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A multiple systems approach to examining physiological stress and its association with internalizing disorders in adolescence

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A multiple systems approach to examining physiological stress and its association with internalizing disorders in adolescence

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A MULTIPLE SYSTEMS APPROACH TO EXAMINING PHYSIOLOGICAL STRESS
AND ITS ASSOCIATION WITH INTERNALIZING DISORDERS IN
ADOLESCENCE

by
Lauren A. Spies

A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
MASTER OF ARTS
(PSYCHOLOGY)

August 2008

Copyright 2008 Lauren Anne Spies

ii
Table of Contents
List of Tables iii
List of Figures iv
Abstract v
Chapter 1: Background and Significance 1
HPA Activity and Internalizing Symptoms 2
Internalizing Disorders, Salivary α-Amylase and a Multiple Systems of
Measurement Approach 6
Physiological and Subjective Reactions to Acute Stressors 8
Adolescence and Gender Differences 9
The Present Study and Hypotheses 11

Chapter 2: Experimental Design and Methods 12
Participants 12
Procedures 13
Measures 15

Chapter 3: Results 19
Chapter 4: Discussion 26
References 35
Appendices 42
Appendix A: Youth Symptom Checklist (YSR) 42
Appendix B: CBCL 45
Appendix C: Discussion Follow-Up 47
Appendix D: Saliva Sample Follow-up Questionnaire 50

iii
List of Tables
Table 1: Descriptive Statistics 19
Table 2: Partial Correlations Among Variables, 21
Adjusting for Time Since Awakening

Table 3: Regression Equations Examining 22
Cortisol and Internalizing Symptoms,
Subjective Distress, and Symptom by Distress Interactions

iv
List of Figures

Figure 1: Interaction between subjective distress 24
and internalizing symptoms (YSR) for cortisol raw increase.

Figure 2: Interaction between subjective distress 25
and internalizing symptoms (YSR) for cortisol AUCi.

Figure 3: Mean salivary cortisol concentration 30
across the six saliva sample time points.

Figure 4: Mean salivary α-amylase concentrations 30
across the six saliva sample time points.

v
Abstract
The present study investigated the association between internalizing symptoms
and physiological reactivity in a sample of 73 adolescents. The adolescents engaged in a
stressor task, involving a 15-minute discussion with their parents, after which subjective
distress was assessed. Saliva samples were collected before the stressor task and over a
70-minute period post-stressor, and were assayed for salivary cortisol and α-amylase as
indices of the HPA axis and SAM system, respectively. Results demonstrate a negative
main effect of internalizing symptoms and a positive main effect of subjective distress on
HPA activity. Internalizing symptoms moderated the association between subjective
distress and HPA reactivity. These findings suggest that attenuated physiological stress
is part of a protective reaction to the effects of chronic HPA activation. The present
study has important implications for the understanding of how mental health and physical
health influence one another during adolescence.

1
Chapter 1: Background and Significance
Depression and anxiety, internalizing disorders that affect 9.5% and 9.9% of the
adolescent population, respectively, (Costello, Mustillo, Erkanli, Keeler, & Angold,
2003) are related to multiple physiological symptoms, such as sleep disturbance, change
of appetite, and weight fluctuation (American Psychiatric Association, 2000).
Internalizing symptoms, which commonly onset during adolescence (Costello et al.,
2003), have been associated with the dysregulation of the hypothalamic-pituitary-
adrenocortical (HPA) axis, a system involved in physiological reactivity to stress. It is
important to understand how internalizing symptoms contribute to dysregulated
physiological stress in adolescents, particularly given the association between HPA
dysregulation and myriad negative outcomes, including memory problems,
immunosuppression, and decreased bone mineral density (Costanzo, 2002; Sheline,
Wsang, Gado, Csernansky, & Vannier, 1996; Furlan et al., 2005).
Recent investigations relate internalizing symptoms to the dysregulation of the
hypothalamic-pituitary-adrenocortical (HPA) axis (Pruessner, Hellhammer, Pruessner, &
Lupien, 2003; Goenjian et al., 2003), and studies commonly investigate this association
using cortisol as an index of HPA activity. In addition to the HPA axis, the sympathetic
adrenal medullary (SAM) system is associated with psychological symptoms (Gordis,
Granger, Susman, & Trickett, 2006). A non-invasive index of this system, salivary α-
amylase (sAA), was identified only recently, and thus knowledge about the association
between internalizing symptoms and sAA is limited. Given the inconsistent findings in
the literature, the examination of internalizing symptoms and their association with

2
physiological stress is an area of research that warrants further investigation. Using a
multiple systems approach, the present study investigates both cortisol and sAA in
conjunction with internalizing symptoms to gain a more comprehensive understanding of
the relationship between internalizing disorders and physiological stress in adolescents.
HPA Activity and Internalizing Symptoms
Research concerning the physiological symptoms of internalizing disorders has
examined cortisol because it is a stress-associated hormone that is secreted during the
activation of the HPA axis (Lovallo & Thomas, 2000). When signaled, the hypothalamus
secretes corticotropin releasing hormone (CRH), resulting in stimulation of the anterior
pituitary gland to secrete adrenal corticotrophin hormone (ACTH), which in turn acts on
the adrenal cortex to secrete cortisol. As part of a negative feedback loop, circulating
cortisol levels then modulate the secretion of CRH and ACTH to maintain the desired
equilibrium. Typically, cortisol levels peak just before awakening and decline
throughout the day (Lovallo & Thomas, 2000). When the HPA axis is activated,
regulatory mechanisms work to restore equilibrium, an adaptive process known as
allostasis (McEwen & Stellar, 1993; Schulkin, Gold, & McEwen, 1998; Sterling & Eyer,
1988). Findings on the association between cortisol and internalizing symptoms are
inconsistent; the variability in findings may be due in part to the variety of ways cortisol
is measured, including with basal cortisol, cortisol reactivity, and morning cortisol levels
(e.g., Burke, Davis, Otte, and Mohr, 2005; Luby et al., 2003; Pruessner, Hellhammer,
Pruessner, & Lupien, 2003).

3
An important consideration when examining physiological stress is the negative
consequences that result from chronic physiological stress. In response to prolonged
stress and chronic stimulation, the regulatory negative feedback mechanisms involved in
allostasis can become less effective (Lovallo & Thomas, 2000). The process of damage to
the HPA activation cycle, called allostatic load, can be related to chronic, repeated
overactivation, chronically elevated cortisol, or inadequate levels of cortisol in response
to stress (McEwen & Seeman, 1999; Schulkin et al., 1998). Inefficient control of the
HPA responses leaves the body vulnerable to wear and tear, including atrophy of the
hippocampus, which in turn further compromises HPA functioning (Schulkin, 1994).
Glover (2006) found that allostatic load can be present not only in older adults, but also
in relatively young mothers with histories of stress. The attenuation hypothesis describes
how the detrimental effects of chronic arousal and allostatic load may lead to the
downregulation of physiological stress systems (Susman, 2006). Susman (2006) posits
that this is an adaptive physiological strategy to minimize the harmful effects of
chronically activated stress systems.
A number of studies investigating internalizing symptoms as they relate to
physiological stress have focused on the diurnal pattern of cortisol, which includes basal
levels, morning levels, and nocturnal levels of cortisol. Data on the association between
internalizing disorders and basal cortisol levels are best summarized in Burke, Davis,
Otte, and Mohr’s (2005) meta-analysis of eight studies examining adults. Burke and
colleagues found no statistical difference in basal cortisol levels of depressed and non-
depressed individuals, with an average Cohen’s d value of .36. In a sample limited to

4
adult males, Pruessner and colleagues (2003) found greater depressive symptoms to be
associated with greater awakening cortisol levels. Researchers have also examined
diurnal patterns of physiological stress in younger samples. Rao and colleagues (Rao,
McCracken, Lutchmansingh, Edwards & Poland, 1997) investigated a sample of
adolescents, finding that depressed adolescents had higher nocturnal urinary cortisol
when experiencing current depressive symptoms than when their symptoms had remitted.
In Schiefelbein and Susman’s (2006) recent longitudinal study, no differences in basal
cortisol levels were found for boys, but girls’ general and social anxiety were positively
associated with basal cortisol levels.
Investigators have also examined the association between internalizing symptoms
and physiological stress within the context of specific stressor tasks, which relate more
closely to the focus of the present study. Physical challenges, biological challenges,
academic stressors, and psychosocial stressors are all methods that have been used in
research to initiate a physiological stress response. For example, Miller, Chen, and Zhou
(2007) conducted a meta-analysis comparing adults who had chronic stress with and
without depression, and found that those with depression had higher cortisol levels
following dexamethasone suppression. In a biological challenge study that investigated a
child sample, Birmaher and colleagues (1996) found no difference in cortisol reactivity
between depressed and non-depressed children after the infusion of CRH, which activates
the HPA axis. Jansen and colleagues (1999) investigated a clinical population of
children, finding that children with dysthymia had a lower cortisol response to a physical

5
challenge than did healthy control participants (Jansen, Gispen-de Wied, Jansen, Rutger-
Jan van der Gaag, Matthys, van Engeland, 1999).
Psychosocial stressors relate more closely to stressors encountered in everyday
life, and researchers have incorporated these stressors into their studies, increasing
external validity. Beaton et al. (2006) found that after a public speaking task, socially
phobic adults had lower levels of cortisol than did those without social phobia. In a study
that investigated a much younger sample, depressed three to five-year-olds had higher
levels of cortisol after a separation task than did their non-depressed counterparts (Luby
et al., 2003). Granger and colleagues (Granger, Schwartzman, Lehoux, Cooperman, &
Ikede 1998) found that internalizing symptoms related to lower cortisol levels before a
parent-child discussion task, suggesting an anticipatory decrease in cortisol levels prior to
the upcoming stressor. In a separate investigation of HPA reactivity, Granger and
colleagues measured cortisol in a group of clinic-referred seven to 17 year-olds before
and after a parent-child conflict discussion task. In this study, depressive and anxious
symptoms were examined both separately and together with respect to post-task cortisol.
These investigators found social anxiety and social withdrawal to be associated with
higher cortisol reactivity, but did not find an association between internalizing symptoms
and post-task cortisol levels (Granger, Weisz, & Kauneckis, 1994).
Some evidence indicates that chronic internalizing symptoms may be related to
the dysregulation of cortisol levels. Depression has been related to chronically elevated
cortisol levels (Michelson, Stratakis, Reynolds, & Galliven, Chrousos, 1996), for
example, through sleep deprivation (McEwen & Seeman, 1999), as well as to low levels

6
of cortisol (Adam, 2005; Stetler & Miller, 2005). Adam (2005) addressed the possible
influence of the chronicity of internalizing symptoms, investigating cortisol as it relates
to both state and trait levels of these symptoms in a community sample of adolescents.
Although the study was limited in its measurement of “trait” depression (defined as the
rating of symptom frequency and severity for the preceding week), this study does
indicate that the chronic nature of depressive and anxious symptoms in adolescents may
suppress cortisol levels. Cortisol levels may be attenuated as a result of allostatic load
(Susman, 2006).
Important considerations in synthesizing results for the association between
internalizing symptoms and cortisol include the variability in how internalizing disorders
are operationalized, differences in the measurement of cortisol and internalizing
symptoms, and the inattention to directional effects. Because measurements of cortisol
are taken at various times of the day (although not always adjusted for in analyses), and
under varying conditions (e.g., measuring the morning awakening response versus the
response to a psychosocial stressor), there are many unexplored questions that warrant
investigation.
Internalizing Disorders, Salivary α-Amylase and a Multiple Systems of Measurement
Approach
To obtain a more complete picture of physiological stress as it relates to
psychopathology, Bauer, Quas, and Boyce (2002) propose that the HPA axis and SAM
system are complementary, and that both need to be considered in order to fully
understand their association with emotional and behavioral problems. Chatterton and

7
colleagues (Chatterton, Vogelsong, Lu, Ellman, & Hudgens, 1996) demonstrated that
sAA is a promising, non-invasive index of SAM activity. Salivary α-amylase, a more
recently identified biomarker of stress, has not yet received much attention in
psychophysiological research studies. Although the mechanism that results in the release
of sAA in response to stress is not entirely clear, sAA is associated with changes in
catecholamines (e.g., eprinephrine and norepinephrine), is produced locally in the mouth,
and is accepted as a biomarker of stress within the SAM system (Chatterton et al., 1996;
Granger, Kivlighan, El-Sheikh, Gordis, & Straud, 2007). Salivary α-amylase follows a
diurnal pattern, decreasing within 60 minutes of awakening, and then increasing
throughout the day (Nater, Rohleder, Schlotz, Ehlert, & Kirschbaum, 2007).
Research has supported the idea that the HPA and SAM stress systems do not
respond in tandem. Kivlighan and Granger (2006) noted differences in cortisol and sAA
reactivity, finding that sAA reactivity accounted for more variance in measures of team
bonding and dominance in athletes than did cortisol reactivity after a physical stressor.
Roelofs, Elzinga, and Rotteveel (2005) examined both cortisol and sAA in response to
the Trier Social Stress Test, and found no difference in sAA levels between high and low
cortisol response groups. These studies support the finding that cortisol and sAA
reactivity are not necessarily correlated, and the measurement of both might allow for a
more comprehensive understanding of psychobiology. No studies have yet examined the
association between sAA, cortisol, and internalizing symptoms in adolescents within the
context of a triadic family psychosocial stressor. Examining these associations provides

8
a more thorough understanding of the psychobiology of stress within the context of
internalizing disorders.
Physiological and Subjective Reactions to Acute Stressors
Researchers utilize a variety of methods to investigate physiological stress,
including biological, physical, psychological, and social challenges. The biological
challenge typically involves the injection of a hormone which activates the desired
system of stress (e.g., Ronsaville et al., 2006). Physical exertion is another form of
challenge, either through sports activities (Kivlighan & Granger, 2006) or through other
physical activities (e.g. heavy lifting) (Flinn & England, 1995). Researchers often
investigate psychological stress as it relates to physiological stress through the Trier
Social Stress Test (TSST), which involves a public speaking task, an individual
interview, and a mental arithmetic task. The TSST consistently demonstrates
physiological stress activation (Nater et al., 2005).
Social challenges, viewed to be more naturalistic, aim to measure a stress
response representative of what participants experience outside of the lab, such as a
parent-child conflict task (Granger, Weisz, and Kauneckis, 1994). For example, in
Granger and colleagues’ (1994) study, the parent and child rated topics that are a
common source of parent-child conflict. The experimenter then chose a topic that both
the parent and child listed as conflictual, and asked the dyad to discuss the topic for six
minutes. After the conflict discussion, children were asked to rate their affect during the
discussion. The children’s physiological reactivity, as measured by the increase from
pre-task to post-task cortisol levels, was positively associated with their subjective rating

9
of social anxiety during the discussion, indicating that the subjective experience of
distress may play a role in physiological stress. In a meta-analysis that further supports
this idea, Miller and colleagues (2007) demonstrated that HPA activity increases with
subjective distress (Miller, Chen, & Zhou, 2007). While not many studies investigate the
association between subjective distress and sAA, stressful social and academic
experiences have been associated with increases in SAM system activity (e.g. TSST;
Granger et al., 2007).
There is evidence for the dysregulation of physiological stress in those with
chronic internalizing symptoms (i.e., internalizing disorders), and for the association
between experienced distress and physiological reactivity. Thus, it is important to
examine the physiological response to acute stressors when stress systems have been
chronically active. Research has demonstrated that those with internalizing symptoms
are hypersensitive to stressors that are uncontrollable (e.g., Alloy et al., 1990; Barlow,
1988). Because internalizing symptoms influence the perceptions of stressors, the
present study examines whether this relationship is reflected in physiological reactivity.
Specifically, the present study examines the interaction between internalizing symptoms
and subjective distress in terms of physiological stress.
Adolescence and Gender Differences
Research involving the association between psychopathology and the
physiological response to stress is largely conducted with adult samples and does not
always examine gender differences. Although some studies do involve child participants,
more research is needed to elucidate the association between psychological symptoms

10
and physiological stress in adolescence. Because adolescence marks the transition into
adulthood, understanding the psychobiology of this age group would provide useful
information about how physiological stress changes as children get older. This is a
particularly important age to examine within the context of internalizing disorders, as
prevalence rates of internalizing disorders increase throughout adolescence (Costello et
al., 2003). Furthermore, studies have demonstrated that cortisol responses vary
according to puberty stage (Atko, Laaneots, Karelson, Smirnova, & Viru, 1998),
suggesting that the association between internalizing disorders and cortisol activity
changes as children develop.
The associations between biomarkers of stress and psychopathology not only vary
across age, but also across gender. In some studies, young males appear to have greater
HPA axis reactivity to stress than females (Kudielka & Kirschbaum, 2005; Seeman,
Singer, Wilkinson, & McEwen, 2001). Interestingly, Seeman and colleagues (2001)
found that young males had greater HPA axis reactivity than females, while older females
had greater reactivity than males. Davis and Emory (1995) studied infants and found no
gender differences in salivary cortisol at baseline, but they did find that males had greater
cortisol reactivity to stress than females. Schiefelbein and Susman’s (2006) study
demonstrated higher cortisol in anxious girls, age nine to 14, but not in anxious boys.
Schoofs, Hartmann, and Wolf (2008) investigated both cortisol and sAA before and after
an oral exam, and found no gender differences in pre or post-test cortisol or sAA levels.
The present study will investigate gender differences in cortisol and sAA activity. These
potential differences will be investigated in an exploratory manner due to the inconsistent

11
evidence in the literature and the lack of research examining such gender differences
within the context family psychosocial stressors.
The Present Study and Hypotheses
The present study examines internalizing symptoms in adolescence as they relate
to both HPA axis and SAM system reactivity to a psychosocial stressor. The use of
social challenges, as opposed to chemical challenges, relates more closely to actual
stressors an individual might encounter. Furthermore, as family plays a crucial role in the
lives of youth, the investigation of internalizing disorders and physiological stress within
the context of family conflict is important to the understanding of adolescent
development. A triadic family discussion task is utilized as the stressor in order to
maximize the external validity of the study in a controlled environment, and to examine
an important context that is common to many adolescents. In the present study, the
following hypotheses were tested:
1. Internalizing symptoms are associated with dysregulated physiological stress.
Specifically, greater internalizing symptoms are associated with either higher or
lower levels of cortisol and sAA.
2. Subjective distress is associated with cortisol and sAA levels. Specifically, higher
levels of subjective distress during the stressor task are associated with
heightened physiological reactivity.
3. Internalizing symptoms moderate the relationship between subjective distress and
physiological reactivity, as indexed by cortisol and sAA.

12
Chapter 2: Experimental Design and Methods
Participants
The participants are non-clinical adolescents with an age range of 14 to 16 years.
These adolescents, along with their parents, are participants in The Family Studies
Project at the University of Southern California. This longitudinal study examines the
effects of family and community violence, as well as how family interaction and conflict
influences children’s behavior, emotion, and physiology. The participants were recruited
through advertisements posted in newspapers and flyers in the Los Angeles area, and
were subsequently screened over the telephone. Participating families visit the lab
approximately once per year, and have been participating since 2000. There are several
inclusion criteria for participation in the Family Studies Project, including the ability of
all family members to speak English, the availability of a household telephone, and that
the two participating parent figures have lived together with the target youth for at least
three years. The sample for the present study is diverse, as 21.0% is African American,
23.5% is Caucasian, 27.7% is Hispanic/Latino, 5.0% is Asian, and 22.7% of the sample is
multi-ethnic. There are 40 male adolescents in the sample, and 33 female adolescents.
The present study will utilize the data from wave four of the Family Studies Project.
Two families that consented to wave four of the study did not consent to saliva sample
collection due to concerns about others examining their biological information. Five
families participated in components of the wave four procedures from their own homes,
precluding them from providing saliva samples.

13

Procedures
Detailed procedures. In wave four, families were sent a letter asking them to
contact the lab to schedule a visit, and lab visits were scheduled via telephone. Before the
scheduled lab appointment, participants were instructed not to eat or smoke one hour
before their appointment, and were also told not to drink alcohol or consume caffeine for
24 hours before the scheduled appointment. Once the participants arrived at the lab, two
research assistants went through informed consent procedures with both the adolescents
and their parents. Specifically, the experimenters gave each parent a consent form and
the youth an assent form, and then outlined the risks and benefits of participation as well
as the limits of confidentiality. Families were offered the opportunity to discuss their
willingness to consent without the experimenters present, and if they agreed to consent,
the parents signed the consent forms for themselves and their child, and the youth signed
an assent form. Once the consent procedures were finished, the parents were asked to
complete a variety of questionnaires, including the Child Behavior Checklist (CBCL;
Achenbach, 1991a). The adolescents were also administered a variety of questionnaires,
including the Youth Self Report (YSR; Achenbach, 1991b).
In addition to completing questionnaires, the participants provided seven saliva
samples throughout their visit. All saliva samples were collected when the participants
were alone in their individual rooms, and timers were set at the beginning of each lab
session to help ensure the timely collection of all samples. The first sample was collected
after completion of the consent procedures. The participants were instructed to allow

14
saliva to passively drip down a straw into a small vial for a period of five minutes, and
the time of day at which the sample was completed was carefully recorded. After
individually completing questionnaires, the family as a group watched a 10-minute
relaxation video that displayed various nature images. The participants were then asked
for another saliva sample (at this point, 30 minutes had lapsed since the first sample).
The participants resumed filling out questionnaires, and then were asked to engage in a
15-minute family discussion. Before the discussion, the experimenters individually met
with each family member to discuss areas of conflict for the participant’s family. After
these five-minute “priming interviews,” the mother, father, and adolescent sat together in
a room, and the experimenter identified three topics that seemed to be conflictual for
multiple family members. Subsequently, the experimenter instructed the families that
they had 15 minutes to discuss each of these topics, and that they could distribute the
time spent on each topic as they wished. After the discussion, the participants filled out a
form that asked them to rate the level of distress they experienced during the discussion,
and they were also asked for another saliva sample (this occurred 40 minutes after the
second sample was collected). Two more saliva samples were collected in 10-minute
intervals after the collection of the third sample. The last two samples were collected in
20-minute intervals after the collection of the fifth sample. The last four saliva samples
were collected with sorbettes, which are short, plastic sticks that have a sponge tip to
absorb saliva. After all seven saliva samples were collected, they were frozen at -20
degrees Celsius and shipped to Salimetrics LLC to be assayed for cortisol and sAA.

15
Brief Outline of Procedures.

Start timers
Conduct consent; family members and experimenters sign consent
forms
(30 minutes) Saliva Sample 1 collected
Participants fill out questionnaires
(49 minutes) Participants watch relaxation video (10 min)
(1hr) Saliva Sample 2 collected
(1hr, 15) Priming Interviews (5-6 min)
(1hr, 22) Discussion (15 min)
(1hr, 40) Saliva Sample 3 collected (Set timers at 10, 20, 40, 60)
Post discussion questionnaire
(1hr, 50) Saliva Sample 4 collected (2 Sorbettes per person)
Questionnaires
(2hr) Saliva Sample 5 collected (2 Sorbettes per person)
Questionnaires
(2hr, 20) Saliva Sample 6 collected (2 Sorbettes per person)
Questionnaires
(2hr, 40) Saliva Sample 7 collected (2 Sorbettes per person)
Cortisol samples all labeled and placed in a freezer
Measures
Youth-Reported Internalizing Symptoms. The Youth Self Report (YSR;
Achenbach, 1991) is a 112-item questionnaire that inquires about internalizing and
externalizing symptoms, as well as social and academic adjustment. Youth respond using
a likert scale ranging from zero (“not true”) to two (“very true or often true”) (e.g., “I cry
a lot”). This measure is widely used, and has been administered to youth ranging from
six to 18 years of age (Appendix A). The internalizing subscale of this measure has a
Cronbach’s alpha ranging from .89 to .90, and test-retest reliability ranging from .76 to
.85 (Achenbach, 1991b). Raw scores are converted to T-scores based on national age
norms for males and females.

16
Parent-Reported Internalizing Symptoms. The Child Behavior Checklist (CBCL;
Achenbach, 1991a) is a 113-item questionnaire for parents that measures internalizing
symptoms, externalizing symptoms, and adjustment in their children (Appendix B).
Parents respond using the same likert scale, ranging from zero (“not true”) to two (“very
true or often true”) (e.g., “Feels worthless or inferior”). This measure is widely used, and
the internalizing subscale has Cronbach’s alphas ranging from .90 to .92, and test-retest
reliability ranging from .87 to .90 (Achenbach, 1991a). As with the YSR (Achenbach,
1991b), raw scores are converted to T-scores based on national age norms for males and
females.
Salivary Cortisol and α-Amylase. The seven saliva samples (consisting of
sorbettes and vials of at least 25 ul of saliva) were stored at -20 degrees Celsius and then
shipped in dry ice to Salimetrics, LLC, where the samples were assayed for cortisol and
sAA using a high-sensitive enzyme immunoassay. The samples were assayed in
duplicate for reliability, and repeated analysis was used for sample pairs that had results
differing more than seven percent. The statistical analyses of these data utilized several
ways of summarizing the saliva samples. The first sample was not included in the
analyses in order to assure that differential stress families may have experienced before
arriving to the lab did not bias the results. As an index of cortisol and sAA total output
over the course of the adolescents’ lab visit, total area under the curve with respect to
ground (AUCg) was calculated (Equation 1). Total area under the curve with respect to
increase (AUCi) was calculated as an index of cortisol and sAA reactivity to the family
discussion (Equation 2). Both calculations were conducted with the formulas presented

17
by Pruessner and colleagues (2003). The AUCg calculation involves the sum of the
trapezoid areas for each time block, and the AUCi calculation involves subtracting the
baseline rectangle of cortisol or sAA from the AUCg score. Baseline was measured with
the saliva sample that was collected after the relaxation video, toward the beginning of
the lab visit.

n - 1
AUCg = Σ(m(i+1) + mi)·ti
(1)
i = 1 2

n – 1 n – 1
AUCi = (Σ(m(i+1) + mi)·ti) - (m
1
· Σ t
i
)
(2)
i = 1 2 i = 1

Youth Subjective Rating of Distress. Youth complete a 25-item questionnaire
immediately following the 15-minute family discussion. The questionnaire of subjective
distress, which is part of the post-discussion questionnaire, contains eight items. The
subjective distress component asked the youth to rate the degree to which they felt
particular emotions. The measure uses a likert scale ranging from zero to four (“None” to
“A lot”), and some examples of emotions on the measure include “angry,” “frustrated,”
and “upset,” (Appendix C). There is high internal consistency among the eight items
reflecting negative emotions, with a Cronbach’s alpha of .87.

18
Saliva Sample Information. The saliva sample information questionnaire includes
20 items that inquire about behaviors (e.g., “When did you wake up?”), health issues
(e.g., “Have your allergies bothered you in the past 72 hours?”), and medications (e.g.,
“Do you use any medicines that are creams or lotions?”) that could potentially lead to
either inaccurate or altered measurements of cortisol and sAA levels. This measure is a
combination of “yes” or “no” and free response items, and was primarily used in the
present study to capture the time of awakening (Appendix D).

19
Chapter 3: Results
All analyses were conducted using SPSS statistical software, version 13.0 for
Windows. Descriptive statistics were calculated for all measures included in the
analyses, and are presented in Table 1.

Table 1

Descriptive Statistics

N Mean Standard Min Max
Deviation
________________________________________________________________________
YSR-Internalizing 71 49.96 10.36 26.00 77.00
CBCL-Internalizing 69 52.68 11.62 31.00 77.00
Subjective Distress 71 7.48 6.43 .00 26.00
Cortisol AUCg 71 578.23 513.02 58.14 3849.64
Cortisol AUCi 71 40.88 307.37 -372.09 1376.49
Cortisol Raw Increase 71 .043 .082 -.060 .330
sAA AUCg 69 403264.20 293409.35 37981.90 1377715.00
sAA AUCi 69 -24037.10 309000.89 -1982254.40 738467.14
sAA Raw Increase 69 33.68 66.26 -247.23 249.33
Note. T-scores are reported for the YSR and CBCL.

20

Cortisol and sAA concentrations for samples one through six were winsorized to
three standard deviations above the mean, a common procedure used with these indices in
order to handle outliers (Cohen, Cohen, West, & Aiken, 2003). Salivary α-amylase
concentrations below four U/mL were discarded, as were cortisol concentrations above
four ug/dL, as values in these ranges are near impossible. This follows the procedures
recommended by Granger and colleagues (e.g., Granger et al., 2006).
Regression imputation was used to generate values for the three missing cortisol
samples (across two individuals) and six missing sAA samples (across six individuals) to
allow for the calculation of total output and reactivity scores for each physiological index.
Log transformations of the cortisol and sAA AUCg scores were conducted to decrease
the skewness of the distribution.
For the parent-reported internalizing symptoms, the maximum reported score was
used for each item. Because one parent may not observe behaviors that the other parent
sees, use of the maximum score increases the likelihood that all present internalizing
symptoms are represented in the analyses. Regression imputation was used to calculate
two missing CBCL internalizing scores to allow for a complete data set in the analyses.
Independent samples t-tests were conducted in order to determine whether there
were sex differences for internalizing symptoms, subjective distress, or the physiological
indices. A significant difference was found for sAA raw increase, with males’ scores for
sAA raw increase, M = 42.71, significantly higher than females’ scores, M = 22.74, t(71)

21
= 1.29, p = .03. No significant sex differences were found for internalizing symptoms,
subjective distress, or the other physiological indices.
Table 2 presents partial correlations among the youth physiological indices,
adjusting for time since awakening. Total cortisol output (AUCg) was positively
associated with cortisol reactivity to the family discussion, and a positive association was
also found between sAA output and sAA raw increase after the family discussion.
Although cortisol reactivity (AUCi) was negatively associated with sAA total output, no
other cortisol indices were significantly correlated with their respective sAA indices.
Table 2 also presents partial correlations among internalizing symptoms, subjective
distress, and the physiological indices, adjusting for time since awakening to account for
the diurnal pattern of cortisol and sAA.
Table 2
Partial Correlations Among Variables, Adjusting for Time Since Awakening
1 2 3 4 5 6 7 8 9

1. YSR -
2. CBCL .32** -
3. Subjective Distress .38** .04 -
4. Cort AUCg -.20 -.08 .22 -
5. Cort AUCi -.08 -.00 .18 .43**-
6. Cort Raw Increase -.19 -.01 .12 .58** .88**-
7. sAA AUCg .09 -.02 -.01 -.22 -.35** -.29* -
8. sAA AUCi .30* .09 .10 -.07 .11 .06 -.07 -
9. sAA Raw Increase .25* .13 .13 -.18 -.01 -.03 .32** .78** -

22
Table 2, Continued
________________________________________________________________________
*p<0.05. **p<0.01.
Note. YSR = youth self-report T-score. CBCL = child behavior checklist T-score. Cort
= cortisol. sAA = salivary α-amylase. AUCg = area under the curve with respect to
ground. AUCi = area under the curve with respect to increase. Cortisol and sAA AUCg
values were log-transformed for all analyses.

Youth-reported internalizing symptoms were positively associated with parent-
reported internalizing symptoms, and with youth-reported subjective distress. Salivary α-
amylase reactivity was positively associated with self-reported internalizing symptoms,
but no other physiological indices were significantly correlated with internalizing
symptoms or subjective distress.
Table 3 presents a series of multiple regression analyses examining the effect of
youth internalizing symptoms, subjective distress, and their interaction on each of six
physiological measures, three for cortisol, and three for sAA.
Table 3
Regression Equations Examining Cortisol and Internalizing Symptoms, Subjective
Distress, and Symptom by Distress Interactions
β T F Adj R
2
Cortisol AUCg
Step 1 5.20** .19
YSR-Internalizing -.33 -2.76**
Subjective Distress .34 2.87**
Step 2 3.93** .19
YSR-Internalizing -.39 -3.40**
Subjective Distress .37 3.10**
Int. Symptoms by Distress -.07 -.54
Cortisol AUCi
Step 1 2.16 .09

23
Table 3, Continued
YSR-Internalizing -.17 -1.34
Subjective Distress .24 1.89
Step 2 3.47* .17
YSR-Internalizing -.23 -1.87
Subjective Distress .38 2.89**
Int. Symptoms by Distress -.32 -2.61*
Cortisol Raw Increase
Step 1 2.49 .10
YSR-Internalizing -.27 -2.13
Subjective Distress .23 1.80
Step 2 3.27* .16
YSR-Internalizing -.32 -2.13*
Subjective Distress .35 2.63*
Int. Symptoms by Distress -.28 -2.27*

*p<0.05. **p<0.01.
Note. Equations adjust for time since awakening. Cortisol and sAA AUCg measures
were log-transformed. YSR and CBCL T-scores were centered, as were Subjective
Distress scores.

Subjective distress, youth-reported internalizing symptoms, and parent-reported
internalizing symptoms were all centered on their mean scores. The equations yielded
significant results with cortisol AUCg, cortisol AUCi, and cortisol raw increase as the
outcome variable. For cortisol AUCg and cortisol raw increase, subjective distress was
associated with higher cortisol output, while youth-reported internalizing symptoms were
associated with lower cortisol output. For the regression equations examining indices of
cortisol reactivity as the outcome, namely cortisol AUCi and cortisol raw increase, the

24
internalizing symptoms by subjective distress interactions were significant. The
regression equation examining the effect of parent-reported internalizing symptoms and
subjective distress on cortisol AUCg was significant, F(4, 69) = 2.77, p = .05, R
2
= .11,
with a significant main effect of subjective distress, β= .22, t(69) = 1.90, p = .04. None
of the regression analyses examining sAA indices as the outcome were significant.
Both significant interactions were deconstructed using the method recommended
by Cohen and colleagues (Cohen, Cohen, West, & Aiken, 2003). Figures 1 and 2 show
plots of values at one standard deviation above and below the mean for subjective distress
and youth reported internalizing symptoms.
Figure 1

Subjective Distress by Internalizing Symptoms
Interaction
0
0.05
0.1
0.15
0.2
Low Subjective
Distress
High Subjective
Distress
Cortisol Raw Increase
High YSR
Low YSR

25
Figure 2

With different slopes for youth with high and low internalizing symptoms, these plots
show internalizing symptoms as a moderator of the association between subjective
distress and cortisol reactivity. Youth with low internalizing symptoms show the
predicted association between subjective distress and cortisol; high subjective distress
was associated with high cortisol AUCi and raw increase. Youth with high internalizing
symptoms, in contrast, show low cortisol reactivity, regardless of reported subjective
distress.
Internalizing Symptoms by Subjective Distress
Interaction
0
100
200
300
400
500
600
Low Subjective
Distress
High Subjective
Distress
Cortisol AUCi
High YSR
Low YSR

26
Chapter 4: Discussion
The results of the present study support the attenuation hypothesis, which
describes the downregulation of HPA activity in order to minimize the detrimental effects
of allostatic load (Susman, 2006). Adolescents with internalizing symptoms had lower
cortisol total output, as well as an attenuated HPA response to the family discussion task.
There was a positive association between internalizing symptoms and sAA reactivity, as
measured by raw sAA increase. The results also suggest that the experience of distress in
adolescents is related to higher HPA activity, and that internalizing symptoms moderate
the association between subjective distress and HPA reactivity.
The hypothesis that internalizing symptoms are associated with dysregulated
physiological stress was supported in the present study, but primarily for HPA axis
activity. Specifically, a main effect of internalizing symptoms was found, such that
adolescents with greater internalizing symptoms showed lower cortisol total output than
those with fewer internalizing symptoms. A main effect of internalizing symptoms was
also demonstrated with the indices of cortisol reactivity (cortisol AUCi and cortisol raw
increase), but only when the internalizing symptoms by subjective distress interaction
was included in the model. This suggests that the interaction between internalizing
symptoms and subjective distress is particularly important when considering the
association between internalizing symptoms and cortisol reactivity. These results support
the attenuation hypothesis, in that internalizing symptoms are associated with attenuated
HPA activity. In adolescence, internalizing disorders seem to have a long duration, with
some research demonstrating an average duration of 17 months (Birmaher et al, 2004).

27
Given that internalizing symptoms describe general thoughts, feelings, and behaviors
over time, the body may adaptively respond to this prolonged stress through the
downregulation of the HPA response (Susman, 2006).
The present study partially supported the hypothesis that subjective distress is
associated with higher physiological reactivity. This finding suggests a correspondence
between physiological stress within the HPA-axis and adolescents’ experience of their
own distress. This association makes sense, as the cognitive appraisal of a particular
environment as stressful or distressing might be necessary to initiate HPA activity.
Consistent with this concept, Gaab and colleagues demonstrate that anticipatory cognitive
appraisal accounted for 35 percent of the variance in the cortisol response to the TSST
(Gaab, Rohleder, Nater, & Ehlert, 2005). When individuals are confronted with
situations that arouse emotion, their HPA systems are activated as an adaptive response to
help confront or escape the stressor (Cahill & McGaugh, 1998), which is consistent with
the findings in the present study.
The hypothesis that there would be a significant interaction between subjective
distress and internalizing symptoms was also supported, but only for analyses involving
HPA reactivity. The present study demonstrates that adolescents with low internalizing
symptoms seem react to psychosocial stressors with a pattern that would be expected,
involving an increase in HPA activity with increased subjective distress. Interestingly,
adolescents with high internalizing symptoms show an attenuated HPA response, even if
they report high levels of subjective distress during the family discussion task. This
finding is consistent with the attenuation hypothesis (Susman, 2006), as under distressing

28
conditions, those with chronic symptoms show an attenuated HPA response to an acute
stressor. Adolescents with fewer internalizing symptoms may show greater HPA
reactivity because they do not experience attenuated HPA activation due to allostatic
load. Moreover, Schulkin and colleagues (1998) describe how chronic stress, as well as
allostatic load, may be associated with hyperactivity of the amygdala, a brain region
involved with the emotions of fear and anxiety. This association could have important
implications for reactions to acute stressors, as well as for the maintenance of
internalizing symptoms, particularly because internalizing disorders have been associated
with hyperactivity in the amygdala (Sheline et al., 2001).
The adolescents’ report on their own internalizing symptoms corresponded with
their parents’ reports, although moderately. A study in another adolescent population
demonstrated a similar correspondence between parent and youth-reported internalizing
symptoms, with Pearson correlations ranging from .35 for girls, to .38 for boys (van der
Ende & Verhulst, 2005). The adolescents’ reported internalizing symptoms were also
associated with their experiences of subjective distress during the family discussion, such
that higher internalizing symptoms were associated with higher subjective distress.
Adolescents with internalizing symptoms may view the world as more distressing in
general (Puliafico & Kendall, 2006; Allen & Badcock, 2003), which may explain this
positive association. Alternatively, adolescents with internalizing symptoms may live in
family environments that are more distressing, and the discussions of these families may
be more conflictual in nature. Interestingly, unlike youth-reported internalizing
symptoms, parent-reported internalizing symptoms were not associated with their

29
adolescents’ self-reported subjective distress during the discussion. This suggests that
although parents are somewhat aware of their adolescents’ internalizing symptoms,
youth-reported internalizing symptomatology provides different information, as it is
associated with different constructs. Additionally, sex differences were examined for all
measured variables, but only one significant sex difference emerged. The magnitude of
sAA reactivity in male adolescents, as measured by the raw sAA increase, was greater
than that of female adolescents. This is consistent with some findings demonstrating that
males are more physiologically reactive to stress than females (e.g., Kudielka &
Kirschbaum, 2005).
The pattern of findings for SAM system activity was different from that of HPA
axis activity, highlighting the importance of examining both systems of stress. A
significant association was found between youth-reported internalizing symptoms and
sAA reactivity. This suggests that greater internalizing symptoms in adolescents relate to
a stronger SAM system response to psychosocial stress. Consistent with this finding,
Dietrich and colleagues (2007) found that internalizing symptoms were positively
associated with a greater sympathetic response as measured by heart rate (Dietrich et al.,
2007). There was no significant relationship between subjective distress and the sAA
indices. Importantly, there is a noticeable increase in sAA after the family discussion,
supporting the use of psychosocial stressors to induce reactions in not only the HPA axis,
but also the SAM system (see Figures 3 and 4).

30
Figure 3

Figure 4

Mean sAA concentrations rose post-discussion (with a mean raw increase of 33.69
U/mL), and 82.2 percent of adolescents showed an increase in sAA after the discussion.
Youth Mean Cortisol Concentration Over Time
0
0.02
0.04
0.06
0.08
0.1
0.12
1 2 3 4 5 6
Sample
Mean C ortisol
C oncentration (ug/dL)
Youth Mean sAA Concentration Over Time
0
20
40
60
80
100
1 2 3 4 5 6
Sample
Mean sA A C oncentration
(U /m L)

31
This increase was positively correlated with youth-reported internalizing symptoms, but
not with the other variables of interest in the present study. In addition, sAA reactivity
may not have been entirely captured in the present study. The sAA response occurs more
quickly than that of cortisol, peaking approximately 10 minutes post-stressor as opposed
to the 20 minutes it takes for cortisol to peak post-stressor (Granger et al, 2007; Albers,
Riksen-Walraven, Sweep, & de Weerth, 2008). Thus, some of the variability in the sAA
response during the 15-minute family discussion may have occurred prior to our
measurement, and the rise in sAA levels after the discussion may not have captured the
peak level of sAA. Because families did not provide any saliva samples during that 15-
minute period, we do not know whether post-discussion sAA concentrations were at their
peak levels, or already on the decline.
There are limitations to this study, and a primary limitation is sample size.
Because of the small sample size, there are some potentially important covariates that
could not be examined due to insufficient power. For example, although a gender
difference emerged for sAA reactivity, no other significant differences were found. The
analyses may not have yielded significant gender differences because they were under-
powered, and the lack of gender differences demonstrated in the present study should be
considered with caution. Another potentially important covariate that could not be
examined due to a small sample size is the pubertal stage of the adolescents. It is
important to examine the association between psychological and physiological stress
across development, and while the present study does investigate an adolescent sample, it

32
does not examine differences between pubertal stages within the adolescent sample. This
is an important future direction for research concerning stress across development.
There are a number of questions raised by the present study that warrant further
investigation. For example, because the directionality of the association between
internalizing symptoms and physiological stress could not be examined due to the cross-
sectional nature of the study, longitudinal studies are necessary to help tease apart this
association. Although internalizing symptoms may lead to physiological dysregulation,
there also is some evidence that physiological dysregulation leads to later internalizing
symptoms. For example, Granger and colleagues reported that higher cortisol levels in
response to the parent-child discussions predicted anxiety disorders and other
internalizing problems six months later (Granger et al., 1996). Consistent with this
finding, Schiefelbein and Susman (2006) demonstrated that increased cortisol levels
toward the beginning of the study predicted greater general and social anxiety one and a
half years later.
Another important direction for future research is the examination of how the
nature of a psychosocial stressor contributes to physiological reactivity. In the present
study, a conflictual family discussion task served as the psychosocial stressor. Families
have a wide range of interaction styles, and certain patterns of family interaction may
differentially affect both subjective distress and physiological reactivity in adolescents.
Given that maladaptive family functioning can lead to internalizing symptoms in
adolescents (Hughes & Gullone, 2008), it is important to examine how family
functioning can affect physiological stress, as well.

33
The concordance of physiological stress reactivity among family members may
also play a role in adolescent psychological and physiological stress, or, more broadly, in
family interaction patterns. In addition to inter-individual synchrony of stress systems,
intra-individual synchrony of the HPA-axis and the SAM system is an important
direction for future research. Recent studies suggest that asymmetrical responses
between the two systems are associated with problem behaviors and stressful
environments. For example, Gordis and colleagues (Gordis, Granger, Susman, &
Trickett, 2006) investigated cortisol and sAA levels in adolescents, and found that the
combination of low cortisol levels and low sAA accounted for variance in aggressive
behavior in adolescents as reported by both the youth and their parents. In a later study,
Gordis and colleagues demonstrated that adolescents who experienced a trauma
demonstrated asymmetry between HPA and SAM activity (Gordis, Granger, Susman, &
Trickett, 2008).
The present study demonstrates an association between internalizing symptoms in
adolescents and their physiological response to stress. These findings are important to
the understanding of how psychological symptoms contribute to physiological stress in
adolescence, and raise further questions about the nature of how psychological well-being
and physiology influence one another. These data support the biopsychosocial approach
to understanding human behavior, and have important implications for the understanding
of how internalizing symptoms impact adolescents. Studies demonstrate that
dysregulated physiological stress systems can affect the course of development and lead
to adverse health outcomes. For example, prenatal physiological stress has been

34
associated with decreased birth weight and lower gestational age at birth (Wadhwa,
2005). Because adolescence is another important stage of physical development,
physiological alterations associated with internalizing symptoms may influence the
course of development as well as physical health, as HPA dysregulation relates to
increased susceptibility to adverse health outcomes (Chrousos & Gold, 1998; Wolf,
Nicholls, & Chen, 2008). Moreover, if anxious and depressed adolescents already show
an attenuated response to stress, HPA dysregulation in adolescence may contribute to
health problems later in life. It is crucial to continue investigating the interplay between
psychological and physiological stress, as it will allow for a more comprehensive
understanding of how physical symptoms affect mental health, and how psychological
symptoms might alter physiology.

35
References
Achenbach, T.M. (1991a). Manual for the Child Behavior Checklist/4-18 and 1991
Profile. Burlington: University of Vermont, Department of Psychiatry.

Achenbach, T.M. (1991b). Manual for the Youth Self-Report and 1991 Profile.
Burlington: University of Vermont, Department of Psychiatry.

Adam, E.K. (2006). Transactions among adolescent trait and state emotion and diurnal
and momentary cortisol activity in naturalistic settings. Psychoneuroendocrinology , 31
(5) , 664-679.

Albers, E.M., Riksen-Walraven, J.M., Sweep, F.C., & de Weerth, C. (2008). Maternal
behavior predicts infant cortisol recovery from a mild everyday stressor. Journal of
Child Psychology and Psychiatry, 49(1), 97-103.

Allen, N.B., & Badcock, B.T. (2003). The social risk hypothesis of depressed mood:
Evolutionary, psychosocial, and neurobiological perspectives. Psychological Bulletin,
129(6), 887-913.

Alloy, L.B., Kelly, K., Mineka, S., & Clements, C.M. (1990). Comorbidity of anxiety
and depressive disorders: A helplessness-hopelessness perspective. In J.D. Maser& C.R>
Cloninger (Eds.), Comorbidity of mood and anxiety disorders (pp. 499-543).
Washington, DC: American Psychiatric Press.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental
Disorders. 4th ed. DSM-IV-TR. Washington, DC: American Psychiatric Association.

Atko, V., Laaneots, L., Karelson, K., Smirnova, T., &Viru, M. (1998). Exercise-induced
hormone responses in girls at different stages of sexual maturation. European Journal of
Applied Physiology, 77, 401-408.
Barlow, D.H. (1988). Anxiety and its disorders: The nature of treatment of anxiety and
panic. New York: Guilford Press.
Bauer, A.M., Quas, J.A., & Boyce, W.T. (2002). Associations between physiological
reactivity and children’s behavior: Advantages of a multisystem approach.
Developmental and Behavioral Pediatrics, 23(2), 102-113.
Beaton, E. A., Louis, A. S., Ashbaugh, A.R., Santesso, D. L., Antony, M. M., McCabe,
R.E., Segalowitz, S. J., Schulkin, J. (2006). Low salivary cortisol levels among socially
anxious young adults: Preliminary evidence from a selected and a non-selected sample.
Personality and Individual Differences, 41, 1217-1228.

36

Birmaher, B., Dahl, R.E., Perel, J., Williamson, D.E., Nelson, B., Stull, S., Kaufman, J.,
Waterman, G.S., Rao, U., Nguyen, N., Joaquim, P., & Ryan, N. D. (1996). Corticotropin-
releasing hormone challenge in prepubertal major depression. Biological Psychiatry,
39(4), 267-277.
Birmaher, B., Williamson, D.E., Dahl, R.E., Axelson, D.A., Kaufman, J., Dorn, L.D., &
Ryan, D. (2004). Clinical presentation and course of depression in youth: Does onset in
childhood differ from onset in adolescence? Journal of the American Academy of Child
& Adolescent Psychiatry, 43(1), 63-70.
Burke, H.M., Davis, M.C., Otte, C., and Mohr, D.C. (2005). Depression and cortisol
responses to psychological stress: A meta-analysis. Psychoneuroendocrinology 30, 846-
856.
Cahill, L., & McGaugh, J.L. (1998). Mechanisms of emotional arousal and lasting
declarative memory. Trends in Neuroscience, 21, 294-299.

Chatterton, Jr., R.T., Vogelsong, K.M., Lu, Y.C., Ellman, A.B., Hudgens, G.A., 1996.
Salivary alpha-amylase as a measure of endogenous adrenergic activity. Clinical
Physiology 16, 433-448.

Chrousos, G.P. & Gold, P.W. (1998). A healthy body in a healthy mind—and vice
versa—the damaging power of “uncontrollable” stress. The Journal of Clinical
Endocrinology and Metabolism, 83, 1842-1845.

Cohen, J. (1992). A Power Primer. Psychological Bulletin, 112(1), 155-159.
Cohen, J., Cohen, P., West, S.G., Aiken, L.S., 2003. Applied Multiple
Regression/Correlation Analysis for the Behavioral Sciences, Third ed. LEA, Mahwah,
NJ.

Costanzo, L. S. (2002). Physiology, 2
nd
ed. Philadelphia, PA: Saunders.

Costello, E.J., Mustillo, S., Erkanli, A., Keeler, G., Angold, A. (2003). Prevalence and
development of psychiatric disorders in childhood and adolescence. Archives of General
Psychiatry, 60, 837-844.

Davis, M. & Emory, E. (1995). Sex differences in neonatal stress reactivity. Child
Development, 66(1), 14-27.

Dietrich, A., Riese, H., Frouke, Sondeijker, F., Greaves-Lord, K., Roon, A., Ormel, J.,
Neeleman, J., & Rosmalen, J. (2007). Externalizing and internalizing problems in

37
relation to autonomic function: A population-based study in preadolescents. Journal of
the American Academy of Child and Adolescent Psychiatry, 46(3), 378-386.

Flinn, M.V. & England, B.G. (1995). Childhood stress and family environment. Current
Anthropology, 36(5), 854-866.

Furlan, P. M., Have, T. T., Cary, M., Zemel, B., Wehrli, F., Katz, I. R., Gettes, D. R.,
and Evans, D. L. (2005). The role of stress-induced cortisol in the relationship between
depression and decreased bone mineral density. Biological Psychiatry Volume 57, Issue
8, 15 April 2005, Pages 911-917.

Gaab, J., Rohleder, N., Nater, U.M., & Ehlert, U. (2005). Psychological determinants of
the cortisol stress response: the role of anticipatory cognitive appraisal.
Psychoneuroendocrinology, 30(6), 599-610.

Glover, D. A. Stuber, M., & Poland, R.E. (2006). Allostatic load in women with and
without PTSD symptoms. Psychiatry, 69(3), 191-203.

Gordis, E.B., Granger, D.A., Susman, E.J., & Trickett, P.K., (2006). Asymmetry
between salivary cortisol and α-amylase reactivity to stress: Relation to aggressive
behavior in adolescents. Psychoneuroendocrinology, 31, 976-987.

Gordis, E.B., Granger, D.A., Susman, E.J., &Trickett, P.K. (2008). Salivary alpha-
amylase—cortisol asymmetry in maltreated youth. Hormones and Behavior, 53, 96-103.

Granger, D.A., Kivlighan, K.T., Blair, C., El-Sheikh, M., Mize, J., Lisonbee, J.A. &
Buckhalt, J.A. (2006). Integrating the measurement of salivary α-amylase into studies of
child health, development, and social relationships. Journal of Social and Personal
Relationships, 23(2), 267-290.

Granger, D.A., Kivlighan, K.T., El-Sheikh, M., Gordis, E.B., Straud, L.R. (2007).
Salivary α-amylase in biobehavioral research. Annals of the New York Academy of
Sciences, 1098, 122-144.

Granger, D. A., Schwartzman, A., Lehoux, P., Cooperman, J., & Ikede, S. (1998).
Children’s salivary cortisol, internalising behaviour problems, and family environment:
Results from the Concordia Longitudinal Risk Project. International Journal of
Behavioral Development, 22(4), 707-728.

Granger, D. A., Weiszl, J. R., Kauneckis, D. (1994). Neuroendocrine reactivity,
internalizing behavior problems, and control-related cognitions in clinic-referred children
and adolescents. Journal of Abnormal Psychology, Vol. 103 (2), p. 267-276.

38
Granger, D. A.,Weisz, J. R., McCracken, J. T., Ikeda, S. C., & Douglas, P. (1996).
Reciprocal influences among adrenocortical activation, psychosocial processes, and the
behavioral adjustment of clinic-referred children. Child Development, 67, 3250-3262.

Hughes, E.K., & Gullone, E. (2008). Internalizing symptoms and disorders in families of
adolescents: A review of family systems literature. Clinical Psychology Review, 28, 92-
117.

Jansen, L.M., Gispen-de Wied, C.C., Jansen, M.A., Rutger-Jan van der Gaag, Matthys,
W., & van Engeland, H. (1999). Pituitary-adrenal reactivity in a child psychiatric
population: salivary cortisol response to stressors. European Neuropsychopharmacology,
9, 67-75.

Kivlighan, K.T., & Granger, D.A. (2006). Salivary α-amylase response to competition:
Relation to gender, previous experience, and attitudes. Psychoneuroendocrinology, 31,
703–714.

Klerman, G.L., (1989). Depressive disorders: further evidence for increased medical
morbidity and impairment of social functioning. Archives of General Psychiatry 46, 856–
858.

Kudielka, B.M., & Kirschbaum, C. (2005). Sex differences in HPA axis responses to
stress: a review. Biological Psychology, 69, 113-132.

Lovallo, W. R., & Thomas, T. L. (2000). Stress hormones in psychophysiological
research. In J. T. Cacioppo, L. G. Tassinary, & G. G Berntson. (Eds.), Handbook of
Psychophysiology, 2
nd
ed. (pp. 342-367). New York, NY: Cambridge University Press.

Luby, J. L., Heffelfinger, A., Mrakotsky, C., Brown, K., Hessler, M., & Spitznagel, E.
(2003). Alterations in stress cortisol reactivity in depressed preschoolers relative to
psychiatric and no-disorder comparison groups. Archives of General Psychiatry, 60,
1248–1255.

McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to
disease. Archival Internal Medicine, 153, 2093-3101.

McEwen, B., & Seeman, T. (1999). Allostatic load and Allostasis. John D. and
Catherine T. MacArthus Research Network on Socioeconomic Status and Health.

Miller, G. E., Chen, E., & Zhou, E.S. (2007). If it goes up, must it come down? Chronic
stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological
Bulletin, 133(1), 25-45.

39

Nater, U. M., La Marca, R., Florin, L., Moses, A., Langhans, W., Koller, M.M., Ehlert,U.
(2005). Stress-induced changes in human salivary alpha-amylase activity—associations
with adrenergic activity. Psychoneuroendocrinology 31, 49-58.

Nater, U.M., Rohleder, N., Schlotz, W., Ehlert, U., & Kirschbaum, C. (2007).
Determinants of the diurnal course of salivary alpha-amylase.
Psychoneuroendocrinology, 32, 392-401.

Pruessner, M., Hellhammer, D.H., Pruessner, J.C., Lupien, S.J., (2003). Self-reported
depressive symptoms and stress levels in healthy young men: associations with the
cortisol response to awakening. Psychosomatic Medicine, 65, 92-99.

Pruessner, J.C., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D.H. (2003). Two
formulas for computation of the area under the curve represent measures of total hormone
concentration versus time-dependent change. Psychoneuroendocrinology, 28, 916-931.

Puliafico, A.C., & Kendall, P.C. (2006). Threat-related attentional bias in anxious youth:
A review. Clinical Child and Family Psychology Review, 9(3), 162-180.

Rao, U., McCracken, J. T., Lutchmansingh, P., Edwards, C., & Poland, R. E. ~1997!.
Electroencephalographic sleep and urinary free cortisol in adolescent depression:
A preliminary report of changes from episode to recovery. Biological Psychiatry, 41,
369–373.
Roelofs, K., Elzinga, B.M., & Rotteveel, M. (2005). The effects of stress-induced cortisol
responses on approach–avoidance behavior. Psychoneuroendocrinology, 30(7), 665-677.
Ronsaville, D. S., Municchi, G., Laney, C , Cizza, G., Meyer, S. E., Haim,
A., RadkeYarrow, M., Chrousos, G., Gold, P.W., & Martinez, P.E. (2006). Maternal and
environmental factors influence the hypothalamic–pituitary–adrenal axis response to
corticotrophin-releasing hormone infusion in offspring of mothers with or without mood
disorders. Development and Psychopathology, 18, 173-194.

Schiefelbein, V.L., & Susman, E.J. (2006). Cortisol levels and longitudinal cortisol
change as predictors of anxiety in adolescents. The Journal of Early Adolescence, 26(4),
397-413.

Schotte, C.K.W., Van Den Bossche, B., De Doncker, D., Claes, S., and Cosyns, P.
(2006). A biopsychosocial model as a guide for psychoeducation and treatment of
depression. Depression and Anxiety, 23, 312-324.

Schulkin, J. (1994). Melancholic depression and the hormones of adversity. Directions
in Psychological Science, 5, 41-44.

40

Schulkin, J., Gold, P. W., & McEwen, B. S. (1998) Induction of corticotropin-releasing
hormone gene expression by glucocorticoids: Implication for understand the states of
fear and anxiety and allostatic load. Psychoneuroendocrinology, 23, 219-243.

Schoofs, D., Hartmann, R., Wolf, O.T. (2008). Neuroendocrine stress responses to an
oral academic examination: No strong influence of sex, repeated participation and
personality traits. The International Journal on the Biology of Stress, 11(1), 52-61.

Seeman, T.E., Singer, B., Wilkinson, C.W., & McEwen, B. (2001). Gender differences
in age- related changes in HPA axis reactivity. Psychoneuroendocrinology, 26, 225-
240.

Sheline, Y.I., Barch, D.M., Donnelly, J.M., Ollinger, J.M., Snyder, A.Z., & Mintun, M.A.
(2001). Increased amygdala response to masked emotional faces in depressed subjects
resolves with antidepressant treatment: An fMRI study. Biological Psychiatry, 50, 651-
658.

Sheline, Y. I., Wsang, P.W., Gado, M. K., Csernansky, J. G. & Vannier, W.W. (1996).
Hippocampal atrophy in recurrent major depression. Proceedings of the National
Academy of Sciences, 93, 3908-3913.

Stetler, C., & Miller, G.E. (2005). Blunted cortisol response to awakening in mild to
moderate depression: Regulatory influences of sleep patterns and social contacts.
Journal of Abnormal Psychology, 114(4), 697-705.

Susman, E. J. (2006). Psychobiology of persistent antisocial behavior: Stress, early
vulnerabilities and the attenuation hypothesis. Neuroscience and Biobehavioral Reviews,
30, 376-389.

Susman, E. J., Granger, D. A., Murowchick, E., Ponirakis, A., & Worral, B. K. (1996).
Gonadal and adrenal hormones: Developmental transitions and aggressive behavior.
Annals of the New York Academy of Sciences, 794, 18-30.

Tse, W.S. and Bond, A. J. (2004). Relationship between baseline cortisol, social
functioning and depression: a mediation analysis. Psychiatry Research 126, 197-201.

Van der Ende, J., & Verhulst, F.C. (2005). Informant, gender and age differences in
ratings of adolescent problem behavior. European Child and Adolescent Psychiatry, 14,
117-126.

41
Wadhwa, P.D. (2005). Psychoneuroendocrine processes in human pregnancy influence
fetal development and health. Psychoneuroendocrinology, 30, 724-743.
Wolf, J.M., Nicholls, E., & Chen, E. (2008). Chronic stress, salivary cortisol, and α-
amylase in children with asthma and healthy children. Biological Psychology, 78, 20-28.

42
Appendix A

Youth Symptom Checklist (YSR) ID#____________

Below is a list of items that describe kids. For each item that describes you now or within the past
6 months, please circle the 2 if the item is very true or often true of you. Circle 1 if the item is
somewhat or sometimes true of you. If the item is not true of you, circle 0.

0= Not True 1= Somewhat or Sometimes True 2=
Very True or Often True

0 1 2 1. I act too young for my age 0 1 2 40. I hear sounds or
voices that other people
think aren’t there
(describe):
___________________
_________
0 1 2 2. I have an allergy:
Describe:________________
0 1 2 41. I act without
stopping to think
0 1 2 3. I argue a lot 0 1 2 42. I would rather be
alone than with others
0 1 2 4. I have asthma 0 1 2 43. I lie or cheat
0 1 2 5. I act like the opposite sex 0 1 2 44. I bite my fingernails
0 1 2 6. I like animals 0 1 2 45. I am nervous or
tense
0 1 2 7. I brag a lot 0 1 2 46. Parts of my body
twitch or make nervous
movements (describe):
_________________
0 1 2 8. I have trouble concentrating or paying
attention
0 1 2 47. I have nightmares
0 1 2 9. I can’t get my mind off certain thoughts
(describe): _________________________
0 1 2 48. I am not liked by
other kids
0 1 2 10. I have trouble sitting still 0 1 2 49. I can do certain
things better than most
kids
0 1 2 11. I’m too dependent on adults 0 1 2 50. I am too fearful or
anxious
0 1 2 12. I feel lonely 0 1 2 51. I feel dizzy
0 1 2 13. I feel confused or in a fog 0 1 2 52. I feel too guilty
0 1 2 14. I cry a lot 0 1 2 53. I eat too much
0 1 2 15. I am pretty honest 0 1 2 54. I feel overtired
0 1 2 16. I am mean to others 0 1 2 55. I am overweight
0 1 2 17. I daydream a lot 56. Physical problems
without known medical
cause
0 1 2 19. I try to get a lot of attention 0 1 2 a. Aches or pains (not
stomach or headache)
0 1 2 20. I destroy my own things 0 1 2 b. Headaches
0 1 2 21. I destroy things belonging to others 0 1 2 c. Nausea, feel sick

43
0= Not True 1= Somewhat or Sometimes True 2=
Very True or Often True

0 1 2 22. I disobey my parents 0 1 2 d. Problems with eyes
(not if corrected by
glasses) (describe):
___________________
_
0 1 2 23. I disobey at school 0 1 2 e. Rashes or other skin
problems
0 1 2 24. I don’t eat as well as I should 0 1 2 f. Stomachaches or
cramps
0 1 2 25. I don’t get along with other kids 0 1 2 g. Vomiting, throwing
up
0 1 2 26. I don’t feel guilty after doing something I
shouldn’t
0 1 2 h. Other (describe):
___________________
_
0 1 2 27. I am jealous of others 0 1 2 57. I physically attack
people
0 1 2 28. I am willing to help others when they
need help
0 1 2 58. I pick my skin or
other parts of my body
(describe):
___________________
________
0 1 2 29. I am afraid of certain animals, situations,
or places, other than school
(describe):____________
0 1 2 59. I can be pretty
friendly
0 1 2 30. I am afraid of going to school 0 1 2 60. I like to try new
things
0 1 2 31. I am afraid I might think or do something
bad
0 1 2 61. My school work is
poor
0 1 2 32. I feel that I have to be perfect 0 1 2 62. I am poorly
coordinated or clumsy
0 1 2 33. I feel that no one loves me 0 1 2 63. I would rather be
with older kids than with
kids my own age
0 1 2 34. I feel that others are out to get me 0 1 2 64. I would rather be
with younger kids than
with kids my own age
0 1 2 35. I feel worthless or inferior 0 1 2 65. I refuse to talk
0 1 2 36. I accidentally get hurt a lot 0 1 2 66. I repeat certain acts
over and over
(describe):__________
________________
0 1 2 37. I get in many fights 0 1 2 67. I run away from
home

0 1 2 38. I get teased a lot 0 1 2 68. I scream a lot
0 1 2 39. I hang around with kids who get in
trouble
0 1 2 69. I am secretive or
keep things to myself

44
0= Not True 1= Somewhat or Sometimes True 2=
Very True or Often True

0 1 2 70. I see things that other people think aren’t
there
(describe):_______________________
0 1 2 92. I like to make others
laugh
0 1 2 71. I am self conscious or easily
embarrassed
0 1 2 93. I talk too much
0 1 2 72. I set fires 0 1 2 94. I tease others a lot
0 1 2 73. I can work well with my hands 0 1 2 95. I have a hot temper
0 1 2 74. I show off or clown 0 1 2 96. I think about sex too
much
0 1 2 75. I am shy 0 1 2 97. I threaten to hurt
people
0 1 2 76. I sleep less than most kids 0 1 2 98. I like to help others
0 1 2 77. I sleep more than most kids during day
and or night (describe): _________________
0 1 2 99. I am too concerned
about being neat or
clean
0 1 2 78. I have a good imagination 0 1 2 100. I have trouble
sleeping (describe):
___________________
_________________
0 1 2 79. I have a speech problem (describe):
____________________________________
0 1 2 101. I cut classes or
skip school
0 1 2 80. I stand up for my rights 0 1 2 102. I don’t have much
energy
0 1 2 81. I steal at home 0 1 2 103. I am unhappy, sad,
or depressed
0 1 2 82. I steal from places other than home 0 1 2 104. I am louder than
other kids
0 1 2 83. I store up things I don’t need (describe):
____________________________________
0 1 2 105. I use alcohol or
drugs for nonmedical
purposes (describe):
___________________
_
0 1 2 84. I do things other people think are strange
(describe): ___________________________
0 1 2 106. I try to be fair to
others
0 1 2 85. I have thoughts that other people would
think are strange (describe): _____________
____________________________________
0 1 2 107. I enjoy a good joke
0 1 2 86. I am stubborn 0 1 2 108. I like to take life
easy
0 1 2 87. My moods or feelings change suddenly 0 1 2 109. I try to help other
people when I can
0 1 2 88. I enjoy being with other people 0 1 2 110. I wish I were of the
opposite sex
0 1 2 89. I am suspicious 0 1 2 111. I keep from getting
involved with others
0 1 2 90. I swear or use dirty language 0 1 2 112. I worry a lot

45
Appendix B

46

47
Appendix C
ID #_____-3 :Youth

DISCUSSION FOLLOW-UP

Please circle an answer for each of the questions.

1. HOW SIMILAR WAS THIS DISCUSSION TO OTHER FAMILY DISCUSSIONS
YOU HAVE HAD?

Not at all Slightly Somewhat Moderately Very
Similar Similar Similar Similar Similar
0 1 2 3 4

2. HOW MUCH WERE YOU ABLE TO EXPRESS YOUR OWN POINT OF VIEW
ON THE TOPICS?

Not at all A Little Some Moderate Amount A Lot
0 1 2 3 4

3. HOW MUCH CONFLICT DID YOU EXPERIENCE WITH YOUR MOM IN
THIS DISCUSSION?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

4. HOW MUCH CONFLICT DID YOU EXPERIENCE WITH YOUR DAD IN THIS
DISCUSSION?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

5. HOW MUCH DID YOUR MOM UNDERSTAND WHAT YOU WERE SAYING
AND FEELING?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

48

6. HOW MUCH DID YOUR DAD UNDERSTAND WHAT YOU WERE SAYING
AND FEELING?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

7. BASED ON THIS DISCUSSION, HOW MUCH WILL THINGS CHANGE FOR
THE BETTER?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

8. BASED ON THIS DISCUSSION, HOW MUCH WILL THINGS CHANGE FOR
THE WORSE?

None A Little Some Moderate Amount A Lot
0 1 2 3 4

9. WHAT WERE YOU FEELING DURING THE DISCUSSION? (Rate each one)

None
0

A
Little
1

Some
2
Moderate
Amount
3

A Lot
4
9a Calm 0 1 2 3 4
9b Angry 0 1 2 3 4
9c Hopeful 0 1 2 3 4
9d Frustrated 0 1 2 3 4
9e Happy 0 1 2 3 4
9f Anxious 0 1 2 3 4
9g Positively surprised 0 1 2 3 4
9h Irritated or annoyed 0 1 2 3 4
9i Taken seriously by others 0 1 2 3 4
9j Embarrassed 0 1 2 3 4
9k Ignored/not important 0 1 2 3 4
9l Upset 0 1 2 3 4
9m Tense 0 1 2 3 4
9n Relieved 0 1 2 3 4

49
9o Afraid/fearful 0 1 2 3 4
9p Disappointed 0 1 2 3 4
9q Other:
_________________
0 1 2 3 4

50
Appendix D
Saliva Sample Follow-up Questionnaire

Please complete the first half of this questionnaire and, if you need help
remembering any of the information, feel free to ask your family members. The
second part of this questionnaire will be filled out individually later (and any part
you prefer to fill out individually can also be filled out later.)

Part 1:
1. What time did you wake up this morning? ________________________
a. What time do you usually wake up? ________________________
2. When did you last eat? ________________________
a. What did you last eat? ________________________
3. When did you last drink (not including water)? ________________________
a. What did you last drink? ________________________
4. Have you consumed any caffeinated beverages (e.g., coffee, tea, Red Bull,
Mountain Dew, etc.) or food (e.g., chocolate) today? YES NO
a. When ? ______________
b. How much? _________________
5. When did you last brush your teeth (approximate time of day)? ______________
a. Do your gums bleed when you brush your teeth? YES NO
6. Have you flossed your teeth in past 24 hours? If yes, approximate time of day?
_______________________
7. Do you have any cuts or sores in your mouth? YES NO
8. Do you have any untreated cavities? YES NO
9. Are you taking any steroid-based anti-inflammatory medications (e.g., cortisone
shots, creams, or prednisone pills) or any type of performance enhancing
supplements or steroids (e.g., DHEA, testosterone)? YES NO
a. If yes, what kind? ________________________
10. Do you use an inhaler for asthma or allergies? YES NO
a. If yes, what kind? ________________________
b. Did you use it within the prior 48 hours? YES NO
c. When did you last use it? ________________________
11. Do you use any medicines that are creams or lotions? YES NO
d. If yes, what kind? ________________________
e. If yes, when did you last use it? ________________________
12. Are you taking any other medicine? YES NO
f. If yes, what kind? __________________________________________

Part 2:
13. Is your tongue pierced? YES NO
14. Do you smoke? YES NO

51
g. If yes, how many cigarettes have you smoked in the last 48
hours?________
h. When did you last smoke a cigarette? ________________________
i. Is anyone else in your household a smoker? YES NO

15. Have you consumed any alcohol in the past 48 hours? YES NO
j. When? __________
k. How much? _________
16. Have you had any signs or symptoms of illness (fever, swollen glands, nasal
drainage, cough) in the last 72 hours? YES NO
17. Have your allergies bothered you in the past 72 hours? YES NO
18. On a scale from 1 to 5, how would you rate your overall health today?
1 2 3 4 5
very poor poor average good very good

19. [for females] Approximately how many days since the beginning of your last
period? _______________
l. How many days is your typical cycle? ________________
20. [for females] Are you pregnant? YES NO
m. Are you currently using “the pill” or “the patch” as contraceptives?
YES NO

Abstract (if available)

Abstract The present study investigated the association between internalizing symptoms and physiological reactivity in a sample of 73 adolescents. The adolescents engaged in a stressor task, involving a 15-minute discussion with their parents, after which subjective distress was assessed. Saliva samples were collected before the stressor task and over a 70-minute period post-stressor, and were assayed for salivary cortisol and alpha-amylase as indices of the HPA axis and SAM system, respectively. Results demonstrate a negative main effect of internalizing symptoms and a positive main effect of subjective distress on HPA activity. Internalizing symptoms moderated the association between subjective distress and HPA reactivity. These findings suggest that attenuated physiological stress is part of a protective reaction to the effects of chronic HPA activation. The present study has important implications for the understanding of how mental health and physical health influence one another during adolescence.

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Asset Metadata

Creator Spies, Lauren A. (author)

Core Title A multiple systems approach to examining physiological stress and its association with internalizing disorders in adolescence

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 07/30/2010

Defense Date 05/16/2008

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag alpha amylase,cortisol,OAI-PMH Harvest

Language English

Advisor Margolin, Gayla (committee chair), Manis, Franklin R. (committee member), Prescott, Carol A. (committee member)

Creator Email lspies@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m1447

Unique identifier UC1137412

Identifier etd-Spies-20080730 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-89464 (legacy record id),usctheses-m1447 (legacy record id)

Legacy Identifier etd-Spies-20080730.pdf

Dmrecord 89464

Document Type Thesis

Rights Spies, Lauren A.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu