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Master thesis
The chicken and egg dilemma:
Testing the longitudinal relationship between self-esteem
and depression in adolescents within a forensic youth
psychiatric and orthopsychiatry clinic
Naam: Sari Roovers
Studentnummer: 11266627 begeleider GGzE: I.L Bongers begeleider UvA: M.J Noom Datum: 25-07-2017
2 Abstract
In previous research a link between depression and self-esteem was found among youth, but the direction of this relationship remained unclear. Especially among forensic youth, little attention was paid to these internalizing problems and their interrelationship. In this
longitudinal research the direction of the relationship between self-esteem and depression was investigated among adolescents within a clinic for youth forensic psychiatry and
orthopsychiatry in the Netherlands. This was done by testing the both the scar hypothesis and vulnerability model. The scar hypothesis states that depression predict future decreases in self-esteem, whereas the vulnerability model states that decreases in self-esteem indicate a future depressive period. Adolescents (n=272) were assessed every 6 months over a 2 year period using the Youth Self Report (YSR) and Self-Perception Profile of Adolescents (SPPA). Data were analyzed using a four-wave cross-lagged panel design. The results
indicated that both depression and self-esteem are stable over time. Moreover, depression was negatively correlated with self-esteem on every measure moment and over time. In contrast with previous findings, these results supported the scar hypothesis, but not the vulnerability model. The specific characteristics and developmental trajectories of forensic adolescents might explain these differences in results with previous studies. All in all, there can be concluded that for forensic adolescents internalizing problems such as depression and self-esteem are important, and that self-self-esteem can be influenced when focusing on earlier periods of depression. Future research should use different research characteristics, and check for differences between male and female when investigating this relationship.
3 Samenvatting
In eerder onderzoek is er een relatie gevonden tussen depressie en zelfvertrouwen bij adolescenten, maar de richting van dit verband was vooralsnog niet duidelijk. Vooral onder forensische adolescenten bestond er nog een beperkte aandacht voor deze internaliserende problematiek en hun onderlinge relatie. In huidig onderzoek is het longitudinale verband tussen zelfvertrouwen en depressie onderzocht onder een forensische doelgroep in Nederland. Dit is gedaan aan de hand van de scar hypothese en het vulnerability model. De scar
hypothese gaat er van uit dat een depressieve periode leidt tot toekomstig vermindert
zelfvertrouwen, terwijl het vulnerability model verklaard dat een vermindert zelfvertrouwen leidt tot toekomstige depressieve periodes. Bij forensische adolescenten (n=272) is elke 6 maanden voor een periode van twee jaar de Youth Self-Report (YSR) en Competentie Belevingschaal voor Adolescenten (CBSA) afgenomen. Deze data zijn geanalyseerd door middel van het cross-lagged panel design. De resultaten laten zien dat depressie en
zelfvertrouwen over de tijd heen stabiel zijn. Daarnaast was depressie negatief gecorreleerd met zelfvertrouwen, zowel op elk meetmoment als over de tijd heen. In tegenstelling met eerdere bevindingen ondersteunen deze resultaten de scar hypothese, maar niet het
vulnerability model. De specifieke kenmerken en ontwikkelingstrajecten van de forensische adolescenten verklaren mogelijk deze verschillen in resultaat. Toekomstig onderzoek zou kunnen kijken naar studies die gebruik maken van andere onderzoeks-kenmerken, en zou kunnen kijken naar het verschil tussen jongens en meisjes.
4 Introduction
Depression and self-esteem are mutually related to each other, but in previous research the direction of this relationship remains unclear (Orth, Robins, & Meier, 2009; Orth, Robins, & Roberts, 2008; Sowislo, & Orth, 2013). The question is raised whether depression is caused by a decreased self-esteem, or whether a decreased self-esteem is caused by depression (Orth, et al., 2008; Sowislo & Orth, 2013). The direction of this relationship is most often tested in non-clinical samples of adolescents or adults (Nijhof, Dam, Veerman, Engels, & Scholte, 2010; Sowislo & Orth, 2013). However, high rates of internalizing problems are also found in clinical samples of forensic adolescents (Carswell, Maughan, Davis, Davenport, & Goddard, 2004). The present study takes this knowledge further and examines the direction of the relationship between self-esteem and depression in a sample of adolescents within a clinic for forensic youth psychiatry and orthopsychiatry.
Depression is defined in the DSM-IV (American Psychiatric Association, 2014) as a cluster of symptoms with a minimum duration of two weeks of associated impairment, such as a depressed mood during the day, losing interest in activities and an increased susceptibility to become fatigue. Depression can be seen as a worldwide health problem, and especially adolescents are at risk for experiencing periods of depression (Butler, Hokanson, & Flynn, 1994; Rohde, Lewinsohn, Klein, Seeley, & Gau, 2013; Thapar, Collishaw, Pine, & Thapar, 2012; Trzesniewski, et al., 2006). During adolescence, individuals are more vulnerable for depression due to social and biological factors, such as insecurity about their appearance (Shapero, McClung, Bangasser, Abramson, & Alloy, 2017). Moreover, individuals who experience periods of depression in adolescence are four to five times more likely to
experience depressive periods in adulthood (Pine, Cohen, & Brook, 1999). This increases the risk of depression becoming a chronic problem for people of different ages (Thapar et al., 2012). Furthermore, depression is associated with lifelong consequences, such as
unreasonable feelings of remorse, helpless behavior, and guilt, which decreases self-esteem (Pine et al.,1999; Sampson, & Mrazek, 2001; Steiger, Fend, & Allemand, 2015; Thapar et al., 2012).
Depression is often related to a low level of self-esteem (Sowislo, & Orth, 2013; Steiger, Allemand, Robins, & Fend, 2014). Self-esteem is a state and can become a trait, defined as an individual’s subjective emotional evaluation of his worth as a person and their attitude towards themselves (Auerbach, Abela, Moon-Ho Ringo, McWhinnie, & Czajkowska, 2010; Lakey, 1988; Rosenberg, 1965; Steiger, et al., 2014). Self-esteem should be
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we are and what kind of characteristics we have (Hattie, 2014). During adolescence individuals generally show periods of decreased self-esteem due to general developmental patterns (Orth & Robins, 2014). A long-term decreased self-esteem is associated with future difficulties, such as negative coping-styles, beliefs and attributions, which make youth more vulnerable for experiencing depressive moods (Aucherbach, et al., 2010; Trzesniewski et al., 2006; Steiger et al., 2015).
A relationship between depression and self-esteem has been suggested in previous research, but different studies show different perspectives (Aucherbach, 2010; Orth, et al., 2008; Steiger et al., 2015). First, there is the perspective of negative emotionality as the common underlying factor for both concepts (e.g. Orth et al., 2008). Second, there is the perspective of the scar hypothesis, suggesting that a period of depression causes a decrease in self-esteem (e.g. Steiger et al., 2015). Third, there is the perspective of the vulnerability model, suggesting that a decreased self-esteem predicts depressive periods (e.g Kuster, et al., 2012).
In accordance with the first perspective, the possibility of negative emotionality as the common underlying factor for depression and self-esteem is considered. Studies in line with this perspective show that depression and self-esteem share large proportions of variance, and therefore could be seen as the opposite endpoints of negative emotionality (Hankin,
Lakdawalla, Carter, Abela, & Adams, 2007; Neiss, Stevenson, Legrand, Iacono, & Sedikides, 2009). However, Research of Orth et al. (2008) concluded there is no shared factor such as negative emotionality, because the stability of self-esteem was much larger than the stability of depression over time. This indicates both concepts are at least partially driven by different underlying causal dynamics. Moreover, both concepts didn’t share the same biological
background because they had unique genetic effects. Self-esteem is therefore at least partially distinct in genetic influences from depression, and cannot be seen as the opposite endpoints of negative emotionality (Orth, et al., 2008). Another research showed that studies investigating depression and self-esteem had inconsistent correlational results, which is not possible if they are the endpoints of the same underlying variable (Watson, Suls, & Haig, 2002). Altogether, there can be said that self-esteem and depression are two dependent concepts, but are not completely sharing the same underlying factor.
Research in line with the second and third perspective, the scar hypothesis and vulnerability model, assume both concepts are dependent variables without completely
sharing an underlying factor. Both perspectives show the possibility of influencing each other, but the direction of the relationship is different (Beck, 1967; Leeuwis, Koot, Creemers, & van
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Lier, 2015; Orth et al., 2009; Trzesniewski, et al., 2006). The scar hypothesis (Lewinsohn, Steinmetz, Larson, & Franklin, 1981) states that low self-esteem is a consequence of a period of depression. A period of depression lowers your self-esteem, and makes you more
susceptible for another depressive period over time (Kuster, Orth, & Meier, 2012; Orth, et al., 2008; Steiger et al., 2015). A few longitudinal studies found support for the scar hypothesis. For example, Steiger et al. (2015) tested the scar hypothesis in a non-clinical German sample during adolescence and young adulthood. They found small effect sizes supporting the scar hypothesis. Another study by Shahar and Henrich (2010) found small effect sizes supporting the scar hypothesis in a two wave study in young adolescents aged 12 up to 14 years. They suggested that the effect of the scar hypothesis was more evident when using an adolescent sample, than when an adult sample was used. A recent meta-analysis viewed 77 longitudinal studies that assessed the relationship between depression and self-esteem through the scar hypothesis and the vulnerability model. They included studies that differed substantially with respect to research characteristics, but no study used clinical youth sample. In this meta-analysis a few studies indeed supported the scar-hypothesis with small effect sizes. However, there was stronger evidence supporting the vulnerability model. (Sowislo, & Orth, 2013).
Contrary to the scar hypothesis, the vulnerability model states that there is a decrease in self-esteem prior to a period of depression. This decreased self-esteem can be seen as a predictor or cause for the development and the increase of a depressive period (Auerbach,et al., 2010; Orth, et al., 2008). When self-esteem becomes lower and less stable, it will make individuals more vulnerable for negative associations about themselves. Over time, this results in the presence of more and extreme depressive periods (Steiger et al., 2015). An extensive amount of studies found evidence supporting the vulnerability model, using a non-clinical sample of adolescents in different countries (e.g. Auerbach, et al., 2010; Kuster, et al., 2012; Orth, et al., 2008; Rieger, Göllner, Trautwein, & Roberts, 2016; Van Tuijl, De Jong, Sportel, De Hullu, & Nauta, 2014). For example, a longitudinal study in self-reported depression and self-esteem among Mexican origin adolescents reported strong evidence for the vulnerability model (Orth, Robins, Widaman, & Conger, 2014). These results were supported in one study assessing youth in their pre-adolescence (Orth, & Robins, 2014).
The importance of depression and self-esteem in a clinical sample has been shown in research of Neff (2011), who claims that self-esteem underlies almost all psychological processes. These psychological processes can also be influenced by depression (Vermeiren, Jespers, & Moffitt, 2006). A decreased self-esteem and periods of depression are generally increasing during adolescence, and are related to severe impaired functioning later in life
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(Gotlib & Hammen, 2009; Graber, & Sontag, 2004). Despite the importance of internalizing problems during adolescence,the importance of investigating internalizing problems among a forensic adolescents is not often mentioned (Nijhof, et al., 2010; Vermaes, Konijn, Jambroes, & Nijhof, 2014). Previous studies among forensic adolescents mostly focus on externalizing problems, without taking into account their comorbidity with internalizing problems (Imbach, Aebi, Metzke, Bessler, & Steinhausen, 2013; Vermeiren, et al., 2006). For example, low self-esteem might be a risk-factor for developing externalizing problems, and depression can be a risk-factor for substance abuse and delinquency among adolescents (Cairns, Yap, Pilkington, & Jorm, 2014; Donnellan, Trzesniewski, Robins, Moffitt, & Caspi, 2005; Kofler, et al., 2011). Moreover, research showed that when common externalizing problems are excluded, forensic youth still shows high rates of internalizing problems to treat, including a decreased self-esteem and depression (Carswell, et al., 2004; Imbach et al., 2013).
As mentioned above, studies supporting both the scar hypothesis and the vulnerability model were found, with more evidence for the vulnerability model (Aucherbach, et al., 2010; Beck, 1967; Kuster, et al., 2012; Orth et al., 2009; Steiger et al., 2015). Despite the
importance of internalizing problems and their interrelationship among forensic adolescents, the direction of the relationship between depression and self-esteem has not been investigated before in this population (Sowislo, & Orth, 2013; Thapar et al., 2012). The present research takes this shortcoming into account and investigates the direction of the relationship between self-esteem and depression among adolescents within a clinic for youth forensic psychiatry and orthopsychiatry. In line with previous research it is expected that decreases in self-esteem are a strong predictor for increases in depression, as mentioned in the vulnerability model (Auerbach,et al., 2010; Kusters, et al., 2012; Orth, et al., 2008; Rieger, et al., 2016; Van Tuijl et al., 2014). Furthermore, it is expected that there will only be a small indication for a depressive period as a predictor for decreases in self-esteem, as indicated in the scar
hypothesis (Orth et al., 2008; Shahar & Henrich, 2010; Steiger et al., 2015; Van Tuijl et al., 2014).
Method
Data were obtained in a clinic for youth forensic psychiatry and orthopsychiatry. This clinic was part of a mental health care institution (GGzE) in the Netherlands. This clinic offers psychological and psychiatric assessment and treatment to forensic youth.
Participants
The participants were all male adolescents (n= 272) admitted to the Catamaran, a clinic for youth forensic psychiatry and orthopsychiatry. They were selected using the selection criteria:
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(1) participants have been clients from GGzE between January 2005 and November 2016 (2) participants have given permission to use their data for research purpose (3) participants filled in both the YSR and SPPA at least once. Females were also excluded from this study, because the few females that have been admitted to this clinic might not be representative for all female forensic youth. At admission, the participants were aged between 13 and 23 years (M=16.87, SD=1.863) (See Table 1). All participants have given permission to use their data for research purpose, and filled in both the YSR and SPPA at least once.
Table 1. Background characteristics and comparisons between included sample and excluded sample. Included sample (n = 272) Excluded sample (n = 102) χ2 or t statistic Judicial status Criminal law Civil law Voluntary 128 (48.1%) 103 (38.7%) 35 (13.2%) 38 (52.8%) 27 (37.5%) 7 (9.7%) χ2 (19)= 20.023
Mean age at admission (SD) 16.87 (1.85) 17.28 (1.61) t (372)= 2.662
Intelligence (IQ Level) 95.04 (12.17) 89.18 (11.162) t (279) = 2.115
DSM-IV Classification ASD ADHD DRB RAD MR SRD PD MD AD 111 (40.8%) 65 (23.9%) 129 (97.4%) 34 (12.5%) 16 (5.9%) 66 (24.3%) 22 (8.1%) 20 (7.4%) 25 (9.2%) 44 (43.1%) 58 (56.9%) 32 (31.4%) 11 (10.8%) 8 (7.8%) 21 (20.6%) 8 (7.8%) 6 (5.9%) 4 (3.9%) χ2 (1)= .21 χ2 (1)= .82 χ2 (1)= 1.27 χ2 (1)= .93 χ2 (1)= .537 χ2 (1)= 2.309 χ2 (1)= .551 χ2 (1)= .049 χ2 (1)= 1.083
Note: * < 0.001, ** p < 0.05. IV-TR = Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR); ASD = autism spectrum disorder; ADHD = attention deficit hyperactivity disorder; DBD = disruptive behavior disorder; RAD = reactive attachment disorder; MR = mental retardation; SRD = substance related disorder; PD = psychotic disorder; MD = mood disorder; AD = anxiety disorder
Instruments
Every six months, two self-report questionnaires, the Youth Self Report (YSR) (Achenbach, 1991) and Self Perception Profile of Adolescents (SPPA) (Harter, 1988), were filled out by the adolescents. The Internalizing subscale of the YSR was used to measure depression,
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whereas self-esteem was measured using the subscale Global feeling of self-worth of the SPPA.
Youth Self Report. The Youth Self Report (YSR) (Achenbach, 1991) measures emotional- and behavioral problems. It is a self-report questionnaire conducted for adolescents ranging between the age of 11 and 18. The YSR exists of 112 items in eight subscales that are used to measure the broad band scales Internalizing and Externalizing problem behavior. In this study only the broad band scale Internalizing was used to test for depressive symptoms. The Internalizing scale consists of the subscales Anxious/depressive, Withdrawn/depressive, and Somatic complaints. All items are scored with a Likert scale using (0) not true for the last six months, (1) sometimes true for the last six months (2) very often or often true in the last six months (NJI, 2006). The psychometric qualities of the YSR for the broad band scales are good (Achenbach & Rescorla, 2001; Verhulst, Ende, & Koot, 1997). In earlier research the internalizing problem scale has a high degree of internal consistency (α = .91) (Ivanova et al., 2007).
Self-Perception Profile of Adolescents. The Self-Perception Profile of Adolescents (SPPA) (Harter, 1988) is a 45-item self-report questionnaire used to measure adolescents, aged 12-18, self-perception on different areas of life over the past six months. There are 7 sub-scales: Scholastic competence, Social competence, Athletic competence, Physical appearance, Behavioral conduct, Close friendship and Global feeling of self-worth. In the present study, only the subscale Global feeling of self-worth was used. The subscale Global feeling of self-worth measures individuals global evaluation and appreciation of themselves. A lower score on a subscale of the SPPA indicates a lower self-esteem (Barendregt, Van der Laan, Bongers, & Van Nieuwenhuizen, 2016). A percentile score of ≤ 15 is considered as being a (sub)clinical score (Harter, 2016). A two-choices response format is used measuring adolescents experience on two opposing propositions with the options (1) really true for me (2) sort of true for me. This choice will lead to a score on an item with a score of 1 indicating the lowest perceived competence or adequacy, and a score of 4 reflecting the highest level of competence or adequacy. The psychometric qualities of the SPPA are good (Thomson & Zand, 2002). For the subscale Global feeling of self-worth there was both high internal consistency (α=0.72) and a good construct validity (α= 0.70) (Treffers et al., 2002).
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Table 2. Characteristics included sample for the four time waves.
Time waves Included sample (n = 272)
Depression mean (SD) Time 1 Time 2 Time 3 Time 4 Self-esteem mean (SD) Time 1 Time 2 Time 3 Time 4 n Time 1 Time 2 Time 3 Time 4 12.0 (8.9) 12.7 (9.7) 13.2 (10.4) 13.1 (9.7) 14.6 (3.7) 14.9 (3.4) 14.9 (3.4) 15.0 (3.9) 201 147 84 51
Note: Depression is measured using the self-report questionnaire Youth Self Report (YSR). Self-esteem is measured using the self-report questionnaire Self-Perception Profile of Adolescents (SPPA).
Procedure
The participants were selected from an existing database of GGzE. The data were obtained through a system of Routine Outcome Monitoring (ROM), consisting of both self-report questionnaires YSR and SPPA. ROM is used in treatment to assess the current health and progress made during the last six months (De Beurs, & Emmelkamp, 2013). Anonymity was guaranteed by coding the data, and the respondents were given a passive informed consent at the beginning of their treatment at GGzE. Data of participants who decided not to participate in any form of research were removed from the database. Ethical permission was granted by the ethical commission from the University of Amsterdam (nr: 2017-CDE-8158).
File information was used to obtain background characteristics. These characteristics were used to check the selection criteria and for peforming an attrition analysis (See Table 1). The selected individuals (n = 272) were asked to fill in the questionnaires every 6 months over a period of two years after their admission. Data were available for 201 individuals at Time 1, 147 individuals at Time 2, 84 individuals at Time 3, and 51 individuals at Time 4 (See table 2). To control for the influence of attrition, differences in the variables self-esteem and depression are tested between participants who completed the Time 4 assessment and
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participants who dropped out of the study before the time 4 assessment. For both variables, no significant differences emerged. Possible reasons for participants to drop out were refusing to fill in the questionnaires, not being able to fill in the questionnaires due to health reasons, or because their treatment at GGzE was finished.
Statistical analyses
Data were analyzed using descriptive analyses in SPSS 19.0 and a cross-lagged panel analysis in Mplus 7.3, measuring the longitudinal relationship between depression and self-esteem (Kenny,1975). A cross-lagged regression analysis gives insight into (1) the correlation ( r ) between depression and self-esteem (2) the stability coefficients (β) measuring the stability of depression and self-esteem from Time 1 to Time 4 (3) and the cross-lagged coefficients (γ) (Barendregt et al., 2016). An attrition analysis was computed to compare the included and excluded sample on background characteristics (See Table 1). Independent samples t-tests were used to compare continuous variables, whereas chi-square-tests were used to compare categorical variables
For testing the model fit of the cross-lagged model, a Tucker-Lewis Index (TLI), a Comparative Fit Index (CFI) and a Root Mean Square Error of Approximation (RMSEA) were conducted. A good fit for the cross-lagged model was shown with : TLI > .90, CFI > .90, and RMSEA < .05 (Hu & Bentler, 1999). Next, the models were compared with each other by means of a chi-square difference test. This was done to determine whether the addition or deletion of additional constraints in the model was a significant improvement or deterioration of the models (Werner, & Schermelleh-Engel, 2010). When comparing models, the model with the statistically significant lower chi-square values was superior (Shahar, & Davidson, 2003). A non-significant chi-square difference (p >.001) indicated that the more parsimonious model with more degrees of freedom was superior.
Four models were executed. First, the model (M1) in which all cross-lagged structural
paths existed was tested from time 1 depression to time 2 self-esteem, from time 1 self-esteem to time 2 depression, from time 2 depression to time 3 self-esteem, from time 2 self-esteem to time 3 depression, and from time 3 depression to time 4 esteem, and from time 3 self-esteem to time 4 depression. This model tested for cross lagged effects of both the
vulnerability model and the scar hypothesis. Second, the model (M2) with cross-lagged
structural paths from Time 1 self-esteem to Time 2 depression, from Time 2 self-esteem to Time 3 depression, and from time 3 self-esteem to time 4 depression was executed to test for the vulnerability model. Third, the model (M3) with cross-lagged structural paths from time 1
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depression to time 2 self-esteem, from time 2 depression to time 3 self-esteem and from time 3 depression to time 4 self-esteem was executed to test for the scar hypothesis. Finally, a model (M4) with no cross-lagged structural paths was executed to test if there were no effects
over time.
Results Group characteristics
The background characteristics of both the included and excluded sample are presented in Table 1. The mean age of the included sample was 16.87 years (SD = 1.85, Range =13-23) at admission. Mean level of intelligence was IQ = 95.04 (SD =12.17). In the included sample Disruptive Behavior Disorder (DRB) was the most common psychiatric disorder (97.4%) and Autism Spectrum Disorder (ASD) was the second most common psychiatric disorder
(40.8%). More than half of the included sample had a Dutch nationality (57.7%).
Furthermore, of the included sample 47.1% was admitted under criminal law, 37.9% under civil law, and 12,9% was admitted on voluntary bases.
Attrition analysis
The included sample was compared with the excluded sample on different background characteristics (See Table 1). The included sample did only differ significantly on Mean age at admission, whereas the included sample was admitted to the clinic at a later age than the excluded sample. There were no differences found on Judicial status, Age at admission, Ethnicity, DSM classification and Level of intelligence. This indicates there is an selection bias, but for most background characteristics the included sample can be seen as a
representative group for the data.
Cross-lagged panel analysis
The four cross-lagged panel models were tested and compared with each other in Table 3. At first, the models were tested for a good model fit. A good model fit indicates there is a relative good fit between the hypothesized model and the observed data. Only for M1 and M3 a good
model fit was found, with TLI > .95 CFI > .90 RMSEA < .05 (Hu & Bentler, 1999). Second, all models were compared to each other, using a chi-square difference test to see whether deletion of paths would indicate a better model. A non-significant effect (p > .001) indicated that the less parsimonious model a better representation compared to the more parsimonious model. Only the chi-square difference test between the more parsimonious model (M1) and
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the less parsimonious model (M3) was non-significant (M1 – M3 = Δχ2 (3) = 9.162, p =.027).
Therefore, M3 showed the best improvement of the model (χ2 = 24.89, TLI = .95, CFI = .98,
and RMSEA = .05) and therefore will be further described.
Table 3. Goodness of fit indices and chi-square difference tests of nested structural models of self-esteem and depression.
Model χ2 Df TLI CFI RMSEA [CI] Models Δχ2 Δdf
M1 15.73 12 .99 .99 .03 [.00-.08] M2 36.11 15 .88 .92 .07 [.04-.10] M1 – M2 20.382** 3 M3 M4 24.89 50.44 15 18 .95 .90 .98 .95 .05 [.00-.08] .08 [.05-.11] M1 – M3 M1 – M4 M2 – M4 M3 – M4 9.162* 24.706** 14.324*** 25.586** 3 6 3 3 Note: * < 0.05, ** p < 0.001, p < 0.005 *** . M1= all cross lagged paths; M2= self-esteem to depression; M3= depression to
self-esteem; M4 = No cross lagged paths; TLI = Tucker-Lewis Index; CFI = Comparative Fit Model; RMSEA = Root Mean
Square Error of Approximation.
Figure 1 shows the cross-lagged model for M3. In M3 significant stability coefficients
(β) were found for all measure moments for depression (Time 1 toTime 2: β = .684,Time 2 to Time 3: β= .756, Time 3 toTime 4:: β = .786) and self-esteem (Time 1 to Time 2: β =.419,
Time 2 toTime 3: β =.493, Time 3 to Time 4: β =.302). Also, significant correlations (r) were found within all measure moments between depression and self-esteem. That is, there is a negative correlation between depression and self-esteem at each wave, with time 1 (r = -.592, p <.001), time 2 (r = -.362, p <.001), time 3 (r = -.280, p <.001), and time 4 (r = -.253, p <.001). Furthermore, significant negative correlations between depression and self-esteem were found over time, with time 1 depression to time 2 self-esteem (γ = -.245 p <.001), time 2 depression to time 3 self-esteem (γ =-.288, p <.001), time 3 depression to time 4 self-esteem (γ = -.253, p < .001). In other words, this indicated that depression was a significant predictor for self-esteem over time.
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Figure 1. The cross-lagged regression model (M3) for depression and self-esteem.
Note: * < 0.05, ** p < 0.001 *** p < 0.005 . Model 3 characteristics: χ2 = 24.89 (15), p < .001, TLI = .902, CFI = .946, RMSEA = .081. The error variances and covariances are not shown in this model. The values are the standardized coefficients.
Discussion
In this longitudinal research the relationship between depression and self-esteem was investigated among adolescents within a clinic for youth forensic psychiatry and
orthopsychiatry in the Netherlands. The aim of the study was to provide knowledge about the direction of the relationship between depression and self-esteem, and to show the importance of these internalizing problems in a forensic sample of adolescents. By testing both the scar hypothesis and the vulnerability model, the direction of the relationship between depression and self-esteem will become more evident.
In contrast to previous findings, in this study the relationship between self-esteem and depression could not be explained by the vulnerability model (e.g. Auerbach, et al., 2010; Kusters, et al., 2012). In line with the expectations support is found for the scar hypothesis as an explanation for the relationship between self-esteem and depression (e.g. Orth et al., 2008; Shahar & Henrich, 2010). In other words, an increase in depression indicated a decrease in self-esteem 6 months later, but a decrease in self-esteem didn’t predict an increase in depression 6 months later. Nevertheless, a comprehensive amount of earlier studies did not find support for a depressive period as a predictor for decreases in self-esteem, or found a smaller indication for a depressive period leading to future decreases in self-esteem (e.g. Sowislo, & Orth, 2013).
The first possible explanation for these differences in results was the use of an adolescent sample in this research. Shahar and Henrich (2010) suggested that among
Time 1 Depression Time 1 Self-esteem Time 2 Depression Time 2 Self-esteem Time 3 Depression Time 3 Self-esteem Time 1 Depression Time 4 Self-esteem .684** .756** .786** *** .419** .493** .302** -. 5 9 2 ** -. 3 6 2 ** -. 2 8 0 ** -. 2 5 3 **
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adolescents the scar hypothesis is more evident, than among adults. They noted that this is caused by a lower stability of depression in earlier periods in life, because of variability and identity confusion. Shapero et al (2017) also validates that the adolescence is a period of vulnerability and insecurity, in which depressive periods are more evident. In addition, Pine et al. (1999) mention that when experiencing a period of depression in adolescence youth are four to five times more likely to experience a depressive period later in life.
Second, the use of a clinical sample of forensic adolescents, instead of a non-clinical sample, could account for differences in results with previous research. As mentioned before, during adolescence individuals generally show a decreased self-esteem and increases in depressive periods due to general developmental patterns (Gotlib & Hammen, 2009; Graber, & Sontag, 2004; Orth & Robins, 2014). It might be possible that clinical samples of
adolescents, and especially forensic adolescents, have different developmental patterns and therefore are not comparable to non-clinical developmental patterns (Loeber, & Dishion, 1983; Zimmerman, Phelps, & Lerner, 2008). For example, by the time forensic youth reach adolescence, most of them have already experienced multiple types of severe adversity and/or stressful events. These events might cause pathways to differ substantially from other adolescents, and concern the successive development of problematical behaviors (Loeber, & Burke, 2011). In the present study, the first decreases in self-esteem among the forensic sample might already appear during these early stressful events prior to their treatment period. If so, decreases in self-esteem are present and the vulnerability model is supported, but not measured in the present study.
Third, there could be some methodological explanations. The meta-analysis from Sowislo and Orth (2013) included studies that differed substantially with respect to research characteristics, such as time waves, measurement tools, and ages used for describing the adolescent period. It might be possible that when the direction of the relationship is measured in a different way, support for the vulnerability model is found. For example, both self-esteem and depression are in this research measured using report questionnaires. When self-report questionnaires are used, there is the risk of giving social desirable answers (van de Mortel, 2008). Depression was measured with the SPPA, a questionnaire that tries to control for social desirable answering (Harter, 2016). Self-esteem, on the other hand, was not measured with a self-report questionnaire that controls for social desirable answers. Maybe when self-esteem was measured with a similar type of questionnaire that controls for social desirable answers, different results would be found.
16 Practical implications
The current findings highlight the importance of focusing on internalizing problems in general, and to depression in specific, when working with forensic adolescents. Internalizing problems are common issues and often present in forensic adolescents (Carswell, et al., 2004; Imbach et al., 2013). Moreover, internalizing problems show high comorbidity with different externalizing problems, substance use, and delinquency (Cairns et al., 2014; Donnellan et al., 2005; Kofler, et al., 2011; Vermeiren, et al., 2006). Furthermore, a depressive period is related to future decreases in self-esteem, and focusing on depression among forensic adolescents also influences their self-esteem. In this way, more focusing on internalizing problems and effectively treating both concepts together can make treatment more adapted to the specific needs of the forensic adolescents (Venneman, & Evers, 2013).
Limitations
Although the present study had many advantages, such as the longitudinal design and the clinical sample of forensic adolescents, there are several limitations that must be noted when interpreting the results. First, the existence of depressive symptoms was measured through the subscale Internalizing of the YSR. This subscale does not only measures periods of
depression, but also reports the existence of other internalizing problems, such as anxiety, withdrawn behavior, and somatic complaints. By using this subscale, the relationship between self-esteem and all included internalizing problems was investigated, instead of the
relationship between depression and self-esteem. Research shows that anxiety, for example, could indeed account for part of the effect on self-esteem (Sowislo & Orth, 2013). This makes it possible that both depression and anxiety contribute to the effect of the scar hypothesis found in this research. Future research should use instruments that focus solely on depression. Second, both the YSR and SPPA are self-report questionnaires. Even when controlling for social desirable reports, there is a chance of over- or underreporting both depression and self-esteem (Hunt, Auriemma, & Cashaw, 2003; van de Mortel, 2008). Third, despite the fact that for most background characteristics the included sample can be seen as a representative group for the population, the included sample was substantially older than the excluded sample. This makes the included adolescents not fully representative for all forensic adolescents. Moreover, during the administering of the data, there were participants who didn’t complete the
questionnaires at all time moments. They refused to fill in the questionnaires, were not able to fill in the questionnaires due to health reasons, or their treatment was already finished. It is
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possible that the adolescents who filled in the questionnaires at all time moments are not representative for the adolescents who dropped out during the study. Because of the small number of participants that completed the questionnaires at the fourth measure moment, and the difference in age at admission between the included and excluded sample, the results should be interpreted with more caution when generalizing to the entire population of forensic adolescents. Fourth, the study was limited to boys within a clinic for youth forensic psychiatry and orthopsychiatry, and excluded girls from the same setting. It might be interesting to see if the same patterns are shown when studies investigate girls, especially because depression and self-esteem are more common in girls and that might requires specific treatment needs (Day, Zahn, & Tichavsky, 2015).
Conclusion
Despite those limitations, the current study provides first insight in the longitudinal
relationship between self-esteem and depression among male adolescents within a clinic for youth forensic psychiatry and orthopsychiatry. The results show evidence supporting the scar hypothesis over a two year period, but not for the vulnerability model. That is, depressive periods might contribute to a lower self-esteem in forensic adolescents over time. However, this chicken and egg dilemma is not completely solved yet. Future research should extend this knowledge by testing this relationship among forensic adolescents in research with different research characteristics, such as differences in time waves or types of questioning used. It might also be interesting to extend this research to forensic female adolescents to check for differences in the developmental paths of depression and self-esteem among forensic males and females.
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