Carly Guberman. Copyright by Carly Guberman 2012

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1 POTENTIAL PRECURSORS OF COMORBIDITY: EXAMINING HOW EMOTIONS, PARENTAL PSYCHOPATHOLOGY, AND FAMILY FUNCTIONING RELATE TO DEPRESSIVE SYMPTOMS IN YOUNG ANXIOUS CHILDREN by Carly Guberman A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Human Development and Applied Psychology Ontario Institute for Studies in Education University of Toronto Copyright by Carly Guberman 2012

2 POTENTIAL PRECURSORS OF COMORBIDITY: EXAMINING HOW EMOTIONS, PARENTAL PSYCHOPATHOLOGY, AND FAMILY FUNCTIONING RELATE TO DEPRESSIVE SYMPTOMS IN YOUNG ANXIOUS CHILDREN Doctor of Philosophy 2012 Carly Guberman Department of Human Development and Applied Psychology University of Toronto Abstract Objective: Past research indicates that comorbid anxiety and depression in youth is associated with greater functional impairment than anxiety alone. To elucidate those factors which may increase vulnerability to depressive disorders, the current study examined several clinical correlates (i.e., feelings ratings, parental psychopathology symptoms, and family functioning) of comorbid depressive symptoms in young anxious children. Method: Sixty-eight children, aged 6 to 10 years (M = 9.06, SD = 1.10), and caregivers completed measures assessing child depressive symptoms. Furthermore, children completed self reports of anxiety symptoms, feelings ratings, and family functioning, while caregivers completed self reports of psychopathology symptoms and family functioning. Predictors of child depressive symptoms were examined separately for girls and boys. Results: In females, hierarchical regression analyses revealed that, after controlling for anxiety, higher sadness and lower positive feelings accounted for 30% of variance in child-reported depressive symptoms. Further analyses indicated that child-reported overall family dysfunction moderated the relationship between positive feelings and depressive symptoms, such that high family dysfunction increased the risk of depressive symptoms in females with low positive emotions. In males, hierarchical regression analyses revealed that, after controlling for anxiety, higher negative/hostile feelings and childreported overall family dysfunction accounted for 19% of variance in child-reported depressive symptoms. Further analyses of family functioning in males revealed that child-reported family cohesion and conflict were negatively and positively correlated, respectively, with depressive ii

3 symptoms. Family dysfunction did not moderate the relationship between feelings ratings and depressive symptoms. The only significant predictor of caregiver-reported child depressive symptoms, for males only, was caregiver self-reported overall psychopathology symptoms. Further analyses indicated that, for males, caregiver depression and hostility symptoms correlated positively with caregiver-reported child depressive symptoms. Conclusions: Different patterns of emotion and family functioning predicted self-reported depressive symptoms in males and females. Self and caregiver reports of child depressive symptoms were not related, with only caregivers psychopathology symptoms predicting their reports of child depressive symptoms. Results suggest the importance of assessing child-reported feelings and family dysfunction, and parental symptomatology, of clinically anxious children. To prevent future depressive disorders in these children, different targets of intervention for males and females may be warranted. iii

4 Acknowledgements Firstly, this thesis would not have been possible without the expertise and guidance of my supervisor, Dr. Katharina Manassis. I would like to thank her for her constant support throughout our work together over the past 8 years. I would also like to thank my committee members, Dr. Judith Wiener and Dr. Rosemary Tannock, for their constructive advice on this project. As well, thank you to my external committee member, Dr. Lynn Miller, for her insightful contributions and to Dr. Michele Peterson-Badali for participating in my defence. Thank you to Dr. Olesya Falenchuk for her invaluable statistical guidance and to Mr. David Avery for his help and resourcefulness. My appreciation goes out to all of the staff in the Anxiety Disorders Program who assisted with this project. As well, I would like to express my gratitude to the children and parents who participated in this study. Thank you also to the Social Sciences and Humanities Research Council of Canada and to the Hospital for Sick Children for their funding of this work. Finally, thank you to all of my family and friends for their love, laughter, and encouragement throughout my graduate studies. To my mother, Naomi Guberman, thank you for your unremitting patience and optimism. To my husband, Jeremy Ehrlich, I am forever grateful to you for your unwavering love and support. Thank you for continuing to stand by me and for joining me on our next great adventure. iv

5 Table of Contents Page Abstract... ii Acknowledgements... iv List of Tables... viii List of Figures... ix List of Appendices... x Chapter One: Introduction... 1 Theoretical Models of Depression: Support for Emotions, Parental Psychopathology, and Family Dysfunction as Precursors of Comorbid Depression... 4 Cognitive Theories of Depression... 5 Emotion-Related Theories of Depression... 6 Interpersonal Theories of Depression Related to Family Dysfunction... 8 Integrative Models of Depression... 9 Empirical Findings for Characteristics Associated with Comorbid Depression in Anxious Youth Internalizing Symptomatology Overall symptom ratings Affective symptomatology Information processing styles of emotionally negative and positive information Family Characteristics Parental psychopathology Family dysfunction Interaction Between Family Dysfunction and Affective Symptomatology Summary & Study Rationale Study Design Considerations Outline of Objectives and Hypotheses Objective 1: To Determine Predictors of Comorbid Depressive Symptoms in Clinically Anxious Children Objective 2: To Examine the Moderating Effects of Family Functioning on the Relationship Between Emotional Factors and Comorbid Depressive Symptoms in Clinically Anxious Children Chapter Two: Method Participants Procedure Measures Measures Completed by Child Children s Depression Inventory (CDI) Screen for Child Anxiety Related Emotional Disorders (SCARED) v

6 Mood Assessment via Animated Characters (MAAC) Self-Report Measure of Family Functioning Child Version (SRMFF-C) Measures Completed by Caregiver Number of ADIS-IV Child Depressive Symptoms (ADIS-IV Checklist) Self-Report Measure of Family Functioning Parent Version (SRMFF-P) Brief Symptom Inventory (BSI) Demographic information Statistical Analyses Preliminary Analyses Objective 1 Analyses: To Determine Predictors of Comorbid Depressive Symptoms in Clinically Anxious Children Objective 2 Analyses: To Examine the Moderating Effects of Family Functioning on the Relationship Between Emotional Factors and Comorbid Depressive Symptoms in Clinically Anxious Children Chapter Three: Results Preliminary Analyses Analyses by Objective Comment on Statistical Power, Significance, Effect Size Predicting Child-Reported Depressive Symptoms (CDI) in Females Objective 1 analyses: To determine predictors of comorbid depressive symptoms in clinically anxious children Objective 2 analyses: To examine the moderating effects of family functioning on the relationship between emotional factors and comorbid depressive symptoms in clinically anxious children Predicting Child-Reported Depressive Symptoms (CDI) in Males Objective 1 analyses: To determine predictors of comorbid depressive symptoms in clinically anxious children Objective 2 analyses: To examine the moderating effects of family functioning on the relationship between emotional factors and comorbid depressive symptoms in clinically anxious children Predicting Caregiver-Reported Depressive Symptoms (ADIS-IV Checklist) in Males Objective 1 analyses: To determine predictors of comorbid depressive symptoms in clinically anxious children Chapter Four: Discussion Diagnostic Status and Preliminary Analyses Objective 1: To Determine Predictors of Comorbid Depressive Symptoms Negative Emotion Ratings Positive Emotion Ratings Family Dysfunction Parental Psychopathology Objective 2: To Examine the Moderating Effects of Family Functioning on the Relationship Between Emotional Factors and Comorbid Depressive Symptoms Consideration of Developmental Sex Differences vi

7 Discrepancy Between Child and Caregiver Reports Clinical Implications Limitations and Directions for Future Research Summary and Conclusions References vii

8 List of Tables Page Table 1. Demographic Characteristics and Diagnostic Status of Child Participants Table 2. Descriptive Statistics of Outcome and Predictor Measures Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table 10. Table 11. Table 12. Bivariate Correlations for Child Depressive Symptom Measures, Child Anxiety Symptom Measure, and Age of Child Bivariate and Partial Correlations (Controlling for Anxiety Symptoms) for Child Depressive Symptom Measures and Predictor Measures in Females Bivariate and Partial Correlations (Controlling for Anxiety Symptoms) for Child Depressive Symptom Measures and Predictor Measures in Males Hierarchical Regression Analysis on Self-Reported Child Depressive Symptoms in Females Final Hierarchical Regression Analysis Examining the Moderating Effects of Family Functioning in Females...51 Hierarchical Regression Analysis on Self-Reported Child Depressive Symptoms in Males Bivariate and Partial Correlations (Controlling for Anxiety Symptoms) for Self- Reported Child Depressive Symptoms and SRMFF-C Subscales in Males Hierarchical Regression Analysis Examining the Moderating Effects of Family Functioning in Males Hierarchical Regression Analysis on Caregiver-Reported Child Depressive Symptoms in Males Bivariate Correlations for Caregiver-Reported Child Depressive Symptoms and BSI Subscales in Males viii

9 Figure 1. List of Figures Page MAAC positive factor x SRMFF-C total family dysfunction moderation for CDI scores in females ix

10 List of Appendices Page Appendix A Checklist for Number of Caregiver-Reported Child Depressive Symptoms Appendix B Appendix C Preliminary Hierarchical Regression Analysis Examining the Moderating Effects of Family Functioning in Females...99 Results of Hierarchical Regression Analysis on Self-Reported Child Depressive Symptoms in Males with Reversed Order Entry of MAAC Negative/Hostile Factor and SRMFF-C 102 Appendix D Descriptive Statistics of SRMFF-C Subscales for Males Appendix E Descriptive Statistics of BSI Subscales for Males x

11 CHAPTER ONE Introduction 1

12 2 The phenomenon of co-occurring, or comorbid, depression in anxious youth is not uncommon (Brady & Kendall, 1992; Compas & Oppedisano, 2000; Sorensen, Nissen, Mors, & Thomsen, 2005). For example, in their review of studies including youth meeting diagnostic criteria for disorders of anxiety or depression, Brady and Kendall (1992) found that rates of participants meeting criteria for both disorders ranged from 15.9% to 61.9%. Axelson and Birmaher (2001) note that approximately 10% to 20% of youth with anxiety disorders have comorbid depressive disorders. Findings suggest that anxious children with co-occurring depression experience more short- and long-term impairment (e.g., social and academic impairment), greater utilization of mental health services, and increased suicidality, than youth with anxiety alone (Bernstein, 1991; Foley, Goldston, Costello, & Angold, 2006; Franco, Saavedra, & Silverman, 2007; Guberman & Manassis, 2011; Last, Hansen, & Franco, 1997; Manassis & Hood, 1998; Manassis & Menna, 1999; Masi, Favilla, Mucci, & Millepiedi, 2000; O Neil, Podell, Benjamin, & Kendall, 2010). Franco et al. (2007) found that youth with comorbid anxiety and depressive disorders were involved in fewer extracurricular activities, had worse peer relationships, and demonstrated lower levels of academic performance than youth with anxiety disorders only. Masi et al. (2000) and O Neil et al. (2010) found higher clinicianrated functional impairment for clinically anxious youth with comorbid depressive disorders, compared to youth with anxiety alone. Manassis and Hood (1998) and Manassis and Menna (1999) examined children diagnosed with anxiety disorders. Although only a small percentage of these children were diagnosed as meeting criteria for a comorbid depressive disorder, children completed a self-report measure of their depressive symptoms. Theoretically, those children reporting high scores on this measure could be conceived of as having a subthreshold depressive syndrome (i.e., symptoms that do not meet full diagnostic criteria for a disorder). Manassis and Hood (1998) found a significant negative relationship between child-reported depressive symptoms and clinician ratings of adaptive functioning. Manassis and Menna (1999) found that children categorized as having depression based on self reports were rated by clinicians as exhibiting more impaired functioning than anxiety only groups. In their 8-year longitudinal study, Last et al. (1997) found that young adults with diagnoses of comorbid anxiety and depression in childhood were more likely than subjects with histories of anxiety only to report mental health difficulties (most frequently depression). Furthermore, the comorbid group utilized mental health services to a greater degree than their purely anxious counterparts. Higher rates of treatment associated with comorbid anxiety and depression are consistent with findings from other studies (Bernstein, 1991; Guberman & Manassis, 2011).

13 3 Finally, Foley et al. (2006) found elevated risk of suicide in youth with comorbid anxiety and depressive disorders, compared to those with anxiety only. The association between comorbid depression in anxious youth and functional impairment, as well as an increased burden placed on mental health care resources, indicates that further research into the factors associated with comorbidity is merited. Such research is crucial in order to advance our understanding of the prevention and treatment of this comorbidity. Past studies examining the correlates of comorbid depression in anxious youth have found comorbid depression to be associated with more severe internalizing symptoms (Bernstein, 1991; Bernstein & Garfinkel, 1986; Franco et al., 2007; Masi et al., 2000; O Neil et al., 2010; Strauss, Last, Hersen, & Kazdin, 1988) and family characteristics, such as increased parental psychopathology (Beardslee, Versage, & Gladstone, 1998; Beidel & Turner, 1997; Weissman, Leckman, Merikangas, Gammon, & Prusoff, 1984) and impaired family functioning (Guberman & Manassis, 2011; Johnson, Inderbitzen-Nolan, & Schapman, 2005; O Neil et al., 2010; Stark, Humphrey, Crook, & Lewis, 1990; Starr & Davila, 2008), relative to anxiety alone. While previous studies on the symptomatology and family characteristics associated with comorbid depression in anxious youth have examined samples of youth with wide-ranging ages (i.e., early school years to mid to late adolescence), there is a paucity of studies examining these multiple aspects of comorbidity in samples consisting of predominantly younger clinically anxious children (i.e., early school years). Age differences in prevalence rates of depression in youth have been found, with adolescents meeting diagnostic criteria for depression more frequently than children (Birmaher et al., 1996). Furthermore, research findings suggest that anxiety disorders in depressed children are likely to precede the onset of initial depressive episodes (Avenevoli, Stolar, Li, Dierker, & Merikangas, 2001; Cole, Peeke, Martin, Truglio, & Seroczynski, 1998; Kovacs, Gatsonis, Paulauskas, & Richards, 1989). Therefore, young children meeting criteria for an anxiety diagnosis are more likely to exhibit comorbid subthreshold depressive symptoms, as opposed to comorbid depressive symptoms meeting full diagnostic criteria for a disorder. Since subthreshold depressive symptoms have been associated with increased risk of a future major depressive episode (reviewed in Garber, 2006; Georgiades, Lewinsohn, Monroe, & Seeley, 2006; Keenan et al., 2008; reviewed in Kovacs & Lopez-Duran, 2010), examination of the correlates of comorbid subthreshold depressive symptoms in young anxious children may help to elucidate those factors which increase vulnerability to the later development of depressive disorders in anxious youth. Furthermore, a closer look into those factors associated with

14 4 comorbidity in young anxious children may be particularly relevant to our understanding of which characteristics are present early in the development of comorbidity and, therefore, should be targeted by assessment and treatment programs. In an attempt to address the need to examine factors associated with comorbidity in young children, the present study will examine depressive symptoms (self-reported and caregiver-reported) and their relationship to emotionrelated factors (self-reported), parental psychopathology (caregiver-reported), and family functioning (self-reported and caregiver-reported), in young anxious children (aged 6 to 10 years). Below, several theoretical models which support the role of emotions, parental psychopathology, and family functioning as precursors of depression are first presented. Subsequently, a review of the empirical findings regarding characteristics previously associated with depression in youth of all ages (including anxious youth) is presented. Affective symptomatology, parental psychopathology, family dysfunction, and their interactions are highlighted, as these are the factors examined in the present study. Established diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR; American Psychiatric Association [APA], 2000) require that symptoms meet the cut-off point for a specified set of criteria in order to be classified as a psychiatric disorder. While clinically significant findings have been associated with comorbid depression, as defined by diagnostic criteria, there has been recent interest in the clinical significance of subthreshold psychiatric syndromes (Lewinsohn, Shankman, Gau, & Klein, 2004). Research into subthreshold conditions of depressive disorders in isolation has revealed that such conditions are associated with significant impairment and health-care utilization (as reviewed in Lewinsohn et al., 2004). Furthermore, the presence of comorbid subthreshold depressive states has been associated with significantly more impairment than anxious states occurring on their own (reviewed in Rivas-Vazquez, Saffa-Biller, Ruiz, Blais, & Rivas-Vazquez, 2004). Given that the current study conceptualized comorbid depression in anxious children as representing primarily subthreshold symptoms, as opposed to disorders meeting full diagnostic criteria, previous studies conceptualizing depression in youth from both perspectives (i.e., meeting full diagnostic criteria versus subthreshold syndrome) are reviewed below. Theoretical Models of Depression: Support for Emotions, Parental Psychopathology, and Family Dysfunction as Precursors of Comorbid Depression Multiple pathways have been implicated in the etiology of depression (Costello et al., 2002) including, but not limited to, cognitive, emotion-related, interpersonal, genetic, and

15 5 biological vulnerabilities (Abela & Hankin, 2008; Durbin & Shafir, 2008; Lau & Eley, 2008; Nantel-Vivier & Pihl, 2008; Rudolph, Flynn, & Abaied, 2008). These risk factors have been described in numerous theoretical models of the etiology of depression. Below, a sample of current theoretical models of depression, which focus on either individual risk factors or an integration of multiple factors, is briefly reviewed. Although the below-noted theories of depression do not represent an exhaustive survey, they were chosen in order to highlight how the variables under examination in the current study (i.e., emotional experiences, parental psychopathology, and family dysfunction) have been linked conceptually with a vulnerability to depression. Cognitive Theories of Depression A number of cognitive theories of depression have been posited (reviewed in Abela & Hankin, 2008) which focus on maladaptive cognitive patterns as sufficient causes of depression. Two such examples (i.e., Abramson, Metalsky, & Alloy, 1989; Beck, 1987) comprise cognitive diathesis-stress models which posit that individuals possessing a cognitive vulnerability are more likely than individuals without this vulnerability to develop depression when encountering adverse events. Abramson et al. s (1989) hopelessness theory of depression represents a revision of Abramson, Seligman, and Teasdale s (1978) earlier reformulated theory of helplessness and depression. In their hopelessness theory, Abramson et al. (1989) propose that individuals who are prone to a negative inferential style are more likely to make negative inferences in regard to negative events (i.e., attribute them to stable and global causes, infer negative consequences, infer negative characteristics about the self). Such inferences increase one s chances of developing hopelessness which is considered a cause of depression. Abramson et al. (1989) define hopelessness as having a high expectation that negative events will occur and a low expectation that positive events will occur, coupled with the expectation of helplessness in regard to changing the occurrence of such events. Similar to the hopelessness theory, Beck s (1987) cognitive theory of depression posits that individuals who are prone to depressogenic schemata, or dysfunctional attitudes (e.g., the attitude that one s self-worth depends solely on others approval), are more vulnerable to depression. Following the occurrence of an adverse event, depressogenic schemata are activated in these individuals and elicit a negatively biased information processing style (e.g., cognitive distortions such as overgeneralization). Such distortions or thinking errors are posited to increase the individual s vulnerability to developing the negative cognitive triad consisting of

16 6 three cognitive components (i.e., negative view of the self, the world, and the future) that lead to depression symptoms. Although the examination of cognitive factors was beyond the scope of examination in the current study, other models of depression (described below) suggest that factors related to emotions, parental psychopathology, and family dysfunction may influence and interact with thought patterns, such as those implicated in the above models (Abramson et al., 1989; Beck, 1987), to increase the anxious child s vulnerability to depression. Emotion-Related Theories of Depression While cognitive processes have been the focus of much theoretical and empirical attention within the field of depression since the latter half of the twentieth century (Abela & Hankin, 2008), the role of emotions and emotion regulation in the development of psychopathology, such as depression, has more recently garnered attention by theorists and researchers (Durbin & Shafir, 2008). For example, Izard s (1991) differential emotions theory, although not dedicated solely to the development of depression, offers a conceptual framework for understanding the potential role of emotions in the development of this disorder. According to this theory, an emotion represents a combination of physiological activation, expressive behaviour, and a conscious (i.e., feeling) experience (Izard, 1991). Emotions can be viewed as independent entities that interact with and influence various perceptual, cognitive, behavioural, and biological processes in ways that promote both adaptive and maladaptive outcomes (e.g., Izard, 1991; Izard & Schwartz, 1986; Izard, Fine, Mostow, Trentacosta, & Campbell, 2002). Emotions are considered to serve adaptive purposes, such that positive feelings typically produce positive outcomes. For example, positive feelings, such as happiness, can stimulate learning and exploration, social bonding, and participation in activities that help to reduce the effects of stressful negative emotional experiences (reviewed in Izard, 2002 and Izard et al., 2002). Similarly, negative emotions can also yield adaptive outcomes. For example, sadness can lead one to identify problems and obtain social support, while anger can lead one to productively assert oneself (reviewed in Izard, 2002 and Izard et al., 2002). However, it has been posited that when certain emotion patterns become prolonged and extreme in intensity, perhaps due to a genetic predisposition, a low threshold for certain emotions, an inability to adaptively regulate emotions, and/or repeated exposure to adverse environmental events, such patterns can contribute to maladaptive thoughts and behaviours characteristic of internalizing disorders (Davidson, 2000; Izard 1991; Izard et al., 2002; Izard & Schwartz, 1986; Malatesta & Wilson, 1988). Izard and Schwartz (1986) note that, while negative emotions (e.g., sadness,

17 7 anger) are not viewed as the direct cause of depression, increased susceptibility to these emotions may contribute to other determinants of depression such as the maladaptive cognitive patterns and attribution styles (e.g., Abramson et al., 1989; Beck, 1987) described above. For example, enduring feelings of sadness or anger can bias how one perceives and processes information and, therefore, lead one to generate a negative and inaccurate interpretation of an event consistent with one s low mood. While the experience of negative emotions has been implicated in the development of depression, the experience of lowered positive emotions and/or difficulties regulating positive emotions has been theorized to play a role in contributing to the development of depression (Durbin & Shafir, 2008). The field of positive psychology helps to provide an understanding of the mechanisms that may underlie the protective role of positive emotions in the development of depressive symptoms. Positive psychology strives to understand those circumstances that enable individuals to thrive (Seligman & Csikszentmihalyi, 2000). Fredrickson s (2001) broaden-andbuild theory of positive emotions represents one theory in the field of positive psychology and posits that positive emotions have the ability to broaden the individual s thought-action repertoires. Fredrickson (2001) explains that negative emotions tend to restrict, or narrow, the individual s range of thoughts and related action choices. For example, a fearful thought likely leads one to focus solely on thinking about and executing a method of escape from a feared stimulus. Such thought-action repertoires prove to be beneficial in threatening situations. In nonthreatening situations, however, the experience of positive emotions expands the individual s thought-action repertoires. Positive emotions, such as joy, interest, and pride, which are associated with increased urges to be creative, explore, learn, and share positive experiences with others, broaden the individual s exposure to thoughts and experiences that serve as lasting beneficial resources. In this way, people who experience increased positive emotions have more helpful psychological resources at their disposal which, in turn, enable them to better cope with adverse events and become increasingly resilient to such events over time. Frederickson s theory represents one potential way of understanding the unique contributions of positive emotions to the individual s well-being and how positive emotions may play a role in buffering against the development of depression. In line with the view that positive and negative emotion patterns may play a role in the development of depression is Clark and Watson s (1991) tripartite model, which was proposed as an explanation for the common and distinct features among anxiety and depressive disorders. This model posits that, while the temperamental/personality dimension of high negative

18 8 affectivity, or general distress (e.g., tendency to experience aversive emotions such as fear, sadness, anger), is common to both anxiety and depression, the dimension of low positive affectivity (e.g., tendency to experience low pleasure and enjoyment) is uniquely related to depression, and high physiological arousal (e.g., muscle tension, increased heart rate) is uniquely related to anxiety. It has been proposed that the dimensions of high negative and low positive affectivity may increase the individual s vulnerability to depression (Clark, Watson, & Mineka, 1994). As evidenced by the above examples, multiple theoretical perspectives regarding the role of emotion-related processes in depression exist (Durbin & Shafir, 2008). These various theories support the importance of assessing and understanding emotion patterns in relation to the development of depression and/or depressive symptoms. Interpersonal Theories of Depression Related to Family Dysfunction Given the family s pervasive presence within the child s life and the child s dependence on his or her parents, interactions in the familial environment represent a major influence on the child s development and, potentially, his or her vulnerability to depression. Rudolph et al. (2008) propose a transactional interpersonal model of depression which outlines how early family disruption, such as insecure parent-child attachment and parental depression (see below for Goodman & Gotlib s [1999] model of parental depression as a risk factor for child depression), heightens children s risk of developing deficient social skills and relationship disturbances which then increase their vulnerability to depression. Depressive symptoms, in turn, can negatively impact on interpersonal functioning. Problematic interpersonal functioning can then serve to reinforce the development of depression. Rudolph et al. (2008) describe a number of reasons why interpersonal dysfunction (i.e., deficient social skills and maladaptive relationships) may increase the child s vulnerability to depression. They propose that the experience of interpersonal dysfunction (e.g., with peers or family) may influence the child to adopt maladaptive ways of processing social information as well as negative self-evaluations. They refer to Cole s competence-based model of child depression (Cole, Martin, & Powers, 1997) and note that, when children regularly receive negative appraisals from others, such negative information is internalized and can contribute to the formation of a negative self-image, which increases the risk of depression. Furthermore, they note that children who regularly experience dysfunctional interactions with others may come to doubt their worth as perceived by others, as well as their social competence, which may lead them to feel helpless in their ability to form positive and functional relationships. Such negative beliefs and thoughts of

19 9 helplessness may lead to depressive symptoms. Rudolph et al. (2008) also propose that children involved in dysfunctional interpersonal relationships may have fewer chances to acquire adaptive emotion-regulation strategies, leading them to experience more intense negative emotions which might predispose them to depression. Such explanations can be applied to the relationship between interpersonal dysfunction within the family and the child s increased risk for depression. For example, negative parenting and family functioning styles consisting of high criticism and rejection, and low warmth and acceptance, may lead to maladaptive cognitive styles in the child (e.g., thoughts of decreased self-worth, negatively biased information processing, and increased helplessness; Hankin et al., 2009). Integrative Models of Depression While theories focused on cognition, emotions, and interpersonal functioning are highlighted above, a number of etiological theories of depression focus on integrating these multiple factors, in addition to others (e.g., genetic and neurobiological factors). These integrative models are particularly important in understanding the possible role of parental psychopathology in the development of depression in children. One such theory is Hankin and Abramson s (2001) elaborated cognitive vulnerabilitytransactional stress theory. This theory builds on the basic cognitive vulnerability stress models (i.e., Abramson et al., 1989; Beck, 1987) by positing that the occurrence of an adverse event (e.g., death, conflict in relationships with friend or family) contributes to an increase in initial levels of negative affect (e.g., negative emotions), which can lead to increased depressive symptoms. The model proposes that cognitive vulnerabilities (e.g., dysfunctional attitudes, negative inferential style, rumination) can interact with the negative event (e.g., causing increased hopelessness) to increase depressive symptoms. It also proposes that cognitive vulnerabilities can interact with the initial negative affect. For example, cognitive vulnerabilities might cause the initial negative affect to intensify and thus lead to greater depressive symptoms. Hankin and Abramson (2001) also note that the experience of negative affect might increase the likelihood that negative attributions are applied to negative events. Furthermore, the model posits a transactional component such that the behaviours of individuals experiencing depressive symptoms can generate interpersonal stress (Hammen, 1991). Such interpersonal stress can lead the individual to experience additional negative events which can then restart the process of the development of depression as described by the model (Hankin & Abramson, 2001). Finally, the elaborated model proposes that a genetic risk for depression, certain personality traits (i.e., tendency towards negative affective states), and environmental adversity (e.g., distal negative

20 10 events such as abuse, death of a parent) can increase the individual s susceptibility to experiencing negative events and increased cognitive vulnerabilities. Another integrative model by Goodman and Gotlib (1999) focuses on parental psychopathology (specifically maternal depression) as a risk factor for child depression and four mechanisms through which parental psychopathology imparts this risk on the child. The model also posits that interactions among the four mechanisms will influence how risk is transmitted. The first mechanism is one of genetic risk. Goodman and Gotlib propose that the child of a depressed mother inherits genetic material that increases his or her vulnerability to depression. Genes inherited from the depressed parent are assumed to increase the child s risk of depression by influencing various child characteristics such as biological functioning, personality traits (e.g., negative affectivity), cognitive styles (e.g., negatively biased information processing styles), and environment (e.g., parenting quality). The second proposed mechanism of risk is that children of depressed mothers are born with dysfunctional neuroregulatory mechanisms. Goodman and Gotlib suggest that, in utero, the fetus of a depressed mother is exposed to factors such as neuroendocrine alterations related to the mother s depression. Such factors then lead to abnormal development of the fetus which may emerge as various behavioural traits after birth (e.g., negative affectivity). The third mechanism of risk comprises multiple components. Goodman and Gotlib first posit that the depressed parent experiences negative cognitions, behaviours, and affect which render the parent ill-equipped at fulfilling the child s developmental (i.e., social and emotional) needs. Furthermore, they hypothesize that the child s social and cognitive skills are negatively impacted by this deficient parenting and that the child comes to emulate the depressive cognitive, behavioural, and affective styles of the parent. The child s deficient skills and depressive styles increase his or her vulnerability to depression. Inherent in this proposed mechanism is the concept that maladaptive parent-child interactions, or family dysfunction, may increase the child s vulnerability to depression. Goodman and Gotlib propose a fourth mechanism of risk in which the stressors associated with maternal depression (e.g., stress related to marital conflict, finances, and child-parent relationship) mediate the relationship between maternal and child depression. Lastly, Goodman and Gotlib (1999) propose several moderators of the relationship between maternal and child depression. For example, they suggest that fathers may increase the child s vulnerability to developing psychopathology (e.g., if fathers also have depression) or protect the child from developing a disorder (e.g., if fathers are healthy and have a supportive relationship with the child). They also propose that the child s characteristics (i.e., ability to

21 11 resist stress, coping styles) may moderate the relationship between maternal and child depression. For example, they note that children with easy temperament styles may be less affected by maladaptive parenting styles (e.g., due to greater flexibility). Goodman and Gotlib s proposal that child characteristics such as temperament may interact with the environment (e.g., parenting styles) to produce adaptive or maladaptive psychological outcomes in the child is consistent with other models (reviewed in Sanson & Rothbart, 1995). Similar to Goodman and Gotlib s moderation proposal (1999), Lengua, Wolchik, Sandler, and West (2000) propose that children who display increased negative emotional arousal (e.g., experience greater negative emotions, are more sensitive to negative feedback, or have difficulties regulating their emotions) may be more negatively influenced by adverse parenting styles (e.g., rejection) and, therefore, more prone to difficulties such as depression. Conversely, Lengua et al. suggest that children with a more positive affective style may be less affected by the same negative parenting approaches, due to their greater tendency to experience positive emotions in the face of adversity. The above review provides theoretical support for the examination of emotion, parental psychopathology, and family dysfunction variables as potential precursors of comorbid depression in anxious children. Although other variables (e.g., cognitive, genetic, and biological factors) are also implicated in depression theories, their examination was beyond the scope of the current study. Below, empirical findings supporting the relationship between comorbid depression and emotion, parental psychopathology, and family dysfunction variables are reviewed. Empirical Findings for Characteristics Associated with Comorbid Depression in Anxious Youth Internalizing Symptomatology Overall symptom ratings. Expectedly, children with comorbid anxiety and depressive diagnoses, compared to those with anxiety diagnoses only, have been found to endorse greater overall symptom ratings on reports of depression (Bernstein, 1991; Bernstein & Garfinkel, 1986, Franco et al., 2007; O Neil et al., 2010). A more interesting finding is that comorbid youth tend to endorse greater overall symptom ratings on reports of anxiety, compared to purely anxious youth (Bernstein, 1991; Bernstein & Garfinkel, 1986, Franco et al., 2007; Masi et al., 2000; O Neil et al., 2010; Strauss et al., 1988), suggesting that comorbid depression is related to an exacerbation in reported severity of anxiety symptoms. Studies in which comorbid depression included subthreshold depressive symptoms have also found increased severity of

22 12 symptoms on self and maternal reports of anxiety in the comorbid group, as compared to the purely anxious group (Guberman & Manassis, 2011; Manassis & Menna, 1999). One explanation for the above finding is a possible overlap in the content of items on psychometric instruments commonly used to measure anxiety and depression, such that these instruments are not effective in distinguishing between symptoms of anxiety and depression (Bernstein, 1991; Brady & Kendall, 1992; Seligman & Ollendick, 1998). Seligman and Ollendick (1998) note that significant correlations have been found between self reports of anxiety and depression and such measures tend to contain a sizeable proportion of similar items. Related to the issue of content overlap in assessment measures is the proposal that anxiety and depression in youth do not in fact represent entirely distinct constructs but rather constructs with overlapping features (reviewed in Seligman & Ollendick, 1998). In their review of studies of youth populations employing factor analysis to determine whether anxiety and depression represent one single underlying construct or two distinct constructs, Seligman and Ollendick (1998) conclude that evidence supports the need for a combination of these two models the tripartite model. As described above, a tripartite, or three-factor model, in which the distinctive characteristics of anxiety are represented by one factor (i.e., high physiological arousal), the distinctive characteristics of depression are represented by another factor (i.e., low positive affectivity), and the overlapping features between anxiety and depression are represented by yet another (i.e., high negative affectivity), has been proposed in the adult literature regarding the distinctness of anxiety and depression (Clark & Watson, 1991). Some studies have found evidence for this tripartite structure in youth (reviewed in De Bolle & De Fruyt, 2010). It could be that increased levels of the shared feature of anxiety and depression (i.e., high negative affectivity) may account for the increased anxiety symptoms reported by the comorbid group in the above studies involving youth. In order to address the possibility that anxiety and depression share common symptoms, the current study attempted to control for anxiety symptoms when conducting analyses predicting depressive symptoms. Another possible explanation for the greater reports of anxiety symptoms in comorbid youth than in purely anxious youth is the existence of different sub-groups of anxious youth, with some being more vulnerable to depression than others. For example, Brady and Kendall (1992) suggest that youth with more impairing anxiety symptoms may be at greater risk for developing depression over time than youth whose functioning is less severely impacted by their anxiety. As suggested by Manassis and Menna (1999), this relationship could be mediated by the development of increased depression-related feelings, such as helplessness and despair, in

23 13 more impaired anxious children (e.g., children who display increased avoidance and social withdrawal). Indeed, research has found that greater anxiety symptoms predict later depressive symptoms in young adolescents (e.g., Chaplin, Gillham & Seligman, 2009). In line with this possibility, the current study investigated whether more severe affective symptomatology (e.g., increased negative emotions such as fear or nervousness) in anxious children predicted depressive symptoms, over and above general anxiety symptoms. Affective symptomatology. Depression in youth can be characterized by a variety of symptoms, including affective (e.g., frequent feelings of sadness or irritability), cognitive (e.g., concentration difficulties, negative thought patterns or information-processing styles), behavioural (e.g., decreased interest in activities, social withdrawal, poor school performance), physical (e.g., increased or decreased appetite), and psychomotor (e.g., inability to sit still or slowed body movements) changes that cause impairment in functioning (APA, 2000). Although affective, or emotion-related factors, represent only one component of a depressive profile, examination of the relationship between emotional experiences and comorbid depressive symptoms in clinically anxious children may represent one pathway towards helping to improve understanding of the development of comorbidity and informing intervention practices (Izard et al., 2002). Consistent with the emotion-related theories of depression described above (i.e., Clark et al., 1994; Fredrickson, 2001; Izard, 1991), a number of studies of youth have found a relationship between depressive symptoms and both increased negative emotions and decreased positive emotions (Blumberg & Izard, 1985; Blumberg & Izard, 1986; Carey, Finch, & Carey, 1991; Dougherty, Klein, Durbin, Hayden, & Olino, 2010; Suveg, Hoffman, Zeman, & Thomassin, 2009; Wetter & Hankin, 2009; Zeman, Shipman, & Suveg, 2002). Blumberg and Izard (1985, 1986) conducted two studies with a non-clinical sample of 10- and 11-year-old children. In their first study, they found that a pattern of increased negative feelings (e.g., sadness, self-directed hostility, anger, shame, contempt, fear, shyness) and decreased positive feelings (i.e., joy), were significantly correlated with greater self-reported depression ratings. In their second study, after controlling for anxiety symptoms, increased negative feelings of sadness, self-directed hostility, and anger, as well as decreased positive feelings of joy and interest, were significant predictors of concurrent depressive symptoms. Even after controlling for prior depressive symptoms, lower joy and higher fear predicted future depressive symptoms. This finding is consistent with the proposal that youth experiencing more severe and impairing anxiety symptoms, such as feelings of fear, might be more vulnerable to future depression

24 14 (Brady & Kendall, 1992). Moreover, Blumberg and Izard (1986) comment that the prominent role of anger, in addition to sadness, in the emotional experience of children with depressive symptoms suggests that, unlike the clinical presentations of depressed adults, anger may play a larger role in the diagnosis of depression in children. This idea is consistent with current diagnostic criteria for depression in children, which state that an irritable or cranky mood, instead of a sad or dejected mood, may be present (APA, 2000). Interestingly, in their study of a non-clinical sample of 10-year-olds, Zeman et al. (2002) found that suppression of angry feelings (e.g., feeling angry but not showing it), dysregulation (e.g., expressing feelings in an unproductive and extreme manner) of anger and sadness, and unconstructive coping (e.g., no attempt to calmly deal with angry feelings), were related to greater internalizing symptoms (i.e., both anxiety and depression combined). Suveg et al. (2009) studied a similar non-clinical age group as Blumberg and Izard (1985, 1986) and Zeman et al. (2002). They found that selfreported depressive symptoms, not anxiety symptoms, were related to decreased positive emotions (i.e., interest, enjoyment, surprise), while negative emotions (i.e., sadness, anger, disgust, contempt, fear, guilty, shame, and shyness) were related to both anxiety and depressive symptoms. In a clinical sample of youth between 10 and 17 years of age, with a variety of research-diagnosed psychiatric disorders (including anxiety, depression, and comorbid anxiety and depression), Carey et al. (1991) found that greater negative (e.g., anger, sadness) and lower positive (i.e., enjoyment) emotions predicted depressive symptoms and/or differentiated between youth with and without a depressive disorder. In Dietz et al. s (2008) study, children and adolescents with depressive disorders were observed to display increased negativity and decreased positivity in child-mother interactions during a problem-solving task, compared to healthy children without any diagnoses. Dougherty et al. (2010) found that both observational and parent-reported measures of lower positive emotionality, as evidenced by fewer joyful behaviours (e.g., smiling, laughter, joyful bodily movements) at age 3, predicted higher depressive symptoms at age 10, after controlling for previous internalizing symptoms and negative emotionality. Furthermore, parent reports of higher negative emotionality (i.e., reports of the child s anger, frustration, sadness, fear, discomfort, and low soothability), in combination with lower positive emotionality, predicted greatest depressive symptoms at age 10, suggesting an interplay between the two types of emotions. Research suggests that positive emotions are associated with better coping abilities and recovery from emotionally negative experiences (e.g., Frederickson, 2001). Therefore, Dougherty et al. (2010) propose it could be the case that positive affect acts as a protective mechanism when facing negative experiences and, therefore,

25 15 individuals low in positive affect may be more prone to experiencing greater negative affect and developing greater overall depressive symptoms. Similar to the results of Dougherty et al. (2010), Wetter and Hankin (2009) found that low levels of positive emotionality and high levels of negative emotionality, in a non-clinical sample of 6 th to 10 th graders, each predicted greater levels of future anhedonic depressive symptoms. Furthermore, positive and negative emotionality interacted, such that youth with both low positive and high negative emotionality reported greater depressive symptoms 5 months later. Unlike the samples in the above studies, the current study examined the relationship between comorbid depressive symptoms and positive and negative emotions in a sample of clinically anxious youth, in an attempt to better understand the development of comorbidity in this population. Given that the above studies found that different types of increased negative emotions (e.g., anger and sadness) were related to depressive symptoms, the current study examined separate groupings of negative emotions. Furthermore, in line with the possibility that anxious children with more impairing anxiety symptoms might be more prone to developing comorbid depression (Brady & Kendall, 1992), the current study also examined whether more severe anxiety-related negative feelings (i.e., fear and nervousness) were related to comorbidity. Information processing styles of emotionally negative and positive information. While it was beyond the scope of the current study to examine the cognitive information processing styles associated with comorbid depression, as noted above, it has been posited that the emotional experiences of individuals can influence their thinking and information processing patterns (Hankin & Abramson, 2001; Izard, 1991; Izard et al., 2002). Information processing patterns may also exert a reciprocal effect and influence one s experience of emotion (Hankin & Abramson, 2001; Izard, 1991). Interestingly, consistent with the notion that anxious and depressed children tend to experience increased negative emotions and depressed children tend to experience decreased positive emotions (Clark & Watson, 1991), past research suggests that anxious and depressed children demonstrate similar styles in their processing of emotionally negative and positive information (Gencoz, Voelz, Gencoz, Pettit, Joiner, 2001; reviewed in Jacobs, Reinecke, Gollan, & Kane, 2008; Kagan, MacLeod, & Pote, 2004; Muris & van der Heidin, 2006; reviewed in Vasey & MacLeod, 2001). When presented with ambiguous information (e.g., words, social situations), anxious children tend to interpret it as threatening (e.g., Hadwin, Frost, French, & Richards, 1997; Taghavi, Moradi, Neshat-Doost, Yule, Dalgleish, 2000). Some evidence has also been found for anxious children to display a selective memory bias for negative information (Daleiden, 1998;