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“I Am a Total…Loser” – The Role of Interpretation Biases in Youth Depression

“I Am a Total…Loser” – The Role of Interpretation Biases in Youth Depression Negative interpretation biases have been found to characterize adults with depression and to be involved in the development and maintenance of the disorder. However, less is known about their role in youth depression. The present study investigated i) whether negative interpretation biases characterize children and adolescents with depres- sion and ii) to what extent these biases are more pronounced in currently depressed youth compared to youth at risk for depression (as some negative interpretation biases have been found already in high-risk youth before disorder onset). After a negative mood induction interpretation biases were assessed with two experimental tasks: Ambiguous Scenarios Task (AST) and Scrambled Sentences Task (SST) in three groups of 9–14-year-olds: children and adoles- cents with a diagnosis of major depression (n = 32), children and adolescents with a high risk for depression (children of depressed parents; n = 48), as well as low-risk children and adolescents (n = 42). Depressed youth exhibited sub- stantially more negative interpretation biases than both high-risk and low-risk groups (as assessed with both tasks), while the high-risk group showed more negative interpretation biases than the low-risk group only as assessed via the SST. The results indicate that the negative interpretation biases that are to some extent already present in high-risk populations before disorder onset are strongly amplified in currently depressed youth. The different findings for the two tasks suggest that more implicit interpretation biases (assessed with the SST) might represent cognitive vulnera- bilities for depression whereas more explicit interpretation biases (assessed with the AST) may arise as a consequence of depressive symptomatology. . . . . Keywords Interpretation bias Major depression Children and adolescents Familial risk for depression Ambiguous scenarios task Scrambled sentences task Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10802-020-00670-3) contains supplementary material, which is available to authorized users. * Anca Sfärlea Elske Salemink anca.sfaerlea@med.uni-muenchen.de e.salemink@uu.nl Gerd Schulte-Körne Christina Buhl gerd.schulte-koerne@med.uni-muenchen.de christina.buhl@med.uni-muenchen.de Belinda Platt Johanna Loechner belinda.platt@med.uni-muenchen.de johanna.loechner@psy.lmu.de Department of Child and Adolescent Psychiatry, Psychosomatics and Jakob Neumüller Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, jakobneumueller@gmx.de 80336 Munich, Germany Laura Asperud Thomsen Department of Clinical Psychology and Psychotherapy, LMU laura.asperud.t@gmail.com Munich, Munich, Germany Kornelija Starman Department of Clinical Psychology, Utrecht University, connolulu@gmx.de Utrecht, The Netherlands 1338 J Abnorm Child Psychol (2020) 48:1337–1350 Introduction Still, research on the association of interpretation biases and depression in children and adolescents is rather scarce Depression is one of the most common psychiatric disorders (Platt et al. 2017). Some studies have reported correlations in childhood and adolescence (Costello et al. 2003; between interpretation bias scores and depressive symptoms Lewinsohn et al. 1993) with up to 20% of young people hav- in unselected adolescent samples (e.g., Klein et al. 2018; ing experienced at least one episode of major depression (MD) Orchard et al. 2016a; Smith et al. 2018)aswellas samples by the end of adolescence (Thapar et al. 2012). Early-onset with elevated symptoms of depression (de Voogd et al. 2017), MD is associated with adverse outcomes later in life such as but only two studies have compared interpretation biases in educational underachievement (Fergusson and Woodward clinically depressed versus healthy youth. As part of a validity 2002), impairments in psychosocial functioning (Hammen check in their study of an intervention for clinically depressed et al. 2008), and reduced life satisfaction (Lewinsohn et al. adolescents and young adults (14–21 years old), Micco et al. 2003). In addition, early-onset MD often follows a recurrent (2014) compared the depressed group’s baseline interpretation course (e.g., Lewinsohn et al. 1999;Weissman et al. 1999), bias (assessed with the experimental Ambiguous Scenarios which further contributes to the negative consequences of the Task, AST; Mathews and Mackintosh 2000) with that of a disorder (Wilson et al. 2015;Hammen etal. 2008). healthy control group and found the depressed adolescents Cognitive theories of depression propose that cognitive and young adults to show a more negative interpretation bias. vulnerabilities such as cognitive biases play a crucial role in However, as the comparison of depressed and non-depressed the development and maintenance of depressive disorders groups was not the main aim of the study, this result is pre- (e.g., A. T. Beck and Haigh 2014;Disneretal. 2011). sented only briefly and its importance is not discussed. Negative cognitive biases are tendencies to preferentially pro- Orchard et al. (2016b) on the other hand, used the cess negative compared to positive or neutral information and Ambiguous Scenarios Test for Depression in Adolescents, a can be found on various levels of information processing, questionnaire measure they had previously adapted and vali- including attention, interpretation, and memory (Everaert dated (Orchard et al. 2016a), to investigate interpretation et al. 2012; LeMoult and Gotlib 2019). Negative interpretation biases in 12–18-year-old adolescents. They found a more neg- biases, in particular, refer to tendencies to create more nega- ative interpretation bias in adolescents with a diagnosis of MD tive and fewer positive meanings to explain ambiguous emo- not only compared to healthy adolescents from the community tional information (Everaert et al. 2017). For example, a situ- but also to clinically-referred non-depressed youth and ado- ation in which one is giving a speech in front of a group and lescents from the community with elevated depressive people are laughing could be interpreted negatively in terms of symptoms. people laughing at one or positively in terms of people appre- To date, no study has focused on comparing interpretation ciating one’s jokes. In adults, the association between negative biases in depressed and non-depressed youth using experi- interpretation biases and depression has received particularly mental tasks. These do not rely on participants’ awareness of substantial empirical support (see Everaert et al. 2017,for a their depressive cognitions and are less prone to distortions comprehensive meta-analysis). due to demand characteristics (i.e., participants matching their However, results obtained from studies on adults with MD responses to the experimenter’s presumed expectation), re- cannot be directly transferred onto depressed youth sponse biases (i.e., participants endorsing negative responses (Lakdawalla et al. 2007), as major cognitive and affective irrespective of the content corresponding to their interpretation development is ongoing during childhood and adolescence or not), and deliberate response strategies (i.e., participants (Blakemore and Choudhury 2006;Steinberg 2005). generating their responses based on a voluntary strategy in- Therefore, cognitive vulnerabilities might either play a smaller stead of their immediate reaction to the ambiguous informa- role in youth than adult depression as cognitive patterns might tion) that are typical for self-report measures (e.g., Gotlib and not have evolved into stable, trait-like “cognitive styles” yet at Joormann 2010; Hirsch et al. 2016). Thus, experimental tasks this younger age (e.g., Lakdawalla et al. 2007). Alternatively, enable a more objective assessment of cognitive processes and young people might be particulartly susceptible to negative allow more automatic and unconscious processes that operate cues in ambiguous emotional information due to brain matu- outside a person’s awareness to be captured. Therefore, the ration and hormonal changes associated with an enhanced first aim of the present study was to investigate interpretation emotional sensitivity (see e.g., Paus et al. 2008), resulting in biases in youth depression using age-adapted experimental more pronounced negative cognitive biases. Considering the approaches to assess interpretation biases in children and ad- particularly detrimental consequences of early-onset MD, un- olescents with MD. derstanding the mechanisms that are involved in the develop- We administered the AST (Mathews and Mackintosh ment and maintenance of the disorder at this early age is cru- 2000) in which participants read several self-referent ambigu- cial in order to improve prevention and early intervention ous scenarios and are then presented with different interpreta- (Loechner et al. 2018; Weisz et al. 2006). tions of each scenario. Interpretation bias is indexed by the J Abnorm Child Psychol (2020) 48:1337–1350 1339 difference between the endorsement of negative and positive Weissman et al. 2006), and investigating older children of interpretations (de Voogd et al. 2017). In addition, the depressed parents that had not yet suffered from an episode Scrambled Sentences Task (SST; Wenzlaff and Bates 1998), of MD might result in examining a particularly resilient and which was specifically developedtoassessinterpretation therefore non-representative high-risk sample. biases in depressive disorders, was applied. In this task, par- With respect to the first aim of the study, we expected to ticipants form sentences out of arrays of words which can be find more negative interpretation biases in children and ado- either positive or negative. The proportion of negatively re- lescents with MD in comparison to healthy children and ado- solved sentences indicates the interpretation bias. Applying lescents (both high- and low-risk youth), based on theoretical two experimental measures of interpretation bias allows the predictions (e.g., Disner et al. 2011) and previous findings examination of different aspects of interpretation, with the (Orchard et al. 2016b; Micco et al. 2014). Regarding the sec- AST presumably measuring a more conscious and explicit ond aim, we expected negative interpretation biases to be to aspect and the SST capturing a more automatic and implicit some extent present in youth at high risk for depression com- aspect (Sfärlea et al. 2019). Both tasks have already been used pared to youth at low risk for depression (corresponding to our in adolescent samples (e.g., de Voogd et al. 2017; Burnett previous results, Sfärlea et al. 2019; as well as Dearing and Heyes et al. 2017) where they demonstrated at least acceptable Gotlib 2009; Goodman and Gotlib 1999), but to be more reliability (Micco et al. 2014; Sfärlea et al. 2019). pronounced in depressed versus high-risk youth (as found Children and adolescents with MD were compared to two for memory biases; Fattahi Asl et al. 2015). groups of non-depressed children and adolescents that varied in their risk for depression: children of parents with a history of depression, who are known to have an increased risk for Methods MD themselves (e.g., Weissman et al. 2006) and children of parents with no history of depression or any other mental The present data on interpretation biases were collected within disorder, who have a low risk for depressive disorders. This a broader project on cognitive biases in depressed as well as allowed us to pursue the second aim of our study: to determine high- and low-risk youth. It was planned as an add-on to a the extent to which interpretation biases are more pronounced study on cognitive biases in the offspring of depressed versus in currently depressed youth compared to at-risk youth (that non-depressed parents (Platt 2017; Sfärlea et al. 2019). Data have been found to be characterized by more negative from interpretation bias tasks are presented here while data interpretation biases than youth at low risk for depression; from attention bias tasks are presented elsewhere (Buhl et al. Dearing and Gotlib 2009; Sfärlea et al. 2019). While negative in preparation; Platt et al. submitted). interpretation biases in children and adolescents at high risk for depression indicate that these biases might be cognitive Participants vulnerabilities or risk factors contributing to the development of depression (as suggested by theoretical models, e.g., Disner A total of 122 children and adolescents aged 9–14 years were et al. 2011), even more pronounced interpretation biases in included in the data analysis. The sample consisted of n =32 currently depressed children and adolescents indicate that children and adolescents with MD, n = 48 children and adoles- these biases might be exacerbated as a consequence of depres- cents at high familial risk for depression (HR group), and n =42 sive symptomatology. No study to date has directly compared children and adolescents at low familial risk for depression (LR interpretation biases in depressed, high-, and low-risk youth. group). The data from 87% of the HR and LR children was One study that investigated memory biases in children and collected within a study investigating the transgenerational adolescents with MD, children and adolescents whose transmission of cognitive biases (Platt 2017; Sfärlea et al. mothers were affected by MD, and children and adolescents 2019), in which they participated with one of their parents. Of without familial history of MD (Fattahi Asl et al. 2015)found the HR children, 28 were recruited through a study evaluating negative memory biases in both depressed as well as at-risk an intervention to prevent the development of depression in youth compared to low-risk youth. However, the negative memory biases were more pronounced in currently depressed In addition to the AST and the SST that are presented here, a short, picture- children and adolescents than in the at-risk group. based task (resembling that used by Haller et al. 2016) was piloted. However, the validity of this task was limited in our study (see Supplement 1). In order to be able to compare currently depressed youth to Altogether, 126 children and adolescents were tested. Two participants were at-risk youth we focused on children and adolescents aged 9– excluded due to bad compliance and two because of severe reading difficulties 14 years. Children younger than 9 years were not included due (as both interpretation bias tasks are based on reading). The sample size was to concerns about their ability to understand and perform the based on an a priori power analysis (α error probability = .05, power = .8, one- tailed) for the comparison of HR and LR groups (as a smaller effect size was tasks. Adolescents older than 14 years were not included since expected for this effect than for the comparisons with the MD group). An the incidence of depression in children of parents with a his- effect size around d = 0.6 (corresponding to Dearing and Gotlib 2009)was tory of depression increases substantially after that age (e.g., expected, therefore a sample of at least n = 36 per group was aimed for. 1340 J Abnorm Child Psychol (2020) 48:1337–1350 children of parents with a history of depression (Platt et al. Psychopathology Assessment 2014). Eleven of those had already received the prevention program by the time they took part in the present study while All participants underwent extensive diagnostic assess- the others took part before receiving the intervention. Other HR ment before inclusion in the study. A standardized, as well as the LR families were recruited via local advertise- semi-structured psychiatric interview (K-DIPS; ments, previous studies, and mailings to randomly-selected Schneider et al. 2009)was conductedwithbothpartici- families with children in the corresponding age range provided pants and one of their parents to assess psychiatric diag- by the local registry office. Youth with MD were mostly in- or noses in children and adolescents. The K-DIPS is a well- outpatients from a Department of Child and Adolescent established German diagnostic interview that allows di- Psychiatry, Psychosomatics and Psychotherapy of the agnosis of a wide range of psychiatric axis I disorders University Hospital of the LMU Munich, n = 2 were recruited according to DSM-IV (American Psychiatric Association through licensed outpatient psychotherapists, and n =3 were 2000) with good interrater-reliability (accordance rates of respondents to our mailings. at least 97% were reported for all diagnoses; Exclusion criteria for all participants were intelligence quo- Neuschwander et al. 2013). The interviews were con- tient (IQ) < 85 (assessed with the CFT 20-R; Weiß 2006), per- ducted and evaluated by trained interviewers. Interrater- vasive developmental disorders, attention deficit and hyperac- reliability was determined for 18% of the participants of tivity disorder, and a history of schizophrenia or bipolar disor- the HR and LR groups by an independent researcher re- der. Children and adolescents were included in the MD group if rating audio recordings of the diagnostic interviews and they currently met criteria for MD according to DSM-IV found the accordance rate for lifetime diagnosis of de- (American Psychiatric Association 2000) as assessed with a pression (pre-defined criterion) to be 100%. Interviews standardized psychiatric interview (see below). Of the 32 par- from the MD group were not audiotaped, but the partic- ticipants in this group, n = 4 had recurrent episodes of MD, n =2 ipants in this group were referred to our study because were partially remitted (analyses excluding these participants they had a clinical diagnosis of depression which was revealed the same pattern of results), n = 15 fulfilled criteria confirmed with the diagnostic interview. for at least one comorbid anxiety disorder, and n =3 (9.4%) The adult version of the interview (DIPS; Schneider were receiving psychotropic medication (selective serotonin re- and Margraf 2011) was used to assess psychiatric diag- uptake inhibitors). Children and adolescents were included in noses in the parents of the HR and LR participants (for the HR group if they did not meet criteria for any current or past HR participants it was applied to the parent affected by axis I disorder but at least one of their parents met criteria for depression; for LR participants it was applied to both MD (n = 46) or dysthymia (n = 2; analyses excluding these par- parents whenever possible, i.e., for 79% of participants). ticipants revealed the same pattern of results) during the child’s Interrater-reliability of the DIPS has been found to be lifetime. Children of parents with a history of bipolar disorder, good (with accordance rates of at least 87% reported for schizophrenia, or substance abuse were not included. Children all diagnoses; Suppiger et al. 2008) and the accordance and adolescents were included in the LR group if they did not rate for lifetime diagnosis of depression was 94% in our meet criteria for any current or past axis I disorder and none of sample. In addition, depressive symptoms of the parents their parents met criteria for any past or current axis I disorder. were assessed with the German version of the Beck All procedures were approved by the ethics committee of Depression Inventory-II (BDI-II; Hautzinger et al. the Medical Faculty of the LMU Munich (Project 441–15). 2006, obtained from both parents for 81% of HR and Written informed consent was obtained from all participants LR participants) and differed significantly (ts=3.2, p- and their parents after a comprehensive explanation of the s ≤ .002) between parents of HR (parent with a history study procedures. HR and LR participants who participated of MD: M =9.9, SD =8.5; other parent: M =4.2, SD = together with their parents in the study on transgenerational 4.5) and LR participants (M =1.6, SD =3.2). transmission of cognitive biases received a reimbursement of Depressive symptoms of the participants were 50 € per family while participants taking part only in this study assessed with the German version of the Children’s received a reimbursement of 30 €. Depression Inventory (DIKJ; Stiensmeier-Pelster et al. 2014) and anxiety symptoms were measured by the trait scale of the German version of the State Trait Anxiety Two of the participants in the MD group scored just below 85. However, the Inventory for Children (STAIC; Unnewehr et al. 1992). substandard IQ did not correspond to the clinical impression and was most A score for depressive symptoms was available for 121 likely due to a lack of compliance and inability to concentrate on that particular day so those participants were still included. and a score for anxiety symptoms for 117 of the 122 DSM-IV criteria were used as the diagnostic interviews for DSM-V were not participants. Reliability of both self-report measures was available in German by the beginning of data collection. excellent in our sample (DIKJ: Cronbach’s α =.96; One girl met criteria for enuresis in the past. However, as she did not report STAIC-T: Cronbach’s α = .93). symptoms of any other mental disorder she was included nonetheless. J Abnorm Child Psychol (2020) 48:1337–1350 1341 Ambiguous Scenarios Task Software Tools Inc 2013). In the first part of the task, each trial started with the title and the description of a situation with A computerized version of the AST (Mathews and one word missing at the end. Participants were instructed to Mackintosh 2000; adapted from Belli and Lau 2014) was used read the description carefully and to imagine they were in that to assess the tendency to interpret ambiguous situations as situation. After reading the description, participants pressed positive or negative. the spacebar to reveal a fragment of the missing word. They completed the word by typing in the missing letter. Stimuli Stimuli consisted of ten ambiguous scenarios, i.e., Subsequently, a comprehension question that had to be an- descriptions of self-referent situations that could be interpreted swered by pressing “J” for Yes and “N” for No was presented, either positively or negatively. Stimuli were based on the orig- followed by feedback. The word completion and comprehen- inal stimulus set by Mathews and Mackintosh (2000) which sion question were included to ensure that participants read was developed to assess interpretation biases in relation to the scenarios carefully. anxiety. The set was translated and adapted to be age- After the first part, the task continued with a second part in appropriate (by creating situations related to school, sports, which the title of each scenario was presented with four probe or friends to which the studied age group could relate; Belli statements. Participants had to rate the similarity of the state- and Lau 2014; Klein et al. 2018; Lothmann et al. 2011)and ments to the original scenario from 1 (“not similar at all”)to 4 more depression-specific (by including not only social situa- (“very similar”). The statements consisted of one valid nega- tions that might lead to rejection but also situations targeting tive and one valid positive interpretation (targets), as well as low self-esteem and the tendency to overgeneralize/ one negative statement and one positive statement that were catastrophize potentially negative events, which are typical not directly related to the scenario (foils). For each scenario, of depressive thinking). Separate versions for girls and boys the four probe statements were presented consecutively in were generated (differing mainly in using female or male random order. words when referring to, e.g., friends or classmates). See The ten scenarios were presented in random order in both Fig. 1 for an example scenario (and Sfärlea et al. 2019, parts and were preceded by one neutral scenario to familiarize Supplement 3, for an English translation of all scenarios). participants with the task. Task Procedure The trial procedure is depicted in Fig. 1.The Outcome Variables An interpretation bias score (IB )was AST experiment was presented using E-Prime 2.0 (Psychology calculated by subtracting the mean positive target score from Fig. 1 Example scenario from the Ambiguous Scenarios Task (AST; Mathews and Mackintosh 2000) 1342 J Abnorm Child Psychol (2020) 48:1337–1350 the mean negative target score (e.g., de Voogd et al. 2017)so the first or last position and counterbalanced whether the that scores > 0 indicated a negative interpretation bias and positive or negative target word was presented first. scores < 0 indicated a positive interpretation bias. A foil ratio was similarly calculated. Comparing the interpretation bias Task Procedure The trial procedure is depicted in Fig. 2. score and the foil ratio allows analyzing the endorsement of The experiment was presented using Experiment Builder negative versus positive interpretations of ambiguous scenar- 1.10 (SR Research Ltd 2013). Each trial started with a ios (i.e., an interpretation bias, represented by the IB score) fixation cross presented for 500 ms on the left side of the AST compared to the tendency to simply endorse non-specific neg- screen. After that, the stimulus display appeared, ative versus positive statements (i.e., a negative response bias, consisting of six words in scrambled order presented at represented by the foil ratio; Belli and Lau 2014). the center of the screen on a single line. Participants were instructed to read the words, mentally form a grammatical- Reliability Split-half reliability of the task was assessed by ly correct five-word sentence as quickly as possible, and correlating bias scores based on odd versus even trials (see click on the mouse button as soon as they did so to contin- e.g., Van Bockstaele et al. 2017) and was good (r =.66, ue to the response part of the trial. The scrambled sentence p < .001, Spearman-Brown-corrected reliability: .80). was presented for a maximum of 8000 ms; if no mouse click occurred during that time the response part was omit- Scrambled Sentences Task ted and the next trial began. In the response part, five boxes appeared below the scrambled sentence and participants A computerized version of the SST (Wenzlaff and Bates were required to build the sentence they had mentally 1998; adapted by Everaert et al. 2014) was used to assess formed by ordering the words into the five boxes via the tendencytoformnegativeorpositivestatementsout of mouse click. ambiguous verbal information. The task was administered Trials were randomly divided into five blocks of ten, each during eye-tracking in order to simultaneously assess attention containing six emotional and four neutral trials presented in biases (Everaert et al. 2014), but these data are reported else- random order. Before the first block participants completed where (Buhl et al. in preparation). five practice trials to familiarize themselves with the task. Similarly to earlier studies (e.g., Everaert et al. 2014; Stimuli The stimuli consisted of 50 scrambled sentences: 30 Burnett Heyes et al. 2017) a cognitive load procedure was emotional sentences (e.g., “total I winner a loser am”)and included to prevent deliberate response strategies. Before each 20 neutral sentences (e.g., “like watching funny I exciting block, a 4-digit number was presented for 5000 ms which had movies”). The emotional sentences were based on the orig- to be memorized and recalled at the end of the block. inal stimulus set developed by Wenzlaff and Bates (1998) and included, e.g., sentences targeting low mood, low self- Data Processing and Outcome Variables Participants’ re- worth, and negative thoughts about oneself and the future, sponses were rated as correct or incorrect. Trials in which no which are typical cognitions in depression. The sentences grammatically correct sentence was built (time-out or were translated into German (Rohrbacher 2016), extended, incorrect sentence) were excluded from the analysis. and adapted to be easily understandable and relevant to Participants with a correct sentence rate of three standard- children and adolescents (see Supplement 4 of Sfärlea deviations (SD) below the mean were identified as outliers et al. 2019, for an English translation of the stimuli). All in terms of accuracy and excluded (2 HR children), resulting sentences contained six words and had two possible solu- in a sample of 119 children (as data from only 121 of 122 tions. In emotional trials, one solution was positive (e.g., “I participants were available for the SST due to technical prob- am a total winner”) whereas the other was negative (e.g., “I lems) for analysis of the SST data. In that remaining sample, am a total loser”). In neutral trials both solutions were on average 44.2 correct trials (SD = 4.1; 88% of 50 trials) per emotionally neutral. Across the stimulus set, target words participant were available (not different between groups, (the words in each sentence that accounted for the positive p >.1). or negative solution) were matched for length and frequen- The correctly unscrambled emotional sentences were cate- cy in the German language. In line with Everaert et al. gorized as either positive or negative. An interpretation bias (2014), word position within each sentence was random- score (IB ) was calculated as the proportion of negatively SST ized, with target words not allowed next to each other or in resolved sentences from the total number of correctly resolved emotional sentences (Everaert et al. 2014). Positive target words: Word length M =7.3 (SD = 2.6) characters, word fre- Reliability Split-half reliability of the SST was calculated anal- quency (category according to http://wortschatz.uni-leipzig.de/de) M =10.3 ogous to the AST and was excellent (r =.89, p < .001, (SD = 2.9); Negative target words: word length M =7.4 (SD =2.6) characters, word frequency M =10.3 (SD =4.0); ts<1inpaired t-tests. Spearman-Brown-corrected reliability: .94). J Abnorm Child Psychol (2020) 48:1337–1350 1343 Fig. 2 Example of an emotional trial of the Scrambled Sentences Task (SST; Everaert et al. 2014; Wenzlaff and Bates 1998) Experiment Procedure Results Tasks were administered in random order. The course of the Sample Characteristics experimental session was the same as in Sfärlea et al. (2019; see Supplement 5). Sample characteristics are presented in Table 1.Groups did As cognitive models of depression suggest that cognitive not differ significantly in gender ratio or IQ but in terms of vulnerabilities such as negative biases are activated by stress- age: participants in the MD group were significantly older ful life events or negative mood (e.g., Disner et al. 2011; Scher than participants in the HR and LR groups. To examine et al. 2005), a negative mood induction procedure was admin- whether interpretation bias scores were related to age, istered twice during the experimental session: Participants Pearson’s correlations between age and IB as well as AST watched a 2 min scene from the movie The Lion King (Hahn IB scores were calculated separately for each group: no SST et al. 1994) that had successfully induced negative mood in significant correlations emerged (rs ≤ .29, ps > .1). As expect- children in earlier studies (von Leupoldt et al. 2007). In our ed, groups also differed in psychopathology with the MD study participants also reported significantly worse mood group reporting significantly more symptoms of depression (assessed using the valence dimension of the 9-point Self- and anxiety than the groups of healthy children (which did Assessment Mannequin scale; Lang 1980) after watching the not differ from each other, further indicating that the HR group movie scene compared to baseline (ts ≥ 7.9, ps < .001). Details was indeed as psychiatrically healthy as the LR group yet). are presented in Supplement 2. Ambiguous Scenarios Task Data Analysis The one-way ANOVA revealed a significant effect of group (F =13.0, p <.001, η = .18) that was followed up by t- 2,119 Statistical data analysis was conducted with SPSS 25. To as- tests: the MD group’sIB score was significantly more AST sess group differences in demographic and clinical character- negative than that of the HR group (t =4.1, p <.001, d = 48.0 istics, interpretation bias scores (IB and IB ), as well as AST SST 1.0) and the LR group (t =3.3, p =.002, d = 0.8), while the 44.8 the AST foil ratio, one-way analyses of variance (ANOVAs) HR and LR groups did not differ from each other (t =1.5, and follow-up t-tests (Bonferroni-Holm corrected; Holm p > .1). The IB score was significantly > 0 in the MD group AST 1979) were conducted. Correlations were calculated between (M =0.4, SD =1.0; t =2.2, p = .034), indicating a negative bias scores and depression and anxiety symptoms to assess interpretation bias, and significantly < 0 in the HR and LR relationships between psychopathology and interpretation bi- groups (HR: M = −0.4, SD =0.6; LR: M = −0.2, SD =0.5; ts ≥ as. Furthermore, in order to examine if interpretation bias 2.9, ps ≤ .006), indicating a positive interpretation bias. scores from the two tasks were related, a correlation between The one-way ANOVA on foil ratios also yielded a signif- IB and IB scores was computed. AST SST icant effect of group (F =8.0, p =.001, η =.12)withsim- 2,119 All analyses were repeated excluding the participants that ilar results in the post-hoc t-tests but smaller effect sizes (MD were taking psychotropic medication, as this might influence vs. HR: t = 3.6, p = .001, d = 0.8; MD vs. LR: t = 2.6, 78 47.9 cognitive biases (e.g., Wells et al. 2014). As the overall pattern p =.013, d =0.6; HR vs. LR: t =1.3, p >.1). T-tests against of results remained the same, the findings based on the whole zero revealed that while foil ratios in the HR (M = −0.4, SD = sample are reported. 0.6) and LR groups (M = −0.3, SD =0.5) were significantly < 0(ts ≥ 3.3, ps ≤ .002), the foil ratio of the MD group (M =0.2, Relative bias score were used since significantly larger effect sizes were reported for studies computing relative bias scores compared to studies com- SD = 0.9) was not significantly different from zero (t =1.2, puting absolute positive or negative bias scores (Everaert et al. 2017). In p >.1). IB scores and foil ratios are presented in Fig. 3. AST addition, relative bias scores allow to examine if bias scores from different Furthermore, positive correlations between IB scores AST tasks are related to each other. An alternative analysis of the AST with absolute positive and negative values can be found in Supplement 3. and depression (r =.44, p < .001) as well as anxiety symptoms 1344 J Abnorm Child Psychol (2020) 48:1337–1350 Table 1 Demographic and clinical characteristics of the sample MD HR LR Post-hoc tests n =32 n =48 n =42 Gender m/f 6/26 19/29 17/25 χ = 4.7 n.s. Age; M (SD) 13.4 (1.4) 11.8 (1.7) 12.2 (1.7) F =9.3 p <.001 MD >HR=LR 2,119 IQ; M (SD) 105.2 (13.6) 109.1 (11.5) 111.7 (10.3) F = 2.8 n.s. 2,119 Depression symptoms; M(SD) 31.5 (8.9) 7.8 (5.8) 6.6 (5.3) F =161.0 p <.001 MD >HR=LR 2,118 Anxiety symptoms; M(SD) 45.1 (8.8) 30.1 (6.4) 28.0 (6.2) F =56.3 p <.001 MD >HR=LR 2,114 MD Major depression, HR high-risk, LR low-risk Depressive symptoms were assessed with the DIKJ (raw values presented) and anxiety was assessed with the STAIC-T. Post-hoc t-tests were all significant with p ≤ .001 (r =.41, p < .001) were found. These two correlations did not depressive symptoms was significantly stronger than with differ in size (z =0.4, p > .1; Lee and Preacher 2013). As the anxiety (z =5.7, p < .001; Lee and Preacher 2013). When groups differed in both, psychopathology scores as well as recalculated within groups, correlations of IB scores with SST IB scores, the correlational analyses were repeated within depressive symptoms were evident in each group (MD: AST the groups. In the MD group, significant correlations between r =.70, p < .001; HR: r =.56, p < .001; LR: r =.43, p =.005) IB scores and depression (r =.39, p = .026) as well as anx- and correlations with anxiety symptoms became apparent in AST iety symptoms (r =.39, p = .047) emerged, while in the HR the MD (r =.39, p =.046) and HR groups (r =.48, p =.001; and LR groups no such correlations were apparent (rs ≤ .22, LR: r =.22, p >.1). ps > .1). Relationship between AST and SST Scrambled Sentences Task A significant positive correlation between IB and IB AST SST scores emerged across groups (r =.53, p < .001) but within The one-way ANOVA on IB scores revealed a significant SST groups this relationship was only found in the MD group effect of group (F = 129.0, p < .001, η = .69) that was 2,116 (r =.56, p = .001; HR and LR: rs ≤ .18, ps > .1). followed up by t-tests: the MD group (M = .65, SD = .26) had a significantly more negative bias than the HR (M = .14, SD=.12; t = 10.4, p < .001, d=2.5) and LR (M=.08, SD = .09; t = 40.7 37.3 11.8, p < .001, d = 2.9) groups, and the HR group had a more Discussion negative interpretation bias than the LR group (t = 2.5, 82.5 p = .014, d = 0.6). Results are presented in Fig. 4. The present study investigated the role of interpretation biases Strong positive correlations of IB scores with symptoms SST in youth depression. Two experimental tasks capturing differ- of both depression (r =.89, p < .001) as well as anxiety ent aspects of interpretation were used to assess interpretation (r =.72, p < .001) were found, although the relationship with Fig. 3 IB scores and foil ratios for the three groups. Error bars AST represent standard errors. Significant group differences are indicated: Fig. 4 IB scores for the three groups. Error bars represent standard SST *** p < .001, ** p <.01, * p <.05 errors. Significant group differences are indicated: *** p < .001, * p <.05 J Abnorm Child Psychol (2020) 48:1337–1350 1345 biases in three groups of children and adolescents: currently vs. adolescents, or investigate interpretation biases longitudinally depressed children and adolescents (MD group), children and across childhood and adolescence. adolescents at high risk for depression due to having a parent The bias score was strongly positively related to depressive with a history of depression (HR group), and children and symptoms in the full sample, replicating previous results in adolescents with a low risk for depression (LR group). Both youth with depression (Micco et al. 2014)or elevated symp- tasks revealed a more negative interpretation bias in children toms of depression (de Voogd et al. 2017) aswellasunselect- and adolescents with MD compared to both groups of healthy ed samples of adolescents (e.g., Klein et al. 2018; Orchard youth and strong correlations between bias scores and depres- et al. 2016a). However, when correlations were calculated sion and anxiety symptoms (collapsed across groups), while separately within each group, consistent correlations with de- only one task (SST) revealed a more negative interpretation pressive symptoms were found only for interpretation bias as bias in youth at risk for depression compared to low-risk youth assessed with the SST, while the interpretation bias assessed (see also Sfärlea et al. 2019). with the AST only correlated with depressive symptoms with- The first aim of the present study was to test the assumption in the MD group, probably due to lower values and/or less that children and adolescents with MD show more negative in- variance of depression, anxiety, and IB scores in the HR AST terpretation biases compared to healthy youth. As expected, we and LR groups. Similar relationships were found for anxiety found the MD group to draw more negative interpretations of symptoms, which is not surprising considering the well- ambiguous scenarios (AST) as well as sentences (SST), i.e., to established association of anxiety and interpretation biases in show more negative interpretation biases, than the two groups of children and adolescents (Stuijfzand et al. 2018). However, a healthy children and adolescents. The effect sizes of the group comparison of the correlation coefficients indicated that for differences were large, especially for the SST, and comparable to the interpretation bias score as assessed with the SST, the those found with questionnaire measures of interpretation bias association with depressive symptoms was significantly stron- (Orchard et al. 2016b). Of note, as we calculated relative bias ger than the association with anxiety symptoms, suggesting at scores, our results do not elucidate if the more negative interpre- least partial specificity. For the interpretation bias score as tation biases in depressed children and adolescents were due to a assessed with the AST, on the other hand, correlations with lack of positive interpretations or an excess of negative interpre- symptom scores did not differ. tations. However, an additional analysis of the AST data with The second aim of the study was to determine the extent to absolute positive and negative scores instead of a relative bias which interpretation biases are more pronounced in currently score indicated that group differences in the AST were mainly depressed youth compared to at-risk youth. In line with our driven by the MD group being more likely to endorse negative expectations and previous studies (Dearing and Gotlib 2009), interpretations compared to HR and LR groups while no differ- children and adolescents at high risk for depression showed a ences were found for positive interpretations (results of this more negative interpretation bias compared to children and analysis are presented in Supplement 3). It also has to be ac- adolescents at low risk for depression (see also Sfärlea et al. knowledged that the foil ratio of the AST was also more negative 2019). However, only the interpretation bias as assessed with in the MD group than in the HR and LR groups (although with the SST (not the AST) was more negative in the HR group smaller effect sizes: d=0.6–0.8 vs. d=0.8–2.9). As the foil ratio than in the LR group and it was much less pronounced than in represents the tendency to endorse non-specific negative state- the MD group. This is the first time interpretation biases are ments this suggests that the more negative interpretation bias in compared between currently depressed children and adoles- the MD group may partly be explained by a more general neg- cents and children and adolescents with a high or low risk for ative response bias. Our study is the first to focus on comparing depression. The results indicate that while being to some ex- interpretation biases in depressed versus non-depressed youth tent already present in at-risk populations, negative interpre- using multiple experimental measures. The results extend those tation biases are strongly exacerbated in currently depressed of prior studies that have investigated interpretation biases in children and adolescents. depressed adolescents (aged 12–18; Orchard et al. 2016b;and The two tasks assessing interpretation biases yielded diver- 14–21 years; Micco et al. 2014) to a younger age group. The gent results: the AST differentiated only between depressed presence of negative interpretation biases in depressed children and non-depressed children and adolescents and was related to and adolescents corroborates the assumption that negative inter- depressive symptoms only within the MD group, while the pretation biases are a characteristic of individuals with depression SST also differentiated between high- and low-risk youth not only in adults and adolescents but also in 9–14 year old youth and provides empirical support that cognitive theories of depres- Note that parental history of depression is not the only risk factor for depres- sion (e.g., Disner et al. 2011) apply to this group as well. sion. Psychosocial factors like exposure to stressful life events (e.g., bereave- ment) or chronic adversity (e.g., maltreatment, bullying) also put children and However, as it remains unclear how interpretation biases emerge adolescents at risk for developing depression (Thapar et al. 2012). It remains across childhood and adolescence, future studies may compare unclear if our results are specific for children of depressed parents or apply to interpretation biases between different age groups, e.g., children other risk groups as well. 1346 J Abnorm Child Psychol (2020) 48:1337–1350 and was associated to depressive symptoms within all groups. depressed youth might be more efficient if they address interpre- Moreover, interpretation bias scores from the two tasks were tation biases not only explicitly via Cognitive Behavioral only related within the MD group. Based also on our previous Therapy (e.g., J. S. Beck 2011) but also implicitly, for example results (Sfärlea et al. 2019), we suppose that the AST and the via Cognitive Bias Modification interventions that have been SST capture different aspects of interpretation (an issue which shown to successfully modify interpretation biases not only in Everaert et al. 2017, pointed out as especially important to healthy (Lothmann et al. 2011) but also in depressed adolescents investigate): the SST is more cognitively demanding due to (LeMoultetal. 2018; Micco et al. 2014). the time constraint and the cognitive load procedure, so less The presence of negative implicit interpretation biases also in resources are left for volitional control and deliberate response youth at high risk for depression, on the other hand, indicates that strategies. Therefore, the SST may capture a more automatic this kind of interpretation bias might also be a target for preven- (in terms of quick and effortless processing that occurs tive approaches trying to reduce the impact of cognitive vulnera- unintentionally and uncontrollably; cf. Beevers 2005; bilities in children of depressed parents. Modifying cognitive pro- Teachman et al. 2012) and implicit aspect of interpretation. cesses using implicit methods might enhance the efficacy of pre- The AST, on the other hand, allows more reflection on one’s vention programs in this high-risk group, whose effects are rather answers and might therefore be more susceptible to distorted small and short-term (Loechner et al. 2018). However, as some responding, similarly to self-report measures (e.g., Gotlib and studies implementing Cognitive Bias Modification interventions Joormann 2010). Hence, the AST presumably measures a for interpretation bias reported that those lacked transfer effects more conscious and explicit aspect of interpretation (see (e.g., LeMoult et al. 2018; Yiend et al. 2014), these interventions Sfärlea et al. 2019, for more details). According to this as- clearly need to be refined and improved before representing use- sumption, our results suggest that an implicit interpretation ful therapeutic tools for treatment and prevention of depressive bias can already be found in at-risk youth before onset of a disorders. Moreover, as any intervention intended for younger depressive disorder and thus might act as a cognitive vulner- age groups, Cognitive Bias Modification interventions for chil- ability or risk factor contributing to the development of de- dren and adolescents need to be age-adapted, e.g., by using pression (as suggested by theoretical models; e.g., Disner et al. picture-based instead of text-based stimuli for younger children. 2011). The explicit interpretation bias, on the other hand, was Furthermore, as the two measures of interpretation bias only found in the currently depressed group, indicating that presumably capture different aspects of interpretation, the this type of bias may arise as a consequence of depressive AST and the SST could be useful tools for assessing the extent symptomatology. The finding that these two aspects of inter- to which existing interventions are able to change interpreta- pretation operate differently with respect to the question of tion biases in children and adolescents with MD separately on being present already in youth at risk for depression or only conscious as well as automatic levels. in currently depressed children and adolescents contributes to a more comprehensive and differentiated understanding of Strengths interpretation biases in youth depression. However, the cross-sectional design of the study does not allow any conclu- The present study makes a significant contribution to our sions about time course or causality: we cannot determine the knowledge of the role of interpretation biases in youth depres- predictive value of interpretation biases for prospectively sion holding several methodological strengths. predicting the onset of an episode of MD, i.e., whether the Two different tasks were administered to experimentally more negative interpretation bias in the HR group compared assess interpretation biases. The reliability of the tasks was to the LR group indeed acts as a risk factor for the develop- determined and turned out to be at least good for both mea- ment of MD. Likewise, we cannot conclude if the more neg- sures (corresponding to e.g., Micco et al. 2014;Novović et al. ative interpretation biases we found in the MD group com- 2014). Furthermore, the correlations between bias scores and pared to the HR group are consequences of the depressive depressive symptoms underline the construct validity of the disorder or had already characterized those individuals that measures as indicators of depressive processing. developed MD before disorder onset. Longitudinal research Moreover, not only did all participants included in the is needed to address these important questions as well as to study undergo extensive diagnostic assessment, psychopa- investigate what role negative interpretation biases play in the thology was also carefully assessed in one (HR group) or both maintenance of depressive symptoms. (LR group) of their parents via a diagnostic interview instead of relying on self-report of mental disorder history only. Clinical Implications Limitations We found strong negative interpretation biases in children and adolescents with MD on explicit as well as implicit levels. This One limitation of the present study is that the three groups suggests that therapeutic attempts to modify these biases in investigated differed in age with participants in the MD group J Abnorm Child Psychol (2020) 48:1337–1350 1347 being significantly older than participants in the HR and LR Conclusion groups. This probably results from the prevalence of depres- sion being rather low in childhood and rising substantially The present study provides evidence for the presence of ex- with puberty (Thapar et al. 2012) and therefore the majority plicit as well as implicit negative interpretation biases in chil- of the participants in the MD group being 12 to 14 years old. dren and adolescents with MD and implicit interpretation However, as age was not related to bias scores, it is unlikely biases in children and adolescents at risk for depression. that the age difference accounts for the group differences we Pending replication in longitudinal studies, this suggests that found. implicit interpretation biases might represent cognitive vulner- Another limitation results from nearly half of the partici- abilities for depression while explicit interpretation biases pants in the MD group having a comorbid anxiety disorder. seem to arise as a consequence of depression. The results have Also, not only depressive but also anxiety symptoms were important clinical implications for the improvement of inter- related to interpretation biases, which was to be expected con- ventions to prevent and treat youth depression. sidering that the stimuli used in the tasks – even though Acknowledgements The present study was supported by the adapted to our study population – were not entirely “Förderprogramm für Forschung und Lehre” (FöFoLe; Reg.-Nr. 895) depression-specific due to the symptom overlap between de- of the Medical Faculty of the LMU Munich, the “Hans und Klementia pression and particular anxiety disorders like social anxiety Langmatz Stiftung”,the “Friedrich-Baur-Stiftung”, and the LMU Gender disorder or generalized anxiety disorder. Therefore, it cannot Mentoring Program. We thank all participants and their parents. Furthermore, we thank be ruled out that comorbid psychopathology contributed to Petra Wagenbüchler as well as Sonja Stolp and her team for their help our results. However, the association with depressive symp- with participant recruitment as well as Petra Wagenbüchler, Veronika toms was stronger than the association with anxiety symptoms Jäger, Lisa Ordenewitz, Ann-Sophie Störmann, and Moritz Dannert for (for the SST, which is the more depression-specific measure), their help with data collection. suggesting at least partial specificity. Funding Information Open Access funding provided by Projekt DEAL. Furthermore, it remains unknown if group differences in in- terpretation bias, particularly the difference between HR and LR Compliance with Ethical Standards groups in the SST, can also be observed during baseline mood and without the cognitive load, as interpretation biases were only Conflict of Interest The authors declare that they have no conflicts of assessed following a negative mood induction and the SST was interest. not applied without the cognitive load procedure. These possi- bilities should be addressed by future studies as they have im- Ethical Approval All procedures were approved by the ethics committee portant implications for cognitive models of depression. of the Medical Faculty of the LMU Munich (Project 441–15) and were in accordance with the latest version of the Declaration of Helsinki. Finally, since most participants in the MD group were re- cruited at a Department of Child and Adolescent Psychiatry or Informed Consent Written informed consent was obtained from all par- through licensed outpatient psychotherapists, it is likely that ticipants and their parents after a comprehensive explanation of the study most of them were receiving some form of psychotherapy at procedures. the time of their participation (unfortunately, this was not Open Access This article is licensed under a Creative Commons assessed systematically). Since psychotherapy, particularly Attribution 4.0 International License, which permits use, sharing, Cognitive Behavioral Therapy, targets negative interpretation adaptation, distribution and reproduction in any medium or format, as biases, our effect sizes might be underestimates of the effect long as you give appropriate credit to the original author(s) and the sizes in untreated youth depression. Furthermore, since a con- source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article siderable proportion of the participants in the HR group were are included in the article's Creative Commons licence, unless indicated recruited through a study evaluating a family-based preven- otherwise in a credit line to the material. If material is not included in the tion program for children of parents with a history of depres- article's Creative Commons licence and your intended use is not sion (Platt et al. 2014), our HR participants might have been permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a less vulnerable to depression than the average offspring of copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. depressed parents (see Sfärlea et al. 2019, for a more detailed discussion). 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“I Am a Total…Loser” – The Role of Interpretation Biases in Youth Depression

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Abstract

Negative interpretation biases have been found to characterize adults with depression and to be involved in the development and maintenance of the disorder. However, less is known about their role in youth depression. The present study investigated i) whether negative interpretation biases characterize children and adolescents with depres- sion and ii) to what extent these biases are more pronounced in currently depressed youth compared to youth at risk for depression (as some negative interpretation biases have been found already in high-risk youth before disorder onset). After a negative mood induction interpretation biases were assessed with two experimental tasks: Ambiguous Scenarios Task (AST) and Scrambled Sentences Task (SST) in three groups of 9–14-year-olds: children and adoles- cents with a diagnosis of major depression (n = 32), children and adolescents with a high risk for depression (children of depressed parents; n = 48), as well as low-risk children and adolescents (n = 42). Depressed youth exhibited sub- stantially more negative interpretation biases than both high-risk and low-risk groups (as assessed with both tasks), while the high-risk group showed more negative interpretation biases than the low-risk group only as assessed via the SST. The results indicate that the negative interpretation biases that are to some extent already present in high-risk populations before disorder onset are strongly amplified in currently depressed youth. The different findings for the two tasks suggest that more implicit interpretation biases (assessed with the SST) might represent cognitive vulnera- bilities for depression whereas more explicit interpretation biases (assessed with the AST) may arise as a consequence of depressive symptomatology. . . . . Keywords Interpretation bias Major depression Children and adolescents Familial risk for depression Ambiguous scenarios task Scrambled sentences task Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10802-020-00670-3) contains supplementary material, which is available to authorized users. * Anca Sfärlea Elske Salemink anca.sfaerlea@med.uni-muenchen.de e.salemink@uu.nl Gerd Schulte-Körne Christina Buhl gerd.schulte-koerne@med.uni-muenchen.de christina.buhl@med.uni-muenchen.de Belinda Platt Johanna Loechner belinda.platt@med.uni-muenchen.de johanna.loechner@psy.lmu.de Department of Child and Adolescent Psychiatry, Psychosomatics and Jakob Neumüller Psychotherapy, University Hospital, LMU Munich, Nußbaumstr. 5a, jakobneumueller@gmx.de 80336 Munich, Germany Laura Asperud Thomsen Department of Clinical Psychology and Psychotherapy, LMU laura.asperud.t@gmail.com Munich, Munich, Germany Kornelija Starman Department of Clinical Psychology, Utrecht University, connolulu@gmx.de Utrecht, The Netherlands 1338 J Abnorm Child Psychol (2020) 48:1337–1350 Introduction Still, research on the association of interpretation biases and depression in children and adolescents is rather scarce Depression is one of the most common psychiatric disorders (Platt et al. 2017). Some studies have reported correlations in childhood and adolescence (Costello et al. 2003; between interpretation bias scores and depressive symptoms Lewinsohn et al. 1993) with up to 20% of young people hav- in unselected adolescent samples (e.g., Klein et al. 2018; ing experienced at least one episode of major depression (MD) Orchard et al. 2016a; Smith et al. 2018)aswellas samples by the end of adolescence (Thapar et al. 2012). Early-onset with elevated symptoms of depression (de Voogd et al. 2017), MD is associated with adverse outcomes later in life such as but only two studies have compared interpretation biases in educational underachievement (Fergusson and Woodward clinically depressed versus healthy youth. As part of a validity 2002), impairments in psychosocial functioning (Hammen check in their study of an intervention for clinically depressed et al. 2008), and reduced life satisfaction (Lewinsohn et al. adolescents and young adults (14–21 years old), Micco et al. 2003). In addition, early-onset MD often follows a recurrent (2014) compared the depressed group’s baseline interpretation course (e.g., Lewinsohn et al. 1999;Weissman et al. 1999), bias (assessed with the experimental Ambiguous Scenarios which further contributes to the negative consequences of the Task, AST; Mathews and Mackintosh 2000) with that of a disorder (Wilson et al. 2015;Hammen etal. 2008). healthy control group and found the depressed adolescents Cognitive theories of depression propose that cognitive and young adults to show a more negative interpretation bias. vulnerabilities such as cognitive biases play a crucial role in However, as the comparison of depressed and non-depressed the development and maintenance of depressive disorders groups was not the main aim of the study, this result is pre- (e.g., A. T. Beck and Haigh 2014;Disneretal. 2011). sented only briefly and its importance is not discussed. Negative cognitive biases are tendencies to preferentially pro- Orchard et al. (2016b) on the other hand, used the cess negative compared to positive or neutral information and Ambiguous Scenarios Test for Depression in Adolescents, a can be found on various levels of information processing, questionnaire measure they had previously adapted and vali- including attention, interpretation, and memory (Everaert dated (Orchard et al. 2016a), to investigate interpretation et al. 2012; LeMoult and Gotlib 2019). Negative interpretation biases in 12–18-year-old adolescents. They found a more neg- biases, in particular, refer to tendencies to create more nega- ative interpretation bias in adolescents with a diagnosis of MD tive and fewer positive meanings to explain ambiguous emo- not only compared to healthy adolescents from the community tional information (Everaert et al. 2017). For example, a situ- but also to clinically-referred non-depressed youth and ado- ation in which one is giving a speech in front of a group and lescents from the community with elevated depressive people are laughing could be interpreted negatively in terms of symptoms. people laughing at one or positively in terms of people appre- To date, no study has focused on comparing interpretation ciating one’s jokes. In adults, the association between negative biases in depressed and non-depressed youth using experi- interpretation biases and depression has received particularly mental tasks. These do not rely on participants’ awareness of substantial empirical support (see Everaert et al. 2017,for a their depressive cognitions and are less prone to distortions comprehensive meta-analysis). due to demand characteristics (i.e., participants matching their However, results obtained from studies on adults with MD responses to the experimenter’s presumed expectation), re- cannot be directly transferred onto depressed youth sponse biases (i.e., participants endorsing negative responses (Lakdawalla et al. 2007), as major cognitive and affective irrespective of the content corresponding to their interpretation development is ongoing during childhood and adolescence or not), and deliberate response strategies (i.e., participants (Blakemore and Choudhury 2006;Steinberg 2005). generating their responses based on a voluntary strategy in- Therefore, cognitive vulnerabilities might either play a smaller stead of their immediate reaction to the ambiguous informa- role in youth than adult depression as cognitive patterns might tion) that are typical for self-report measures (e.g., Gotlib and not have evolved into stable, trait-like “cognitive styles” yet at Joormann 2010; Hirsch et al. 2016). Thus, experimental tasks this younger age (e.g., Lakdawalla et al. 2007). Alternatively, enable a more objective assessment of cognitive processes and young people might be particulartly susceptible to negative allow more automatic and unconscious processes that operate cues in ambiguous emotional information due to brain matu- outside a person’s awareness to be captured. Therefore, the ration and hormonal changes associated with an enhanced first aim of the present study was to investigate interpretation emotional sensitivity (see e.g., Paus et al. 2008), resulting in biases in youth depression using age-adapted experimental more pronounced negative cognitive biases. Considering the approaches to assess interpretation biases in children and ad- particularly detrimental consequences of early-onset MD, un- olescents with MD. derstanding the mechanisms that are involved in the develop- We administered the AST (Mathews and Mackintosh ment and maintenance of the disorder at this early age is cru- 2000) in which participants read several self-referent ambigu- cial in order to improve prevention and early intervention ous scenarios and are then presented with different interpreta- (Loechner et al. 2018; Weisz et al. 2006). tions of each scenario. Interpretation bias is indexed by the J Abnorm Child Psychol (2020) 48:1337–1350 1339 difference between the endorsement of negative and positive Weissman et al. 2006), and investigating older children of interpretations (de Voogd et al. 2017). In addition, the depressed parents that had not yet suffered from an episode Scrambled Sentences Task (SST; Wenzlaff and Bates 1998), of MD might result in examining a particularly resilient and which was specifically developedtoassessinterpretation therefore non-representative high-risk sample. biases in depressive disorders, was applied. In this task, par- With respect to the first aim of the study, we expected to ticipants form sentences out of arrays of words which can be find more negative interpretation biases in children and ado- either positive or negative. The proportion of negatively re- lescents with MD in comparison to healthy children and ado- solved sentences indicates the interpretation bias. Applying lescents (both high- and low-risk youth), based on theoretical two experimental measures of interpretation bias allows the predictions (e.g., Disner et al. 2011) and previous findings examination of different aspects of interpretation, with the (Orchard et al. 2016b; Micco et al. 2014). Regarding the sec- AST presumably measuring a more conscious and explicit ond aim, we expected negative interpretation biases to be to aspect and the SST capturing a more automatic and implicit some extent present in youth at high risk for depression com- aspect (Sfärlea et al. 2019). Both tasks have already been used pared to youth at low risk for depression (corresponding to our in adolescent samples (e.g., de Voogd et al. 2017; Burnett previous results, Sfärlea et al. 2019; as well as Dearing and Heyes et al. 2017) where they demonstrated at least acceptable Gotlib 2009; Goodman and Gotlib 1999), but to be more reliability (Micco et al. 2014; Sfärlea et al. 2019). pronounced in depressed versus high-risk youth (as found Children and adolescents with MD were compared to two for memory biases; Fattahi Asl et al. 2015). groups of non-depressed children and adolescents that varied in their risk for depression: children of parents with a history of depression, who are known to have an increased risk for Methods MD themselves (e.g., Weissman et al. 2006) and children of parents with no history of depression or any other mental The present data on interpretation biases were collected within disorder, who have a low risk for depressive disorders. This a broader project on cognitive biases in depressed as well as allowed us to pursue the second aim of our study: to determine high- and low-risk youth. It was planned as an add-on to a the extent to which interpretation biases are more pronounced study on cognitive biases in the offspring of depressed versus in currently depressed youth compared to at-risk youth (that non-depressed parents (Platt 2017; Sfärlea et al. 2019). Data have been found to be characterized by more negative from interpretation bias tasks are presented here while data interpretation biases than youth at low risk for depression; from attention bias tasks are presented elsewhere (Buhl et al. Dearing and Gotlib 2009; Sfärlea et al. 2019). While negative in preparation; Platt et al. submitted). interpretation biases in children and adolescents at high risk for depression indicate that these biases might be cognitive Participants vulnerabilities or risk factors contributing to the development of depression (as suggested by theoretical models, e.g., Disner A total of 122 children and adolescents aged 9–14 years were et al. 2011), even more pronounced interpretation biases in included in the data analysis. The sample consisted of n =32 currently depressed children and adolescents indicate that children and adolescents with MD, n = 48 children and adoles- these biases might be exacerbated as a consequence of depres- cents at high familial risk for depression (HR group), and n =42 sive symptomatology. No study to date has directly compared children and adolescents at low familial risk for depression (LR interpretation biases in depressed, high-, and low-risk youth. group). The data from 87% of the HR and LR children was One study that investigated memory biases in children and collected within a study investigating the transgenerational adolescents with MD, children and adolescents whose transmission of cognitive biases (Platt 2017; Sfärlea et al. mothers were affected by MD, and children and adolescents 2019), in which they participated with one of their parents. Of without familial history of MD (Fattahi Asl et al. 2015)found the HR children, 28 were recruited through a study evaluating negative memory biases in both depressed as well as at-risk an intervention to prevent the development of depression in youth compared to low-risk youth. However, the negative memory biases were more pronounced in currently depressed In addition to the AST and the SST that are presented here, a short, picture- children and adolescents than in the at-risk group. based task (resembling that used by Haller et al. 2016) was piloted. However, the validity of this task was limited in our study (see Supplement 1). In order to be able to compare currently depressed youth to Altogether, 126 children and adolescents were tested. Two participants were at-risk youth we focused on children and adolescents aged 9– excluded due to bad compliance and two because of severe reading difficulties 14 years. Children younger than 9 years were not included due (as both interpretation bias tasks are based on reading). The sample size was to concerns about their ability to understand and perform the based on an a priori power analysis (α error probability = .05, power = .8, one- tailed) for the comparison of HR and LR groups (as a smaller effect size was tasks. Adolescents older than 14 years were not included since expected for this effect than for the comparisons with the MD group). An the incidence of depression in children of parents with a his- effect size around d = 0.6 (corresponding to Dearing and Gotlib 2009)was tory of depression increases substantially after that age (e.g., expected, therefore a sample of at least n = 36 per group was aimed for. 1340 J Abnorm Child Psychol (2020) 48:1337–1350 children of parents with a history of depression (Platt et al. Psychopathology Assessment 2014). Eleven of those had already received the prevention program by the time they took part in the present study while All participants underwent extensive diagnostic assess- the others took part before receiving the intervention. Other HR ment before inclusion in the study. A standardized, as well as the LR families were recruited via local advertise- semi-structured psychiatric interview (K-DIPS; ments, previous studies, and mailings to randomly-selected Schneider et al. 2009)was conductedwithbothpartici- families with children in the corresponding age range provided pants and one of their parents to assess psychiatric diag- by the local registry office. Youth with MD were mostly in- or noses in children and adolescents. The K-DIPS is a well- outpatients from a Department of Child and Adolescent established German diagnostic interview that allows di- Psychiatry, Psychosomatics and Psychotherapy of the agnosis of a wide range of psychiatric axis I disorders University Hospital of the LMU Munich, n = 2 were recruited according to DSM-IV (American Psychiatric Association through licensed outpatient psychotherapists, and n =3 were 2000) with good interrater-reliability (accordance rates of respondents to our mailings. at least 97% were reported for all diagnoses; Exclusion criteria for all participants were intelligence quo- Neuschwander et al. 2013). The interviews were con- tient (IQ) < 85 (assessed with the CFT 20-R; Weiß 2006), per- ducted and evaluated by trained interviewers. Interrater- vasive developmental disorders, attention deficit and hyperac- reliability was determined for 18% of the participants of tivity disorder, and a history of schizophrenia or bipolar disor- the HR and LR groups by an independent researcher re- der. Children and adolescents were included in the MD group if rating audio recordings of the diagnostic interviews and they currently met criteria for MD according to DSM-IV found the accordance rate for lifetime diagnosis of de- (American Psychiatric Association 2000) as assessed with a pression (pre-defined criterion) to be 100%. Interviews standardized psychiatric interview (see below). Of the 32 par- from the MD group were not audiotaped, but the partic- ticipants in this group, n = 4 had recurrent episodes of MD, n =2 ipants in this group were referred to our study because were partially remitted (analyses excluding these participants they had a clinical diagnosis of depression which was revealed the same pattern of results), n = 15 fulfilled criteria confirmed with the diagnostic interview. for at least one comorbid anxiety disorder, and n =3 (9.4%) The adult version of the interview (DIPS; Schneider were receiving psychotropic medication (selective serotonin re- and Margraf 2011) was used to assess psychiatric diag- uptake inhibitors). Children and adolescents were included in noses in the parents of the HR and LR participants (for the HR group if they did not meet criteria for any current or past HR participants it was applied to the parent affected by axis I disorder but at least one of their parents met criteria for depression; for LR participants it was applied to both MD (n = 46) or dysthymia (n = 2; analyses excluding these par- parents whenever possible, i.e., for 79% of participants). ticipants revealed the same pattern of results) during the child’s Interrater-reliability of the DIPS has been found to be lifetime. Children of parents with a history of bipolar disorder, good (with accordance rates of at least 87% reported for schizophrenia, or substance abuse were not included. Children all diagnoses; Suppiger et al. 2008) and the accordance and adolescents were included in the LR group if they did not rate for lifetime diagnosis of depression was 94% in our meet criteria for any current or past axis I disorder and none of sample. In addition, depressive symptoms of the parents their parents met criteria for any past or current axis I disorder. were assessed with the German version of the Beck All procedures were approved by the ethics committee of Depression Inventory-II (BDI-II; Hautzinger et al. the Medical Faculty of the LMU Munich (Project 441–15). 2006, obtained from both parents for 81% of HR and Written informed consent was obtained from all participants LR participants) and differed significantly (ts=3.2, p- and their parents after a comprehensive explanation of the s ≤ .002) between parents of HR (parent with a history study procedures. HR and LR participants who participated of MD: M =9.9, SD =8.5; other parent: M =4.2, SD = together with their parents in the study on transgenerational 4.5) and LR participants (M =1.6, SD =3.2). transmission of cognitive biases received a reimbursement of Depressive symptoms of the participants were 50 € per family while participants taking part only in this study assessed with the German version of the Children’s received a reimbursement of 30 €. Depression Inventory (DIKJ; Stiensmeier-Pelster et al. 2014) and anxiety symptoms were measured by the trait scale of the German version of the State Trait Anxiety Two of the participants in the MD group scored just below 85. However, the Inventory for Children (STAIC; Unnewehr et al. 1992). substandard IQ did not correspond to the clinical impression and was most A score for depressive symptoms was available for 121 likely due to a lack of compliance and inability to concentrate on that particular day so those participants were still included. and a score for anxiety symptoms for 117 of the 122 DSM-IV criteria were used as the diagnostic interviews for DSM-V were not participants. Reliability of both self-report measures was available in German by the beginning of data collection. excellent in our sample (DIKJ: Cronbach’s α =.96; One girl met criteria for enuresis in the past. However, as she did not report STAIC-T: Cronbach’s α = .93). symptoms of any other mental disorder she was included nonetheless. J Abnorm Child Psychol (2020) 48:1337–1350 1341 Ambiguous Scenarios Task Software Tools Inc 2013). In the first part of the task, each trial started with the title and the description of a situation with A computerized version of the AST (Mathews and one word missing at the end. Participants were instructed to Mackintosh 2000; adapted from Belli and Lau 2014) was used read the description carefully and to imagine they were in that to assess the tendency to interpret ambiguous situations as situation. After reading the description, participants pressed positive or negative. the spacebar to reveal a fragment of the missing word. They completed the word by typing in the missing letter. Stimuli Stimuli consisted of ten ambiguous scenarios, i.e., Subsequently, a comprehension question that had to be an- descriptions of self-referent situations that could be interpreted swered by pressing “J” for Yes and “N” for No was presented, either positively or negatively. Stimuli were based on the orig- followed by feedback. The word completion and comprehen- inal stimulus set by Mathews and Mackintosh (2000) which sion question were included to ensure that participants read was developed to assess interpretation biases in relation to the scenarios carefully. anxiety. The set was translated and adapted to be age- After the first part, the task continued with a second part in appropriate (by creating situations related to school, sports, which the title of each scenario was presented with four probe or friends to which the studied age group could relate; Belli statements. Participants had to rate the similarity of the state- and Lau 2014; Klein et al. 2018; Lothmann et al. 2011)and ments to the original scenario from 1 (“not similar at all”)to 4 more depression-specific (by including not only social situa- (“very similar”). The statements consisted of one valid nega- tions that might lead to rejection but also situations targeting tive and one valid positive interpretation (targets), as well as low self-esteem and the tendency to overgeneralize/ one negative statement and one positive statement that were catastrophize potentially negative events, which are typical not directly related to the scenario (foils). For each scenario, of depressive thinking). Separate versions for girls and boys the four probe statements were presented consecutively in were generated (differing mainly in using female or male random order. words when referring to, e.g., friends or classmates). See The ten scenarios were presented in random order in both Fig. 1 for an example scenario (and Sfärlea et al. 2019, parts and were preceded by one neutral scenario to familiarize Supplement 3, for an English translation of all scenarios). participants with the task. Task Procedure The trial procedure is depicted in Fig. 1.The Outcome Variables An interpretation bias score (IB )was AST experiment was presented using E-Prime 2.0 (Psychology calculated by subtracting the mean positive target score from Fig. 1 Example scenario from the Ambiguous Scenarios Task (AST; Mathews and Mackintosh 2000) 1342 J Abnorm Child Psychol (2020) 48:1337–1350 the mean negative target score (e.g., de Voogd et al. 2017)so the first or last position and counterbalanced whether the that scores > 0 indicated a negative interpretation bias and positive or negative target word was presented first. scores < 0 indicated a positive interpretation bias. A foil ratio was similarly calculated. Comparing the interpretation bias Task Procedure The trial procedure is depicted in Fig. 2. score and the foil ratio allows analyzing the endorsement of The experiment was presented using Experiment Builder negative versus positive interpretations of ambiguous scenar- 1.10 (SR Research Ltd 2013). Each trial started with a ios (i.e., an interpretation bias, represented by the IB score) fixation cross presented for 500 ms on the left side of the AST compared to the tendency to simply endorse non-specific neg- screen. After that, the stimulus display appeared, ative versus positive statements (i.e., a negative response bias, consisting of six words in scrambled order presented at represented by the foil ratio; Belli and Lau 2014). the center of the screen on a single line. Participants were instructed to read the words, mentally form a grammatical- Reliability Split-half reliability of the task was assessed by ly correct five-word sentence as quickly as possible, and correlating bias scores based on odd versus even trials (see click on the mouse button as soon as they did so to contin- e.g., Van Bockstaele et al. 2017) and was good (r =.66, ue to the response part of the trial. The scrambled sentence p < .001, Spearman-Brown-corrected reliability: .80). was presented for a maximum of 8000 ms; if no mouse click occurred during that time the response part was omit- Scrambled Sentences Task ted and the next trial began. In the response part, five boxes appeared below the scrambled sentence and participants A computerized version of the SST (Wenzlaff and Bates were required to build the sentence they had mentally 1998; adapted by Everaert et al. 2014) was used to assess formed by ordering the words into the five boxes via the tendencytoformnegativeorpositivestatementsout of mouse click. ambiguous verbal information. The task was administered Trials were randomly divided into five blocks of ten, each during eye-tracking in order to simultaneously assess attention containing six emotional and four neutral trials presented in biases (Everaert et al. 2014), but these data are reported else- random order. Before the first block participants completed where (Buhl et al. in preparation). five practice trials to familiarize themselves with the task. Similarly to earlier studies (e.g., Everaert et al. 2014; Stimuli The stimuli consisted of 50 scrambled sentences: 30 Burnett Heyes et al. 2017) a cognitive load procedure was emotional sentences (e.g., “total I winner a loser am”)and included to prevent deliberate response strategies. Before each 20 neutral sentences (e.g., “like watching funny I exciting block, a 4-digit number was presented for 5000 ms which had movies”). The emotional sentences were based on the orig- to be memorized and recalled at the end of the block. inal stimulus set developed by Wenzlaff and Bates (1998) and included, e.g., sentences targeting low mood, low self- Data Processing and Outcome Variables Participants’ re- worth, and negative thoughts about oneself and the future, sponses were rated as correct or incorrect. Trials in which no which are typical cognitions in depression. The sentences grammatically correct sentence was built (time-out or were translated into German (Rohrbacher 2016), extended, incorrect sentence) were excluded from the analysis. and adapted to be easily understandable and relevant to Participants with a correct sentence rate of three standard- children and adolescents (see Supplement 4 of Sfärlea deviations (SD) below the mean were identified as outliers et al. 2019, for an English translation of the stimuli). All in terms of accuracy and excluded (2 HR children), resulting sentences contained six words and had two possible solu- in a sample of 119 children (as data from only 121 of 122 tions. In emotional trials, one solution was positive (e.g., “I participants were available for the SST due to technical prob- am a total winner”) whereas the other was negative (e.g., “I lems) for analysis of the SST data. In that remaining sample, am a total loser”). In neutral trials both solutions were on average 44.2 correct trials (SD = 4.1; 88% of 50 trials) per emotionally neutral. Across the stimulus set, target words participant were available (not different between groups, (the words in each sentence that accounted for the positive p >.1). or negative solution) were matched for length and frequen- The correctly unscrambled emotional sentences were cate- cy in the German language. In line with Everaert et al. gorized as either positive or negative. An interpretation bias (2014), word position within each sentence was random- score (IB ) was calculated as the proportion of negatively SST ized, with target words not allowed next to each other or in resolved sentences from the total number of correctly resolved emotional sentences (Everaert et al. 2014). Positive target words: Word length M =7.3 (SD = 2.6) characters, word fre- Reliability Split-half reliability of the SST was calculated anal- quency (category according to http://wortschatz.uni-leipzig.de/de) M =10.3 ogous to the AST and was excellent (r =.89, p < .001, (SD = 2.9); Negative target words: word length M =7.4 (SD =2.6) characters, word frequency M =10.3 (SD =4.0); ts<1inpaired t-tests. Spearman-Brown-corrected reliability: .94). J Abnorm Child Psychol (2020) 48:1337–1350 1343 Fig. 2 Example of an emotional trial of the Scrambled Sentences Task (SST; Everaert et al. 2014; Wenzlaff and Bates 1998) Experiment Procedure Results Tasks were administered in random order. The course of the Sample Characteristics experimental session was the same as in Sfärlea et al. (2019; see Supplement 5). Sample characteristics are presented in Table 1.Groups did As cognitive models of depression suggest that cognitive not differ significantly in gender ratio or IQ but in terms of vulnerabilities such as negative biases are activated by stress- age: participants in the MD group were significantly older ful life events or negative mood (e.g., Disner et al. 2011; Scher than participants in the HR and LR groups. To examine et al. 2005), a negative mood induction procedure was admin- whether interpretation bias scores were related to age, istered twice during the experimental session: Participants Pearson’s correlations between age and IB as well as AST watched a 2 min scene from the movie The Lion King (Hahn IB scores were calculated separately for each group: no SST et al. 1994) that had successfully induced negative mood in significant correlations emerged (rs ≤ .29, ps > .1). As expect- children in earlier studies (von Leupoldt et al. 2007). In our ed, groups also differed in psychopathology with the MD study participants also reported significantly worse mood group reporting significantly more symptoms of depression (assessed using the valence dimension of the 9-point Self- and anxiety than the groups of healthy children (which did Assessment Mannequin scale; Lang 1980) after watching the not differ from each other, further indicating that the HR group movie scene compared to baseline (ts ≥ 7.9, ps < .001). Details was indeed as psychiatrically healthy as the LR group yet). are presented in Supplement 2. Ambiguous Scenarios Task Data Analysis The one-way ANOVA revealed a significant effect of group (F =13.0, p <.001, η = .18) that was followed up by t- 2,119 Statistical data analysis was conducted with SPSS 25. To as- tests: the MD group’sIB score was significantly more AST sess group differences in demographic and clinical character- negative than that of the HR group (t =4.1, p <.001, d = 48.0 istics, interpretation bias scores (IB and IB ), as well as AST SST 1.0) and the LR group (t =3.3, p =.002, d = 0.8), while the 44.8 the AST foil ratio, one-way analyses of variance (ANOVAs) HR and LR groups did not differ from each other (t =1.5, and follow-up t-tests (Bonferroni-Holm corrected; Holm p > .1). The IB score was significantly > 0 in the MD group AST 1979) were conducted. Correlations were calculated between (M =0.4, SD =1.0; t =2.2, p = .034), indicating a negative bias scores and depression and anxiety symptoms to assess interpretation bias, and significantly < 0 in the HR and LR relationships between psychopathology and interpretation bi- groups (HR: M = −0.4, SD =0.6; LR: M = −0.2, SD =0.5; ts ≥ as. Furthermore, in order to examine if interpretation bias 2.9, ps ≤ .006), indicating a positive interpretation bias. scores from the two tasks were related, a correlation between The one-way ANOVA on foil ratios also yielded a signif- IB and IB scores was computed. AST SST icant effect of group (F =8.0, p =.001, η =.12)withsim- 2,119 All analyses were repeated excluding the participants that ilar results in the post-hoc t-tests but smaller effect sizes (MD were taking psychotropic medication, as this might influence vs. HR: t = 3.6, p = .001, d = 0.8; MD vs. LR: t = 2.6, 78 47.9 cognitive biases (e.g., Wells et al. 2014). As the overall pattern p =.013, d =0.6; HR vs. LR: t =1.3, p >.1). T-tests against of results remained the same, the findings based on the whole zero revealed that while foil ratios in the HR (M = −0.4, SD = sample are reported. 0.6) and LR groups (M = −0.3, SD =0.5) were significantly < 0(ts ≥ 3.3, ps ≤ .002), the foil ratio of the MD group (M =0.2, Relative bias score were used since significantly larger effect sizes were reported for studies computing relative bias scores compared to studies com- SD = 0.9) was not significantly different from zero (t =1.2, puting absolute positive or negative bias scores (Everaert et al. 2017). In p >.1). IB scores and foil ratios are presented in Fig. 3. AST addition, relative bias scores allow to examine if bias scores from different Furthermore, positive correlations between IB scores AST tasks are related to each other. An alternative analysis of the AST with absolute positive and negative values can be found in Supplement 3. and depression (r =.44, p < .001) as well as anxiety symptoms 1344 J Abnorm Child Psychol (2020) 48:1337–1350 Table 1 Demographic and clinical characteristics of the sample MD HR LR Post-hoc tests n =32 n =48 n =42 Gender m/f 6/26 19/29 17/25 χ = 4.7 n.s. Age; M (SD) 13.4 (1.4) 11.8 (1.7) 12.2 (1.7) F =9.3 p <.001 MD >HR=LR 2,119 IQ; M (SD) 105.2 (13.6) 109.1 (11.5) 111.7 (10.3) F = 2.8 n.s. 2,119 Depression symptoms; M(SD) 31.5 (8.9) 7.8 (5.8) 6.6 (5.3) F =161.0 p <.001 MD >HR=LR 2,118 Anxiety symptoms; M(SD) 45.1 (8.8) 30.1 (6.4) 28.0 (6.2) F =56.3 p <.001 MD >HR=LR 2,114 MD Major depression, HR high-risk, LR low-risk Depressive symptoms were assessed with the DIKJ (raw values presented) and anxiety was assessed with the STAIC-T. Post-hoc t-tests were all significant with p ≤ .001 (r =.41, p < .001) were found. These two correlations did not depressive symptoms was significantly stronger than with differ in size (z =0.4, p > .1; Lee and Preacher 2013). As the anxiety (z =5.7, p < .001; Lee and Preacher 2013). When groups differed in both, psychopathology scores as well as recalculated within groups, correlations of IB scores with SST IB scores, the correlational analyses were repeated within depressive symptoms were evident in each group (MD: AST the groups. In the MD group, significant correlations between r =.70, p < .001; HR: r =.56, p < .001; LR: r =.43, p =.005) IB scores and depression (r =.39, p = .026) as well as anx- and correlations with anxiety symptoms became apparent in AST iety symptoms (r =.39, p = .047) emerged, while in the HR the MD (r =.39, p =.046) and HR groups (r =.48, p =.001; and LR groups no such correlations were apparent (rs ≤ .22, LR: r =.22, p >.1). ps > .1). Relationship between AST and SST Scrambled Sentences Task A significant positive correlation between IB and IB AST SST scores emerged across groups (r =.53, p < .001) but within The one-way ANOVA on IB scores revealed a significant SST groups this relationship was only found in the MD group effect of group (F = 129.0, p < .001, η = .69) that was 2,116 (r =.56, p = .001; HR and LR: rs ≤ .18, ps > .1). followed up by t-tests: the MD group (M = .65, SD = .26) had a significantly more negative bias than the HR (M = .14, SD=.12; t = 10.4, p < .001, d=2.5) and LR (M=.08, SD = .09; t = 40.7 37.3 11.8, p < .001, d = 2.9) groups, and the HR group had a more Discussion negative interpretation bias than the LR group (t = 2.5, 82.5 p = .014, d = 0.6). Results are presented in Fig. 4. The present study investigated the role of interpretation biases Strong positive correlations of IB scores with symptoms SST in youth depression. Two experimental tasks capturing differ- of both depression (r =.89, p < .001) as well as anxiety ent aspects of interpretation were used to assess interpretation (r =.72, p < .001) were found, although the relationship with Fig. 3 IB scores and foil ratios for the three groups. Error bars AST represent standard errors. Significant group differences are indicated: Fig. 4 IB scores for the three groups. Error bars represent standard SST *** p < .001, ** p <.01, * p <.05 errors. Significant group differences are indicated: *** p < .001, * p <.05 J Abnorm Child Psychol (2020) 48:1337–1350 1345 biases in three groups of children and adolescents: currently vs. adolescents, or investigate interpretation biases longitudinally depressed children and adolescents (MD group), children and across childhood and adolescence. adolescents at high risk for depression due to having a parent The bias score was strongly positively related to depressive with a history of depression (HR group), and children and symptoms in the full sample, replicating previous results in adolescents with a low risk for depression (LR group). Both youth with depression (Micco et al. 2014)or elevated symp- tasks revealed a more negative interpretation bias in children toms of depression (de Voogd et al. 2017) aswellasunselect- and adolescents with MD compared to both groups of healthy ed samples of adolescents (e.g., Klein et al. 2018; Orchard youth and strong correlations between bias scores and depres- et al. 2016a). However, when correlations were calculated sion and anxiety symptoms (collapsed across groups), while separately within each group, consistent correlations with de- only one task (SST) revealed a more negative interpretation pressive symptoms were found only for interpretation bias as bias in youth at risk for depression compared to low-risk youth assessed with the SST, while the interpretation bias assessed (see also Sfärlea et al. 2019). with the AST only correlated with depressive symptoms with- The first aim of the present study was to test the assumption in the MD group, probably due to lower values and/or less that children and adolescents with MD show more negative in- variance of depression, anxiety, and IB scores in the HR AST terpretation biases compared to healthy youth. As expected, we and LR groups. Similar relationships were found for anxiety found the MD group to draw more negative interpretations of symptoms, which is not surprising considering the well- ambiguous scenarios (AST) as well as sentences (SST), i.e., to established association of anxiety and interpretation biases in show more negative interpretation biases, than the two groups of children and adolescents (Stuijfzand et al. 2018). However, a healthy children and adolescents. The effect sizes of the group comparison of the correlation coefficients indicated that for differences were large, especially for the SST, and comparable to the interpretation bias score as assessed with the SST, the those found with questionnaire measures of interpretation bias association with depressive symptoms was significantly stron- (Orchard et al. 2016b). Of note, as we calculated relative bias ger than the association with anxiety symptoms, suggesting at scores, our results do not elucidate if the more negative interpre- least partial specificity. For the interpretation bias score as tation biases in depressed children and adolescents were due to a assessed with the AST, on the other hand, correlations with lack of positive interpretations or an excess of negative interpre- symptom scores did not differ. tations. However, an additional analysis of the AST data with The second aim of the study was to determine the extent to absolute positive and negative scores instead of a relative bias which interpretation biases are more pronounced in currently score indicated that group differences in the AST were mainly depressed youth compared to at-risk youth. In line with our driven by the MD group being more likely to endorse negative expectations and previous studies (Dearing and Gotlib 2009), interpretations compared to HR and LR groups while no differ- children and adolescents at high risk for depression showed a ences were found for positive interpretations (results of this more negative interpretation bias compared to children and analysis are presented in Supplement 3). It also has to be ac- adolescents at low risk for depression (see also Sfärlea et al. knowledged that the foil ratio of the AST was also more negative 2019). However, only the interpretation bias as assessed with in the MD group than in the HR and LR groups (although with the SST (not the AST) was more negative in the HR group smaller effect sizes: d=0.6–0.8 vs. d=0.8–2.9). As the foil ratio than in the LR group and it was much less pronounced than in represents the tendency to endorse non-specific negative state- the MD group. This is the first time interpretation biases are ments this suggests that the more negative interpretation bias in compared between currently depressed children and adoles- the MD group may partly be explained by a more general neg- cents and children and adolescents with a high or low risk for ative response bias. Our study is the first to focus on comparing depression. The results indicate that while being to some ex- interpretation biases in depressed versus non-depressed youth tent already present in at-risk populations, negative interpre- using multiple experimental measures. The results extend those tation biases are strongly exacerbated in currently depressed of prior studies that have investigated interpretation biases in children and adolescents. depressed adolescents (aged 12–18; Orchard et al. 2016b;and The two tasks assessing interpretation biases yielded diver- 14–21 years; Micco et al. 2014) to a younger age group. The gent results: the AST differentiated only between depressed presence of negative interpretation biases in depressed children and non-depressed children and adolescents and was related to and adolescents corroborates the assumption that negative inter- depressive symptoms only within the MD group, while the pretation biases are a characteristic of individuals with depression SST also differentiated between high- and low-risk youth not only in adults and adolescents but also in 9–14 year old youth and provides empirical support that cognitive theories of depres- Note that parental history of depression is not the only risk factor for depres- sion (e.g., Disner et al. 2011) apply to this group as well. sion. Psychosocial factors like exposure to stressful life events (e.g., bereave- ment) or chronic adversity (e.g., maltreatment, bullying) also put children and However, as it remains unclear how interpretation biases emerge adolescents at risk for developing depression (Thapar et al. 2012). It remains across childhood and adolescence, future studies may compare unclear if our results are specific for children of depressed parents or apply to interpretation biases between different age groups, e.g., children other risk groups as well. 1346 J Abnorm Child Psychol (2020) 48:1337–1350 and was associated to depressive symptoms within all groups. depressed youth might be more efficient if they address interpre- Moreover, interpretation bias scores from the two tasks were tation biases not only explicitly via Cognitive Behavioral only related within the MD group. Based also on our previous Therapy (e.g., J. S. Beck 2011) but also implicitly, for example results (Sfärlea et al. 2019), we suppose that the AST and the via Cognitive Bias Modification interventions that have been SST capture different aspects of interpretation (an issue which shown to successfully modify interpretation biases not only in Everaert et al. 2017, pointed out as especially important to healthy (Lothmann et al. 2011) but also in depressed adolescents investigate): the SST is more cognitively demanding due to (LeMoultetal. 2018; Micco et al. 2014). the time constraint and the cognitive load procedure, so less The presence of negative implicit interpretation biases also in resources are left for volitional control and deliberate response youth at high risk for depression, on the other hand, indicates that strategies. Therefore, the SST may capture a more automatic this kind of interpretation bias might also be a target for preven- (in terms of quick and effortless processing that occurs tive approaches trying to reduce the impact of cognitive vulnera- unintentionally and uncontrollably; cf. Beevers 2005; bilities in children of depressed parents. Modifying cognitive pro- Teachman et al. 2012) and implicit aspect of interpretation. cesses using implicit methods might enhance the efficacy of pre- The AST, on the other hand, allows more reflection on one’s vention programs in this high-risk group, whose effects are rather answers and might therefore be more susceptible to distorted small and short-term (Loechner et al. 2018). However, as some responding, similarly to self-report measures (e.g., Gotlib and studies implementing Cognitive Bias Modification interventions Joormann 2010). Hence, the AST presumably measures a for interpretation bias reported that those lacked transfer effects more conscious and explicit aspect of interpretation (see (e.g., LeMoult et al. 2018; Yiend et al. 2014), these interventions Sfärlea et al. 2019, for more details). According to this as- clearly need to be refined and improved before representing use- sumption, our results suggest that an implicit interpretation ful therapeutic tools for treatment and prevention of depressive bias can already be found in at-risk youth before onset of a disorders. Moreover, as any intervention intended for younger depressive disorder and thus might act as a cognitive vulner- age groups, Cognitive Bias Modification interventions for chil- ability or risk factor contributing to the development of de- dren and adolescents need to be age-adapted, e.g., by using pression (as suggested by theoretical models; e.g., Disner et al. picture-based instead of text-based stimuli for younger children. 2011). The explicit interpretation bias, on the other hand, was Furthermore, as the two measures of interpretation bias only found in the currently depressed group, indicating that presumably capture different aspects of interpretation, the this type of bias may arise as a consequence of depressive AST and the SST could be useful tools for assessing the extent symptomatology. The finding that these two aspects of inter- to which existing interventions are able to change interpreta- pretation operate differently with respect to the question of tion biases in children and adolescents with MD separately on being present already in youth at risk for depression or only conscious as well as automatic levels. in currently depressed children and adolescents contributes to a more comprehensive and differentiated understanding of Strengths interpretation biases in youth depression. However, the cross-sectional design of the study does not allow any conclu- The present study makes a significant contribution to our sions about time course or causality: we cannot determine the knowledge of the role of interpretation biases in youth depres- predictive value of interpretation biases for prospectively sion holding several methodological strengths. predicting the onset of an episode of MD, i.e., whether the Two different tasks were administered to experimentally more negative interpretation bias in the HR group compared assess interpretation biases. The reliability of the tasks was to the LR group indeed acts as a risk factor for the develop- determined and turned out to be at least good for both mea- ment of MD. Likewise, we cannot conclude if the more neg- sures (corresponding to e.g., Micco et al. 2014;Novović et al. ative interpretation biases we found in the MD group com- 2014). Furthermore, the correlations between bias scores and pared to the HR group are consequences of the depressive depressive symptoms underline the construct validity of the disorder or had already characterized those individuals that measures as indicators of depressive processing. developed MD before disorder onset. Longitudinal research Moreover, not only did all participants included in the is needed to address these important questions as well as to study undergo extensive diagnostic assessment, psychopa- investigate what role negative interpretation biases play in the thology was also carefully assessed in one (HR group) or both maintenance of depressive symptoms. (LR group) of their parents via a diagnostic interview instead of relying on self-report of mental disorder history only. Clinical Implications Limitations We found strong negative interpretation biases in children and adolescents with MD on explicit as well as implicit levels. This One limitation of the present study is that the three groups suggests that therapeutic attempts to modify these biases in investigated differed in age with participants in the MD group J Abnorm Child Psychol (2020) 48:1337–1350 1347 being significantly older than participants in the HR and LR Conclusion groups. This probably results from the prevalence of depres- sion being rather low in childhood and rising substantially The present study provides evidence for the presence of ex- with puberty (Thapar et al. 2012) and therefore the majority plicit as well as implicit negative interpretation biases in chil- of the participants in the MD group being 12 to 14 years old. dren and adolescents with MD and implicit interpretation However, as age was not related to bias scores, it is unlikely biases in children and adolescents at risk for depression. that the age difference accounts for the group differences we Pending replication in longitudinal studies, this suggests that found. implicit interpretation biases might represent cognitive vulner- Another limitation results from nearly half of the partici- abilities for depression while explicit interpretation biases pants in the MD group having a comorbid anxiety disorder. seem to arise as a consequence of depression. The results have Also, not only depressive but also anxiety symptoms were important clinical implications for the improvement of inter- related to interpretation biases, which was to be expected con- ventions to prevent and treat youth depression. sidering that the stimuli used in the tasks – even though Acknowledgements The present study was supported by the adapted to our study population – were not entirely “Förderprogramm für Forschung und Lehre” (FöFoLe; Reg.-Nr. 895) depression-specific due to the symptom overlap between de- of the Medical Faculty of the LMU Munich, the “Hans und Klementia pression and particular anxiety disorders like social anxiety Langmatz Stiftung”,the “Friedrich-Baur-Stiftung”, and the LMU Gender disorder or generalized anxiety disorder. Therefore, it cannot Mentoring Program. We thank all participants and their parents. Furthermore, we thank be ruled out that comorbid psychopathology contributed to Petra Wagenbüchler as well as Sonja Stolp and her team for their help our results. However, the association with depressive symp- with participant recruitment as well as Petra Wagenbüchler, Veronika toms was stronger than the association with anxiety symptoms Jäger, Lisa Ordenewitz, Ann-Sophie Störmann, and Moritz Dannert for (for the SST, which is the more depression-specific measure), their help with data collection. suggesting at least partial specificity. Funding Information Open Access funding provided by Projekt DEAL. Furthermore, it remains unknown if group differences in in- terpretation bias, particularly the difference between HR and LR Compliance with Ethical Standards groups in the SST, can also be observed during baseline mood and without the cognitive load, as interpretation biases were only Conflict of Interest The authors declare that they have no conflicts of assessed following a negative mood induction and the SST was interest. not applied without the cognitive load procedure. These possi- bilities should be addressed by future studies as they have im- Ethical Approval All procedures were approved by the ethics committee portant implications for cognitive models of depression. of the Medical Faculty of the LMU Munich (Project 441–15) and were in accordance with the latest version of the Declaration of Helsinki. Finally, since most participants in the MD group were re- cruited at a Department of Child and Adolescent Psychiatry or Informed Consent Written informed consent was obtained from all par- through licensed outpatient psychotherapists, it is likely that ticipants and their parents after a comprehensive explanation of the study most of them were receiving some form of psychotherapy at procedures. the time of their participation (unfortunately, this was not Open Access This article is licensed under a Creative Commons assessed systematically). Since psychotherapy, particularly Attribution 4.0 International License, which permits use, sharing, Cognitive Behavioral Therapy, targets negative interpretation adaptation, distribution and reproduction in any medium or format, as biases, our effect sizes might be underestimates of the effect long as you give appropriate credit to the original author(s) and the sizes in untreated youth depression. Furthermore, since a con- source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article siderable proportion of the participants in the HR group were are included in the article's Creative Commons licence, unless indicated recruited through a study evaluating a family-based preven- otherwise in a credit line to the material. If material is not included in the tion program for children of parents with a history of depres- article's Creative Commons licence and your intended use is not sion (Platt et al. 2014), our HR participants might have been permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a less vulnerable to depression than the average offspring of copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. depressed parents (see Sfärlea et al. 2019, for a more detailed discussion). 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