The current study analyzes the efficacy of acceptance and commitment therapy (ACT) focused on repetitive negative thinking (RNT) for child depression. A randomized, nonconcurrent, multiple-baseline design was conducted with nine children, aged between 8 and 13 years, who showed a main diagnosis of child depression. Measures of psychological inflexibility, RNT, and generalized pliance were administered on a weekly basis throughout the study, whereas measures of emotional symptoms and parents’ report of problematic behavior were applied at pretreatment, posttreatment, and the 4-week follow-up. All participants showed evidence of a treatment effect for psychological inflexibility and RNT. The standardized mean difference effect sizes for single-case experimental designs were very large for these measures. No participant showed the diagnosis of child depression or comorbid disorders at the 4-week follow-up. Pretreatment to follow-up changes in emotional symptoms and problematic behavior reported by parents were statistically significant, with large effect sizes. RNT-focused ACT interventions for child depression deserve further empirical tests.
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Abela, J. R. Z., Aydin, C. M., & Auerbach, R. P. (2007). Responses to depression in children: Reconceptualizing the relation among response styles. Journal of Abnormal Child Psychology, 35, 913–927.
Abela, J. R. Z., Brozina, K., & Haigh, E. (2002). An examination of the response styles theory of depression in third and seventh grade children: A short term longitudinal study. Journal of Abnormal Child Psychology, 30, 515–527.
Abela, J. R. Z., Vanderbilt, E., & Rochon, A. (2004). A test of the integration of the response styles and social support theories of depression in third and seventh grade children. Journal of Social & Clinical Psychology, 23, 653–674.
Achenbach, T. M., & Rescorla, L. A. (2001). The manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.
Au, T. M., Sauer-Zavala, S., King, M. W., Petrocchi, N., Barlow, D. H., & Litz, B. T. (2017). Compassion-based therapy for trauma-related shame and post-traumatic stress: Initial evaluation using a multiple baseline design. Behavior Therapy, 48, 207–221.
Avenevoli, S., Swendsen, J., He, J. P., Burstein, M., & Merikangas, K. R. (2015). Major depression in the National Comorbidity Survey—Adolescent Supplement: Prevalence, correlates, and treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 54, 37–44.
Beeson, P. M., & Robey, R. R. (2006). Evaluating single-subject treatment research: Lessons learned from the aphasia literature. Neuropsychology Review, 16, 161–169.
Bijttebier, P., Raes, F., Vasey, M. W., Bastin, M., & Ehring, T. W. (2015). Assessment of repetitive negative thinking in children: The Perseverative Thinking Questionnaire–Child Version (PTQ-C). Journal of Psychopathology & Behavioral Assessment, 37, 164–170.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire—II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42, 676–688.
Brumariu, L. E., & Kerns, K. A. (2010). Parent–child attachment and internalizing symptoms in childhood and adolescence: A review of empirical findings and future directions. Development & Psychopathology, 22, 177–203.
Caselli, G., Gemelli, A., Querci, S., Lugli, A. M., Canfora, F., Annovi, C., et al. (2013). The effect of rumination on craving across the continuum of drinking behaviour. Addictive Behaviors, 38, 2879–2883.
Colón-Soto, M., Díaz, V., Soto, O., & Santana, C. (2005). MINI KID Mini International Neuropsychiatric Interview. Tampa, FL: University of South Florida.
Costello, E. J., Erkanli, A., & Angold, A. (2006). Is there an epidemic of child or adolescent depression? Journal of Child Psychology & Psychiatry, 47, 1263–1271.
Dereix-Calonge, I., Ruiz, F. J., Sierra, M. A., Peña-Vargas, A., & Ramírez, E. S. (2019). Acceptance and commitment training focused on repetitive negative thinking for clinical psychology trainees: A randomized controlled trial. Journal of Contextual Behavioral Science, 12, 81–88.
de Vries, R. M., & Morey, R. D. (2013). Bayesian hypothesis testing for single-subject designs. Psychological Methods, 18, 165–185.
de Vries, R. M., & Morey, R. D. (2015). A tutorial on computing Bayes factors for single-subject designs. Behavior Therapy, 46, 809–823.
DuBois, D. L., Felner, R. D., Bartels, C. L., & Silverman, M. M. (1995). Stability of self-reported depressive symptoms in a community sample of children and adolescents. Journal of Clinical Child Psychology, 24, 386–396.
Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology & Psychiatry, 47, 313–337.
Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy, 1, 192–205.
Esbjørn, B. H., Normann, N., Christiansen, B. M., & Reinholdt-Dunne, M. L. (2018). The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: An open trial. Journal of Anxiety Disorders, 53, 16–21.
Fekkes, M., Pijpers, F. I., Fredriks, A. M., Vogels, T., & Verloove-Vanhorick, S. P. (2006). Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics, 117, 1568–1574.
Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and Adolescent Mental Health Survey 1999: The prevalence of DSM-IV disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 1203–1211.
Gelman, A., Carlin, J. B., Stern, H. S., Dunson, D. B., Vehtari, A., & Rubin, D. B. (2014). Bayesian data analysis (Vol. 2). Boca Raton, FL: CRC Press.
Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20, 93–102.
Harvey, M. T., May, M. E., & Kennedy, C. H. (2004). Nonconcurrent multiple baseline designs and the evaluation of educational systems. Journal of Behavioral Education, 13, 267–276.
Hayes, L., Boyd, C. P., & Sewell, J. (2011). Acceptance and commitment therapy for the treatment of adolescent depression: A pilot study in a psychiatric outpatient setting. Mindfulness, 2, 86–94.
Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York, NY: Kluwer Academic Press.
Hayes, S. C., & Strosahl, K. D. (Eds.). (2004). A practical guide to acceptance and commitment therapy. New York, NY: Springer Science & Business Media.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy. An experiential approach to behavior change. New York, NY: Guilford Press.
Hayes, S. C., & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17, 289–303.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. D. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting & Clinical Psychology, 64, 1152.
Hedges, L. G., Pustejovsky, J. E., & Shadish, W. R. (2012). A standardized mean difference effect size for single-case designs. Research Synthesis Methods, 3, 224–239.
Hedges, L. G., Pustejovsky, J. E., & Shadish, W. R. (2013). A standardized mean difference effect size for multiple baseline designs across individuals. Research Synthesis Methods, 4, 324–341.
Henker, B., Whalen, C. K., & O'Neil, R. (1995). Worldly and workaday worries: Contemporary concerns of children and young adolescents. Journal of Abnormal Child Psychology, 23, 685–702.
JASP Team. (2018). JASP (version 0.9.0.1) [computer software]. Retrieved from https://jasp-stats.org/
Jeffreys, H. (1961). Theory of probability. Oxford, UK: Oxford University Press.
Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark, E. (1990). Comparison of cognitive-behavioral, relaxation, and self-modeling interventions for depression among middle-school students. School Psychology Review, 19, 196–211.
Kaufman, A. S., & Kaufman, N. L. (1990). Kaufman Brief Intelligence Test (KBIT-2) (2nd ed.). Circle Pines, MN: American Guidance Service.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., & Wang, P. S. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). Journal of American Medical Association, 289, 3095–3105.
Kessler, R. C., & Bromet, E. J. (2013). The epidemiology of depression across cultures. Annual Review of Public Health, 34, 119–138.
Kratochwill, T. R., & Levin, J. R. (2010). Enhancing the scientific credibility of single-case intervention research: Randomization to the rescue. Psychological Methods, 15, 124–144.
Lee, P. M. (2004). Bayesian statistics: An introduction (3rd ed.). New York, NY: Wiley.
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research & Therapy, 33, 335–343.
Luciano, C. (2017). The self and responding to the own’s behavior. Implications of coherence and hierarchical framing. International Journal of Psychology & Psychological Therapy, 17, 267–275.
Luciano, C., & Hayes, S. C. (2001). Trastorno de evitación experiencial [Experiential avoidance disorder]. International Journal of Clinical & Health Psychology, 1, 109–157.
Luciano, C., Valdivia-Salas, S., & Ruiz, F. J. (2012). The self as the context for rule-governed behavior. In L. McHugh & I. Stewart (Eds.), The self and perspective taking: Research and applications (pp. 143–160). Oakland, CA: Context Press.
Maughan, B., Collishaw, S., & Stringaris, A. (2013). Depression in childhood and adolescence. Journal of the Canadian Academy of Child & Adolescent Psychiatry, 22, 35–40.
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., et al. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980–989.
Muñiz, J., Elosua, P., & Hambleton, R. K. (2013). International Test Commission Guidelines for test translation and adaptation. Psicothema, 25, 151–157.
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder: A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology Review, 31, 371–382.
Nolen-Hoeksema, S., Stice, E., Wade, E., & Bohon, C. (2007). Reciprocal relations between rumination and bulimic, substance abuse, and depressive symptoms in female adolescents. Journal of Abnormal Psychology, 116, 198–207.
Parker, R. I., Brossart, D. F., Vannest, K. J., Long, J. R., Garcia de Alba, R., Baugh, F. G., & Sullivan, J. R. (2005). Effect sizes in single case research: How large is large? School Psychology Review, 34, 116–132.
Parker, R. I., & Vannest, K. (2009). An improved effect size for single-case research: Nonoverlap of all pairs. Behavior Therapy, 40, 357–367.
Parker, R. I., & Vannest, K. J. (2012). Bottom-up analysis of single-case research designs. Journal of Behavioral Education, 21, 254–265.
Păsărelu, C. R., Dobrean, A., Balazsi, R., Predescu, E., Şipos, R., & Lupu, V. (2016). The Penn State Worry Questionnaire for Children: Age, gender and clinical invariance. Child Psychiatry & Human Development, 48, 359–369.
Perren, S., & Alsaker, F. D. (2009). Depressive symptoms from kindergarten to early school age: Longitudinal associations with social skills deficits and peer victimization. Child & Adolescent Psychiatry & Mental Health, 3, 28–38.
Petts, R. A., Duenas, J. A., & Gaynor, S. T. (2017). Acceptance and commitment therapy for adolescent depression: Application with a diverse and predominantly socioeconomically disadvantaged sample. Journal of Contextual Behavioral Science, 6, 134–144.
Pustejovsky, J. E. (2016). scdhlm: A web-based calculator for between-case standardized mean differences (Version 0.3.1) [Web application]. Retrieved from: https://jepusto.shinyapps.io/scdhlm
Pustejovsky, J. E., Hedges, L. V., & Shadish, W. R. (2014). Design-comparable effect sizes in multiple baseline designs: A general modeling framework. Journal of Educational & Behavioral Statistics, 39, 368–393.
Rao, U., Weissman, M. M., Martin, J. A., & Hammond, R. W. (1993). Childhood depression and risk of suicide: A preliminary report of a longitudinal study. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 21–27.
Rouder, J. N., Morey, R. D., Verhagen, A. J., Swagman, A. R., & Wagenmakers, E.-J. (2017). Bayesian analysis of factorial designs. Psychological Methods, 22, 304–321.
Rouder, J. N., Speckman, P. L., Sun, D., Morey, R. D., & Iverson, G. (2009). Bayesian t-tests for accepting and rejecting the null hypothesis. Psychonomic Bulletin & Review, 16, 225–237.
Ruiz, F. J., Flórez, C. L., García-Martín, M. B., Monroy-Cifuentes, A., Barreto-Montero, K., García-Beltrán, D. M., et al. (2018). A multiple-baseline evaluation of a brief acceptance and commitment therapy protocol focused on repetitive negative thinking for moderate emotional disorders. Journal of Contextual Behavioral Science, 9, 1–14.
Ruiz, F. J., García-Beltrán, D. M., Monroy-Cifuentes, A., & Suárez-Falcón, J. C. (2019). Single-case experimental design evaluation of repetitive negative thinking-focused acceptance and commitment therapy in generalized anxiety disorder with couple-related worry. International Journal of Psychology and Psychological Therapy, 19, 261–276.
Ruiz, F. J., & Perete, L. (2015). Application of a relational frame theory account of psychological flexibility in young children. Psicothema, 27, 114–119.
Ruiz, F. J., Riaño-Hernández, D., Suárez-Falcón, J. C., & Luciano, C. (2016). Effect of a one-session ACT protocol in disrupting repetitive negative thinking: A randomized multiple-baseline design. International Journal of Psychology & Psychological Therapy, 16, 213–233.
Ruiz, F. J., Salazar, D. M., Suárez-Falcón, J. C., Peña-Vargas, A., Ehring, T., Barreto-Zambrano, M. L., & Gómez-Barreto, M. P. (in press). Psychometric properties and measurement invariance across gender and age-group of the Perseverative Thinking Questionnaire–Children (PTQ-C) in Colombia. Assessment.
Ruiz, F. J., Suárez-Falcón, J. C., Barbero-Rubio, A., & Flórez, C. L. (2019). Development and initial validation of the Generalized Pliance Questionnaire. Journal of Contextual Behavioral Science, 12, 189–198.
Salazar, D. M., Ruiz, F. J., Flórez, C. L., & Suárez-Falcón, J. C. (2018). Psychometric properties of the Generalized Pliance Questionnaire—Children. International Journal of Psychology & Psychological Therapy, 18, 271–284.
Salazar, D. M., Ruiz, F. J., Suárez-Falcón, J. C., Barreto-Zambrano, M. L., Gómez-Barreto, M. P., & Flórez, C. L. (2019). Psychometric properties of the Avoidance and Fusion Questionnaire—Youth in Colombia. Journal of Contextual Behavioral Science, 12, 305–313.
Sander, J. B., & McCarty, C. A. (2005). Youth depression in the family context: Familial risk factors and models of treatment. Clinical Child & Family Psychology Review, 8, 203–219.
Sen, P. K. (1968). Estimates of the regression coefficient based on Kendall’s tau. Journal of the American Statistical Association, 63, 1379–1389.
Sheehan, D., Shytle, D., Milo, K., Janavs, J., & Lecrubier, Y. (2009). MINI International Neuropsychiatric Interview for Children and Adolescents, English Version 6.0. Tampa, FL: University of South Florida.
Silverman, W. K., LaGreca, A. M., & Wasserstein, S. (1995). What do children worry about? Worries and their relation to anxiety. Child Development, 66, 671–686.
Swain, J., Hancock, K., Dixon, A., & Bowman, J. (2015). Acceptance and commitment therapy for children: A systematic review of intervention studies. Journal of Contextual Behavioral Science, 4, 73–85.
Tate, R. L., Perdices, M., Rosenkoetter, U., McDonald, S., Togher, L., Shadish, W., et al. (2016). The Single-Case Reporting Guideline In BEhavioural Interventions (SCRIBE) 2016: Explanation and elaboration. Archives of Scientific Psychology, 4, 10–31.
Thapar, A., Collishaw, S., Pine, D. S., & Thapar, A. K. (2012). Depression in adolescence. The Lancet, 379, 1056–1067.
Törneke, N., Luciano, C., Barnes-Holmes, Y., & Bond, F. W. (2016). Relational frame theory and three core strategies in understanding and treating human suffering. In R. D. Zettle, S. C. Hayes, D. Barnes-Holmes, & A. Biglan (Eds.), The Wiley handbook of contextual behavioral science (pp. 254–272). Oxford, UK: Wiley-Blackwell.
Urbaniak, G. C., & Plous, S. (2013). Research Randomizer, Version 4.0 (Web-based application. Available at www.randomizer.org
Valentine, J. C., Tanner-Smith, E. E., & Pustejovsky, J. E. (2016). Between-case standardized mean difference effect sizes for single-case designs: A primer and tutorial using the scdhlm web application. Oslo, Norway: Campbell Collaboration.
Vannest, K. J., Parker, R. I., Davis, J. L., Soares, D. A., & Smith, S. L. (2012). The Theil-Sen slope for high stakes decision from progress monitoring. Behavioral Disorders, 37, 271–280.
Vannest, K. J., Parker, R. I., & Gonen, O. (2011). Single-case research: Web-based calculator for SCR analysis, Version 1.0 (Web-based application). College Station, TX: Texas A&M University Available from www.singlecaseresearch.org.
Wagenmakers, E. J., Wetzels, R., Borsboom, D., & van der Maas, H. L. J. (2011). Why psychologists must change the way they analyze their data: The case of Psi: Comment on Bem (2011). Journal of Personality & Social Psychology, 3, 426–432.
Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological Bulletin, 134, 163–206.
Watkins, E. R. (2016). Rumination-focused cognitive-behavioral therapy for depression. New York, NY: Guilford Press.
Weersing, V. R., Jeffreys, M., Do, M. C. T., Schwartz, K. T., & Bolano, C. (2017). Evidence base update of psychosocial treatments for child and adolescent depression. Journal of Clinical Child & Adolescent Psychology, 46, 11–43.
Wells, A. (2009). Metacognitive therapy for anxiety and depression. New York, NY: Guilford Press.
Yang, L., Zhou, X., Zhou, C., Zhang, Y., Pu, J., Liu, L., et al. (2017). Efficacy and acceptability of cognitive behavioral therapy for depression in children: A systematic review and meta-analysis. Academic Pediatrics, 17, 9–16.
Zhou, X., Hetrick, S. E., Cuijpers, P., Qin, B., Barth, J., Whittington, C. J., et al. (2015). Comparative efficacy and acceptability of psychotherapies for depression in children and adolescents: A systematic review and network meta-analysis. World Psychiatry, 14, 207–222.
Availability of Data and Materials
The raw data of this study can be downloaded at https://osf.io/7r3gn/. The results of the statistical analyses that are not reported in the manuscript for the sake of brevity can be found at https://osf.io/a7z6q/ and https://osf.io/7bp3f/. The RNT-focused ACT protocol employed in this study can be downloaded at https://osf.io/ub2n8/
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The authors declare that they have no conflict of interest.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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Salazar, D.M., Ruiz, F.J., Ramírez, E.S. et al. Acceptance and Commitment Therapy Focused on Repetitive Negative Thinking for Child Depression: A Randomized Multiple-Baseline Evaluation. Psychol Rec 70, 373–386 (2020). https://doi.org/10.1007/s40732-019-00362-5
- Child depression
- Acceptance and commitment therapy
- Relational frame theory
- Repetitive negative thinking