VULNERABILITIES AND RISK FACTORS

FOR PSYCHOPATHOLOGY

Risk and Resilience in Child and Adolescent

Psychopathology

Processes of Stress, Coping, and Emotion Regulation

BRUCE E. COMPAS AND CHARISSA ANDREOTTI

HISTORICAL CONTEXT

P

ROCESSES OF RISK ANDresilience are central to understanding the nature and etiology of psychopathology during childhood and adolescence. Under-standing risk factors and processes of risk is important in the identification of those children/adolescents most in need of early intervention, whereas clarifi-cation of protective factors and processes of resilience can inform characteristics of interventions to strengthen those at greatest risk (e.g., Cicchetti & Blender, 2006;

Compas & Reeslund, 2009; Luthar & Cicchetti, 2000). Two constructs, exposure to stress and the ways that individuals cope with stress, have a long history in risk and resilience research and theory in developmental psychopathology (e.g., Garmezy &

Rutter, 1983) and remain central constructs after more than four decades of research.

However, recent work has led to more refined and nuanced views on stress and coping that have made these long-standing constructs even more relevant to under-standing the development of psychopathology. In this chapter we first consider the concepts of risk and resilience in developmental psychopathology more broadly.

We then briefly review processes related to stress and coping—central constructs for understanding risk and resilience. Next, we examine recent work that can enhance our understanding of stress and coping processes, including research on allostatic load, exposure to adversity early in development, and emotion regulation as a pro-cess closely related to coping. Finally, we examine research on depression during adolescence as an exemplar of progress and continued challenges to research on risk and resilience during adolescence.

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TERMINOLOGICAL AND CONCEPTUAL ISSUES

Research and theory on processes of risk and resilience as they relate to psy-chopathology in childhood and adolescence have a long and rich history. However, there has been considerable confusion and debate about the definitions of these constructs. We begin by briefly summarizing several recent attempts to bring clarity to risk and resilience for child and adolescent psychopathology.

Risk and Resilience

Risk. The term risk refers to increased probability of a negative developmental outcome in a specified population (Kraemer et al., 1997; Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001). Thus, risk (or degree of risk) is a quantitative concept that is reflected as either an odds ratio (see Chapter 3) when outcomes are measured categorically, or as some variant of a regression weight when outcomes are con-tinuous or quantitative. For example, the odds of developing a mood disorder (major depressive disorder or dysthymic disorder) or a disruptive behavior disorder (oppositional defiant disorder or conduct disorder) can be calculated as a function of characteristics of the individual (e.g., age, sex), family factors (e.g., harsh parenting, parental psychopathology), and neighborhood characteristics (e.g., violence, inad-equate housing). A risk factor is an agent or characteristic of the individual or the environment that is related to the increased probability of a negative outcome. The degree of risk associated with a given risk factor can be calculated at various levels, including the degree of risk for an individual person, a family, or a community. A landmark report by the National Research Council and the Institute of Medicine (NRC/IOM, 2009) further distinguished between risk factors that are specific to a particular outcome (e.g., depression) as opposed to nonspecific risk factors that are related to a number of outcomes (e.g., depression, anxiety, eating disorders).

In addition to distinguishing levels of risk, temporal precedence must be estab-lished between risks and outcomes; that is, the presence of or exposure to the risk factor must precede evidence of the development of the outcome. Kraemer et al.

(2001) address the issue of temporal precedence within a typology of risk factors. If a factor is simply associated with an outcome at a single point in time, it is identified as a correlate. A correlate that precedes an outcome is a risk factor, and a risk factor that can be changed or changes with development is a variable risk factor. Finally, if manipulation of the risk factor changes an outcome, it is a causal risk factor. In human research the final step in risk research is likely to involve preventive interven-tions designed to change established risk factors to determine their possible causal role. Cumulative risk refers to the co-occurrence of more than one risk factor for a given individual or within a population (Sameroff, 2006). For example, poverty and economic hardship are associated with multiple additional risks factors, including neighborhood crime and violence, lack of access to quality schools, single parent-hood, and family conflict (e.g., Chen, 2007; Evans & Kim, 2007; Evans & Wachs, 2010; Miller, Chen, & Parker, 2011). Similarly, parental psychopathology, another important risk factor throughout childhood and adolescence, is linked with family

conflict and discord and possible genetic risk for psychopathology (e.g., Goodman et al., 2011; see Chapter 3). The probability of negative outcomes may increase additively or exponentially as the number of risk factors increases.

The effects of risk factors can also be nonlinear. Kraemer et al. (2001) spell out conditions in which one risk factor (A) moderates the effects of a second risk factor (B) on an outcome (O). For A to function as a moderator of B, A must precede B, A and B must not be correlated, and A cannot influence B directly. However, the strength of the effect of B on O must be affected by the level of A. For example, there is an interaction between sex and pubertal timing in predicting depression in adolescence, such that girls with early onset puberty have an increased likelihood of a major depressive episode (Negriff & Susman, 2011). Following the principles outlined by Kraemer et al. (2001), in this case sex (A) precedes pubertal timing (B), sex is uncorrelated with pubertal timing, and both are related to depression (O). However, the strength of the association between early onset puberty and depression is greater for girls than for boys; that is, pubertal timing moderates the relation between sex and depression. Thus, pubertal timing is a source of increased vulnerability to depression among girls but not among boys. Greater precision of the relations among risk factors and their moderating effects will contribute to greater clarity in distinguishing between risk factors and sources of vulnerability.

Resilience. The concept of resilience is closely linked to risk. Luthar and Cicchetti (2000) define resilience as a ‘‘dynamic process wherein individuals display positive adaptation despite experiences of significant adversity or trauma’’ (p. 858). Similarly, Masten (2001) defines resilience as ‘‘a class of phenomena characterized by good outcomes in spite of threats to adaptation or development’’ (p. 228). Resilience does not merely imply a personality trait or an attribute of the individual; rather, it is intended to reflect a process of positive adaptation in the presence of risk that may be the result of individual factors, environmental factors, or the interplay of the two (Luthar, 2006; Luthar & Cicchetti, 2000). Resilience research is concerned with identifying mechanisms or processes that might underlie evidence of positive adaptation in the presence of risk. Masten (2001) distinguished among several models of resilience. Variable-focused models of resilience test relations among quantitative measures of risk, outcomes, and potential characteristics of the individual or the environment that may serve a protective function against the adverse effects of risk. Within this approach, researchers can test for mediators and moderators of risk that can provide evidence of protection or resilience. Person-focused models of resilience examine individuals in an attempt to identify and compare those who display patterns of resilience (as evidenced by positive outcomes) and those who succumb to risk (as reflected in negative outcomes).

Risk and resilience. Although there is merit to distinguishing between risk and resilience, there are challenges in the conceptualization of these factors and processes (Compas & Reeslund, 2009). Foremost is the difficulty of determining whether risk and resilience are distinct constructs, or whether they exist along a continuum. In some instances, high levels of a factor protect individuals from risk whereas low levels of the same factor amplify risk (Luthar, Sawyer, & Brown, 2006). For example, high IQ may serve as a protective factor in the face of socioeconomic adversity,

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whereas low IQ may increase the potency of the effects of poverty. Thus, IQ may both increase and decrease risk associated with socioeconomic hardship. In other instances, high levels of a factor are protective, but low levels may be neutral or benign in relation to the source of risk. For example, temperamental characteristics of negative affectivity and positive affectivity, respectively, are risk and resilience factors for emotional problems (Compas, Connor-Smith, & Jaser, 2004). However, these two traits are independent, as low negative affectivity does not denote positive affectivity. Thus, low negative affectivity indicates the absence of this vulnerability factor, but it does not necessarily serve as a protective factor.

The situation is further complicated because some risk and protective factors are stable, whereas others change with development. For example, some tempera-mental characteristics emerge in infancy and remain stable throughout childhood and adolescence. Stable individual differences in temperament may function as either risk or protective factors in adolescence, depending on the characteristic in question. Similarly, some features of the environment may be stable sources of risk or protection throughout childhood and adolescence (e.g., chronic poverty, a supportive and structured family environment). Other factors may emerge during adolescence as sources of risk and protection and can be defined as developmen-tal risk and protective factors. For example, some aspects of cognitive and brain development change dramatically during early adolescence and mark this as a period of heightened risk for many adolescents (Casey, Getz, & Galvan, 2008;

Spear, 2011; Steinberg, 2005, 2008). Similarly, it appears that the effects of certain types of stressful events are relatively benign during childhood but are much more likely to be associated with negative outcomes during adolescence (Hankin &

Abramson, 2001).

Stress and Coping: Unifying Concepts for Understanding Risk and Resilience

Research on exposure to stressful events and circumstances and the ways in which children and adolescents respond to and cope with stress are central to under-standing processes of risk and resilience for psychopathology in young people.

Specifically, exposure to stressful events and circumstances, including the gen-eration of stressors in neighborhood, school, peer, and family environments, are primary risk factors that exert effects on child and adolescent mental (and physical) health. Furthermore, individual differences in coping and related processes of stress reactivity and emotion regulation are crucial sources of resilience in the face of both distal and proximal sources of stress.

Stress

In spite of strong criticisms of the construct (e.g., Lazarus, 1993), stress remains a centrally important factor in understanding risk for psychopathology. Prevailing definitions of stress all include environmental circumstances or conditions that threaten, challenge, exceed, or harm the psychological or biological capacities of

the individual (see Chapter 8). Definitions of stress differ, however, in the degree to which processes of cognitive appraisal are implicated in determining what is and is not stressful to a given individual. Transactional approaches suggest that the occurrence of stress is dependent on the degree to which individuals perceive environmental demands as threatening, challenging, or harmful (Lazarus

& Folkman, 1984). Alternatively, environmental perspectives have emphasized the importance of objectively documenting the occurrence of environmental events and conditions independent of the potential confounds of cognitive appraisals (Cohen, Kessler, & Gordon, 1995).

Although the transactional definition of stress continues to be widely embraced, it poses problems for stress research with children and adolescents. For example, research on stress during infancy and early childhood indicates clear negative effects of maternal separation, abuse, and neglect on infants (e.g., Miskovic, Schmidt, Goergiades, & Boyle, 2010; Pollak et al., 2010). Whether these events are subjectively experienced as stressful, it is clear that adverse effects can occur in young children without the complex cognitive appraisals that are central to the transactional approach. In addition, research indicates that cognitive appraisal processes do not interact with stressful events in the prediction of symptoms until late childhood or early adolescence and that appraisals increase in significance during this period (e.g., Cole et al., 2008).

Given limitations of transactional definitions of stress for research with children and adolescents, other developmental perspectives on stress focus on objective external, environmental events or circumstances. Grant, Compas, Stuhlmacher, Thurm, and McMahon (2003) proposed a definition of stressors that emphasizes objective environmental events or chronic conditions that threaten adolescents’

physical and/or psychological health or well being of youth. This definition is consistent with traditional stimulus-based definitions of stress and more recent definitions of stressors and objective measures of stress (e.g., Rudolph & Hammen, 2000). Events or chronic circumstances can threaten the well-being of an individual without leading to a negative outcome. Thus, stressful events and conditions are defined independent of their effects or outcomes. This definition allows for positive outcomes in the face of objectively threatening circumstances; that is, it allows for resilience.

The study of stressful events and circumstances remains central to current etio-logical theories of child and adolescent psychopathology. This is evident in the more than 1,500 empirical investigations of the relation between stressors and psycho-logical symptoms among youth identified by Grant, Compas, Thurm, McMahon, and Gipson (2004). However, the level of interest in the relation between stressors and psychological problems in adolescence has not been matched by progress in the field. Variability in the conceptualization and operationalization of stress and stressors has created significant problems (Grant et al., 2003). Underlying these specific measurement concerns is the broader issue that most studies of relations between stressors and psychological problems in children and adolescents have not been theory-driven beyond the general notion that stressors pose risk for psychopathology (Grant et al., 2003; Steinberg & Avenevoli, 2000).

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In a series of reviews, Grant and colleagues (Grant et al., 2003, 2004, 2006;

McMahon, Grant, Compas, Thurm, & Ey, 2003) identified several overarching findings from research on stress and psychopathology in children and adolescents.

First, as noted above, Grant et al. (2003) suggest that stress is best conceptualized in terms of the occurrence of acute events or chronic conditions or circumstances (referred to as stressors) that threaten the physical or mental health of the child or adolescent. The nature of events (e.g., parental divorce, family move) and chronic conditions (e.g., poverty, chronic parental conflict and discord) that constitute sources of stress vary as a function of children’s development and social context.

Second, more than 50 prospective longitudinal studies have provided evidence that exposure to stressful events and chronic adversity predict increases in both internalizing and externalizing symptoms over time (Grant et al., 2004). Most importantly, there is substantial evidence that stressful events and adversities at one point in time predict increases in both internalizing and externalizing symptoms of psychopathology at a later time point, suggesting that stressors may play a causal role in the development of both types of symptoms (although see Chapter 3 for alternative Gene x Environment interaction and gene-environment correlation models). Thus, stressful events in the lives of children and adolescents meet criteria for risk factors as outlined by Kraemer et al. (2001). Third, consistent with a heuristic model proposed by Nolen-Hoeksema and Watkins (2011), exposure to stressful life events functions as a distal risk factor whose association with internalizing and externalizing symptoms is mediated by more proximal family characteristics, including disrupted parenting and parent–child relationships (Grant et al., 2003, 2006; Chapter 14). Evidence is particularly strong for poverty and economic disadvantage as distal risk factors that affect child/adolescent internalizing and externalizing symptoms through their effects on positive and negative parenting (Grant et al., 2003).

Finally, McMahon et al. (2003) concluded exposure to stressful events and chronic sources of adversity appears to operate as a nonspecific risk factor that places children and adolescents at risk for the full range of internalizing and externalizing forms of psychopathology. These authors reviewed studies of the effects of a wide range of stressors in childhood and adolescence including exposure to violence, physical and sexual abuse, divorce/marital conflict, poverty, physical illness, and cumulative life events across multiple domains. Exposure to stressful events and adversity plays a role in virtually all types of psychopathology including total internalizing and externalizing problems, as well as symptoms of depression, anxiety, eating disorders, aggressive behavior problems, conduct problems, substance use and abuse, and somatization. McMahon et al. (2003) note that across the various stressors examined, the most consistent evidence for specificity was found in the association of sexual abuse with internalizing symptoms, PTSD, and sexual acting out symptoms across several studies. Subsequent research indicates specificity among a wider set of psychosocial risk factors that include but are not limited to stressful events (Shanahan, Copeland, Costello, & Angold, 2008). On the other hand, recent evidence from the National Comorbidity Survey Replication (Green et al., 2010) suggests that childhood adversities, including interpersonal loss (parental death, parental divorce, and other separation from parents or caregivers), parental maladjustment

(mental illness, substance abuse, criminality, and violence), maltreatment (physical abuse, sexual abuse, and neglect), life-threatening childhood physical illness, and extreme childhood family economic adversity are associated with all types of psychopathology in adulthood. Thus, current evidence suggests that exposure to stressful life events and circumstances of adversity are broad, non-specific risk factors for a wide range of co-occurring patterns of symptoms and disorders in childhood and adolescence.

NEW DIRECTIONS IN RESEARCH ON STRESS

The large body of evidence on the role of stressors in child and adolescent psy-chopathology could suggest that research in this area has reached its zenith and that there is little new to be learned. However, several new perspectives have emerged that have the potential to expand on the decades of research on stressful life events, including the construct of allostatic load and the importance of exposure to early adversity. Allostatic load refers to the cost or wear and tear on biological and psychological systems as a result of chronic or repeated exposure to significant stress (McEwen, 2003; Chapter 8). Underlying biological systems can become dys-regulated as a result of prolonged exposure to stressful events or conditions leading to behavioral, emotional, and biological dysfunction (Juster, McEwen, Bruce, &

Lupien, 2010). The concept of allostatic load has added value for understanding the role of stress in developmental psychopathology in part because unlike traditional research on stressful life events it emphasizes the integration of multiple levels of analyses, including genetic and neurobiological processes, developmental history, and current context and experience (Cicchetti, 2011). Drawing on both human and animal research, these multiple levels of analyses hold promise for delineating some of the processes through which exposure to stressful events and circumstances contribute the development of psychopathology.

Research guided by an allostatic load model has generated a number of findings that are potentially important to child and adolescent psychopathology. For example, initial conceptualizations of allostatic load emphasized the effects of chronic stress on activation and dysregulation of the hypothalamic-pituitary-adrenal axis and the production of cortisol. However, Beauchaine, Neuhaus, Zalewski, Crowell, and Potapova (2011) have noted the importance of dysregulation in monoamine neural systems including dopamine, norepinephrine, and serotonin. For example, repeated and prolonged exposure to stress often alters central serotonin expression through epigenetic mechanisms, conferring lifelong risk for anxiety, depression, and other adverse outcomes. Research on allostatic load highlights the important role of chronic exposure to stress as a major source of risk for other biological systems and behaviors as well. For example, repeated exposure to violence alters neurodevelopment in the hippocampus and prefrontal cortex, conferring risk for learning and memory difficulties, disrupted social affiliation, and substance use and abuse (Mead, Beauchaine, & Shannon, 2010).

Research on the effects of stressful life events has typically focused on the occurrence of events within a specified and relatively recent period of time (e.g.,

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the prior 6 months). In contrast, recent research on stress has placed greater emphasis on the developmental timing of exposure to stress, with increasing evidence accumulating for the long-term significance of early exposure to stress and adversity. For example, work by Evans and colleagues has documented long-term effects of growing up with the chronic stress engendered by poverty on later psychological and physical health (e.g., Evans et al., 2010; Evans & Schamberg, 2009). Extensive research also indicates that exposure to abuse and neglect early in development is related to increased risk for subsequent psycholopathology in childhood and adolescence (e.g., Mead et al., 2010).

Coping

Given the significant role of stress in psychopathology during childhood and adolescence, it is somewhat axiomatic that the ways that individuals attempt to cope with stress in their lives is a potential source of resilience. The most widely cited definition of coping is that of Lazarus and Folkman (1984), which is derived from their appraisal-based model of stress and coping. Lazarus and Folkman define coping as ‘‘constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person’’ (p. 141). Coping is viewed as an ongoing dynamic process that changes in response to the changing demands of a stressful encounter or event.

Furthermore, coping is conceptualized as purposeful responses that are directed toward resolving the stressful relationship between the self and the environment (problem-focused coping) or toward palliating negative emotions that arise as a result of stress (emotion-focused coping).

Perspectives on coping that are more explicitly concerned with childhood and adolescence include those outlined by Weisz and colleagues (Rudolph, Dennig, &

Weisz, 1995; Weisz, McCabe, & Dennig, 1994), Skinner and colleagues (e.g., Skinner

& Zimmer-Gembeck, 2007), and Eisenberg and colleagues (e.g., Eisenberg, Fabes,

& Guthrie, 1997; see Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001, for a review of these perspectives). A central issue in defining coping during adolescence (and childhood) is whether coping includes all responses to stress, particularly both controlled and automatic responses. Skinner’s (1995) original defi-nition of coping included both volitional and involuntary or automatic responses to manage threats to competence, autonomy, and relatedness, and although Eisenberg et al. (1997) acknowledge that coping and emotional regulation are processes that typically involve effort, coping is not always conscious and intentional.

Consensus has slowly emerged regarding the nature and dimensions or types of coping in childhood and adolescence. Skinner, Edge, Altman, and Sherwood (2003) identified more than 400 categories or types of coping that have been represented in research on this construct. Previous categories include problem-versus emotion-focused coping as described earlier, approach problem-versus avoidance, and active versus passive coping. Although the problem- and emotion-focused distinction may be important historically, an alternative three-factor control-based model of coping (Compas et al., 2001, in press; Connor-Smith, Compas, Thomsen,

Wadsworth, & Saltzman, 2000; Rudolph et al., 1995) has been validated successfully in several samples. Within this model, responses to stress are first distinguished along the dimension of automatic versus controlled processes. Coping responses are considered controlled, volitional efforts to regulate cognition, behavior, emotion, and physiological processes, as well as aspects of the environment in response to stress. Coping responses are further distinguished as primary control engagement (problem solving, emotional modulation, emotional expression), secondary control engagement (acceptance, cognitive reappraisal, positive thinking, distraction), or disengagement (cognitive and behavioral avoidance, denial, wishful thinking). This model has been supported in at least seven confirmatory factor analytic studies with children, adolescents, and adults coping with a wide range of stressors (e.g., peer stressors, war-related stressors, family stressors, economic stressors, chronic pain, cancer), from diverse socioeconomic and cultural backgrounds and international samples (e.g., Euro-American, Native American Indian, Spanish, Bosnian, Chinese), using multiple informants (Benson et al., 2011; Compas et al., 2006a; Compas et al., 2006b; Connor-Smith et al., 2000; Connor-Smith & Calvete, 2004; Wadsworth, Reickmann, Benson, & Compas, 2004; Yao et al., 2010).

NEW DIRECTIONS IN RESEARCH ON COPING

In addition to recent progress in research on coping in childhood and adolescence, processes of adaptation to stress are also reflected in recent research on the closely related construct of emotion regulation (Chapter 11). In spite of considerable overlap in the conceptualization and measurement of coping and emotion regulation, the literatures on these two constructs have developed quite independently, with the former largely preceding the latter (Compas, 2009). We see this as problematic, as a richer understanding of adaptation to stress will result from an integration of these lines of work. To that end, we now consider recent work on emotion regulation and coping. To examine processes involved in the regulation of emotion, it is first necessary to define what is meant by the terms emotion and emotion regulation.

Emotion is broadly defined as a person-environment interaction requiring attention that involves considerable personal significance and evokes a complex, continuously evolving response (Gross & Thompson, 2007). The environment may include external stimuli or internal representations involving thoughts and memories. Emotions have historically been divided into primary emotions (including anger, sadness, fear, happiness, disgust, surprise) and secondary emotions (e.g., shame, pride). Whereas primary emotions are direct responses to environmental stimuli and constitute a biological preparation for appraisal and response (Izard, 2002), secondary emotions occur as a result of primary emotions. Seminal work by Zajonc (1980, p. 151) posited the primacy of emotions in human thought and behavior patterns, stating that,

‘‘preferences need no inferences.’’ That is, personal beliefs about one’s likes and dislikes are based in automatic affective responses and do not require higher-order cognitive processes.

A widely accepted definition of emotion-regulation has been offered by Thompson (1994): ‘‘The extrinsic and intrinsic processes responsible for monitoring, evaluating,

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and modifying emotional reactions, especially their intensive and temporal feature, to accomplish one’s goals’’ (pp. 27–28). This definition includes the set of processes that allow for the increase, decrease, or maintenance of an affective state (Davidson, Putnam, & Larson, 2000). Although some behaviors may be performed to alter the emotions of others, emotion regulation generally refers to processes focused on the self and one’s own emotions. This definition includes the child and her or his social context as part of the regulatory process, both of which are of central importance in the development of emotion-regulation. Young children rely on parents and other adult caregivers to soothe and manage negative emotions, but during adolescence emotion-regulation may become more internal and autonomous. Thompson also points to the multiple facets of emotion-regulation that range from recognizing and understanding one’s emotions to taking steps to try to alter or modify their intensity and duration. Cole, Martin, and Dennis (2004; Chapter 11) further distinguish between two types of regulation—emotion as regulating and emotion as regulated. In the former, changes are observed in other domains (e.g., behavior or cognition) as a result of an emotion, whereas the latter refers to changes in the valence, intensity, or time course of an emotion that may occur within an individual or between individuals.

A multistage process model of the generation and modulation of emotions maintains that regulation can occur during several sequential steps in the generation of an emotion (Gross, 1998). At any of these stages, emotion regulation can be an automatic or controlled process (Gross & Thompson, 2007). Conscious, controlled strategies of emotion regulation have received the greatest attention in research.

These strategies require effort, and studies have shown that individuals are able to accurately report their own use of such effortful strategies in daily functioning (Connor-Smith et al., 2000; Connor-Smith & Compas, 2004). However, emotion regulation can also be automatic, and an individual may be unaware when such a strategy is employed (Masters, 1991; Mauss, Bunge, & Gross, 2007). An example of an automatic emotion-regulation strategy is the unconscious diversion of attention away from a negative stimulus. Further, emotion regulation includes both the up-regulation of positive emotions and the down-regulation of negative emotions (Gross, 1998). However, research by Gross and colleagues indicates that adolescents and young adults down-regulate negative emotions more often than they up-regulate positive ones (Gross & Thompson, 2007).

Although coping and emotion regulation overlap significantly in that both involve volitional efforts to reduce negative emotions associated with stressful experiences and circumstances, there have traditionally been some differences between these two constructs. Whereas coping typically refers to the down-regulation of a negative emotion, emotion regulation also includes the maintenance or augmentation of a positive emotion (Eisenberg et al., 1997). However, recent conceptualizations of coping have included the regulation of both negative and positive emotions in response to stress (Folkman & Moskowitz, 2000). For example, Austenfeld and Stanton (2004) have used the term emotional approach coping, to describe coping that involves acknowledging, expressing, and understanding emotions in response to stressors. Their conceptualization of emotional approach coping provides an

alternative to emotion-focused coping, which has been previously associated with poorer psychological and health-related outcomes. In addition, Jaser et al. (2011) found that secondary control coping is related to both the down-regulation of negative affect (sadness) and up-regulation of positive affect.

Several strategies have been discussed widely across the literatures as means of both affect regulation and coping with stress. For example, cognitive restructuring, as viewed in the context of coping as efforts to actively reinterpret stressful or negative events in more neutral or positive terms, overlaps heavily with the cognitive reappraisal form of emotion regulation. Implementation of this strategy is linked to reduced physiological and emotional arousal when an individual is presented with an emotional stimulus (e.g., Oschner, Bunge, Gross, & Gabrieli, 2002), and it is used clinically as part of evidence-based cognitive behavioral therapy treatments for several disorders (e.g., Stark, Krumholz, Ridley, & Hamilton, 2009).

Although taking actions to act directly on a source of stress in the environment, including addressing or solving the problem eliciting negative affect, has historically been unique to the construct of coping (Compas et al., 2009; Compas, Connor, Thomsen, Saltzman, & Wadsworth, 1999), some recent work has posited problem solving as a means of emotion regulation as well (Nolen-Hoeksema, in press). The inclusion of problem solving as a form of emotion regulation begs the question of whether the act of problem solving is actually undertaken to specifically regulate negative emotions. The need to regulate negative emotion before attempting to address a problem in order to more adeptly engage with the stressor and the use of problem solving strategies to achieve goals other than the regulation of one’s emotions are important processes to consider.

In contrast to strategies such as cognitive reappraisal and problem solving, often considered adaptive means of coping with stress, other less adaptive strategies and responses to stress such as rumination and the suppression of both negative cog-nitions and emotions have been linked to emotion dysregulation. Rumination, the repetitive deliberation of the cause, experience, and consequence of negative emo-tions, increases negative affect and may actually hinder problem solving abilities (Aldo, Nolen-Hoeksema, & Schweizer, 2010). Furthermore, according to Roemer and Borkovec (1994), active attempts to suppress a negative thought may result in the formation of an association between the thought and a negative emotion.

The intrusive qualities of the thought may be increased due to the relationship with negative emotionality, and increased thought intrusion may lead to height-ened attempts to suppress the thought. As effective suppression requires additional distraction through neutral or positive stimuli (e.g., Wegner & Erber, 1992), suppres-sion of negative thoughts may be significantly less effective as a coping mechanism, especially in depressed or chronically stressed populations. In several studies (Aldo et al., 2010), the use of such maladaptive strategies was significantly more strongly related to development of symptoms of psychopathology, including depression, anxiety, and eating disorders, than the use of adaptive strategies was related to more positive outcomes.

Deficits in the use of adaptive strategies in response to stress have been tied to sig-nificant emotional and behavioral problems including mood and anxiety disorders

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in adults (e.g., Campbell-Sills & Barlow, 2007), as well as depressive symptoms and disorders in children and adolescents (Compas et al., 2010). Deficits in emotion regulation specifically in the presence of stress have been tied to many DSM Axis I diagnoses in adults, including mood, anxiety, eating, and substance use disorders, as well as Axis II personality disorders (e.g., Campbell-Sills & Barlow, 2007; Gross &

Levenson, 1997; Miller, Rathus, & Linehan, 2007). In addition, a deficiency in regu-lating negative emotions has been linked to depressive symptoms and disorders in children and adolescents (Compas, Jaser, & Benson, 2009). The biological and psy-chological mechanisms underlying these relationships continue to remain unclear, however. For example, several possibilities have emerged to explain the role of emo-tion regulaemo-tion deficits in major depressive disorder (Rottenberg, Gross, & Gotlib, 2005). One hypothesis links depression to a decreased ability to experience positive emotions. This notion stems from a series of past findings describing decreased positive affect in individuals suffering from major depressive disorder (Watson &

Tellegen, 1985). Research has expanded on this view by examining the underlying neurobiology of this phenomenon. For example, Davidson and Tomarken (1989) found evidence for frontal laterality in the experience of positive and negative affect. Specifically, left anterior frontal regions have been associated with approach behaviors, and Henriques and Davidson (1991) found that hypoactivation in left anterior frontal regions in depressed individuals.

RISK AND RESILIENCE: EXAMPLES FROM RESEARCH ON STRESS, COPING, AND DEPRESSION

To further exemplify stress and coping processes in child and adolescent risk and resilience for psychopathology, we focus here on examples from research on the development of depression during childhood and adolescence. Depression provides a useful example of risk and resilience because it increases dramatically in preva-lence over the course of childhood and adolescence and there is now a substantial body of work identifying stress as a significant source of risk, stress reactivity as a potential vulnerability factor, and coping as a source of resilience. Specifically, children and adolescents whose parents experience one or more episodes of depres-sion are exposed to a significant source of risk for depresdepres-sion and other mental health problems.

The high prevalence of depression in the general population represents a sig-nificant mental health problem in the United States (see Chapter 17). As reported in the National Comorbidity Survey Replication, Kessler et al. (2003) found the lifetime prevalence of major depressive disorder to be 16.9%. It is expected that 32 to 35 million adults in the United States will experience an episode of depression over the course of their lifetime. Depression increases significantly from childhood to adolescence. Longitudinal studies suggest that middle adolescence (age 15 to 16 years old) is the peak time for the onset of major depression (e.g., Hankin et al., 1998). Depression is also a highly recurrent disorder, as more than 80% of depressed individuals experience more than one episode and about 50% of those who undergo an episode experience a recurrence within 2 years of recovery (Belsher & Costello,