- 297-772-7113,:7.7“};7-777-773-7727
3 3‘ 3 $7?“ 1“, ‘3, 33““ “1va .3 :““‘7 ‘9‘- 71,73”? ‘ 3 .3 .
”I-fi‘hfl I'WW‘ I7 -
1 3 ”"4 ‘1.“‘33233—3‘3333 33kg“; ‘3‘373‘3‘1‘ ‘(3‘1 71‘3-73?‘
3% 3“?” w} 57
917711773“, ,3,“ '7

  
  
    
   
 

     
    

'3_,‘ 7
’7"" ‘3"! ’77}; .'

  

  
  
 
 
 
 
   
   
  

   
   
 

  

   

73

J 71.3;

'7“ 177
.7!“‘,. “ 7‘3 3.,

30.,7
3‘ 'IO '31:}?

7 53' . 7.- 7". I
“V N ’ “7’0”“2747 "31'7““ ‘33“
3| k 13% 77 7‘ 31" "3‘13, “1 ”£313

#313 ‘33:.“ 33,5.

.5

33‘5“” 7 3““ .3“
u ‘. 37,-; ,
.‘ Ili‘é‘r‘ ‘33:: ‘1‘];

 
      

    
   

   
       

  
 
  
   
    
   
   
   
  
      
  
 

  

.
Q
4:“

’7'}? ~

r‘ 7

3..-.

 
 
 

'.7 '0 4 ,
1;.
'a-u'

.— ex.
.' 'L -
kt”
'. a

I .3"- 4
. .‘

  

  

. .
i
7"}:

4L.

     
 
 
 
 
  
      
  
   

   

.3
v
\.

 

  
  
   

3 7 :
73131.13- .“: 37:10., .
77737427"

33113137171.
‘57.,

 
  
  
 
 
 
 
   
  
         

 
  

   
    
   
 

   

     

   

   

  
 

   

   
  
 
  

 

4%?

~ 3r,

  

  
     
   
      
  
     
   
  

-7:.

. 7 3;",-
‘1‘": #:7777343" .:‘:'7 ‘1‘ 323,3
4 77777-7 77-. 272-. 777.7.
3" ”3373‘“ 3‘3 - 957‘ 33?: 3‘7, _7.77i‘75.7,§., .73,"
. 7 “3“,- ‘ l W 0.7.310: .3? , _ -. ‘71,:13271“ -; '7. “‘5.
' " 131“" .‘k‘ 2:3,: ‘3?“‘37‘3‘? 3‘ - ‘ xggi’ 79,: ""‘7, 33:3 \
- 7-:- 3“. 3377‘ " 37‘, 72737.73 .7 ' "-330 3g. 5%! @7437,
II 7 3 '72”. ~ “37379.?!" {.4 ' 425-1377;" 7'7' 7-,
- 3,, 77‘
77
'7

:1!“
”3:. v y.

    

  

   

 
  
    

 
  

  
    

  
  
 
  

 
    
  

  
  
  
 

  
 
   
 
 
 
 
   

    

. fl '
. ' 3
7 ‘ z 3'3; 33333.
2 '3 “3
73 773‘ 77.337771
I ‘ 3‘, 0‘3 '3‘
7 .
-‘. ‘3
7 xi" . .- .' .. .T': 7 5’ 3:3‘7 ‘7‘,"
7 7:. 7' ‘7 7.. 7. . . {.9 7 7-- - - 77 7‘77“"““‘ a
5' 7,, . . t . Y ._ 37",": ”72",} 75:7 7*." $5.1m. £333., 7 "1 {,3 :‘zg‘azg “N331-
. 7 77- '- ~ g 7 77777-- - 77722
7 7’: 7‘“. .. :4 377‘ 7317‘ 7 7 7- - 7““
'7' 7775-. 77773772272777 7‘ “ii-‘7‘, 72727777-
_. 7- :. 7~ 7,3737 . ,
713-07 573337575, ' 3337‘3‘
. 'fi‘uwm77 a 27
"7 --777 7‘. ‘1' ' ‘3 3 3

ME- 77722777
7 3 ._

7‘7‘
313 3: £15.":

     
 

“7‘.7 .0..."
“:3 '7‘33- .3 3"

 

 

   

.—'—
. .a ’AA '
A v-' ..\ ‘

‘1:
‘37‘33'379‘l. “73337
7“'

  
  
      
   
   
     
   

  

77
£7v7

. :‘73‘ 7" :7 ‘7,

'3"

1373 ,7
“I'VE? ,333‘

    

‘3
“77"7'
3,7,7, 7

   
 

"-l

 

7&3

xi71. ’3
“3“ 3"“.
77“. A '27

 

.7
H

71 .l “71:435.
.,y%mn¢7.

3v:-

    
  

 

‘
b-
..—__
J-pr— g
74";-
5.7-2.2:
fr
7.5;»—
v:—

   
  
 
  
 

   

       
     
 
 
 
  

  
 
  
 
  

      

 

    
    
   
 

7 . ,r'. 7':

1“ : ‘,| 7\“‘ ,7“ 7773 ‘3,’ “‘5 c!

"I 3 ‘ "7‘ - 133.3‘l 7 3‘ “71‘73‘33” ‘3”‘ 3.3"; 3:333 3717 I“ ;' '3

‘7 3i 39.11717, ‘ ‘I.37,‘:7‘g;‘,3. ‘77 _',|. ' “‘3‘,“ ‘ 77 337'“ 7 _!‘-7 3‘9‘3‘ 1. 3’ ‘3‘ 7 3‘ ”~31“. .3 3'
“"“k‘ “‘7‘,‘ $3.33 Eiléi‘lkfl. "1“;37,‘ 7,7‘;‘37,‘.3“, '33". ‘7‘3‘37‘f‘s- _ :3“ 3,3,3," 7‘13}; . T" 72976:; ,7“,7 , ‘. 7
77777-777777717777717777:757'.773.777777".7777717777277 “ .-, 7-7772 .
““7“: 3‘7“.” 7“.“‘“31'7'§777‘,“,1 “7" ‘3‘ 3L"3‘ 7:1“, l“ "7 3 " ‘ 2“‘7“‘.‘3~J 7‘ ‘7'- [7- 71,3?

..
4
It.

  

‘7“M,,,33m¢

u "7' ‘ ““3033: '

   
 

$2!

7 7'17 7:
77773“ 377375-3122
,7; 91‘!3'.‘3‘h 77-73;,» ~
.7? g‘mki) ‘ A“ ‘.
“"36... . 'l“ _.

 
 
 

    
 
 
 
 

 

'77:... 7-7», 5
77373733377“ '
Wat 3“ 3‘ 3 33%
“17‘3‘,“3“33“Lt£,‘1,:, me‘ik 3,331?"

7 ‘33,}..‘7,
‘7‘“,
.~‘ 371%
3

.7 37'7.-,I
777 7.7 577777 7 37

- Wq-
‘7 ‘ -:'.'""-" 'r‘ 7:33-59»?

3 3 ". -‘ “‘3‘“ 3333‘3333. ‘37 : 7"7":"'7l "' 7‘3 33317‘“777777323‘.l ‘ "
.. ‘77 77.3372‘7777‘t77’777‘7‘27‘77.. .77.77.77771‘7'7'7.7‘77'=..‘7-‘ ’."7-‘-‘.-"7‘7'7‘ 77‘7- “7'7”? .‘777' 2“ '

 

 

ANSTAT TEU

:l IUIHIHIWUllllmlmllllllll“HI

293 01568 0055

LIBRARY

Michigan State
University

                                

 

 

 

 

 

 

 

 

 

This is to certify that the

dissertation entitled

Shame, Symptom- Expression, and
Destructive Behavior in Adolescent Depression

presented by
John Anthony Loraas

has been accepted towards fulfillment
of the requirements for

Ph . D . degree in Psychology

Aimkflm

ajor professor

Date A3l/‘Q \Sl/q -}

MS U is an Affirmative Action/Equal Opportunity Institution 0—12771

 

PLACE ll RETURN BOX to remove thie checkout from your record.
TO AVOID FINES return on or before date due.

DATE DUE DATE DUE DATE DUE

W T
m 11.912902 11W 01 no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU to An Affirmative Action/Equal Oppottunity Inetitution
W

 

SHAME, SYMPTOM-EXPRESSION, AND DESTRUCTIVE BEHAVIOR
IN ADOLESCENT DEPRESSION

By

John Anthony Loraas

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

1997

ABSTRACT

SHAME, SYMPTOM-EXPRESSION, AND DESTRUCTIVE BEHAVIOR
IN ADOLESCENT DEPRESSION

BY

John Anthony Loraas

Questionnaire data, projective testing, and a semi—
structured suicidal interview were utilized in this study of
inpatient adolescents (n = 89) examining the relationships of
both conscious shame and unconscious shame to depression and ways
of c0ping with emotional turmoil. A new assessment tool--the
Shame Rating Scale (SRS; Loraas, l994)—-was developed and used to
tap the dimension of unconscious shame. Two independent raters
used the SRS to evaluate projective test protocols for shame-
themes, and also used a suicide rating scale to assess lethality
of adolescent suicide attempts.

Results indicate that depression, conscious shame, and
suicidal ideation are highly related psychological constructs
which have implications for coping and behavioral patterns among
male and female, inpatient teenagers (ages 13 to 15 years).
Special emphases are placed upon an expected 2—way interaction
between unconscious shame and conscious shame in predicting
externalization and an unexpected 2-way interaction between
conscious shame and gender in predicting suicidal ideation. No

support was found for the hypothesis that risk—taking behaviors

were related to high levels of externalization, high unconscious
shame, and low conscious shame. The final hypothesis addressing
whether suicide attempts would be most severe among adolescents
with high levels of externalization, high unconscious shame, and
high conscious shame could not be tested because very few
participants actually undertook highly lethal suicide attempts.
Overall, the study's findings are deemed valuable because they
underscore the importance of assessing both accessible and
nonaccessible emotional experiences and provide an empirical way

of investigating "masked" or concealed emotional experiences in

young adolescents.

In memory of my father and
in honor of my mother.
Both were educators who, by silent example,

instilled in me the value of education.

iv

ACKNOWLEDGMENTS

This dissertation represents the completion of a
research project initially begun in 1993. However, nearly
three-and-a—half years later I remain keenly aware of the
many people who provided support and assistance to me along
the way.

First, I am grateful Dr. Susan Frank who served as the
Chairperson of my dissertation committee. During the early
stages of this project Dr. Frank was instrumental in getting
me to narrow my topic and to think critically about it. As
the study progressed, Dr. Frank remained interested in my
efforts, and was very giving and generous with her time,
especially during the periods of data analysis and
manuscript writing. Dr. Frank's insights and high standards
for excellence are imprinted throughout this dissertation.

In addition, I would be remiss if I did not mention the
influence that Dr. Frank has had upon me as a clinical
psychologist. Between 1989 and 1994 Dr. Frank served as one
of my clinical supervisors, and taught me how to
insightfully interpret clinical data, how to write high-

quality psychological reports, and how to work effectively

with challenging and difficult-to-treat children,

adolescents, and families. Dr. Frank and I have always had
a strong working relationship, and I am sincerely thankful
for the guidance and support she has offered me over the
years.

Secondly, I would like to thank Dr. Gary Stollak for
all that he has done for me since I first arrived in East
Lansing. Dr. Stollak, who was a member of my Dissertation
Committee, was the Chairperson of my Ph.D. Guidance
Committee, and I completed my Master's Thesis under his
direction in 1991. Over the years Dr. Stollak has served as
a clinical supervisor and course professor. But, above all
this, Dr. Stollak was an individual who took an interest in
me early on and was always available to talk.

Thirdly, I am much appreciative of the efforts of Dr.
Joel Aronoff and Dr. Gershen Kaufman, the third and fourth
members of my Dissertation Committee. My working
relationship with Dr. Aronoff began in 1989 when I started
collecting data for my Master's thesis. From Dr. Aronoff I
learned the importance of slowing down and thinking through
the details in conceptualizing and carrying out a research

study. Although Dr. Aronoff may not recall a conversation

vi

he had with me in his Baker Hall office in the early 19905,

this discussion was valuable. Dr. Aronoff spoke about the
importance of every person having "a passion" in terms of
their life's work. This sage advice was quite timely, and
helped me to evaluate how I wanted to position myself for
the future.

Unfortunately, my working relationship with Dr. Kaufman
did not begin until late in my graduate school career (1993-
94) when I decided to focus my dissertation on the role of
shame in adolescent depression. I had reviewed Dr.
Kaufman's excellent books on shame as part of my background
readings on the topic. I am grateful that Dr. Kaufman, a
recognized authority on shame, agreed to serve on my
committee. He made several helpful suggestions during the
early stages of the study, and was instrumental in helping
me clarify my thinking about the Shame Rating Scale (SRS:
Loraas, 1994).

Fourth, I would like to acknowledge the efforts of
other persons who assisted me in the course of this
project. Ms. Sondra Wilen, M.A., served as my
psychometrician. She did an excellent job working with the

teenagers, collecting the data, and keeping everything

vii

organized. I am deeply indebted to her. I also would like
to thank Ms. Jennifer Paul, M.A., and Mr. Mikhail Lyubansky,
M.A., for their work in coding and rating the projective
stories and the suicidal history interviews.

Fifth, I would like to thank Rivendell of Michigan, the
child and adolescent psychiatric hospital in St. Johns where
the data for this study was gathered. Although many
Rivendell staff persons, especially those in the Admissions
office, helped to make data collection easier, I would like
to thank Dr. Daniel Field, Medical Director, and Dr. John
Taylor, Director of Psychology, for their interest in my
dissertation topic as well as their friendship and support
over the past few years.

Sixth, I am grateful to the many teenagers who agreed
to participate in this study. All of these individuals were
hospitalized due to depression and associated behavioral and
emotional problems. Their willingness to complete the
assessment battery and to share information about themselves
made this study possible.

Seventh, I am deeply indebted to two people affiliated
with the University of Minnesota--Twin Cities: Mr. Jon

Hubbard, M.A., Ph.D. Candidate, and Dr. Norman Garmezy,

viii

Professor Emeritus. Jon assisted me with statistical
analyses and data management. Although Jon and I knew each
other briefly as undergraduates at Minnesota, our friendship
was solidified during the 1995—96 academic year when we
completed our Predoctoral Clinical Psychology Internships at
Hennepin County Medical Center in Minneapolis. Jon is a
unique, bright, and highly talented individual; I am deeply
appreciative of his time and efforts. In addition, I have a
strong respect for my undergraduate Honors mentor at
Minnesota, Dr. Garmezy. A pioneering figure in stress-
resilience, Dr. Garmezy urged me to attend Michigan State in
1989.

Finally, I am most grateful for the support that my
family has given me over the years. Most notably, I wish to
acknowledge the love and patience of my wife and treasured
companion, Kathy Jo. She has always encouraged me to set
goals, and has worked with me to reach them. Moreover,
during the completion of this dissertation, Kathy Jo kept
our boys, Alex (age 5) and Gabriel (age 3), busy on the

weekends and during the evenings so that I could write.

ix

TABLE OF CONTENTS

LIST OF TABLES O O O O O O O O O O O O O O O O O O O O O O 0 v
LIST OF FIGURES O O O O O O O O O O O O O O O O O O O O 0 .Vi
I 0 INTRODUCTION 0 O O O O O I O O O O O O O O O O O O O 1

II. ADOLESCENT DEPRESSION. . . . . . . . . . . . . . . . 5
Early Stumbling Blocks . . . . . . . . . . . . . . 5
Symptoms, Prevalence, and Gender Differences

in Depressive Disorders. . . . . . . . . . . . . 7
Coping Styles, Depression, and Comorbidity . . . .12
Coping Failures: Suicidal Ideation and

Attempts. . . . . . . . . . . . . . . . . . . . 15

III. SHAME. . . . . . . . . . . . . . . . . . . . . . . .19

The Painful Emotion of Shame and Its Relationship

to Depression. . . . . . . . . . . . . . . . . .19
Shame versus Guilt . . . . . . . . . . . . . . . .21
Sources of Shame in Adolescence. . . . . . . . . .22
The Internalization of Shame from an

Interpersonal to Intrapersonal Experience. . . .25
Shame, Coping Styles, and Defensive Maneuvers. . .29
Risk—Taking, Depression, Shame, and Indirect

Suicidal Behavior. . . . . . . . . . . . . . . .33

IV. SUMMARY OF LITERATURE REVIEW . . . . . . . . . . . .38

V. HYPOTHESES . . . . . . . . . . . . . . . . . . . . .41
Hypothesis 1A. . . . . . . . . . . . . . . . . . .41
Hypothesis lB. . . . . . . . . . . . . . . . . . .41
Hypothesis 2 . . . . . . . . . . . . . . . . . . .42
Hypothesis 3 . . . . . . . . . . . . . . . . . . .42
Hypothesis 4 . . . . . . . . . . . . . . . . . . .43

VI. METHOD . . . . . . . . . . . . . . . . . . . . . . .43
Participants . . . . . . . . . . . . . . . . . . .43
Measures . . . . . . . . . . . . . . . . . . . . .45
Procedures . . . . . . . . . . . . . . . . . . . .56

VII.

VIII.

IX.

RESULTS .

Measurement
Demographic
Test of the

DISCUSSION.

Summary

Limitations

APPENDICES
Appendix
Appendix
Appendix
Appendix
Appendix

A.
B.
C.
D.
E.

Issues.
Variables .
Major Hypotheses.

of

The

LIST OF REFERENCES.

Current St dy.
The Importance of The Current Study

xi

.66
6G
61
65

73
73
81
84

87
89
91
93
95

97

LIST OF TABLES

Table l-Characteristics of the Sample . . . . . . . .
Table 2—FISCA Level of Impairment: An Example. . . .

Table 3-Interrater Agreement for Unconscious Shame
Scores for the 11 Roberts Cards . . . . . .

Table 4—Adolescent Measures and Internal Reliability
Coefficients for the Questionnaire Measures

Table 5-Correlation Coefficients among the Variables
Used to Test the Research Hypotheses. . . .

Table 6—Hypothesis 1A: Correlations between Coping
Mechanisms and Depressed Mood and Conscious
Shame Scores. . . . . . . . . . . . . . . .

Table 7-Lethality Ratings of Suicide Attempts
(11:40). 0 e e e e e e e e e e e e e e e e

xii

LIST OF FIGURES

Figure l-Hypothesis lB: Interaction between Unconscious
Shame and Conscious Shame . . . . . . 69

Figure 2-Hypothesis 2: Interaction of Conscious Shame
and Sex .

O O O O O O O O 0 7g

xiii

I. INTRODUCTION

Adolescence is often viewed as a period of emotional
instability and behavioral disorganization. This
perception, adhered to by many professional and lay persons
alike, has its historical roots in the seminal work of G.
Stanley Hall (1964), an early pioneer in the field of
developmental psychology. Hall believed that the rapid
physical, cognitive, and social changes that characterize
the teenage years have an adverse effect upon the
adolescent's psychosocial functioning. As a result, he
postulated a storm—and-stress model in which unpredictable
behavior, acute emotional distress, and rebellion against
parental and other adult authority were viewed as normative
phenomena of adolescence.

Hall's model of adolescent development was widely
accepted among developmental and clinical investigators for
most of the 26th century (Sisson, Hersen, & Van Hasselt,
1987). However, during the 19603 and early 19795, the
theory of storm—and-stress was challenged by researchers
(Douvan & Adelson, 1966; Offer & Offer, 1975: Weiner and Del

Gaudio, 1976) who demonstrated empirically that emotional

turmoil was not the sine qua non of the teenage years. It

 

is now generally acknowledged (Ingersoll & Goldstein, 1995:
Peterson et al., 1993: Golombek & Marton, 1992) that most
adolescents do not develop major psychiatric, behavioral, or
emotional disorders, and that they are able to maintain
positive relationships both with immediate family members
and peers.

Although chronic maladaptive behavior and intense
emotional turmoil are no longer viewed as typical adolescent
experiences, between 13 and 20 percent of all adolescents
will encounter great difficulty coping with the demands of
this developmental stage (Rutter, Graham, Chadwick, & Yule,
1976: Kashani et al., 1987). Hence, it remains vital that
clinical and developmental investigators continue working
collectively toward a greater understanding of the unique
stressors, problems, and experiences that confront today's
teenagers. Various types of psychopathology, including
substance abuse, conduct problems, anxiety disorders,
depression, suicide, and eating disorders, are found to
occur quite frequently during the adolescent years (Rutter,
1992; Kashani et al., 1987).

Depression appears to play a primary or secondary role
in numerous types of disturbances during adolescence, and

has received considerable empirical attention since the

mid-19865 (Kovacs, 1996; Peterson et al., 1993). Depressed
adolescents, compared to their nondepressed age mates, are
found to experience lower self—worth and higher rates of
substance abuse, academic difficulty and failure, family and
peer difficulty, and suicide (Reinherz et al., 1990).
Moreover, depression in adolescence is related to more
difficulty in psychosocial functioning during young
adulthood (Kandel & Davies, 1982) and with major affective
disorders throughout the adult years (Ingersoll & Goldstein,
1995: Langer, Gersten, Wills, & Simcha—Fagan, 1983).

This dissertation is directed at broadening the
understanding of adolescent depression by examining the
relationships among internalizing and externalizing styles
of coping with depressive issues, experiences of shame, and
self-destructive behavior. Shame has been described as an
acutely painful awareness that one's innermost self has been
exposed to others who are likely to respond with ridicule,
criticism, denigration, and even rejection (Kaufman, 1984,
1992; Yorke, 199G; Hultberg, 1988; Spero, 1984). Helen
Block Lewis (1971), a pioneering figure in shame—theory,
maintained that shame results in a passive, self-hatred that
immobilizes a person's coping and emotional resources, and
leaves the individual feeling "small, helpless, and

childish" (p. 430).

The intense emotions generated by shame-~help1essness,
powerlessness, and acute self-consciousness—-are affective
experiences that are also frequently seen in the clinical
presentation of adolescents with depressive illness
(Roberts, Lewinsohn, & Seeley, 1995; Peterson et al., 1993:
Reynolds, 1987a) and among those teens who have contemplated
or attempted suicide (Curran, 1987). Yet, clinical
researchers focusing on adolescent depression have failed to
examine ways in which shame can "drive" both self—
destructive behaviors and aggressive, acting-out behaviors
directed against other persons, objects, or society as a
whole.

Given these factors, the purpose of this study is to
outline a rationale and empirical design for investigating
the extent to which destructive self-directed and other—
directed behaviors are outcomes of a complex interaction
between more or less accessible shame experiences and
externalizing versus internalizing coping styles. A review
of the relevant literature will explicate these
relationships by examining the features and issues relevant
to adolescent depression; by highlighting the
characteristics and ramifications of shame during childhood

and adolescence; and by suggesting ways in which the

adolescent's primary coping style may affect the expression

of depression and shame.

II. ADOLESCENT DEPRESSION

Early Stumbling Blocks. Although abundant research

 

has been conducted on adult depressive illness over the past
three decades (Lewinsohn, Hops, Roberts, Seeley, & Andrews,
1993; Achenbach, 1982), clinical concern about and interest
in childhood and adolescent depression was nearly
nonexistent until the 19705 (Anthony, 1976, 1983: Cytryn &
McKnew, 1972; Carlson & Strober, 1978: Kovacs & Beck,

1977). This lack of scientific attention to depression in
children and adolescents was largely attributable to the
widespread influence of psychoanalytic thought between 196%
and 1960 (Gelfand, Jenson, & Drew, 1988).

Analytic theorists, such as the renowned child analyst,
Margaret Mahler (1952), argued that children and most
adolescents lacked the mature cognitive skills and ego
functions to experience adult-like depression. Although
Mahler (1965) believed that children could experience
depressed mood, they were incapable of developing true

depressive illness because they reacted to loss and

emotional distress by utilizing more primitive defenses such
as denial and repression (Mahler, 1952).

Other clinical investigators (see Gelfand, Jenson, &
Drew, 1988: see Kazdin, 1989) doubted the clinical
significance of most depressive symptoms and behavioral
problems in children and adolescents. In general,
depressive symptomatology were perceived as natural and
commonplace and as a short-lived consequence of growing up.
However, some theorists speculated that other childhood
problems, ranging from aggressive, disruptive behaviors on
the one hand to the anxiety disorders on the other, might
conceal or "mask" underlying sadness and depressive
feelings, but were not equivalent to adult-like depression
(Carlson, 1981).

The construct of masked depression was highly
inferential, and, for this reason, it was generally dropped
from diagnostic nosology by the early 19865 (Kashani et al.,
1981). However, as Kazdin (1989) pointed out, the idea of
depression being masked in children and adolescents was
"historically very important" (p.136) for several reasons.
First, it postulated that depressive illness could exist in
children. Second, it fostered clinical interest and
research on depression and overall emotional functioning

among children and adolescents. Finally, the notion of

masked depression caused clinical investigators to assess
how depressive illness might manifest itself differently in
children, adolescents, and adults and in individuals at

various sub-stages within each of those major life periods.

Symptoms, Prevalence, and Gender Differences in

 

Depressive Disorders. Currently, it is generally agreed

 

that depression during both childhood and adolescence can
be diagnosed using the standard, essential features outlined

in the Diagnostic and Statistical Manual for Mental

 

Disorders-Fourth Edition (DSM-IV: American Psychiatric

 

Association, 1994). Adolescents suffering a depressive
disorder can be diagnosed with a major depressive disorder
(MDD), a dysthymic disorder, or both. With regard to MDD,

an adolescent diagnosed with this condition must have
experienced five or more of the following symptoms for a two-
week period which results in an overall decrease in the

quality of their previous level of functioning:

* depressed or irritable mood for most of each
day

* a loss of interest from previously enjoyable
activities

* significant weight fluctuations (weight-gain,
weight—loss)

* sleep disturbances (insomnia, hypersomnia,
hyposomnia)

* psychomotor agitation or retardation

* fatigue or loss of energy

* feelings of worthlessness and increased guilt

* poor concentration and difficulty making
decisions

* suicidal ideation, suicide attempts, or
suicidal plans.

The diagnosis of dysthymic disorder can be made when the
adolescent has experienced at least one year of depressed or
irritable mood nearly every day without more than two non—
symptomatic months. However, for this diagnosis to be made,
two or more of the following symptoms must also be present:
eating problems

sleeping problems

reduced energy

feelings of low self-esteem or self—worth

reduced concentration and increased indecision
feelings of hopelessness.

at-al-at-al-aI-zt-

Furthermore, a diagnosis of dysthymia requires that during
the first year of the disorder, the adolescent is not
affected by a major depressive disorder. When a major
depressive disorder follows the onset of a dysthymic
disorder, the condition is sometimes called double
depression (Peterson et al., 1993).

The incidence and prevalence of depression among
adolescents has been assessed infrequently by major
epidemiologic investigations (Kandel & Davies, 1982).

Moreover, such studies have often focus on features of

depressive disorders such as depressed mood and symptoms
rather than directly measuring the prevalence of specific
disorders such as MDD or dysthymia.

Epidemiologic investigations of nonclinical (Roberts,
Lewinsohn, & Seeley, 1995; Lewinsohn et al., 1993) and
clinical populations (Kashani et al., 1981: Kovacs et al.,
1984: Reynolds, 1984) report discrepant statistics
concerning the rates of depression among adolescent youth.
The discrepancies, according to Kazdin (1989), can be
attributed to several factors, including the ages of the
adolescents studied and inconsistencies in the types of
measures used to assess and diagnose depressive disorders.

Although estimates of prevalence rates for adolescent
depression among community-based populations have ranged
from zero to eighteen percent (Reynolds, 1984), several
investigators (McGee et al., 1996; Lewinsohn et al., 1993;
Bird et al., 1988) have placed these rates between two and
nine percent. A review of fourteen nonclinical studies (see
Peterson et al., 1993) found that the average prevalence
rate for adolescent depression was seven percent.

Among clinical populations, the prevalence rate for
adolescent depression is predictably much higher. Some
investigators (Kovacs et al., 1984; Kashani et al., 1981)

have assessed prevalence at nearly sixty percent. However,

10

a review of six clinical studies (see Peterson et al., 1993)
places the prevalence rate at 42 percent. Chronic
depression, defined as a recurrent major depressive disorder
and dysthymia (Shain, King, Naylor, & Alessi, 1991), also
has been found to have high prevalence rates (eight percent
and 48 percent, respectively) among both community (Kashani
et al., 1987) and clinical samples (Ryan et al., 1987, cited
in Shain et al., 1991).

Although gender differences are quite small for rates
of depression among males and females in childhood (Gelfand
& Peterson, 1985), these rates begin to diverge in mid-to-
late adolescence (Ingersoll & Goldstein, 1995). From this
point onward and throughout adulthood, females are
approximately two to three times as likely as males to
experience depressive disorders (Peterson et al., 1993;
Lewinsohn et al., 1993; Reinherz et al., 1993: Rierdan,
Koff, & Stubbs, 1988, 1989: Kandel & Davies, 1982).

Researchers have concluded that these consistent
differences in depressive experiences are due, in large
part, to socialization factors (Campbell, Byrne, & Baron,
1992). Males in Western cultures are taught to conceal and
"bottle up” their painful emotions, while the open
expression of depressive symptoms is generally accepted

among females. This has implications for how adolescents

11

cope with emotional turmoil. Whereas males tend to respond
to stress by distracting themselves with other concerns or
activities, females tend to brood and ruminate about their
difficulties which ultimately exacerbates their depressive
states (Peterson et al., 1993).

In a study examining patterns of responses to items on
a self-report questionnaire assessing depressive symptoms,
Baron and Joly (1988) identified two response-styles that
differentiated males and females. Adolescent males tended
to endorse items indicating that they became socially
withdrawn, experienced sleeping difficulties, and had a
reduction in their level of work-motivation. In contrast,
adolescent females frequently reported body-image concerns,
appetite disturbances, and weight loss. In another study,
Campbell, Byrne, and Baron (1992) found that among a
community sample, adolescent females obtained higher raw-
scores than males on the Reynolds Adolescent Depression
Scale. In addition, females scored higher than males on
items involving crying, stomachaches, fatigue, sad mood, and
feeling ill. Taken together, these results supported the
notion that adolescent girls are more inclined than their
male counterparts to report depressive symptoms, and that
their symptomatology are often related to stereotypically

feminine characteristics.

12

Coping Styles, Depression, and Comorbidity. During

 

childhood and adolescence depression in both sexes can be
linked to fundamental deficits in managing stress, resolving
interpersonal problems, and meeting the challenges and
demands of daily life. Whether a child or adolescent copes
with emotional distress by withdrawing and experiencing
anxiety or by becoming disruptive, aggressive, or overactive
is, in part, determined by temperamental factors (Eysenck,
1975). Introverted individuals, who tend to be passive and
shy in general, are likely to become less communicative,
less sociable, and more anxious as their level of stress
increases and control over their environment decreases. In
contrast, persons who are more extroverted will likely
respond to similar circumstances by taking a more active,
impulsive, and aggressive stance toward their environment.
Achenbach (1982) and Achenbach and Edlebrock (1983,
1987) have identified two major broad-band scales--measuring
internalizing and externalizing symptoms of disorder--that
make it possible to classify types of psychopathology found
among children and adolescents in both clinical and
nonclinical samples. Internalizing coping styles denote
attempts to overcontrol emotional reactions by turning
inward the stress generated by such experiences (see Mash &

Barkley, 1989: Ingersoll & Goldstein, 1995). This results

13

in symptoms such as anxiety, somatic complaints, social
withdrawal, uncommunicativeness, and depressive
functioning. In contrast, externalizing coping styles
typically involve undercontrol and poor modulation of
affective impulses that are expressed outwardly toward the
environment (Hinshaw, 1992). Externalizing behavior
problems are characterized by aggressiveness, delinquency,
and hyperactivity.

The differentiation between internalizing and
externalizing behavioral problems is a highly stable and
consistent finding (Verhulst & Van Der Ende, 1992). In
comparison to internalizing disorders, externalizing
behavioral difficulties are more difficult to treat
successfully, are more stable, and carry with them more
negative implications for long—term prognosis (see Mash &
Barkley, 1989; Verhulst & Van Der Ende, 1992; Feehan, McGee,
& Williams, 1993; Fergusson, Horwood, & Lynskey, 1993).
Moreover, among children and adolescents, boys tend to
manifest more externalizing behavioral problems, whereas
girls usually present with symptoms more frequently
associated with an internalizing coping style (see Mash &
Barkley, 1989; Lewinsohn et al., 1993).

A common finding in the adolescent literature is that

depression frequently co-occurs with other internalizing and

14

externalizing disorders (Kovacs, 1996; Biederman, Faraone,
Mick, Moore, & Lelon, 1996: Roberts, Lewinsohn, & Seeley,
1995: Sanford et al., 1995: Harrington, Fudge, Rutter,
Pickles, & Hill, 1991; Bernstein, 1991: Strauss, 1988:
Clarizio, 1989). Comorbidity in adolescent depression has
major implications. Compared to their age mates with only
one disorder, youth who suffer multiple disorders are at
significant risk for developing more serious, long-term
mental health and psychosocial adjustment difficulties
(Fleming, Boyle, & Offord, 1993: Feehan, McGee, & Williams,
1993: Offord et al., 1992; Rutter, 1992).

Comorbidity between depression and anxiety disorders
has been estimated at 36 to 7? percent (Goldston et al.,
1996: Goodyear & Altham, 1991a, 1991b; Connell & Meyer,
1991), and anxiety symptoms frequently occur prior to the
onset of a major depressive disorder (Reinherz et al.,
1993). Among adolescents with conduct problems, the rate of
comorbidity for depressive symptomatology is estimated
between 19 and 35 percent (Fleming, Boyle, & Offord, 1993).
Adolescents who exhibit both externalizing and internalizing
problems in mid-adolescence-—conduct problems/oppositional
behavior and depression/anxiety--are at heightened risk, in
comparison to their counterparts experiencing simply

internalizing symptomatology, for continued difficulties in

15

later adolescence (Feehan, McGee, Williams, 1993) and
adulthood (Harrington, Fudge, Rutter, Pickles, & Hill,
1991).

Depressive disorders are also frequently a part of the
clinical picture 1) in the occurrence of eating disorders
and body-image problems, especially among adolescent females
(Rierdan, Koff, & Stubbs, 1989) and 2) in the occurrence of
post-traumatic stress disorder (PTSD) and suicidality
subsequent to sexual abuse trauma (Brand et al., 1996).
Similarly, substance abuse among adolescents is often
driven, in large part, by underlying depressive feelings and
emotional turmoil (King et al., 1996; Goodwin & Guze, 1989)
and by maladaptive patterns in self—regulation (Horowitz,

Overton, Rosenstein, & Steidl, 1992).

Coping Failures: Suicidal Ideation and Attempts.

 

Suicidal ideation and suicide attempts are potentially
serious consequences of adolescent depression, regardless of
whether a depressed adolescent's primary coping style is
externalizing or internalizing in nature (Hollis, 1996:
Rotherrom—Borus et al., 1996; Fergusson & Lynskey, 1995;
Pfeffer, Hurt, Peskin, & Siefker, 1995; Rao, Weissman,
Martin, & Hammond, 1993; Hafen, 1986; Diekstra & Moritz,

1987: Curran, 1987). Over the past four decades, the

 

16

suicide rate among adolescents has increased by
approximately 275 to 290 percent (Ohberg, Lonnqvist, Sarna,
& Vuori, 1996; Cimbolic & Jobes, 1990). Among 15 to 19 year
olds, this increase in suicide has been even more marked (2
in every 100,000 in 1960 compared to 12 in every 100,000 in
the early 19905 (Andrews & Lewinsohn, 1992). The number of

attempted suicides is believed to be considerably greater

 

than the number of completed suicides (Ohberg, Lonnqvist,

 

Sarna, & Vuori, 1996: Petti & Larson, 1987; Hafen &
Frandsen, 1986). In short, emotionally—troubled teenagers
often consider suicide as a viable option for escaping
emotional turmoil, depressed mood, and personal problems
(Pinto & Whisman, 1996). In particular, depressed
adolescents also diagnosed with a personality disorder,
experiencing intense anxiety, shame, and guilt, manifesting
impulse-control difficulties, or engaging in antisocial or
conduct-disordered behavior are especially likely compared
to other depressed teenagers without these problems to be
bothered by suicidal thoughts and to make suicide attempts
(Ohring et al., 1996; Brent et al., 1993; Hafen & Frandsen,
1986: Marttunen, Aro, & Lonnqvist, 1992: Shaffer, 1974;
Shaffer & Fisher, 1981).

Sex and racial differences have been found in the rates

of adolescent completed versus noncompleted suicide attempts

17

(Petti & Larson, 1987). In most cases, males tend to use
more lethal methods for taking their life (gunshots,
hanging, jumping from high places), whereas females tend to
utilize less lethal, more reversible methods (overdosing on
a few aspirin or medication pills superficial cuts to the
wrist) (Ohberg, Lonnqvist, Sarna, & Vuori, 1996: Hafen &
Frandsen, 1986). However, there is some evidence (Cimbolic &
Jobes, 1990) that this pattern may be slowly changing in
that a slight increase has been noted in the number of
adolescent females using more lethal methods to commit
suicide (Hollis, 1996). In general, however, during the
adolescent years, suicide attempters are more likely to be
non-Caucasian females who are early adolescents, whereas
suicide completers more typically are older, Caucasian males
(Deykin, Hsieh, Joshi, and McNamarra, 1986).

A long list of factors have been implicated in
adolescent suicide and suicide attempts (Mattunen et al.,
1995). These include severe family problems, family history
of mental illness, school failure, perceived rejection from
peers or romantic partners, and physical, sexual, or
emotional maltreatment (Ingersoll & Goldstein, 1995: see
Diekstra & Hawton, 1987; Cimbolic & Jobes, 1990: Hafen &
Frandsen, 1986: Petti & Larson, 1987). Overall, adolescent

suicide appears to be an "endpoint of long—term

18

[psychosocial] difficulties" (Marttunen, Hillevi, &
Lonnqvist, 1992, p. 649). Hence, in addition to family and
social factors, severe emotional problems, depression,
antisocial behavior, substance abuse, and previous suicide
attempts place adolescents at heightened risk for
contemplating and committing suicide (Andrews & Lewinsohn,
1992: Hodgman, 1990: Schaffer, 1974; Schaffer & Fisher,
1981).

An adolescent's decision to attempt suicide is, to a
large extent, an internally mediated, cognitive process.
Although family, peer, and psychosocial stressors can be
emotionally disruptive and overwhelming, especially when
they are intense, prolonged, or cumulative, it is the
adolescent who ultimately decides to harm himself or herself
and to end their life. Given this reality, it is important
to explore underlying emotional and personality variables
that may be driving ineffective coping and self-destructive
behaviors. In this regard, there is reason to believe that
intense experiences of shame play an important role in the
adolescent's "choice" of suicide as a means of coping with

external stressors and internal distress.

19

III. SHAME

The Painful Emotion of Shame and Its Relationship to

 

Depression. Over the past 25 to 30 years, research on shame

 

has become more prominent in the literature, and is now
perceived as a viable approach to better understanding
maladaptive behaviors and psychological disorders (Kaufman,
1989: 1992; Lewis, 1971, 1987: Sidoli, 1988). Depression
and shame have been repeatedly found to co-occur in studies
of both community and clinical samples (Lewis, 1971, 1987;
Izard & Schwartz, 1986; Hoblitzelle, 1987: Beck & Steer,
1987). Affect theorists (Tomkins, 1963; Kaufman, 1989;
Nathanson, 1987, 1992) have maintained that depression is
often the result of a dual—process involving cumulative
shame experiences and intense, prolonged emotional turmoil.
Shame is generally perceived as an intensely powerful
affect that is "central to the human experience" (Kaufman,
1989, p. 7). It is believed to emerge initially during the
second and third years of life (Erikson, 1962) as children
attempt to assert greater autonomy and independence over
their functioning. As the child grows older, matures, and
eventually achieves adult—status, the factors that evoke
shameful experiences become more complex, and may or may not

be related to shame-inducing experiences of childhood

20

(Spero, 1988). Yet, according to Lewis (1971), shame is a
fundamentally primitive reaction to which all persons
respond in similar ways. The individual's "body gestures
and attitudes include head bowed, eyes closed, body curved
in on itself, making the person as small as possible" (p.
427). In addition to these observable phenomena, the
individual's autonomic nervous system becomes activated, and
the person may blush, sweat, or experience a diffuse rage
which Lewis (1971) described as a "flood' of sensations" (p.
427).

Shame can be characterized by four basic features that
make it a highly powerful and unpleasant emotion. First,
shame is characterized by an immediate reduction or loss of
self-worth (Spero, 1988). This emotionally-charged
experience has been referred to by Laing (1960) as the
"implosion of the self." Second, shame leaves the
individual feeling isolated from others and extremely angry
at the self (Spero, 1988). Shame—reactions cause the
individual to perceive themselves as the "bad thing" and to
believe erroneously that this self-perception is, therefore,
a reflection of a "bad self" (Tangney, Wagner, Fletcher, &
Gramzow, 1992, p. 670). Shame often is experienced in the
form of mental imagery in which the individual's thinking is

dominated by representations of an "internalized other"

21

(Lewis, 1971) that the individual experiences as an
explicitly or implicitly disapproving or rejecting external
figure. This sense that others are acutely aware of the
individual's shortcomings and utter worthlessness is a third
feature of the shame experience.

Finally, shame results in heightened self-consciousness
and a sense that the person's innermost weaknesses and
vulnerabilities have been exposed for public viewing and
condemnation (Yorke, 1990: Kaufman, 1984, 1992: Spero,
1988). This intense self—awareness leads to withdrawal from
the social interaction in which feelings of shame have
arisen, and the person is overtaken by a need to hide from

others (Yorke, 1990).

Shame versus Guilt. It is important to distinguish

 

shame from guilt which is a related, but separate, negative
emotion. Although both shame and guilt are considered to be
the result of superego functions and operate in both
conscious and unconscious awareness (Lewis, 1971), an
important distinction between these two affects is the
source from which each emotion arises. In guilt, the
negative emotion stems from a perception that one is
responsible for injuring or hurting another by acting or

failing to act in a certain manner (Hultberg, 1988; Lewis,

22

1971). The person experiences anxiety that, in turn, stems
from "remorse or regret over the 'bad thing' that [he or she
has] done and a sense of tension that often serves to
motivate reparative action" (Tangney, et al., 1992, p.

669). Hence, guilt arises from the sense of having wronged
another, and is characterized by an active stance toward
fixing the situation. In contrast, shame is a passive
emotion that is directed totally at the self. The person
feels that they are the object of other's scorn, contempt,
and ridicule, and believes that there is no way to
successfully resolve the consequent feelings of
unpleasantness and confusion, except to flee from the
situation (Lewis, 1971). Whereas guilt creates a need to
repair a situation, "shame motivates a desire to hide—~to
sink into the floor and disappear" (Tangney, et al., 1992,
p. 670). In shame, the boundaries that separate self-from-
others are highly permeable (Yorke, 1990). Individuals
acutely experiencing this emotion are susceptible to periods
of overwhelming and immobilizing anxiety during which they
may be keenly aware of their most negative qualities and

attributes (Spero, 1988).

Sources of Shame in Adolescence. Although shame is an

 

emotion that can manifest at any point during the life—cycle

23

(Kaufman, 1984, 1992; Erikson, 1963), it is frequently
experienced during the childhood and adolescent years. As
part of the socialization experience, the child encounters
failure and disappointment, is reprimanded by parental and
other authority-figures, and begins to understand the nature
of their own weaknesses and shortcomings (Sidoli, 1988).

In the very young child, shame—reactions can be evoked
by a caretaker's anger, disgust, or refusal to offer
positive affirmation or physical contact (Kaufman, 1984,
1992). These emotionally-charged, social interactions
create instability for and insecurity within the child. In
temporarily fracturing the "interpersonal bridge" (Kaufman,
1992, p. 13) binding the child to its caregiver(s), they
intensify abandonment fears and exacerbate feelings of
rejection and low self-worth. Kaufman (1992) emphasizes
that early shame experiences in and of themselves do not
"launch a child on a path toward a shame—based identity" (p.
20). Rather, it is when reactions by significant others are
extreme and frequent that shame experiences are likely to
become more chronic.

In older children and adolescents whose verbal skills
and cognitive abilities are more advanced, shame—experiences
can be induced within the family, among peers, at school, or
in extracirricular activities. In fact, adolescence has

been identified as a period of intense self-consciousness

24

and significant concerns about the reactions of others
(Steinberg, 1985).

Adolescent children are likely to feel shame when they
are told that they should be ashamed of their
transgressions, that they are a disappointment to their
parents or family, or that they have let their parents down
by embarrassing them in public (Kaufman, 1992). Similarly,
teenage children are likely confronted with feelings of
shame when they are repeatedly ridiculed or rejected by
peers, or when they perceive themselves as consistently
performing poorly on academic tasks which they fear will
cause respected others to think less highly of them. Given
the rapid physical changes during the teenage years (see
Lerner, 1987), coupled with changing family and peer
relationships (Steinberg, Lamborn, Dornbusch, & Darling,
1992: Steinberg, Elmen, & Mounts, 1989: Bird & Harris, 1990;
Papini & Roggman, 1992: Stivers, 1988; Eccles et al., 1993:
Barrera & Garrison-Jones, 1992), achievement-related
stressors (Simmons, Carlton—Ford, & Blyth, 1987; Steinberg,
1985), and heightened sexual awareness (Steinberg, 1985;
Peterson & Taylor, 1987), it seems readily apparent that

adolescents are especially susceptible to feelings of shame.

The Internalization of Shame from an Interpersonal to

 

Intrapersonal Experience. Shame begins as an interpersonal

 

experience, but becomes more chronic and problematic as
these painful social interactions are internalized. Shame
initially emanates from negative interactions with
significant others, usually parents, who are perceived as
nurturant figures and important role-models (Kaufman,
1992). The early process of feeling emotionally connected
to primary caregivers and other significant adults has major
implications for personality development. This process not
only plays am integral role in identity formation during
adolescence (Erikson, 1968) and in the ability to form and
maintain satisfying attachment relationships throughout the
life cycle (Bowlby, 1969, 1973), but it also is a necessary
condition for developing shameful experiences (Kaufman,
1992).

During childhood and adolescence, the individual
searches for adult-figures whose behaviors and actions can
be emulated or internalized. Kaufman (1992) noted that
this process has three very important characteristics.
First, internalizations are built upon the foundation of the
individual's own understanding about who they are themselves
as individuals and what attitudes and emotions they hold

(referred to as "core affect-beliefs"). Second, the manner

26

in which one is treated by others influences the person's
own thoughts and feelings about themselves. Finally, the
individual who has identified with others carries around
mental images of these significant persons. According to
Kaufman (1992), it is through this process of identification
and internalization that "the conscious experience of the
self . . . is shaped and a relationship with that self
develops" (p. 43).

Kaufman (1989, 1992) has identified several avenues
that facilitate the internalization of shame from an
interpersonal to intrapersonal process for children and
adolescents. The first involves the link between affect and
shame-inducing experience (Kaufman, 1989, 1992: Tomkins,
1962, 1963). According to Kaufman (1992), affect elicits
shame in the following manner:

Whenever the expression of a particular
affect, whether it be anger, fear, even
enjoyment, is followed by some parental
response which induces shame, an internalized
affect—shame bind can result . . . .The
development of an affect-shame bind then
functions to control the later expression

of the particular affect involved (p.45).

The danger associated with affect—shame binds is that the

situations, thoughts, or feelings that function to initially

27

cause shame in children and adolescents "can come to
spontaneously activate shame without shame itself being
directly induced" (Kaufman, 1992, p. 45).

A second pathway for shame to evolve from an
interpersonal to an intrapersonal experience is through the
child's or adolescent's expression of basic human drives
that are met with parental scorn or communications that such
behaviors are shameful. As an example of what Kaufman
(1989, 1992) termed a drive—shame bind, he describes the
scenario of a child caught by his parents masturbating and
told that such behavior is wrong and highly inappropriate.
The negative and confusing emotions that accompany such an
experience, especially if repeated over time, will,
according to Kaufman, cause the child to conceal such
activity and to feel shame.

The final pathway for shame to be transformed from an
interpersonal to an intrapersonal experience in children and
adolescents is through the development of need—shame binds.
With regard to these phenomena, Kaufman (1992) identifies
several basic interpersonal needs that help not only to
foster one's sense of identity, but also play an important
role in the development of shame if they go unmet for
significant periods of time. These needs include

participating in close relationships, engaging in and

receiving physical touch, identifying with significant
others, being able to differentiate oneself from others and
to show mastery and competence, receiving positive
affirmation from external figures, and being able to nurture
and show love and affection for others.

In summary, shame arises from an interaction of both
interpersonal and intrapersonal factors. When basic human
emotions, drives, or needs are experienced as negative and
worthy of scorn by others whom the individual admires, the
foundation is laid for shame to fester within the
individual, and is likely to negatively influence the

person's feelings of self—worth. As Kaufman (1992) noted:

Internalization of shame means that the
affect of shame is no longer merely one
affect or feeling among many which become
activated at various times and then pass
on. Rather, internalized shame is now
experienced as a deep abiding sense of
being defective, never quite good enough
as a person. It forms the foundation
around which other feelings about the self
will be experienced, This affect-belief
lies at the core of the self and gradually
recedes from consciousness. In this way,
shame becomes basic to the sense of identity.
While the underlying affect is the same,
the conscious experience of internalized
shame differs widely. For example, feelings
of inadequacy, rejection, or self—doubt,
feeling guilt-ridden or unlovable as a
person, pervasive loneliness are all
conscious or semiconscious expressions of
internalized shame (pp. 73-74).

29

Shame, Coping Styles, and Defensive Maneuvers. Shame

 

is clearly a negative and very powerful emotion that can be
evoked in all individuals, including children and
adolescents. However, the extent to which an individual
responds to and is consciously affected by this affect is
somewhat variable. In fact, how a person handles shame
feelings and experiences—-both intra-psychically and
interpersonally—-is related, in part, to interpersonal
styles and defensive strategies. According to Kaufman
(1989, 1992), introverted individuals are more likely than
extroverted persons to respond to shame—inducing situations
by "withdrawing [themselves] deeper inside, allowing escape
from the torment of shame" (p. 102). Conversely, the
extrovert, who tends to externalize and openly display
thoughts and feelings, is prone in similar situations to
exhibit mood lability. Hence, as Kaufman (1989) summarized,
"the introvert moves, psychologically speaking, 'in and out'

while the extrovert cycles 'up and down" (p. 98).
The mental operations people use to avoid the painful

and immobilizing affective experience of shame are

frequently referred to as defense mechanisms in the clinical

and personality literatures (Liebert & Speigler, 1982).

These mechanisms of defense serve a valuable function. They

30

can ward off feelings of anxiety, and can decrease an
individual's sense of threat from the environment (A. Freud,
1946/1958: 1965).

A very common reaction to shame experiences is intense
anger and rage (H. Lewis, 1971; Tangney et al., 1992;
Kaufman, 1989, 1992: M. Lewis, 1992; Nathanson, 1992).

Anger is considered to occur as a response to a specific
shaming incident; rage is believed to occur as a result of
prolonged shaming (M. Lewis, 1992). In either instance,
anger and rage reactions provide the individual with an
opportunity to avoid confronting their shameful feelings, to
exert a temporary sense of power and control over their
emotional life, and to keep others at a safe, emotional
distance. Individuals who primarily rely on anger and rage
to defend against shame are perceived as substituting or
replacing anger and explosive reactions instead of openly
acknowledging their shame (M. Lewis, 1992).

Although anger and rage offer individuals temporary
stress—release and protection from consciously confronting
shame, these undercontrolled reactions ultimately increase

the individual's sense of underlying distress. The

31

reasoning behind this process is illustrated succinctly in a

review by Lewis (1971) who noted the following:

In shame, hostility against the self is
experienced in the passive mode. The self
feels not "in control" but overwhelmed

and paralyzed by the hostility directed
against it. One could "crawl through a
hole," or "sink through the floor," or
"die" with shame. The self feels small,
helpless, and childish. . . . So long as
shame is experienced, it is the "other" who
is experienced as the source of hostility.
Hostility against the rejecting other is
almost always simultaneously evoked. But
it is humiliated fury, or shame-rage, and
the self is still in part experienced as the
object of the "other's" scorn. Hostility
against the "other" is trapped in this
directional bind. To be furious with
someone . . . renders one easily and
simultaneously guilty of being furious.
Evoked hostility is readily redirected
back against the vulnerable self (p. 430).

In addition to anger and rage, Kaufman (1992, 1989) has
identified five other defensive reactions that people may
use to avoid fully confronting shame. These may include 1)
showing contempt for others: 2) exhibiting an intense
striving for power that serves to erase underlying feelings
of defectiveness or low self-worth; 3) striving for
perfection in nearly all areas of one's life: 4) projecting
or transferring blame onto external figures or factors; or
5) retreating or withdrawing from interpersonal

relationships into active fantasy which helps to lessen

32

one's degree of emotional turmoil. These coping strategies,
along with anger and rage, are consistent with Nathanson's
(1992) formulation of withdrawal, avoidance, attacking the
self, and attacking others as the four main ways that
individuals attempt to defend against shame-related affect.
The manner in which adolescents "defend" against
distress in general may be vitally important in predicting
whether they express resulting feelings of anger and rage in
an inner—directed or other—directed fashion. The literature
reviewed to this point would suggest that depressed
adolescents who internalize their thoughts and feelings will
be inclined to withdraw in reaction to shame experiences.
In addition, so-called "internalizers" should be more able
to acknowledge underlying feelings of shame. Because these
internalizing adolescents are more likely to experience
intense emotional distress, it is further conceivable that
they will not only report more depressive affect, but also
will engage in more suicidal thinking and will turn their
anger inward in the form of suicide attempts. In contrast,
depressed teenagers with externalizing c0ping styles are
more likely to rely heavily upon other-directed, defensive
operations such as anger and rage outbursts and probably
will deny and, hence, under-report feelings of shame. In
one of only a few studies examining shame, anger, and

externalizing coping mechanisms in adolescents, Spielberger

33

(1988, cited in Cook, 1993) found that self-reported shame
was highly correlated with the suppression of anger and
sensitivity to criticism or negative evaluations by others.
However, the relationship (r = .21) between shame and anger
expressed primarily in aggressive acts toward other persons
or objects was relatively low and nonsignificant. One
explanation of the failure to find a shame-hostility versus
others link is that adolescents with a more externalizing
coping style were driven by more "unconscious" or less

accessible feelings of shame.

Risk—Taking, Depression, Shame, and Indirect Suicidal

 

Behavior. The notion of unconscious shame presumes that
shame can go "underground" and can be blocked from conscious
awareness. This study will examine the possibility that
unconscious shame and externalizing coping styles interact
in predicting risk-taking and sensation-seeking behaviors
that put the adolescent's life at risk, and, as such, may
represent an indirect form of suicidal behavior in
adolescents.

Adolescence has been identified as a period when risk-
taking and sensation-seeking behaviors increase (Tonkin,
1987). An important question is whether some emotionally-

distressed adolescents cope with their personal problems and

34

feelings of shame by engaging in behaviors that might be
considered indirect forms of suicidal behavior and that
conceal underlying depressive symptomatology and shame-based
affect (Puig-Antich, 1982). These forms would include
direct risk—taking and self-injurious (self-destructive)
behaviors.

Risk—taking and sensation-seeking actions among older
children and adolescents have been identified as serious
medical and mental health concerns (Guyer, Lescohier,
Gallagher, Hausman, & Azzara, 1989: Russo et al., 1993).
Accidents and violent acts, along with suicide, consistently
fall at the top of surveys assessing major causes of death
among children and adolescents in the United States (Clark,
Sommerfeldt, Schwarz, & Hedeker, 1990: Guyer et al., 1989).
Moreover, promiscuous sexual behavior, which often arises
from underlying unmet dependency needs, can lead to unwanted
pregnancies, venereal diseases, and Acquired Immune—
deficiency Syndrome (AIDS) (Rosen, Xiangdong, & Blum, 1990:
Davis, 1990: Giovacchini, 1986: DiClemente & Ponton, 1993).
Similarly, substance abuse places the adolescent at-risk for
multiple psychosocial problems, including school and family
difficulties, depression, and antisocial behavior (Comerci &
Macdonald, 1990). Both promiscuous sexual behavior and

substance abuse are addictive disorders that may be "rooted

35

in internalized scenes of shame" (Kaufman, 1989, p. 126),
and mask or conceal underlying emotional turmoil.

Self—destructive behaviors such as burning one's skin,
excessive scratching, and eating disorders can also be
considered indirect suicidal actions (Delga, Heinssen,
Fritsch, Goodrich, & Yates, 1989), and are related to the
internalization of shame (Kaufman, 1989: Nathanson, 1992).
Furthermore, in comparison to external, risk-taking
behaviors, such actions more readily appear to be driven by
emotional problems. In his review of several studies on
self-destructive behavior in children and adolescents, Green
(1978) reported that youth who engage in such behavior have
been historically viewed as suffering from major ego—
deficits, neurological impairment, and/or mental
retardation. However, he maintained that environmental
factors, including severe emotional trauma, intense parental
rejection, family disorganization, and severe maltreatment,
also can lead to the development of self-destructive
behavior. Based on the results of his own study, Green
(1978) found that among "abused," "neglected," and "normal"
children, the physically abused and maltreated children were
at greatest risk for self-injurious behavior.

Like rates for depression, suicide, and externalizing

and internalizing disorders, there tend to be sex

36

differences in the rates for risk-taking and self-
destructive behaviors among adolescents. In general,
whereas male teenagers are more likely to engage in direct
risk-taking and sensation—seeking behaviors, female
adolescents are more likely to engage in self-injurious
behaviors (Guyer et al., 1989). However, it would be
misleading to simply breakdown the differences in risk—
taking and self-destructive behaviors along gender lines.
For example, early—maturing girls and late-maturing boys
have been found to manifest more risk-taking behaviors than
other adolescents who are of the same age and sex (Irwin,
1990). With respect to early—maturing girls, they manifest
developmental needs and interests at an earlier time than
their peers. This causes them to feel shame and to be
perceived as "different" from their peers. This results in
a "proclivity for initiating risk behaviors" (Irwin, 1990,
p. 6) within the realm of striving for independence,
increasing interest in sexual relationships, and socializing
with an older peer group. Like the early-maturing girl, the
late-maturing boy is likely to experience shame and to feel
"different" from his same—sex peers which alters his self-

concept and his sense of masculine identity. In an effort

37

to counteract these helpless and powerless feelings, the
late—maturing boy may be especially prone to risk-taking
behaviors.

Regardless of gender, adolescents with externalizing
coping styles, as compared to those with internalizing
coping styles, are more prone to aggressive, impulsive, and
undercontrolled behaviors and emotional reactions when
confronted with heightened stress or emotionally-charged
thoughts, feelings, and situations. An important clinical
as well as empirical issue involves identifying variables
that provide insight into why a good number of depressed,
externalizing adolescents engage in overt risk-taking
behaviors, whereas others, like their depressed,
internalizing counterparts, may be more inclined to
contemplate suicide and manifest overt suicidal behavior
(for example, wrist-cutting: drug overdose: etc.).

One possibility may involve whether shame is
experienced in conscious awareness or through "hidden,"
unconscious processes. This distinction has potentially
important implications for how adolescents (both
externalizers and internalizers) cope with and react to the
feelings of powerlessness and despair that often accompany
depressive illness. For example, the levels of conscious

and unconscious shame among depressed, externalizing

38

adolescents may provide valuable information about their
susceptibility toward engaging in or acting outwardly
through risky and dangerous or direct suicidal behaviors in
order to alleviate their experience of negative, painful
affect. Hence, the depressed, externalizing adolescent who
reports little conscious shame might be more inclined to
cope with depressive thoughts and feelings through denial of
self-destructive urges and a greater willingness to engage
in risk—taking and sensation-seeking behaviors. Such
reactions might "mask" or conceal their underlying distress,
and represent a counter—attempt at neutralizing their
unpleasant feelings of powerlessness, helplessness, and
vulnerability. In contrast, the depressed, externalizing
adolescent, whose shame—related cognitions and feelings have
"broken through" into conscious awareness, will likely admit
to greater emotional distress and suicidal ideation, and may
be more prone to planning or attempting more serious

(lethal) suicides.

IV. SUMMARY OF LITERATURE REVIEW

Depression and shame are related, affect-based

phenomena that influence the emotional well-being of

children and adolescents. The former is influenced by

39

situational stress, coping deficits, and poor social problem
solving skills. The latter evolves from repeatedly painful
and rejecting interactions involving significant others with
whom the child or adolescent has identified. In time, these
interactions, like the youth's identifications with highly
regarded others, are internalized, and become the basis for
experiencing shame.

The manner by which adolescents cope with depressive
and shameful feelings presumably is related, in part, to
interpersonal styles and defensive strategies. Briefly
stated, introverted adolescents may be inclined to respond
to stress and shame—inducing situations by retreating or
withdrawing deeper inside themselves, relying upon inner—
directed defenses, and showing greater awareness of their
shameful feelings. In contrast, extroverted adolescents may
be prone to openly displaying and acting out their thoughts
and feelings through other—directed defenses, and may show
less conscious awareness of (and a greater reluctance to
admit to) their feelings of shame.

Whereas the former group of adolescents—~the so-called
"internalizers"—-are more focused on their innermost
thoughts and emotions, the latter group—~the so-called
"externalizers"--are more likely to deny or minimize their

strong emotions. Among internalizing adolescents, it is

40

conceivable that they are in more conscious distress, and
will be more likely to acknowledge their despair whether it
takes the form of depressive feelings, shame experiences,
and/or suicidal ideation. Conversely, depressed
externalizing adolescents will likely be more oriented
toward behavioral action rather than thinking about their
painful thoughts or feelings. Hence, these teenagers are
expected to minimize or under—report their depressive
feelings, shame experiences, and suicidal thoughts.
Although internalizing adolescents are expected to
report more suicidal ideation and undertake more direct
suicide attempts, externalizing adolescents are expected to
engage in more sensation-seeking and risk—taking behaviors
that not only provide them with a temporary sense of power,
control, and invulnerability (Quadrel, Fischoff, & Davis,
1993), but also may represent indirect forms of suicidal
behavior. Within this framework, the experience of shame is
suppressed and goes "underground" in externalizing
adolescents whose feelings of despair get blocked from
conscious awareness. In order to assess this notion of
"unconscious" shame, projective testing with a storytelling
task (such as the Roberts Apperception Test for Children) is
required. Partial support for this idea would be obtained

if a significant sub-group of externalizing adolescents who

41

report low conscious shame nevertheless scored high in
regard to story-contents that were related to shame-based
thoughts, feelings, emotions, and conflicts. However, among
all depressed adolescents, the ones believed to be at
greatest risk for undertaking the most lethal suicide
attempts would be those teenagers who possess an
externalizing coping style and whose unconscious shame has

' so to speak, into consciousness (hence,

”broken through,‘

they would report significant levels of conscious shame).

V. HYPOTHESES

Hypothesis 1

 

A) Adolescent inpatients with highly externalizing
coping styles (as assessed by parental report) will report
relatively lower levels of conscious shame and depressive
symptoms, whereas depressed adolescents with highly
internalizing coping styles will report relatively higher
levels of conscious shame and depressive symptoms.

B) Conscious shame will moderate the relationship
between unconscious shame and externalizing coping styles so
that high unconscious shame will be negatively related to

externalizing coping styles among adolescents with high

42

conscious shame, but unconscious shame will be positively

related to externalizing coping style among adolescents

reporting low levels of conscious shame.

Hypothesis 2

 

Conscious shame will moderate the relationship between
internalizing coping styles and suicidal ideation so that
internalizing COping will be positively related to suicidal
ideation among adolescent reporting high conscious shame,
but will be unrelated to suicidal ideation among adolescents

reporting low levels of conscious shame.

Hypothesis 3

 

Externalizing coping styles and experiences of
conscious shame and unconscious shame will interact in
predicting risk-taking behavior so that adolescents with
high levels of externalization, high unconscious shame, and
low levels of conscious shame will report higher levels of
risk-taking behaviors than will adolescents with other
combinations of externalization, conscious shame, and

unconscious shame.

43

Hypothesis 4

 

Externalizing coping styles and experiences of
conscious shame and unconscious shame will interact in
predicting the lethality of suicide attempts so that
adolescents with high externalizing coping styles, high
unconscious shame, and high conscious shame will undertake
more serious suicide attempts than will adolescents with
other combinations involving coping styles, conscious shame,

and unconscious shame.

VI. METHOD

Participants

 

The sample for this study (see Table 1) included 50
females and 39 males, all of whom were between the ages of
13 and 15 years. The sample was predominantly Caucasian
(i.e., 80 percent). All participants were selected from a
pool of psychiatric inpatients. Shortly after their
admission, each adolescent was interviewed by a child
psychiatrist, and received a DSM-IV, primary diagnosis that
fell within the spectrum of depressive disorders. Hence,
adolescent participants were selected for this study when
they were identified as meeting criteria for Major

Depressive Disorder: Major Depression, Recurrent: Dysthymic

44

Table 1

Characteristics of the Sample

 

 

SEX

50

Females n

Males n 39

Total Sample n = 89

 

AGE Females Males

 

13 years old n = 10 n = 16

 

14 years old n = 18 n = 13

 

15 years old n = 22 n = 10

 

ETHNICITY Sample Size Percentage

 

 

 

Caucasian 7
African-American

Native-American

Hispanic

Other

mw-bUIH

 

n = 89 100.00

 

45

Disorder: or Depressive Disorder, Not Otherwise Specified
(NOS). No teenager was included in the sample whose
psychiatric examination suggested the presence of Mental
Retardation, a Pervasive Developmental Disorder such as
autism, or Bipolar Disorder.

At the conclusion of data collection and prior to data
analysis, 27 of the 89 cases in this study (30.3 percent)
were randomly selected for review of intake-admission and
final—discharge diagnoses. In 26 of the randomly-selected
27 cases (96.3 percent), intake-admission and final
discharge diagnoses remained consistent with depressive-

spectrum disorders.

Measures

The Functional Impairment Scale for Children and

 

Adolescents (FISCA) (Frank and Paul, 1995) is a

 

questionnaire that measures functional impairment in
children between the ages of 6 and 18 years. It is
completed by parents, caregivers, or other adults who
possess a good deal of knowledge about the coping and
behavioral functioning of a particular child or adolescent.
The FISCA assesses emotional and behavioral impairment and
functioning within eight major areas of a youth's life.

These have been labeled 1) School: 2) Home: 3) Community:

46

4) Thinking: 5) Aggression: 6) Moods and Emotions: 7) Self-
Harm: and 8) Alcohol and Drug Use. In this study, 69 of the
89 participants (77.5 percent) had FISCA data available for
inclusion during statistical analyses. Although parents
completed the FISCA as part of the inpatient admission
process, FISCA data were not available for some participants
if, for example, the admission occurred late at night, if
the teenager had been hospitalized in the previous three
months, or if the parent/caregiver had significant trouble
with reading.

The FISCA is based on criteria for impairment as
outlined in the Child and Adolescent Functional Assessment
Scale (CAFAS: Hodges, 1990), and utilizes a multiple-choice
format. Responses to each item are keyed to specific
criteria allowing for automatic and easy scoring.

Impairment criteria associated with each of the eight areas
define impairment at three levels denoted as mild, moderate,
and severe ("mild" receives a score of 10: "moderate"
receives a score of 20: and "severe" receives a score of
30). A child receives a score of 0 (no impairment) for a
particular area if he or she does not meet any of the
criteria associated with mild, moderate, or severe levels of
impairment within that area. Impairment levels are usually

defined by a number of different criteria (see Appendix A),

47

but a child only needs to meet one of the listed criteria to
be classified at a particular level. The child's score for
each impairment area reflects the highest level of
impairment for which he or she meets one or more criteria
(see Table 2 for an example).

Exploratory factor analysis of the FISCA (Frank, Paul,
& Jackson, 1997, in progress) has identified an
Externalizing factor (computed by averaging scores for the
School, Home, Community, Thinking, and Aggression domains):
an Internalizing factor (computed by averaging scores for
the Moods/Emotions and Self—Harm domains): and an Alcohol
and Drug Use factor. A series of statistical studies
involving the FISCA have found it to possess good face,
construct, concurrent, predictive, and discriminant validity
(see Paul, 1996, for a review). In addition, FISCA scores
have been found to predict length-of-stay (LOS) in child and
adolescent psychiatric hospitals and recidivism (Frank,
Paul, & Jackson, 1997, in progress).

The Reynolds Adolescent Depression Scale (RADS: Reynolds,

 

1987a) is a quickly administered 30—item self-report
questionnaire that assesses clinically relevant levels of
depressive symptomatology in adolescents between ages 13 to
18 years and in grades seven and twelve. Item-statements

are presented in a 4—point Likert-like format, and require

48

Table 2

FISCA Level of Impairment: An Example

 

 

 

HOME
Severe Moderate Mild
Ran away from home Ran away from home Frequently
overnight two times overnight one time refuses to
or more and where- only: whereabouts do age
abouts unknown to known by parents appropriate
parents or guardians chores:
intermittent
defiance at home
Child highly Persistently refused
unmanageable or to comply with
impaired needing requests for age
removal from appropriate behavior
home or in the in home. Chronic failure
near future to meet age appropriate

expectations in home

Child can only Repeatedly failed to

be maintained in mind rules about safety
home with outside

assistance

 

NOTE: A 14 year old child who refuses to do his/her chores,
ignores his/her curfew, and who has runaway from
home four times in the 155? month without his/her
parents certain of their whereabouts would receive
a Home Impairment score of "30" since the running
away behavior is one level higher than the chore and
curfew concerns.

the adolescent to mark their answers based on how often they
feel a certain way (almost never, hardly ever, sometimes, or
most of the time). In this study 82 of the 89 participants
(92.1 percent) completed this self-report questionnaire.
Scoring for the RADS allows for computation of raw scores as
well as standardized percentile scores for a teenager's age
and sex. Except where otherwise indicated, standardized
scores were used in this research.

The RADS demonstrates high internal consistency with
reliability coefficients across different grades ranging
from .91 to .94 and with a total sample alpha of .92
(Reynolds, 1987a). On the RADS, as is often the case with
other depression self-report questionnaires, females tend to
obtain higher scores (on average, 5 to 7 points higher) than
their male counterparts (p < .001) (Reynolds, 1987).
Validity studies indicate that the RADS has good concurrent
validity (Atlas & DiScipio, 1992: Reynolds, 1987a) and
captures many of the domains of depression usually
identified in the depression literature (Campbell, Byrne, &
Baron, 1994). Similarly, as measures of its convergent
validity, the RADS correlates positively with measures of

anxiety, hopelessness, loneliness, and suicidal ideation,

50

and correlates negatively with measures of self-esteem and

learned helplessness in academic situations (Reynolds,

1987a).

The Suicidal Ideation Questionnaire (SIQ: Reynolds,

1987b) was developed in order to assess suicidal ideation.

The $10 consists of 30 items, and is typically used with

adolescents in grades 10 through 12. A modified version of

the SIQ, called the SIQ-JR, is comprised of a lS-item subset

caf the original 30 SIQ items, and is designed for

zadolescents in grades 7 through 9. Both versions present

snaicidal thoughts and cognitions to the adolescent who uses
ea 7-point scale to report on frequency of ideation over the

Ipaist month Items are assigned severity scores from 6 (very

frequent) to 0 (never). In this study, 19 participants

(:21..3 percent) completed the SIG, whereas 60 participants

((577.4 percent) completed the SIQ—JR.

According to Reynolds (1987b), the SIQ and SIQ—JR are

hm31:P1 characterized by high internal consistency reliability

CC>€3i5ficients (alphas greater than .90). The SIQ and SIQ-JR

tx:1:y, have reasonable face-validity. Items range from minor
alldl Inonspecific thoughts (e.g., "I thought about death." "I

wished I were dead.") to more major and specific cognitions

("It ‘thought about how I would kill myself." "I thought

atNDLTt when I would kill myself." "I thought about writing a

51

will.") (Reynolds, 1987b). Scores on these measures
correlate positively with depression, anxiety, hopelessness,
and negative life events,and correlate negatively with
academic self-esteem and learned helplessness in academic
situations (Reynolds, 1987b).

The Internalized Shame Scale (ISS: Cook, 1994) is a
self—report questionnaire that assesses feelings and
emotions associated with conscious shame. It is is
comprised of 30 items, twenty-four of which are considered
”shame items" ("I feel like I am never quite good enough" or
"I have an overpowering dread that my faults will be

rwevealed in front of others"). The remaining six
:stLatements, modified from the Rosenberg Self—Esteem Scale

(1%osenberg, 1965), are viewed as measuring self-esteem and
£31763 worded in a positive direction ("All in all, I am
:i11c21ined to feel that I am a success" or "I feel I am a
person of worth at least on equal plane with others"). In
'triias study, 82 of the 89 participants (92.1 percent)
C“Drnlgbleted this measure. The six self—esteem items were
e3(C31JJded from all data analyses

The ISS shame scale is highly internally consistent

Eunc>rug both clinical and nonclinical populations (alphas
greater than .95). The ISS has been shown to differentiate

betNveen clinical and nonclinical populations, and reportedly

52

is not sensitive to gender influences (Cook, 1994). Among a
nonclinical subset of individuals, the ISS demonstrated
adequate test—retest reliability over a seven-week period
(r = .84 for shame items: r = .69 for self-esteem
items). The ISS has good face and construct validity, and
has shown strong convergence with assessment measures of
global self-esteem (Cook, 1994), depression (Cook, 1994:
Berndt, 1986: Rybak, 1991: Lighty, 1990: Waite-O'Brien,
1991), anxiety (Cook, 1993: McFarland, 1992: Rybak, 1991),
sand anger (Cook, 1994).
The Sensation Seeking Scale for Children (SSSC: Russo,
.15391) was completed by 82 of the 89 participants (92.1
Iaearcent) in this study, and is 26—item, forced-choice, self—
report questionnaire modeled on the Sensation Seeking Scale
(£3535) for adults (Zuckerman, 1979, 1983). The SSSC is
czarnpuised of three major scales: Thrill and Adventure
Seeking [TAS]: Drug & Alcohol. Attitudes [DAA]: and Social
Disinhibition [SD]. Only the TAB scale score was computed
fc>r‘ Ipurposes of data analysis because it best described the

ConStruct of risk—taking attitudes utilized in this study.

I tern examples include :

5.- A. "I'd never do anything that's dangerous."
B. "I sometimes like to do things that are a little

scary."

53

"I think riding fast on a skateboard is fun."
B. "Some of the daring acts of skateboarders seem

scary to me."

10. A. "I would like to try jumping from a plane with a
parachute."

B. "I would never try jumping from a plane with a
parachute."
15. A. "I think skiing fast down a snowy mountain would
be dangerous."
B. "I think skiing fast down a snowy mountain would

be exciting and fun."
18. A. "I enjoy the feeling of riding my bike fast down

a big hill."
B. "Riding my bike fast down a big hill is too scary

for me."

The psychometric properties of the SSSC have been

srtudied using children and adolescents ages 9 to 15 years.

135; a child self—report measure, the SSSC has demonstrated

adequate internal consistency (alpha for TAS = .81), but

ftiradings for test—retest reliability over a three-week

irat:erval are inconsistent (Russo et al., 1993). Although

(brie: subsample of children and adolescents (from Rhode

:[SLlEind) demonstrated moderate correlation coefficients
(€317CJUnd .50), another subsample (from Virginia) obtained
““JC5F1 lower correlations (around .15). According to Russo

et; £11. (1993), these latter scores may have been negatively

affected by environmental factors such as large testing

54

groups since the former subsample, in contrast with the

latter, were tested in smaller groups with closer

supervision.

Scores for the SSSC correlate positively with age and
intellectual ability: males typically have higher scores
than females: and Caucasian subjects usually score higher
than African—American subjects (Russo et al., 1993).
Similar results have been found in studies of late

adolescents and young adults and also in adult samples using

-the adult version of the measure (SSS: Zuckerman, 1979,

J1983: Zuckerman & Neeb, 1980: Farley, 1977: Kurtz &

znlckerman, 1978).
The Roberts Apperception Test for Children (RATC:

bdchrthur & Roberts, 1982) is a projective storytelling task

(fleessigned for children and adolescents ages 6 to 15 years.
Respondents are shown a series of 16 stimulus cards, each
svj.tfla one to four child or adult figures involved in some

ia<riljavity or interpersonal situation (see Appendix B for a

lfirflieef summary of what scenes are depicted on each of the

iliéiisvidual cards). The respondent is asked to create a

St-0-‘l:."yfor each card, making sure that they tell a story that
deSCribes what is happening in the picture, what led up to

tr“? scene, and hOW'the situation ends. They are also

55

instructed to describe what the characters are talking
about, thinking, feeling, and doing in the picture.
Respondents stories are assumed to reflect unconscious
drives, thoughts, conflicts, fears, and motivations.

Although a respondent's RATC stories are usually rated

by McArthur's and Roberts' (1982) standardized scoring

system, the stories generated in this study by adolescents

were analyzed and scored using the Shame Rating Scale (SRS:

.Loraas, 1994: see Appendix C) which was developed

.specifically for this study to assess "unconscious shame."

the SRS was created to evaluate how frequently the emotion
c>f shame was used to describe the thoughts, feelings,
cxoncerns, or reactions of characters in RATC stories.
(Icpntent for the criteria used on the SRS was based on
Incbciification of the 24—5hame items on the ISS (Cook, 1989)
E15; \Nell as references to shame-based thoughts and feelings
.111 'the clinical research literature (Kaufman, 1989, 1992:
Lewis, 1971, 1987).

The Suicidal Behavior History Form (SBHF: Reynolds &
Mazza, 1992) is a brief, semistructured interview that
pro\7ides a systematic way to gain information and
(“3(3tnnentation about a person's past history of suicidal
behavior. This includes information about the situation and

ruitllre of prior suicide attempts. The interview inquires

56

about method, severity, lethality, intent, and other aspects
of the attempt suggesting the seriousness of the behavior.
Information garnered from the SBHF interview were rated in
this study using the Lethality of Suicide Attempts Ratings
Scale (LSARS: Smith, Conroy, & Ehler, 1984). The LSARS is
an 11—point linear interval scale ranging from "0," "death
is an impossible outcome or result," to "10," "death is an
almost certainty." High lethality ratings include hanging
(aneself from a tree (person survived because tree branch
laroke) or jumping in front of a car (person survived because
tihe automobile swerved or stopped). Low lethality ratings
unsuld include taking 10 aspirin or superficially cutting
(Drie's wrists, followed by immediate first-aid or
11c>tification to another person. The LSARS is considered a
Irealgiable measure, and has demonstrated very strong

irjtzerrater reliabilities ranging from .94 to .98.

Efocedures

Adolescent and parent/caregiver data collection
oC’Cur’red between March 1995 and June 1996 at a child and
adolescent psychiatric hospital in the Midwest United
StaIles. At the time of admission parents/caregivers signed

a. CKDrisent form (see Appendix D) describing the present study

57

and outlining how parental and adolescent intake
information, questionnaire responses, and other test data
would be used in the research. Parents or caregivers
completed the Functional Impairment Scale for Children and
Adolescents (FISCA: Frank & Paul, 1995) as part of the
standardized admission procedures.

A third-year, female graduate student in Clinical
Psychology who was blind both to the purpose and hypotheses
()f the study served as the psychometrician and primary

:research assistant. Her duties were varied. They included

1 ) reviewing the adolescent's chart and psychiatric
exxamination report in order to ensure the presence of a

ciezpressive—spectrum disorder (e.g., Major Depression,
13)/sthymic Disorder: Depressive Disorder, NOS): 2) initially
rneeeating with the adolescent on the hospital unit to briefly
(escrvlain the purpose of the study: and 3) administering the
research test protocol.

Adolescent participants completed the various
Glléésrtionnaires and other research assessment measures within
2? t1C> 4 days from their date of admission. After reviewing
relevant. chart information the psychometrician introduced
herself to the adolescent patient, briefly explained the

reSearch study, and ascertained whether the teen would be

willing to participate. The adolescent was informed that

58

testing would take between 45 and 50 minutes, that their
participation was ngt_mandatory, and that they would not
receive any negative consequences if they preferred not to
complete the testing battery. Only 8 teenagers (6 males and
2 females) declined to participate.

If the adolescent agreed to participate, he or she was
escorted to a private testing office by the
psychometrician. Once an adequate working rapport was
established the psychometrician presented the teenager with
the Adolescent Assent form (see Appendix E). The teenager

Vvas encouraged to read the Assent form carefully, to ask
quaestions, and to sign it when they were ready to begin.

During their testing session with the psychometrician,

aiéholescent subjects completed the Internalized Shame Scale

(21538: Cook, 1993) and the Sensation Seeking Scale for
(:lelldren (SSSC: Russo, 1991). All adolescent subjects were
iacinministered the Roberts Apperception Test for Children
(IQZXEKZ: McArthur & Roberts, 1982), and their verbal responses
““3176! transcribed by the psychometrician in accordance with
t}1€3 'test's standardized administration procedures. Those
teens who attempted suicide prior to their hospital
a‘dl‘nission (n = 40: 44.9 percent of the sample) also
CCHRIDIeted the Suicidal Behavior History Form (SBHF: Reynolds

& MEizza, 1992). All measures were administered in the same

59

order for the entire adolescent sample so that participants
would never have to begin the testing session with the
projective storytelling task.

The two remaining questionnaires—-Reynolds Adolescent
Depression Scale (RADS: Reynolds, 1987) and the Suicidal
Ideation Questionnaire (SIQ: Reynolds, 1987)--were
administered to adolescent participants within 24 to 36
hours of their admission. These measures routinely were
administered to adolescent patients as part of a screening
assessment used by the hospital for clinical purposes.
During the course of this study, all RADS and SIQ data were
collected by closely supervised MSU psychology,
undergraduate research assistants completing externships at
the hospital.

In the Summer of 1996, two MSU doctoral students in
Clinical Psychology (one male and one female), both of whom
were blind to this study's purpose and hypotheses, were
trained to use the Shame Rating Scale (SRS: Loraas, 1994) as
well as the Lethality of Suicide Attempt Rating Scale
(LSARS: Smith, Conroy, & Ehler, 1984). The two graduate
raters were initially trained to score the RATC protocols on
a sample of twenty adolescents (ages 13 to 15 years) who
were not a part of the present sample. During the training

process, the statistic used to ascertain interrater

60

reliability was the percentage—agreement statistic. This
coefficient is determined by the following formula: Number
of times raters agree/Number of times raters disagree and
agree. Raters continued to train until reliabilities were
between .75 and .80. In addition, interrater reliabilities
were obtained on every seventh to ninth protocol using the
study sample in order to avoid rater-drift. During the
scoring process, interrater reliabilities never fell below

07%.

VII. RESULTS

Measurement Issues

 

Levels of unconscious shame were obtained by using the
Shame Rating Scale (Loraas, 1994) to score the adolescents'
projective story protocols. Unfortunately, 12 participants
(8 females, 4 males) were discharged before projective
testing could be undertaken. In addition, 3 male
participants refused or declined the projective test, while
the data of 3 other male participants and 1 female
participant were not used because they were incomplete. In
all, a total of 70 protocols were used in the data

analyses. Reliability analyses using all 16 cards of the

61

Roberts Apperception Test for Children (RATC) produced an
alpha of .55. Five cards (Cards 1, 3, 4, 6, and 13) were
eliminated in order to increase internal consistency: alpha
for the remaining eleven cards was .64. The interrater
correlations for the two graduate student raters on each of
the RATC cards are shown in Table 3, while the overall
interrater correlation was .85. Interrater agreement for
the Lethality of Suicide Attempt Rating Scale (LSARS) was

.88.

Demographic Variables

 

Table 4 shows the internal reliability coefficients
(alphas) indicative of the internal consistency
reliabilities for the measures used to assess depressive
symptoms, suicidal ideation, conscious shame, and sensation-
seeking attitudes, and Table 5 shows the correlations among
all of the variables used in the study. None of these
variables correlated significantly with father education,
father occupation, mother education, mother occupation, or
family income.

Males and females differed significantly in their
experiences of depression and shame. Raw scores on the RADS
for females (m = 80.7) were significantly higher than scores

for males (m = 73.9: t (80) = 6.84, p < .05). Similarly, on

62

Table 3

Interrater Agreement for Unconscious Shame Scores for the

 

11 Roberts Cards

 

 

 

 

RATC Card Number Pearson r
2 .63
5 .79
7 .78
8 .62
9 .61

10 .68
ll .83
12 .74
14 .61
15 .84

16 .88

 

63

Table 4

Adolescent Measures and Internal Reliability Coefficients

 

for the Questionnaire Measures

 

 

 

 

Measure Alpha
1) Reynolds Adolescent Depression Scale (RADS) .92
2) Suicidal Ideation Questionnaire (SIQ) .97

Suicidal Ideation Questionnaire-Junior (SIQ-JR) .93

 

3) Internalized Shame Scale (ISS) (based upon

 

the 24 shame items only) .96

4) Sensation—Seeking Scale for Children (SSSC)

 

A) Thrill and Adventure Seeking (TAS) scale .82

 

 

64

ml

V

l\l

Ammucv
es.n

Ameucv
as.

0|

Aseucv Amkucv
am. as.
Ammucv “money

SH. as.u
Ammucv Ameucv
0E. eermd.

Ammucv
1:- RH.
m w

Ammucv
ms.1

Amoucv
«mN.l

Amends
5mm.

Aemucv
ms.1

Assume
«eewm.

mI

Ammucv
ma.u

Amoucv
AH.1

Amoucv
as.

”sense
we.

Amkncv

«seem.

Ammncv
sesvw.

NI

Assume
ag.-

Avmuco
ms.u

kamucv
ms.

Ammncv
mu.u

Amwucv
em.

Aooncv
sew.

Assncv
sew.

HI

 

Amaev mcnxmmm Haeuse Am

 

seeumueamcuouxm AS

 

COHDMNeemcuoch Am

 

Swedenpmq oceoesm Am

 

aceumooe Hmseoflsm Aw

 

COAmmoumoQ Am

 

mEmzm mSOeuucOO AN

 

oEmLm maceomCOUCD AH

Mddem<>

 

 

momwfiuom>m Loumommm one once Op com: moaflmeum> one WCOEm mesmeoemwmoo :Oeumemuuoo

m menus

65

the ISS, the mean raw shame score for females was 46.1
whereas the mean raw shame score for males was 35.2 ( E (87)
= 10.97, p < .05). Sex was not related to any of the other

variables used in the analyses.

Tests of the Major Hypotheses

 

Regression analyses were used to test the hypotheses.
Because gender differences in depression emerge in early—to-
middle adolescence (Ingersoll & Goldstein, 1995), I
controlled for sex in each of the regression analyses, and
also tested all possible sex by predictor variable
interactions.

The first set of regression analyses testing Hypothesis

 

15 assessed whether adolescents with highly externalizing
coping styles would report legs depression and conscious
shame, and whether those with highly internalizing coping
styles would report mg£g_depression and conscious shame.
The results only partly supported the hypothesis. In
particular, there was a two—way interaction between sex and
externalization. As expected, highly externalizing females
reported less depression (r = —.38, p < .05) and less
conscious shame (r = -.35, p < .05). However, highly
externalizing males reported high levels of conscious shame

(r = .32, p < .05). Male scores for externalizing coping

rn

66

style were unrelated to reports of depressed mood (r =
.06). None of the predicted relationships between
internalizing coping style and depression or shame were
supported, either for the total sample or for males and
females, alone, even though the variables correlated
positively which was the predicted direction (see Table 6).

Hypothesis lB postulated that externalizing behaviors

 

would be highest among adolescents experiencing high levels
of unconscious shame and underlying low levels of conscious
shame, and would be lowest among adolescents experiencing
both high levels of unconscious shame and conscious shame.
In examining this hypothesis, I tested the 2—way interaction
between conscious shame and unconscious shame (computed as a
cross-product). Additional procedures tested the 3-way
interaction as well as all possible 2—way interactions with
sex (following tests of the main effects, interactions at
each level were assessed in a step-wise fashion).

The 3—way interaction was not statistically
significant. However, in addition to the significant 2—way
interaction between sex and conscious shame already
described (i.e., conscious shame correlated negatively with
externalization for females and positively for males), there
was a significant 2—way interaction between conscious shame

and unconscious shame (beta = —.36, p < .05). Taken

Table 6

Hypothesis

and Depressed Mood and Conscious Shame Scores

67

1A: Correlations between Coping Mechanisms

 

 

 

 

 

 

 

Measure
All Subjects Males Females
552 INT EXT INT EXT INT
Depression —.24* .25* .06 .15 -.38* .26
(n = 65) (n = 26) (n = 39)
Conscious
Shame _e17 e19 032* e?@ -035* elg
(n = 69) (n = 28) (n = 41)
NOTE: A) * = p < .35
B) "EXT" = "Externalizing"
C) "INT" = "Internalizing"

68

together, the two-way interactions accounted for 20 percent
of the variance in parental reports of adolescent
externalization. The nature of the interaction between
unconscious shame and conscious shame is shown in Figure 1.
As expected, adolescents experiencing high unconscious shame
and low conscious shame were most externalizing, while those
participants with high unconscious shame and high conscious
shame were the least externalizing.

Hypothesis 2 postulated that internalizing coping

 

styles would be positively related to suicidal ideation
among adolescents with high levels of conscious shame, and
unrelated to suicidal ideation among adolescents with low
levels of conscious shame. Once again, the 3—way
interaction was not statistically significant, nor was the
predicted interaction between internalization and conscious
shame. However, a 2-way interaction was found between sex
and conscious shame (beta = -.26, p < .05). This
unpredicted interaction is shown in Figure 2. As can be
seen, conscious shame is more strongly (and positively)
related to suicidal ideation among females than among males.

Hypothesis 3 stated that risk—taking attitudes (as

 

measured by the Thrill and Adventure Seeking scale) would be
strongest among adolescents possessing a highly

externalizing coping style, experiencing high levels of

69

Figure 1

Hypothesis lB: Interaction between Unconscious Shame and

Conscious Shame

 

EXT ERNALIZATION

 

 

 

‘-° conscuous SHAME
.5 LOW
o
-.5
HIGH
4.0
.1 .0 O 1 .0

UNCONSCIOUS SHAME

70

Figure 2

Hypothesis 2: Interaction of Conscious Shame and Sex

SUICIDAL IDEATION

 

 

 

1.0
GENDER
FEMALES
.5
MALES
0
-.5
-1.0
-1 0 0 1 0

CONSCIOUS SHAME

71

unconscious shame, and reporting little conscious shame.
This prediction was not supported. In fact, none of the
main effects nor any of the interactions were statistically
significant.

Finally, Hypothesis 4 postulated that the lethality of

 

a participant's suicide attempt would be greatest among
adolescents possessing highly externalizing coping styles
and experiencing high levels of unconscious shame combined
with high levels of conscious shame. The rationale for this
hypothesis was that externalizing adolescents would make
more lethal suicide attempts when unconscious shame "broke
through" into conscious awareness. Unfortunately, it was
not possible to test this hypothesis. Although 40 of the 89
adolescents (45 percent) in the total sample made suicide
attempts prior to their hospitalization, these attempts were
overwhelmingly low in lethality. First, FISCA data were
available on only 21 of the 40 suicide attempters, so it was
not possible to consider an interaction with
externalization. Secondly, as can be seen in Table 7, only
2 of 40 teens (5 percent) who made an attempt undertook an
action that could potentially have resulted in death.
Exploratory regression analyses predicting a dichotomous

variable (the teen did/did not make a suicide attempt) were

72

Table 7

Lethality Ratings of Suicide Attempts (n = 40)

 

 

Degree of Lethality Number in Sample Percentage

 

 

 

Death An Impossible Outcome . . . l7. . . . . . . . 42.5

 

Death Very Highly Improbable . . . .9. . . . . . . . 22.5

 

Death Improbable. . . . . . . . . .5. . . . . . . . 12.5

 

Death Not Likely So Long As
FirSt—Aid IS Obtained e ee e e e e60 e e e e e e e 150$

 

 

Death is a 50/50 Chance Either
Directly or Indirectly. O. I O O .1. C O O O O O O .2.5

 

 

Death is Probable Unless There
Is Immediate and Vigorous
First—Aid O O O O O O O O O O O O .1. O O O O O O O .2.5

 

 

 

Death Is Likely Since No
Attempt Made at
Communication or Since
Suicidal Act Done in Private.. . .1. . . . . . . . .2.5

 

 

 

Death Highly Probable, Except for
iiChance" Intervention . . . .. . .0. . . . . . . . .0.0

 

 

Death 15 Almost Certainity,
Regardless of Interventions
Or Circumstances. . . . . . .. . .0. . . . . . . . .0.0

 

 

 

 

73

carried out on the data for unconscious shame and for sex:
none of the main effects nor any of the interactions were

statistically significant as well.

VIII. DISCUSSION

Summary

The results of this study demonstrate moderately strong
and positive correlations among depressive symptoms,
suicidal ideation, and conscious shame experiences in
adolescent inpatients. These associations, which have been
reported by other investigators as well (Reynolds, 1987a,
1987b: Cook, 1994), were expected, and suggest that
depression, suicidal ideation, and conscious shame, although
separate psychological constructs, might be conceptualized
as occupying overlapping regions in a larger universe of
emotional distress. Given this backdrop, the current study
is unique in its effort to assess unconscious shame as a
variable that might contribute to an adolescent's experience
and/or expression of psychological turmoil. Weaker
correlations between unconscious shame on the one hand and
conscious shame, depression, and suicidal ideation on the

other hand suggest that shame which is relatively

74

inaccessible to the adolescent but able to be observed and
measured via responses to a projective test defines a
separate dimension with its own unique properties.

The present study sought to examine the relationships
of both conscious shame and unconscious shame to
adolescents' experiences of depression ang_their ways of
coping with emotional distress. In order to clarify these
processes, each of the major research hypotheses set forth
in this study will be reviewed and discussed. Although the
data presented only provide partial support for the research
hypotheses, they nevertheless suggest that the interface
between unconscious shame and conscious shame is important
in understanding the links between adolescent depression and
externalizing behaviors.

First, Hypothesis 1A maintained that externalizing
coping styles (as judged by parental report) would be
associated with lower levels of self-reported depression and
conscious shame among adolescents, whereas internalizing
coping styles (also as judged by parental report) would be
associated with higher levels of self-reported depression
and conscious shame among the adolescents. Alternatively,
when parents indicated that their adolescents were showing
overt signs of emotional distress (i.e., they described

their teenager as internalizing), the adolescent themselves

75

should be able to acknowledge these experiences. Partial
support for this hypothesis was found. As expected, parent
report of internalization for both males and females
correlated with adolescents' reports of depressed mood, but
the relationship between internalization and conscious shame
was not statistically significant. In addition, for
females, externalization correlated in the predicted
(negative) direction with both depression and conscious
shame. However, different relationships were found for
males. In particular, males described by parents as
externalizing reported more (rather than less) conscious
shame and were no more or less likely to describe themselves
as depressed. In sum, the relationships between
externalizing behaviors and conscious shame are divergent
for males and females, and thus may be driven by different
underlying mechanisms.

For girls (who psychiatrists had diagnosed as depressed
but who did not themselves acknowledge negative emotional
experiences), it seems plausible that highly externalizing
behaviors "masked" or obscured feelings of conscious shame.
Conceivably, these girls may have used acting-out and
disruptive behaviors such as anger outbursts, mood lability,
school truancy, argumentativeness, running away, and

fighting to defensively avoid painful, affective

76

experiences. Alternatively, it may not be necessary to
assume any underlying motivation in that externalizing
coping styles (which generally are less typical of girls
than boys) simply may have made these "internal" experiences
relatively inaccessible to these girls. However, the notion

that externalizing styles of coping by definition make

 

negative affect less accessible is inconsistent with the
findings for boys in that externalization and conscious
shame to some extent went hand—in—hand.

The findings for Hypothesis 1A rule out the usefulness
of the concept of masked or concealed shame for males,
although the underlying reasons for sex differences in the
associations between conscious shame and externalization for
males and females cannot be explained by these data. In any
event, it is possible that inpatient male adolescents rated
by their parents as externalizing have frequently
experienced scoldings, deprecation, depreciation, or scorn
from adults who found attempts to set limits on these boys
to be chronically unsuccessful. Hence, these males may
have been all too familiar with shame-inducing experiences,
and had an easier time "recognizing" or identifying shame-
related feelings in themselves ("I feel as if I am somehow
defective as a person, like there is something basically

wrong with me"). Nevertheless, this tentative formulation

77

works only for boys. Why externalizing girls report low
conscious shame when the opposite is true for boys remains
unanswered.

In contrast to Hypothesis 1A in which externalization

was viewed as a predictor variable, tests of Hypothesis 1B

 

conceptualized externalization as an outcome variable. In
particular, analyses of Hypothesis 18 showed, as expected,
that when adolescents experienced high levels of conscious
shame accompanied by high levels of unconscious shame, they
were relatively unlikely to exhibit externalizing
behaviors. In contrast, when adolescents experienced low
levels of conscious shame but high levels of unconscious
shame, they were, in fact, likely to exhibit externalizing
behaviors.

One explanation for low externalization among
adolescents with high unconscious shame and high conscious
shame is that the adolescent may be attempting to work
through at an intra—psychic level experiences of shame in
conscious mentation. This might explain why conscious shame
alone for males was positively related to externalization
(as shown by the test of Hypothesis 1A), but why conscious
shame and unconscious shame were linked to less
externalization. Alternatively, a second, more simple

explanation in this regard might be that among adolescents

78

reporting high levels of conscious shame, stories indicating
the presence of high unconscious shame on a projective test
merely reflect what is on the adolescent's mind.

The finding of high externalization among adolescents
with high unconscious shame and low conscious shame is
consistent with what was argued in the literature review.
Presumably, depressed, externalizing adolescents who report
little conscious shame may be more inclined to c0pe with
negative emotional experiences, including shame, through
denial and acting—out behaviors aimed at neutralizing
untenable feelings of powerlessness and vulnerability. In
such cases, it seems plausible that acting-out and
disruptive behaviors may have served to ward off the
irritating and threatening feelings associated self—
deprecating fantasies not available in conscious awareness.
Yet, it is impossible to say for certain from this data
whether it is more appropriate to make an analytic
interpretation suggesting that externalizing behavior is a
defense allowing for the repression of shame-based feelings
or to give a cognitive explanation that emphasizes that
these teens lacked the cognitive skills necessary to
articulate their feelings and were left to express them

behaviorally through undercontrolled actions.

79

In the larger picture, these findings may have
important implications for therapeutic interventions with
adolescent inpatients. They suggest that therapists, after
a careful assessment of the presenting problems, might
consider trying to "access" and bring into conscious
awareness the shame—based thoughts and feelings of their
depressed, acting—out adolescents. The treating professional
working from such a treatment plan obviously would need to
closely monitor the teenager's level of distress and ability
to cope with such powerful emotions: in particular, the
therapist would need to exercise considerable caution so as
to avoid "pushing" the adolescent beyond the point where
coping attempts would be unsuccessful.

In this study, high levels of conscious shame were
associated with high levels of suicidal ideation.
Fortunately, because the hospital enVironment is structured
and staff are prepared to deal with individuals in acute
emotional distress, it may provide the externalizing
adolescent with highly supportive and safe surroundings in
which to address potentially disrupting shame-based thoughts
and feelings. Relatedly, Hypothesis 2 was formulated to
test whether internalizing coping was positively related to
suicidal ideation among adolescents reporting high levels of

conscious shame and unrelated to suicidal ideation among

80

those reporting low levels of conscious shame. Although no
evidence was found to support Hypothesis 2 as postulated,
there was an unexpected interaction between conscious shame
and gender in predicting suicidal ideation. Because very
few teens in the sample (40 of 89 adolescents) actually made
a suicide attempt prior to admission and because most of
these were predominantly very low in lethality, it is
interesting to consider what might have been the motivations
for such actions. Although it is impossible to know for
certain the factors that drive a teenager to consider
suicide, one possible explanation for the numerous low
lethality attempts in this study could be that such actions
served, in large part, an "attention-seeking" function
(Curran, 1987). If so, the suicidal actions of the teens in
this sample may have been driven to some extent by life,
situational, or relationship circumstances with which the
teen felt unable to cope, and may have functioned to
publicize to significant others the adolescent's experience
of despair, hopelessness, depression, or conscious shame.
With regard to Hypothesis 3, there was no evidence to
support that risk—taking behaviors were related to high
levels of externalization, high unconscious shame, and low
conscious shame as well as to the interactions among these

variables. In addition, Hypothesis 4 (i.e. that lethality

81

of suicide attempts would be most severe among teens with
high levels of externalization, high unconscious shame, and
high conscious shame) could not be tested. However, given
the failure to find support for Hypothesis 3, it is likely
that the prediction laid out in Hypothesis 4 would not have
been supported as well. Nevertheless, it is important to
remember that risk-taking is not equivalent to lethal
suicide attempts, and that the data to test Hypothesis 4
were inadequate since few teens actually undertook highly
lethal suicide attempts. To test this hypothesis in the
future, it would be necessary to collect data on a very
large sample of adolescent inpatients in order to ensure
that there would be an adequate number of teens who had, in

fact, made potentially lethal suicide attempts.

Limitations of The Current Study

 

Obviously it is necessary to take this study's
limitations into account in considering the various
results. First, there are questions about
generalizability. This study only examined depressed
adolescents between 13 and 15 years of age. Because
adolescence is a developmental period falling between 10 and

13 years at the point of entry and between 19 and 21 years

82

at the point of exit (Sisson, Hersen, & Van Hasselt, 1987),
future investigations might want to consider older samples
of teens such as 15 to 17 year olds or 18 to 21 year olds.
Conceivably, shame—based thoughts and feelings are
relatively mature affective and cognitive experiences.

Older teens might be more cognizant of and be better able to
report these feelings. Hence, in a young sample such as
this, it is possible that the measure of conscious shame was
confounded with level of cognitive development.

Secondly, due to sample-size constraints, it was
impossible to assess the implications of shame for lethality
of suicide attempts. This is an important omission since
suicide remains a very serious national health problem among
our nation's youth (Hollis, 1996: Ingersoll & Goldstein,
1995). There is clearly much value in examining this
question in future clinical studies.

Third, the sample in this study was predominantly
Caucasian, and thus it is difficult to confidently
generalize the study's research findings to teens of other
racial groups (e.g., African-American: Hispanic—Americans).
Fourth, this study neither addressed nor controlled for
issues linked to differential diagnoses or comorbidity.
Future investigations might want to examine the multitude of

questions that are related to shame and coping style among

depressed teens who, for example, suffer anxiety disorders
as compared to those who show comorbidity with Attention-
deficit Hyperactivity Disorder (ADHD) or Oppositional
Defiant Disorder.

Fifth, this study did not utilize a nonclinical sample
of teenagers whose data then could have been compared to
the inpatient depressed adolescents. Such data would have
been useful for gaining a better understanding about
conscious and unconscious shame in general during the
adolescent years. Finally, this study was somewhat limited
by the lack of well-standardized and validated measures for
tapping into unconscious shame. The Shame Rating Scale
(SRS: Loraas, 1994) which was designed specifically for this
study was useful, but the level of reliability between the
two independent raters, though adequate, was somewhat
disappointing. This circumstance may have been partially
due to the SRS' 19 separate shame-theme categories which
could have made the scale somewhat cumbersome. Future
studies with the SRS might want to consider reducing its 19
shame-theme categories to four or five broad-band categories
under which similar, individual shame themes could be

grouped.

84

The Importance of The Current Study

 

Despite its limitations, this study was nonetheless
important for several reasons. Adolescence is a very unique
developmental stage that is characterized by rapid changes
in the physical, social, and cognitive realms (Eccles et
al., 1993). Although such changes "have an important impact
on adolescents' behavior and also interact with physical
development in predicting adjustment" (Alsaker, 1996, p.
249), the rapidity of changes leaves most teenagers quite
susceptible to shame-based experiences (Kaufman, 1992).
Hence, a valuable feature of this study is that it utilized
a relatively large sample of hospitalized teenagers from
whom self—report data on shame experiences was gathered. In
addition, the painful affective experience of shame has long
been considered the neglected emotion of clinical psychology
and psychiatry (Nathanson, 1992). Although researchers
began studying shame about three decades ago (Lewis, 1971),
the general focus has been on the effect of this emotion on
psychological and interpersonal functioning (Kaufman, 1992:
Sidoli, 1988). The present study is unique because of its
focus on individuals at earlier points in the life—cycle:
adolescents between the ages of 13 and 15 years.

Finally, what may be this study's most valuable aspect

is that it tried to assess and take into consideration the

85

role of unconscious shame experiences. Because this focus
was new, it was necessary to develop a measurement tool to
tap this variable. Hence, the uniqueness of the measure and
the possibility of using it as a tool for assessing
unconscious shame in future studies is an important strength
of this research. Moreover, evidence for the predicted
interaction between unconscious shame and conscious shame in
the present study underscores the importance of assessing
both accessible Eng nonaccessible experiences. Such
measures, like the one developed here, provide an empirical
way of investigating "masked" emotional experiences which
heretofore have been considered not only highly
controversial (Kazdin, 1989: Carlson, 1981), but also

inaccessible to the empirical investigator.

APPENDIX A

86

APPENDIX A

FISCA IMPAIRMENT CRITERIA: Some Examples

 

1) School:

2) Home:

3) Community:

 

(Severe Impairment) Child not attending
school because of school refusal, school
phobia, or school expulsion. Child seriously
harmed a teacher or peer or put others at
risk by bringing a weapon to school. Failing
all classes.

 

(Moderate Impairment) Child frequently
skipped or refused to go to school. Poor
academic performance. Chronic non—
compliance at school.

 

(Mild Impairment) Child occasionally
skips or is truant from school. Minor rule
Violations.

 

(Severe Impairment) Child has runaway two
or more times without parental knowledge

of their whereabouts. Behavior highly
unmanageable.

 

(Moderate Impairment) Child has runaway only
one time and whereabouts of child were known
by parents.

 

(Mild Impairment) Child frequently
refuses to do chores: intermittently
defiant.

 

(Severe Impairment) Set fires with
malicious intent. Severely delinquent or
criminal behavior involving confrontation of
a victim or serious lawbreaking.

 

(Moderate Impairment) Serious lawbreaking
but no confrontation of a victim. On
probation. Play with fire.

 

(Mild Impairment) Occasional and minor
violations of the law.

 

4) Thinking:

5) Aggression:

6)

 

Moods &

Emotions:

87

APPENDIX A

(Severe Impairment) Child cannot be in a
normal classroom AND does not have normal
friendships OR cannot interact adequately in
the community due to poor reality testing,
confusion, or bizarre communications.

 

(Moderate Impairment) Thinking or behavior
more bizarre or impaired than other same age
children AND child requires special school
program or special supervision because of
reality testing impairment, poor control
over mentation, or periods of confusion.

 

(Mild Impairment) Thinking or behavior
more bizarre or impaired than other same age
children because of intermittent

obsessions, occasional lapses in reality
testing, or occasional confusion.

 

(Severe Impairment) Child has no friends
because behavior is chronically hostile. Is
cruel to animals. Threatened or used a
weapon against others. Sexually abused or
molested someone.

 

(Moderate Impairment) Persistent difficulty
in being liked. Sometimes cruel to animals.
Markedly poor impulse or anger control.

 

(Mild Impairment) Trouble interacting
with peers. Sometimes harasses others or
is mean—spirited.

 

(Severe Impairment) Mood problems
accompanied by suicidal intent. Extreme
dysregulation. Depression or anxiety
associated with academic incapacitation or
social isolation or withdrawal.

 

 

7) Self-Harm:

 

8) Alcohol &
Drug Use:

 

88

APPENDIX A

(Moderate Impairment) Severe separation-
anxiety. Persistent depression or anxiety
with somatic complaints, poor concentration,
or sleep difficulties.

 

(Mild Impairment) Periodic mood
fluctuations or anxiety. Periods of intense
sadness. Overly self-critical.

 

(Severe Impairment) Child attempted to
hurt or kill self in a way likely to cause
serious injury or death.

 

(Moderate Impairment) Child attempted to
kill or hurt self in a way suggesting
serious self—harm tendencies. Includes non-
life threatening but non--trivial gestures
and self—mutilation.

 

(Mild Impairment) Repeated non-
acEidental behavior suggesting self-harm
tendencies, but unlikely to cause serious
injury.

 

(Severe Impairment) Frequently intoxicated
or high Tat least two times per week). Use
of alcohol or drugs has resulted in severe
impairment in role functioning (at school,
at home, in the community) or injury (e.g.,
car accident).

 

(Moderate Impairment) High or intoxicated
once a week. Use has led to negative social
consequences (e.g., conflicts at home or
with friends) or situations where the child
or others are put at risk.

 

(Mild Impairment) Regular use (at least
once a week), but without intoxication or
getting high. Occasional intoxication
without any serious consequences.

 

APPENDIX B

89

APPENDIX B

Major Themes of Stimulus Cards

 

from the Roberts Apperception Test for Children

 

 

The B/G distinction following certain cards denotes
that the child-figures depicted in the picture are
either male or female. Male respondents are
administered the "B" cards, whereas female
respondents are administered the "G" cards.

CARD

CARD

CARD

CARD

CARD

CARD

CARD

SB/G:

6B/G:

7B/G:

Family Confrontation: Depicts a father-figure,

 

a mother—figure, and a child all of whom
appear to be in a serious discussion.

Maternal Support: Depicts a mother—figure and

 

child on their knees hugging each other.

School Attitude: Depicts a child sitting at a

 

desk with paper and books and staring.

Child Support/Aggression: Depicts two girls.

 

One is standing, the other is laying on the
ground with eyes closed.

Parental Affection: Depicts a mother—figure

 

and a father-figure in a loving embrace while
the child is standing near them and observing
their interaction.

Peer/Racial Interaction: Depicts three

 

children standing and talking. Two of the
children are Caucasian, and one child is
African-American.

Dependency/Anxiety: Depicts a child sitting up

 

in bed.

CARD

CARD

CARD

CARD

CARD

CARD

CARD

CARD

CARD

108/6:

11:

12B/G:

135/5:

14B/G:

168/6:

90

APPENDIX B

Family Conference: Depicts a father-figure, a
mother—figure, a male child, and a female
child standing. They appear to be having a
discussion.

 

Physical Aggression: Depicts two boys. One
boy is standing with his fists clenched. The
other boy is sitting on the ground and
looking up at the other child.

 

Sibling RivalEy: Depicts a mother-figure

 

holding an infant while an older child is
standing near them and observing.

Fear: Depicts a female child with arms raised
in front of her, leaning backwards and
appearing frightened.

 

Parental Conflict/Depression: Depicts a child
looking over the top of a chair and watching
her parents. The mother—figure appears sad
and is holding onto the wall from a sitting
or kneeling position. The father-figure is
standing near the mother—figure and appears
concerned.

 

Aggression Release: Depicts a child holding a
chair in the air. The child appears to be
getting ready to slam the chair against the
floor.

 

Maternal Limit Setting: Depicts a child making
handprints on the wall after getting into a
can of paint. The mother-figure appears to
be turning the corner and sees what the child
has been doing.

 

Nudity/Sexuality: Depicts a boy looking
through a bathroom door and observing an
adult female taking a bath.

 

Parental Support: Depicts a child standing
near and looking at a father—figure who is
sitting in a chair and reviewing a paper or
letter.

 

APPENDIX C

91

APPENDIX C

NAME: SUBJECT NUMBER:

 

 

 

 

SHAME RATINGS SCALE (SRS)

 

DIRECTIONS: The SRS is designed to evaluate how frequently
the emotion of shame is used to describe the thoughts,
feelings, concerns, or reactions of characters in stories
generated to the stimulus cards of Roberts Apperception Test
for Children (RATC). Each SRS rater should be familiar with
the following story themes or contents in order to determine
whether RATC stories are positive for shame-related
references. The rater should read each RATC story, examine
the SRS list, and place the number(s) of the theme or
content statements in the space provided for each of the
sixteen cards on the SRS Frequency Sheet.

 

Shame Themes, Contents, and Conflicts

 

Characters are described as:

1) Looking or feeling embarrassed or ashamed.
2) Appearing extremely angry or out—of-control.
3) Failing to live up to their own or others'

expectations.

4) Being criticized, ridiculed, looked down upon, exposed,
or denigrated by others.

5) Being or feeling left-out, rejected, or scorned by
others.
6) Being self—critical or self-deprecating (scolding

themselves or putting themselves down).

7) Self—conscious and worrying about and concerned with
others' reactions or thoughts.

8) Feeling isolated and lonely or believing that they do
not fit in with others.

9) Feeling angry or disgusted with themselves, or being
the object of others' anger, disgust, or disapproval.

10)

11)

12)

13)

14)

15)

16)

17)

18)

92

APPENDIX C
Possessing low self—worth or feeling "stupid,"
inadequate, or full of self-doubt.

Thinking of themselves (or being perceived by others)
as small, unimportant, or insignificant.

Defective, worthless, or ineffective.
Totally confused or overwhelmed by emotion(s) or a
situation that causes them to flee in panic or

despair.

Striving for perfection, attempting to do more than
what is realistically possible.

Falling short of their goals, unable to attain what
they expected.

Helpless, powerless, vulnerable, or weak.

Worrying that others' will find out that they did
something wrong, immoral, or "bad."

Experiencing a sense of emptiness or lack of
fulfillment from interpersonal relationships.

Having disappointed themselves or others.

APPENDIX D

93

APPENDIX D

ADOLESCENT DEPRESSION STUDY: Informed Consent Agreement

 

 

l) I, , parent and/or legal
guardian of , a minor, am freely
consenting to allow my child to take part in a scientific,
Ph.D. dissertation research project being conducted at
Rivendell by Mr. John Loraas, M.A., and under the
supervision of Susan J. Frank, Ph.D., Associate Professor of
Psychology, Michigan State University, East Lansing, MI.

2) I understand that this research project involves the
study of depression in young adolescents, ages 13 to 15
years, and is examining the relationship between depression,
coping styles, and destructive or maladaptive behaviors. In
addition to the standard clinical assessment battery that is
already given to each adolescent as part of the treatment
planning process at Rivendell, I understand that my child
also will be asked to complete a questionnaire about
feelings of shame, a questionnaire about risk-taking
behaviors, a projective storytelling task, and a short,
clinical interview. I understand that my child's time
commitment for completing these additional assessment
measures will be approximately 40 to 50 minutes.

3) I understand that questionnaire data I complete
during the standard admission and assessment process
regarding my child's overall emotional and behavioral
functioning may be used to help identify important and
relevant aspects of my child's functioning for purposes of
this research project. I also understand that my child's
participation as well as my decision to allow my child to
participate is voluntary. I understand that either my child
or I may choose not to participate in this research project,
may choose to participate only in certain procedures or to
answer only certain questions, or may discontinue
participation at any time without penalty. Moreover, I
understand that my decision regarding participation will not
affect the quality of care we will receive here at
Rivendell.

4) I understand that my child's additional assessment
information for this study, like the information collected
during the standard clinical assessment process, may be used
to assist in the development of my child's individual
treatment plan while hospitalized at Rivendell. Moreover, I

 

 

94

APPENDIX D

understand that the results of this project will be treated
in strict confidence and that both my child and I will
remain anonymous in any scientific reports or discussions of
the research findings.

5) I understand that both my child and I can request to
discuss this research project with either Mr. John Loraas or
Dr. Susan Frank, both of whom can be contacted through
Rivendell. In addition, I understand that Ms. Michielle
Poorman, M.A., Director of Clinical Services at Rivendell,
is familiar with this study, and is also available to answer
any questions that I have. I further understand that if
either myself or my child would like any publication that
might follow from this study, we can contact Mr. Loraas or
Dr. Frank as well.

 

 

Signature of Parent or Legal Guardian Date

 

 

Witness Date

Medical Records #

 

cc: John Loraas, M.A.

APPENDIX E

 

95

APPENDIX E

ADOLESCENT RESEARCH STUDY
Assent Agreement

 

 

John A. Loraas, M.A.
Michigan State University
Department of Psychology
East Lansing, MI 48824

Dear Teen:

As you may already know from talking with your doctor, your
therapist, or other peers on your unit, all kids who stay at
Rivendell fill out worksheets with questions about their
thoughts, feelings, and behaviors. This information is very
important, because it helps your doctor and therapist develop a
treatment plan especially for you.

This short letter was written to let you know about a research
project that is being done at Rivendell. Mr. John Loraas, who

has worked in our Psychology Department for over four years and
who is currently employed part-time, is interested in learning
more about teenagers who have been feeling unhappy, sad, or "down—
in-the-dumps." For his study, Mr. Loraas is asking teens who are
13, 14, and 15 years old to complete two worksheets, a
storytelling task, and a short interview. Mr. Loraas expects

that these activities will take about 40 to 50 minutes to
complete.

Unlike the other worksheets and questionnaires that you are
required to do as a patient at Rivendell, Mr. Loraas wants you to
know that participation in his study is voluntary. If you wish,
you can choose not to participate. Or you can start, and then
decide to stop without a problem.

 

Again, Mr. Loraas works at Rivendell part-time. Although he may
not be immediately available to talk with you, his research
assistant, Ms. Sondra Wilen, who will be working with you today,
knows a lot about this project and is able to answer any
questions that you may have. If you would like to speak with Mr.
Loraas, please tell Ms. Wilen who then can relay your message.

96

APPENDIX E

Mr. Loraas is really excited about this project, and he hopes
that you will be willing to help him out.

*i:**********************************************************
************************************************************

I have read the above information and voluntarily
agree to participate in this study. I understand that
the information I provide will be held in strict
confidence. However, I realize: 1) that the
information I provide maybe used to assist in the
development of my individual treatment plan: and

2) that any scientific report or discussion that may
arise from this study will keep my identity unknown.

 

 

Adolescent Date

 

 

Witness Date

LI ST OF REFERENCES

97

LIST OF REFERENCES

Achenbach, T. M. (1982). Developmental psychopathology
2nd ed.). New York: John Wiley.

 

Achenbach, T. M., & Edelbrock, C. S. (1983). Manual for
the child behavior checklist and revised behavior
profile. Burlington, VT: University Associates in
Psychiatry.

 

 

Achenbach, T. M., & Edelbrock, C. S. (1987). Manual for
the youth self-report and profile. Burlington, VT:
University Associates in Psychiatry.

 

 

Adams, K. S. (1985). Attempted suicide. In A. Roy (Ed.),
The psychiatric clinics of north america: Symposium on
self-destructive behavior (pp. 183-201). Philadelphia:
W. B. Saunders.

 

 

Alsaker, F. D. (1996). Annotation: The impact of puberty.
Journal of Psychology and Psychiatry, 31, 249-258.

 

American Psychiatric Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.).
Washihgton, DC: Author.

 

 

Andrews, J.A., & Lewinsohn. (1992). Suicidal attempts
among older adolescents: Prevalence and co—occurrence
with psychiatric disorders. Journal of the American
Academy of Child and Adolescent Psychiatry, 31, 655-662.

 

 

Anthony, E. J. (1970). Two contrasting types of adolescent
depression and their treatment. Journal of the American
Psychoanalytic Association, 1, 841-859.

 

 

Anthony, E. J. (1983). Depression in adolescence: A
psychodynamic approach to nosology. In H. Golombek & B.
D. Garfinkel (Fds.), The adolescent and mood disturbances
(pp. 151-165). New York: International Universities
Press.

 

Atlas, J., & DiScipio, W. (1992). Correlations of beck
depression inventory and reynolds adolescent depression
scale. Psychological Reports, 10, 621-622.

 

98

Baron, P., & Joly, E. (1988). Sex differences in the
expression of depression in adolescents. Sex Roles, 18,
1-7 e

 

Barrera, M., Jr., & Garrison-Jones, C. (1992). Family and
peer social support as specific correlates of adolescent
depressive symptoms. Journal of Abnormal Child
Psychology, 20, 1-16.

 

 

Beck, A. T., & Steer, R. A. (1987). Beck depression
inventory manual. San Antonio, TX: The Psychological
Corporation.

 

 

Berndt, D. J., & Zinn, D. (1988). Stressful life events
and adolescent depressive symptomatology. In E. J.
Anthony & C. Chiland (Eds.), The child in his family (pp.
353-376). New York: John Wiley.

 

Bernstein, G. A. (1991). Comorbidity and severity of
anxiety and depressive disorders in a clinic sample.
Journal of the American Academy of Child and Adolescent
Psychiatry, 30, 43-50.

 

 

Biederman, J., Faraone, 8., Mick, R., Moore, P., & Lelon, E.
(1996). Child behavior checklist findings further
support comorbidity between ADHD and major depression in
a referred sample. Journal of the American Academy of
Child and Adolescent Psychiatry, 35, 734-742.

 

 

Bird, H. R., Canino, G., Rubio-Stipec, M., Gould, M. S.,
Ribera, J., Sesman, M., Woodbury, M., Huertas-Goldman,
S., Pagan, A., Sanchez-Lacay, A., & Moscoso, M. (1988).
Estimates of the prevalence of childhood maladjustment in
a community survey in Puerto Rico: The use of combined
measures. Archives of General Psychiatry, 45, 1120-1126.

 

Bird, G. W., & Harris, R. L. (1990). A comparison of role
strain and coping strategies by gender and family
structure among early adolescents. Journal of Early
Adolescence, 10, 141-158.

 

 

Blatt, S. J., & Homann, E. (1992). Parent-child
interaction in the etiology of dependent and self-
critical depression. Clinical Psychology Review, 12,
47-91 0

 

Bowlby, J. (1969/1982). Attachment and loss. Vol. 1:
Attachment (2nd rev. ed.). New York: Basic Books.

 

 

99

Bowlby, J. (1973). Attachment and loss. Vol. 2:
Separation. New York: Basic Books.

 

 

Brand, E. P., King, C. A., Olson, B., Ghaziuddin, N., &
Naylor, M. (1996). Depressed adolescents with a history
of sexual abuse: Diagnostic comorbidity and
suicidality. Journal of the American Academy of Child
and Adolescent Psychiatry, 35, 34-41.

 

 

Brent, D. A., Johnson, B., Bartle, 8., Bridge, J., Rather,
C., Matta, J., Connolly, J., & Constantine, D. (1993).
Personality disorder, tendency to impulsive violence,
and suicidal behavior in adolescent. Journal of the
American Academy of Child and Adolescent Psychiatry, 32,
69—75.

 

 

Campbell, T. L., Byrne, B. M., & Baron, P. (1992). Gender
differences in the expression of depressive symptoms in

early adolescence. Journal of Early Adolescence, 12,
326-338.

 

Campbell, T. L., Byrne, B., & Baron, P. (1994). The
reynolds adolescent depression scale: An exploratory
factor analytic study. Special Issue: Facets of social

intelligence. European Review of Applied Psychology,
44, 319-325.

 

Carlson, G. A., & Strober, M. (1978). Manic-depressive
illness in early adolescence. Journal of the American
Academy of Child Psychiatry, 11, 138-153.

 

 

Carlson, G. A. (1981). The phenomenology of adolescent
depression. Adolescent Psychiatry, 1, 410-418.

 

Cimbolic, P., & Jobes, D. A. (1990). Youth suicide: The
scope of the problem. In P. Cimbolic & D. A. Jobes
(Eds.), Youth suicide (pp. 3-8). Springfield, IL:
Charles Thomas.

 

Clark, D.C., Sommerfeldt, L., Schwarz, M., Hedeker, D., &
Watel, L. (1990). Physical recklessness in
adolescence: Trait or by-product of depressive/suicidal
states. Journal of Nervous and Mental Disease, 178,
423-433. _—-

 

Clarizio, H. F. (1989). Continuity in childhood
depression. Adolescence, 24, 253-267.

 

Q1 ‘ 5 édfémbx
F7 5 I L Cw/ >
H 01:10 O"?

f ) Z La— 2;}
,7 20’ KavfmanO‘i “liq ”LIE

P) SM) geeks ‘1

100

Comerci, G. D., & Macdonald, D. I. (1990). Prevention of
substance abuse in children and adolescents. In V.C.
Strasburger & D. E. Greydanus (Eds.), Adolescent
medicine: The at-risk adolescent (Pp. 127-143).
Philadelphia: Hanley & Belfus.

 

 

Connell, D. K., & Meyer, R. G. (1991). Adolescent suicidal
behavior and popular self-report instruments of
depression, social desirability, and anxiety.
Adolescence, 26, 113-119.

 

Cook, D. R. (1994). Internalized shame scale:
Professional manual. Menomonie, WI: Channel Press.
(Available from the author: E 5886 803rd Ave.,
Menomonie, WI 54751).

 

 

Curran, D. K. (1987). Adolescent suicidal behavior. New
York: Hemisphere.

 

.- ytryn, L., & McKnew, D. H. (1972). Proposed
~:’ classification of childhood depression. American
Journal of Psychiatry, 129, 149-155.

 

Davis, S. M. (1990). Preventing adolescent pregnancy. In
V.C. Strasburger & D. E. Greydanus (Eds.), Adolescent
medicine: The at-risk adolescent (pp. 113-126).
Philadelphia: Hanley & Belfus.

 

 

Delga, I., Heinssen, R. K., Fritsch, R. C., Goodrich, W., &
Yates, B. T. (1989). Psychosis, aggression, and self-
destructive behavior in hospitalized adolescents.
American Journal of Psychiatry, 146, 521-525.

 

Deykin, E. Y., Chung-Chen, H., Joshi, N., McNamarra, J. J.
(1986). Adolescent suicidal and self-destructive
behavior. Society for Adolescent Medicine, 1, 88-95.

 

DiClemente, R. J., & Ponton, L. E. (1993). HIV-related
risk behaviors among psychiatrically hospitalized
adolescents and school-based adolescents. American
Journal of Psychiatry, 150, 324-325.

 

Diekstra, R. F. W., & Moritz, B. J. M. (1987). Suicidal
behaviour among adolescents: An overview. In R. F. W.
Diekstra & K. Hawton (Eds.), Suicide in adolescence (PP.
7-24). Dordrecht, The Netherlands: Martinus Nijhoff.

 

101

Douvan, E., & Adelson, J. (1966). The adolescent
experience. New York: John Wiley.

 

 

Eccles, J. S., Midgley, C., Wigfield, A., Buchanan, C.,
Reuman, D., Flanagan, C., & Mac Iver, D. (1993).
Development during adolescence: The impact of stage-
environment fit on young adolescents' experiences in
schools and families. American Psychologist, 48, 90-101.

 

Erikson, E. (1963). Childhood and society. New York:
Norton.

 

Erikson, E. (1968). Identity: Youth and crisis. New
York: Norton.

 

Eysenck, H. J. (1975). The inequality of man. San Diego,
CA: Edits Publishers.

 

Farley, F. H. (1977). The stimulation-seeking motive and
extraversion in adolescents and adults. Adolescence, 1,
65.7]. e

 

Feehan, M., McGee, R., & Williams, S. M. (1993). Mental
health disorders from age 15 to 18 years. Journal of the
American Academy of Child and Adolescent Psychiatry, 32,
1118-1126. —’

 

Fergusson, D. M., Horwood, L. J., & Lynskey, M. T. (1993).
Prevalence and comorbidity of DSM-III-R diagnoses in a
birth cohort of 15 year olds. Journal of the American
Academy of Child and Adolescent Psychiatry, 32, 1127-
1134.

 

Fergusson, D., & Lynskey, M.T. (1995). Suicide attempts
and suicidal ideation in a birth cohort of l6-year-old
New Zealanders. Journal of the American Academy of
Child and Adolescent Psychiatry, 34, 1308-1317.

 

Fleming, J. E., Boyle, M. H., & Offord, D. R. (1993). The
outcome of adolescent depression in the Ontario child
health study follow-up. Journal of the American Academy
of Child and Adolescent Psychiatry, 33, 28-33.

Frank, S., & Paul, J. (1995). Functional impairment scale
for children and adolescents. Unpublished, Michigan
State University, Outcomes Evaluation Center, Department
of Psychology, East Lansing.

 

102

Frank, S. J., Paul, J., & Jackson, S. (1997). [Validity
of FISCA for children and adolescents]. Unpublished raw
data.

Freud, A. (1946/1958). The ego and the mechanisms of
defense. New York: International Universities Press.

 

Freud, A. (1965). The writings of Anna Freud (Vol. VI).
New York: International Universities Press.

 

Gelfand, D. M., & Peterson, L. (1985). Child development
and psychopathology. Beverly Hills, CA: Sage.

 

 

Gelfand, D. M., Jenson, W. R., & Drew, C. J. (1988).
Understanding child behavior disorders. New York: Holt,
Rinehart, & Winston.

 

Giovacchini, P. L. (1986). Promiscuity in adolescents and
young adults. Medical Aspects of Human Sexuality, 24-31.

 

Goldston, D.B., Daniel, S., Reboussin, D. M., Kelley, A.,
levers, C., & Brunstetter, R. (1996). First-time
suicide attempters repeat attempters, and previous
attempters on an adolescent inpatient psychiatry unit.
Journal of the American Academy of Child and Adolescent
Psychiatry, 35, 631-639.

 

Golombek, H., Marton, P., Stein, B., & Korenblum, M.
(1987). Personality functioning status during early and
middle adolescence. In S. Feinstein (Ed.), Adolescent
psychiatry (pp. 365—377). Chicago: University of
Chicago Press.

 

 

Golombek, H., & Marton, P. (1992). Adolescents over time:
A longitudinal study of personality development. In S.
Feinstein (Ed.), Adolescent Psychiatry: Developmental
and Clinical Studies: Vol. 18 (pp. 465-490). Chicago:
University of Chicago Press.

 

 

Goodyear, I. M. (1990). Family relationships, life events
and childhood psychopathology. Journal of Child
Psychology and Psychiatry, 31, 161-192.

 

 

Goodyear, I. M., & Altham, P. M. E. (1991a). Lifetime exit
events and recent social and family adversities in
anxious and depressed school-age children and
adolescents--I. Journal of Affective Disorders, 21,
219-228. "—

 

103

Goodyear, 1. M., & Altham, P. M. E. (1991b). Lifetime exit
events and recent social and family adversities in
anxious and depressed school-age children and
adolescents--II. Journal of Affective Disorders, 21,
229-238. ‘-

 

Gordon, D. W., & Guze, S. B. (1989). Psychiatric diagnosis
4th ed.). Oxford, England: Oxford University Press.

 

Green, A. H. (1978). Self-destructive behavior in battered
children. American Journal of Psychiatry, 135, 579-582.

 

Guyer, B., Lescohier, I., Gallagher, 8., Hausman, A., &
Azzara, G. (1989). Intentional injuries among children
and adolescents in Massachusetts. The New England
Journal of Medicine, 321, 1584-1589.

 

 

Hafen, B. Q., & Frandsen, K. J. (1986). Youth suicide:
Depression and loneliness. Evergreen, CO: Cordillera
Press.

 

 

Hall, G. S. (1904). Adolescence: Its psychology, and its
relations to physiology, anthropology, sociology, sex,
crime, religion, and education (Vols. 1 & 2). New York:
Appleton-Century-Crofts.

 

 

 

Harrington, R., Fudge, H., Rutter, M., Pickles, A., & Hill,
J. (1991). Adult outcomes of childhood and adolescent
depression: II. Links with antisocial disorders.
Journal of the American Academy of Child and Adolescent
Psychiatry, 30, 434-439.

 

 

Hinshaw, S. P. (1992). Externalizing behavior problems and
academic underachievement in childhood and adolescence:
Causal relationships and underlying mechanisms.
Psychological Bulletin, 111, 127—155.

 

Hoblitzelle, W. (1987). Differentiating and measuring
shame and guilt: The relation between shame and
depression. In H. B. Lewis (Ed.), The role of shame in
symptom formation (pp. 207-235). Hillsdale, NJ:
Erlbaum.

 

 

Hodges, K. (1990). Manual for the Child and Adolescent
Functional Assessment Scale. Unpublished manuscript.
Eastern Michigan University, Department of Psychology,
Ypsilanti, MI.

 

 

104

Hodgman, C. H. (1990). Adolescent depression and suicide.
In V.C. Strasburger & D. E. Greydanus (Eds.), Adolescent
medicine: The at-risk adolescent (pp. 81—95).
Philadelphia: Hanley & Belfus.

 

 

Hollis, C. (1996). Depression, family environment, and
adolescent suicidal behavior. Journal of the American
Academy of Child and Adolescent Psychiatry, 35, 622-630.

 

 

Horowitz, H. A., Overton, W. F., Rosenstein, D., & Steidl,
J. H. (1992). Comorbid adolescent substance abuse: A
maladaptive pattern of self-regulation. In S. Feinstein
(Ed.), Adolescent Psychiatry: Developmental and Clinical
Studies: Vol. 18 (pp. 465-490). Chicago: University of
Chicago Press.

 

 

Hultberg, P. (1988). Shame--a hidden emotion. Journal of
Analytical Psychology, 33, 109-126.

 

 

Ingersoll, B.D., & Goldstein, S. (1995). Lonely, sad, and
angry. New York: Doubleday.

 

Irwin, C. E. (1985). The theoretical concept of at-risk
adolescents. In V.C. Strasburger & D. E. Greydanus
(Eds.), Adolescent medicine: The at-risk adolescent (pp.
1-14). Philadelphia: Hanley & Belfus.

 

Izard, C. B., & Schwartz, G. M. (1986). Patterns of
emotion in depression. In M. Rutter, C. E. Izard, & P.
B. Read (Eds.), Depression in young people: Developmental
and clinical perspectives (pp. 33-70). New York:
Guilford.

 

 

Kandel, D. B., & Davies, M. (1982). Epidemiology of
depressive mood in adolescents: An empirical study.
Archives of General Psychiatry, 32, 1205-1212.

 

Kashani, J. H., Husain, A., Shekim, W. O., Hodges, K. K.,
Cytryn, L., & McKnew, D. H. (1981). Current
perspectives of childhood depression: An overview.
American Journal of Psychiatry, 138, 143-153.

 

Kashani, J. H., Carlson, G. A., Beck, N. C., Hoeper, E. W.,
Corcoran, C. M., McAllister, J. A., Fallahi, C.,
Rosenberg, T. K., & Reid, J. C. (1987). Depression,
depressive symptoms, and depressed mood among a community
sample of adolescents. American Journal of Psychiatry,
144, 931-934.

 

105

Kaufman, G. (1985). Shame: The power of caring (rev.
ed.). Cambridge, MA: Schenkman Books.

Kaufman, G. (1989). The psychology of shame: Theory and
treatment of shame-based syndromes. New York: Springer.

 

Kaufman, G. (1992). Shame: The power of caring (3rd
ed., rev. ed.). Rochester, VT: Schenkman Books.

 

Kazdin, A. E. (1989). Childhood depression. In E. J. Mash
& R. A. Barkley (Eds.), Treatment of childhood disorders
(pp. 135-166). New York: Guilford.

Kellam, S. G., & Hendricks, C. H. (1986). Social
adaptional and psychological antecedents in the first
grade of adolescent psychopathology ten years later. In
G. L. Klerman (Ed.), Suicide and depression among
adolescents and young adults iPP. 147-183‘. Washington:
American Psychiatric Press.

 

King, C. A., Ghaziuddin, N., McGovern, L., Brand, E., Hill,
E., & Naylor, M. (1996). Predictors of comorbid alcohol
and substance abuse in depressed adolescents. Journal of
the American Academy of Child and Adolescent Psychiatry,
42, 743-751.

 

Koenig, L. J. (1988). Self-image of emotionally disturbed
adolescents. Journal of Abnormal Child Psychology, lg,
111-126.

 

Kovacs, M., & Beck, A. T. (1977). An empirical-clinical
approach toward a definition of childhood depression. In
J. Schulterbrandt & A. Raskin (Eds.), Depression in
childhood: Diagnosis, treatment, and conceptual models.
New York: Raven Press.

 

Kovacs, M., Feinberg, T. L., Crouse-Novak, M., Paulauskas,
S. L., Pollack, M., & Finkelstein, R. (1984). Depressive
disorders in childhood: II. A longitudinal study of the
risk for a subsequent major depression. Archives of
General Psychiatry, 44, 643-649.

 

 

Kovacs, M. (1996). Presentation and course of major
depressive disorder during childhood and later years of
the lifespan. Journal of the American Academy of Child
and Adolescent Psychiatry, 22, 705-715.

 

 

106

Kurtz, J. P., & Zuckerman, M. (1978). Race and sex
differences on the sensation seeking scales.
Psychological Reports, 43, 529-530.

 

Laing, R. (1960). The divided self. Chicago: Quadrangle
Books.

 

Langner, T. S., Gersten, J. C., Wills, T. A., & Simcha-
Fagan, O. (1983). The relative roles of early
environment and early behavior as predictors of later
child behavior. In D. F. Ricks & B. S. Dohrenwend
(Eds.), Origins of psychopathology (pp. 43-70).
Cambridge, England: Cambridge University Press.

 

Leibert, R. M., & Spiegler, M. D. (1982). Personality (4th
ed.). Homewood, IL: Dorsey Press.

 

Lerner, R. M.. (1987). A life-span perspective for early
adolescence. In R. M. Lerner & T. T. Foch (Eds.),
Biological-psychosocial interaction in early adolescence
(pp. 9-34). Hillsdale, NJ: Lawrence Erlbaum.

Lewinsohn, P. M., Hops, H., Roberts, R. B., Seely, J. R., &
Andrews, J. A. (1993). Adolescent psychopathology: I.
Prevalence and incidence of depression and other DSM-III-
R disorders in high school students. Journal of Abnormal
Psychology, 143, 133-144.

 

 

Lewis, H. B. (1971). Shame and guilt in neurosis.
Psychoanalytic Review, 2, 419-438.

 

Lewis, H. B. (1987). Shame and narcissistic personality.
In D. L. Nathanson (Ed.), The many faces of shame (PP.
133-161). New York: Guilford.

 

Lewis, M. (1992). Shame: The exposed self. New York:
Free Press.

 

Loraas, J. A. (1994). Shame rating scale. Unpublished,
Michigan State University, Department of Psychology,
East Lansing.

 

Mahler, M. (1952). On child psychosis and schizophrenia:
Autistic and symbiotic infantile psychosis. In A. Freud,
H. Hartmann, & E. Kris (Eds.), Psychoanalytic study of
the child (Vol. 7). New York: International
Universities Press.

 

107

Marttunen, M. J., Hillevi, A., & Lonnqvist, J. K. (1992).
Adolescent suicide: Endpoint of long-term difficulties.
Journal of the American Academy of Children and
Adolescent Psychiatry, 24, 649-654.

 

Marttunen, M. J., Henriksson, M. M., Aro, H. M., Heikkinen,
M. E., Isometsa, E. T., & Lonnqvist, J. K. (1995).
Suicide among female adolescents: Characteristics and
comparison with males in the age group 13 to 22 years.
Journal of the American Academy of Child and Adolescent
Psychiatry, 44, 1297-1307.

 

Mash, E. J., & Barkley, R. A. (Eds.). (1989). Treatment
of childhood disorders. New York: Guilford.

 

 

McArthur, D. S., & Roberts, G. E. (1982). Roberts
apperception test for children: Manual. Los Angeles:
Western Psychological Services.

McCartney, J. R. (1987). Adolescent depression: A growth
and development perspective. In S. Feinstein (Ed.),
Adolescent psychiatry (pp. 208-217). Chicago:
University of Chicago Press.

 

McConaughy, S., Stanger, C., & Achenbach, T. (1992).
Three-year course of behavioral/emotional problems in a
national sample of 4- to l6-year-olds: I. Agreement
among informants. Journal of the American Academy of
Child and Adolescent Psychiatry, El, 932-940.

McGee, R., Feehan, M., Williams, S., & Anderson, S. (1992).
DSM-III disorders from age 11 to age 15 years. Journal
of the American Academy of Child and Adolescent
Psychiatry. 24, 50-59.

 

Nathanson, D. L. (1987). A timetable for shame. In D. L.
Nathanson (Ed.), The many faces of shame (pp. 1-63). New
York: Guilford.

 

Nathanson, D. L. (1992). Shame and pride: Affect, sex,
and the birth of the self. New York: Norton.

 

 

Offer, D., & Offer, J. B. (1975). From teenager to young
manhood. New York: Basic Books.

 

Offer, D. (1987). The mystery of adolescence. In S.
Feinstein (Ed.), Adolescent psychiatry (pp. 7-27).
Chicago: University of Chicago Press.

 

108

Offord, D. R., Boyle, M H., Racine, Y. A., Fleming, J. E.,
Cadman, D. T., Blum, H., Byrne, C., Links, P. S., Lipman,
E. L., MacMillian, H. L., Grant, N. A. I., Sanford, M.
N., Szatmari, P., Thomas, H., & Woodward, C. A. (1992).
Outcome, prognosis, and risk in a longitudinal follow-up
study. Journal of the American Academy of Child and
Adolescent Psychiatry, El, 916-923.

 

Ohberg, A., Lonnqvist, J., Sarna, S., & Vuori, .. (1996).
Violent methods associated with high suicide mortality
among the young. Journal of the American Academy of
Child and Adolesceht Psychiatry, 45, 144-153.

Ohring, R., Apter, A., Ratzoni, G., Weizman, R., Tyano, S.
& Plutchik, R. (1996). State and trait anxiety in
adolescent suicide attempts. Journal of the American
Academy of Child and Adolescent Psychiatry, 22, 154-157.

I

 

Papini, D. R., & Roggman, L. A. (1992). Adolescent
perceived attachment to parents in relation to
competence, depression, and anxiety: A longitudinal
study. Journal of Early Adolescence, 44, 420-440.

Patros, P. G., & Shamoo, T. K. (1989). Depression and

suicide in children and adolescents. Boston, MA: Allyn
& Bacon.

 

Patton, W. (1991). Relationship between self-image and

depression in adolescents. Psychological Reports, g8,
867-870.

 

Paul, J. (1996). A measure of functional impairment in
children and adolescents and its relation to
symptomatology and diagnosis. Unpublished master's
thesis, Michigan State University, Department of
Psychology, East Lansing.

Paulson, J. H. (1990). Injuries: The leading cause of
morbidity and mortality in adolescents. In V.C.
Strasburger & D. E. Greydanus (Eds.), Adolescent
medicine: The at-risk adolescent (pp. 97-112).
Philadelphia: Hanley & Belfus.

 

Peterson, A. C., & Taylor, B. (1980). The biological
approach to adolescence: Biological change and
psychological adaptation. In J. Adelson (Ed.), Handbook
of adolescent psychology (pp. 117-155). New York: ~—
Wiley.

109

Peterson, A. C., & Craighead, W. E. (1986). Emotional and
personality development in normal adolescents and young
adults. In G. L. Klerman (Ed.), Suicide and depression
among adolescents and young adults (pp. 17-52).
Washington: American Psychiatric Press.

 

Peterson, A. C., Compas, B. E., Brooks-Gunn, J., Stemmler,
M., By, S., & Grant, K. E. (1993). Depression in
adolescence. American Psychologist, 48, 155-168.

 

Petti, T. A., & Larson, C. N. (1987). Depression and
suicide. In V. B. Van Hasselt & M. Hersen (Eds.),
Handbook of adolescent psychology (pp. 288-312). New
York: Pergamon Press.

Pfeffer, C. R. (1985). Self-destructive behavior in
children and adolescents. In A. Roy (Ed.), The
psychiatric clinics of north america: Sympogifim on self-
destructive behavior (pp. 183-201). Philadelphia: W. B.

Saunders.

 

Pfeffer, C. R., Hurt, S. W., Peskin, J. R., & Siefker, C.
A. (1995). Suicidal children grow up: Ego functions

 

 

associated with suicide attempts. Journal of the
American Academy of Child and Adolescent Psychiatry, 34,
1318-1325.

Pinto, A., & Whisman, M. A. (1996). Negative affect and
cognitive biases in suicidal and nonsuicidal hospitalized
adolescents. Journal of the American Academy of Child
and Adolescent Psychiatry, :5, 158-165.

 

 

Protinsky, H. (1988). Identity formation: A comparison of
problem and nonproblem adolescents. Adolescence, 24, 67-
7?.

Quadrel, M. J., Fischoff, B., & Davis, W. (1993).
Adolescent (in)vulnerability. American Psychologist, 48,
102-116.

Rao, U., Weissman, M. M., Martin, J. A., & Hammond, R. W.
(1993). Childhood depression and risk of suicide: A
preliminary report of a longitudinal study. Journal of
the American Academy of Child and Adolescent Psychiatry,
32, 21-27.

110

Reinherz, H. Z., Frost, A. K., Stewart-Berghauer, G., Pakiz,
B., Kennedy, K., & Schille, C. (1990). The many faces
of correlates of depressive symptoms in adolescents.
Journal Early Adolescence, 10, 455-471.

 

Reinherz, H. Z., Giaconia, R., Pakiz, B., Silverman, A.,
Frost, A., & Lefkowitz, E. (1993). Psychosocial risks
for major depression in late adolescence: A longitudinal
study. Journal of the American Academy of Child and
Adolescent Psychiatry, 23, 1155-1163.

 

 

Reynolds, W. M. (1984). Depression in children and
adolescents: Phenomenology, evaluation, and treatment.
School Psychology Review, 42, 171-182.

 

Reynolds, W. M. (1987a). Reynolds adolescent depression
scale (RADS) professional manual. Odessa, FL:
Psychological Assessment Resources.

 

 

Reynolds, W. M. (1987b). Suicidal ideation questionnaire
(810) professional manual. Odessa, FL: Psychological
Assessment Resources.

 

 

Reynolds, W. M. (1992). Suicidal behavior history form
(SBHF) clinician's manual. Odessa, FL: Psychological
Assessment Resources.

 

 

Rierdan, J., Koff, E., & Stubbs, M. L. (1988). Gender,
depression, and body image in early adolescents. Journal
of Early Adolescence, 8, 109-117.

 

Rierdan, J., Koff, E., & Stubbs, M. L. (1989). A
longitudinal analysis of body image as a predictor of the
onset and persistence of adolescent girls' depression.
Journal of Early Adolescence, 3, 454-466.

 

Roberts, R. F., Lewinsohn, P. M., & Seeley, J. R. (1995).
Symptoms of DSM-III-R major depression in adolescence:
Evidence from an epidemiological survey. Journal of the
American Academy of Child and Adolescent Psychiatry, 34,
1608-1617. ’—

 

 

Rosen, D. S., Xiangdong, M., & Blum, R. (1990). Adolescent
health: Current trends and critical issues. In V.C.
Strasburger & D. E. Greydanus (Eds.), Adolescent
medicine: The at-risk adolescent (pp. 15-31).
Philadelphia: Hanley & Belfus.

 

 

111

Rotherram-Borus, M.J., Piacentini, J., Van Rossem, R.,
Graae, F., Cantwell, C., Castro-Blanco, D., Miller, S., &
Feldman, J. (1996). Enhancing treatment adherence with
a specialized emergency room program for adolescent
suicide attempters. Journal of the American Academy of
Child and Adolescent Psychiatry, §§, 664-653.

 

 

Russo, M.F. (1991). Sensation seeking scale for children
(SSSC). Unpublished, University of Pittsburgh, Western
Psychiatric Institute and Clinic, Pittsburgh, PA.

 

Russo, M. F., Lahey, B. B., Chris, M. G., Frick, P. J.,
McBurnett, K., Walker, J. L., Loeber, R., Stouthhamer-
Loeber, M., & Green S. M. (1991). Preliminary
develOpment of a sensation seeking scale for children.
Personality and Individual Differences, lg, 399-405.

 

Russo, M. F., Stokes, G. S., Lahey, B. B., Christ, M. G.,
McBurnett, K., Loeber, R., Stouthamer-Loeber, M., &
Green, S. M. (1993). A sensation seeking scale for
children: Further refinement and psychometric
development. Journal of Psychopathology and Behavioral
Assessment, 45, 69-86.

 

 

Rutter, M., Graham, P., Chadwick, O. F. D., & Yule, W.
(1976). Adolescent turmoil: Fact or fiction? Journal of
Child Psychology and Psychiatry, 11, 35-56.

 

 

Rutter, M. (1989). Isle of Wright revisited: Twenty-five
years of child psychiatric epidemiology. Journal of the
American Academy of Child and Adolescent Psychiatry, 28,
633-653. ——

 

 

Rutter, M. (1992). Adolescence as a transition period:
Continuities and discontinuities in conduct disorder.
Journal of Adolescent Health Care, 13, 451-460.

Sanford, M., Szatmari, P., Spinner, M., Munroe-Blum, H.,
Jamieson, B., Walsh, C., & Jones, D. (1995). Predicting
the one-year course of adolescent major depression.
Journal of the American Academy of Child and Adolescent
Psychiatry, 24, 1618-1628.

 

Shaffer, D. (1974). Suicide in childhood and early

adolescence. Journal of Child Psychology and Psychiatry,
45, 275-291.

 

112

Shaffer, D., & Fisher, P. (1981). Suicide in children and
young adolescents. In C. F. Wells & I. R. Wells (Eds.),
Self- destructive behavior in children and adolescents.
New York: Van Nostrand.

 

Shain, B. N., King, C. A., Naylor, M., & Alessi, N. (1991).
Chronic depression and hospital course in adolescents.
Journal of the American Academy of Child and Adolescent
Psychiatry, 40, 428-433.

 

 

Shamoo, T. K., & Patros, P. G. (1990). "I want to kill
myself." Lexington, MA: Lexington Books.

 

Sidoli, M. (1988). Shame and the shadow. Journal of
Analytical Psychology, 23, 127-142.

 

 

Simmons, R. G., Carlton-Ford, S. L., Blyth, D. A. (1987).
Predicting how a child will cope with the transition to
junior high school. In R. Lerner & T. T. Foch (Eds.),
Biological-psychosocial interactions in early adolescence
(pp. 325-375). Hillsdale, NJ: Lawrence Erlbaum.

Sisson, L. A., Hersen, M., & Van Hasselt, V. B. (1987).
Historical perspectives. In V. B. Van Hasselt & M.
Hersen (Eds.), Handbook of adolescent psychology (pp. 3-
10). New York: Pergamon Press.

 

Smith, G. M. (1986). Interrelations among measures of
depressive symptomatology. other measures of
psychological distress, and young adult substance abuse.
In G. L. Klerman (Ed.), Suicide and depression among
adolescents and young adults (pp. 299-315). Washington:
American Psychiatric Press.

 

 

Smith, K., Conroy, R. W., & Ehler, B. D. (1984).
Lethality of suicide attempt rating scale. Suicide and
Life Threatening Behaviors, 24, 215-242.

 

 

Spero, M. H. (1984). Shame: An object-relational
formulation. Psychoanalytic Study of the Child, 39, 259-
282.

 

Stanger, C., McConaughy, S., & Achenbach, T. (1992).
Three-year course of behavioral/emotional problems in a
national sample of 4- to l6-year-olds: II. Predictors
of syndromes. Journal of the American Academy of Child
and Adolescent Psychiatry, 34, 941-950.

 

 

113

Steinberg, L. (1985). Adolescence. New York: Alfred
Knopf.

 

Steinberg, L., Elmen, J. D., & Mounts, N. S. (1989).
Authoritative parenting, psychosocial maturity, and
academic success among adolescents. Child Development,
42, 1424—1436.

 

Steinberg, L., Lamborn, S. D., Dornbusch, S. M., & Darling,
N. (1992). Impact of parenting practices on adolescent
achievement: Authoritative parenting, school
involvement, and encouragement to succeed. Child
Development, fig, 1266-1281.

 

 

Stivers, C. (1988). Parent-adolescent communication and
its relationship to adolescent depression and suicide
proneness. Adolescence, 41, 291-295.

 

Strauss, C. C. (1987). Social deficits of children with
internalizing disorders. In B.B. Lahey & A. E. Kazdin
(Eds.), Advances in clinical child psychology (Vol. 11)
(pp. 159-191). New York: Plenum.

 

Strober, M., Lampert, C., Schmidt, 8., & Morrell, W.
(1993). The course of major depressive disorder in
adolescents: 1. Recovery and risk of manic switching in
a follow—up of psychotic and non-psychotic subtypes.
Journal of the American Academy of Child and Adolescent
Psychiatry, 23, 34-42.

 

Tangney, J. P., Wagner, P., Fletcher, C., & Gramzow, R.
(1992). Shamed into anger? The relation of shame and
guilt to anger and self-reported aggression. Journal of
Personality and Social Psychology, 42, 669-675.

 

 

Tomkins, S. S. (1962). Affect, imagery, consciousness:
The positive affects (Vol. 1). New York: Springer.

 

 

Tomkins, S. S. (1963). Affect, imagery, consciousness:
The positive affects (Vol. 2). New York: Springer.

 

 

Tonkin, R. S. (1987). Adolescent risk-taking behavior.
Journal of Adolescent Health Care, 8, 213-220.

 

Verhulst, F. C., & van der Ende, J. (1992). Six-year
developmental course of internalizing and externalizing
problem behaviors. Journal of the American Academy of
Child and Adolescent Psychiatry, 34, 924-931.

 

 

 

114

Weiner, I. B., & Del Gaudio, A. C. (1976). Psychopathology
in adolescence: An epidemiological study. Archives of
General Psychiatry, 33, 187-193.

 

 

Yorke, C., & et. a1. (1990). The develOpment and
functioning of the sense of shame. In A. J. Solnitt, P.
B. Neubauer, S. Abrahams, & A. S. Dowling (Eds.), The
psychoanalytic study of the child (Vol. 45) (PP. 377:
409). New Haven, CT: Yale University Press.

 

 

 

Zuckerman, M. (1979). Sensation seeking: Beyond the
optimal level of arousal. Hillsdale, NJ: Lawrence
Erlbaum.

Zuckerman, M. (1983). Biological bases of sensation
seeking, impulsivity, and anxiety. Hillsdale, NJ:
Lawrence Erlbaum.

 

 

Zuckerman, M., & Neeb, M. (1980). Sensation seeking and
psychopathology. Psychiatry Research, 4, 255-264.

 

 

"TmT111111“