THE DEVELOPMENT and VALIDATION of an OBSERVATIONAL CODING SYSTEM for REAL-TIME PARENT-ADOLESCENT MENTALIZING by Salome Vanwoerde
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THE DEVELOPMENT AND VALIDATION OF AN OBSERVATIONAL CODING SYSTEM FOR REAL-TIME PARENT-ADOLESCENT MENTALIZING by Salome Vanwoerden A dissertation submitted to the Department of Psychology, College of Liberal Arts and Social Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology Chair of Committee: Carla Sharp, PhD Committee Member: Barbara De Clercq, PhD Committee Member: Stephanie Stepp, PhD Committee Member: Paras Mehta, PhD Committee Member: Julia Babcock, PhD University of Houston May 2020 Copyright 2020, Salome Vanwoerden DEDICATION This dissertation is dedicated to my parents, Cas and Gita Vanwoerden. Nobody works harder to do what they love more than you, beyond any obstacles that are placed in your way. You both have always encouraged me to chase my dreams, whatever they may be, and believed in me completely that I could achieve them. With your support, everything seems possible and yet it is a constant source of comfort to know that you will accept me for whatever I choose. Thank you. iii ACKNOWLEDGMENTS There are a number of people that I owe my most sincere gratitude for their support in completing this project. First and foremost, I would like to thank my advisor, Dr. Carla Sharp, for providing guidance throughout my PhD. Thank you for opening so many doors for me and allowing me to chase big ideas while reigning me in when I’ve gone too far. I am ever grateful for our intellectual conversations and I look forward to opportunities to continue this collaboration. Thank you to Daniel Paulus for being my rock through this graduate school experience. I appreciate your encouragement when I need the motivation, your ear when I need support, and the enthusiasm when it is time to go on an adventure. This research would not have been possible without the tireless work of the graduate students in the Developmental Psychopathology Lab: Francesca Penner, Kiana Wall, Jake Leavitt, Ronnie McLaren, Eric Sumlin, Jessica Hernandez, and Sophie Kerr. Francesca, Kiana, Ronnie, and Eric dedicated many hours to code the data. All graduate students, in addition to research assistants Miana Graves, Estrella Godinez, Samantha Annab, Lauren Palmer, Frances Saubon, Dakota Broadway, Caroline Pearson, and Kathleen DiBacco, helped recruit and assess participants as well as manage many organizational aspects of the study. A special thank you to Francesca and Kiana for being an ever-helpful sounding board for ideas and thoughts while running this study. I appreciate the care that you put into this study. Dr. Laurel Williams facilitated our team’s access to the Texas Children’s Hospital Outpatient Psychiatry Clinic in order to recruit a large proportion of our sample. Dr. Karyn Hall provided access to the Dialectical Behavior Therapy Center of Houston for recruitment. This project would not have been possible without their support. Dr. Stephanie Stepp also generously made her data available for the development study. I would also like to thank my funding sources, including the NIMH with an F31 predoctoral training fellowship and APA’s Division 53 with the Routh Dissertation Award. Last but not least, I would like to acknowledge all of the families who participated in these studies. iv ABSTRACT Mentalizing, or the ability to attribute mental states to the self and others and to understand how mental states affect behavior, forms the basis of humans’ capacity to build and maintain relationships with one another. Mentalizing deficits can be categorized as hypermentalizing or hypomentalizing and are found in a range of pathology, contributing to poor psychosocial functioning. Adolescence is a key developmental period in the study of mentalizing given dramatic changes in the adolescent social brain that coincide with social reorientation. Despite the importance of mentalizing for adolescent mental health, existing tools assess mentalizing as a stagnant property of a single individual, relying mostly on non-self-referential stimuli or hypothetical scenarios. Further, existing tools fail to account for the developmental origins of mentalizing, which are based in the parent-child relationship. Across two studies, we addressed this gap by developing (Study 1) and evaluating (Study 2) a coding system that can measure mentalizing as it occurs during a real-time parent- adolescent interaction. In Study 1, archival data of parent-adolescent dyads participating in a conflict-discussion paradigm were used to develop a coding manual and evaluate reliability and face validity. In Study 2, we tested the validity of the coding system against existing measures of mentalizing, interpersonal problems, relationship quality, and borderline personality disorder in a sample of 72 outpatient adolescents and their mothers. Results demonstrated that the coding system was reliable across raters and face valid. Furthermore, convergent validity with a task- based measure of mentalizing (but not self-report or narrative-based mentalizing) was demonstrated. Quality of observed mentalizing in the dyad converged with v relationship quality of the dyad. Lastly, low quality mentalizing as assessed with the observational coding system was associated with adolescents’ borderline personality features, particularly for those who were highest in severity. In conclusion, this is the first observational measure of real-time mentalizing based in the parent-adolescent relationship, which can be reliably and validly used to advance clinical and research interests. vi TABLE OF CONTENTS DEDICATION ............................................................................... III ACKNOWLEDGMENTS ............................................................. IV ABSTRACT ..................................................................................... V LIST OF TABLES ...................................................................... VIII LIST OF FIGURES ....................................................................... IX I. INTRODUCTION .........................................................................1 Background and Significance ......................................................................... 1 The Current Study ....................................................................................... 10 II. STUDY 1..................................................................................... 12 THE DEVELOPMENT OF AN OBSERVATIONAL CODING SYSTEM FOR MOTHER-ADOLESCENT MENTALIZING .... 12 Methods ....................................................................................................... 13 Results ......................................................................................................... 18 III. STUDY 2 ................................................................................... 19 AN EMPIRICAL EVALUATION OF AN OBSERVATIONAL CODING SYSTEM FOR ADOLESCENT MENTALIZING ...... 19 Methods ....................................................................................................... 21 Results ......................................................................................................... 32 IV. GENERAL DISCUSSION ....................................................... 48 Limitations, Strengths, and Future Directions .............................................. 63 REFERENCES ............................................................................... 66 APPENDICES ................................................................................. 97 A. OBSERVATIONAL CODING SYSTEM............................ 97 vii LIST OF TABLES Table 1. Interrater reliability and descriptive statistics for observational codes .................................................................. 124 Table 2. Correlations and descriptive statistics for main study variables (focused on adolescent variables) ............................................. 125 Table 3. Correlations and descriptive statistics for main study variables (focused on mother variables)................................................... 126 Table 4. Correlations and descriptive statistics for main study variables (focused on dyadic variables) ................................................... 127 Table 5. Results from APIM model with forms of maladaptive mentalizing ............................................................................... 128 Table 6. Results from APIM models with forms of maladaptive observed mentalizing and total MASC scores ........................... 129 Table 7. Linear regression predicting borderline symptoms from indicators of mentalizing including MASC error scores ............ 130 viii LIST OF FIGURES Figure 1. Theoretical model of mentalizing ..................................................... 131 Figure 2. Significant results from APIM model with forms of maladaptive mentalizing ........................................................... 132 Figure 3. Significant results from APIM model with MASC total score and maladaptive observed mentalizing...................................... 133 Figure 4. Simple slopes analysis of the effect of adolescent-reported borderline features on observed mentalizing at different levels of mother-reported borderline features ............................ 134 UHGS V1:1 062019 ix I. INTRODUCTION The NIMH Research Domain Criteria (RDoC) project has defined Systems for Social Processes as one of the five domains that stand to reclassify psychopathology in terms of the underlying dimensions of observable behavior and neurobiological measures (Insel et