Child Psychiatry Hum Dev (2017) 48:107–119
DOI 10.1007/s10578-016-0658-z
ORIGINAL ARTICLE
Antecedents of Treatment Resistant Depression in Children
Victimized by Peers
KL Healy1 • MR Sanders1
Published online: 8 June 2016
Ó Springer Science+Business Media New York 2016
Abstract Children victimized by peers are at increased
risk of ongoing depression. This study investigates treatment resistant depression in children victimized by peers,
following participation in a targeted cognitive behavioral
family intervention. The sample comprised 39 children
aged 6–12 years with elevated depression compared with a
general sample, prior to the intervention. Six months after
the intervention, 26 were no longer depressed and 13 were
still depressed. This study investigated the differentiation
of these two groups on the basis of parenting and child
factors. Children with treatment resistant depression were
discriminated from other children by lower levels of peer
support and facilitative parenting immediately after the
intervention. It was concluded that ongoing support from
parents and peers is needed to reduce the risk of ongoing
depression even if victimization has been reduced. Further
research could develop a comprehensive profile of children
at risk of depression following peer victimization.
Keywords Peer victimization Victim Treatment
resistant depression Family intervention Parenting
Introduction
Between 2 and 4 % of preadolescent children are formally
diagnosed with depression [1], with non-diagnostic
depressive symptoms at much higher levels [2]. Depressive
& KL Healy
k.healy@psy.uq.edu.au
1
Parenting and Family Support Centre, School of Psychology,
The University of Queensland, Brisbane, QLD 4072,
Australia
symptoms in childhood often persist into adolescence, and
beyond [3], which negatively impacts on children’s health,
school performance, relationships, and may lead to suicide
[4]. Victimization by peers at school is well-established as
a risk factor for children’s depression; it contributes
increasingly over time to depression [5, 6], which can
persist months after victimization has ceased [7]. Carefully
controlled studies show that peer victimization between the
ages of six to eight years increases the risk of depression
for many years afterwards, including well into adulthood
[8, 9]. Depression is both a consequence of victimization
and a risk factor for further victimization, which can result
in a recursive downward spiral of internalizing and victimization over time [10, 11]. Cognitive behavior therapy is
considered an effective treatment for mild to moderate
childhood depression [12, 13] and pharmacological treatment is utilized in more severe cases [14]. However,
treatment is not always effective. The term ‘treatment
resistant’ refers to the failure of an individual to improve
despite receiving treatment which is usually effective in
reducing symptoms [15]. This study examines depressive
symptoms in children following victimization by peers and
their subsequent participation in a targeted cognitive
behavioral intervention, Resilience Triple P. We examined
child and family factors which discriminated those children
with ongoing depressive symptoms following the intervention, from the majority of children whose depressive
symptoms were successfully alleviated.
Resilience Triple P is a cognitive behavioral family
intervention for children victimized at school by peers. The
program is designed to reduce both victimization and child
distress, thus interrupting the downward spiral of ongoing
internalizing problems and victimization. The program
targets child and family protective factors against child
distress and victimization by teaching children cognitive
123
108
behavioral skills, and involving parents in supporting their
children through ‘‘facilitative parenting.’’ Facilitative parenting describes a set of parenting practices which are
supportive of children’s development of peer skills and
relationships. Facilitative parenting is warm and responsive, encouraging of independence (rather than over-controlling), includes coaching of social and emotional skills,
and support of children’s friendships. Facilitative parenting
has been found to discriminate between children reported
by teachers as victimized by peers [16], and to concurrently
predict children’s depression [17].
A randomized controlled trial (RCT) evaluated the
effectiveness of Resilience Triple P for families of 111
children who had been victimised by peers at school [18].
Children whose families received the program had greater
reductions in victimization, distress and depression, and
greater improvements in peer acceptance over nine
months than children in the control condition. At nine
months 64 % of children in the intervention group with
elevated depression at the initial assessment had moved
into the normal range for depressive symptoms compared
with 21 % of control children. The current study focused
on a subgroup of children involved in the trial of Resilience Triple P: specifically the 39 children who were
both (a) randomized to the intervention condition, and
(b) had elevated depression at the initial assessment, when
compared to a general sample of children of the same
age. Of these 39 children, 26 no longer had elevated
depression 6 months after participating in the intervention; however a minority of 13 children still had elevated
depression. This study investigates child and family
antecedents which discriminated those children with
ongoing depressive symptoms six months after participating in the intervention, from the other children who
were no longer depressed. There is no previous research
which specifically investigates risk of child depression
following an intervention for children victimized by
peers. However there is previous research on child and
family factors risk and protective factors for child
depression in general.
Child and Family Factors Relevant to Risk of Child
Depression
Previous research implicates several child and family
variables relevant to risk of child depression, and therefore
likely to influence the risk of ongoing depression following
victimization by peers and participation in a targeted
intervention. These include history of previous depression,
victimization, children’s cognitive processing of peer situations, support from peers, and the parenting children
receive. A high level of depression immediately following
the intervention is likely to be associated with increased
123
Child Psychiatry Hum Dev (2017) 48:107–119
risk of later depression. As previously identified, victimization is well-established as a risk factor for ongoing
depression, so failure of an intervention to effectively
reduce victimization is likely to increase the risk of
ongoing depression. The relevance of cognitive interpretations, peer support, and parenting to ongoing risk of
depressive is discussed below.
Previous research shows that children’s cognitive
interpretations of social situations mediate the impact of
negative social experiences on depression. According to
Hopelessness theory, strong emotional reactions are caused
by inferring negative consequences and self-criticism from
aversive events [19]. At least two studies have found that
children’s negative cognitive interpretations mediate the
relationship between negative peer behavior and depression [20, 21]. Another study [22] found that for children
with higher levels of self-blaming attributions, peer victimization was linked more strongly with increases in
internalizing problems over time. On the other hand, having a more optimistic cognitive style can buffer children
from later depression following a stressful situation [23].
Resilience Triple P directly targets children’s cognitive
interpretation of peer social behavior; however if the program has not successfully addressed a child’s cognitive
negativity, this may pose a risk for ongoing depression
following participation in the intervention.
Children’s vulnerability to ongoing depression is also
influenced by their relationships with peers and parents.
Supportive relationships with peers and parents can protect
against symptoms of depression in general [24, 25].
Friendships also buffer children against internalizing
problems following victimization. A longitudinal study of
4th and 5th grade children [26] found that having a mutual
best friend mitigated the internalizing consequences of peer
victimization over time. Several cross-sectional studies of
young adolescents have found that peer support at least
partially mediates the relationship between victimization
and depressive symptoms, as well as independently
impacting depressive symptoms [27–29]. Therefore the
quality of peer relationships following participation in
intervention is likely to predict children’s risk of ongoing
depression.
Parenting also influences children’s risk of depression.
There is a great deal of evidence linking supportive parenting with children’s social and emotional well-being
[30, 31], regulation of negative emotions [32–34], and
resilience following stressful life events [35]. A large-scale
longitudinal study using a cohort of monozygotic twins
disparate on victimization [36] found that warm family
relationships buffered children from depression and anxiety
following victimization. A mediational study [37] found
that supportive parenting and peer victimization each
independently predicted later depressive symptoms and
Child Psychiatry Hum Dev (2017) 48:107–119
cognitions, but did not interact, and concluded that supportive parenting compensates for the negative impact of
peer victimization on later depression.
Negative forms of parenting have also been associated
with child depression. Over-controlling parenting predicts
lower capacity of young children to regulate negative
emotions over time [38]. A meta-analysis of 45 studies [3]
found that both parental rejection (lack of warmth) and
parental control accounted for a significant amount of
variance in childhood depression. Facilitative parenting is
also associated with both children’s victimization and
depression. Facilitative parenting draws together parenting
practices which are supportive of children’s development
of peer skills and relationships; it includes warm relating,
encouragement of independence (rather than over-control),
and incorporates explicit coaching of social and emotional
skills, and support of children’s friendships. Facilitative
parenting has previously been found to discriminate
between children reported by teachers as bullied from those
who were not [16]. Another study [17] found that, after
controlling for negative parenting, facilitative parenting
concurrently predicted children’s depression, and that two
facilitative parenting subscales were associated with
depression: child-parent communication, and less parent–
child conflict. No study has previously investigated whether facilitative parenting predicts later depression in
children. The current study investigated whether facilitate
parenting predicts treatment resistant depression following
participation in a program which specifically targeted
facilitative parenting skills.
Aims of this Study
This study aimed to investigate if child and family factors
could discriminate children with treatment resistant
depression following victimization by peers, and subsequent
participation in a targeted family cognitive-behavioral
intervention. Treatment resistant depression was defined as
ongoing elevated symptoms of depression (compared with a
school community sample of the same age) 6 months after
participation in Resilience Triple P. We hypothesized that
children with treatment resistant depression 6 months after
participating in the program would be discriminated from
children who were no-longer depressed by higher levels of
depression, peer victimization, and negative interpretations
of peer behavior, and lower levels of peer support and
facilitative parenting, immediately following program participation. On the basis of previous research on parenting
practices associated with depression, we further hypothesized that children with treatment resistant depression would
be identified by lower levels of parenting warmth and childparent communication, and higher levels of over-directiveness and parent–child conflict.
109
Method
Participants
This study tracked a sub-sample of 39 children of a total of
111 recruited between 2010 and 2012 for the RCT of the
Resilience Triple P program, as described previously [18].
Families were recruited through notices in school
newsletters in state and private schools in South East
Queensland, Australia. The trial was open to families of
children who had been bullied at school by peers,
according to their parent. Bullying was defined behaviorally as ‘‘hurtful behavior which is typically repeated, and
could be physical or verbal or indirect social, and carried
out in person or through technology.’’ The parent needed to
verify that the child had experienced either (a) ongoing
bullying for at least the past month and/or (b) a recurrent
problem with being bullied over more than one year. There
were several other eligibility criteria: the target child needed to be (1) aged between 6 and 12 years, (2) living at
home, and (3) attending a regular school. Following an
initial assessment, the 111 families were randomly allocated to the control (n = 55) or the intervention condition
(n = 56). Families in the intervention condition were
offered an immediate start on Resilience Triple P.
The current study focussed on the 39 children allocated
to the intervention condition with an elevated score for
depressive symptoms at the initial assessment. Elevated
depression was determined by scores above the clinical
cut-off on a parental depression checklist [39] calculated
by comparison with a general school community sample of
children from the same age-group, using methods for
assessing clinical significance described by Jacobson and
Truax [40]. The 39 children in the intervention condition
with elevated depression at the initial assessment, included
27 boys (69 %) boys and 12 (31 %) girls ranging from 6 to
12 years with a mean age of 8.64 years (SD = 1.75 years).
Of these 39 children, parents of 12 children (33 %)
reported their child had a pre-existing psychiatric diagnosis
including five children (13 %) with a diagnosis of autistic
spectrum disorder, one child with diagnoses of both autistic
spectrum and attention deficit, one child with a diagnosis of
attention deficit, two children with specific learning disability, one child with sensory integration disorder, one
child with an anxiety disorder, and one child with a medical condition affecting socialization.
Design
This study utilised a longitudinal data set which tracked
children’s progress through three assessments over nine
months including pre-intervention (0 months), post-intervention (3 months after recruitment), and a follow-up
123
110
assessment 6 months later (9 months after recruitment).
The 39 children included in this study had clinically elevated scores on the depression checklist at the pre-intervention assessment. Apart from five families who dropped
out following the first assessment, the 34 other families
participated in Resilience Triple P prior to the post-intervention assessment 3 months later. We sought to discriminate children with treatment resistant depression at the
9-month follow-up (6 months after completion of intervention) on the basis of post-intervention assessment scores
on depressive symptoms, peer victimisation, negative
interpretations of peer social behavior, peer support and
facilitative parenting.
Measures
Assessments were completed by children, parents and
teachers at pre-intervention (0 months), post intervention
(3 months), and a follow-up assessment 6 months later
(9 months).
Outcome Variable: Child Depression at 9 months
The Preschool Feelings Checklist (PFC) [39] is a brief
16-item checklist of symptoms of depression. Parents
answer ‘‘yes’’ or ‘‘no’’ for each question (e.g. ‘‘Frequently
appears sad or says he/she feels sad’’). The scale correlates
well with established depression measures [41], and has
previously been shown to discriminate children reported by
teachers to be bullied from those who are not in children
aged 6–12 years [16]. This measure demonstrated acceptable internal consistency for the current sample (a = .73).
Predictor Variables: Child Victimisation at 3 months
The Preschool Peer Victimization Measure (PPVM) is a
nine-item teacher report of peer treatment of the child [42].
All items are developmentally appropriate for children
from 6 to 12 years of age. Teachers rate items from 0
(never or almost never true) to 5 (always or almost always
true). Subscales include Overt Victimization comprising
physical and verbal items (e.g. ‘‘This child is called a mean
name’’) and Relational Victimization (e.g. ‘‘This child gets
ignored by playmates when they are mad at him/her’’).
Both subscales demonstrated reasonable internal consistency (a = .70, a = .74 respectively).
Things Kids Do (TKD) [43] asks children to rate the
frequency of specific peer behaviors in the last week at
school on a 5-point scale from ‘‘not at all’’ to ‘‘heaps.’’
This is facilitated by a research assistant reading each
question and pointing to a chart on which ratings are represented by coloured shapes of size corresponding to rating. The TKD Victimization scale includes 14 items about
123
Child Psychiatry Hum Dev (2017) 48:107–119
verbal, physical or relational behaviors (e.g. ‘‘Did other
kids at school give you mean looks?’’). It has previously
been used with this age group [16] and demonstrated
acceptable internal consistency for the current sample
(a = .78). After answering questions about the occurrence
of peer behaviors, the child rates how upset they felt about
these peer behaviors on a 5-point scale from ‘‘not upset’’ to
‘‘very upset’’, comprising the TKD Upset scale.
Predictor Variables: Peer Support at 3 months
Friendedness The Loneliness Questionnaire [44]
includes 24 statements on friendedness (e.g. ‘‘I can find a
friend when I need one’’), which children rate from 5 (always true) to 1 (not true at all). Although originally trialled
with children from 3rd to 6th grade [45], a recent study
[16] found it could be utilized with individual children
from five years old, through use of a chart with different
sized circles representing levels of agreement. The same
materials produced very good internal consistency with this
sample (a = .92).
Peer Acceptance We used two single-item scales from
the Preschool Social Behavior Scale –Teacher (PSBS-T)
[46] which ask teachers to rate the child’s acceptance by
peers of the same sex and opposite sex (e.g. ‘‘This child is
well-liked by peers of the same sex’’). Teachers rate items
from 1 (never or almost never true) to 5 (always or almost
always true).
Predictor Variables: Cognitive Negativity at 3 months
The Sensitivity to Peer Behaviour Interview (SPBI) [47]
measures children’s negative thoughts and feelings in six
hypothetical scenarios of negative peer behavior (e.g. ‘‘A
child calls you stupid’’). A felt board and ten felt characters
are used to demonstrate scenarios according to an explicit
protocol. Firstly the child designs a character for themselves (i.e. chooses clothes and hair style). The research
assistant then depicts scenarios in which other felt characters act towards the child’s character in a way which
could be interpreted as negative (e.g. has a birthday party
but does not invite the child). The child then answers
specific questions about each scenario before the next
scenario is introduced. Some felt characters were antagonists and others are neutral (i.e. are not described as acting
one way or another).The Internalizing Cognitions scale
measures children’s negative beliefs for six scenarios,
including interpretations of motive (e.g. ‘‘They are trying
to upset you’’), whether behavior will continue (‘‘lots of
days’’ as opposed to ‘‘just today’’), and expectation that
other neutral children would act similarly. Internalizing
Feelings measures how upset children report they would
Child Psychiatry Hum Dev (2017) 48:107–119
feel in each situation from ‘‘not upset’’, ‘‘a bit upset’’ or
‘‘very upset.’’ These two scales have previously discriminated bullied from non-bullied children [16], and produced
reasonable internal consistency in this sample (a = .72;
a = .70).
Predictor Variables: Facilitative Parenting at 3 months
The Facilitative Parenting Scale (FPS) [48] is a self-report
measure of parenting which is supportive of children’s peer
skills and relationships. Parents rate 58 statements from 1
(not true) to 5 (extremely true) over the last few weeks.
Internal consistency for the whole scale was acceptable (a = .82). A previous study reported there are 11
subscales [16] all of which demonstrated acceptable internal consistency in the current study1: Warmth (e.g. ‘‘My
child and I enjoy time together’’), (a = .82); Supports
Friendships (e.g. ‘‘I arrange for my child to see friends out
of school’’), (a = .76); Not Over-Protective (e.g. ‘‘I tend to
baby my child’’), (a = .79); Not Conflicting (e.g. ‘‘My
child and I argue a lot’’), (a = .85); Child Communicates
to Parent (e.g. ‘‘My child comes to see me if s/he has a
problem’’), (a = .74); Parent Coaches (e.g. ‘‘I help my
child practise standing up for him/herself’’), (a = .76);
Communicates with Teacher (e.g. ‘‘I can calmly discuss
any concerns that might arise with my child’s teacher’’),
(a = .52; mean r = .27); Not Over-Involved in School
(e.g. ‘‘I talk to my child’s teacher much more than other
parents do’’) (a = .76), Not Aggressively Defensive (e.g.
‘‘If another child acts meanly to my child, I might tell him/
her off’’), (a = .43; mean r = .26); Enables Independence
(e.g. ‘‘I encourage my child to decorate his/her own
space’’), (a = .69; mean r = .45); Not Overly Directive,
(e.g. ‘‘When my child has a problem, I tell him/her what to
do’’), (a = .51; mean r = .34).
Procedure
The assessment procedure was described comprehensively
in the paper reporting the RCT [18]. Ethical clearance was
first obtained from the university and educational authorities. After reading about the trial in school newsletters,
families made contact with the researchers. In this initial
phone call, parents were informed about the requirements
of the research and screened against eligibility criteria.
Eligible families were invited to visit a family clinic for an
initial assessment. Formal consent was obtained from all
parents, children, teachers, and school Principals.
1
As Cronbach’s alpha is sensitive to the numbers of items in scales,
we calculated the mean inter-item correlation for scales with only two
three items which exhibited a low alpha, as recommended [49]; the
optimal range for inter-item correlation (r) is between .20 and .40.
111
Following the initial assessment, each family was randomly allocated to intervention or control conditions.
Families were asked to attend subsequent assessments 3
and 9 months after the initial assessment. At each assessment, children were interviewed by research assistants with
training in psychology or social work who had been trained
in conducting the child assessments, according to the
protocols. A research assistant read through each questionnaire with the child and utilized concrete materials
provided to assist children to respond to the TKD, Loneliness Questionnaire, and SPBI. This took half an hour on
each occasion. Whilst children were interviewed by
research assistants, parents completed questionnaires.
Questionnaires were mailed to teachers with return envelopes. The current study focuses on children allocated to the
intervention condition who had elevated depressive
symptoms at the initial assessment.
Resilience Triple P is a manualized family intervention
designed to address known modifiable risk and protective
factors for children bullied at school [50]. The eight-session program includes four sessions for parents and four
sessions for children with their parents present. Children
learn play and friendship skills, everyday body language,
how to interpret and respond to negative peer behavior and
how to resolve conflicts. Parents learn facilitative parenting
strategies to promote a warm parent–child relationship,
support children’s friendships, address problem behavior,
coach effective responses to bullying and conflict, and
communicate with school staff. The program involves
active skills practice and homework tasks in between sessions in which behavioral and cognitive strategies are
practiced and coached. The program was delivered at a
child and family clinic in groups of between three and eight
families, and included between eight and 15 children aged
6–16 years (including siblings). If families missed a session they were invited to make this up in another group, or
individually, resulting in mean attendance of 7.6 of eight
sessions for families who commenced the program [18].
Statistical Analyses
We first conducted data screening and missing data analysis. Before calculating scale scores we imputed missing
data points through Expectation Maximisation, on each
scale separately as recommended [51]. We used discriminant analyses through the Statistical Package for Social
Sciences (SPSS) to ascertain whether children with treatment resistant depression at the follow-up assessment
(6 months after post-assessment) could be discriminated on
the basis of post-assessment scores on children’s distress
and depression, peer victimisation, peer support, facilitative parenting, and cognitive negativity. We conducted an
additional analysis to investigate whether treatment
123
112
resistant depression at 9 months could be predicted from
facilitative parenting subscales at 3 months. For both discriminant analyses, the number of predictor variables was
limited by the number of participants in the smallest group
(n = 12) as recommended [52] in order to prevent overfitting of the discriminant function to the specific sample.
Discriminant analysis through SPSS does not include an
option to correct for cumulative alpha levels. We have
therefore assessed alpha levels independently using the
Bonferroni-Holm correction using both family-wise corrections and by treating each separate predictor variable as
a repetition of the analysis [53]. Family-wise corrections
were based on variable groups defined in this study
including victimization, peer support, cognitive negativity,
and parenting. For the discriminant analysis involving just
facilitative parenting subscales, each subscale was conservatively treated as a repeated analysis for the purpose of
calculating Bonferroni-Holm alpha cut-offs.
Results
Child Psychiatry Hum Dev (2017) 48:107–119
We checked if the still-depressed versus non-depressed
groups were different on demographic factors. There were
no significant differences between groups on the demographics tested including child age (F [1, 32] = .001,
p = .981), grade (F [1, 32] = .004, p = .953), gender (v2
(1) = .54, p = .714), parent income (F [1, 32] = .007,
p = .936), parent education (F [1, 32] = .029, p = .865)
or whether the child had a pre-existing diagnosis v2
(7) = 710.27, p = .111). There was no significant difference between still-depressed and non-depressed groups at
9 months for attendance to the program (F [1, 32] = 1.036,
p = .316).
Table 1 shows the means, standard deviations, and
correlations between the outcome variable of child
depression at 9 months and predictor variables at
3 months. There was a significant positive correlation
between child depression at 9 months and child depression
at 3 months. Child depression at 9 months had significant
negative associations with peer acceptance (by same and
opposite sex peers), and facilitative parenting at 3 months.
That is, ongoing depression at 9 months was associated
with higher levels of depression, and lower levels of peer
acceptance and facilitative parenting at 3 months.
Preliminary Analyses
Predictors of Depression at 9 Months
Several variables had a significant positive skew, which is
quite common for psychological measures [54], and not a
strong concern in discriminant analysis [52]. Box’s M test
was significant (p = .005) indicating non-normality of the
variance–covariance matrix. However, Box’s M test is
known to be highly sensitive to departures from normality
[52], and an inspection of scatterplots revealed distributions for each group were of similar shape. Several data
transformations were attempted: as these produced similar
patterns to the original scores, the original scores were
retained. Scores of Mahalanobis Distance showed no outliers exceeded the critical values.
A missing data analysis (including that due to attrition)
revealed 10.59 % of total values were missing including
the five cases lost to attrition. Little’s test indicated that
data points were missing completely at random, v2
(11,634) = .00, p = 1.000. The five families who dropped
out after the initial assessment were compared to the 34
families who were retained. There were no differences
between these groups on 19 of the 21 scales and subscales.
Families who dropped out had higher ratings on child
reports of Internalizing Feelings, t (37) = -2.17, p = .037
and FPS Child Communicates to Parent t (37) = -2.11,
p = .042 and lower scores on FPS Not Over-Involved in
School t (37) = 2.09, p = .044. When we applied Bonferroni-Holm corrections, none of these differences met the
more stringent significance criteria.
123
Table 2 includes means and standard deviations of all
3-month predictor variables for children with treatment
resistant depression or no depression at 9 months. One
discriminant function was identified which correlated .74
with treatment resistant depression and significantly discriminated between the two groups, Wilks’ k = .45, v2
[11] = 24.98, p = .009. Table 2 shows the structure
matrix and F-tests of equality of the means for the two
groups for each predictor variable. The 3-month variables
which best distinguished children with treatment resistant
depression at 9 months and significantly correlated with
the discriminant function were acceptance by opposite sex
peers (r = .64), child depression (r = -.53), acceptance
by same sex peers (r = .50), facilitative parenting
(r = .38), and social victimization (r = -.22). When we
applied Bonferroni-holm adjustments using family-wise
corrections, all of these variables were significant according to the more stringent alpha levels. When we applied
Bonferroni-Holm stepwise alpha criteria taking each predictor as a separate measure, social victimization failed to
meet the new criteria of p \ .007, but all other variables
remained significant according to the more stringent alpha
levels. Classification of cases using the discriminant
function resulted in 87.2 % of the total sample being correctly classified including 90.2 % of the not depressed
group and 69.2 % of children still depressed at 9 months.
–
-.41**
.31
-.14
-.44**
-.42**
-.11
.06
.16
.37*
-.26
-.11
Parent
12. Child depression 9 months
* p \ .05; ** p \ .01; *** p \ .001
.32*
9 months
3.00 (3.97)
.28
.26
.11
-.26
-.26
-.41*
.05
.15
Parent
3 months
11. Facilitative parenting
10. Internalizing feelings
Child
3.96 (.33)
-.08
.00
-.15
-.21
.03
.24
.44**
.30
–
3 months
.52 (.44)
.01
.59***
.15
-.65***
-.02
-.14
-.48**
.13
-.10
-.37*
-.09
.28
.20
-.02
Child
3 months
3.01 (.92)
Teacher
3 months
9. Internalizing cognitions
8. Accepted by opposite sex peers
Teacher
7.Accepted by same sex peers
3 months
0.23 (.16)
–
.13
–
-.40*
-.57**
-.34*
.11
-.13
-.21
-.39*
4.19 (.63)
Child
6. Friendedness
3 months
3.35 (.94)
-.06
–
.52**
-.18
.04
–
.27
.19
Teacher
5. Overt victimisation
3 months
1.42 (.63)
-.04
-.19
–
.03
.06
Teacher
4. Social victimisation
3 months
2.38 (.82)
–
-.18
.64***
-.18
–
2. Child distress about peer behaviour
3. Child depression at 3 months
.58 (.59)
Child
Child
Parent
3 months
3 months
3 months
1. Victimisation in previous week
1.10 (1.07)
3.81 (2.38)
-.08
–
.12
–
10.
9.
8.
7.
6.
5.
4.
3.
2.
1.
Respondent
Mean (SD)
We investigated whether the facilitative parenting subscales at 3 months could discriminate between children
with treatment resistant depression at 9 months. Table 3
shows means, standard deviations and correlations between
facilitative parenting subscales at 3 months and child
depression at 9 months. Two facilitative parenting subscales had significant negative correlations with children’s
depression at 9 months: Not Over-Protective (r = -.39),
and Not Aggressively Defensive (r = -.38). That is,
children with treatment resistant depression at 9 months
had parents who reported they were more over-protective
and more likely to act aggressively towards others in
defending their child.
Table 4 includes means and standard deviations of 3month facilitative parenting subscales as predictors for
children were depressed or not at 9 months. One discriminant function was identified which correlated .68
with child depression group at 9 months and significantly
discriminated between the still-depressed and no-longerdepressed groups, Wilks’ k = .53, v2 [11] = 19.90,
p = .047. Table 4 shows the structure matrix for the
discriminant function and F-tests of equality of the means
between the groups for each predictor variable. The
parenting subscales which significantly distinguished
treatment resistant depression at 9 months and had the
highest correlations with the discriminant function were
Not Conflicting (r = .41), Not Overly Directive
(r = .41), Parent Coaches (r = .41), Not Aggressively
Defensive (r = .38), and Not Over-Protective (r = .36).
However, when we applied Bonferroni-Holm stepwise
alpha criteria taking each predictor as a separate instance,
none of the subscales met the more stringent cut-offs for
alpha levels. Nevertheless, classification using the discriminant function resulted in 92.3 % of the total sample
being correctly classified including 100.0 % of the nolonger-depressed depressed group and 76.9 % of the stilldepressed group.
Timing
Variable
Table 1 Means, standard deviations and correlations between 3 month predictors and child depression at 9 months
Facilitative Parenting Subscales as Predictors
of Depression
.20
113
11.
Child Psychiatry Hum Dev (2017) 48:107–119
Discussion
This study focused on treatment resistant depression in
children following victimization by peers. We sought to
identify factors which characterized children who continued to experience high levels of depressive symptomatology 6 months after participating in a targeted cognitivebehavioral family intervention. We hypothesized that
children with treatment resistant depression 6 months after
participating in the program would be discriminated by
higher levels of depression, peer victimization and
123
114
Child Psychiatry Hum Dev (2017) 48:107–119
Table 2 Discriminant analysis using 3 month variables to predict child depression at 9 months
No longer depressed at
9 months (n = 26)
Still depressed at
9 months (n = 13)
Mean (SD)
Mean (SD)
1. Victimisation in previous
week (TKD)
.69 (.67)
.37 (.33)
.24
.94
2.53
.120
2. Child distress about peer
behaviour (TKD)
1.27 (1.14)
.75 (.83)
.22
.94
2.18
.148
3. Child depression at
3 months
2.98 (1.93)
5.48 (2.36)
-.53
.75
12.49
.001
4. Social victimisation
(PPVM)
2.14 (.72)
2.86 (.82)
-.22
.82
7.89
.008
5. Overt victimisation
(PPVM)
1.31 (.49)
1.62 (.88)
-.17
.94
2.18
.148
6. Friendedness
4.19 (.66)
4.18 (.60)
.03
1.00
.00
.985
7. Accepted by same sex
peers
3.67 (0.87)
2.72 (.77)
.50
.79
11.16
.002
8. Accepted by opposite sex
peers
3.37 (.70)
2.27 (.88)
.64
.67
18.21 \.001
9. Internalizing cognitions
.24 (.18)
.21 (.12)
.06
1.00
.18
10. Internalizing feelings
.54 (.43)
.47 (.48)
.07
.99
.21
.647
11. Facilitative parenting
4.07 (.32)
3.75 (.25)
.47
.79
9.86
.003
Predictor variable
negative interpretations of peer behavior, and lower levels
of peer support and facilitative parenting immediately
following program participation. As hypothesized, support
from peers and parents immediately following the intervention significantly distinguished children with treatment
resistant depression, as did post-intervention reports of
depressive symptoms and teachers’ reports of children’s
social victimization. Ongoing depression in children has
been well-documented following victimization. This study
suggests, that following an intervention, positive, supportive relationships with parents and peers continue to play a
role in determining whether depression is a longer term
issue.
Consistent with hypotheses, teacher reports of social
victimization of children discriminated between groups;
contrary to hypotheses overt victimization did not. The
RCT paper [18] reported an immediate significant reduction in overt victimization in the intervention group following program participation but a more gradual reduction
in social victimization over 9 months. Hence it may be that
following participation in the program, overt victimization
was at a reduced level for most children so did not significantly impact treatment resistant depression. However
social victimization is more subtle and may have persisted
for some children leading to greater risk of ongoing
depressive symptoms. Social victimization is also strongly
associated with lower levels of peer acceptance (See
123
Correlation with
discriminant function
Tests of equality of group
means
Wilk’s
lambda
F
p
.674
Table 1) which distinguished children with treatment
resistant depression.
Contrary to hypotheses, no children’s report measures
discriminated children with treatment resistant depression
including measures of victimization, friendedness, and
negative interpretations of peer behavior at 3 months.
Previous research has found that victimization, friendedness and children’s negative interpretations of peer
behavior predict ongoing depression [14, 23, 28]. The
current study differs from previous studies in that it
reported children’s outcomes following their participation
in a targeted intervention. The RCT of Resilience Triple P
[18] found that post-intervention scores on children’s
measures were no different to the comparison general
sample of children (i.e. means were within the expected
normal range). Therefore the failure of children’s report
measures to distinguish treatment resistant depression may
be due to a floor effect on children’s report measures.
Another reason why children’s report measures did not
distinguish children with ongoing depression may be that
they focused primarily on overt rather than social victimization. As reported in the RCT of Resilience Triple P,
incidents of overt victimization post-intervention were
significantly reduced [18], so may have been less relevant
to ongoing depression than social victimization, peer
rejection, and acceptance. This is consistent with results of
the current study that show that teacher reports of social
Child Psychiatry Hum Dev (2017) 48:107–119
115
Table 3 Means, standard deviations and correlations between 3 month facilitative parenting subscales and child depression at 9 months
Variable
Timing
Mean (SD)
1.
2.
3.
1. Warmth
0 months
4.22 (.45)
–
2. Supports
friendships
0 months
3.96 (.62)
.58***
3. Not overprotective
4. Not conflicting
0 months
3.88 (.55)
.27
.17
4.
5.
6.
7.
8.
11.
–
0 months
4.27 (.69)
.63***
.18
.18
0 months
3.92 (.55)
.62***
.51**
.17
6. FP parent
coaches
7. FP
communicates
with teacher
0 months
3.92 (.50)
.34*
.25
.41*
0 months
4.23 (.60)
.52**
.22
.12
.18
.46**
.13
8. FP not overinvolved in
school
0 months
3.99 (1.01)
-.36*
.34*
.14
.09
.00
.01
9. Not
aggressively
defensive
0 months
4.44 (.59)
.21
-.12
.59***
.21
.23
.22
.24
10. FP enables
independence
0 months
3.50 (.60)
.16
.09
.05
.02
.37*
11. FP not overly
directive
0 months
3.27 (.81)
.34*
.16
.13
.26
.49**
12. Child
depression
9 months
9 months
3.00 (3.97)
-.28
-.26
-.20
10.
–
5. FP child
communicates
to parent
-.01
9.
-.15
-.01
.48**
-.39*
–
.23
-.02
–
.30
–
-.29
–
–
.52**
–
-.05
-.08
-.06
.18
-.13
.27
.09
-.26
-.38*
–
.27
-.16
–
-.29
* p \ .05; ** p \ .01; *** p \ .001
victimization discriminated children with treatment resistant depression whereas overt victimization did not.
On the basis of previous research, we made further
hypotheses about facilitative parenting subscales which
would discriminate children with treatment resistant
depression: we predicted that children with treatment
resistant depression would be identified by lower levels of
parenting warmth and child-parent communication, and
higher levels of over-directiveness and parent–child conflict. Five facilitative parenting subscales made a significant contribution to discriminating children with treatment
resistant depression. However, when alpha criteria were
adjusted using the Bonferroni-Holm method, no individual
subscale met the more conservative criteria. However alpha
corrections methods have been criticized for setting levels
of significance which are overly stringent and which can
result in important differences being overlooked (i.e. Type
2 errors) [55]. We will therefore interpret the pattern of
results as reported in Table 4 cautiously and against relevant literature. As hypothesized, the parents of children
with treatment resistant depression had reported higher
levels of parent–child conflict and over-directive parenting
than parents of children who were no longer depressed at
follow-up. This is consistent with previous research
showing that parent–child conflict and high levels of parental control are associated with children’s depression
[3, 17]. Contrary to hypothesis, child-parent communication did not significantly discriminate children with treatment resistant depression; however this prediction was
made on the basis of a previous cross-sectional study [17]
and cross-sectional associations between variables do not
necessarily reflect relationships over time [56]. Parental
warmth was marginally significant in discriminating
depression-resistant depression; previous longitudinal
research shows that warm family relationships buffer
children from depression and anxiety following victimization [36]. Three additional subscales helped discriminate
children with treatment resistant depression: higher levels
of over-protective parenting, aggressively defensive parenting and lower levels of parental coaching of the child in
social and emotional skills. Although these subscales have
not previously been associated with children’s depression,
they have all been previously implicated as relevant to
development of children’s peer relationships and risk of
123
116
Child Psychiatry Hum Dev (2017) 48:107–119
Table 4 Discriminant analysis using facilitative parenting subscales at 3 months to predict depression at 9 months
Predictor variable
No longer depressed at
9 months (n = 26)
Still depressed at
9 months (n = 13)
Correlation with
discriminant function
Mean (SD)
Mean (SD)
1. Warmth
4.32 (.41)
4.02 (.48)
.35
2. Supports friendships
4.04 (.58)
3.81 (.71)
.19
3. Not over-protective
4.00 (.52)
3.63 (.53)
.36
Tests of equality of
group means
Wilk’s
lambda
F
p
.90
3.94
.055
.97
1.18
.285
.90
4.33
.044
4. Not conflicting
4.44 (.47)
3.92 (.92)
.41
.87
5.56
.024
5. Child communicates
with parent
3.95 (.51)
3.87 (.64)
.08
.99
.21
.650
6. Parent coaches
4.05 (.49)
3.67 (.44)
.41
.87
5.60
.023
7. Communicates with
teacher
4.23 (.64)
4.25 (.51)
-.01
1.00
.06
.936
8. Not over-involved in
school
4.19(.88)
3.58 (1.15)
.32
.92
3.42
.073
9. Not aggressively
defensive
4.58 (.48)
4.18 (.65)
.38
.89
4.76
.036
10. Enables
independence
3.60 (.62)
3.30 (.51)
.26
.94
2.26
.141
11. Not overly directive
3.47 (.79)
2.87 (.70)
.41
.87
5.39
.026
peer victimization. Parental coaching of children in social
and emotional skills has previously been identified as a
path for children’s competence with peers and peer
acceptance [57]. Through participation in Resilience Triple
P, parents learnt specific strategies to support their child in
responding to and interpreting peer situations [18]. A previous study [58] found that parental feedback interacts with
negative life events to exacerbate children’s vulnerability
to depression. Parental coaching may then assist children to
view events more realistically and optimistically, thereby
facilitating children’s ongoing emotional regulation. Overprotective parenting has previously been associated with
victimization [59]. There has been very little previous
research examining the relationship between over-protective parenting and child depression, and results with been
mixed [60, 61]. To our knowledge no previous research has
specifically examined the relationship between parents
aggressively defending the child, and child depression. It
may be that both parental over-protection and aggressive
defensiveness disrupt children’s peer relationships and
their ability to self-regulate.
This study investigated treatment resistant depression in
children bullied by peers following receipt of the targeted
cognitive behavioral family intervention that significantly
reduced depression and victimization. Children with treatment resistant depression 6 months after participating in the
intervention were characterized by lower levels of facilitative parenting and peer support immediately after intervention. The intervention, Resilience Triple P, teaches
parents facilitative parenting skills. So, following an
123
intervention which targeted and increased facilitative parenting in parents, facilitative parenting still predicted child
depression outcomes 6 months later. This implies that,
following participation in Resilience Triple P some parents
may benefit from additional support to improve their use of
facilitative parenting strategies such as coaching children in
social and emotional skills, resolving conflicts with their
child, and supporting their child without being overly
directive or overly protective. Further evaluation of Resilience Triple P using larger sample sizes would enable
development of a more comprehensive profile of responders
and non-responders to the treatment on the variable of child
depression. This would enable early identification of families of children at-risk for ongoing depressive symptoms.
This is the first study to examine antecedents of treatment resistant depression in children bullied by peers. The
findings have extended previous cross-sectional research
which showed associations between facilitative parenting
and child depression. The strengths of this study include a
longitudinal design with a specific sample of children
victimized by peers who had participated in a targeted
cognitive-behavioral intervention. The main limitation was
the small sample size which limited the number of variables which could be included in a single discriminant
analysis. Future research could extend findings of this
study by using clinical diagnostic assessments to assess
depression of children victimized by peers following their
participation in targeted interventions.
Children with treatment resistant depression in this
study were characterized by lower levels of facilitative
Child Psychiatry Hum Dev (2017) 48:107–119
parenting and peer support than children whose depressive
symptoms were alleviated. This suggests that children who
participate in Resilience Triple P and have elevated
symptoms of depression immediately following participation in the program may benefit from further practitioner
support promoting facilitative parenting and peer support.
These findings have broader implications for schools and
professionals supporting children victimized by peers. Peer
victimization increases the ongoing risk of depression for
children, even after victimization has been addressed. It is
therefore important for parents and schools supporting
children, who have been victimized by peers, to ensure that
these children have ongoing warm, supportive relationships
with parents and peers well after victimization has abated.
Summary
Children bullied by peers are at increased risk of ongoing
depressive symptoms months and years after victimization
has ceased. This study investigated treatment resistant
depression in children victimized by peers following their
participation in a targeted family cognitive-behavioral
intervention. Treatment resistant depression was defined as
ongoing elevated depressive symptoms compared to a
general sample, 6 months after participating in the program. This study investigated whether facilitative parenting
and child social and emotional variables immediately following program participation would differentiate children
with treatment resistant depression 6 months later. The
sample of 39 children in the current study was a subsample of children who participated in the RCT of Resilience Triple P. These children had been randomly allocated to receiving the intervention and all had elevated
levels of depressive symptoms prior to participation in the
program. This study sought to identify child and family
factors which differentiated the minority of children with
ongoing elevated depressive symptoms 6 months after
participating in the program from those who were nolonger depressed. Children with treatment resistant
depression were characterized by higher levels of peer
support and facilitative parenting immediately following
the intervention. This suggests that facilitative parenting
and peer support may continue to protect children against
the risk of ongoing depression following an intervention
which reduces victimization and distress. Further research
could identify a comprehensive profile of children at risk of
depression following an intervention, who may benefit
from more intensive support.
Acknowledgments Thank you to the children and families who
participated in this trial of Resilience Triple P, the data-base of which
was used for analyses reported in this paper. We gratefully
117
acknowledge the funding of the trial by the Australian Research
Council supplemented by a philanthropic donation by the Butta and
Filewood families. We thank local theme-park, Dreamworld for
providing discount cards for families.
Compliance with Ethical Standards
Conflict of interest The Triple P–Positive Parenting Program is
developed and owned by The University of Queensland. The university, through its main technology transfer company Uniquest Pty
Ltd, has licensed Triple P International (TPI) Pty Ltd to publish and
disseminate Triple P worldwide. Royalties stemming from published
Triple P resources are distributed to the Faculty of Health and
Behavioural Sciences, School of Psychology, Parenting and Family
Support Centre and contributory authors. Karyn L. Healy and Matthew R. Sanders are both contributory authors of Resilience Triple P
and may in future receive royalties from TPI. Karyn L. Healy is
employed on occasion as a contract trainer for TPI and may, in future,
be offered contract work training practitioners in Resilience Triple P.
TPI is a private company and no author has any share or ownership of
it. TPI had no involvement in the study design, collection, analysis or
interpretation of data, or writing of this report.
References
1. Coghill D, Usala T (2006) Mood disorders in children and adolescents. Psychiatry 5:123–127
2. Lack CW, Green AL (2009) Mood disorders in children and
adolescents. J Pediatr Nurs 24:13–25
3. McLeod BD, Weisz JR, Wood JJ (2007) Examining the association between parenting and childhood depression: a meta-analysis. Clin Psychol 27:986–1003
4. Bhatia SK, Bhatia SC (2007) Childhood and adolescent depression. Am Fam Phys 75:73–80
5. Egan SK, Perry DG (1998) Does low self-regard invite victimization? Dev Psychol 34:299
6. Olweus D (1992) Victmization by peers: antecedents and longterm outcomes. In: Rubin KH, Asendorf JB (eds) Social withdrawal, inhibition and shyness in childhood. Lawrence Erlbaum,
Hillsdale, pp 315–341
7. Kochenderfer BJ, Ladd GW (1996) Peer victimization: cause or
consequence of school maladjustment? Child Dev 67:1305–1317
8. Farrington DP, Loeber R, Stallings R, Ttofi MM (2011) Bullying
perpetration and victimization as predictors of delinquency and
depression in the Pittsburgh Youth Study. J Aggress Confl Peace
Res 3:74–81
9. Sourander A, Jensen P, Rönning JA, Niemelä S, Helenius H,
Sillanmäki L et al (2007) What is the early adulthood outcome of
boys who bully or are bullied in childhood? The Finnish ‘‘From a
Boy to a Man’’ study. Pediatrics 120:397–404
10. Hodges EVE, Perry DG (1999) Personal and interpersonal antecedents and consequences of victimization by peers. J Personal
Soc Psychol 76:677–685
11. Reijntjes A, Kamphuis JH, Prinzie P, Telch MJ (2010) Peer
victimization and internalizing problems in children: a metaanalysis of longitudinal studies. Child Abuse Negl 34:244–252
12. Harrington R, Whittaker J, Shoebridge P (1998) Psychological
treatment of depression in children and adolescents: a review of
treatment research. Br J Psychiatry 173:291–298
13. Weisz JR, McCarty CA, Valeri SM (2006) Effects of psychotherapy for depression in children and adolescents: a metaanalysis. Psychol Bull 132:132–149
123
118
14. Emslie GJ, Mayes TL, Laptook RS, Batt M (2003) Predictors of
response to treatment in children and adolescents with mood
disorders. Psychiatr Clin North Am 26:435–456
15. Fava M, Davidson KG (1996) Definition and epidemiology of
treatment-resistant depression. Psychiatr Clin North Am
19:179–200
16. Healy KL, Sanders MR, Iyer A (2015) Parenting practices,
children’s peer relationships and being bullied at school. J Child
Fam Stud 24:127–140
17. Healy KL, Sanders MR, Iyer A (2015) Facilitative parenting and
children’s social, emotional and behavioral adjustment. J Child
Fam Stud 24:1762–1779
18. Healy KL, Sanders MR (2014) Randomized controlled trial of a
family intervention for children bullied by peers. Behav Ther
45:760–777
19. Abramson LY, Metalsky GI, Alloy LB (1989) Hopelessness
depression: a theory-based subtype of depression. Psychol Rev
96:358–372
20. Cole DA, Turner JE (1993) Models of cognitive mediation and
moderation in child depression. J Abnorm Psychol 102:271–281
21. Prinstein MJ, Cheah CSL, Guyer AE (2005) Peer victimization,
cue interpretation, and internalizing symptoms: preliminary
concurrent and longitudinal findings for children and adolescents.
J Clin Child Adolesc Psychol 34:11–24
22. Perren S, Ettekal I, Ladd G (2013) The impact of peer victimization on later maladjustment: mediating and moderating effects
of hostile and self-blaming attributions. J Child Psychol Psychiatry 54:46–55
23. O’Donnell EH, Moreau M, Cardemil EV, Pollastri A (2010)
Interparental conflict, parenting, and childhood depression in a
diverse urban population: the role of general cognitive style.
J Youth Adolesc 39:12–22
24. Auerbach RP, Bigda-Peyton JS, Eberhart NK, Webb CA, Ho MH
(2011) Conceptualizing the prospective relationship between
social support, stress, and depressive symptoms among adolescents. J Abnorm Child Psychol 39:475–487
25. Cornwell B (2003) The dynamic properties of social support:
decay, growth, and staticity, and their effects on adolescent
depression. Soc Forces 81:953–978
26. Hodges EVE, Boivin M, Vitaro F, Bukowski WM (1999) The
power of friendship: protection against an escalating cycle of peer
victimization. Dev Psychol 35:94–101
27. Baker ÖE, Bugay A (2011) Mediator and moderator role of
loneliness in the relationship between peer victimization and
depressive symptoms. Aust J Guid Couns 21:175–185
28. Papafratzeskakou E, Kim J, Longo GS, Riser DK (2011) Peer
victimization and depressive symptoms: role of peers and parent–
child relationship. J Aggress Maltreatment Trauma 20:784–799
29. Tanigawa D, Furlong MJ, Felix ED, Sharkey JD (2011) The
protective role of perceived social support against the manifestation of depressive symptoms in peer victims. J Sch Violence
10:393–412
30. Egeland B, Kalkoske M, Gottesman N, Erickson MF (1990)
Preschool behavior problems: stability and factors accounting for
change. J Child Psychol Psychiatry 31:891–909
31. Kim-Cohen J, Caspi A, Rutter M, Polo-Tomas M, Moffitt TE
(2006) The caregiving environments provided to children by
depressed mothers with or without an antisocial history. Am J
Psychiatry 163:1009–1018
32. Eisenberg N, Fabes RA, Schaller M, Carlo G, Miller PA (1991)
The relations of parental characteristics and practices to children’s vicarious emotional responding. Child Dev 62:1393–1408
33. Fabes RA, Eisenberg N, Karbon M, Bernzweig J, Speer AL,
Carlo G (1994) Socialization of children’s vicarious emotional
responding and prosocial behavior: relations with mothers’
123
Child Psychiatry Hum Dev (2017) 48:107–119
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
perceptions of children’s emotional reactivity. Dev Psychol
30:40–55
Robinson LR, Morris AS, Heller SS, Scheeringa MS, Boris NW,
Smyke AT (2009) Relations between emotion regulation, parenting, and psychopathology in young maltreated children in out
of home care. J Child Fam Stud 18:421–434
Masten AS, Shaffer A (2006) How families matter in child
development: reflections from research on risk and resilience. In:
Clarke-Stewart A, Dunn J (eds) Families count: effects on child
and adolescent development. Cambridge University Press, New
York, pp 5–25
Bowes L, Maughan B, Caspi A, Moffitt TE, Arseneault L (2010)
Families promote emotional and behavioural resilience to bullying: evidence of an environmental effect. J Child Psychol Psychiatry 51:809–817
Bilsky SA, Cole DA, Dukewich TL, Martin NC, Sinclair KR,
Tran CV et al (2013) Does supportive parenting mitigate the
longitudinal effects of peer victimization on depressive thoughts
and symptoms in children? J Abnorm Psychol 122:406–419
Graziano PA, Keane SP, Calkins SD (2010) Maternal behaviour
and children’s early emotion regulation skills differentially predict development of children’s reactive control and later effortful
control. Infant Child Dev 19:333–353
Luby J, Heffelfinger A, Mrakotsky C, Hildebrand T (1999) Preschool feelings checklist. Washington University, St Louis
Jacobson NS, Truax P (1991) Clinical significance: a statistical
approach to defining meaningful change in psychotherapy
research. J Consult Clin Psychol 59:12–19
Luby JL, Heffelfinger A, Koenig-McNaught AL, Brown K,
Spitznagel E (2004) The preschool feelings checklist: a brief and
sensitive screening measure for depression in young children.
J Am Acad Child Adolesc Psychiatry 43:708–717
Crick NR, Casas JF, Ku HC (1999) Relational and physical forms
of peer victimization in preschool. Dev Psychol 35:376–385
Healy KL, Sanders MR (2008) Things Kids Do. Parenting and
Family Support Centre, The University of Queensland, Brisbane
Asher SR, Wheeler VA (1985) Children’s loneliness: a comparison of rejected and neglected peer status. J Consult Clin Psychol
53:500–505
Asher SR, Hymel S, Renshaw PD (1984) Loneliness in children.
Child Dev 55:1456–1464
Crick NR, Casas JF, Mosher M (1997) Relational and overt
aggression in preschool. Dev Psychol 33:579–588
Healy KL, Sanders MR (2008) Sensitivity to peer behaviour
interview. Parenting and Family Support Centre, The University
of Queensland, Brisbane
Healy KL, Sanders MR (2008) Facilitative parenting scale. Parenting and Family Support Centre, The University of Queensland,
Brisbane
Briggs SR, Cheek JM (1986) The role of factor analysis in the
development and evaluation of personality scales. J Pers 54:106–148
Healy KL, Sanders MR (2016) Resilience Triple P Facilitator’s
Manual. Brisbane: Triple P International Pty Ltd
Gold MS, Bentler PM (2000) Treatments of missing data: a
Monte Carlo comparison of RBHDI, iterative stochastic regression imputation, and expectation-maximization. Struct Equ
Model 7:319–355
Tabachnick BG, Fidell LS (2007) Using multivariate statistics.
Allyn & Bacon/Pearson Education, Boston
Strassburger K, Bretz F (2008) Compatible simultaneous lower
confidence bounds for the Holm procedure and other Bonferronibased closed tests. Stat Med 27:4914–4927
Blanca MJ, Arnau J, López-Montiel D, Bono R, Bendayan R
(2013) Skewness and kurtosis in real data samples. Methodology
(Gott) 9:78–84
Child Psychiatry Hum Dev (2017) 48:107–119
55. Perneger TV (1998) What’s wrong with Bonferroni adjustments.
BMJ 316(7139):1236–1238
56. Cole DA, Maxwell SE (2003) Testing mediational models with
longitudinal data: questions and tips in the use of structural
equation modeling. J Abnorm Psychol 112:558
57. McDowell DJ, Parke RD (2009) Parental correlates of children’s
peer relations: an empirical test of a tripartite model. Dev Psychol
45(1):224–235
58. Mezulis AH, Hyde JS, Abramson LY (2006) The developmental
origins of cognitive vulnerability to depression: temperament,
parenting, and negative life events in childhood as contributors to
negative cognitive style. Dev Psychol 42(6):1012–1025
119
59. Finnegan RA, Hodges EVE, Perry DG (1998) Victimization by
peers: associations with children’s reports of mother-child interaction. J Pers Soc Psychol 75:1076–1086
60. Kiel EJ, Maack DJ (2012) Maternal BIS sensitivity, overprotective parenting, and children’s internalizing behaviors. Personal
Individ Differ 53:257–262
61. Mullins LL, Fuemmeler BF, Hoff A, Chaney JM, Van Pelt J,
Ewing CA (2004) The relationship of parental overprotection and
perceived child vulnerability to depressive symptomotology in
children with type 1 diabetes mellitus: the moderating influence
of parenting stress. Child Health Care 33:21–34
123