Cognitive Behavioral Intervention for Depressed, Substance Abusing Adolescents

John F. Curry, Ph.D., Karen C. Wells, Ph.D., John E. Lochman, Ph.D.,

W. Edward Craighead, Ph.D., Paul Nagy, M.A.

Battery of Supplementary Assessment Measures of Cognitive, Behavioral, and Family Factors:

Measures of Cognitive Processes and Skill Deficits Associated with Substance Abuse. The following measures were taken from, or adapted from, the work of Botvin and his colleagues (Botvin et al., 1990):

1. Drug Knowledge Measure. This is a 20-item true/false scale to assess knowledge of short-term consequences, and social prevalence of alcohol and marijuana use.

2. Normative Beliefs. Four items were used to measure adolescents' beliefs about the prevalence of alcohol and marijuana use among: (1) adolescents; and (2) adults. Each item asks the adolescent's opinion about how many people in these two age groups use alcohol or smoke marijuana. Responses are rated on a 6-point scale: none, a few, less than half, half, more than half, almost all.

3. Attitudes and Expectancies. Ten items assess attitudes favorable toward the use of alcohol by teenagers, and eleven items assess attitudes favorable toward the use of marijuana by teenagers. Participants were asked if they believe that use of the substance enhances popularity, attractiveness to the opposite sex, and perceived maturity. In work by Botvin and his colleagues (1990) the alcohol scale had an internal consistency reliability of .73 (alpha) and the marijuana scale an internal consistency reliability of .78.

4. Relaxation Skills. Five items taken from the Coping Inventory of Wills (1986) assessed the frequency of each adolescent's use of five different relaxation methods for use when nervous. This scale had internal consistency in the moderate range in Botvin's study (coefficient alpha = .63).

5.  Assertion. Adolescents completed an abbreviated 18-item version of the

Gambrill and Richey (1975) Assertion Inventory, by indicating on a 5-point scale, ranging from never to almost always, how often they engage in each of 18 assertive behaviors. Internal consistency of this scale was moderate (coefficient alpha = .70) in Botvin's study.

B. Measures of Cognitive Processes Associated with Depression.

Automatic Thoughts Questionnaires. (ATQ, Hollon & Kendall, 1980). The 30-item measure of negative automatic thoughts has high internal consistency (alpha = .96) and correlates significantly with depression, low self-esteem and hopelessness in children (Kazdin, 1990). A 30-item version measuring positive thoughts, the ATQ-P, also has high internal consistency (alpha = .95) and high one month test-retest reliability (r = .80) (Ingram, Kendall, Siegle, Guarino, & McLaughlin, 1995). In our study, both positive and negative thoughts were assessed.

Hopelessness Scale for Children. (HSC; Kazdin, Rodgers, & Colbus, 1986). This is a 17-item, True/False scale, measuring negative expectations about the future, a risk factor for suicide. Among emotionally disturbed youths, internal consistency is high (alpha = .84), and among non-referred youths, test-retest reliability is moderate (r = .53) (Spirito, Williams, Stark, & Hart, 1988).

Children's Attributional Style Questionnaire. This 48-item scale presents either positive or negative events to which respondents choose one of two likely causes. The scale yields composite scores of internal, stable, global attributions for positive, and for negative events. We modified the scale very slightly to change several events to make them more age-appropriate for adolescents. The original Children's Attributional Style Questionnaire (CASQ; Seligman, Peterson, Kaslow, Tannenbaum, Alloy, & Abramson, 1984) has moderate internal consistency (alpha = .42 to .73) and good 6 month test-retest reliability (r = .66 to .71) (Gladstone & Kaslow, 1995).

Perceived Competence Scale. This scale (Harter, 1982) reliably measures perceived competence in social, academic, athletic, behavioral, and general realms. The adolescent form was used.

Measures of Family Functioning.

Family Assessment Measure (FAM; Skinner, Steinhauer, & Santa-Barbara, 1995). The FAM is a 50-item questionnnaire, and the respondent is asked to rate the extent to which each statement is characteristic of their family on a 4-point scale. The central family process, and major scale, is Task Accomplishment, or the degree to which a family attains the objectives central to its life. Task Accomplishment is similar to what our treatment program terms "Problem-Solving," i.e., identifying tasks or problems, generating, evaluating, and implementing solutions, and evaluating results. The FAM also measures several processes hypothesized to contribute to successful Task Accomplishment:

Role Performance (members' clarity about and willingness to perform assigned activities)

Communication (clarity of expression and receptivity to communication)

Affective Expression (whether members communicate emotions)

Involvement (the degree and quality of interest of members for one another)

Control (consistency, constructiveness, and responsibility of management style)

Values and Norms (whether rules are explicit and consistent with cultural norms)

Normative data for the FAM is based on 247 normal adults and 65 normal adolescents. Internal consistency reliability of FAM scales ranges from .60 to .87 (alpha). One to two-week test-retest reliability with a sample of 138 families with adolescents ranged from .45 to .72. (Skinner, Steinhauer, & Santa-Barbara, 1995)

Issues Checklist (IC; Robin & Foster, 1989). The IC is a 44-item list of issues that may lead to conflict or disagreement between parents and adolescents. The respondent first indicates whether the issue has been a source of conflict in the previous month, and then rates the intensity of anger generated by the conflict on a 5-point scale. Scores include: (1) quantity of conflictual issues; (2) mean anger intensity of conflicts; (3) weighted average of the frequency and anger intensity of all endorsed issues. Six to eight-week test-retest reliability of IC scores for clinical samples of adolescents and their parents are acceptable to moderately good for the quantity score only, ranging from .49 to .87. All scores were significantly higher in distressed than in non-distressed families.

Conflict Behavior Questionnaire (CBQ; Robin & Foster, 1989; Prinz, Foster, Kent, & O'Leary, 1979). The CBQ measures perceived conflict and negative communication in the family in the two to three weeks preceding the assessment session. Parallel forms are completed by the adolescent and the parent. In two parent families, the adolescent completes two CBQ's, one with reference to each parent. Each form yields an appraisal of the other, and an appraisal of the relationship between the respondent and the other.

The 44-item version (Prinz et al., 1979) was used in our pilot study. It correlates .98 with the 75-item version. Six to eight week test-retest reliabilies of the long form are high for father-adolescent scores (.61 to .85), and moderate for mother-adolescent scores (.37 to .68). All scores are significantly more distressed for clinically referred than for non-referred families (Robin & Foster, 1989).

Perceived Criticism. Two 10-point Likert scales were used to measure the adolescent's perception of parental criticism and of their own criticism toward parents, or parental perception of their criticism of the adolescent and of the adolescent's criticism of them. Hooley (1986) employed this format successfully with marital criticism in a study of depressed patients and spouses.

Measure of HIV-Risk Behavior.

Scale of Sexual Risk-Taking. This 11-item measure was derived from the scale of Metzler, Noell, and Biglan (1992) and measures high-risk sexual behaviors over the lifetime, and in the previous three months

Supplementary Substance Abuse Measure. For our second pilot group we added a well-validated dimensional self-report measure of substance abuse.

Personal Experience Screening Questionnaire (PESQ, Winters, 1991). This 40-item self-report scale includes three sections: Problem Severity, Psychosocial Risk, and Drug Use History. Problem Severity contains 18 items that measure the extent to which the adolescent is psychologically and behaviorally involved with drugs. Psychosocial Risk contains 8 items and measures personal and social problems which are frequently associated with drug use, such as emotional distress, thought problems and victimization by physical or sexual abuse. Drug Use History is a 6-item scale that measures frequency of use over the past 12 months of each of 12 different substances. The PESQ also contains items that measure defensiveness or exaggerated response style. The PESQ major scale, Problem Severity, has excellent internal consistency reliability (coefficient alpha = .90 to .95) across samples of normal, delinquent, and substance abusing adolescents. Validity has been demonstrated by significant group differences in PESQ Problem Severity scores between these three types of adolescent samples, and differences between groups of adolescents referred or not referred for drug abuse evaluation by school personnel (Winters, 1991).

References

Botvin, G.J., Baker, E., Dusenbury, L., Tortu, S., & Botvin, E.M. (1990). Preventing adolescent drug abuse through a multimodal cognitive-behavioral approach: Results of a three-year study. Journal of Consulting and Clinical Psychology, 58, 437-446.

Gambrill, E.D., & Richey, C.A. (1975). An assertion inventory for use in assessment and research. Behavior Therapy, 6, 550-561.

Gladstone, T.R.G., & Kaslow, N.J. (1995). Depression and attributions in children and adolescents: A meta-analytic review. Journal of Abnormal Child Psychology, 23, 597-606.

Harter, (1982). The perceived competence scale for children. Child Development, 53, 87-97.

Hollon, S.D., & Kendall, P.C. (1980). Cognitive self-statements in depression: Development of an automatic thoughts questionnaire. Cognitive Therapy and Research, 4, 383-395.

Hooley, J.M. (1986). Expressed emotion and depression. Journal of Abnormal Psychology, 95, 237-246.

Ingram, R.E., Kendall, P.C., Siegle, G., Guarino, J., & McLaughlin, S.C. (1995). Psychometric properties of the Positive Automatic Thoughts Questionnaire. Psychological Assessment, 7, 495-507.

Kazdin, A.E. (1990). Evaluation of the Automatic Thoughts Questionnaire: Negative cognitive processes and depression among children. Psychological Assessment, 2, 73-79.

Kazdin, A.E., Rodgers, A., & Colbus, D. (1986). The Hopelessness Scale for Children: Psychometric characteristics and concurrent validity. Journal of Consulting and Clinical Psychology, 54, 241-245.

Metzler, C.W., Noell, J., & Biglan, A. (1992). The validation of a construct of high-risk sexual behavior in heterosexual adolescents. Journal of Adolescent Research, 7, 233-249.

Prinz, R.J., Foster, S.L., Kent, R.N., & O'Leary, K.D. (1979). Affective communication differences between distressed and nondistressed mother-adolescent dyads. Journal of Applied Behavior Analysis, 12, 691-700.

Robin, A.L., & Foster, S.L. (1989). Negotiating parent-adolescent conflict. New York: Guilford.

Seligman, M.E.P., Peterson, C., Kaslow, N.J., Tannenbaum, R.L., Alloy, L.B., & Abramson, L.Y. (1984). Attributional style and depressive symptoms in children. Journal of Abnormal Psychology, 93, 235-238.

Skinner, H.A., Steinhauer, P.D., & Santa-Barbara, J. (1995). Family Assessment Measure-III manual. N. Tonawanda, NY: Multi-health Systems.

Spirito, A., Williams, C.A., Stark, L.J., & Hart, K. (1988). The Hopelessness Scale for Children: Psychometric properties with normal and emotionally disturbed adolescents. Journal of Abnormal Child Psychology, 16, 445-458.

Wills, T. (1986). Stress, coping, tobacco, and alcohol use in early adolescence. In S. Shiffman, & T.A. Wills (Eds.), Coping and substance use (pp.67-94). New York: Academic Press.

Winters, K.C. (1991). Personal Experience Screening Questionnaire manual. Los Angeles: Western Psychological Services.