Rumination and Anxiety Sensitivity in Preadolescent Girls:Independent, Combined, and Specific Associationswith Depressive and Anxiety Symptoms

Catherine C. Epkins & Christie Gardner &

Natalie Scanlon

# Springer Science+Business Media New York 2013

Abstract Rumination and anxiety sensitivity are posited cog-nitive vulnerabilities in the development and/or maintenanceof depression and anxiety and they have been examinedseparately in youth, and primarily in adolescents. Depressionand anxiety are also highly comorbid. In 125 preadolescentgirls (aged 9 to 12), we examined the independent, combined,and specific relations of rumination and anxiety sensitivity togirls’ depression and anxiety, both before and after controllingfor comorbid symptoms. Results found both rumination andanxiety sensitivity were independently related to depressivesymptoms; and, both rumination and anxiety sensitivity wereindependently related to anxiety symptoms. After controllingfor anxiety, rumination, and not anxiety sensitivity, showed aunique and specific relation to depression. In contrast, aftercontrolling for depression, anxiety sensitivity, and not rumi-nation, showed a unique and specific relation to anxiety.Rumination and anxiety sensitivity did not interact in relationto girls’ depression or anxiety. These findings suggest: 1) thereare distinctions between rumination and anxiety sensitivity; 2)rumination and anxiety sensitivity are overlapping yet inde-pendent vulnerabilities or correlates for both depression andanxiety; and 3) when comorbid symptoms are considered,rumination is uniquely and specifically related to depressionand not anxiety, and anxiety sensitivity is uniquely and spe-cifically related to anxiety and not depression. Our results addto recent advances in integrative cognitive vulnerabilitymodels, which highlight the importance of examining multi-ple cognitive vulnerabilities and examining the specificity ofeach to depression and anxiety.

Keywords Children’s depression . Children’s anxiety .

Rumination . Anxiety sensitivity . Cognitive vulnerability

The importance of examining the independent, combined, andthe unique or specific relations that various cognitive vulner-abilities have with respect to anxiety and depression has beena focus of much empirical and theoretical work in the adultliterature (e.g., Elwood et al. 2009; Fergus and Wu 2010,2011; Mathews and MacLeod 2005; Reardon and Williams2007), and in the child literature (e.g., Alloy et al. 2012;Weems et al. 2007; Weems and Watts 2005). For example,integrative cognitive vulnerability models call for examiningmultiple cognitive vulnerabilities and the specificity of each toanxiety and depression (cf., Elwood et al. 2009; Weems andWatts 2005). The independent and specific contributions ofmultiple cognitive vulnerabilities to depression and anxietyin preadolescents are not well understood. These issues areamplified by the well-documented comorbidity of anxiety anddepressive symptoms and disorders (Seligman and Ollendick1998). Identifying anxiety-specific and/or depression-specificcognitive vulnerabilities potentially involved in depressionand/or anxiety has not only theoretical implications but alsoimplications for cognitive behavioral treatments of depression(e.g. Stark et al. 2012) and anxiety (e.g., Kendall 2012). Thecurrent study focuses on two cognitive vulnerabilities, rumi-nation and anxiety sensitivity, and examines their indepen-dent, combined, and unique or specific relations to preadoles-cent girls’ depression and anxiety symptoms.

We elected to study preadolescent girls, because femaleshave higher rates of depressive and anxiety symptoms anddisorders thanmales, beginning in adolescence and continuingin adulthood (Craske 2003; Hankin et al. 2008). Moreover,cognitive vulnerabilities to depression and anxiety becomemore stable during this period (Craske 2003; Hankin 2008b),more so for girls than for boys (Cole et al. 2009). In addition,cognitive vulnerabilities have been found to have a greater rate

We thank Jessica Clark and Jill Schlabaugh for assistance with datacollection and data management.

C. C. Epkins (*) :C. Gardner :N. ScanlonDepartment of Psychology, Texas Tech University, Box 42051,Lubbock, TX 79409-2051, USAe-mail: catherine.epkins@ttu.edu

J Psychopathol Behav AssessDOI 10.1007/s10862-013-9360-7

of growth over time in girls than in boys, beginning at age 11(Mezulis et al. 2010). Girls also report significantly morerumination and anxiety sensitivity than boys in numerouschild and adolescent samples (e.g., Driscoll et al. 2009; Hiltet al. 2010; Lopez et al. 2009; Muris 2002; Muris et al. 2001;Roelofs et al. 2009; Rood et al. 2009; Weems et al. 2007).

Nolen-Hoeksema (1987; 1991) developed the ResponseStyles Theory to explain sex differences in depression inadults. The theory posits three response styles: 1) thedistracting response style, which consists of activities thatdirect attention away from depressive symptoms; 2) theruminative response style, which focuses attention on nega-tive thoughts and feelings resulting in the intensification andprolonging of depressive symptoms; and 3) the problem-solving response style, which attempts to alleviate depres-sive symptoms by engaging in problem-solving strategies.The theory contends that women are more likely to havea ruminative response style whereas men are more likelyto have a distracting response style, and as noted abovemany studies find girls report more rumination than boys.In contrast, anxiety sensitivity is conceptualized as acognitive vulnerability for anxiety and anxiety disorders(Noel and Francis 2011; Taylor 1999). Anxiety sensitivityinvolves the belief that anxiety and anxiety-related bodilysensations may result in harmful social, psychological, orphysiological consequences.

Relations Between Rumination and Anxiety Sensitivity

We chose to examine rumination and anxiety sensitivitycognitive vulnerabilities because they both share key features,and prior studies with adults have found relations betweenanxiety sensitivity and rumination (Cox et al. 2001). At ageneral level, both rumination and anxiety sensitivity are re-sponses to negative affect, emotion, or symptoms, and bothrumination and anxiety sensitivity have been conceptualizedas forms of distress tolerance or maladaptive emotion regula-tion strategies (Aldao et al. 2010; Weems 2011). Emotiondysregulation has been viewed as a core factor in anxietyand depression, although only more recently has researchon emotion regulation been extended to depression andanxiety in youth (see Carthy et al. 2010; Cisler et al.2010; and Durbin and Shafir 2008 for reviews). However,no study has examined multiple emotion regulation strate-gies and depression and anxiety simultaneously. Therefore,it is unknown what specific emotion regulation strategiesare differentially related to anxiety versus depression inyouth (Cole and Hall 2008; Durbin and Shafir 2008).Examining such questions has not only theoretical implica-tions, but also implications for emotion regulation interven-tions in youth that are gaining increased attention in theempirical and clinical literature (Southam-Gerow 2013).

Theoretically, cognitive information-processing biases indepression and anxiety affect emotion regulation (for reviewssee Gotlib and Joormann 2010;Mathews andMacLeod 2005).In particular, cognitive biases in attention and interpretationseem to be commonalities between anxiety sensitivity andrumination. For example, although anxiety sensitivity is con-ceptualized as an interpretation bias (Weems and Watts 2005),it can also be viewed as a selective attention bias becauseindividuals with high anxiety sensitivity selectively attend toor focus on their anxiety-related sensations (Elwood et al.2009), which are then catastrophically interpreted as beingsevere and having negative consequences. Rumination alsoinvolves focusing attention on negative affect and is associatedwith both attention and memory biases. Individuals whoruminate focus more attention on, and retrieve more, nega-tive information from their past memories than individualswho do not ruminate, and they also show negative inter-pretation biases for past events (Nolen-Hoeksema et al.2008). Individuals who ruminate repetitively focus theirattention on the experience of the emotion, and its meaningand causes (Aldao et al. 2010).

Thus, both rumination and anxiety sensitivity involveincreased attention to symptoms and distress, particularlyconcerning their harmful meaning. However, ruminationinvolves thinking pervasively about past events and failures,whereas anxiety sensitivity involves perceiving threat that is amore future-oriented consequence. Cognitive theory of emo-tional disorders and the cognitive content-specificity hypothe-sis contend that cognitive information-processing and thoughtsin depression focus on past loss and failure, whereas in anxietythe focus is on perceived threat and an overestimation ofanticipated harm and danger in future situations (Beck et al.1987; Beck and Clark 1988; Clark and Beck 1999). So,according to cognitive theory and the cognitive-content spec-ificity hypothesis, rumination would be theoretically moreclosely linked to depression, and anxiety sensitivity moreclosely linked to anxiety. However, whether ruminationand anxiety sensitivity have unique or specific relations withdepressive and anxiety has not been examined. Identifyingthe overlapping and/or unique or specific relations rumina-tion and anxiety sensitivity show to depression and/or anxietysymptoms has implications for refining theoretical models, aswell as informing prevention and intervention strategies thatfocus on cognitive vulnerabilities and/or emotion regulationstrategies.

Rumination, Depression, and Anxiety

Youth rumination has been examined in a number of samples.A meta-analysis found that rumination is concurrently relatedto depression in children (M r=0.36, a medium effect size)and adolescents (M r=0.48, a medium to large effect size), and

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is related to depression in children (M r=0.27) and adoles-cents (M r=0.36) over time (Rood et al. 2009). Recent studiesnot included in that meta-analysis (Abela and Hankin 2011;Driscoll et al. 2009; Gibb et al. 2012; Hankin 2008a; Hilt et al.2010) have also found rumination is related to depression inchildren and adolescents, both concurrently and over time.

Although rumination has been established as a correlateand a risk factor for depressive symptoms in children andadolescents, rumination also appears to be a correlate andrisk factor for anxiety in youth. For example, meta-analysesdemonstrate large effect sizes for the associations betweenrumination and both depression (M r=0.55) and anxiety(M r=0.42), and age group (i.e., child/adolescent versusadult) did not moderate these relations (Aldao et al. 2010).Recent studies have found rumination (as assessed withthe Children’s Response Style Scale (CRSS); Ziegert andKistner 2002) to be concurrently related to both depres-sive and anxiety symptoms, and associated with an in-crease in depressive and anxiety symptoms over an 8 to10 week period, in samples of 10 to 18-year old students(Roelofs et al. 2009, M age=12.9, SD=2.1; Rood et al.2010, M age=12.84, SD=1.9). However, the unique andspecific relation that rumination demonstrates to depres-sion and anxiety, controlling for comorbid symptoms, wasnot examined in these studies.

Fewer studies have examined the unique and specificrelations rumination shows to depression versus anxiety, andvirtually all of these studies have been with adolescents. Oneprospective study documented that rumination (as assessedwith the Children’s Response Styles Questionnaire (CRSQ);Abela et al. 2002) demonstrated specificity to depressivesymptoms versus anxious arousal and externalizing problemsin 6th to 10th grade adolescent students (M age 14.5, SD=1.40;Hankin 2008a). However, other studies examining concurrentrelations in nonclinical adolescent (aged 12–18) and preado-lescent school samples (aged 8–13,M Age=10.73, SD=1.01)have found rumination (as assessed with the CRSS) wasrelated to anxiety symptoms after controlling for depression,but rumination was not related to depressive symptoms aftercontrolling for anxiety (Broeren et al. 2011; Muris et al. 2009;Muris et al. 2004). Moreover, in some of these studies, rumi-nation showed a stronger relation to children’s and adoles-cents’ anxiety as opposed to their depression (Broeren et al.2011; Muris et al. 2004). In contrast, in Alloy et al.’s (2012)large community-based sample of 12 to 13-year olds, earlyadolescents’ rumination (on the CRSQ) demonstrated littlesymptom specificity with respect to anxiety and depressionsymptoms and diagnoses. Although higher rumination wasrelated to more depressive symptoms and greater current andlifetime depressive disorder diagnoses (even after controllingfor comorbid anxiety symptoms/diagnoses), higher rumina-tion was also related to more anxiety symptoms and lifetimegeneralized anxiety disorder diagnoses (after controlling for

comorbid depressive symptoms/diagnoses), especially forgirls (Alloy et al. 2012).

Rumination thus appears to be related to both youthdepression and anxiety, although conflicting findings haveemerged with specificity to depression versus anxiety. Someof these conflicting results may be due to the measure ofrumination used (CRSS vs. CRSQ). More importantly, manystudies in this area have used self-report measures that do notadequately distinguish between depression and anxiety symp-toms (i.e., the Children’s Depression Inventory (CDI), Kovacs1992; e.g., Abela et al. 2007; Abela and Hankin 2011; Alloyet al. 2012; Hankin 2008a; Hilt et al. 2010; Lopez et al. 2009;Muris et al. 2004; Roelofs et al. 2009; Rood et al. 2010). Inaddition, most studies examining specificity have been withadolescents. One exception is Broeren et al. (2011), whoexamined rumination (on the CRSS) and depression andanxiety in a sample of 8 to 13-year old boys and girls.Broeren et al. found rumination was related to anxiety symp-toms after controlling for depression and worry, yet rumina-tion was not related to depression after controlling for anxietyand worry. Unfortunately, their 5-item depression measurehad no reported validity and had poor internal consistency(α=0.58). Moreover, their sample combined boys and girlswhich may have masked any findings for girls. We extendtheir study by using the CRSQ to assess rumination inpreadolescent 9 to 12-year old girls’ depression and anxiety,and we use the Beck Youth Inventories (Beck et al. 2005) thatare valid and reliable measures developed to discriminatebetween depression and anxiety symptoms. We are unawareof any studies examining either rumination or anxiety sensi-tivity using the Beck Youth Inventories. Finally, we extendpast research by also examining anxiety sensitivity.

Anxiety Sensitivity, Anxiety, and Depression

A recent meta-analysis found positive and significant rela-tions between anxiety sensitivity and anxiety in both chil-dren (M r=0.26, a small to medium effect size) and adoles-cents (M r=0.36, a medium effect size; Noel and Francis2011). Although anxiety sensitivity has been established as acorrelate and a risk factor for anxiety in children and adoles-cents (McLaughlin and Hatzenbuehler 2009; Noel andFrancis 2011), many studies have found anxiety sensitivityis also associated with children’s and adolescents’ depres-sion symptoms (e.g., McLaughlin and Hatzenbuehler 2009;Muris 2002; Reiss et al. 2008).

As with rumination, fewer studies have examined theunique and specific relations anxiety sensitivity shows toanxiety and depression, and most of these studies have beenwith adolescents or a wide age range of youth. Several ofthese studies have found significant concurrent relationsbetween anxiety sensitivity and symptoms of anxiety after

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controlling for depression, yet anxiety sensitivity was notrelated to depressive symptoms after controlling for anxiety.This pattern of findings has emerged in 9 to 17-year-oldinpatient youth (M age=14.23, SD=1.89; Joiner et al.2002), 13 to 16-year-old adolescent students (M age=14.2,SD=1.0; Muris et al. 2001), and a diverse community sampleof 6 to 17-year old youth (M age=11.36, SD=3.5; Weemset al. 2007). In contrast, another study found significantrelations between anxiety sensitivity and depression aftercontrolling for anxiety in a sample of youth aged 6 to 17(M age=10.4) referred for anxiety disorders (Weems et al.1997). In terms of prospective relations, in a sample of 11 to14-year-old youth in grades 6–8, anxiety sensitivity wasfound to be associated with anxiety symptoms after control-ling for depressive symptoms, but anxiety sensitivity was notrelated to depressive symptoms after controlling for anxietysymptoms, over a 7-month period (McLaughlin andHatzenbuehler 2009). Thus, as with rumination, anxietysensitivity is related to both youth depression and anxiety,and may be an important cognitive vulnerability for depres-sion as well as anxiety in youth. Unfortunately, four of thesefive studies noted above used the CDI as a measure ofdepressive symptoms, with the exception of Weems et al.(2007). We extend Weems et al. (2007) by examining anarrow age range of only girls and using measures thatadequately distinguish between depressive and anxioussymptoms. Moreover, we examine rumination in additionto anxiety sensitivity, and also explore whether they interactin relation to girls’ depression and/or anxiety symptoms.

Present Study

In sum, in bringing these areas of research together, weexamine the independent, combined, and unique relations ofrumination and anxiety sensitivity to preadolescent girls’ de-pression and anxiety, both before and after controlling forcomorbid symptoms. Based on past literature that has exam-ined rumination and anxiety sensitivity separately, we expectedboth rumination and anxiety sensitivity to be related to bothgirls’ depressive and anxiety symptoms. Given the commonal-ities as well as the differences in rumination and anxietysensitivity, we anticipated that they would both demonstrateindependent relations to both girls’ depression and anxiety.However, in line with the theoretical literature, particularlythe cognitive content-specificity hypothesis, we anticipated thatafter considering comorbid symptoms that: 1) anxiety andrumination (and not anxiety sensitivity) would remain uniquelyand specifically related to girls’ depression; and 2) depressionand anxiety sensitivity (and not rumination) would remainuniquely and specifically related to girls’ anxiety. This patternof findings would show not only distinctions to rumination andanxiety sensitivity, but would also show that rumination and

depression are empirically and conceptually distinct andthat anxiety and anxiety sensitivity are empirically andconceptually distinct.

Method

Participants

The sample was 125 girls aged 9–12 (M age 10.46 years,SD=1.12 years) recruited through community activities (e.g.,camps, athletic events, churches, seasonal events). Only onechild per household was allowed to participate and the girlswere placed in a drawing to win a free I-pod shuffle. Themajority were Caucasian (86.4 %), with some Hispanic(10.4 %), African-American (0.8 %), and mixed ethnicity(2.4 %). On Hollingshead’s (1975) index of socioeconomicstatus (SES), which is based on both parents’ education andoccupation, the majority of families’ SES levels were 4(58.4 %) and 5 (36.0 %), reflecting a middle-upper SES.

Measures

Children’s Response Style Questionnaire (CRSQ) The CRSQ(Abela et al. 2002) is a 25-item self-report questionnaire thatdescribes children’s responses to depressive symptoms. TheCRSQ is modeled after Nolen-Hoeksema’s Response StylesQuestionnaire that was developed for adults. The CRSQhas two subscales, Rumination and Distraction/Problem-Solving. The 13-item rumination subscale contains itemssuch as, “When I am sad, I go away by myself and thinkabout why I feel this way”, “When I am sad, I thinkabout all of my failures, faults, and mistakes”, and “When Iam sad, I think: ‘I am disappointing my friends, family, orteachers’”. Scores for each item are on a Likert-type scale andrange from 0 to 3 (almost never to almost always). Higherscores indicate a stronger tendency to engage in a ruminativeresponse style. In children aged 7 to 12, factor analysisrevealed two factors. The first, interpreted as rumination,had an internal consistency of α=0.77, a mean inter-itemcorrelation of r=0.21, and a test-retest reliability of r=0.72over 4 weeks (Abela et al. 2007). The second factor,interpreted as distraction and problem-solving, contains8 items and was not used in the current study. Previousstudies have found good internal consistency of the rumina-tion subscale (e.g., ranging from 0.87 to 0.89; Abela andHankin 2011; Hilt et al. 2010), and convergent and discrimi-nant validity have been reported (Abela et al. 2007; Abelaet al. 2004). The CRSQ rumination subscale had good internalconsistency in the current sample (α=0.90).

Child Anxiety Sensitivity Index (CASI) The CASI (Reisset al. 2008; Silverman et al. 1991) is an 18-item measure

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assessing anxiety sensitivity. Each item (e.g., “When mystomach hurts, I worry that I might be really sick”, “WhenI am afraid, I worry that I might be crazy”, “When I noticethat my heart is beating fast, I worry that there might besomething wrong with me”) is rated on a 3-point Likert-typescale ranging from 1 (none) to 3 (a lot). Scores on the 18items are summed to form a total score, with higher scoresreflecting greater anxiety sensitivity. Good 2-week (r=0.79),6-month (r=0.48) and 1-year (r=0.48) test-retest reliabilities,and good internal consistencies (αs ranging from 0.83 to 0.89),have been reported in clinical and nonclinical samples ofchildren (Reiss et al. 2008). Convergent, discriminant, andconstruct validity with questionnaires have been demonstrated,as has validation with behavioral measures (Rabian et al. 1999;Reiss et al. 2008; Silverman et al. 1991; Weems et al. 2001;Weems et al. 2007). Internal consistency in the current samplewas good (α=0.85).

Beck Depression Inventory for Youth (BDI-Y) The BDI-Y(Beck et al. 2005) is a commonly-used and well-validatedmeasure that assesses depressive symptoms in youth. TheBDI-Y contains 20 items (e.g., “I think I do things badly”, “Ifeel like crying”, “I feel no one loves me”). Responses foreach item can range from 0 (“Never”) to 3 (“Always”), with ahigher score reflecting more severe depression symptoms.The internal consistency of the BDI-Y has been found toexceed 0.90 in a number of samples (Beck et al. 2005;Stapleton et al. 2007). Good 1-week test-retest reliabilitiesfor girls aged 7 to 10 and 11 to 14 have been demonstrated(rs=0.81 and 0.91 respectively; Beck et al. 2005). Convergentvalidity has been demonstrated with questionnaire measuresas well as diagnostic interviews (Beck et al. 2005; Stapletonet al. 2007). Discriminant validity has also been demonstratedas youth diagnosed with depressive disorders have been foundto have higher BDI-Y scores than youth with anxiety disor-ders, other disorders, and no disorders (Beck et al. 2005;Stapleton et al. 2007). The suicidal ideation item was blackedout for this study, at IRB request. The 19-item BDI-Y hadgood internal consistency in the current sample, α=0.93.

Beck Anxiety Inventory for Youth (BAI-Y) The BAI-Y (Becket al. 2005) consists of 20 items that assess children’s fear,worry, and physiological aspects of anxiety (e.g., “I worry”,“I am afraid that I will make mistakes”, “I have problemssleeping”). Like the BDI-Y, items are rated on a scale from0 (“Never”) to 3 (“Always”), with a higher score reflectingmore anxiety symptoms. Good internal consistency (αs rangingfrom 0.89 to 0.91) and one-week test-retest reliabilities(rs ranging from 0.77 to 0.93) in 7 to 14-year-old youth havebeen demonstrated (Beck et al. 2005). Convergent and diver-gent validity has been demonstrated with questionnaires aswell as diagnostic interviews (Beck et al. 2005). The BAI-Yhad good internal consistency in the current sample (α=0.92).

Procedure

After IRB approval, at community events mothers wereprovided with an oral presentation that said the study focusedon girls’ thoughts, feelings, and behaviors. If interested inpossibly participating, mothers provided their name and con-tact information, which was used at a later time to schedule atime for data collection for the dyad either at our Universitylaboratory or in their home (84 % of dyads selected home).Procedures were the same at both locations. Written informedconsent for girls’ participation was obtained from theirmothers as well as the girls. Girls independently completed apacket of randomly-orderedmeasures that included three othermeasures that were not part of this study.

Results

Initial Analyses

There were no missing data or skipped items on any of the125 girls’ measures. Initial analyses examined the data forany univariate and multivariate outliers, distributions of vari-ables (including normality, skew and kurtosis), and to assesswhether assumptions for multiple regression were met, fol-lowing guidelines by Tabachnick and Fidell (2007). Oneunivariate outlier (an extreme score) was found on each ofthe depression and anxiety measure, and each of these wasre-assigned a raw score to be one unit larger than the nextmost extreme score. After this, all four variables were foundto have moderate positive skewness, via z-scores calculatedat p<0.001, and hence a square root transformation wasapplied to each of them (Tabachnick & Fidell). Thesetransformations resulted in: 1) nonsignificant values forskew and kurtosis for all four variables, and 2) tests ofnormality (i.e., Kolmogorov-Smirnov) were significant forall four variables. Then, Mahalanobis Distance scoreswere examined for multivariate outliers, and zero caseswere found to be an outlier at p<0.001 for the appropriate χ2

value (i.e., with df equal to the number of variables). Finally,no issues with multicollinearity (e.g., correlations above 0.90)or singularity were present indicating the data (with thefour transformed variables) met the assumptions for multipleregression analyses.

Preliminary Analyses

Means and Standard Deviations on, and correlations among,the measures are shown in Table 1. Girls’ depression andanxiety T-scores on the BDI-Y and BAI-Y in our sample areconsistent with those for community samples, as reported inthe instrument manual (cf., T-scoreMs ranging from 48.10 to48.69, SDs ranging from 7.0 to 9.35; Beck et al. 2005).

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Preliminary analyses examined whether girls’ ethnicity(Caucasian vs. Minority), age, and family SES were relatedto the four measures. T-tests found Caucasian and Minoritygirls did not significantly differ on any measure (all p>0.46).Girls’ age was not significantly associated with any of thefour measures (all p>0.07); neither was family SES (allp>0.55). Despite these nonsignificant relations, girls’ eth-nicity, age, and family SES were statistically controlled for inthe main analyses.

Main Analyses

Hierarchical multiple regression analyses were conducted toexamine the independent, combined, and unique or specificrelations of rumination and anxiety sensitivity (examinedsimultaneously) to girls’ depressive and anxiety symptoms,both before and after controlling for comorbid symptoms.We examine statistical significance and report effect sizesregarding the magnitude of significant unique relations; withsr2 of 0.01, 0.09, and 0.25 indicating small, medium, andlarge effect sizes, respectively (Cohen et al. 2003).

Depression After entering girls’ ethnicity, age and familySES in step one, when considered together in step two, bothgirls’ rumination and anxiety sensitivity were related to girls’depressive symptoms (R2=0.53, ΔR2=0.51, ΔF=63.03,p<0.001). As seen in Table 2, both rumination (β=0.38,p<0.001) and anxiety sensitivity (β=0.42, p<0.001) wereindependently related to girls’ depressive symptoms. Girls’rumination showed a significant relation to girls’ depressionwhen the variance attributed to other variables (ethnicity,age, SES, and girls’ anxiety sensitivity) was partialed out(sr=0.30, sr2=0.09, a medium effect size). Girls’ anxietysensitivity also showed a significant relation to girls’ depres-sion when the variance attributed to other variables (ethnicity,age, SES, and girls’ rumination) was partialed out (sr=0.33,sr2=0.11, a medium effect size).

Depression Controlling for Anxiety Girls’ anxiety symptomswere entered along with girls’ ethnicity, age and family SES

in step one (R2=0.63, F=50.57, p<0.001), and only girls’anxiety symptoms were related to depression (β=0.79,p<0.001). As also shown in Table 2, when considered to-gether in step two, both girls’ rumination and anxiety sensi-tivity were related to girls’ depressive symptoms (R2=0.68,ΔR2=0.05,ΔF=8.76, p<0.001). However, only girls’ rumi-nation (β=0.25, p<0.001) and not girls’ anxiety sensitivity(β=0.07) was independently related to girls’ depressivesymptoms. Girls’ rumination showed a unique and specificrelation to girls’ depression when the variance attributed toother variables (ethnicity, age, SES, girls’ anxiety, and girls’anxiety sensitivity) was partialed out (sr=0.19, sr2=0.04, asmall to medium effect size). Moreover, girls’ anxiety showeda unique and specific relation to girls’ depression when thevariance attributed to other variables (ethnicity, age, SES,girls’ rumination, and girls’ anxiety sensitivity) was partialedout (sr=0.39, sr2=0.15, a medium to large effect size). Thus,girls’ rumination and anxiety, and not girls’ anxiety sensitivity,both showed unique and specific relations to girls’ depression.

Anxiety After entering girls’ ethnicity, age and family SES instep one, when considered together in step two, both girls’rumination and anxiety sensitivity were related to girls’anxiety symptoms (R2=0.57, ΔR2=0.54, ΔF=74.47,p<0.001). Both rumination (β=0.23, p<0.01) and anxietysensitivity (β=0.58, p<0.001) were independently related togirls’ anxiety symptoms (see Table 2). Girls’ ruminationshowed a significant relation to girls’ anxiety when thevariance attributed to other variables (ethnicity, age, SES,and girls’ anxiety sensitivity) was partialed out (sr=0.18,sr2=0.03, a small effect size). Girls’ anxiety sensitivity alsoshowed a significant relation to girls’ anxiety when thevariance attributed to other variables (ethnicity, age, SES,and girls’ rumination) was partialed out (sr=0.45, sr2=0.20,a medium to large effect size).

Anxiety Controlling for Depression Girls’ depressive symp-toms were entered along with girls’ ethnicity, age and familySES in step one (R2=0.63, F=51.70, p<0.001), and onlygirls’ depressive symptoms were related to their anxiety

Table 1 Intercorrelations, means, and standard deviations on measures

Measure 1 2 3 4 M SD Possible Range Sample Range

1. Rumination (CRSQ) ——— 12.72 8.59 0–39 0–39

2. Anxiety Sensitivity (CASI) 0.60* ——— 30.09 6.11 18–54 20–50

3. Depression (BDI-Y) 0.63* 0.65* ——— 12.42 (47.97) 8.35 (10.15) 0–57 0–37

4. Anxiety (BAI-Y) 0.57* 0.73* 0.79* ——— 15.18 (47.85) 9.77 (11.11) 0–60 1–49

CRSQ children’s response style questionnaire, rumination subscale; CASI child anxiety sensitivity index; BDI-Y beck depression inventory for youth;BAI-Y beck anxiety inventory for youth. Correlations are based on transformed variables.

T-scores and SDs on T-scores are noted in parentheses.

p<0.001.

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(β=0.78, p<0.001). As also shown in Table 2, when con-sidered together in step two both girls’ rumination and anx-iety sensitivity were related to girls’ anxiety symptoms(R2=0.71,ΔR2=0.08,ΔF=15.10, p<0.001). However, onlygirls’ anxiety sensitivity (β=0.36, p<0.001) and not girls’rumination (β=0.03) was independently related to girls’anxiety. Girls’ anxiety sensitivity showed a unique and specificrelation to girls’ anxiety when the variance attributed to othervariables (ethnicity, age, SES, girls’ depressive symptoms, andgirls’ rumination) was partialed out (sr=0.25, sr2=0.06, a smallto medium effect size). Moreover, girls’ depressive symptomsshowed a unique and specific relation to girls’ anxiety when thevariance attributed to other variables (ethnicity, age, SES, girls’rumination, and girls’ anxiety sensitivity) was partialed out(sr=0.37, sr2=0.14, a medium to large effect size). Thus, girls’anxiety sensitivity and depressive symptoms, and not girls’rumination, both showed unique and specific relations to girls’anxiety symptoms.

Supplemental Analyses

As the analyses above assessed the additive and independentrelations of rumination and anxiety sensitivity to girls’ de-pression and anxiety, we explored whether rumination andanxiety sensitivity interact in relation to girls’ symptoms.Cumulative or interacting risks are widespread in the litera-ture (Sameroff et al. 2003). As such, we explored whether

rumination moderated the relation between anxiety sensitiv-ity and girls’ depression and anxiety, and/or whether anxietysensitivity moderated the relation between girls’ ruminationand their depression and anxiety.

Moderator analyses in regression were conducted, afterpredictors were centered and then product (i.e., interaction)terms computed on the centered variables (cf., Holmbeck2002). After controlling for girls’ ethnicity, age, and familySES in step one, entering anxiety sensitivity and rumination instep two, no significant interaction emerged in step three. Instep three, anxiety sensitivity and rumination did not interact inrelation to girls’ depressive symptoms (ΔR2=0.00,ΔF=0.39).Likewise, the regression on anxiety revealed in step three thatanxiety sensitivity and rumination did not interact in relation togirls’ anxiety symptoms (ΔR2=0.00, ΔF=0.01).

Discussion

Past literature has found rumination and anxiety sensitivitycognitive vulnerabilities to be related to youths’ (primarilyadolescents’) depression and anxiety symptoms. We extendedthe literature by examining the independent, combined, andunique or specific associations of rumination and anxiety sen-sitivity to preadolescent girls’ depression and anxiety, bothbefore and after controlling for comorbid symptoms. Our find-ings, overall, highlight distinctions in rumination and anxietysensitivity as they relate to depression and anxiety, particularly

Table 2 Hierarchical regression analyses examining girls’ rumination and anxiety sensitivity predicting girls’ depression and anxiety (Before andafter controlling for comorbid symptoms)

DEPRESSION ANXIETY

Predictor R2 ΔR2 ΔF β sr2 Predictor R2 ΔR2 ΔF β sr2

Step 1 0.02 0.02 0.78 Step 1 0.03 0.03 1.36

Control Variables ns Control Variables ns

Step 2 0.53 0.51 63.03** Step 2 0.57 0.54 74.47**

Rumination 0.38** 0.09 Rumination 0.23* 0.03

Anxiety Sensitivity 0.42** 0.11 Anxiety Sensitivity 0.58** 0.20

DEPRESSION (Controlling for Anxiety) ANXIETY (Controlling for Depression)

Predictor R2 ΔR2 ΔF β sr2 Predictor R2 ΔR2 ΔF β sr2

Step 1 0.63 0.63 50.57** Step 1 0.63 0.63 51.70**

Control Variables ns Control Variables ns

Anxiety 0.79** 0.59 Depression 0.78** 0.60

Step 2 0.68 0.05 8.76** Step 2 0.71 0.08 15.10**

Rumination 0.25** 0.04 Rumination 0.03 0.00

Anxiety Sensitivity 0.07 0.00 Anxiety Sensitivity 0.36** 0.06

(Anxiety) 0.59** 0.15 (Depression) 0.54** 0.14

Betas reported are at the step in which the variable was entered

Control variables included girls’ age, ethnicity, and family socioeconomic status

* p<0.01. ** p<0.001

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when considering comorbid symptoms.Moreover, our findingsdemonstrated empirical distinctions between rumination anddepression, and between anxiety sensitivity and anxietysymptoms.

Consistent with past literature that has examined rumina-tion or anxiety sensitivity separately (e.g., Noel and Francis2011; McLaughlin and Hatzenbuehler 2009; Muris 2002;Roelofs et al. 2009; Rood et al. 2010), we found both rumi-nation and anxiety sensitivity were each significantly relatedto girls’ depressive symptoms and to girls’ anxiety symptoms.When examined simultaneously, rumination and anxiety sen-sitivity combined accounted for 51 % of the variance in girls’depressive symptoms, and 54 % of the variance in girls’anxiety symptoms (after controlling for girls’ age, ethnicity,and family SES). Perhaps more importantly, as we expected,rumination and anxiety sensitivity demonstrated independentassociations with both girls’ depression and anxiety. That is,both rumination and anxiety sensitivity were significantly andindependently related to girls’ depressive symptoms; and,both rumination and anxiety sensitivity were significantlyand independently related to girls’ anxiety symptoms. Thesefindings suggest that: 1) there are distinctions between rumi-nation and anxiety sensitivity; and 2) rumination and anxietysensitivity are overlapping yet independent vulnerabilities orcorrelates for both depression and anxiety.

Moreover, given that cognitive vulnerabilities are oftenassociated (c.f., Fergus and Wu 2010), as they were in oursample (r=0.60), integrative cognitive vulnerability models(e.g., Weems and Watts 2005) stress the importance of exam-ining whether each cognitive construct incrementally predictssymptoms. Our results found that both rumination and anxietysensitivity are incrementally related to depression, andboth are incrementally related to anxiety, in our sampleof preadolescent girls.

Given the high comorbidity of depression and anxietysymptoms and disorders, perhapsmost importantly our study’sfindings highlight the importance of considering comorbidsymptoms in examining specificity in the relations betweencognitive vulnerabilities and depression and/or anxiety. In linewith the theoretical literature (e.g., Nolen-Hoeksema et al.2008) and the cognitive-content specificity hypothesis (Becket al. 1987; Beck and Clark 1988; Clark and Beck 1999), weanticipated and found that after controlling for girls’ anxietysymptoms, girls’ rumination (and not girls’ anxiety sensitivity)was uniquely and significantly related to girls’ depression.Indeed, girls’ rumination had a significant and unique relationto girls’ depression after partialing out variance attributed togirls’ anxiety as well as their anxiety sensitivity. Thisfinding provides strong support for rumination being spe-cifically related to depression and not anxiety, at least inpreadolescent girls when comorbid symptoms are considered.Moreover, anxiety and rumination (and not anxiety sensitivity)were uniquely and specifically related to girls’ depression.

Thus, these findings show not only distinctions to ruminationand anxiety sensitivity, but also show that anxiety and anxietysensitivity are empirically and conceptually distinct.

In contrast, in line with the theoretical literature (e.g.,Taylor 1999; Weems and Watts 2005) and the cognitive-content specificity hypothesis (Beck et al. 1987; Beck andClark 1988; Clark and Beck 1999), we anticipated and foundthat after controlling for girls’ depressive symptoms, girls’anxiety sensitivity (and not girls’ rumination) was uniquelyand significantly related to girls’ anxiety. Here, girls’ anxietysensitivity had a significant and unique relation to girls’anxiety after partialing out variance attributed to girls’depression as well as their rumination. This finding pro-vides strong support for anxiety sensitivity being specif-ically related to anxiety and not depression, at least inpreadolescent girls when comorbid symptoms are takeninto consideration. Moreover, depression and anxiety sensi-tivity (and not rumination) were uniquely and specificallyrelated to girls’ anxiety symptoms. Thus, these findings shownot only distinctions to rumination and anxiety sensitivity, butalso show that depression and rumination are empirically andconceptually distinct.

Our specificity findings with respect to rumination arealigned with Hankin’s (2008a) study on adolescent studentsthat used the CRSQ as we did, yet inconsistent with or oppositeto other studies that used the CRSS (e.g., Broeren et al. 2011;Muris et al. 2009; Muris et al. 2004). The CRSQ is modeledafter Nolen-Hoeksema’s Response Styles Questionnaire(RSQ) that was developed for adults, whereas the CRSS wasdeveloped based on a pool of items from the RSQ, anothermeasure, and some researcher-constructed items. The CRSQrumination scale has 13 items (rated 0–3), the final version ofthe CRSS rumination scale has 10 items (rated 0 – 10). Eachitem on the CRSQ begins, “When I am sad, I . . .”, whereas theCRSS directions say “circle a number to show how often youthink or do each one when you feel sad” and each item is listedwithout a reminder that the thought or behavior is in thecontext of when they feel sad. Each measure has demonstratedpsychometric characteristics. Future correlational and prospec-tive studies might incorporate both of these measures to iden-tify their similarity and differences in associations (and theirunique and specific associations) with youth depression andanxiety, alone, and in conjunction with other cognitive vulner-abilities. Moreover, to better address anxiety versus depressionspecificity issues, these future studies might use the BeckYouth forms as we did, as opposed to the CDI which manyprevious studies have used.

Other possible reasons for the inconsistency betweenfindings, apart from whether the CRSS or CRSQ was utilizedto assess rumination, may be that we focused exclusively on anarrow age range of preadolescents (and not adolescents orwide age range of youth). Additionally, we only examinedgirls, and/or we used theBeck youth forms to assess depressive

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and anxiety symptoms. However, unlike our specificity find-ings with respect to rumination, our specificity findings withrespect to anxiety sensitivity are consistent with a number ofstudies on adolescents or studies including a wide age range ofyouth (Joiner et al. 2002; McLaughlin and Hatzenbuehler2009; Muris et al. 2001; Weems et al. 2007).

Limitations of our study suggest important avenues forfuture research. Our findings are cross-sectional and corre-lational, and no causal or temporal relations can be demon-strated. Further research is needed to understand how anxietysensitivity and rumination, in tandem, might contribute tothe development of anxious and/or depressive symptomsover time in youth. Longitudinal prospective studies, follow-ing youth of varying ages, could elucidate potential temporalrelations and capture potential age-related trajectories withrespect to anxiety sensitivity and rumination and their pos-sible interaction that was not uncovered in the current study.Moreover, examining sex differences in prospective rela-tions, as well as examining reciprocal relations and processesbetween these cognitive vulnerabilities and depression andanxiety is warranted in future research (cf., Nolen-Hoeksemaet al. 2007). Furthermore, both rumination and anxiety sen-sitivity have recently been conceptualized and examinedthrough a vulnerability-stress perspective. Consistent withthis perspective, studies have revealed rumination interactswith (i.e., moderates) the relation between negative lifeevents and depression. For example, higher rumination in11 to 15-year-old youth was found to be associated withgreater increases in depressive symptoms and depressivedisorders following increases in negative life events (Abelaand Hankin 2011); and in a sample of 7 to 14-year-old youth,higher rumination was related to prospective increases indepressive symptoms after negative life events, more so forgirls than boys (Abela et al. 2012). Although these studiesare important, specificity issues were not examined as anxietyand anxiety sensitivity were not assessed. However, althoughHankin (2009) did not examine anxiety sensitivity, he foundin a sample of 6th to 10th grade students that ruminationinteracted with stressors in predicting girls’ increasing depres-sive and anxious arousal symptoms over a 5-month period.Likewise, the limited anxiety sensitivity literature examiningprospective relations with internalizing symptoms has notincorporated rumination. For example, McLaughlin andHatzenbuehler (2009) found anxiety sensitivity was a uniquevulnerability factor for 11 to 14-year-old youth to developanxiety symptoms, but not depressive symptoms, over a 7-month period. Indeed, given then the associations among andoverlap in cognitive vulnerabilities, as well as the comorbidityof depression and anxiety, integrative cognitive vulnerabilitymodels, as well as the results of the current study, call forexamining multiple cognitive vulnerabilities and examiningthe specificity of each vulnerability to anxiety versus depres-sion (cf., Elwood et al. 2009; Weems and Watts 2005).

Sample characteristics are also a limitation to our study.We focused on a community sample of preadolescent girls,mostly Caucasian and middle-upper SES. Whether our find-ings generalize to boys, adolescent samples, more ethnicallyand/or socioeconomically diverse samples, or clinical sam-ples is unknown. With respect to rumination, our effect sizesfound were consistent with those found in meta-analyses forrumination and depression in children (i.e., moderate effectsizes; although ours was also while controlling for anxietysensitivity), yet effect sizes for adolescent samples are moder-ate to high (cf., Rood et al. 2009) indicating stronger relationsbetween rumination and depression would likely emerge inadolescent samples. Moreover, meta-analyses find clinicalsamples yield larger effect sizes than nonclinical samples forboth rumination in relation to depression (M r=0.92 vs.M r=0.57) as well as anxiety (M r=0.70 vs. M r=0.42; Aldaoet al. 2010). With respect to anxiety sensitivity, our effect sizeswere consistent with those found in meta-analyses on anxietysensitivity and anxiety in children, after controlling for depres-sion and sex (i.e., small to medium effect size; although ourswas also while controlling for rumination), yet effect sizes foradolescent samples are significantly higher than those in sam-ples of children (medium effect size, Noel and Francis 2011),indicating stronger relations between anxiety and anxiety sen-sitivity would likely emerge in adolescent samples. Largereffect sizes regarding the relation between anxiety and anxietysensitivity emerge for anxiety-disordered youth relative tononclinical youth (Noel and Francis 2011).

Importantly, our measures were also all self-report, weonly had one measure of each of the four constructs, and wedid not conduct or include clinical diagnostic interviews.Thus, even though we found some differential findings, ourfindings could be due in part to shared method variance, andmay be limited due to mono-method bias. Examining similarquestions with experimental methodologies and tasks and/ordiagnostic measures is an area for future research.

Despite these limitations, our results may have someimplications for treatment. Cognitive-behavioral treatmentfor depression and/or anxiety might target rumination andanxiety sensitivity, or even if not targeted, these vulnerabil-ities may mediate depression and anxiety treatment outcomein youth. A meta-analysis found CBT is effective in reducinganxiety sensitivity in high-risk and treatment-seeking adults,and other work suggests anxiety sensitivity mediates therelation between CBT and a reduction in depressed moodand anxiety in adults (see Smits et al. 2008). However,whether anxiety sensitivity and/or rumination mediates therelation between CBT and youth depression and/or anxietysymptoms has yet to be examined. Moreover, as Gotlib andJoormann (2010) highlight, rumination appears to be onepotential mechanism in the link between cognitive processingbiases and emotion dysregulation in depression. As such,rumination and anxiety sensitivity might be targeted and/or

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assessed in intervention strategies that focus on youths’ emo-tion regulation (e.g., Southam-Gerow 2013). Finally, the adultliterature on cognitive bias modification interventions fordepression and anxiety shows promising effects on depres-sion, anxiety, and on interpretation and attention biases (seeHallion and Ruscio 2011). As rumination and anxiety sensi-tivity both involve interpretation and attention biases, inextending cognitive bias modification interventions to youthit may be beneficial to incorporate questionnaire measures ofrumination and/or anxiety sensitivity. The CASI contains only18 items and the Rumination subscale on the CRSQ containsonly 13 items. Adding these brief measures to CBT, emotionregulation, and/or cognitive bias modification treatmentprotocols (i.e., pre-, post-, and follow-up measures), andincluding them in prevention screening programs, would beboth cost and time effective and may in due time prove fruitfulfor the better understanding of, prevention of, and treatmentfor, depression and anxiety in youth.

References

Abela, J. R. Z., Aydin, C. M., & Auerbach, R. P. (2007). Responses todepression in children: Reconceptualizing the relation amongresponse styles. Journal of Abnormal Child Psychology, 35,913–927. doi:10.1007/s10802-007-9143-2.

Abela, J. R. Z., Bronzina, K., & Haigh, E. P. (2002). An examina-tion of the response styles theory of depression in third andseventh grade children: A short-term longitudinal study. Journalof Abnormal Child Psychology, 30, 515–527. doi:10.1023/A:1019873015594.

Abela, J. R. Z., Hankin, B. L., Sheshko, D. M., Fishman, M. B., &Stolow, D. (2012). Multi-wave prospective examination of thestress-reactivity extension of response styles theory of depressionin high-risk children and early adolescents. Journal of AbnormalChild Psychology, 40, 277–287. doi:10.1007/s10802-011-9563-x.

Abela, J. R. Z., & Hankin, B. L. (2011). Rumination as a vulnerabilityfactor to depression during the transition from early to middleadolescence: A multiwave longitudinal study. Journal of Abnor-mal Psychology, 120, 259–271. doi:10.1037/a0022796.

Abela, J. R. Z., Vanderbilt, E., & Rochon, A. (2004). A test of theintegration of the response styles and social support theories ofdepression in third and seventh grade children. Journal of Socialand Clinical Psychology, 23, 653–674. doi:10.1521/jscp.23.5.653.50752.

Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic re-view. Clinical Psychology Review, 30, 217–237. doi:10.1016/j.cpr.2009.11.004.

Alloy, L. B., Black, S. K., Young, M. E., Goldstein, K. E., Shapero, B.G., Stange, J. P., & Abramson, L. Y. (2012). Cognitive vulnera-bilities and depression versus other psychopathology symptomsand diagnoses in early adolescence. Journal of Clinical Child andAdolescent Psychology, 41, 539–560. doi:10.1080/15374416.2012.703123.

Beck, A. T., Brown, G., Steer, R. A., Eidelson, J. I., & Riskind, J. H.(1987). Differentiating anxiety and depression: A test of thecognitive content-specificity hypothesis. Journal of AbnormalPsychology, 96, 179–183. doi:10/1037/0021-843X.96.3.179.

Beck, A. T., & Clark, D. A. (1988). Anxiety and depression: Aninformation processing perspective. Anxiety Research, 1, 23–36.doi:10.1080/10615808808248218.

Beck, J. S., Beck, A. T., Jolly, J. B., & Steer, R. A. (2005). Thebeck youth inventories (2nd ed.). San Antonio: PsychologicalCorporation.

Broeren, S., Muris, P., Bouwmeester, S., van der Heijden, K. B., &Abee, A. (2011). The role of repetitive negative thoughts in thevulnerability for emotional problems in non-clinical children.Journal of Child and Family Studies, 20, 135–148. doi:10.1007/s10826-010-9380-9.

Carthy, T., Horesh, N., Apter, A., & Gross, J. J. (2010). Patterns ofemotional reactivity and regulation in childrenwith anxiety disorders.Journal of Psychopathology and Behavioral Assessment, 32, 23–36.doi:10.1007/s10862-009-9167-8.

Cisler, J. M., Olatunji, B. O., Feldner, M. T., & Forsyth, J. P. (2010).Emotion regulation and the anxiety disorders: An integrativereview. Journal of Psychopathology and Behavioral Assessment,32, 68–82. doi:10.1007/s10862-009-9161-1.

Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitivetheory and therapy of depression. New York: Wiley.

Cohen, J., Cohen, P., West, S. G., & Aiken, L. S. (2003). Appliedmultiple regression/correlation analysis for the behavioral sciences(3rd ed.). Mahwah: Lawrence Erlbaum Associates, Inc.

Cole, D. A., Jacquez, F. M., Truss, A. E., Pineda, A. Q., Weitlauf, A. S.,Tilghman-Osborne, C. E., & Maxwell, M. A. (2009). Genderdifferences in the longitudinal structure of cognitive diathesesfor depression in children and adolescents. Journal of ClinicalPsychology, 65, 1312–1326. doi:10.1002/jclp.20631.

Cole, P., & Hall, S. (2008). Emotion dysregulation as a risk factor forpsychopathology. In T. P. Beauchaine & S. P. Hinshaw (Eds.),Child and adolescent psychopathology (pp. 265–298). Hoboken:John Wiley & Sons Inc.

Cox, B. J., Enns, M. W., & Taylor, S. (2001). The effect of ruminationas a mediator of elevated anxiety sensitivity in major depression.Cognitive Therapy and Research, 25, 525–534. doi:10.1023/A:1005580518671.

Craske, M. G. (2003). Origins of phobias and anxiety disorders: Whymore women than men? Oxford: Elsevier Ltd.

Driscoll, K. A., Lopez, C. M., & Kistner, J. A. (2009). A diathesis-stresstest of response styles in children. Journal of Social and ClinicalPsychology, 28, 1050–1070. doi:10.1521/jscp.2009.28.8.1050.

Durbin, C. E., & Shafir, D. M. (2008). Emotion regulation and risk fordepression. In J. R. Abela & B. L. Hankin (Eds.), Handbook ofdepression in children and adolescents (pp. 149–176). New York:Guilford Press.

Elwood, L. S., Hahn, K. S., Olatunji, B. O., & Williams, N. L. (2009).Cognitive vulnerabilities to the development of PTSD: A review offour vulnerabilities and the proposal of an integrative vulnerabilitymodel. Clinical Psychology Review, 29, 87–100. doi:10.1016/j.cpr.2008.10.002.

Fergus, T. A., &Wu, K. D. (2010). Do symptoms of generalized anxietyand obsessive-compulsive disorder share cognitive processes?Cognitive Therapy and Research, 34, 168–176. doi:10.1007/s10608-009-9239-9.

Fergus, T. A., & Wu, K. D. (2011). Searching for specificity betweencognitive vulnerabilities and mood and anxiety symptoms. Jour-nal of Psychopathology and Behavioral Assessment, 33, 446–458.doi:10.1007/s10862-011-9245-6.

Gibb, B. E., Grassia, M., Stone, L. B., Uhrlass, D. J., & McGeary, J. E.(2012). Brooding rumination and risk for depressive disordersin children of depressed mothers. Journal of Abnormal ChildPsychology, 40, 317–326. doi:10.1007/s10802-011-9554-y.

Gotlib, I. H., & Joormann, J. (2010). Cognition and depression: Currentstatus and future directions. Annual Review of Clinical Psychology,6, 285–312. doi:10.1146/annurev.clinpsy.121208.131305.

J Psychopathol Behav Assess

Hallion, L. S., & Ruscio, A. M. (2011). A meta-analysis of theeffect of cognitive bias modification on anxiety and depres-sion. Psychological Bulletin, 137, 940–958. doi:10.1037/a0024355.

Hankin, B. L. (2008a). Rumination and depression in adolescence:Investigating symptom specificity in a multiwave prospectivestudy. Journal of Clinical Child and Adolescent Psychology, 37,701–713. doi:10.1080/15374410802359627.

Hankin, B. L. (2008b). Stability of cognitive vulnerabilities to de-pression: A short-term prospective multiwave study. Journalof Abnormal Psychology, 117, 324–333. doi:10.1037/0021-843X.117.2.324.

Hankin, B. L. (2009). Development of sex differences in depressive andco-occurring anxious symptoms during adolescence: Descriptivetrajectories and potential explanations in a multiwave prospectivestudy. Journal of Clinical Child and Adolescent Psychology, 38,460–472. doi:10.1080/15374410902976288.

Hankin, B. L., Wetter, E., & Cheely, C. (2008). Sex differences in childand adolescent depression: A developmental psychopathologicalapproach. In J. R. Z. Abela & B. L. Hankin (Eds.), Handbook ofdepression in children and adolescents (pp. 377–414). New York:Guilford Press.

Hilt, L. M., McLaughlin, K. A., & Nolen-Hoeksema, S. (2010). Exam-ination of the response styles theory in a community sample ofyoung adolescents. Journal of Abnormal Child Psychology, 38,545–556. doi:10.1007/s10802-009-9384-3.

Hollingshead, A. B. (1975). Four factor index of social status. NewHaven: Yale University, Department of Sociology. Unpublishedmanuscript.

Holmbeck, G. N. (2002). Post-hoc probing of significant moderationaland mediational effects in studies of pediatric populations. Journalof Pediatric Psychology, 27, 87–96. doi:10.1093/jpepsy/27.1.87.

Joiner, T. E., Schmidt, N. B., Schmidt, K. L., Laurent, J., Catanzaro, S.J., Perez, M., & Pettit, J. W. (2002). Anxiety sensitivity as aspecific and unique marker of anxious symptoms in youth psychi-atric inpatients. Journal of Abnormal Child Psychology, 30, 167–175. doi:10.1023/A:1014757300294.

Kendall, P. C. (2012). Anxiety disorders in youth. In P. C. Kendall (Ed.),Child and adolescent therapy: Cognitive-behavioral procedures(4th ed., pp. 143–189). New York: The Guilford Press.

Kovacs, M. (1992). Children’s Depression inventory manual. NorthTonawanda: Multi-Health Systems, Inc.

Lopez, C. M., Driscoll, K. A., & Kistner, J. A. (2009). Sex differencesand response styles: Subtypes of rumination and associations withdepressive symptoms. Journal of Clinical Child and AdolescentPsychology, 38, 27–35. doi:10.1080/15374410802575412.

Mathews, A., & MacLeod, C. (2005). Cognitive vulnerability to emo-tional disorders. Annual Review of Clinical Psychology, 1, 167–195. doi:10.1146.annurev.clinpsy.1.102803.143916.

McLaughlin, K. A., & Hatzenbuehler, M. L. (2009). Stressful lifeevents, anxiety sensitivity, and internalizing symptoms in adoles-cents. Journal of Abnormal Psychology, 118, 659–669. doi:10.1037/a0016499.

Mezulis, A. H., Funasaki, K. S., Charbonneau, A. M., & Hyde, J. S.(2010). Gender differences in the cognitive vulnerability-stressmodel of depression in the transition to adolescence. CognitiveTherapy and Research, 34, 501–513. doi:10.1007/s10608-009-9281-7.

Muris, P. (2002). An expanded childhood anxiety sensitivity index: Itsfactor structure, reliability, and validity in a non-clinical adoles-cent sample. Behaviour Research and Therapy, 40, 299–311.doi:10.1016/S0005-7967(00)00112-1.

Muris, P., Fokke, M., & Kwik, D. (2009). The ruminative response stylein adolescents: An examination of its specific link to symptoms ofdepression.Cognitive Therapy and Research, 33, 21–32. doi:10.1007/s10608-007-9120-7.

Muris, P., Roelofs, J., Meesters, C., & Boomsma, P. (2004). Ruminationand worry in nonclinical adolescents. Cognitive Therapy andResearch, 28, 539–554. doi: 0147-5916/04/0800-0539/0

Muris, P., Schmidt, H., Merckelbach, H., & Schouten, E. (2001).Anxiety sensitivity in adolescents: Factor structure and relation-ships to trait anxiety and symptoms of anxiety disorders anddepression. Behaviour Research and Therapy, 39, 89–100.doi:10.1016/S0005-7967(99)00179-5.

Noel, V. A., & Francis, S. E. (2011). A meta-analytic review of the roleof child anxiety sensitivity in child anxiety. Journal of AbnormalChild Psychology, 39, 721–733. doi:10.1007/s10802-011-9489-3.

Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression:Evidence and theory. Psychological Bulletin, 101, 259–282.doi:10.1037//0033-2909-101.2.259.

Nolen-Hoeksema, S. (1991). Responses to depression and their effectson the duration of depressive episodes. Journal of AbnormalPsychology, 100, 569–582. doi:10.1037//0021-843X.100.4.569.

Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007).Reciprocal relations between rumination and bulimic, substanceabuse, and depressive symptoms in female adolescents. Journalof Abnormal Psychology, 116, 198–207. doi:10.1037/0021-843X.116.1.198.

Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Re-thinking rumination. Perspectives on Psychological Science, 3,400–424. doi:10.1111/j.1745-6924.2008.00088.x.

Reardon, J. M., & Williams, N. L. (2007). The specificity of cognitivevulnerabilities to emotional disorders: Anxiety sensitivity, loomingvulnerability and explanatory style. Journal of Anxiety Disorders,21, 625–643. doi:10.1016/j.janxdis.2006.09.013.

Rabian, B., Embry, L., & MacIntyre, D. (1999). Behavioral valida-tion of the childhood anxiety sensitivity index in children.Journal of Clinical Child Psychology, 28, 105–112. doi:10.1207/s15374424jccp2801_9.

Reiss, S., Peterson, R., Taylor, S., Schmidt, N., & Weems, C. F. (2008).Anxiety sensitivity index consolidated user manual: ASI, ASI-3,and CASI. Worthington: IDS Publishing.

Roelofs, J., Rood, L., Meesters, C., Dorsthorst, V., Bogels, S., Alloy, L.B., & Nolen-Hoeksema, S. (2009). The influence of ruminationand distraction on depressed and anxious mood: A prospectiveexamination of the response styles theory in children and adoles-cents. European Journal of Child and Adolescent Psychiatry, 18,635–642. doi:10.1007/s00787-009-0026-7.

Rood, L., Roelofs, J., Bogels, S. M., Nolen-Hoeksema, S., & Schouten,E. (2009). The influence of emotion-focused rumination and dis-traction on depressive symptoms in non-clinical youth: A meta-analytic review. Clinical Psychology Review, 29, 607–616.doi:10.1016/j.cpr.2009.07.001.

Rood, L., Roelofs, J., Bogels, S. M., & Alloy, L. B. (2010). Dimensionsof negative thinking and the relations with symptoms of depres-sion and anxiety in children and adolescents. Cognitive Therapyand Research, 34, 333–342. doi:10.1007/s10608-009-9261-y.

Sameroff, A., Gutman, L. M., & Peck, S. C. (2003). Adaptation amongyouth facing multiple risks: Prospective research findings. In S. S.Luthar (Ed.), Resilience and vulnerability: Adaptation in the con-text of childhood adversities (pp. 364–391). New York: Cam-bridge University Press.

Seligman, L. D., & Ollendick, T. H. (1998). Comorbidity of anxiety anddepression in children and adolescents: An integrative review.Clinical Child and Family Psychology Review, 1, 125–144.

Silverman, W. K., Fleisig, W., Rabian, B., & Peterson, R. A. (1991).Childhood anxiety sensitivity index. Journal of Clinical ChildPsychology, 20, 162–168. doi:10.1207/s15374424jccp2002_7.

Smits, J. A. J., Berry, A. C., Tart, C. D., & Powers, M. B. (2008).The efficacy of cognitive-behavioral interventions for reducinganxiety sensitivity: A meta-analytic review. Behaviour Researchand Therapy, 46, 1047–1054. doi:10.1016/j.brat.2008.06.010.

J Psychopathol Behav Assess

Southam-Gerow, M. A. (2013). Emotion regulation in children andadolescents: A practitioner’s guide. New York: Guilford Press.

Stapleton, L. M., Sander, J. B., & Stark, K. D. (2007). Psychometricproperties of the beck depression inventory for youth in a sampleof girls. Psychological Assessment, 19, 230–235. doi:10.1037/1040-3590.19.2.230.

Stark, K. D., Streusand, W., Arora, P., & Patel, P. (2012). Child-hood depression: The ACTION treatment program. In P. C.Kendall (Ed.), Child and adolescent therapy: Cognitive-behavioral procedures (4th ed., pp. 190–233). New York:The Guilford Press.

Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics(5th ed.). Boston: Pearson, Education, Inc.

Taylor, S. (1999). Anxiety sensitivity: Theory, research, and treatmentof the fear of anxiety. Mahwah: Erlbaum.

Weems, C. F. (2011). Anxiety sensitivity as a specific form of distresstolerance in youth: Developmental assessment, origins, and appli-cations. In M. J. Zvolensky, A. Bernstein, & A. A. Vujanovic(Eds.), Distress tolerance: Theory, research, and clinical applica-tions (pp. 28–51). New York: Guilford Press.

Weems, C. F., Berman, S. L., Silverman, W. K., & Saavedra, L. M. (2001).Cognitive errors in youthwith anxiety disorders: The linkages betweennegative cognitive errors and anxious symptoms. Cognitive Therapyand Research, 25, 559–575. doi:10.1023/A:1005505531527.

Weems, C. F., Costa, N. M., Watts, S. E., Taylor, L. K., & Cannon, M. F.(2007). Cognitive errors, anxiety sensitivity, and anxiety controlbeliefs: Their unique and specific associations with childhood anxietysymptoms. Behavior Modification, 31, 174–201. doi:10.1177/0145445506297016.

Weems, C. F., Hammond-Laurence, K., Silverman, W. K., & Ferguson,C. (1997). The relation between anxiety sensitivity and depression inchildren and adolescents referred for anxiety. Behaviour Researchand Therapy, 35, 961–966. doi:10.1016/S0005-7967(97)00049-1.

Weems, C. F., & Watts, S. E. (2005). Cognitive models of childhoodanxiety. In C. M. Velotis (Ed.), Anxiety disorder research(pp. 205–232). Hauppauge: Nova Science Publishers, Inc.

Ziegert, D. I., & Kistner, J. A. (2002). Response styles theory:Downward extension to children. Journal of Clinical Child andAdolescent Psychology, 31, 325–334. doi:10.1207/S15374424JCCP3103_04.

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