Sally M. Weinstein

Mood Variability and Cigarette Smoking Escalation Among Adolescents

The current study examined how affect dysregulation, as indexed via within-person negative mood variability, related to longitudinal patterns of smoking among adolescents. Students in the 8th and 10th grades (N = 517, 56% girls) provided data on cigarette use at baseline, 6-, and 12-month waves and provided ecological momentary assessments of negative moods via palmtop computers for 1 week at each wave. Mood variability was examined via the intraindividual standard deviations of negative mood reports at each wave. As predicted, high levels of negative mood variability at baseline significantly differentiated participants who escalated in their smoking behavior over time from participants who never progressed beyond low levels of experimentation during the course of the study. Mixed-effects regression models revealed that participants who escalated in their smoking experienced a reduction in mood variability as smoking increased, whereas participants with consistently high or low levels of cigarette use had more stable mood variability levels. Results suggest that high negative mood variability is a risk factor for future smoking escalation and that mood-stabilizing effects may reinforce and maintain daily cigarette use among youths.

The Time-Varying Influences of Peer and Family Support on Adolescent Daily Positive and Negative Affect

The time-varying influences of peer and family support on adolescent daily mood were explored among youth transitioning from middle school to high school (8th to 9th grade, N = 268) as compared to youth transitioning from 10th to 11th grade (N = 240). Real-time measures of daily positive and negative affect (ecological momentary assessments) were collected via palmtop computers at baseline, 6 months, and 12 months. Participants rated 12 mood adjectives in response to 5 to 7 random prompts per day for 7 consecutive days. Perceived peer and family support were assessed via self-report. Mixed-effects regression analyses revealed significant grade by time by peer support interactions for positive and negative mood, with the younger cohort showing greater increases in the relation between peer support and affect over time than the older cohort. Family support did not interact with cohort or time.

Treatment Moderators of Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder

OBJECTIVE Prior work has demonstrated the efficacy of child- and family-focused cognitive-behavioral therapy (CFF-CBT) versus enhanced treatment as usual (TAU; unstructured psychotherapy) for pediatric bipolar disorder (PBD). The current study builds on primary findings by examining baseline child, parent, and family characteristics as moderators of symptom response trajectories. METHOD A total of 69 youth aged 7 to 13 years (mean = 9.19 years, SD = 1.61 years) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) were randomly assigned, with family members, to CFF-CBT or TAU. Both treatments consisted of 12 weekly sessions and 6 monthly booster sessions. Participants were assessed at baseline, 4, 8, and 12 weeks, and 6-month follow-up on mania and depression symptoms and overall psychiatric severity. Parents and youth also provided self-report data on baseline characteristics. RESULTS CFF-CBT demonstrated greater efficacy for youth depressive symptoms relative to TAU for parents with higher baseline depressive symptoms and lower income, and marginally for families with higher cohesion. In addition, youth with lower baseline depression and youth with higher self-esteem showed a poorer response to TAU versus CFF-CBT on mania symptom outcomes. Age, sex, baseline mania symptoms, comorbidity, and suicidality did not moderate treatment response. CONCLUSION Results indicate that CFF-CBT was relatively immune to the presence of treatment moderators. Findings suggest the need for specialized treatment to address symptoms of PBD in the context of parental symptomatology and financial stress.

Co-morbid Disruptive Behavior Disorder and Aggression Predict Functional Outcomes and Differential Response to Risperidone Versus Divalproex in Pharmacotherapy for Pediatric Bipolar Disorder

OBJECTIVE Co-morbid diagnoses, such as disruptive behavior disorders (DBDs) and high levels of aggression, are extremely common among youth with pediatric bipolar disorder (PBD) and may interfere with treatment response; however, they have rarely been examined as predictors of response to pharmacotherapy. The current study examines co-morbid DBD and aggression prospectively as predictors of pharmacotherapy outcome, as well as potential moderators of response to a specific medication (risperidone vs. divalproex), among children with PBD. METHODS Data are from a prospective 6-week double-blind, placebo-controlled, randomized outpatient medication treatment trial of risperidone versus divalproex for manic episodes in 65 children 8-18 with PBD. Outcome measures were administered at pretest, post-test, and weekly during the 6 weeks of treatment. Mixed-effects regression models were used to examine pharmacotherapy response. RESULTS Results indicated that youth with co-morbid DBD experienced greater improvement in manic symptoms in response to risperidone versus divalproex, whereas youth with non-co-morbid DBD experienced similar trajectories of symptom improvement in both medication groups. In addition, the non-DBD group experienced greater improvement in global functioning over time as compared with youth with co-morbid-DBD, and this gap increased over the course of treatment. Results also indicated that high-aggression youth experienced worse global functioning by end treatment versus low-aggression youth. CONCLUSIONS In conclusion, a co-morbid diagnosis of DBD and/or high levels of aggressive symptoms in youth with PBD may be important clinical predictors of variation in treatment response to pharmacotherapy. These findings may help researchers and clinicians develop tailored treatment approaches that optimize symptom and functional outcomes.

Dynamic Associations of Negative Mood and Smoking Across the Development of Smoking in Adolescence

Self-medication models of smoking posit that the emotional benefits of smoking reinforce and maintain cigarette use, yet research demonstrates both positive and adverse affective consequences of smoking. The current study examined longitudinal changes in adolescent mood variability and overall negative mood at various stages of smoking behavior to inform understanding of the etiology of adolescent smoking. Participants included 461 adolescents (M age = 15.67 years, SD = 0.61; 55% girls, 56.8% White) drawn from a longitudinal study of adolescent smoking. Youth provided data on smoking behavior at baseline and a 15-month follow-up wave. Ecological momentary assessments were used to measure overall levels of negative mood as well as within-person mood fluctuations (i.e., negative mood variability) at each wave. Findings revealed that smoking–mood relations vary across different stages of smoking behavior. Youth who rapidly escalated in their smoking during the study experienced improved mood regulation (for girls) and improved overall mood (for boys) as smoking increased. However, mood improvements were not observed among youth with sustained heavy use and symptoms of dependence. The current data argue for a model of smoking that accounts for changes in risk and maintenance factors at different points along the developmental trajectory of smoking, involving elements of both self-medication and dependence.

Cognitive and family correlates of current suicidal ideation in children with bipolar disorder.

BACKGROUND Suicidality among youth with bipolar disorder is an extreme, but largely unaddressed, public health problem. The current study examined the psychosocial characteristics differentiating youth with varying severities of suicidal ideation that may dictate targets for suicide prevention interventions. METHODS Participants included 72 youth aged 7-13 (M=9.19, SD=1.61) with DSM-IV-TR bipolar I, II, or NOS and a parent/caregiver. Current suicidal ideation and correlates were assessed at intake, including: demographics and clinical factors (diagnosis, symptom severity, psychiatric comorbidity); child factors (cognitive risk and quality of life); and family factors (parenting stress, family cohesion, and family rigidity). RESULTS Current ideation was prevalent in this young sample: 41% endorsed any ideation, and 31% endorsed active forms. Depression symptoms, quality of life, hopelessness, self-esteem, and family rigidity differentiated youth with increasing ideation severity. Separate logistic regressions examined all significant child- and family-level factors, controlling for demographic and clinical variables. Greater family rigidity and lower self-esteem remained significant predictors of current planful ideation. Diagnosis, index episode, comorbidity, and mania severity did not differentiate non-ideators from those with current ideation. LIMITATIONS Limitations include the small sample to examine low base-rate severe ideation, cross-sectional analyses and generalizability of findings beyond the outpatient clinical sample. CONCLUSIONS Findings underscore the importance of assessing and addressing suicidality in preadolescent youth with bipolar disorder, before youth progress to more severe suicidal behaviors. Results also highlight child self-esteem and family rigidity as key treatment targets to reduce suicide risk in pediatric bipolar disorder.

Psychosocial intervention for pediatric bipolar disorder: current and future directions

Pediatric bipolar disorder (PBD) affects approximately 2% of the population and disrupts mood regulation, psychosocial functioning and quality of life among affected youths and families. Given the significant psychosocial impairment and poor long-term prognosis associated with PBD, psychosocial intervention is considered to be an essential component of a multimodal treatment approach. This relatively young field of research has witnessed significant growth in the evidence base for psychosocial treatments targeting youths in the past decade, particularly family-based interventions grounded in a biopsychosocial framework. This article reviews existing empirically supported interventions for children and adolescents with PBD. Common elements of successful interventions are identified, and future research directions to address current limitations in the field and advance understanding of treatment for PBD are discussed.

Mediators in the randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy for pediatric bipolar disorder.

Mediation analyses can identify mechanisms of change in Cognitive-Behavioral Therapy (CBT). However, few studies have analyzed mediators of CBT for youth internalizing disorders; only one trial evaluated treatment mechanisms for youth with mixed mood diagnoses. This study evaluated mediators in the randomized trial of Child- and Family-Focused CBT (CFF-CBT) versus Treatment As Usual (TAU) for pediatric bipolar disorder (PBD), adjunctive to pharmacotherapy. Sixty-nine children ages 7-13 with PBD were randomly assigned to CFF-CBT or TAU. Primary outcomes (child mood, functioning) and candidate mediators (family functioning, parent/child coping) were assessed at baseline and 4-, 8-, 12- (post-treatment), and 39-weeks (follow-up). Compared with TAU, children receiving CFF-CBT exhibited greater improvement in mania, depression, and global functioning. Several parent and family factors significantly improved in response to CFF-CBT versus TAU, and were associated with the CFF-CBT treatment effect. Specifically, parenting skills and coping, family flexibility, and family positive reframing showed promise as mediators of child mood symptoms and global functioning. Main or mediating effects for youth coping were not significant. CFF-CBT may impact childrens mood and functioning by improving parenting skills and coping, family flexibility, and family positive reframing. Findings highlight the importance of parent coping and family functioning in the treatment of PBD.

Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes

Non-suicidal self-injury (NSSI) in childhood is not well documented, especially among youth with pediatric bipolar disorder (PBD). The current study evaluated prevalence and correlates of NSSI, and its impact on intervention response, in a randomized trial of Child- and Family-Focused Cognitive-Behavioral Therapy (CFF-CBT) versus Treatment As Usual (TAU), adjunctive to pharmacotherapy. This study included 72 children ages 7–13 (58% male) with PBD. NSSI and correlates were assessed at baseline; mood and psychiatric severity were measured longitudinally. NSSI was common: 31% endorsed NSSI behaviors; 10% reported thoughts of NSSI, in the absence of behaviors. Children engaging in NSSI reported higher depression, psychosis, suicidality, and hopelessness; lower self-esteem; and reduced family help-seeking in univariate analyses. In a multivariate logistic regression, high child depression and psychosis, and low family help-seeking, remained significantly associated with baseline NSSI. In mixed-effects regression models, presence of NSSI at baseline did not influence the response of depressive symptoms to treatment. Children who endorsed NSSI experienced steeper response trajectories for psychiatric severity, regardless of treatment group. Youth who denied NSSI showed poorer response to TAU for manic symptoms; mania trajectories in CFF-CBT were similar across youth. Thus, NSSI in PBD is common and associated with impairment. As children might engage in NSSI for different reasons, the function of NSSI should be considered in treatment. Since children without NSSI fared worse in TAU, it may be important to ensure that youth with PBD receive structured, intensive interventions. CFF-CBT was efficacious regardless of NSSI, and thus shows promise for high-risk children with PBD.