Participants
Adolescents
The sample consisted of 58 adolescents (14 males and 41 females, and three adolescents did not disclose their gender). All participants were patients in the psychiatric units of a large children’s hospital in Canada. Participants ranged in age from 13 to 19 years (M = 15.52, SD = 1.41). Approximately 82.1% of the adolescents identified as Caucasian, 10.7% identified as Asian, and the remaining 7.1% identified as First Nations or Hispanic Canadians. All participants had the Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR; APA, 1994) diagnoses of depressive disorders, including Major Depressive Disorder (64.3%), Dysthymic Disorder (16.1%), or Depressive Disorder NOS (19.6%) as assessed by the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1996). Regarding comorbid diagnoses, 25.9% of the participants had a comorbid anxiety disorder, 7.4% had a comorbid behavioral disorder, 5.5% had a comorbid alcohol use disorder, and 1.8% had a comorbid eating disorder. Potential participants with current psychotic symptoms or developmental difficulties were excluded from the study.
Parents
A total of 58 parents (51 mothers and four fathers, and three parents did not identify their gender) participated alongside the adolescents. Parents ranged in age from 30 to 58 years (M = 46.08, SD = 5.74). With respect to marital status, 78.2% of the parents were married or cohabiting, 7.3% were single, 14.5% were divorced, separated, or widowed at the time of the study. Additionally, 20.8% of the parents finished high school or equivalent, 26.4% completed college or technical school, 35.8% acquired undergraduate degrees, and 15.7% received graduate degrees
Measures
Adolescent Diagnostic Interview
The Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version (K-SADS-PL; Kaufman et al., 1996) is a semi-structure diagnostic interview designed to assess current and lifetime episodes of psychopathology in children and adolescents according to DSM-IV-TR criteria. Summary ratings are derived from the interviews with both the adolescent and a primary caregiver and all the relevant information available. The items are rated on a 4-point scale where a score of 0 indicates lack of adequate information and scores from 1 to 3 reflect the degree of symptom severity. Specifically, score 1 connotes lack of symptoms, a score 2 equates to subthreshold levels of symptomatology, and a score of 3 reflects symptoms meeting threshold criteria. If threshold criteria are met for any of the symptoms in the initial screening interview, additional information was gathered during a follow-up interview for an accurate diagnosis.
Diagnostic interviews were conducted by a psychology graduate student or a BA-level psychology student who had undergone extensive trainings in clinical interviewing and the K-SADS-PL administration. Satisfactory inter-rater reliability was established between the two interviewers for 20% of the interviews on symptom ratings (ICC = .97), presence of diagnosis (100% agreement), and assigned diagnoses (86% agreement). Previous research demonstrated that combining parental and adolescent reports of psychopathology, should there be discrepancies, is an effective counter measure (Piacentini et al., 1992). As such, symptoms were considered present if either parent or adolescent endorsed any of the symptoms. In case of discrepant diagnoses arising from inconsistent reports from parent and adolescent, adolescents’ psychiatrist’s diagnosis was used.
Adolescent Alcohol Problems
Adolescents’ alcohol-related problems were measured by the Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989). The RAPI is a 23-item measure assessing the occurrence of specific alcohol-related problems (e.g., “not able to do your homework or study for a test,” “getting into fights,” and “been in trouble with the police for having or drinking alcohol”) in adolescents and young adults. Each item is rated from 0 (none) to 3 (more than 5 times). The RAPI encompasses items assessing a range of negative psychological, social, academic, and physical health consequences associated with alcohol use. The RAPI can be used over various timeframes while maintaining favorable psychometric properties, with test-retest reliabilities ranging from r = .83 (one month) to r = .88 (one year). In this study, adolescents were asked to indicate the number of times they have experienced each alcohol-related problem within the past year. Higher scores indicate greater occurrences of alcohol-related negative consequences.
Adolescent Suicidal Ideation
Adolescents’ suicidal ideation was assessed by the Suicidal Ideation Questionnaire (SIQ; Reynolds, 1987). The SIQ consists of 30 items intended to assess thoughts about suicide in youth during the past month. Adolescents rated the frequency with which each thought occurred to them on a 7-point Likert type scale from 1 (never having the thought) to 7 (having the thought almost every day). Higher scores reflect greater suicide ideation. Internal consistency reliability is high (α>0.95) and test-retest reliability is adequate (r = 0.72) over 4 weeks, a finding that is consistent with the state nature of the scale (Reynolds, 1987).
Parental Perfectionistic Self-Presentation
Parents’ perfectionistic self-presentation was measured by the Perfectionistic Self-Presentation (PSPS; Hewitt et al., 2003). The PSPS is a 27-item scale assessing perfectionistic self-presentation styles in adults, and it consists of the following subscales: perfectionistic self-promotion (10 items, e.g., “I try always to present a picture of perfection”), nondisplay of imperfection (10 items, e.g., “I will do almost anything to cover up a mistake”), and nondisclosure of imperfection (7 items, e.g., “I never let others know how hard I work on things”). Parents responded to all items on a scale from 1 (disagree strongly) to 7 (agree strongly). The three subscales have shown to be internally consistent yet distinct from the trait perfectionism dimensions assessed by the Hewitt and Flett’s Multidimensional Perfectionism Scale (Hewitt & Flett, 1991).
Parent and Adolescent Depressive Symptoms
Symptoms of depression were assessed by the Beck Depression Inventory - 2nd Edition (BDI-II; Beck et al., 1996) for both parents and adolescents. The BDI-II is a 21-item inventory that assesses severity of depression over the past two weeks in adults and youth aged 13 years and above. Symptoms are assessed with a 4-point rating scale for which a rating of zero indicates that a symptom is not present (e.g., “I do not feel sad”) and a rating of three indicates the most severe form of a symptom (e.g., “I am so sad or unhappy that I can’t stand it”).
Parent- and Adolescent-reported Familial Affective Responsiveness
Parents and adolescents indicated their perceptions of family functioning in affective responsiveness using the McMaster Family Assessment Device (MFAD; Epstein et al., 1983). The MFAD is a self-report questionnaire designed to be completed independently by family members over the age of 12 years. The 60-item MFAD consists of six subscales assessing six dimensions of family functioning and a seventh subscale assessing general family functioning. In this study, we focused only on the subscale assessing family functioning in affective responsiveness. The 6-item affective responsiveness subscale evaluates the extent to which the family responds to a range of stimuli with the appropriate quality and quantity of feelings (e.g., “we are reluctant to show our affection for one another”). Participants rate each item on a 4-point scale (1 = strongly agree, 4 = strongly disagree), with higher scores indicating more problematic family functioning.
Procedure
Ethical approval for this study was obtained from the University of XX Behavioral Research Ethics Board and the Children’s and Women’s Research Ethics Board at the university-affiliated children’s hospital serving one of Canada’s largest metropolitan areas. All adolescent participants were currently undergoing psychiatric treatment at the Mood Disorders Clinic at the hospital. Adolescents between the ages of 13-19 and presenting with symptoms of a depressive disorder were identified via chart review and intake interview and invited to participate in the study. The nature of the study was explained as voluntary and confidential. It was also made clear to the participants that their involvement with the study was separate from families’ original reasons for visiting the units, and that a decision not to participate would have no impact on their existing services. After obtaining informed parental consent and adolescent assent for the study, adolescents and their parents completed the diagnostic interview (i.e., K-SADS-PL) and self-report measures in separate sessions. Upon completion of the study, adolescents were provided with a small honorarium in appreciation for their time. Parents were reimbursed for transportation costs incurred during the study. All participants were debriefed at the end of the study.
Analytic Plan
Before conducting further analyses, we examined the data for missing values, univariate and multivariate outliers, the presence of curvilinear relationships as well as for the assumption of normality and collinearity (Tabachnick & Fidell, 2007). Next, to investigate the first two hypotheses that parental perfectionistic self-presentation would be associated with 1) greater perceptions of family dysfunction in affective responsiveness and 2) poorer adolescent psychological adjustment as indicated by measures of depression, suicidal ideation, and alcohol-related problems, we examined zero-order correlation coefficients for the variables of interest.
Then, we tested our third hypothesis that the association between parental perfectionistic self-presentation and adolescent psychological outcomes would be mediated by greater adolescent-reported family dysfunction in affective responsiveness. Because of the small sample size (N=58), we tested three separate models with adolescent depressive symptoms, suicidal ideation, and alcohol-related problems as the dependent variable, respectively. We conducted path analyses with both latent and observed variables and examined indirect (i.e., mediated) effects of our path models. Additionally, parents’ symptoms of depression were covaried in the path analyses to control for the effects of parental depression on adolescent outcomes.
We checked the Chi-square results for significance of the path models and computed parameter estimates using a maximum likelihood estimation method. An optimal model fit was evaluated using the following criteria: a root mean-square error of approximation (RMSEA) of 0.05 or less, an upper RMSEA’s 90% confidence interval bound of 0.08 or less, a comparative fit index (CFI) and a Tucker-Lewis index (TLI) of 0.95 or more, and a standardized root mean squared residual (SRMR) of 0.05 or less (Hu & Bentler, 1999). The magnitude of both path and zero-order correlation coefficients was interpreted according to Cohen’s criteria (small ≥ .10, medium ≥ .30, and large ≥ .50; Cohen, 1988). Additionally, we reported the completely standardized indirect effects to represent the strength of the indirect effect. All indirect effects were subjected to bootstrap analyses with 10,000 bootstrap samples and a 95% confidence interval (CI). A bias-corrected bootstrap 95% confidence interval for the product of these paths that does not include zero provides evidence of a significant indirect effect (Byrne, 2016). All path analyses were conducted using Analysis of Moment Structures (AMOS 26.0; Arbuckle, 2019), while all other analyses were completed by using IBM Statistical Package for Social Sciences (SPSS) v. 26.0. Finally, all statistical tests were two-tailed, and a p value ≤ .05 was considered statistically significant.