. The interview thus yielded a more complete record of the occurrence of events. The authors suggested that the interview not only assists in the recall of events, but also does not rely on the participant’s own judgment and interpretation of whether the event was stressful. Furthermore, the interview is more suited to identify low base rate, but potentially highly personally relevant events that would not likely be included on checklists. It might also be noted that the contextual method of eliciting and scoring stressor information is suited to taking developmental considerations into account, an issue that sometimes makes checklists additionally problematic when administered to youth varying in ages between early and later adolescence within a study.

General Criticisms of Stressor Assessment Methods

As Grant and colleagues noted in their review (2004), only a small proportion of studies of adolescent stress-symptom associations used one of the few well-validated checklist or interview methods, and no single measure was used in more than 3% of the 500 studies they reviewed. The lack of standard instruments in wide use limits the comparability of findings across different populations, and impedes understanding of distributions of both normative and atypical levels and types of stress experienced by youth of different ages and environmental circumstances. It also means that most studies may be based on relatively less psychometrically developed measures. Grant et al. (2004) have called for the standardization of measures and development of taxonomies of stressor occurrence as important research targets.

Another important gap in stress assessment ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface
• About the Editors
• Contributors
• Section I: Assessment, Diagnosis, and Epidemiology
• Section II: Related Conditions
• Section III: Biological Factors
• Section IV: Psychosocial Factors
• Section V: Treatment of Adolescent Depression
• Section VI: Prevention of Adolescent Depression
• Index