Correlates of hopelessness in psychiatrically hospitalized children

Correlates

of Hopelessness in Psychiatrically Hospitalized Children

Javad H. Kashani, Stephen M. Soltys, Alison C. Dandoy, Alzira F. Vaidya, and John C. Reid The importance of hopelessness within the study of childhood psychiatric disorders is becoming increasingly apparent. The present study divides a child inpatient sample (age 7 to 12 years) into two groups based on scores from the Kazdin Hopelessness Scale for Children. Comparisons made between the two groups on various measures showed that children with high hopelessness had lower cognitive ability, “difficult child” temperament characteristics, more anxiety, lower self-esteem, and a higher degree of psychopathology than the lowhopelessness group. The role of hopelessness in academic success and future psychopathology are discussed. Copyright 0 1991 by W.B. Saunders Company

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OPELESSNESS, defined as negative expectancies toward oneself and toward the future,’ has been receiving increasing attention in the childhood psychiatric literature due to the emergence of several instruments to measure severity of childhood depression and hopelessness. Considerable work in the past 30 years within adult populations has focused on the importance of hopelessness as a factor in a variety of psychopathological conditions (e.g., depression, suicide, locus of control). Some investigations have studied children to understand continuities and/or discontinuities in hopelessness or depressive tendencies across the developmental spectrum. According to Beck’s cognitive theory,2 hopelessness is at the core of depression. This model emphasizes the role of negative self-perceptions in the development and maintenance of depressive symptoms. The distorted style of thinking is encompassed within a cognitive triad: an unrealistic negative and systematically biased view of self, experiences, and future. Additionally, the depressed individual feels that he/she lacks positive characteristics that would enable him/her to achieve self-satisfaction.’ The adult version of the Hopelessness Scale3 served as a model for the Hopelessness Scale for Children developed by Kazdin et al.4 They administered their scale to 66 children to assess hopelessness and its relation to depression and suicidal intent.4 These researchers found that performance on the Hopelessness Scale positively correlated with severity of depression on several measures and negatively correlated with self-esteem. Similar to results from studies of adult populations (e.g., Minkoff et al.‘), the relationship between hopelessness and suicide intent was not significant when depression was controlled statistically.

From the Departments ofPsychiatty, Psychology, Pediatrics, and Biosfatistics, and the Children and Youth Services and Children’s Inpatient Services at Mid-Missouri Mental Health Center, University of Missouti-Columbia; Dr. Vaidya is a psychiatrist in private practice of child psychiatry in Ponca City, OK Address reprint requests to Javad H. Kashani, M.D., Department of Psychiatry, University of MissoutiColumbia, Three Hospital Dr, Columbia, MO 65201. Copyright 0 1991 by W B. Saunders Company 0010-44OXl91/3204-0011$03.OOlO

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These findings indicate continuities among childhood and adult depression; hopelessness, suicidal ideation, and depression seem to be related in a similar manner in both children and adults. Along these same lines, an investigation by Asarnow and Bates6 of the cognitive and attributional patterns of 53 child psychiatric inpatients (aged 6 to 13 years) suggested that depressed children had maladaptive cognitive and attributional patterns similar to those of adults. Children diagnosed as being depressed reported having significantly more hopelessness, lower perceptions of self-worth, scholastic competence, athletic competence, and physical appearance. The theoretical assumption that negative expectations are more likely in adolescence than in childhood has been challenged by Kashani et al.,’ who investigated the construct at three age levels (8, 12, and 17 years) in 210 children and adolescents from a community sample. One of the major findings of this study showed that hopelessness did not increase with age from preadolescence through adolescence. Additionally, children designated as having high hopelessness scores reported significantly more school problems than children with no hopelessness or moderate hopelessness. These results were based on Kazdin’s Hopelessness Scale for Children and Child Assessment Schedule (CAS) school content scale. This content area, school, was noteworthy because it was the only one that was based on the individual’s performance in school. One construct not investigated with hopelessness is temperament characteristics. Research in the field of temperament supports the assertion that individual differences in temperament play a critical role in the development of behavior disorders (e.g., Chess’ and Graham et al.‘). Three clusters of temperamental traits have been identified: easy, slow-to-warm-up, and difficult.” More specifically, the difficult child is characterized by low rhythmicity, high withdrawal, low adaptability, negative mood, and high intensity. A significant relationship has been found between difficult temperament and later psychopathology. Development, whether deviant or normal, results from the interaction between the child’s individual temperamental makeup and significant figures in the environment. Temperament also reacts with additional aspects of individuality-abilities and motives. Hence, any temperamental pattern could significantly contribute to the development of behavior disorder if the contextual demands and expectations are sufficiently dissonant with a child’s behavioral style.” The present study focuses on the relation of hopelessness to temperament, anxiety, and personality traits. To our knowledge, no studies have investigated the relation between hopelessness, temperament, and personality characteristics. Furthermore, although anxiety disorders are the most common psychiatric disorders among children and adolescents, these disorders are neglected within the hopelessness literature. This is surprising given that anxiety and hopelessness are similar by definition and conceptual basis. Finally, studies pursuing the relation between personality characteristics and hopelessness are nonexistent. This may be due, in part, to the difficulty of measuring personality in children. We also will investigate constructs more prevalent in hopelessness literature (depression, suicidal ideation, and self-esteem) in an attempt to validate previous findings.

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METHOD Subjects The subjects included 100 children (73 boys and 27 girls, aged 7 to 12 years) who were all inpatients within a child psychiatry service at a community mental health center (CMHC). Ninety-one percent were white and 9% were black. To obtain our sample of 100 children, 155 children consecutively admitted to the inpatient setting were evaluated. Forty-two of these 155 were excluded because of a Full Scale Wechsler Intelligence Scale for Children-Revised (WISC-R) score of less than 70 (which may call into question the reliability of the interview results) or because their age fell outside of the 7to 12-year range. The sampling was stopped after 100 subjects had qualified for the study. Diagnoses of the children were obtained during the first week of admission through direct interviews of the children by a Ph.D. candidate in clinical psychology who was trained to administer the DICA and DICA-P. The same interviewer also administered the various instruments discussed in the following section. In addition, all parent(s) were interviewed and completed self-report questionnaires. Family social class, calculated by the Hollingshead and Redlich” index, yielded the following breakdown: class V (lo%), class IV (34%), class III (50%), class II (5%) and class 1(5%).

Distinction Between High- and Low-Hopelessness Groups To examine the relations among hopelessness and various correlates, children who scored at or above the 65th percentile, n = 35 (hopelessness score > 7.0) on the hopelessness scale were delineated as high hopelessness, and those children at or below the 43rd percentile, n = 43 (hopelessness score < 4), were delineated as low hopelessness. These 78 children were chosen from the total sample of 100 subjects. This division is similar to the inpatient study of Kazdin et al.” The present study uses hopelessness as a primary dependent variable.

Instruments Diagnostic Interview for Children and Adolescents (DICA). The DICA14 is a structured diagnostic interview keyed to DSM-III criteria. This instrument assesses common psychiatric disorders in children and adolescents. Reliability and validity are satisfactory.‘4,‘5 Hopelessness Scale for Children. The Hopelessness Scale for Children' was modeled after the scale used for adults.3 Adult scale items were rephrased and pilot tested with inpatient children to ensure comprehensibility (e.g., “I don’t think I will have any real fun when I grow up”). The children’s version contains 17 true/false items; the higher the score, the greater the hopelessness or negative expectancies for the future. Internal consistency, item-total score correlations, and test-retest reliability over a 6-week period for this scale are satisfactory.‘3 Piers-Ham> Children S Self-Concept Scale. The Piers-Harris scale,‘” “The Way I Feel About Myself,” is an 80-item self-report questionnaire appropriate for a wide age range of children. Subjects are asked to respond “yes” or “no” depending on whether the statement pertains to him or her (e.g., “I am a happy person”). The six subscales include: behavior, intellectual and school status, physical appearance, anxiety, popularity, and happiness and satisfaction. Reliability and validity of this scale are summarized in the Piers-Harris manual; both are described as being satisfactory. Dimensions of Temperament Survey (DOTS). The DOTS” is an 89-item dichotomous questionnaire. Analyses in the present study focus on responses by the child about the child. The nine New York Longitudinal Study categories are identified with this scale. Reliability and validity of these categories range from low to moderate levels.” Revised Children’s Manifest Anxiety Scale (RCMAS). The RCMAS’” is a 37-item true/false self-rating scale of anxiety. Five factors make up the scale: physiological, worry/oversensitivity, concentration, a lie score, and a total anxiety score. The reliability and validity of the RCMAS have been well established.‘8,‘9 Children’s Depression Rating Scale (CDRS). The CDRS% is an instrument developed to measure the severity of depression in children. The scale has 15 categories, with a maximum score of 61 and a minimum score of 15. A score of 15 indicates no depression. Reliability and validity have been shown to be acceptable.z’2’ Scale for Suicide Ideation (SSI). The SSP2 was designed to quantify the intensity of current conscious suicidal intent by scaling various dimensions of self-destructive thoughts or wishes. The

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19-item instrument was read to the children. Each item consisted of three alternative statements graded in intensity from 0 to 2. The scale has been found to have high internal consistency and construct validity.22 Diagnostic Interview for Children and Adolescents-Parent Version (DICA-P). The DICA-P’” parallels the children’s version, the DICA. Questions on both interviews are identical with the exception of developmental questions which only appear on the DICA-P. Personality Inventoryfor Children (PIG). The PICz3 is a questionnaire about personality characteristics of the child to which parent(s) respond with a true or false. Twelve clinical and four validity scales comprise the 16 scales of the PIC in addition to four factor scales. Lachar et al.‘4describe the internal consistency, test-retest reliability of the scales and validity. Each factor scale was found to significantly differentiate groups in a meaningful manner.

Statistical Analyses All analyses performed were either chi-square (Yates-corrected) tests for dichotomous data or Mann-Whitney U tests for interval data. All were two-tailed tests. The results section reports only the obtained probability levels for the instruments. Bonferroni probability levels for the PIC, Piers-Harris, DOTS, and RCMAS are ,004, ,008, ,005, and .Ol, respectively.

RESULTS Demographics No differences in race (x2 = 1.8, df= 1, P > .18) or sex (x2 = .29, d’= 1, P > 58) were found between the groups of children (Yates-corrected chi-square

test), nor were there significant differences between groups in regard to age (x’ = .Ol, df= 1, P > .93) or socioeconomic status (x2 = 2.75, df = 1, P > .09) (Mann-Whitney U). However, the high-hopeless group did have a lower full scale IQ score as compared with the low-hopeless group (x2 = 4.3, df = 1, P < .04) (Mann-Whitney U). DZCA Diagnoses

Children in the high-hopeless group had a higher prevalence of the diagnosis of depression (x’ = 13.9, df = 1, P < .OOl), as well as a greater number of DICA diagnoses than the low-hopelessness group (x2 = 5.8, df = 1, P < .Ol). Znstruments

Table 1 shows the means and SDS and group differences on each of the instruments administered to the children. According to the parents’ responses to the PIC, high-hopeless children had significantly different personality manifestations characteristic of poor achievement, poor intellectual and physical development, and impaired intellectual functioning, as well as age-inappropriate academic achievement. Children with high hopelessness also had significantly lower self-concepts as shown by all six areas of the Piers-Harris Self-Concept Scale than did the low-hopelessness children. Additionally, results from the DOTS scale showed that high-hopeless children reported being less able to modify behavior in response to environmental structure (e.g., low adaptability), experienced a negative mood such that they were sad and unhappy, and finally, were more withdrawn than the rest of the sample. High-hopeless children also reported more anxiety and depression than the low hopeless group, according to the RCMAS and the CDRS, respectively. Finally, children designated as having high hopelessness also reported having more suicide ideation than the non-hopeless group.

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Tablel. Comparisons Between Children With High Hopelessness(n = 35) andChildrenWithLowHopelessness(n = 43) High Hopelessness (n = 35) Mean PIG Achievement Development Intellectual screening Cognitive development Piers-Harris Total Behavior Intellect Physical appearance Anxiety Popularity Happiness satisfaction DOTS Adaptability Mood Approach/withdrawal RCMAS Total Physiological Worry Concentration SSI CDRS

factor

SD

Low Hopelessness (n = 43) Mean

SD

x2

P

17.9 11.4 18.1 8.3

5.0 4.0 4.6 4.8

15.5 8.9 15.7 5.6

4.9 4.2 4.1 4.1

4.2 5.6 5.4 6.9

.04 .02 .02 .008

14.9 9.2 9.9 6.9 5.7 5.1 5.1

14.0 4.1 3.6 3.4 3.1 3.3 2.3

62.4 14.2 14.5 9.9 8.8 9.4 7.5

10.6 3.0 3.0 2.3 3.0 2.4 1.5

34.5 27.5 25.8 16.5 16.7 27.6 22.6

.OOOl .OOOl .OOOl .OOOl .OOOl .OOOl .OOOl

2.1 1.5 2.3

6.7 4.6 6.2

2.7 1.2 2.1

11.9 15.6 8.9

.0006 .OOOl ,002

12.7 7.2 9.8 15.6 4.9 4.0

.0004 .007 .002 .OOOl .02 .04

4.7 3.2 4.6 16.2 5.1 6.7 4.4 2.9 36.1

NOTE. Results based on Mann-Whitney

7.2 2.7 3.4 2.2 4.0 12.3

9.7 3.4 4.0 2.4 1.2 31.2

7.0 2.7 3.7 1.8 3.0 11.0

Utest.

DISCUSSION

The present study investigated a variety of constructs in relation to hopelessness. The major findings show that children with high hopelessness (1) have a lower level of intellectual functioning as shown by the PIC scales, the SelfConcept Scale, and the Full Scale IQ than children with low hopelessness, (2) have a temperamental constellation that resembles that of the “difficult child,” (3) have more anxiety and lower self-esteem than children with low hopelessness, and, finally, (4) have a greater number of DICA diagnoses than the lowhopelessness group. Before discussing these findings, it is important to note their limitations. First, results cannot be generalized to other age groups (such as preschoolers) nor can results be generalized to community samples, since this study exclusively used an inpatient sample. Also, results from the PIC are based on parents’ observations of the child and do not reflect the child’s self-report of his/her own personality. Finally, despite the fact that the SSI was read to the child to insure comprehensibility by the child, the scale was originally designed for adults and hence the applicability to children is yet to be replicated. The findings that high-hopeless children showed poorer intellectual achievement and more cognitive deficits than the low-hopeless children were consistent across objective measures: the parents’ observations on the PIC, the child’s perception of his abilities (Piers-Harris Self-Concept Scale), and the WISC-R.

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Although causal links cannot be determined between hopelessness and intellectual ability, motivation might explain this finding. Students who have failed repeatedly at a task may develop low expectancies for positive outcomes in the future resulting in negative affect and minimal desire to perform well. Some may give up trying altogether because they do not see themselves as capable of academic success. Alternatively, if the curiosity and enthusiasm for learning has been impeded by a pervasive sense of hopelessness during the early stages of development, then he/she will not become intrinsically motivated or work toward a “delayed gratification.” Consequently, he/she will not perform well on any evaluative measure, academic or psychological. Another finding that has profound implications for both hopelessness and temperament research was that children with high hopelessness were more likely than the low-hopelessness group to have temperament dimensions characteristic of a “difficult child”: negative mood, low adaptability, and withdrawal.‘” As mentioned earlier, the data clearly indicate that children with the difficult child syndrome have the greatest risk for developing a behavior problem. The three difficult characteristics mentioned above can be construed as being consistent with the negative outlook of the hopeless child. Negative mood is descriptive of the hopeless child and the child who is always in a bad mood is more likely to provoke the displeasure of parents, teachers, and peers. The hopeless child-who by definition has negative expectations for his environment-was also likely to be more withdrawn than those children with low hopelessness. Because the hopeless child withdraws from new aspects of the environment8 any change such as a transfer to a new school may create a great deal of stress. Consequently, the stressful interaction may intensify the difficulty, causing the child to be more vulnerable to an anxious state, for example. Finally, the low adaptability finding suggests that hopeless children are uneasy when making adaptations to their environment.8 Hence, a bright but less adaptable child may be misjudged by a teacher as slow to learn. This may partially explain the earlier findings of poor intellectual functioning in children with high hopelessness. However, the fact remains that in this study and in the general population study mentioned earlier,’ school problems have been found to be highly related to hopelessness. The implications of the relation between temperament and hopelessness are important in terms of prevention of future behavior difficulties though we do not assume causality. However, children who report a higher degree of hopelessness could be at greater risk for future depression or overall psychiatric disorders than children who do not have these qualities. It is not surprising that children in the high-hopelessness group have lower self-concepts (according to the Piers-Harris) than children in the lowhopelessness group. In order for an individual to have positive expectations for the future, he/she must feel liked and must feel adequate and capable in comparison to others. Again, scholastic motivation may be lessened if a child feels little self-worth. A large body of literature discusses the pervasive comorbidity between anxiety and depression. The RCMAS data in the present study add to the literature in that the present study shows that anxiety is comorbid with both depression and hopelessness. Given the pressures and stressors that are connected to the negative

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child-often viewed as “obstinate” by the parents-anxiety and apprehension are likely outcomes. Fear of not being accepted at school, with peers and with parents, may result in excessive worry and distress by the hopeless individual. Suicidal thoughts and depression may be a precursor or a consequence of this hopelessness. Our results validate those found in other studies, namely that suicide and depression are highly correlated with hopelessness (e.g., Kazdin et al.“). Our findings also have important implications for the prevention of suicide. In cognitive therapy, modification of negative cognitions should be the focus to reduce negative views and lift the depression. Finally, our findings that high-hopeless individuals were more likely to have a higher number of DICA diagnoses than low-hopeless individuals lend themselves to various interpretations. It may be that children with a large number of disorders (and consequently more problems to face) become hopeless due to their condition. However, these results could also be interpreted to indicate the consequences of a hopeless condition; such negative expectations toward self, future, and environment may cause the child to become more vulnerable to stressors, resulting in compounded disorders. Nevertheless, the data underscore the relevance of hopelessness as a key component in the severity of various behavior disorders. In the Kashani et al.’ general population study mentioned earlier, similar findings were revealed. Children with high hopelessness scores were found to be at greater risk for depression, suicide, and overall psychopathology. Hence, the construct of hopelessness has been found to be an important determinant of psychopathology in both clinical and general population samples. More studies need to be conducted in order to validate these initial findings which carry such import in the field of childhood psychopathology. For example, by focusing on the preschool population, we may be able to elucidate the causal links between hopelessness and poor school performance. Insight through this group may also be gained into risk factors associated with hopelessness. Hence, developmental trends in this area are needed to further understand the nature of childhood psychopathology. REFERENCES 1. Stotland E: The Psychology of Hope. San Francisco, CA, Josey-Bass, 1969 2. Beck AT: Depression: Clinical, Experimental, and Theoretical Aspects. New York, NY, Harper & Row, 1967 3. Beck AT, Weissman A, Lester D, et al: The measurement of pessimism: The Hopelessness Scale. J Consult Clin Psycho1 42:861-8651974 4. Kazdin AE, French NE, Unis AS, et al: Hopelessness, depression, and suicidal intent among psychiatrically disturbed inpatient children. J Consult Clin Psycho1 51:504-510,1983 5. Minkoff K, Bergman E, Beck AT, et al: Hopelessness, depression, and attempted suicide. Am J Psychiatry 130:455-459,1973 6. Asarnow JR, Bates S: Depression in child psychiatric inpatients: Cognitive and attributional patterns. J Abnorm Child Psycho1 16:601-615,1988 7. Kashani JH, Reid JC, Rosenberg TK: Levels of hopelessness in children and adolescents: A developmental perspective. J Consult Clin Psycho1 57:496-499,1989 8. Chess S: Temperament and children at risk, in Anthony EJ, Koupernik C (eds): The Child in His Family. New York, NY, Wiley, 1970, pp 121-130 9. Graham P, Rutter M, George S: Temperamental characteristics as predictors of behavior disorders in children. Am J Orthopsychiatry 43:328-339,1973 10. Chess S, Hassibi M: Principles and Practice of Child Psychiatry (ed 3). New York, NY, Plenum, 1986

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11. Thomas AH, Chess S: Temperament and Development. New York, NY, BrunneriMazel, 1977 12. Hollingshead AB, Redlich FC: Social Class and Mental Illness. New York, NY, Wiley, 1958 13. Kazdin AE, Rodgers A, Colbus D: The Hopelessness Scale for Children: Psychometric characteristics and concurrent validity. J Consult Clin Psycho1 54:241-245.1986 14. Herjanic B, Reich W: Development of a structured psychiatric interview for children: Agreement between child and parent on individual symptoms. J Abnorm Child Psycho1 10:307-324, 1982 15. Welner Z, Reich W, Herjanic B, et al: Reliability, validity, and parent-child agreement studies of the Diagnostic Interview for Children and Adolescents (DICA). J Am Acad Child Adolesc Psychiatry 26:649-653,1987 16. Piers EV: Manual of the Piers-Harris Children’s Self-Concept Scale (The Way I Feel About Myself). Nashville, TN, Counselor Recordings and Tests, 1969 17. Lerner R, Palermo J, Spiro A, et al: Assessing the dimensions of temperamental individuality across the life span: The Dimensions of Temperament Survey (DOTS). Child Dev 53:149-159, 1982 18. Reynolds CR, Richmond BO: What I Think and Feel: A reviewed measure of children’s manifest anxiety. J Abnorm Child Psycho1 6:271-280, 1978 19. Reynolds CR, Richmond BO: Factor structure and construct validity of “What I Think and Feel”: The Revised Children’s Manifest Anxiety Scale. J Pers Assess 43:281-283,1979 20. Poznanski EO, Cook SC, Carroll BJ: A depression rating scale for children. Pediatrics 64:442-450, 1979 21. Poznanski EO, Cook SC, Carroll BJ, et al: Use of the Children’s Depression Rating Scale in an inpatient psychiatric population. J Clin Psychiatry 44:200-203, 1983 22. Beck AT, Kovacs M, Weissman A: Assessment of suicidal intention: The scale for Suicide Ideation. J Consult Clin Psycho1 47:343-352, 1979 23. Wirt RD, Lachar D, Klinedinst JH, et al: Multidimensional Description of Child Personality: A Manual for the Personality Inventory for Children. Los Angeles, CA, Western Psychological Services, 1977 24. Lachar D, Gdowski CL, Snyder DK: Broadband dimensions of psychopathology: Factor scales for the personality inventory for children. J Consult Clin Psycho1 50:634-642,1982