Rumination and the Risk of Substance Abuse in Adolescents

Journal of Abnormal Psychology Copyright 2007 by the American Psychological Association 2007, Vol. 116, No. 1, 198 207 0021-843X/07/$12.00 DOI: 10.1037/0021-843X.116.1.198 Reciprocal Relations Between Rumination and Bulimic, Substance Abuse, and Depressive Symptoms in Female Adolescents Susan Nolen-Hoeksema Yale University Eric Stice, Emily Wade, and Cara Bohon University of Texas at Austin The authors examined the reciprocal relations between rumination and symptoms of depression, bulimia, and substance abuse with longitudinal data from 496 female adolescents. Rumination predicted future increases in bulimic and substance abuse symptoms, as well as onset of major depression, binge eating, and substance abuse. Depressive and bulimic, but not substance abuse, symptoms predicted increases in rumination. Rumination did not predict increases in externalizing symptoms, providing evidence for the specificity of effects of rumination, although externalizing symptoms predicted future increases in rumination. Results suggest rumination may contribute to the etiology of depressive, bulimic, and substance abuse pathology and that the former two disturbances may foster increased rumination. Results imply that it might be beneficial for prevention programs to target this cognitive vulnerability. Keywords: depression, eating disorders, substance abuse, rumination, adolescence A ruminative response style is the tendency to repetitively focus on symptoms of distress and possible causes and consequences of these symptoms without engaging in active problem solving (Nolen-Hoeksema, 2004). Prospective studies have found that a ruminative response style predicts depressive symptoms and disorders in adults (see Lyubomirsky & Tkach, 2004, for a comprehensive review). Prospective studies of adolescents and children have similarly suggested that those who engage in more rumination are more prone to show increases in depressive symptoms (Abela, Brozina, & Haigh, 2002; Schwartz & Koenig, 1996). Various theorists have attempted to explain the origins of a ruminative response style. Nolen-Hoeksema (2004) posited that children and young adolescents who are temperamentally prone to distress, or who experience depression early in childhood, are more likely to develop a ruminative response style, particularly if their caregivers do not teach them adaptive mood regulation skills. The lack of mood regulation skills in these young children may lead them to focus on their distress and feel helpless to cope (Fabes, Eisenberg, Karbon, Troyer, & Switzer, 1994). Crick and Zahn-Waxler (2003) suggested that distressed girls may be especially likely to receive parenting that reinforces a helpless, rather than instrumental, response to distress. Parents are more likely to Susan Nolen-Hoeksema, Department of Psychology, Yale University; Eric Stice, Emily Wade, and Cara Bohon, Department of Psychology, University of Texas at Austin. This study was supported by a career award (MH01708) and National Institute of Health Grant MH64560 to Eric Stice. We thank project research assistants, Sarah Kate Bearman, Emily Burton, Melissa Fisher, Lisa Groesz, Natalie McKee, and Katy Whitenton, our numerous undergraduate volunteers, the Austin Independent School District, and the participants who made this study possible. Correspondence concerning this article should be addressed to Susan Nolen-Hoeksema, Department of Psychology, Yale University, P.O. Box 208205, New Haven, CT 06520. E-mail: Susan.Nolen-Hoeksema@ yale.edu encourage and reward sadness in girls than in boys (Fivush, Brotman, Buckner, & Goodman, 2000; Garside & Klimes- Dougan, 2002). In contrast, parents may encourage active coping responses for boys, such as engaging in distracting behaviors (Crick & Zahn-Waxler, 2003). Thus, early experiences of distress or depression, particularly in girls, may contribute to the future development of a ruminative response style, which may contribute to later experiences of depressive symptoms. Although we know of no studies that test whether childhood or adolescent depression predicts development of a ruminative response style, prospective studies have supported this relation in adults (Nolen-Hoeksema, Larson, & Grayson, 1999). In the present study, we examined the relations between depression and rumination from early adolescence to later adolescence in a community sample of girls. We hypothesized that early depressive symptoms would predict future increases in ruminative tendencies and that these tendencies would also predict future increases in depression. Female adolescents are a particularly appropriate group in which to test our predictions because the prevalence of depressive symptoms increases markedly across adolescence in girls but not in boys (Twenge & Nolen-Hoeksema, 2002), and as noted, theorists have argued that early distress may lead to passive, ruminative coping tendencies more in girls than in boys (Crick & Zahn-Waxler, 2003). Escape From Rumination In addition to increasing risk for depressive symptoms, a ruminative response style may increase risk for maladaptive behaviors used to avoid self-directed ruminations. Some social psychologists suggest that people with high levels of self-consciousness sometimes use alcohol to escape from the self (Heatherton & Baumeister, 1991; Hull, 1981). For example, experimental studies indicate that people who report high levels of private self-consciousness, the tendency to focus on and analyze the self (Fenigstein, Scheier, & Buss, 1975), drink more after they have been made to fail at a task, particularly if a heightened self-awareness is induced along 198

RECIPROCAL RELATIONS 199 with the failure (Hull, Levenson, Young, & Sher, 1983; Hull & Levy, 1979). Private self-consciousness is correlated, although not synonymous, with rumination (Nolen-Hoeksema, 1991). In a prospective study of community-based adults, Nolen-Hoeksema and Harrell (2002) found that women and men who scored higher on a measure of rumination were more likely to report drinking to cope with distress and greater problematic substance use. In addition, rumination predicted increases in social problems related to substance use, particularly among women. Therefore, in the present study we tested the hypothesis that rumination would predict future increases in substance abuse symptoms in female adolescents. Theorists have also suggested that binge eating serves as an escape from the self (Abramson, Bardone-Cone, Vohs, Joiner, & Heatherton, 2006; Heatherton & Baumeister, 1991). We know of no studies testing the relation between rumination as we operationalize it and bulimic symptoms. Several models of bulimia, however, suggest that binge eating is used as a strategy to escape from symptoms of depression or general distress, and purging is used to reduce the distress caused by fear of weight gain (Fairburn et al., 1995; McCarthy, 1990). Depressive symptoms and negative affect have been found to predict future onset or exacerbation of bulimic symptoms (Cooley & Toray, 2001; Field, Camargo, Taylor, Berkey, & Colditz, 1999; Killen et al., 1996; Stice, Burton, & Shaw, 2004; Stice, Presnell, & Spangler, 2002). In the current study, we tested whether rumination predicted future increases in bulimic symptoms in female adolescents. We also examined whether early experiences of bulimic symptoms or substance abuse predicted increases in rumination. An inability to control eating behavior or substance use might result in negative self-perceptions and negative social consequences. These negative self-perceptions and social problems could fuel ruminations about one s self-worth and relationships, contributing to a ruminative response style (Nolen-Hoeksema et al., 1999). Thus, in the current study, we tested the reciprocal relations between rumination and symptoms of bulimia nervosa and substance abuse. The Specificity of Rumination Researchers attempting to determine whether rumination is reciprocally related to depressive, bulimic, and substance abuse symptoms should test whether there are forms of psychopathology not related to rumination. An important step in validating a hypothesized etiologic process is to provide evidence of predictive specificity (Ralph & Mineka, 1998). Antisocial, aggressive behaviors are related to difficulties in perspective taking, lack of empathy for others, and making otherblaming attributions for events (Crick & Dodge, 1994; Crick & Zahn-Waxler, 2003). In contrast, rumination is associated with excessive concern for relationships and the opinions of others and self-blaming attributions (Nolen-Hoeksema & Jackson, 2001; Robinson & Alloy, 2003). Thus, we hypothesized that rumination would not be reciprocally related to delinquent and aggressive behaviors. Method Participants Participants were 496 female adolescents from four public (82%) and four private (18%) middle schools in a metropolitan area. Adolescents ranged in age from 11 to 15 years (M 13.5 years, SD 0.67) at baseline. The sample included 2% Asian or Pacific Islanders, 7% African Americans, 68% Caucasians, 18% Hispanics, 1% Native Americans, and 4% who specified other or mixed racial heritage. This was representative of the ethnic composition of the schools from which we sampled (2% Asian or Pacific Islanders, 8% African Americans, 65% Caucasians, 21% Hispanics, 4% other or mixed racial heritage). Average parental education, a proxy for socioeconomic status, was 29% high school graduate or less, 23% some college, 33% college graduate, and 15% graduate degree, which was representative of the metropolitan area from which we sampled (34% high school graduate or less, 25% some college, 26% college graduate, 15% graduate degree). Procedures The study was described to parents and participants as an investigation of adolescent mental and physical health. An active parental consent procedure, wherein an informed consent letter describing the study and a stamped self-addressed return envelope were sent to parents of eligible girls (a second mailing was sent to nonresponders), was used to recruit participants. Adolescents provided assent immediately before data collection. This resulted in an average participation rate of 56%, which was comparable with rates in other school-recruited samples that used active consent procedures and structured interviews (e.g., 61% for Lewinsohn et al., 1994). Participants completed a survey and participated in a structured interview at baseline and at five annual follow-up assessments. One-year intervals were used for follow-ups to avoid seasonal effects and because previous work by our group has shown that adolescents are willing to complete assessments once per year, but more frequent assessments can result in more substantial attrition. Because we did not assess rumination prior to the third assessment, we focused this article solely on data from the third, fourth, fifth, and sixth annual assessments (which are referred to as T1, T2, T3, and T4, respectively, for this article). Adolescents ranged in age from 14 to 17 years at T1 (M 15.0, SD 0.73), 15 to 18 years at T2 (M 16.0, SD 0.73), 16 to 19 years at T3 (M 17.0, SD 0.73), and 17 to 20 years at T4 (M 18.0, SD 0.73). Female clinical assessors with a bachelor, masters, or doctoral degree in psychology conducted all interviews. Assessors initially attended 24 hr of training, wherein they were taught structured interview skills, reviewed diagnostic criteria for relevant Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM IV; American Psychiatric Association, 1994) disorders, observed simulated interviews, and role-played interviews. Before the assessors collected data, we reviewed 12 tape-recorded interviews they conducted with individuals with and without eating disorders and major depression to ensure high interrater agreement (.80) with the project coordinator. Assessors also attended refresher interviewer training workshops twice a year throughout the study. We recorded interviews periodically during the study to ensure that assessors continued to show acceptable interrater agreement (.80) with the project coordinator and so that continued supervision could be provided. A randomly selected subset of interviews (5% annually) was recorded to ensure that assessors continued to show acceptable interrater agreement (.80).

200 NOLEN-HOEKSEMA, STICE, WADE, AND BOHON Another randomly selected subset of participants (5% annually) completed a second interview by the same assessor to ensure acceptable test retest reliability. Assessments took place at the school during or immediately after school hours or at participants houses. Participants received a gift certificate to a local book and music store or a cash payment for compensation at each assessment. Measures Rumination. Six items from the original 22-item Rumination Scale of the Response Styles Questionnaire (Nolen-Hoeksema & Jackson, 2001) were used to measure rumination; only six items were used because of respondent burden concerns. These items were chosen on the basis of two criteria: (a) They covered ruminations about current feelings, self-evaluations, and recent situations; and (b) they correlated highly (rs.90) with total scores on the full Rumination Scale in an adult sample (Nolen-Hoeksema et al., 1999). In a sample of adolescent girls, this abbreviated six-item scale correlated highly (r.93) with the full Rumination Scale, and the abbreviated and the full scales showed similar correlations with self-reported depression (r.46 and r.56, respectively; M. Kovacs, personal communication, August 8, 2005). Sample items were think about all my shortcomings, failings, faults, and mistakes and think about how upset I feel. Participants in this study were instructed to please choose the number that best describes what you generally do when you are upset, on a scale from 1 (never or almost never) to4(always or almost always). The items used in the present study reflected the brooding factor from the original 22-item Rumination Scale, which Treynor, Gonzalez, and Nolen-Hoeksema (2003) found predicted depression in an adult sample, rather than the pondering items that did not predict depression. This abbreviated scale showed acceptable internal consistency in the present study (.82.83), as well as test retest reliabilities (see Table 1) similar to those found for the full scale in adult samples (see Nolen-Hoeksema et al., 1999). Depressive symptoms. An adapted version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Puig-Antich & Chambers, 1983), a semistructured diagnostic interview, was used to assess DSM IV symptoms of major depression. The past-year severity ratings for each symptom were averaged to form a continuous depressive symptom composite at each assessment point. These items ask participants to report on the peak severity of each symptom during any time that they experienced this symptom during the prior 12 months. It was not necessary for the peak severity periods across symptoms to co-occur. Response options ranged from 1 (not at all) to4(severe symptoms). Responses were also used at each annual assessment to determine whether each participant met diagnostic criteria for DSM IV major depression over the past year. It was necessary for the symptoms to occur simultaneously for a diagnosis. The Schedule for Affective Disorders and Schizophrenia for School-Age Children has been found to have acceptable test retest reliability (.63 1.00), interrater reliability (.73 1.00) for depression diagnoses, and internal consistency (.68.84), and to discriminate between depressed and nondepressed individuals (Ambrosini, 2000). To assess the interrater reliability in our study, we randomly selected a subset of participants (5% annually) to be reinterviewed within a 3-day period by a second assessor who was blind to the first diagnosis. This resulted in high interrater agreement for diagnoses ( 1.0) and for the continuous symptom composite (r.87). Another randomly selected subset of participants (5% annually) completed a second diagnostic interview with the same assessor 1 week later and showed high test retest reliability for diagnoses ( 1.0) and for the continuous symptom composite (r.86). Furthermore, depressive symptoms and major depression diagnoses derived from this interview in the current Table 1 Correlations Between Ruminative, Depressive, Bulimic, Substance Abuse, and Externalizing Symptom Composites Variable 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 M SD Skew 1. T1 ruminative coping.52.26.20.32.44.34.29.15.23.37.30.21.21.15.32.21.13.23.13 2.24 0.66 0.50 2. T1 depressive symptoms.37.33.37.30.55.27.22.30.31.46.23.21.24.21.39.18.26.22 1.38 0.37 1.74 3. T1 bulimic symptoms.16.23.17.30.37.17.18.20.26.33.19.17.10.24.28.19.16 0.50 0.59 0.32 4. T1 substance use.51.04.19.15.46.34.06.17.03.48.32.06.17.02.37.22 0.09 0.26 1.73 5. T1 externalizing symptoms.20.30.12.38.66.15.24.10.33.55.12.24.07.25.39 1.67 0.60 1.89 6. T2 ruminative coping.39.25.17.34.49.36.33.20.26.38.28.19.14.23 2.36 0.66 0.40 7. T2 depressive symptoms.25.26.42.36.64.22.27.40.30.53.21.20.38 1.41 0.41 1.60 8. T2 bulimic symptoms.16.18.23.25.38.17.12.17.19.31.13.07 0.52 0.48 0.03 9. T2 substance use.46.08.15.04.62.30.13.16.06.46.27 0.12 0.29 1.36 10. T2 externalizing symptoms.22.32.09.37.67.22.30.11.33.49 1.61 0.54 1.95 11. T3 ruminative coping.53.19.23.31.56.35.19.17.28 2.34 0.67 0.42 12. T3 depressive symptoms.24.32.42.36.55.20.23.36 1.44 0.43 1.62 13. T3 bulimic symptoms.12.10.21.26.33.08.12 0.52 0.57 0.33 14. T3 substance use.36.17.19.09.54.32 0.10 0.26 1.48 15. T3 externalizing symptoms.30.33.15.35.63 1.58 0.50 1.94 16. T4 ruminative coping.36.21.22.40 2.28 0.64 0.50 17. T4 depressive symptoms.32.25.35 1.46 0.42 1.47 18. T4 bulimic symptoms.13.24 0.57 0.73 0.71 19. T4 substance use.43 0.10 0.26 1.42 20. T4 externalizing symptoms 1.47 0.42 2.26 Note. Absolute correlations greater than.09 are significant at p.05. The skew coefficients for the bulimic symptom and substance abuse symptom composites are from the transformed version of these variables used in the analyses. T1 Time 1; T2 Time 2; T3 Time 3; T4 Time 4.

RECIPROCAL RELATIONS 201 data set have been found to have predictive validity for future onset of bulimia nervosa, substance abuse, and obesity (Stice et al., 2004; Stice, Presnell, Shaw, & Rohde, 2005). This symptom composite showed internal consistency in the present study (.79.82). Bulimic pathology. We used the Eating Disorder Examination (Fairburn & Cooper, 1993), a semistructured psychiatric interview, to assess diagnostic symptoms of DSM IV bulimia nervosa. The severity ratings for each month over the past year for each diagnostic item were averaged to form a continuous bulimic symptom composite at each assessment. This composite reflected binge frequency, compensatory behavior frequency (vomiting, diuretic use, laxative use, fasting), and overvaluation of weight and shape over the past year. As the symptom composite was skewed, a normalizing square root transformation was applied. Responses were also used to determine whether each participant reported onset of binge eating or compensatory behaviors (i.e., vomiting, laxative or diuretic use, fasting, or excessive exercise for weightcontrol purposes) over the study period (at least two episodes). The Eating Disorder Examination has good internal consistency (.76.90), has good interrater reliability (.70.99), and it discriminates between eating disordered individuals and controls (Fairburn & Cooper, 1993; Williamson, Anderson, Jackman, & Jackson, 1995). We randomly selected a subset of girls (5% annually) to complete a second blinded diagnostic interview to assess interrater agreement. This assessment showed high interrater agreement for eating disorder diagnoses (.88) and for the symptom composite (r.70). Another randomly selected subset of girls (5% annually) completed a second diagnostic interview with the same clinical assessor 1 week later and showed high test retest reliability for eating disorder diagnoses ( 1.0) and the symptom composite (r.62). The symptom composite showed internal consistency in the present study (.92.94). Substance abuse. We used survey items adapted from Stice, Barrera, and Chassin (1998) to assess DSM IV substance abuse symptoms over the past year. Because the DSM IV criteria for substance abuse are based on the impairment and distress caused by substance use rather than the frequency or duration of use itself, the items used in this study were specifically developed to assess substance use-related negative consequences in adolescents (e.g., items assessing obligation impairment inquired about negative consequences in both the school and work environments). Items focused on obligation impairment, health problems, physically hazardous behavior, legal problems, and social difficulties resulting from substance use (e.g., got arrested because of substance use, had an accident or injury because of substance use, lost a job or got kicked out of school because of substance use). Items inquiring about the frequency of eight substance use-related negative consequences during the past year were averaged to create a continuous substance abuse symptom composite at each assessment. Response options ranged from 1 (never) to3(twice or more). Because this composite was skewed, we used a log 10 transformation to normalize the distribution. Responses were also used to determine whether each participant satisfied DSM IV criteria for substance abuse in the past year at each of the four assessment points. These items have shown internal consistency (.85), 1-month test retest reliability (r.78), and predictive validity for future onset of depression (Stice et al., 1998, 2004). The substance abuse diagnoses derived from these items showed 1-month test retest reliability (.74) in a sample of 481 adolescent girls (Stice, Shaw, Burton, & Wade, 2006). More generally, self-reports of substance use appear to be the most valid measure of substance abuse (Winters, Stinchfield, Henly, & Schwartz, 1991). This symptom composite showed internal consistency in the present study (.84.86). Externalizing symptoms. Survey items from the Externalizing Syndrome of the Child Behavior Checklist (Achenbach & Edelbrock, 1983) were used to assess externalizing symptoms. Five items came from the delinquency subscale and 8 came from the aggression subscale. Participants reported on the frequency of each behavior over the past year using an expanded response format that ranged from 1 (never) to5(always). Severity ratings for all 13 symptoms were averaged to form an externalizing symptom composite at each assessment. This scale has shown internal consistency (.88), 1-year test retest reliability (r.62), and predictive validity for future substance abuse (Stice et al., 1998). This symptom composite showed internal consistency in the present study (.88.90). Scores from the scale used in the present study were significantly correlated with scores from the full externalizing scale of the Child Behavior Checklist Youth Self-Report (r.87) in a female subset (N 87) of a community sample of adolescents (see Little & Garber, 2005, for sample description). Preliminary Analyses Results Data were collected for 486 participants at T1 (98%), 490 participants at T2 (99%), 484 participants at T3 (98%), and 478 participants at T4 (96%); 466 participants provided data at all four assessments (94%). Attrition analyses verified that participants who were missing data at any follow-up did not differ significantly from the remaining participants on demographic factors or any of the variables examined in this article, suggesting that attrition did not introduce bias. Because adolescent age, ethnicity, and parental education did not predict change in the four symptom outcomes examined in this article, these demographic variables were not included as covariates. The correlations among the T1, T2, T3, and T4 values of ruminative coping, depressive symptoms, bulimic symptoms, substance abuse symptoms, and externalizing symptoms are reported in Table 1, along with the means, standard deviations, and skew coefficients. Analytic Overview of Tests of Reciprocal Relations Following the recommendations of Singer and Willett (2003), we estimated lagged growth mixture models, with time-varying covariates, to test whether the continuous ruminative coping variable showed prospective reciprocal relations with the four continuous symptom composites. We estimated four separate N 1 lagged time-varying covariate models that tested whether rumination predicted future increases in each symptom domain over the subsequent 1-year period and whether each symptom domain predicted future increases in rumination over the subsequent 1-year period. These models tested the average predictive effect of the independent variable on the dependent variable over each of the three 1-year intervals in the present four-wave data set, con-

202 NOLEN-HOEKSEMA, STICE, WADE, AND BOHON trolling for the 1-year lag of the dependent variable (i.e., the autoregressive effects for the dependent variable). For example, the first model tested whether rumination assessed at T1, T2, and T3 predicted depressive symptoms at T2, T3, and T4, respectively, controlling for the effects of depressive symptoms at the prior assessment, as well as whether depressive symptoms at T1, T2, and T3 predicted rumination at T2, T3, and T4, respectively, controlling for the effects of rumination at the prior assessment. Models were estimated with the hierarchical linear modeling program (Version 6; Bryk, Raudenbush, & Congdon, 2004). In all models, variables were mean centered and the Level-1 intercept was treated as random to represent individuals variation on levels of the dependent variable. All estimated models used an equation that was parallel in form to the following, expressed in mixed model format, which models depressive symptoms as a function of the lag of depressive symptoms and the lag of ruminations: Depressive Symptoms 00 ( 10 Lag Depressive Symptoms) ( 20 Lag Ruminations) r 0 (r 2 Lag Ruminations) e. (1) To prevent a constant sigma squared value, we treated only one of the covariate slopes as a random effect. Thus, the lagged dependent variable was fixed, and the other covariate in the model was treated as a random effect. If the random effect for the slope parameter was not significant (e.g., r 2 Lag Ruminations), it was removed and models were reestimated. Reciprocal Relations Between Ruminative Coping and Depression The first aim was to test the hypothesis that ruminative coping would predict future increases in depressive symptoms and that depressive symptoms would predict future increases in ruminative coping. The 1-year lag of ruminative coping, controlling for the 1-year lag of depressive symptoms, exhibited a trend toward predicting higher levels of depressive symptoms, t(1408) 1.85, B 0.03, p.06. The 1-year lag of depressive symptoms, controlling for the 1-year lag of ruminative coping, predicted higher levels of ruminative coping, t(478) 4.95, B 0.23, p.001. Results from all lagged hierarchical linear modeling models are presented in Table 2. Reciprocal Relations of Ruminative Coping to Bulimic and Substance Abuse Symptoms The second aim was to test whether ruminative coping predicted future increases in bulimic and substance abuse symptoms that might be motivated in part by an effort to escape from aversive self-awareness and whether these symptom domains would predict future increases in ruminative coping. As hypothesized, the 1-year lag of ruminative coping, controlling for the 1-year lag of bulimic symptoms, predicted higher levels in bulimic symptoms, t(1401) 5.12, B 0.08, p.001. In addition, the 1-year lag of bulimic symptoms, controlling for the 1-year lag of ruminative coping, predicted higher levels in ruminative coping, t(1394) 3.56, B 0.15, p.01. With regard to substance abuse, the 1-year Table 2 Results of N 1 Lagged Hierarchical Linear Models Predictor Coefficient SE p Effects of rumination on depressive symptoms Depressive symptoms.54.028.00 Rumination a.03.014.06 Effects of depressive symptoms on rumination Rumination.39.032.00 Depressive symptoms.23.046.00 Effects of rumination on bulimic symptoms Bulimic symptoms.29.032.00 Rumination a.08.016.00 Effects of bulimic symptoms on rumination Rumination.46.030.00 Bulimic symptoms a.15.042.00 Effects of rumination on substance abuse symptoms Substance abuse symptoms.53.033.00 Rumination a.07.023.00 Effects of substance abuse symptoms on rumination Rumination.48.030.00 Substance abuse symptoms a.00.023.90 Effects of rumination on externalizing symptoms Externalizing symptoms.55.029.00 Rumination.02.020.21 Effects of externalizing symptoms on rumination Rumination.44.031.00 Externalizing symptoms.12.033.00 Note. Coefficient refers to unstandardized slope coefficient. a Slope treated as a fixed effect because p.05 for random effect. lags of ruminative coping, controlling for the 1-year lag of substance abuse symptoms, predicted higher levels of substance abuse symptoms, t(1397) 2.84, B 0.07, p.01. However, the 1-year lag in substance abuse symptoms, controlling for the 1-year lag of ruminative coping levels, did not predict ruminative coping levels, t(1396) 0.12, B 0.00, p ns. Relations Between Ruminative Coping and Externalizing Symptoms The third aim of this study was to provide a test of the specificity of ruminative coping by investigating whether ruminative coping and externalizing symptoms showed prospective reciprocal relations. As anticipated, the 1-year lag of ruminative coping, controlling for the 1-year lag of externalizing symptoms, did not predict externalizing symptoms, t(478) 1.25, B 0.02, p ns. However, the 1-year lag of externalizing symptoms, controlling for the 1-year lag of ruminative coping, predicted higher levels of ruminative coping, t(478) 3.81, B 0.12, p.001.

RECIPROCAL RELATIONS 203 Ancillary Analyses In the above analyses, we focused on predicting change in the continuous symptom measures because this allowed us to conduct parallel analyses for the four symptom domains examined in this article. We were also able to conduct analyses predicting onset of major depression and substance abuse. We were not able to predict onset of bulimia nervosa because of the low base rates in our sample on an annual basis, and we were not able to predict onset of externalizing pathology because we used a continuous measure. However, we were able to predict the onset of binge eating and compensatory behaviors. We first tested whether rumination predicted onset of major depression among participants who did not satisfy criteria for depression at T1. Following the recommendation of Singer and Willett (2003), we used Cox proportional hazards regression analyses to test whether initial level of ruminative coping increased risk for onset of major depression over the 3-year follow-up period. This analytic technique, also known as survival analysis, has the advantage of allowing for varying lengths of follow-up in longitudinal studies, which minimizes biases because of attrition and accommodates right censored cases that do not experience the target event during the study period. In total, 53 participants who were nondepressed at T1 showed onset of major depression over the 3-year follow-up period. The hazard model indicated that elevated ruminative coping scores at T1 increased risk for onset of major depression (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.51 3.29, p.001). This OR represents a moderate effect size according to Cohen s (1988) criteria. In additional analyses, we also tested whether elevated rumination showed predictive effects for onset of binge eating and compensatory behavior among initially asymptomatic participants, because these are the key behavioral features of bulimia nervosa and because escape models suggest that binge eating in particular is used to reduce self-focus or provide distraction. Binge eating was defined as eating, in a brief period of time, an amount of food that is definitely larger than most people would eat and experiencing a subjective loss of control over eating (American Psychiatric Association, 1994). Compensatory behavior was defined as use of one or more of the following methods to prevent weight gain following an episode of overeating: self-induced vomiting; laxative, diuretic, or enemas use; fasting; or excessive exercise (American Psychiatric Association, 1994). Over the 3-year follow-up, 35 participants showed initial onset of binge eating (at least twice), and 78 participants showed initial onset of compensatory behaviors (at least twice). The hazard models indicated that elevated ruminative coping scores at T1 increased risk for onset of recurrent binge eating (OR 1.82, 95% CI 1.13 2.92, p.013) but only showed a marginal relation to onset of compensatory behavior (OR 1.34, 95% CI 0.97 1.86, p.076). These ORs represent small effect sizes per Cohen s (1988) criteria. Finally, we tested whether ruminative coping predicted onset of DSM IV substance abuse. In total, 63 participants showed onset of substance abuse over the 3-year follow-up. The hazard models indicated that elevated ruminative coping scores at T1 increased risk for onset of substance abuse (OR 2.00, 95% CI 1.40 2.86, p.001). This OR represents a small effect size per Cohen s (1988) criteria. Discussion In this study, we examined the relations between rumination and depressive symptoms, bulimic symptoms, and substance abuse symptoms in adolescent females. Overall, the results suggest that rumination prospectively predicts increases in bulimic and substance abuse symptoms at least as well as it predicts increases in depressive symptoms in this age group of girls. Rumination did not predict externalizing behaviors, however, providing support for our hypothesis that rumination contributes to only certain kinds of psychopathology. We also found that depressive symptoms, bulimic symptoms, and externalizing symptoms predicted increases in rumination, suggesting pathways by which a ruminative response style might develop. Rumination and Depressive Symptoms Female adolescents who scored higher on our rumination measure showed nearly significantly elevated increases in depressive symptoms across the 1-year lags in our models of the continuous depression measure. In addition, girls with higher rumination scores at the initial assessment were more likely to develop episodes of major depression over the 4 years of the study. These results are largely consistent with numerous prospective studies of adults (see Lyubomirsky & Tkach, 2004) and with previous prospective studies of adolescents and children (Abela et al., 2002; Schwartz & Koenig, 1996). A particularly unique finding was that rumination predicted onset of clinically significant major depression, whereas prior prospective studies of adolescents have primarily been focused on predicting change in self-reported depressive symptoms. Depressive symptoms predicted increases in rumination over time. This supports arguments that early experiences of depressive symptoms foster a self-focused, ruminative coping style (Nolen- Hoeksema, 2004). There may be an ongoing reciprocal process across adolescence whereby depressive symptoms contribute to the development of a ruminative response style, which increases the risk for greater depressive symptoms, which then further increases risk for rumination. This corresponds to findings in longitudinal studies of cognitions and depressive symptoms in youths, showing that early depressive symptoms significantly predict the development of more negative cognitive styles, which subsequently predict increases in depressive symptoms (Nolen- Hoeksema, Girgus, & Seligman, 1992). Rumination and Bulimic and Substance Abuse Symptoms We hypothesized that girls who were more ruminative would show increases in bulimic and substance abuse symptoms because they would turn to these behaviors to escape from their ruminations. Girls with elevated rumination scores showed subsequent increases in bulimic symptoms and were more likely to show onset of binge eating over the course of the study. This represents a novel contribution to the literature. In addition, girls with elevated rumination scores showed subsequent increases in substance abuse symptoms across the study and were more likely to meet diagnostic criteria for substance abuse over the 4 years of the study. This result replicates earlier findings with adult women (Nolen- Hoeksema & Harrell, 2002).

204 NOLEN-HOEKSEMA, STICE, WADE, AND BOHON We note that our measures of bulimic behaviors and substance abuse focused on clinically significant symptoms, such as the frequency of bingeing and purging for bulimia and being suspended from school or arrested for substance use. Thus, a ruminative response style appears to predict not just mild symptoms of these disorders but symptoms that could have significant negative consequences for adolescents health and well-being. In addition, our survival analyses found that girls with elevated rumination scores at the first assessment were more likely to meet criteria for binge eating and substance abuse over the 4 years of the study. Our results suggest that adolescent girls may commonly turn to escapist behaviors to quell self-consciousness. In addition to having clinical implications, which we discuss below, these results raise questions about claims in early versions of the response styles theory (Nolen-Hoeksema, 1991) that rumination and distraction represented different, perhaps opposite, responses to depression. These two responses do indeed have opposite effects on mood and cognition when they are induced in dysphoric people in the laboratory (Lyubomirsky & Tkach, 2004). But if, in daily life, people more prone to rumination turn to maladaptive distraction strategies, such as bulimic behaviors and substance use, might they also turn to adaptive distraction strategies? The relationships between rumination and the use of positive distractions in previous studies in which researchers have measured both variables have been inconsistent (e.g., Chang, 2004; Knowles, Tai, Christensen, & Bentall, 2005; Kuehner & Weber, 1999; Nolen-Hoeksema, Parker, & Larson, 1994). Sometimes these variables are negatively correlated, and sometimes they are positively correlated. The inconsistent findings across studies may be due to differences in populations (e.g., younger vs. older, clinical vs. community). It is also possible that people prone to rumination often attempt to distract themselves in adaptive ways, as well as in maladaptive ways, but are less likely to succeed in this distraction than are people not prone to rumination. People high in rumination may move from one distracting activity to another (e.g., try to read a book, then try taking a walk, then try talking with a friend) but have difficulty pouring their attention fully into any of these activities; thus, they get drawn back into rumination easily. Joorman (in press) recently found that people high in rumination have difficulty suppressing negative information and switching attention to positive information (these effects are found even when controlling for the higher depression levels in people high in rumination). Thus, it may be that ruminators turn to both positive and negative distracters to relieve their aversive self-focus but cannot use positive distracters as effectively as can people low in rumination. We also examined the effects of bulimic and substance abuse symptoms on the development of a ruminative style over time and found different patterns for the two types of symptoms. Bulimic symptoms predicted increases in rumination, but substance abuse symptoms did not predict increases in rumination. Bulimic behaviors may be more likely than substance abuse to lead to rumination because bulimic behaviors are more internally directed and provide a shorter relief from self-consciousness than does substance abuse. Girls who engage in bulimic behaviors may become more self-conscious as they attempt to regulate their behaviors. Their chronic self-monitoring could lead to bodyfocused ruminations. Failures at self-regulation (e.g., bingeing) raise more questions about the self (Baumeister & Heatherton, 1996), which then leads to ruminations such as, Why can t I stop bingeing? What s wrong with me? These ruminations may then increase the likelihood that a girl will turn to bingeing as a way to escape her self-consciousness. The link between bulimic behaviors and rumination may also be due to third variables. Bulimic behaviors have been related to low self-esteem and perceived control, as well as a rigid, perfectionistic thinking style and excessive concern about the evaluations of others (Jacobi, Paul, dezwaan, Nutzinger, & Dahme, 2004; Striegel-Moore, Silberstein, & Rodin, 1993; Wilson, Becker, & Heffernan, 2003). A ruminative response style has also been linked to low self-esteem and perceived control, excessive concern about relationships, and perfectionism (Ciesla & Roberts, 2002; Flett, Madorsky, Hewitt, & Heisel, 2002; Nolen-Hoeksema & Jackson, 2001). Understanding the mechanisms by which bulimic behaviors and rumination are linked will be important for interventions. If this link is due to third variables, such as perfectionism, then those variables are the appropriate targets for intervention. If the psychological consequences of bulimic behaviors lead to ruminations, which then increase the chance of future bulimic behaviors, then interventions should focus on helping girls interrupt this process and develop more adaptive self-regulatory and coping strategies. Rumination and Externalizing Symptoms Consistent with our predictions, rumination did not predict future increases in externalizing symptoms. This suggests that rumination is not simply a nonspecific factor that promotes any psychopathology but a specific risk factor for depressive, bulimic, and substance abuse symptoms. Contrary to our expectations, externalizing behaviors did predict subsequent increases in rumination. This may be because girls who are violating social and gender norms by acting aggressively toward others and engaging in delinquent behaviors experience peer rejection and conflict with their parents and teachers. In turn, these social consequences of externalizing behaviors may contribute to rumination in these girls. Limitations Although we tested our hypotheses in prospective analyses, correlational studies cannot establish causality. However, the effects of rumination on depressive symptoms, and of heightened self-awareness on substance use, have been shown experimentally (Hull, 1981; Lyubomirsky & Nolen-Hoeksema, 1993, 1995; Lyubomirsky & Tkach, 2004). Future researchers should attempt to confirm our results in randomized experiments. Moreover, we have suggested several mechanisms to explain the links between rumination and bulimic and substance abuse symptoms. Investigating these possible mechanisms will be an important goal for future researchers and for the designers of new interventions. In particular, it will be important to determine, through experimental studies that test the self-reflective consequences of these behaviors, whether bulimic behaviors and substance use actually do provide an escape from ruminative self-awareness. We have similarly offered possible mechanisms to explain why bulimic and externalizing symptoms might contribute to subsequent increases in rumination, but future researchers should measure the mediating variables we have suggested (e.g., increases in shame and body dissatisfaction in the case of bulimic symptoms, social rejection

RECIPROCAL RELATIONS 205 and conflict in the case of externalizing symptoms) and test whether these variables account for the effects of bulimic and externalizing symptoms on subsequent rumination. Our measures of depressive and bulimic symptoms were semistructured clinical interviews, but we used questionnaire items to assess substance abuse and externalizing symptoms. Survey measures of substance use and abuse appear to be at least as valid as interview measures (Winters et al., 1991). Adolescents in particular may be more willing to admit to substance use and resulting social problems on a confidential questionnaire than in a face-toface interview with an adult clinician. The sample for this study was all female and was taken from one geographic region. Our hypotheses were especially relevant to adolescent girls because they show marked increases in depressive and bulimic symptoms in adolescence, whereas boys do not (Patton, Selzer, Coffey, Carlin, & Wolfe, 1999; Twenge & Nolen- Hoeksema, 2002), and because we reasoned that early symptoms of depression would be particularly likely to contribute to the development of a ruminative response style in girls. Still, it will be important to test our hypotheses in boys and other age groups. We also relied exclusively on data from the adolescents, which produces some risk that parameter estimates are biased by shared reporter bias. Finally, the moderate participation rate and the relatively few participants from certain ethnic minority groups suggest that some caution should be exercised in generalizing these findings. The finding that rumination predicted subsequent increases in depressive symptoms at only a marginally significant level ( p.06) could be considered to be inconsistent with the results from previous studies of children and adolescents. Certain methodological differences between this study and others may account for this inconsistency. First, the lag time between assessments in studies by Abela et al. (2002) and Schwartz and Koenig (1996) was 6 weeks; the lag time between concurrent assessments in this study was 1 year. It may be that in adolescents, rumination consistently predicts increases in depressive symptoms over shorter periods of time but not over longer periods of time. Second, we used a shortened version of our ruminative coping measures, which might also have contributed to the findings for this variable observed in our study. As noted earlier, however, this abbreviated measure correlates highly with the full rumination scale and has similar relationships to depressive symptoms in our study of adults (Nolen-Hoeksema et al., 1999) and a sample of adolescents (M. Kovacs, personal communication, August 2005). Third, both of the previous studies of adolescents used survey measures of both rumination and depressive symptoms, but we used a survey to assess rumination and a semistructured interview to assess depressive symptoms. Thus, shared method bias may have inflated the parameter estimates in the previous studies (though shared reporter bias probably inflated the parameter estimates in the present study and in previous studies). We note, however, that rumination did predict onset of major depression across the 4 years of this study, suggesting that rumination was associated with increased risk for more severe depressive episodes in these adolescents, even if it was not associated with increases in milder depressive symptoms at conventional levels of statistical significance. Conclusions In female adolescents, a ruminative response style may be a risk factor for the development of bulimic symptoms, major depression, and substance abuse. In turn, a ruminative response style may develop partially in response to early adolescent experiences of bulimic and depressive symptoms and externalizing symptoms. If future research confirms our findings, interventions for girls suffering from depression, bulimia nervosa, or externalizing symptoms should attend to the possibility that these syndromes will contribute to the development of a ruminative response style. 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