Child Maltreatment and Emerging Adulthood: Clinical Populations

Trajectories of Depressive Symptoms in Foster Youth Transitioning Into Adulthood: The Roles of Emotion Dysregulation and PTSD

Child Maltreatment 2014, Vol. 19(3-4) 209-218 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077559514551945 cmx.sagepub.com

Christine E. Valdez1, Brenda E. Bailey1, Alecia M. Santuzzi1, and Michelle M. Lilly1

Abstract Foster youth often experience considerable adversity both in and out of foster care, including histories of abuse and/or neglect, and further stressors within the foster system. These adverse experiences often occur at key developmental periods that can compromise emotional functioning and lead to posttraumatic symptomatology, including posttraumatic stress disorder (PTSD) and emotion dysregulation. In the face of difficult histories and ongoing mental health challenges, youth transitioning into adulthood may be particularly vulnerable to increases in depressive symptoms. We explored the trajectory of depressive symptoms in foster youth from age 17 to 19 using a piecewise linear growth model, examining the effects of PTSD and emotion dysregulation on youth’s depressive symptoms over time. Results revealed depressive symptoms decreased from age 17 to 18 but increased from 18 to 19. PTSD and emotion dysregulation predicted greater baseline depressive symptoms and decreases in symptoms from age 17 to 18, whereas only PTSD predicted increases in depressive symptoms from 18 to 19. Females reported higher levels of depressive symptoms compared to males. Additionally, emotion dysregulation was a stronger predictor of depressive symptoms for females than males. Implications for service delivery for foster youth transitioning into adulthood are discussed. Keywords foster youth, adulthood transition, depression trajectories, PTSD, emotion dysregulation

The majority of all youth in the general population have experienced at least one traumatic event, with prevalence estimates hovering around 60% (McLaughlin et al., 2013). Foster care youth, in particular, have high rates of trauma exposure and are often removed from their family-of-origin home for reasons of abuse and/or neglect. In fact, trauma exposure rates for foster youth approach 90% (Stein et al., 2001), and a sizable proportion (21%) have reported maltreatment while in foster care (Pecora et al., 2003). A recent meta-analysis found high rates of physical abuse (6–48%), sexual abuse (4–35%), emotional abuse (8–77%), and neglect (18–78%), as well as other compromising experiences such as having an unavailable caregiver (21–30%) and parental substance abuse (14–30%; Oswald, Heil, & Goldbeck, 2010). Such childhood maltreatment and adverse experiences often occur at key developmental periods that can compromise a child’s emotional functioning and place them at risk of adverse mental health consequences, which may persist even after their foster care placement. For example, a recent study found that childhood maltreatment was associated with a greater likelihood of mental health disorders across the life span, including

a 10-fold increase in risk of posttraumatic stress disorder (PTSD; Scott, Smith, & Ellis, 2010). In one foster youth sample, Salazar, Keller, Gowen, and Courtney (2013) found the lifetime prevalence of PTSD to be 20% in those who reported physical assault and 33.5% in those who reported sexual assault. Additionally, it has been observed that one in four foster youth still cope with symptoms of PTSD after leaving the foster care system; 25.2% of one sample of foster youth alumni (i.e., former recipients of foster care) aged 20–33 met criteria for PTSD in the past year (Pecora et al., 2005). Given their higher rates of trauma exposure and increased vulnerability due to other stressful experiences created in foster care, it is not surprising that the lifetime prevalence of PTSD is significantly higher among foster youth alumni (30%) compared to the 1

Northern Illinois University, DeKalb, IL, USA

Corresponding Author: Christine E. Valdez, Department of Psychology, Northern Illinois University, PM 400, DeKalb, IL 60115, USA. Email: [email protected]

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general population (7.6%; Pecora, White, Jackson, & Wiggins, 2009). Furthermore, the psychological sequelae of child maltreatment include symptoms that extend beyond PTSD, especially in foster youth. In one study, 94% of foster youth alumni with PTSD were found to have another emotional, behavioral, or physical health condition (Pecora et al., 2009). One common symptom presentation found in child abuse survivors is emotion dysregulation, which occurs with equal, if not greater, frequency than the PTSD symptom constellation (Roth , Newman, Pelcovitz, van der Kolk, & Mandel, 1997). Emotion dysregulation is broadly defined as the tendency to have low-threshold, high-intensity emotional reactions followed by slow return to baseline (Linehan, 1993). It is a relatively distinct feature of childhood maltreatment, which may derive from the disruptive impact of trauma on the child’s development of emotion regulation skills (van der Kolk, 1996). Over 70% of childhood abuse survivors endorse problems in getting upset easily, having trouble calming down, and letting go of upsetting events/ thoughts (van der Kolk, Roth, & Pelcovitz, 1993). Studies have found that the younger the age of onset of trauma and other adverse experiences, the more likely one is to demonstrate a cluster of symptoms that includes emotion dysregulation, in addition to PTSD (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Both PTSD and emotion dysregulation have been found to be associated with other adverse mental health outcomes, particularly depression. In the National Survey of Adolescents, 62% of PTSD cases also met criteria for a major depressive episode in the previous 6 months (Kilpatrick et al., 2003). Additionally, several components of emotion function and dysregulation (i.e., heightened intensity of emotions, poor understanding of emotions, negative reactivity, and maladaptive emotion management) have been found to be positively associated with depressive symptoms in a young adult sample (Mennin, Holaway, Fresco, Moore, & Heimberg, 2007). The aforementioned difficulties can be even more troubling to adolescents navigating transitional periods. Young adulthood is a difficult developmental period, as it is a time fraught with dense transitions in education, living situations, relationships, and employment. These changes can be stressful as youth transition into adulthood, which can adversely impact their mental health, especially if the resources necessary to make such transitions are not available (Osgood, Foster, Flanagan, & Ruth, 2005). Thus, although there are likely multiple genetic and environmental factors involved, the stress-related transition to adulthood may be a significant contributing factor to the increased risk of depression during late adolescence. Studies have shown that prevalence rates for depression steadily increase with age and peak during adolescence and into adulthood (Burke, Burke, Regier, & Rae, 1990; Hankin et al., 1998). In the face of difficult histories and ongoing mental health challenges, youth in transition from foster care to adulthood are a particularly vulnerable population, given their abrupt transition from dependency to the responsibility of self-sufficiency.

Many foster youth are transitioning into adulthood while they are still attempting to process highly traumatic experiences. Additionally, many foster youth do not have emotional, social, and financial support that is typical of young people in the midst of transitioning into adulthood. Thus, foster youth are in particular jeopardy of experiencing negative outcomes and face considerable challenges to secure resources and opportunities needed to lead stable and productive lives. Studies have shown that after entering into independent living, many foster youth alumni fair relatively poor across a number of important domains, including education, unstable employment and economic well-being, mental health, early pregnancy, family formation, and crime and incarceration (Courtney & Dworsky, 2006; Reilly, 2003). Therefore, foster youth are at even greater risk of depression during their transition to adulthood, as they lack critical foundations of relational support and resources necessary to build the emotional security that is essential to face key developmental tasks. It is probable that transitioning into adulthood carries different risks of increasing rates of depressive symptoms in foster youth, depending on a variety of genetic and environmental factors, including biological sex (Ge, Conger, & Elder, 2001), negative life events, and parental depression (Stoolmiller, Kim, & Capaldi, 2005). In fact, Munson and McMillen (2010) observed three depressive symptom trajectory classes in a sample of Missouri foster youth from age 17 to 19, including the majority of youth who maintained low levels of depressive symptoms, those with increasing symptoms, and those with decreasing symptoms. It was found that males, those living on their own at age 17, using substances at age 17, having a family history of mental health problems, and who left care were overrepresented in the increasing depressive symptom trajectory class (Munson & McMillen, 2010). Furthermore, examination of functional outcomes at age 19 found that those who were employed, using alcohol and other drugs, committing crimes, and charged with a crime were overrepresented in the increasing depressive symptom trajectory class (Munson & McMillen, 2010). These results suggest that those who may have been less prepared for the demands of adulthood, as well as those who exhibited antisocial behaviors, were at greater risk of increases in depressive symptoms. Munson and McMillen (2010) advised that additional predictors should be considered when modeling depressive symptoms among foster youth, and ongoing mental health difficulties that are common in this population may be one factor that significantly differentiates depressive symptom trajectories in foster youth transitioning into adulthood. That is, stressful life transitions may be difficult to manage and result in increased depressive symptoms in foster youth struggling with symptoms of posttraumatic stress and associated features of emotion dysregulation, as they transition out of foster care and into adulthood. The purpose of this study is to replicate and extend the study conducted by Munson and McMillen (2010) by examining curvilinear changes in depressive symptoms in their sample of youth preparing to leave the foster care system and transition

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to adulthood, given the challenges of living independently that began midway through the study. To this end, secondary data analysis was conducted on the Mental Health Service Use of Youth Leaving Foster Care (Voyages) 2001–2003 study (McMillen, 2010), which followed a sample of 404 youth from the Missouri foster care system, interviewing them every 3 months from age 17 to 19. The secondary data analysis goals are 3-fold: (1) establish the pattern of change in depressive symptoms before and after 18 years of age, (2) examine sex differences in the change of depressive symptoms before and after 18 years of age, and (3) determine whether PTSD and emotional dysregulation at age 17 affect the change in depressive symptoms before and after 18 years of age. Informed by previous research (e.g., Munson & McMillen, 2010), it is first hypothesized that depressive symptom severity will decrease from age 17 to 18, but that there will be an increase in depressive symptom severity from the age of 18 to 19 as youth struggle with the transition into adulthood. Second, given prior research suggesting sex differences in depression and that sex differentially predicted depressive symptom trajectories examined by Munson and McMillen (2010), it was of particular interest to examine the effects of biological sex on depressive symptom trajectories, though no specific hypotheses were made with regard to sex differences due to inconsistencies in the literature. Finally, it is hypothesized that youth struggling with PTSD and emotion dysregulation will show pronounced depressive symptom trajectories, as they struggle to master the developmental tasks of adulthood.

Method Participants Participants consisted of 406 youth around age 17 (M ¼ 16.99 years, ranging from 16.9 to 17.5) in foster care residing in eight selected counties in Missouri (McMillen, 2010). The sample included 228 (57%) females and 178 (43%) males and consisted of the following racial/ethnic backgrounds: 204 African American (50%), 178 Euro-American (44%), 14 mixed race (3.4%), 4 Latino (1%), 3 American Indian (0.7%), and 2 representing other races (0.5%; McMillen, 2010). Two youth were later excluded because the research team discovered that their IQs were lower than 70, resulting in a final sample size of 404 (Munson & McMillen, 2010).

Measures PTSD diagnosis. PTSD was assessed with the Diagnostic Interview Schedule-Version IV (DIS-IV; Robins, Cottler, Bucholz, & Compton, 1995). The DIS-IV is a structured diagnostic interview schedule designed to assess the recency, onset, and duration of DSM-IV diagnoses (American Psychiatric Association, 2000). PTSD status was dummy coded such that 0 represents no PTSD diagnosis and 1 represents a PTSD diagnosis at initial assessment. In this sample, 7% of youth met diagnostic criteria for PTSD within the previous year (n ¼ 28; 18 female). This is almost double that of the 12-month prevalence rate of PTSD

(3.9%) in the National Comorbidity Survey Replication Adolescent Supplement (Kessler et al., 2012). One person did not have a score for initial PTSD and, thus, was not included in the main analyses. Emotion dysregulation. Emotion dysregulation was assessed by the Affect Dysregulation (AD) subscale from the Inventory of Altered Self-Capacities (IASC; Briere, 2000; Briere & Runtz, 2002). The IASC is a 63-item standardized measure of disturbed functioning in relation to self and others in seven distinct areas: Interpersonal Conflict, IdealizationDisillusionment Abandonment Concerns, Identity Impairment, Susceptibility to Influence, AD, and Tension Reduction Activities. AD refers to problems in emotion regulation and control, which includes mood swings, inhibition problems in terms of anger expression, and difficulty moving out of depressed states without externalization (Briere, 2000). The AD subscale consists of 9 items (e.g., ‘‘Having a hard time calming down once you get started’’) with response options ranging from 1 (never) to 5 (very often). Responses were summed to create a current AD score (9–45), with higher scores indicating greater emotion dysregulation. The AD subscale has been found to have acceptable reliability, with an a coefficient of .89 in a standardization sample and .95 in a clinical sample (Briere & Runtz, 2002). Internal consistency in this sample was .90. Depressive symptoms. Depressive symptoms were assessed with the Depression-Arkansas Scale (D-ARK; Smith et al., 2002; Walter, Meresman, Kramer, & Evans, 2003) of the Depression Outcomes Module (DOM; Smith, Burnam, Burns, Cleary, & Rost, 1994). The D-ARK is an 11-item measure used to assess the experience of depressive symptoms in the past 4 weeks (e.g., ‘‘How often in the past 4 weeks did you have days in which you experienced little or no pleasure in most of your activities?’’). Response options ranged from 1 (not at all) to 4 (nearly every day for at least 2 weeks). Following the directions of Smith et al. (2002), raw scores were transformed to scores scaled from 0 to 100 with scores 30 or greater reflecting clinically significant depression. The percentage of those who reported clinically significant depressive symptoms at the initial interview, age 19, and at the end of the study were 19.5% (n ¼ 79; 59 female), 13.1% (n ¼ 53; 39 female), and 15.3% (n ¼ 62; 40 female), respectively. These rates are somewhat lower than the rates of clinically significant depression (19% in females and 16% in males) as assessed with the D-ARK in a primary care sample under the age of 65 (Walter et al., 2003). The D-ARK has been tested in culturally diverse populations and has evidenced adequate internal consistency (ranging from .81 to .86) and convergent validity, with depressive symptom severity on the D-ARK being correlated with depressive symptom ratings on Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) as well as a factor structure similar to the BDI-II (Walter et al., 2003). Internal consistency of the D-ARK in this sample was .84 at the initial interview.

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Procedure The data used in this publication were made available by the National Data Archive on Child Abuse and Neglect (NDACAN), Cornell University, Ithaca, NY, and have been used with permission. Data were taken from the Mental Health Service Use of Youth Leaving Foster Care (Voyages) 2001–2003 originally collected by Curtis McMillen, Lionel Scott, and Wendy Fran Auslander (McMillen, 2010). Funding for the project was provided by the National Institute of Mental Health (Award Number: 1R01 MH 61404). The original study was funded to explore the changes in mental health service use as older youth leave the foster care system, but the study examined many parameters of the lives of older youth in the foster care system. The study was a longitudinal cohort design. Participants were interviewed every 3 months from age 17 to 19 and invited to participate in a total of nine interviews. Data collection began on December 2001 and ended on June 2003. Few variables were assessed at each interview time point. The outcome variable of interest for this study was assessed across the nine time points. However, the predictors were assessed only at initial assessment and are therefore assumed to be timeinvariant. The collector of the original data, the funder, NDACAN, Cornell University, and their agents or employees bear no responsibility for the analyses or interpretations presented here. Participants were recruited through the Missouri Children’s Division (MCD), the child welfare authority in Missouri. Each month from December 2001 to May 2003, the MCD provided the research team the names and caseworkers of youth who were turning 16.9 years of age and were in the custody and care of the MCD. The MCD foster care case manager was then contacted to provide informed consent. After the case manager consented, youth were contacted and asked whether they wanted to participate. A total of 647 youth were referred to the project, but only 451 were determined to be eligible to participate. Only those participants who were able to speak and understand English, had an IQ above 70, and who were not on ‘‘runaway status’’ for more than 45 days were included. Of the 451 youth determined to be eligible to participate, 406 (90%) were interviewed; 404 participants are included in each imputed data set. The first and last interviews were in person and the data were collected via multiple measures combined together into one survey that was administered in person. Data for Time 2 to Time 8 were collected via telephone interviews. Youth were paid US$40 for the initial and final interviews and US$20 for Interviews 2 through 8. The interviews were conducted by trained interviewers at the youths’ homes or the facilities in which they were living.

Data Analysis Plan A piecewise linear growth model was used to examine the linear rate of change in depressive symptoms as youth transition into adulthood. The piecewise analysis was chosen, as it

Table 1. Standardized Estimates for Unconditional, Quadratic, and Sex Models Predicting Depressive Symptom Scores. Predictors Unconditional model Intercept Phase 1 Phase 2 Intercept and Phase 1 Intercept and Phase 2 Phase 1 and Phase 2 Tests of quadratic growth Intercept Phase 1 Phase 2 Phase 1 Q Phase 2 Q Intercept and Phase 1 Intercept and Phase 2 Intercept and Phase 1 Q Intercept and Phase 2 Q Phase 1 and Phase 2 Phase 1 and Phase 1 Q Phase 1 and Phase 2 Q Phase 2 and Phase 1 Q Phase 2 and Phase 2 Q Phase 1 Q and Phase 2 Q Tests of sex differences Intercept (sex) Phase 1 (sex) Phase 2 (sex)

B

SE B z-score

p

1.27 0.39 0.44 .60 .01 .35

0.10 0.10 0.15 0.06 0.15 0.19

13.22 3.74 3.00 9.86 0.08 1.82

Trajectories of depressive symptoms in foster youth transitioning into adulthood: the roles of emotion dysregulation and PTSD.

Foster youth often experience considerable adversity both in and out of foster care, including histories of abuse and/or neglect, and further stressor...
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