Story stem responses of preschoolers with mood disturbances

Story stem responses of preschoolers with mooddisturbances

CAROL BERESFORD1, JOANN L. ROBINSON2, JOHN HOLMBERG1, &

RANDAL G. ROSS1

1University of Colorado at Denver, USA, and 2University of Connecticut at Storrs, USA

AbstractObserving the young child’s affect regulation and thought processes during a clinic assessment visit isof critical importance although challenging for children referred for mood disturbance. In this study,parents reported symptoms using standardized clinical interviews and story stems narratives wereadministered to 20 referred and 12 typically developing preschool age children. Comparison of thereferred and typically developing children in our sample showed that specific story contexts varied ineliciting responses reflecting disorganization and thought disturbance from the referred children. Theexperience of using story stem narratives in the clinical assessment process suggests it provides avaluable complement to parent report for children referred for mood disturbance and mania symptomsbut additional development and study of the method is necessary.

Keywords: Mood disturbance, mania symptoms, story stem narratives, young children, clinical research

Introduction

While controversy about the presence of manic depression in very young children continues,

important advances are being made in the assessment of preschool children with symptoms

and risks of significant mood disorders (Luby & Belden, 2006). Prevalence rates of bipolar

illness in children are still being clarified in the literature but the rates of distress among

preschool samples suggest a significant public health problem (Dilsaver & Akiskal, 2004). A

tertiary care child psychiatry clinic reported that 12% of 1658 consecutive referrals were for

preschool children with comorbid psychiatric conditions with onset dating more than 2 years

prior to the initial evaluation (Wilens, Biederman, Brown, Monuteaux, Prince, & Spencer,

2002). The presence of mania symptoms has been reported in up to 25% of preschool

clinical samples (Dilsaver & Akiskal, 2004) but the validity of these early symptoms to

predict later disorder remains uncertain. Clinicians are faced with diagnostic decisions and

must make the most of the resources available to diagnose and treat mania in preschoolers.

In this paper, we present our experience of using story stem narratives in a research

assessment, highlighting its level of correspondence with parent reports of symptoms and

Correspondence: Carol Beresford, MD, Box C268-71, Department of Psychiatry, University of Colorado at Denver and Health

Sciences Center, 4200 East 9th Avenue, Denver, CO 80262, USA. Tel: 303 315 2155. Fax: 303 315 5347.

E-mail: [email protected]

Attachment & Human Development,

September 2007; 9(3): 255 – 270

ISSN 1461-6734 print/ISSN 1469-2988 online � 2007 Taylor & Francis

DOI: 10.1080/14616730701455429

how the emotional challenges inherent in different story stems permit a rich opportunity to

observe the child’s affect regulation and thought processes.

Parent reports of mood symptoms

Assessment of a referred child generally begins with a description from the parents or

caregivers of the child’s observable emotional and behavioral difficulties. The distress

illustrated in the parent’s retelling of periods of significant volatility in behavior and

decision-making are palpable. Examples from the literature and our own research

experience are revealing. In a case series by Tumuluru, Weller, Fristad, and Weller

(2003), the following examples are representative:

. 4½-year-old boy who was ‘‘volatile, hyperactive, hyper-verbal, and violent toward

others (e.g., hurt a puppy and set fire to his baby sibling’s crib) concomitant with a

cranky/irritable mood. During his initial evaluation (he) was noted to be expansive with

poor self-esteem. He had pressured speech and racing thoughts per parental report and

observation by one of the authors’’ (p. 491).

. A 5-year-old boy with a ‘‘one-year history of oppositionality and mood swings per

parental report. He would vacillate from being ‘sweet and loving’ one minute to violent

and aggressive the next. The aggressive outbursts were reflective of a concomitant

irritable mood. (He) had insomnia, low self-esteem, increased energy, and racing

thoughts’’ (p. 492).

In the experience of the first author, parents of preschool children referred with mood

disorder symptoms retell how these children struggle with their reactivity to stressors and

influence home life in general. A representative parent statement, in answer to diagnostic

questioning about hypertalkativeness accompanying high mood, is as follows: ‘‘She becomes

a chatterbox when she is in a high mood. She will interrupt you, and not listen when you ask

her to stop. She can talk nonsense. She seems to be blabbering. When in a calm mood, she

tells an actual account of something; she makes sense.’’ The parent-based information

reveals, in summary, a picture of young children who are highly mood-labile, and who

frequently enter mood states in which they can behave and think in extreme, unpredictable,

dangerous, and irrational ways. Given the lack of control that parents have over these

seemingly biologically determined mood states, many report the sense of walking on

eggshells within the home. Frequently, mood-disordered children come to have more and

more control over the workings of the household as parents seek to avoid the extreme mood

and behavioral episodes.

Direct child assessment

Moving beyond parent-report, child psychiatrists are faced with the dilemma of how to

evaluate the child’s own experience of psychiatric symptoms, including mood dysregulation

and in some cases psychotic ideation or sensory experiences. According to the literature

(Jensen et al., 1999), it is important to obtain information from both parents and child,

especially when the symptoms are of the type that the child experiences internally; such

symptoms would include, for instance, suicidal ideation and thought disorder including

delusional thinking and hallucinations.

To access a young child’s mental representations of their experience, including

relationships, clinicians have traditionally utilized play therapy. However, most play therapy

256 C. Beresford et al.

approaches are not standardized and rely on individual clinical experience to develop

impressions and inferences. In older children, child-informant reports of symptoms can be

vital in the identification of certain psychiatric diagnoses (Jensen et al., 1999) and bipolar

disorder specifically (Geller et al., 2001). Edelbrock, Costello, Dulcan, Conover, and Kala

(1986) conducted structured interviews with 299 psychiatrically ill children aged 6 – 18 and

their parents, and found that correlations between derived scores showed only low-to-

moderate levels of agreement. Agreement was lower on anxiety, obsessions and

compulsions, psychotic symptoms, and affective disturbance, as compared to behavioral

issues. The agreement between parents and children was found to increase sharply with age.

In this study, we evaluate children younger than represented in the Edelbrock study

(Edelbrock et al., 1986). Because such young children, and especially psychiatrically ill

young children, are difficult to interview directly, we elected to utilize a semi-structured

interaction rather than structured interview as a more reliable and valid approach. The

MacArthur Story Stem Battery (MSSB; Bretherton, Oppenheim, Emde, & the MacArthur

Narrative Working Group, 2003) is one such approach.

A substantial literature has emerged suggesting that the MSSB is able to elicit information

from the child that is both related to parent and teacher symptom reports, but also adds

qualitative information about the child’s internal experience of relationships (see Robinson,

2007 for a brief review). Prior studies of typically developing children have shown that the

child’s story incoherence as well as the content of their representations, specifically

dysregulated aggression, and the intrusion of negative atypical themes are substantially

correlated with parent reports of externalizing symptoms (e.g., von Klitzing, Kelsey, Emde,

Robinson, & Schmitz, 2000; Warren, Oppenheim, & Emde, 1996). Important contributions

by Oppenheim, Emde, and Warren (1997) also made salient children’s representations of

parent figures as nurturing, protective, and warm (i.e., positive representations), as con-

taining and limit-setting of the story child’s misbehaviors and emotional reactions (i.e.,

disciplinary representations), and hostile, ineffectual, and/or dysregulated (i.e., negative

representations). These parent representations were also associated with parent report of

externalizing symptoms; Oppenheim et al. (1997) reported associations between elevated

behavior problems and fewer positive and disciplinary and more negative parental

representations. Warren’s examinations of anxiety symptoms in typical and clinical samples

also demonstrated associations with negative emotions and emotionally incoherent res-

ponses, excessive child power, and an inability to resolve the central conflict of story stems

(Warren, 2003a; Warren, Emde, & Sroufe, 2000). Finally, a particularly significant

contribution to the clinical use of story stems has also been made by Macfie, Cicchetti, and

Toth (2001) with the validation of a scoring of children’s dissociative behaviors during story

stem responses with a teacher-reported symptom questionnaire in a sample of maltreated

children.

Although correlations of child narrative with parent- and teacher-derived information vary

across studies, most found correlations of magnitude 0.2 – 0.4 between child story stem

narrative indicators and parent and teacher report of symptoms. This is comparable to the

Edelbrock et al. study (1986) in which the correlation for global behavior/conduct scales

between parents and children (aged 6 – 18), based on structured interviews for both, is 0.51,

and the correlation for global affective/neurotic scales is 0.17. Thus, the story stem narrative

approach provides a method that allows access to a child’s internal experience in a way that

correlates with, and presumably helps explain more fully, what parents say they are

observing.

We examined parent reported symptoms of manic-like behaviors and depressive mood in

relation to the performance (including dissociation, incoherence, and distressed affects) and

Preschoolers with mood disturbance 257

content of children’s story responses (including more aggressive and fewer prosocial

themes), anticipating that there would be moderately strong associations in a sample that

included children referred for these problems. In addition, given the behavior problems

typical of the children referred for manic-like symptoms, we hypothesized that parent

representations would include less containment and disciplinary themes as well as parental

warmth and nurturance.

While previous investigations have examined performance processes and content themes

across all stories administered from the battery, individual stories evoke differing types and

degrees of stimulation and arousal in the child. The MSSB is particularly effective in the

diversity of story themes that are included in the battery, providing the possibility of

tailoring the assessment for specific purposes (Robinson & Mantz-Simmons, 2003). In

considering the context of referred children, it is very useful to consider selective use of

stories to highlight specific response tendencies and to create new story stems (Kelsay,

2003; Robinson & Kelsay, 2003). From a selected battery of eight story stems that

included two stories outside of the MSSB, we chose to focus this investigation on four

stories to illuminate children’s differentiated responses. These four stories range from

relatively less stimulating (Spilled Juice, a child spills juice at the family table) to relatively

more arousing stories: accidentally cutting one’s finger with a kitchen knife while

pretending to cook (Cooking/Bandage), watching mother and father argue (Lost Keys),

and going down the hall alone and then hearing a noise when no one is around

(Sweater). Although it was unknown at study onset which stories would be most

stimulating for the mood-disordered group, the parental argument story (Lost Keys) is

known to be highly arousing to most children (Robinson & Mantz-Simmons, 2003). The

anticipated high arousal to a story about cooking was related to comments reported by

referring parents that knives have to be hidden from their children who have mood and

psychotic disorders. The story about hearing a noise when no one is around, a potentially

very arousing event, was written for this battery with the hope that it would elicit any

experience of auditory hallucination. It was hypothesized that children’s responses to

highly arousing props and story lines would provide the context to observe clinically

meaningful differences between mood-disordered and non-referred children. Specific

hypotheses are listed below.

Hypothesis 1. Referred children will have significantly higher levels of parent reported

symptoms of mood and thought disturbances compared to typical children. In addition,

referred children’s story stem responses will show elevated levels of internal disorganization

(such as themes of danger, dysregulated aggression, and excessive child power, and

performance that includes dissociation and negative emotion) and less evidence of positive

coping that averts disorganization (such as prosocial relations, narrative coherence, and

positive affect) and reliance on warm and containing parents.

Hypothesis 2. Mania, as reflected in parent-reported child symptoms, will be positively

correlated with disorganized features of the child’s response to the narratives when observed

during high but not low challenge stories.

Hypothesis 3. In the context of high challenge but not low challenge stories, referred

children compared to typically developing non-referred children will show higher levels

of narrative features reflecting internal disorganization and lower levels of features

that reflect positive coping including reliance on warm and containing parental

representations.


Method

Subjects

Community clinicians (psychiatrists, psychologists, and pediatricians) were asked to

refer preschool children, ages 3.5 – 6.0 years, who presented with mania symptoms. Two

of the subjects were referred by parents who suspected mood symptoms, verified as

manic-like upon phone interview. Exclusion criteria for the mood-disordered group

included autism, mental retardation, physical/sexual abuse, major medical/neurological

disorder, and severe language disorder. Twenty parents of preschoolers, recruited over

20 months, agreed to participate. Sixteen typically-developing preschoolers who did not

meet exclusion criteria were recruited by advertisement. Exclusion criteria for the typical

group included: significant psychiatric symptomatology and a family history of major

psychiatric disorder in first or second degree relatives by parent report. We included one

typically-developing child in the comparison group whose second degree relative

developed a mood disorder after a head injury late in life. Four typically-developing

children were excluded due to positive family history (within first and second degree

relatives) for bipolar disorder (two children), past history of sexual abuse (one child), and

a verbal subtest score less than 2 standard deviations below the national average (one

child). The children were deemed typical if the parents did not have complaints

regarding emotional/behavioral issues with impairment. The final sample was comprised

of 32 children (20 clinically-referred, 12 non-referred); each child was accompanied by at

least one parent, the mother in all cases, with the fathers joining in five cases. Thirteen

children were female and 19 male. All participant parents were contacted and con-

sented for their child, as monitored by a local Institutional Review Board; parents were

offered an honorarium for their participation. Table I shows details of the demo-

graphics in each group, and the primary referral complaints. Families were primarily

Table I. Demographic information for preschool children who are typically developing or clinically-referred.

Non-referred Referred

N 12 20

Age (years) 4.35 4.79

Gender

Male 6 13

Female 6 7

Racial background

Hispanic 2 1

White 10 18

African American 0 1

Presenting problem

None 12 0

Mood swings 0 3

Tantrums/rages 0 16

Hearing voices 0 1

Parental education

Graduate school 53% 21%

Bachelor’s degree 16% 25%

Some college 26% 29%

Graduated high school 5% 25%


white (86%); 9% were Hispanic and 5% were African American. Parents’ education

levels varied between high school completion and completion of graduate or professional

school.

Procedure

The child narrative sessions were preceded by a short free-play time, after explanation of

the consent forms to the parent. Following administration of two subtests (vocabulary and

block design) of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI-III;

Wechsler, 2002) and a break, eight story stems were presented to the child in a playroom

setting with a one-way mirror, allowing non-distracting videotaping. The parent was seated

immediately outside, with the door slightly ajar if the child had separation concerns. During

a subsequent session, the parent(s) returned for the administration of semi-structured

interviews regarding mood symptoms, as well as an unstructured clinical interview. The

semi-structured interviews, administered by the first author, provided ample time for

parents to give examples of problematic behaviors. The first author was not blind to group

membership, though the coders of the MSSB tapes were blinded with the exception of one

child’s tape that was coded by the first author. Parents were given US$30 subject payments

for each visit.

Parent-reported symptoms

There were no established diagnostic interviews for mania in the preschool years at the

time this study was conducted, so two instruments were utilized: the mania and psychosis

sections from the original Preschool Age Psychiatric Assessment (PAPA) (Egger &

Angold, 1999), and a modified Section One (mood and psychosis) of the Washington

University Kiddie Schedule for Schizophrenia and Affective Disorders (KSADS; Geller

et al., 2001). PAPA is a structured diagnostic parent interview for assessing psychiatric

symptoms, disorders, and impairment in children aged 2 to 6 years old. The psychometric

reliability and validity of the PAPA is similar to those reported for interviews used with

older children or adults (Egger & Angold, 2004; Egger, Erkanli, Keeler, Potts, Walter, &

Angold, 2006). The mania section of the PAPA was since revised and used by Luby &

Belden (2006) to look at validating a bipolar diagnosis in preschool children and

discriminating bipolar from other diagnoses. KSADS is commonly used for the diagnosis

of bipolar disorder in school-age children. We have adapted it to interview parents of

preschool children by switching to third person questioning. Both the PAPA and the

KSADS provide, for each mania symptom, a score (0, 2, or 3 for the PAPA, meaning 0

for not present and 2 or 3 for present; and 1 – 7, on severity, for the KSADS) and scores

can be added across symptoms to provide an overall severity score. Reported symptom

severity on the PAPA and KSADS instruments ranged from 0 to 36 and 0 to 4.7

respectively. The PAPA mania and psychosis intensity scores that were totaled for our

composite score included the following symptoms occurring with elated or irritable mood:

expansive mood, irritability within the same day as expansive mood, depressed mood

within the same day as expansive mood, the presence of 2 months of remission of mood

symptoms in the previous year, more talkative than usual, pressure of speech, flight of

ideas, motor pressure, agitation, distractibility, decreased need for sleep, grandiosity,

poor judgment, delusions, hallucinations, thought process abnormality, idiosyncratic

behavior.


Structured interaction with the child

The MacArthur Story Stem Battery (MSSB), the instrument chosen for use in this study,

utilizes a story stem narrative method to structure interactions with the child (Bretherton

et al., 2003). The examiner, while delivering the beginning of each story, brings it to a point

of drama or conflict that the child is then invited to complete and/or resolve. The story

characters that potentially appear in each story include Grandma, Dad, Mom, and two

siblings (gender matching the gender of the subject.). The story is both told and enacted, via

small dolls and props, and is videotaped for coding.

Each child completed eight story stems, six from the MSSB and two additional stems

described below. The inclusion of eight stories allowed the examiner to intersperse more

stimulating stories with less stimulating ones, in order to provide a less intensely challenging

experience for the child. Four stories were coded for analysis, one low challenge and three

high challenge stories as described above: Spilled Juice and Lost Keys (MSSB); Cooking/

Bandage (Family Story Task; Shamir, Schudlich, & Cummings, 2002); and Sweater

(developed for this study).

Each story was rated by one of two experienced research assistants using all codes in the

MacArthur Narrative Coding System (MNCS; Robinson, Mantz-Simmons, Macfie, Kelsay,

Holmberg, & the MacArthur Narrative Working Group, 2004). Three narrative indices

were created by aggregating across codes within stories. Codes for a Negative Index that

reflected the children’s internal distress/disorganization were drawn from the content theme

area of Dysregulated Aggressive themes (including aggression weighted by severity of

behavior from 0 – 5 and personal injury rated as present/absent) and from performance

codes, including performed and verbalized emotions (anger, distress, and anxiety rated

present/absent), and codes reflecting dissociative behaviors developed by Macfie, Toth,

Rogosch, Robinson, Emde and Cicchetti (1999). If any of six dissociative behaviors from the

Macfie system occurred (intrusion of traumatic material, spacing out, fantasy proneness,

boundary confusion, fleeing painful subject, sadistic aggression) dissociation was scored

present. Several codes from the Narrative Emotion Coding Manual (Warren, 2003b) also

supplemented the Negative Index, specifically representations of danger, destruction,

inappropriate or excessive child power, and incoherent emotional sequencing. Codes for the

Positive Index reflecting children’s positive coping with story challenges were drawn from

the content theme area of Empathic Relations (including affection, affiliation, sharing,

empathy/helping each rated present/absent); performance codes, including performed and

verbalized emotion of joy (‘‘happy’’ or smiling/laughter) rated present/absent; and narrative

coherence expressed as 0 (containing incoherent story sequencing) or 1 (fully coherent story

sequencing). Codes included within the Negative Index and for the Positive Index were

averaged within each story. A Supportive Parent Index was based on the average of two

codes, positive and discipline/control, from the Parental Representations manual by

Oppenheim and colleagues (Oppenheim, Emde, & Warren, 1997) and a third code from the

MNCS, reliance on adult to resolve conflict (coded present/absent). Children’s responses to

story stems ranged from 0 to 1.0 for the Negative Index (Cronbach’s alpha¼ .72 across

stories), from 0 to .83 for the Positive Index (Cronbach’s alpha¼ .49 across stories), and

from 0 to .67 on the Supportive Parent Index (Cronbach’s alpha¼ .62 across stories).

Means and standard deviations for Negative, Positive, and Supportive Parent Indices by

story stem are reported in Table II. Inter-rater reliability between the two coders and the

second author was demonstrated on a larger sample of low SES children. Based on 51

paired ratings, intraclass R for the Negative Index was .70, for the Positive Index, R¼ .84,


and for the Supportive Parent Index, R¼ .88. When coding in the current study sample was

unclear, one rater would confer with another or the second author to arrive at a consensus

rating.

Data analysis

Differences in demographic characteristics between groups of referred and typical children

were tested with chi-square or t-test and correlations between age and story stem responses

were computed. In order to test the first hypothesis, that referred children will have higher

levels of parent-reported symptoms of mania and depression, ANCOVA were computed

with child age as a covariate and results are reported in Table II using corrected means. In

order to test group differences across stories and the third hypothesis (concerning group

differences that varied by story challenge), a repeated measures analysis was conducted

(GLM routine in SPSS version 13.0) where illness group was a between subjects factor and

story stem was the repeated factor; child age was covaried following preliminary analyses of

group differences described below. For differences across illness groups for the narrative

responses (Hypothesis 1), we used multivariate results for the overall between-subjects effect

of illness group and for the averaged across-story effect for each narrative index. In order to

examine the second hypothesis that the relationship between parent reported mania

symptoms on the KSADS and PAPA interviews will be evident in the two high compared to

low challenge stories, we calculated Pearson correlations between the total KSADS and

PAPA scores and the Negative, Positive, and Supportive Parent Indices for each story,

partialling the effect of child age. No formal test of differences between correlations was

made. In order to test the third hypothesis that the narrative responses of referred (but not

typical) children will vary by story, showing elevated Negative Index and lowered Positive

Table II. Means and (standard deviations) for study variables.

Whole sample Typical Referred

PAPA mania (n¼ 30)a 11.77 (11.59) 1.82 (2.32) 18.78 (9.78)

KSADS mania (n¼28)a 2.19 (1.08) 1.17 (0.27) 2.96 (0.76)

KSADS depression (n¼29)a 0.97 (1.65) 0.0 (0.0) 1.56 (1.89)

Spilled Juice (n¼30)

Negative index 0.16 (0.18) 0.14 (0.14) 0.17 (0.20)

Positive indexa 0.28 (0.17) 0.24 (0.12) 0.30 (0.19)

Support parent 0.14 (0.18) 0.12 (0.18) 0.15 (0.18)

Lost Keys (n¼30)

Negative indexa 0.31 (0.17) 0.21 (0.09) 0.37 (0.19)

Positive indexa 0.25 (0.19) 0.30 (0.19) 0.22 (0.19)

Support parent 0.07 (0.09) 0.07 (0.10) 0.08 (0.09)

Cooking/Bandage (n¼ 31)

Negative indexa 0.32 (0.20) 0.14 (0.11) 0.41 (0.17)

Positive indexa 0.24 (0.22) 0.35 (0.28) 0.18 (0.15)

Support parent 0.19 (0.17) 0.21 (0.19) 0.18 (0.20)

Sweater (n¼30)

Negative index 0.32 (0.17) 0.30 (0.12) 0.33 (0.20)

Positive index 0.23 (0.21) 0.20 (0.16) 0.25 (0.23)

Support parent 0.17 (0.18) 0.14 (0.19) 0.19 (0.18)

asignificant difference between referred and typical children adjusted for child age.


and Supportive Parental Indexes in the higher compared to lower challenge stories, we

examined the multivariate within subjects tests for the illness group X story stem interaction

and the univariate contrasts for each narrative indicator. Stories were ordered according to

how they were presented to the child, Spilled Juice, Lost Keys, Cooking/Bandage, and

Sweater. Hence, confirmation of the hypothesis that high challenge stories would reveal

significant group differences was indicated by a significant quadratic effect.

Results

Group differences were examined and demographic information was found to differ

between the two groups (see Table I). Although referred children tended to be older than

typical children, the difference was not significant. In the referred group, there were twice as

many boys as girls and in the non-referred group gender was evenly split; the group

difference was not significant. Parents of non-referred children were better educated than

parents of referred children, with 5% versus 25% having graduated high school only and

53% versus 21% having attended graduate school. Group differences were also found for

WPPSI Vocabulary and Block Design subtests; referred children had lower Vocabulary

(Referred Mean¼ 11.6, SD¼ 2.1 vs. Non-referred Mean¼ 14.5, SD¼ 2.8; t 1,27¼ 3.18,

p5 .01) and Block Design scores (Referred Mean¼ 11.6, SD¼ 2.5 vs. Non-referred

Mean¼ 13.8, SD¼ 2.4; t 1,28¼ 2.37, p5 .05).

As can be seen in Table III, vocabulary scores were significantly negatively correlated with

parent reported symptoms (r¼7.49 and 7.51 for KSADS and PAPA reports, respectively)

but was not related to narrative indices. Within the Lost Keys story, Block Design was

significantly correlated with all three narrative indices: children with higher standard scores

had fewer negative (r¼7.38), and more positive features (r¼ .43) and parent representa-

tions (r¼ .36). Block Design was not significantly correlated with parent reported symptom

levels. Child age was not significantly correlated with symptom reports or story stem

Table III. Correlation between PAPA, KSADS symptoms, and observed representations partialling child age

(n¼24).

PAPA mania KSADS mania KSADS depression

Spilled Juice

Negative index 70.21 70.04 .01

Positive index 0.21 0.41* .21

Supportive parent 0.26 0.27 .17

Lost Keys

Negative index 0.20 0.30 .04

Positive index 70.04 70.19 .03


Cooking/Bandage

Negative index 0.59** 0.56** .38*

Positive index 70.04 70.22 7.19

Supportive parent 0.15 0.06 7.17

Sweater

Negative index 0.15 0.05 7.06

Positive index 0.14 0.16 .11


*p5 .05; **p5 .01.


responses for the whole sample or among referred children; it was, however, strongly

correlated with narrative responses of typical children. Older, compared to younger typically

developing children included more Supportive Parent representations during the Cooking/

Bandage story (r¼ .78, p5 .001) and higher Negative and lower Positive Index scores

during the Sweater story (r¼ .73 and r¼7.85, p5 .001). Models testing the main

hypotheses were run with Block Design or child age as a covariate; results were very similar

across different models. Results reported here are based on models that corrected for

child age.

In support of the first hypothesis, significantly greater parent-reported mania symptoms

were found for referred compared to typical children on the PAPA and KSADS interviews

(F 1,24¼ 40.38, p5 .001 and F 1,24¼ 56.03, p5 .001); greater depression was reported on

the KSADS (F 1,26¼ 5.04, p5 .05). See Table II. Examining group differences from the

multivariate analysis results across story stems, referred children’s responses estimated over

all three indices did not significantly differ from typicals (F 3,24¼ 1.83, p¼ .17). However,

the between subjects tests of the individual three indicators did show a significant difference

for the Negative Index (F 1,26¼ 5.51, p5 .05) suggesting elevation for referred children

across stories (Mean Referred¼ 0.31 vs. Mean Typicals¼ 0.20). Individual story univariate

statistics presented in Table II support this finding for the Spilled Juice, Lost Keys, and

Cooking/Bandage stories but not the Sweater story.

As can be seen in Table III, contrary to our hypothesis, most correlations between the

parent-reported PAPA, KSADS mania symptoms and the story stem responses were low

and non-significant. However, large and significant positive correlations were observed for

the Negative Index in the Cooking/Bandage story. An unanticipated positive correlation was

also observed between the Positive Index and the KSADS mania in the Spilled Juice story.

Support for the hypothesized differences within subjects across stories was found in the

results of the repeated measures, multivariate analysis for the Negative and Positive Indices

only. The multivariate analysis showed a significant effect for the overall within subjects

illness group by story stem interaction (F 9,18¼ 3.32, p5 .05). The repeated measures

univariate tests showed significant interaction effects for the Negative and Positive Indices

(F 3,78¼ 6.31, p5 .005 and F 3,78¼ 4.06, p5 .05). The interaction for the Supportive

Parent Index was non-significant, p4 .32). Finally, the results of the within subjects

contrasts for illness group by story stem interaction were significant for the quadratic effect

for Negative and Positive Indices (F 1,26¼ 19.96, p5 .005 and F 1,26¼ 9.14, p5 .01).

The means for the three indices within each story are displayed in Table III comparing

referred and typical children. In addition, Figure 1 illustrates the observed variations in

Negative and Positive Indices across stories. This quadratic effect refers to observed large

differences between referred and typical children in the two high challenge stories (Lost

Keys and Cooking/Bandage) that were presented to children following the Spilled Juice and

prior to the Sweater story stems. Typical children showed little variation in the Negative

Index for the first three stories, and had their strongest internally distressed/disorganized

responses to the mild fear induced in the Sweater story. Referred children showed no

elevation in the Negative Index for the Spilled Juice story compared to typicals, but marked

elevation in the Negative Index was observed in subsequent stories, especially the Lost Keys

and Cooking/Bandage. Referred and typical children had comparable internal distress/

disorganization in the Sweater story. For the Positive Index, typical children showed an

increase across stories, with markedly higher positive indicators in the more challenging

stories, Lost Keys and Cooking/Bandage. For referred children, by contrast, the Positive

Index was highest in the Spilled Juice story, exceeding the level of typical children. In the

higher challenge stories, however, the level of positive coping indicators dropped markedly


for referred children and were significantly lower than typicals in the Lost Keys and

Cooking/Bandage stories. The Positive Index in the Sweater story did not differ by illness

group.

Discussion

This study was designed as the beginning of a process of identifying and developing child

assessment processes that can augment parent report of behavior problems in young

children, especially for families with children struggling with manic-like behaviors and mood

symptoms. Preschool age children are rapidly developing a sense of self and are able to

provide, through verbalization and play, diagnostically informative details about their

experience, when clinicians provide them a non-threatening vehicle to share that

perspective. Traditional non-structured observations and play assessments fall short of

meeting the need to obtain a diagnostic picture quickly and efficiently in a managed care

environment. This evocative story stem paradigm allows clinicians to observe behaviors that

parents describe, in the child’s own voice and within a supportive context that is generally

fun and enjoyable for the child. Additionally, the MSSB method can be used in a

standardized manner, allowing comparison between patients, clinical groups, and different

research or clinical teams.

Results of this study found that, as expected and after adjusting for child age, referred

children differed significantly from normally developing children in depression and mania

symptoms by parent report. While there was not a significant multivariate main effect for

referred vs. non-referred children across the three narrative indicators, the between subjects

comparisons of the individual indicators was significant for the Negative Index. Clinic

referred children also had greater distress/internal disorganization across stories. The lack of

a robust finding here may be due to the very small samples in this study, but suggest that

large overall differences for referred children may not be seen reliably.

Figure 1. Variation in negative and positive indices for typical and referred children by story stem.


Associations between the MSSB and parent-reported symptoms on the PAPA and

KSADS were mostly low to non-significant. However, large and significant correlations

were found within the Cooking/Bandage story between the Negative Index and parent

ratings of mania symptoms and, although attenuated, for depression. Children whose

parents reported manic-like behaviors demonstrated substantially greater distress and

disorganization within this high challenge story; both the children’s experiences and the

corroboration of parent report of difficulties are important indicators for clinicians.

Obtaining this information also allows clinicians to benefit from multi-informant perspec-

tives which have been shown in clinical research to be valuable and to reduce error

associated with rater bias (Kraemer, Maeselle, Ablow, Essex, Boyce, & Kupfer, 2003).

Though not hypothesized, on the low-challenge Spilled Juice story, the study found a

significant correlation between the Positive Index and the count of PAPA mania symptoms.

Using this study’s novel repeated measures approach, applying level of challenge as the basis

for contrasting stories, effects for the ill group on the Negative and Positive Index contrasts

were found. Within subject contrasts identified differences for referred children on the

Negative and Positive Indicies in the high-challenge stories (i.e., Lost Keys and Cooking/

Bandage) but not in the lower-challenge stories (i.e., Spilled Juice and Sweater). By

contrast, typically-developing children exhibited the greatest disorganization (e.g., Negative

Index) during the fear-stimulus, Sweater story. In regard to the Positive Index, the referred

children showed elevations for the Spilled Juice story but their Positive Index scores

declined sharply on the high-challenge Lost Keys and Cooking/Bandage stories. Typically

developing children’s stories included more indicators of positive coping perhaps averting

disorganization during these high challenge stories. This more typical pattern of responses,

where distress in the story telling is seemingly managed or minimized as the child

emphasizes more positive story elements, has been found in large samples using a clustering

approach to story responses (Klute, 2004).

While not initially hypothesized, we found a correlation between mania symptoms and the

Positive Index and, as mentioned, a significant group difference (i.e., referred group mean

was nearly double that of the non-referred, typically-developing, group) for the Positive

Index within the Spilled Juice story, a low-challenge stem with a relatively simple and often

rote solution (e.g., child is reprimanded and cleans/corrects the situation). These findings

may point to a vulnerability in referred children in titrating or regulating their response to

novel stimuli. Research on offspring of parents with bipolar disorder find that those children

have an ‘‘extreme tendency to seek novelty, approach stimuli, and display uncontrolled

speech and actions—a predisposing factor’’ (Hirshfeld-Becker, Biederman, Henin, Faraone,

Cayton, and Rosenbaum, 2006). The subsequent ‘‘exhaustion’’ of positive themes for

referred children in high-arousal stems points to an interesting potential extension on this line

of research as does attempting to account for these tendencies through neuropsychological

(e.g., executive functioning) and coping (e.g., sensitivity to relationship threats) mechanisms.

The results of the current study add to a growing collection of studies (see review papers

by David Oppenheim, 2006, and Susan Warren, 2003a, for more information) suggesting

that the MSSB indeed provides insight into the child’s perspective on their life experiences

and strategies for coping with stress. The study also demonstrated that all stems are not

created equal, a point initially described by von Klitzing, Kelsey, Emde, Robinson, and

Schmitz (2003). Rather, particular utility may be found in contrasting children’s

performance in relatively low-affect stems to those with high interpersonal conflict and

rich emotional valence. While not completely analogous to valid indicators from adult

projective assessments (e.g., Rorschach Method Comprehensive System, Perceptual

Thinking Index), the atypical cognitions generated by the children with manic-like


symptoms in their story resolutions, especially during the stressful story conditions, resonate

with the flights from logical thinking seen in biologically based disorders such as bipolar,

schizoaffective, and schizophrenia spectrum disorders (Dao & Prevatt, 2006; Wood,

Nezworski, & Garb, 2003). These atypical cognitions included: bizarre aggression such as

cutting/sticking eyeballs and ears; props taking on lives of their own and floating, fighting, or

running away; invisible characters; and the escalation from one cut finger to all characters

being cut or killed, and many body parts being injured or cut off. Although hypothesized in

the development of the Sweater story, there were no auditory hallucinations reported or

observed by the children, suggesting that it did not stimulate sufficient arousal among the

children.

The crossover in pattern from high positive to high negative indicators in the context of

increasing emotional arousal, danger, and interpersonal conflict from the low-challenge

Spilled Juice to the high-challenge Cooking/Bandage stories also, with replication and

expansion, has the potential to lead to increased knowledge in terms of these children’s

symptoms and difficulties. It will be important to further explore the extent to which

behavioral observations with peers, siblings, and parents under analogous interactive

circumstances generalize these thematic differences, as it may point to etiology as well as

optimal points of entry for intervention.

Mothers and fathers describe parenting these children, with their labile mood states, as

‘‘walking on eggshells.’’ The dramatic mood swings that these children experience are

generally without physical markers that could guide a parent’s response, as would the

appearance and evident pain of a physical injury. Apparent parent – child dysynchrony that

would results from dealing with a ‘‘totally different child from one time to the next’’ puts the

parent – child relationship at great risk for distress and conflict. Despite what one would

expect, there was no significant decline in presentation of positive and available parents in

the stories of referred children. This indirectly reinforces what others have recommended in

terms of employing family therapy approaches to address the needs of children and

adolescents with manic and depressive symptoms (Kowatch et al., 2005).

In having conducted this research, the research team learned that using a standardized

assessment with this clinical population required redoubled sensitivity toward the child and

a new set of behavioral responses. In the ordinary course of an MSSB, the administration is

designed to be child responsive and the evaluator takes an active role in scaffolding the

child’s experiences, especially at the beginning and again as the child escalates in emotion.

Such structuring avoids unnecessary distress from excessive emotional arousal and

disorganization. Structuring helps the normally developing and at-risk children remain

linked to the stem at hand yet still yields rich and diagnostically informative material with

which one can use to generate hypotheses about the child’s symptoms, strengths, and

stressors. Scaffolding also allows clinicians to determine which children may be pressed to

disorganization by internal drives in contrast to children who become disorganized in

attempting to continue their line of verbalizations. The mood affected children, in this study,

required even more scaffolding and sensitivity to overload, and at times rescheduling of a

session in order to complete the brief battery. For example, one 3-year-old child became

anxious while completing the Cooking/Bandage story. During his narrative, the child said,

‘‘I cut him (Robert, the oldest brother) with the knife. Now his arm is bleeding. Now his

tummy is bleeding.’’ Then the child moved the knife toward his own hand. Then he again

poked Robert with the knife (and whispered ‘‘Cut’’). At that point, the child left the room to

rejoin mother. He was allowed to do this and take a break, and was reassured by the

examiner and his mother; he later came back to the task willingly, and did not have to leave

any other story as he did during the cooking story. This need for administration


flexibility and strategies to change administration for affected children was previously noted

by Kelsay (2003) and Robinson and Kelsay (2003) in early discussions about adapting the

story stem method to clinical populations. Also, while no direct assessment of affective

phase (i.e., hypomanic or hypodepressive) was collected, high levels of irritability for some

children led to the need for sessions to be curtailed and rescheduled. Strategies such

as tangible reinforcement (i.e., stickers) for a child giving their best effort and ready

availability of parents to reassure the children also proved to be helpful with this unique

population. Setting an initial tone of safety and openness to creativity is always important

but even more so for children with this profile of manic and mood symptoms. It may be

possible to capture the degree of scaffolding a child required in future derivations of MSSB

coding.

While the current study was a reasonable start, there are many limitations and needs in

order to move forward. First, the small sample size and limited inclusion of children from

diverse backgrounds precludes much generalizability at this stage. Second, while several

themes distinguished the ill and typically developing groups, many of these themes have also

been found to distinguish children who have been maltreated (Macfie, Toth, Rogosch,

Robinson, Emde, & Cicchetti, 1999; Toth, Cicchetti, Macfie, Rogosch, & Maughan, 2000).

Further specificity of coding may allow differential features to be more finely discerned but

for the story stem approach to become a robust clinical method these issues will need to be

addressed. We conclude, however, that the MSSB, a story stem method, has significant

potential as a clinical aid, one that is useful in evaluating the internal state of young children

with major psychiatric symptoms.

Acknowledgements

Financial support from NIMH-sponsored institutional NRSA Training program, T32

MH15442 (Martin Reite, Program Director).

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