Anxiety and depressive disorders are common conditions for adolescents and are associated with significant impairments in functioning. Cognitive behavior therapy (CBT) is an effective treatment modality for these youth, and the behavioral components of CBT protocols, in particular, are thought to be one of the active mechanisms through which positive symptom changes are produced. However, few procedures are available to measure the behavioral changes taking place in adolescents’ daily lives as they make therapeutic progress. This study examined adolescents’ “behavioral engagement” throughout treatment, a construct defined as time spent in social, athletic and academic activities. Behavioral engagement was measured using the Daily Phone Diary (DPD), a validated measure of daily activities utilized in the child health literature, which employs the principles of Ecological Momentary Assessment (EMA). Twenty-four adolescents reported each activity they engaged in throughout the day, in chronological order, over the past 24 hours. Participants were diverse in their ages, ethnicities, socioeconomic statuses and internalizing disorder diagnoses. Activities were reported during phone calls scheduled before, during, and after treatment using a transdiagnostic formulation of CBT and, for a randomized subset of the sample (N=8), both before and following a Waitlist comparison condition. Results indicated that “behavioral engagement” is a construct that is measurable and that daily phone diaries are an acceptable method of data collection for this population. Based on theoretical and empirical literature, three key categories of activities on the DPD comprised behavioral engagement: 1) Time spent socially engaged with others; 2) Time spent on any physical or athletic activity; and 3) Time doing homework. Results supported good inter-rater reliability and potentially reasonable test-retest reliability; data collection via the DPD was feasible and acceptable in this context. Tests of convergent validity with other measures of anxiety and depressive symptoms suggested that prior to treatment, more time spent in some activity categories was associated with more internalizing symptoms for those with anxiety disorders only, but fewer internalizing symptoms for those with depression as well as anxiety. Tests of convergent validity with other measures of weekly mood were promising. Future studies will explore alternate definitions of behavioral engagement, examine this construct in a larger sample that has completed a full course of CBT, and explore this construct’s potential role as a mediator of clinical improvement.

Abstract Although spiritual or religious behaviors are sometimes targeted within behavioral activation protocols (Hopko & Lejuez, 2007; Hopko, Lejuez, Ruggiero, & Eifert, 2003), the efficacy of a protocol that exclusively develops a religiously-based behavioral repertoire has not been investigated. This randomized controlled study investigated the efficacy of a brief protocol for religious action in behavioral activation (PRA-BA) relative to a no-treatment “support” condition among mild to moderately depressed undergraduate students (n = 50). PRA-BA consisted of an individualized one-session intervention and 2-week activation interval. Clinical outcomes assessed depression, environmental reward, anxiety, and quality of life. Repeated measures ANOVAs indicated that the PRA-BA group had significantly greater decreases in depression and anxiety and increases in environmental reward at post-treatment. There was also a statistical trend indicating that PRA-BA may improve quality of life. At one-month follow-up, treatment gains were maintained for the PRA-BA participants. This study provides encouraging support for the efficacy of a strictly religiously-based behavioral intervention toward attenuating symptoms of depression in college students.

Apathy, a symptom reflecting motivational and self-initiation impairment, is one of the most common neuropsychiatric symptoms in Parkinson's disease (PD), with an average estimated prevalence of 40-45%. Elevated apathy has been associated with a host of negative associates and consequences, including cognitive impairment, poor daily functioning, poor treatment compliance and illness outcome, reduced quality of life, and increased caregiver burden and distress. While some studies have evaluated pharmacologic approaches to the treatment of apathy, few studies have evaluated non-pharmacologic approaches and we have identified no studies that have evaluated the efficacy of non-pharmacologic treatments of apathy in Parkinson's patients despite the need for such research. The purpose of the present study was to develop and gather pilot data on the acceptability, feasibility, and estimated efficacy of a primarily telephone-based, 6-week activity scheduling and monitoring intervention that incorporates an external cueing component to target disease-related self-generational deficits, on reducing levels of apathy in non-demented, highly apathetic PD patients. The project included three phases: (1) development of protocol materials, (2) determine ease of training paraprofessional interventionists, and (3) to assess feasibility, acceptability, and estimated effect of treatment in a one-arm uncontrolled trial. Patient apathy, depression, and quality of life significantly improved post-treatment and improvements in apathy and depression were maintained at one-month follow-up. While enrollment proved challenging, feasibility, acceptability, and efficacy data were strong and promising. Larger, randomized controlled trials are needed to investigate the efficacy of the presented intervention.

Behavioral Activation theory (Martell, Addis, & Jacobson, 2001) posits that a pattern of excessive use of avoidant coping strategies removes an individual from environmental sources of reward and reinforcement and subsequently leads to the development (or maintenance) of depressive symptoms. This investigation examined this theory by establishing measures of environmental reward as mediators between avoidance and depression, while further demonstrating that there is a strong connection between avoidance and depression independent of anxiety. Reward was measured by both self-report questionnaire (Reward Probability Inventory; Carvalho et al., under review) and daily activity diary ratings (Hopko, Bell, Armento, Hunt, & Lejuez, 2003), which were considered proxy measures for positive reinforcement. Avoidance was primarily assessed with the Cognitive-Behavioral Avoidance Scale (CBAS; Ottenbreit & Dobson, 2004), which distinguishes between cognitive and behavioral avoidance. When anxiety was controlled, reward significantly mediated the relationships between depression and cognitive, behavioral, and total avoidance. However, when structural equation modeling incorporating latent variables for avoidance and reward tested the same model, reward was not a mediator. In post-hoc mediation analyses, gender differences emerged whereby among females, diary-measured reward only mediated the relation between cognitive avoidance and depression when anxiety was controlled, while in males diary reward was a mediator with all three forms of avoidance. This investigation, while producing mixed results overall, provides initial support for the proposed mediating role of reinforcement in the relationship between avoidance and depression and further highlights the relevance of avoidance and reinforcement in the conceptualization of depression.

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Selective attention towards alcohol-related cues (i.e., “attentional bias”) is thought to reflect increased incentive motivational value of alcohol and alcohol cues acquired through a history of heavy alcohol use, and as such attentional bias is considered to be a clinically relevant factor contributing to alcohol use disorders. This dissertation consists of two studies that investigated specific mechanisms through which attentional bias might serve to promote alcohol abuse. Study 1 compared magnitude of attentional bias in heavy (n = 20) and light (n = 20) drinkers following placebo and two doses of alcohol (0.45 g/kg and 0.65 g/kg). Heavy drinkers displayed significantly greater attentional bias than did moderate drinkers following placebo. However, heavy drinkers displayed a dose-dependent decrease in response to alcohol. Individual differences in attentional bias under placebo were associated with both self-reported and laboratory alcohol consumption, yet bias following alcohol administration did not predict either measure of consumption. These findings suggest that attentional bias is strongest before a drinking episode begins, and as such might be most influential in terms of initiation of alcohol consumption. Study 2 addressed theoretical accounts regarding potential reciprocal interactions between attentional bias and inhibitory control that might promote excessive alcohol consumption. Fifty drinkers performed a measure of attentional bias and a novel task that measures the degree to which alcohol-related stimuli can increase behavioral activation and reduce the ability to inhibit inappropriate responses. As hypothesized, inhibitory failures were significantly greater following alcohol images compared to neutral images. Further, heightened attentional bias was associated with greater response activation following alcohol images. These findings suggest that alcohol stimuli serve to disrupt mechanisms of behavioral control, and that heightened attentional bias is associated with greater disruption of control mechanisms following alcohol images. Taken together, these studies provide strong evidence of an association between attentional bias in sober individuals and alcohol consumption, suggesting a pronounced role of attentional bias in initiation of consumption. Further, findings show that attention to alcohol cues can serve to disrupt mechanisms of inhibitory control that might be necessary to regulate drinking behavior, suggesting a potential means through which attentional bias might promote consumption.

Autism Spectrum Disorder (ASD) is a developmental disorder known for deficits in language and social skills. It is often associated with maladaptive behaviors. Studies have indicated that these behaviors in children lead to increased stress, anxiety and depression in mothers. This study examines the effects of parent-implemented Positive Behavior Support (PBS) and behavioral activation (BA) on reducing problem behaviors and increasing maternal wellness. The single subject study was conducted with three mothers (between the ages of 30 and 45) and their three children (between the ages of 5 and 7) with autism spectrum disorder. The results of this study demonstrate that while PBS implementation does reduce problem behaviors, it does not significantly impact maternal well-being. Results indicated that two of the three mothers were able to implement PBS interventions and their children demonstrated significant behavioral improvements. These mothers also engaged in high levels of valued activities both at baseline and during intervention and showed few depression symptoms. The third mother was not able to implement the interventions and her child demonstrated little behavioral progress. This mother showed signs of depression and did not make gains in this area. Further research may want to examine the relationship between behavioral activation and respite care, as well as the role of socioeconomic status.

Cocaine users display impaired inhibitory control. The influence of cocaine-related stimuli on inhibitory control has not been assessed. The Attentional Bias-Behavioral Activation (ABBA) task uses cocaine and neutral images as cues to determine if drug-related images impair inhibitory control in cocaine users. This dissertation was designed to assess the influence of cocaine images on inhibitory control in cocaine users through the conduct of studies designed to address four aims. The first aim was to demonstrate that cocaine users display impaired inhibitory control following cocaine images compared to neutral images on the ABBA task. This was accomplished through the conduct of two experiments. The first experiment piloted the ABBA task and cocaine users completed the cocaine go (n = 15) or neutral go condition (n = 15) of the task. The second experiment consisted of two studies designed to develop a within-subjects methodology for using the ABBA task. In the first study, cocaine users completed either the cocaine go (n = 20) or neutral go (n = 20) condition of the ABBA task and all participants also completed the Cued Go/No-Go task, with geometric shapes as cues. In the second study, cocaine users (n = 18) completed the cocaine go condition of the ABBA task and a modified version of the ABBA task with all neutral images as cues to further refine a possible within-subjects methodology. The second aim was to demonstrate that inhibitory failures occur most often when cues are presented for short compared to longer durations of time. Data collected during other protocols (n = 91) were combined to investigate the influence of stimulus onset asynchrony (SOA; i.e., the amount of time a cue is presented before a target indicated a response should be executed or withheld) on inhibitory control following cocaine-related and neutral cues on the ABBA task. The third aim was to demonstrate impaired inhibitory control following cocaine images on the ABBA task is specific to cocaine users. Cocaine users (data collected in the second experiment of the first aim) and non-using control participants (n = 16) completed the cocaine go and all neutral conditions of the ABBA task and the Cued Go/No-Go task. The fourth aim was to demonstrate the feasibility and acceptability of inhibitory control training to cocaine-related stimuli with cocaine users. A small pilot clinical trial was conducted and cocaine users were randomly assigned to complete inhibitory control training to cocaine images or geometric shapes. Cocaine images impaired inhibitory control on the ABBA task, as demonstrated by an increased proportion of inhibitory failures in the cocaine go condition compared to the neutral go condition in Experiments 1, 2, and 4. The proportion of inhibitory failures following cocaine images in Experiment 4 was increased at short (i.e., 100, 200) compared to long SOAs. Cocaine images also impaired inhibitory control compared to the Cued Go/No-Go Task in Experiment 2, however there were no differences in the proportion of inhibitory failures between the cocaine go and all neutral conditions of the ABBA task. There were no differences between cocaine users and controls in Experiment 3 for the proportion of inhibitory failures on the ABBA or Cued Go/No-Go tasks, but controls responded faster indicating a speed/accuracy trade off occurred in the control group. Inhibitory control training as an approach to improve treatment outcomes is feasible, as indicated by attendance and accuracy on the training task, and participants rated the overall procedure as satisfactory in Experiment 5. A better understanding of inhibitory control in the presence of cocaine related cues could be crucial to better understand how drug cues contribute to the risk for relapse and the continued use of drugs because both occur in the presence of drug cues.