A Longitudinal Study of Depressive Symptomatology in Young Adolescents CAROL Z. GARRISON, PH.D., KIRBY L. JACKSON, A.B., FREDERICK MARSTELLER, PH.D., ROBERT McKEOWN, PH.D., AND CHERYL ADDY, PH.D.
Abstract. As part of a longitudinal study of depression in adolescents, the Center for Epidemiologic Studies Depression Scale (CES-D) was administered to 550 students 3 times, at the beginning of the seventh, eighth, and ninth grades. Blacks and females had higher scores than did whites and males. Scores of blacks and males declined more over the 3 year period than did those of females and whites. The stability of individual students' depression scores was less consistent than the overall distributions with I and 2 year correlations reaching only 0.53 and 0.36, respectively. The best predictor of subsequent year CES-D scores was the previous year's score. Undesirable life events and family adaptability were significant but less important predictors. J. Am. Acad. Child Adolesc, Psychiatry, 1990,29,4:581-585. Key Words: adolescence, community psychiatry, depression, psychiatric status rating scales.
Recently there has been much interest in identifying the frequency, correlates, and predictors of depressive symptomatology in adolescence. To date, frequency estimates have varied considerably, raising questions regarding the stability of reported symptomatology (Schoenbach et al., 1984; Garrison et al., 1988). Although a number of different correlates and predictors have been suggested, a recurring theme has been that life events and family environment may play important roles in the genesis of depressive symptomatology (Garrison et al., 1985). Accordingly, the purpose of the current study was to: (1) identify the frequency, distribution, and stability of self-reported depressive symptoms in young adolescents; and (2) to describe the relationship among life events, perceived family environment, and the onset or existence of depressive symptomatology in this age group. Method
district in the Southeast. All students enrolled in the seventh grade in 1985 were eligible for inclusion in the study. The data were collected in the classroom where students completed a self-administered questionnaire that included a demographic section, the 20-item CES-D (Radloff, 1977), a modified version of the Coddington Life Events Scale for Adolescents (Coddington, 1972), and the 30-item Family Adaptability and Cohesion Evaluation Scales (Olson et al., 1982). The CES-D is a 20-item self-report symptom rating scale developed to measure depressive symptomatology in community adult populations (Radloff, 1977). The items included in the scale represent the major symptoms of the syndrome of depression as identified by clinical judgment, frequency of use in other questionnaires for depression, and factor analytic studies. When completing the CES-D, the subject is asked to report on his/her feelings during the preceding week. Responses are made on a four-point scale ("rarely or none of the time," "some or little of the time," "a lot of the time," and "most or all of the time") designed to measure the duration or frequency of symptoms. Each item has a possible value of zero to three; thus, the total score has a range of 0 to 60. This single score is used to index the degree of depressive symptomatology present. In adult populations, scores of 16 or more generally have been used to indicate probable cases (Radloff, 1977). Development of the CES-D, its validation with adults, and use in community adult samples have been reported (Radloff, 1977; Weissman et al., 1977). Additionally, Schoenbach et al. (1982, 1983), and Garrison et al. (1989) have used the CES-D with young adolescent populations. The Coddington Life Events Scale for Adolescents (Coddington, 1972) is a life events schedule that evolved out of the Holmes and Rahe (1967) approach to measuring life stress. When completing the instrument, the adolescent is asked to report the number of times within the past 12 months that he or she has experienced certain life events. The scale contains a total of 50 events, judged as requiring a significant amount of social readjustment of adolescents. It was developed by having several groups of judges (243 teachers, pediatricians, and mental health workers) evaluate a list of events in terms of the degree of adjustment required
The data for this investigation were collected during the screening phase of a larger longitudinal study of depressive symptomatology, major depressive disorder, and suicidal ideation in young adolescents. When completed, the larger study (which includes both school-administered depression screens and clinician-administered diagnostic interviews) will provide estimates of the frequency of major depressive disorder and validation of the Center for Epidemiologic Studies Depression Scale (CES-D) in young adolescents. The current analysis, however, focuses on the frequency, stability, and predictors of depressive symptomatology, as determined from the school screening data. Data collection occurred annually in the fall of 3 consecutive years (1985-1987) from subjects attending four public middle schools within a selected suburban school Accepted February 2, 1990. From the Department of Epidemiology and Biostatistics, University of South Carolina. This research was supported through a grant from the National Institute of Mental Health (MH40363) which the authors gratefully acknowledge. Reprint requests to Dr. Garrison, Department ofEpidemiology and Biostatistics, University of South Carolina, Columbia, S.C. 29208. 0890-8567/9012904-0581$02.0010© 1990 by the American Academy of Child and Adolescent Psychiatry.
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by each event. The items are oriented toward the types of stressful life events relevant to the adolescent age group. The Coddington Scale has been modified for use in this study. Items involving drug use and pregnancy were deleted (at the request of the school). Additional items including items involving college plans, employment, marriage, and driving were also omitted, because of the peripheral nature of these concerns to most early adolescents. Two items dealing with physical appearance were added. It was thought that for the purpose of the present study this area was not adequately addressed in the original scale . The modified life events scale contained a total of 41 events (19 desirable and 22 undesirable) . (The designation of events as either desirable or undesirable was done with the realization that just about any event may be viewed as positive or negative depending on the circumstances surrounding the event and the way the event is perceived by the child.) Events could be reported as occurring more than once during the preceding year. Life event scores were calculated for undesirable and desirable events as an unweighted sum of the number of items of the respective type. Items with missing responses were assigned a value of zero . Maximal possible scores were 90 (for undesirable events) and 56 (for desirable events). Unweighted rather than weighted sums were used, as the appropriateness of the weights assigned has not been well documented. In any case , available evidence suggests that weighted and unweighted scores are highly correlated with one another and similarly related to dependent measures (Vinokur and Selzer, 1975; Mueller et aI., 1977; Tausig, 1982; Swearingen and Cohen, 1985). Family environment was operationalized as being represented by the adolescent's perception of the social and emotional climate within his or her family. This parameter focused on the amount of cohesion and adaptability present (Olson et aI., 1982). Both cohesion and adaptability were seen as existing on continuums. In particular, cohesion encompassed the emotional bonding which family members had toward one another as well as the individual autonomy that the teen experienced in the family system. The extreme high of family cohesion and enmeshment signified an overidentification with the family that resulted in extreme bonding and limited individual autonomy. The low extreme, disengagement, was characterized by low bonding and high autonomy . Adaptability was defined as the ability of the family system to change its power structure, role relationships, and rules in response to situational and developmental stress. The low extreme of adaptability signaled rigidity or no change. Alternately, the high extreme denoted chaos or overwhelming change (Olson et aI., 1982). This particular conceptualization of family environment was based on a model developed by Olson et al. (1982). Their model locates families in a matrix created by adaptability and cohesion . The extremes of adaptability and cohesion are deemed detrimental to family functioning. The central area of the matrix is hypothesized as being the most functional and indicates an optimal balance on both dimensions. Family environment was measured using the Family 582
Adaptability and Cohesion Evaluation Scales (FACES II) (Olson et aI., 1982). FACES II is a 30-item, self-report, written questionnaire. The instrument includes 16 cohesion items and 14 adaptability items. Items reflect statements about the individual's family. When completing the questionnaire , individuals are asked to respond to these statements on a five-point scale . The possible range of scores for the family cohesion dimension is 16 to 80. A high score (greater than 64) indicates that the family member perceives extreme closeness and limited autonomy in the family . A low score (less than 48) indicates a perception of low emotional bonding and high individual autonomy. A midrange score (48 to 64) indicates a balance between bonding and autonomy. The possible range for the total adaptability score is 14 to 70. A high total score (greater than 52) characterizes the family as chaotically organized with capriciously shifting rules, roles, and power structure . A low score (less than 38) characterizes the family as rigidly organized. A moderate score (38 to 52) characterizes the family as having a balance between stability and change . Results
The sample included the 550 individuals who participated in all 3 years of the study. Eighty-seven percent were white and 54% were female . At the study's onset, subjects ranged in age from 11 to 15 years, with the majority (95%) between the ages of 12 and 13. Approximately 56% of the subjects lived in a family unit where both natural parents were present, while 23% lived in a single parent family. A large number of subjects did not know the educational status of their mother (25%) or father (35%). Thirteen percent of mothers and 11% of fathers did not finish high school. Slightly more (15% of the mothers and 18% of the fathers) were college graduates. The 550 participating students represent over 70% of the 782 seventh graders who responded to the initial questionnaire in 1985. Since 95% to 98% of the students enrolled in the middle schools completed the questionnaire in any given year, the observed attrition (30%) primarily represents students who moved out of the school district and were no longer available for inclusion in the study. Comparison of those individuals who participated all 3 years with individuals participating less than 3 years indicates that the latter individuals were somewhat more likely to be male and were older (12.52 versus 12.21 years, p = 0.0001), had higher CES-D (17.55 versus 15.60, p = 0.01), undesirable life event (10.52 versus 8.42, p = 0.0001) scores, and had lower adaptability (43.80 versus 45.37, p = 0 .05) and cohesion (54.58 versus 57.47, P = 0 .002) scores . Inspection of the overall distribution of CES-D scores provides some interesting information (Table 1). First, a comparison of mean depression scores for the various race gender groups indicates that blacks generally had higher scores than whites and that females consistently had higher scores than males. Second, a significant time effect is present in that the scores of blacks and males tended to decline more over the 3 year period than did those of females and whites. This trend is most apparent among the black males. J.Am.Acad. Child Adolesc .Psychiatry, 29 :4, July 1990
DEPRESSIVE SYMPTOMS IN ADOLESCENTS T AB LE
1. Mean CES-Da Scores and Standard Deviations by Race-Gender Graul' and Year (N = 550)
Race-Gender
1985
1986
White males N =225 White females N= 254 Black males N= 31 Black females N =40 Total 550
13.98 (8.52) 15.80 (9.58) 18.57
11.76 (7.60) 16.69 (10.90) 14. 13 (5.88) 20.0 7 (10.49) 14.78 (9.37)
a
(9 .78)
21.12 (9.13) 15.60 (9.32)
T ABLE
2. Pearson Correlation of CES-Da Scores over Time (N = 550)
1987 11.66 (8.59) 16.44 (10.79) 11.29 (5.24) 19. 60 (11.0 1) 14.43 (10.07)
Year
Race-Gender
85-86
86-87
85-87
White males White females Black males Black females Total
0.53 0.5 1 0.29 0.65 0.53
0. 39 0.47 0.3 0 0. 57 0.49
0.42 0.31 0.33 0.34 0.36
a
CES-D
=
Center for Epidemiologic Studies Depre ssion Scale.
CES-D = Center for Epidemiologic Studies Depression Scale.
Results from a repeated measures analysis of variance show that these race , gender, time , time x race , and time X gender difference s are all significant (p < 0.03 ). The stability of individual students' depression scores was less consistent than the overall distributions, with 1 and 2 year correlations reaching only 0 .53 (1985-86) and 0.36 (1985-87), respectively. This time related decrease is apparent in both the unadjusted (simple Pearson) correlations and in the residual correlations (0 .5 1 for 1985-86 and 0.35 for 1985-87) that adjust for race and gender. Consideration of these same correlations in the specific race-gender groups shows that the expected pattern of decreasing correlations with increasing time holds only for females (Table 2). A comparison of the students with high versus low depression scores additionally highlights the instability of the reported symptomatolo gy. Two types of dichotomous depression measures were calculated . In the first, subjects with scores greater than or equal to 30 (a score that approximated the top decile in all 3 years) were deemed high scorers . In the second, a classification based on the Research Diagnostic Criteria for major depressive disorder was constructed. All students meeting the criteria were deemed high scorers. Between 8% and 10% of the students obtained high scores depending on the year and the scoring scheme employed. Although over 90% of the students with low scores in 1985 or 1986 had low scores the following year, only about 30% of those with high scores in one year had high scores in the following year. Five students (two black females and three white females) had high scores all 3 years. Multiple regression analyses were done to explore the relationship of the various sociodemographic, life event, and family environment variables to the continuous CES-D score. Separate analyses were performed for each year and for the cross-sectional and longitudinal data . Race, gender, and any other variable meeting a 0 .05 significance level were retained in the models. The variables considered for entry into all models included cohesion, adaptability, undesirable and desirable life events, guardian status, parents' education status, and age. Cross-sectional results indicate that cohesion was the best predictor (in terms of the amount of variance explained ) of the depressive symptom score (Table 3). Undesirable life J .Am .Acad. Child Adolesc .Psychiatry , 29: 4, July 1990
events were significant, but far less important. Adaptability failed to enter the model in 1986 and 1987, a finding possibly explained by the high correlation between adaptability and cohesion. The above factors, together with race and gender, explained 32% to 35% of the variance in CES-D scores. The longitudinal results indicated that the previous years' CES-D scores were the best predictors of subsequent CESD scores, explaining between 12% and 20% of the total variance. Undesirable events retained small but significant effects. Adaptabilit y was significant only in the 1985 model. Cohesion was not significant in either model. Togeth er , the longitudinal factors with race and gender explained between 21% and 28% of the total variation in subsequent years' CES-D scores (Table 4). Discussion
The most prominent characteristics of study subjects lost to follow-up when compared to those participating in all 3 years of the study were male gender, older age , more undesirable events, less cohesion, and less adaptability. Associations among all of these characteristics and the depressive symptom scores were subsequently found. Thus , although the overall participation rate was good, these losses may decrease the ability to generalize the study results and could potentially bias them . The finding that females attain higher depre ssive symptom scores than males and blacks higher scores than whites is consistent with previous results with adolescents (Kandel and Davies , 1982; Schoenbach et al. , 1983; Garrison et al., 1985, 1988). The reason for the time dependent decrease in scores for males but not females is not clear. However , the resulting pattern coincides with findings in adults where females report higher levels of depre ssive symptom atology and higher rates of major depressive disorder (Warheit et aI., 1973; Comstock and Helsing, 1976; Rosenfeld , 1980; Frerichs et al. , 1981; Myers et aI., 1984; Somervell et al. , 1989). This is in contrast to early childhood where similar rates of major depressive disorder have been observed in boys and girls. It may be that the emotional or biological changes that accompany early adolescence are responsible for the attainment of more adult-like patterns. Findings suggest that adolescent depressive symptom scores vary considerably over time. Although 90% of the low scorers remained low scorers, only 30% of high scorers 583
GARRISON ET AL. TABLE
3. Multiple Regression Models of Continuous Depression Scores with Life Event and Family Environment Variables, Cross-Sectional Data Coefficients
1985 Variables Intercept Race Sex Cohesion Undesirable Desirable Adaptability Model R2
1986
Coefficient
Coefficient
Hierarchical R2
25.62 2.56 2.14 -0.19 0.39
0.03 0.01 0.20 0.06
22.84 1.12 3.95 -0.32 0.28
0.01 0.06 0.24 0.03
-0.19
0.02 0.32
remained high over a year's interval. The suggestion is that a single screening score that reflects the amount of symptomatology present during the preceding week may not be indicative of the amount of symptomatology present over long periods of time. This is not surprising as both depressive symptoms and the disorder are generally viewed as evidencing transient or fluctuant natures. The relationship of CES-D measured symptomatology during the previous week to major depression in young adolescents is an important question that cannot be addressed with the data reported here. (Completion of the diagnostic interview phase of the larger study and analysis of that data will allow the authors to address the relationship.) In a community study of adults using the CES-D with a cutpoint of sixteen, Myers and Weissman (1979) reported a sensitivity of 63% and a specificity of 94%. In clinical studies with adults, the reported sensitivities and specificities have ranged from 74% to 97% and from 56% to 86% respectively. Preliminary data from the adolescent group indicates similar results but with a higher cutpoint. The best predictor of the cross-sectional depressive symptom scores was cohesion which explained between 19% and 24% of the CES-D variance in any given year. The observed association was one with higher levels of depressive symptomatology being reported at lower levels of cohesion. It appears that although the perception of a disengaged family (i.e., low emotional bonding and high individual autonomy) is associated with higher depressive symptomatology, the perception of the opposite extreme (enmeshment, signifying an overidentification with the family) is not. This finding coincides with the earlier work of Garrison et al. (198$) and does not support the hypothesized model in which either extremes of family functioning are equally associated with depressive symptomatology. In longitudinal models, the previous year's CES-D score was the best predictor of the subsequent CES-D score, explaining between 12% and 20% of the variance. Cohesion was not significant. It may be that by including previous years' CES-D scores in the longitudinal models, the authors have controlled for baseline symptomatology and thus largely negated the effects of perceived family cohesion. Undesirable life events retained significant but smaller
584
1987
Hierarchical R2
Coefficient
Hierarchical R2
17.54 -0.09 4.80 -0.23 0.56 -0.14
0.003 0.07 0.19 0.08 0.01
0.34
0.35
TABLE 4. Multiple Regression Models Predicting 1987 Scores Using 1985 or 1986 Life Event and Family Environment Variables
1985 Variables Intercept Race Sex CES-D Undesirable Adaptability Model R2
Coefficient
6.72 -0.06 4.76 0.28 0.17 -0.12
1986
Hierarchical R2
0.01 0.06 0.12 0.01 0.01 0.21
Coefficient
Hierarchical R2
1.71 -0.01 3.01 0.44 0.22
0.005 0.07 0.20 0.01 0.28
effects (explaining between 1% and 8% of the variance) in both longitudinal and cross-sectional models. It seems that in early adolescence family environment may be a more important predictor of depressive symptomatology than life events. A product (interaction) term involving the life event and family variables did not enter any of the models, even when the significance level for entry was set at 0.50. The suggestion is that family environment does not interact with negative life events to modify the adverse impact of these events on depressive symptomatology. Although the authors were able to explain between 21 % and 36% of the variance in depressive symptom scores, the majority of the variation was unexplained by the basic demographic, family, and life event data collected. Future investigations in the area will be strengthened by refinement of the tools used to collect these data. Consideration should also be given to additional potential risk factors, such as family history of depression or other affective disorders, socialization and peer relations, substance use and abuse, and problem solving and coping abilities. Although previous studies may have investigated the effect of one or two of these variables, no study to date has collected data on this wide an array of potential predictors and then simultaneously looked at their contribution to the development of depressive symptoms or major depressive disorder. A longitudinal community-based study designed to elicit detailed information regarding all of these parameters from both adolesJ. Am.Acad. Child Adolesc. Psychiatry, 29:4, July 1990
DEPRESSIVE SYMPTOMS IN ADOLESCENTS
cents and their parent(s) could provide the optimal mechanism for improving an understanding of the phenomena. References Coddington, R. D. (1972), The significance of life events as etiologic factors in the diseases of children. J. Psychosom. Res., 16:7-18. Comstock, G. W. & Helsing, K. J. (1976), Symptoms of depression in two communities. Psychol. Med., 6:551-563. Frerichs, R. R., Aneshensel, C. S. & Clark, V. A. (1981), Prevalence of depression in Los Angeles county. Am. J. Epidemiol., 113:691699. Garrison, C. Z., Schoenbach, V. J. & Kaplan, B. H. (1985), Depressive symptoms in early adolescence. In: Depression in Multidisciplinary Perspective, ed. A. Dean. New York: Brunner/Mazel, pp.60-82. - - Schluchter, M. D., Schoenbach, V. J. & Kaplan, B. H. (1989), Epidemiology of depressive symptoms in young adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 28:343-351. - - Schoenbach, V. J. & Kaplan, B. H. (1988), Symptom prevalence of depression in adolescence. In: Advances in Adolescent Mental Health, Volume III. Greenwich, CT: JAI Press. Holmes, T. H. & Rahe, R. H. (1967), The social readjustment rating scale. l. Psychosom. Res., 11:213-218. Kandel, D. B. & Davies, M. (1982), Epidemiology of depressive mood in adolescents. Arch. Gen. Psychiatry, 39:1025-1212. Mueller, D. P., Edwards, D. W. & Yarvis, R. M. (1977), Stressful life events and psychiatric symptomatology: change or undesirability? J. Health Soc. Behav., 18:307-317. Myers, J. K. & Weissman, M. M. (1979, May), Screeningfordepression in a community sample: the use of a self-report symptom scale to detect the depressive syndrome. Paper presented at the American Psychiatric Annual meeting, Chicago. - - - - Tischler, G. L. et al. (1984), Six-month prevalence of psychiatric disorders in three communities. Arch. Gen. Psychiatry, 41:959-967.
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Olson, D., Bell, R. & Portner, J. (1982), FACES II. St. Paul: University of Minnesota. Radloff, L. S. (1977), The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1:385-401. Rosenfeld, S. (1980), Sex differences in depression; do women always have higher rates? J, Health Soc. Behav., 21:33-42. Schoenbach, V. J., Garrison, C. Z. & Kaplan, B. H. (1984), Epidemiology of adolescent depression. Public Health Rev., 12:159189. - - Kaplan, B. H., Wagner, E. H., Grimson, R. C. & Miller, F. T. (1983), Prevalence of self-reported depressive symptoms in young adolescents. Am. J. Public Health, 73: 1281-1287. - - Kaplan, B. H., Grimson, R. C. & Wagner, E. H. (1982), Use of a symptom scale to study the prevalence of a depressive syndrome in young adolescents. Am. J. Epidemiol., 116-791-800. Somervell, P. D., Leaf, P. J., Weissman, M. M., Blazer, D. G. & Bruce, M. L. (1989), The prevalence of major depression in black and white adults in five United States communities. Am. J. Epidemiol., 130:725-735. Swearingen, E. M. & Cohen, L. H. (1985), Measurement of adolescents' life events: the junior high life experience survey. Amer. J. Community Psychol., 13:69-85. Tausig, M. (1982), Measuring life events. J. Health Soc. Behav., 23:52-64. Vinokur, A. & Selzer, M. L. (1975), Desirable vs. undesirable life events: their relationship to stress and mental distress. J. Pers. Soc. Psychol., 32:329-337. Warheit, G. J., Holzer, C. E. & Schwab, J. J. (1973), An analysis of social class and racial differences in depressive symptomatology. J. Health Soc. Behav., 14:291-299. Weissman, M. M., Sholomakas, D., Pottenger, M., Prusoff, B. A. & Locke, B. Z. (1977), Assessing depressive symptoms in five psychiatric populations: a validation study. Am. J. Epidemiol. 106:203-214.
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Abstract. As part of a longitudinal study of depression in adolescents, the Center for Epidemiologic Studies Depression Scale (CES-D) was administered to 550 students 3 times, at the beginning of the seventh, eighth, and ninth grades. Blacks and females had higher scores than did whites and males. Scores of blacks and males declined more over the 3 year period than did those of females and whites. The stability of individual students' depression scores was less consistent than the overall distributions with I and 2 year correlations reaching only 0.53 and 0.36, respectively. The best predictor of subsequent year CES-D scores was the previous year's score. Undesirable life events and family adaptability were significant but less important predictors. J. Am. Acad. Child Adolesc, Psychiatry, 1990,29,4:581-585. Key Words: adolescence, community psychiatry, depression, psychiatric status rating scales.
Recently there has been much interest in identifying the frequency, correlates, and predictors of depressive symptomatology in adolescence. To date, frequency estimates have varied considerably, raising questions regarding the stability of reported symptomatology (Schoenbach et al., 1984; Garrison et al., 1988). Although a number of different correlates and predictors have been suggested, a recurring theme has been that life events and family environment may play important roles in the genesis of depressive symptomatology (Garrison et al., 1985). Accordingly, the purpose of the current study was to: (1) identify the frequency, distribution, and stability of self-reported depressive symptoms in young adolescents; and (2) to describe the relationship among life events, perceived family environment, and the onset or existence of depressive symptomatology in this age group. Method
district in the Southeast. All students enrolled in the seventh grade in 1985 were eligible for inclusion in the study. The data were collected in the classroom where students completed a self-administered questionnaire that included a demographic section, the 20-item CES-D (Radloff, 1977), a modified version of the Coddington Life Events Scale for Adolescents (Coddington, 1972), and the 30-item Family Adaptability and Cohesion Evaluation Scales (Olson et al., 1982). The CES-D is a 20-item self-report symptom rating scale developed to measure depressive symptomatology in community adult populations (Radloff, 1977). The items included in the scale represent the major symptoms of the syndrome of depression as identified by clinical judgment, frequency of use in other questionnaires for depression, and factor analytic studies. When completing the CES-D, the subject is asked to report on his/her feelings during the preceding week. Responses are made on a four-point scale ("rarely or none of the time," "some or little of the time," "a lot of the time," and "most or all of the time") designed to measure the duration or frequency of symptoms. Each item has a possible value of zero to three; thus, the total score has a range of 0 to 60. This single score is used to index the degree of depressive symptomatology present. In adult populations, scores of 16 or more generally have been used to indicate probable cases (Radloff, 1977). Development of the CES-D, its validation with adults, and use in community adult samples have been reported (Radloff, 1977; Weissman et al., 1977). Additionally, Schoenbach et al. (1982, 1983), and Garrison et al. (1989) have used the CES-D with young adolescent populations. The Coddington Life Events Scale for Adolescents (Coddington, 1972) is a life events schedule that evolved out of the Holmes and Rahe (1967) approach to measuring life stress. When completing the instrument, the adolescent is asked to report the number of times within the past 12 months that he or she has experienced certain life events. The scale contains a total of 50 events, judged as requiring a significant amount of social readjustment of adolescents. It was developed by having several groups of judges (243 teachers, pediatricians, and mental health workers) evaluate a list of events in terms of the degree of adjustment required
The data for this investigation were collected during the screening phase of a larger longitudinal study of depressive symptomatology, major depressive disorder, and suicidal ideation in young adolescents. When completed, the larger study (which includes both school-administered depression screens and clinician-administered diagnostic interviews) will provide estimates of the frequency of major depressive disorder and validation of the Center for Epidemiologic Studies Depression Scale (CES-D) in young adolescents. The current analysis, however, focuses on the frequency, stability, and predictors of depressive symptomatology, as determined from the school screening data. Data collection occurred annually in the fall of 3 consecutive years (1985-1987) from subjects attending four public middle schools within a selected suburban school Accepted February 2, 1990. From the Department of Epidemiology and Biostatistics, University of South Carolina. This research was supported through a grant from the National Institute of Mental Health (MH40363) which the authors gratefully acknowledge. Reprint requests to Dr. Garrison, Department ofEpidemiology and Biostatistics, University of South Carolina, Columbia, S.C. 29208. 0890-8567/9012904-0581$02.0010© 1990 by the American Academy of Child and Adolescent Psychiatry.
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GARRISON ET AL.
by each event. The items are oriented toward the types of stressful life events relevant to the adolescent age group. The Coddington Scale has been modified for use in this study. Items involving drug use and pregnancy were deleted (at the request of the school). Additional items including items involving college plans, employment, marriage, and driving were also omitted, because of the peripheral nature of these concerns to most early adolescents. Two items dealing with physical appearance were added. It was thought that for the purpose of the present study this area was not adequately addressed in the original scale . The modified life events scale contained a total of 41 events (19 desirable and 22 undesirable) . (The designation of events as either desirable or undesirable was done with the realization that just about any event may be viewed as positive or negative depending on the circumstances surrounding the event and the way the event is perceived by the child.) Events could be reported as occurring more than once during the preceding year. Life event scores were calculated for undesirable and desirable events as an unweighted sum of the number of items of the respective type. Items with missing responses were assigned a value of zero . Maximal possible scores were 90 (for undesirable events) and 56 (for desirable events). Unweighted rather than weighted sums were used, as the appropriateness of the weights assigned has not been well documented. In any case , available evidence suggests that weighted and unweighted scores are highly correlated with one another and similarly related to dependent measures (Vinokur and Selzer, 1975; Mueller et aI., 1977; Tausig, 1982; Swearingen and Cohen, 1985). Family environment was operationalized as being represented by the adolescent's perception of the social and emotional climate within his or her family. This parameter focused on the amount of cohesion and adaptability present (Olson et aI., 1982). Both cohesion and adaptability were seen as existing on continuums. In particular, cohesion encompassed the emotional bonding which family members had toward one another as well as the individual autonomy that the teen experienced in the family system. The extreme high of family cohesion and enmeshment signified an overidentification with the family that resulted in extreme bonding and limited individual autonomy. The low extreme, disengagement, was characterized by low bonding and high autonomy . Adaptability was defined as the ability of the family system to change its power structure, role relationships, and rules in response to situational and developmental stress. The low extreme of adaptability signaled rigidity or no change. Alternately, the high extreme denoted chaos or overwhelming change (Olson et aI., 1982). This particular conceptualization of family environment was based on a model developed by Olson et al. (1982). Their model locates families in a matrix created by adaptability and cohesion . The extremes of adaptability and cohesion are deemed detrimental to family functioning. The central area of the matrix is hypothesized as being the most functional and indicates an optimal balance on both dimensions. Family environment was measured using the Family 582
Adaptability and Cohesion Evaluation Scales (FACES II) (Olson et aI., 1982). FACES II is a 30-item, self-report, written questionnaire. The instrument includes 16 cohesion items and 14 adaptability items. Items reflect statements about the individual's family. When completing the questionnaire , individuals are asked to respond to these statements on a five-point scale . The possible range of scores for the family cohesion dimension is 16 to 80. A high score (greater than 64) indicates that the family member perceives extreme closeness and limited autonomy in the family . A low score (less than 48) indicates a perception of low emotional bonding and high individual autonomy. A midrange score (48 to 64) indicates a balance between bonding and autonomy. The possible range for the total adaptability score is 14 to 70. A high total score (greater than 52) characterizes the family as chaotically organized with capriciously shifting rules, roles, and power structure . A low score (less than 38) characterizes the family as rigidly organized. A moderate score (38 to 52) characterizes the family as having a balance between stability and change . Results
The sample included the 550 individuals who participated in all 3 years of the study. Eighty-seven percent were white and 54% were female . At the study's onset, subjects ranged in age from 11 to 15 years, with the majority (95%) between the ages of 12 and 13. Approximately 56% of the subjects lived in a family unit where both natural parents were present, while 23% lived in a single parent family. A large number of subjects did not know the educational status of their mother (25%) or father (35%). Thirteen percent of mothers and 11% of fathers did not finish high school. Slightly more (15% of the mothers and 18% of the fathers) were college graduates. The 550 participating students represent over 70% of the 782 seventh graders who responded to the initial questionnaire in 1985. Since 95% to 98% of the students enrolled in the middle schools completed the questionnaire in any given year, the observed attrition (30%) primarily represents students who moved out of the school district and were no longer available for inclusion in the study. Comparison of those individuals who participated all 3 years with individuals participating less than 3 years indicates that the latter individuals were somewhat more likely to be male and were older (12.52 versus 12.21 years, p = 0.0001), had higher CES-D (17.55 versus 15.60, p = 0.01), undesirable life event (10.52 versus 8.42, p = 0.0001) scores, and had lower adaptability (43.80 versus 45.37, p = 0 .05) and cohesion (54.58 versus 57.47, P = 0 .002) scores . Inspection of the overall distribution of CES-D scores provides some interesting information (Table 1). First, a comparison of mean depression scores for the various race gender groups indicates that blacks generally had higher scores than whites and that females consistently had higher scores than males. Second, a significant time effect is present in that the scores of blacks and males tended to decline more over the 3 year period than did those of females and whites. This trend is most apparent among the black males. J.Am.Acad. Child Adolesc .Psychiatry, 29 :4, July 1990
DEPRESSIVE SYMPTOMS IN ADOLESCENTS T AB LE
1. Mean CES-Da Scores and Standard Deviations by Race-Gender Graul' and Year (N = 550)
Race-Gender
1985
1986
White males N =225 White females N= 254 Black males N= 31 Black females N =40 Total 550
13.98 (8.52) 15.80 (9.58) 18.57
11.76 (7.60) 16.69 (10.90) 14. 13 (5.88) 20.0 7 (10.49) 14.78 (9.37)
a
(9 .78)
21.12 (9.13) 15.60 (9.32)
T ABLE
2. Pearson Correlation of CES-Da Scores over Time (N = 550)
1987 11.66 (8.59) 16.44 (10.79) 11.29 (5.24) 19. 60 (11.0 1) 14.43 (10.07)
Year
Race-Gender
85-86
86-87
85-87
White males White females Black males Black females Total
0.53 0.5 1 0.29 0.65 0.53
0. 39 0.47 0.3 0 0. 57 0.49
0.42 0.31 0.33 0.34 0.36
a
CES-D
=
Center for Epidemiologic Studies Depre ssion Scale.
CES-D = Center for Epidemiologic Studies Depression Scale.
Results from a repeated measures analysis of variance show that these race , gender, time , time x race , and time X gender difference s are all significant (p < 0.03 ). The stability of individual students' depression scores was less consistent than the overall distributions, with 1 and 2 year correlations reaching only 0 .53 (1985-86) and 0.36 (1985-87), respectively. This time related decrease is apparent in both the unadjusted (simple Pearson) correlations and in the residual correlations (0 .5 1 for 1985-86 and 0.35 for 1985-87) that adjust for race and gender. Consideration of these same correlations in the specific race-gender groups shows that the expected pattern of decreasing correlations with increasing time holds only for females (Table 2). A comparison of the students with high versus low depression scores additionally highlights the instability of the reported symptomatolo gy. Two types of dichotomous depression measures were calculated . In the first, subjects with scores greater than or equal to 30 (a score that approximated the top decile in all 3 years) were deemed high scorers . In the second, a classification based on the Research Diagnostic Criteria for major depressive disorder was constructed. All students meeting the criteria were deemed high scorers. Between 8% and 10% of the students obtained high scores depending on the year and the scoring scheme employed. Although over 90% of the students with low scores in 1985 or 1986 had low scores the following year, only about 30% of those with high scores in one year had high scores in the following year. Five students (two black females and three white females) had high scores all 3 years. Multiple regression analyses were done to explore the relationship of the various sociodemographic, life event, and family environment variables to the continuous CES-D score. Separate analyses were performed for each year and for the cross-sectional and longitudinal data . Race, gender, and any other variable meeting a 0 .05 significance level were retained in the models. The variables considered for entry into all models included cohesion, adaptability, undesirable and desirable life events, guardian status, parents' education status, and age. Cross-sectional results indicate that cohesion was the best predictor (in terms of the amount of variance explained ) of the depressive symptom score (Table 3). Undesirable life J .Am .Acad. Child Adolesc .Psychiatry , 29: 4, July 1990
events were significant, but far less important. Adaptability failed to enter the model in 1986 and 1987, a finding possibly explained by the high correlation between adaptability and cohesion. The above factors, together with race and gender, explained 32% to 35% of the variance in CES-D scores. The longitudinal results indicated that the previous years' CES-D scores were the best predictors of subsequent CESD scores, explaining between 12% and 20% of the total variance. Undesirable events retained small but significant effects. Adaptabilit y was significant only in the 1985 model. Cohesion was not significant in either model. Togeth er , the longitudinal factors with race and gender explained between 21% and 28% of the total variation in subsequent years' CES-D scores (Table 4). Discussion
The most prominent characteristics of study subjects lost to follow-up when compared to those participating in all 3 years of the study were male gender, older age , more undesirable events, less cohesion, and less adaptability. Associations among all of these characteristics and the depressive symptom scores were subsequently found. Thus , although the overall participation rate was good, these losses may decrease the ability to generalize the study results and could potentially bias them . The finding that females attain higher depre ssive symptom scores than males and blacks higher scores than whites is consistent with previous results with adolescents (Kandel and Davies , 1982; Schoenbach et al. , 1983; Garrison et al., 1985, 1988). The reason for the time dependent decrease in scores for males but not females is not clear. However , the resulting pattern coincides with findings in adults where females report higher levels of depre ssive symptom atology and higher rates of major depressive disorder (Warheit et aI., 1973; Comstock and Helsing, 1976; Rosenfeld , 1980; Frerichs et al. , 1981; Myers et aI., 1984; Somervell et al. , 1989). This is in contrast to early childhood where similar rates of major depressive disorder have been observed in boys and girls. It may be that the emotional or biological changes that accompany early adolescence are responsible for the attainment of more adult-like patterns. Findings suggest that adolescent depressive symptom scores vary considerably over time. Although 90% of the low scorers remained low scorers, only 30% of high scorers 583
GARRISON ET AL. TABLE
3. Multiple Regression Models of Continuous Depression Scores with Life Event and Family Environment Variables, Cross-Sectional Data Coefficients
1985 Variables Intercept Race Sex Cohesion Undesirable Desirable Adaptability Model R2
1986
Coefficient
Coefficient
Hierarchical R2
25.62 2.56 2.14 -0.19 0.39
0.03 0.01 0.20 0.06
22.84 1.12 3.95 -0.32 0.28
0.01 0.06 0.24 0.03
-0.19
0.02 0.32
remained high over a year's interval. The suggestion is that a single screening score that reflects the amount of symptomatology present during the preceding week may not be indicative of the amount of symptomatology present over long periods of time. This is not surprising as both depressive symptoms and the disorder are generally viewed as evidencing transient or fluctuant natures. The relationship of CES-D measured symptomatology during the previous week to major depression in young adolescents is an important question that cannot be addressed with the data reported here. (Completion of the diagnostic interview phase of the larger study and analysis of that data will allow the authors to address the relationship.) In a community study of adults using the CES-D with a cutpoint of sixteen, Myers and Weissman (1979) reported a sensitivity of 63% and a specificity of 94%. In clinical studies with adults, the reported sensitivities and specificities have ranged from 74% to 97% and from 56% to 86% respectively. Preliminary data from the adolescent group indicates similar results but with a higher cutpoint. The best predictor of the cross-sectional depressive symptom scores was cohesion which explained between 19% and 24% of the CES-D variance in any given year. The observed association was one with higher levels of depressive symptomatology being reported at lower levels of cohesion. It appears that although the perception of a disengaged family (i.e., low emotional bonding and high individual autonomy) is associated with higher depressive symptomatology, the perception of the opposite extreme (enmeshment, signifying an overidentification with the family) is not. This finding coincides with the earlier work of Garrison et al. (198$) and does not support the hypothesized model in which either extremes of family functioning are equally associated with depressive symptomatology. In longitudinal models, the previous year's CES-D score was the best predictor of the subsequent CES-D score, explaining between 12% and 20% of the variance. Cohesion was not significant. It may be that by including previous years' CES-D scores in the longitudinal models, the authors have controlled for baseline symptomatology and thus largely negated the effects of perceived family cohesion. Undesirable life events retained significant but smaller
584
1987
Hierarchical R2
Coefficient
Hierarchical R2
17.54 -0.09 4.80 -0.23 0.56 -0.14
0.003 0.07 0.19 0.08 0.01
0.34
0.35
TABLE 4. Multiple Regression Models Predicting 1987 Scores Using 1985 or 1986 Life Event and Family Environment Variables
1985 Variables Intercept Race Sex CES-D Undesirable Adaptability Model R2
Coefficient
6.72 -0.06 4.76 0.28 0.17 -0.12
1986
Hierarchical R2
0.01 0.06 0.12 0.01 0.01 0.21
Coefficient
Hierarchical R2
1.71 -0.01 3.01 0.44 0.22
0.005 0.07 0.20 0.01 0.28
effects (explaining between 1% and 8% of the variance) in both longitudinal and cross-sectional models. It seems that in early adolescence family environment may be a more important predictor of depressive symptomatology than life events. A product (interaction) term involving the life event and family variables did not enter any of the models, even when the significance level for entry was set at 0.50. The suggestion is that family environment does not interact with negative life events to modify the adverse impact of these events on depressive symptomatology. Although the authors were able to explain between 21 % and 36% of the variance in depressive symptom scores, the majority of the variation was unexplained by the basic demographic, family, and life event data collected. Future investigations in the area will be strengthened by refinement of the tools used to collect these data. Consideration should also be given to additional potential risk factors, such as family history of depression or other affective disorders, socialization and peer relations, substance use and abuse, and problem solving and coping abilities. Although previous studies may have investigated the effect of one or two of these variables, no study to date has collected data on this wide an array of potential predictors and then simultaneously looked at their contribution to the development of depressive symptoms or major depressive disorder. A longitudinal community-based study designed to elicit detailed information regarding all of these parameters from both adolesJ. Am.Acad. Child Adolesc. Psychiatry, 29:4, July 1990
DEPRESSIVE SYMPTOMS IN ADOLESCENTS
cents and their parent(s) could provide the optimal mechanism for improving an understanding of the phenomena. References Coddington, R. D. (1972), The significance of life events as etiologic factors in the diseases of children. J. Psychosom. Res., 16:7-18. Comstock, G. W. & Helsing, K. J. (1976), Symptoms of depression in two communities. Psychol. Med., 6:551-563. Frerichs, R. R., Aneshensel, C. S. & Clark, V. A. (1981), Prevalence of depression in Los Angeles county. Am. J. Epidemiol., 113:691699. Garrison, C. Z., Schoenbach, V. J. & Kaplan, B. H. (1985), Depressive symptoms in early adolescence. In: Depression in Multidisciplinary Perspective, ed. A. Dean. New York: Brunner/Mazel, pp.60-82. - - Schluchter, M. D., Schoenbach, V. J. & Kaplan, B. H. (1989), Epidemiology of depressive symptoms in young adolescents. J. Am. Acad. Child Adolesc. Psychiatry, 28:343-351. - - Schoenbach, V. J. & Kaplan, B. H. (1988), Symptom prevalence of depression in adolescence. In: Advances in Adolescent Mental Health, Volume III. Greenwich, CT: JAI Press. Holmes, T. H. & Rahe, R. H. (1967), The social readjustment rating scale. l. Psychosom. Res., 11:213-218. Kandel, D. B. & Davies, M. (1982), Epidemiology of depressive mood in adolescents. Arch. Gen. Psychiatry, 39:1025-1212. Mueller, D. P., Edwards, D. W. & Yarvis, R. M. (1977), Stressful life events and psychiatric symptomatology: change or undesirability? J. Health Soc. Behav., 18:307-317. Myers, J. K. & Weissman, M. M. (1979, May), Screeningfordepression in a community sample: the use of a self-report symptom scale to detect the depressive syndrome. Paper presented at the American Psychiatric Annual meeting, Chicago. - - - - Tischler, G. L. et al. (1984), Six-month prevalence of psychiatric disorders in three communities. Arch. Gen. Psychiatry, 41:959-967.
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Olson, D., Bell, R. & Portner, J. (1982), FACES II. St. Paul: University of Minnesota. Radloff, L. S. (1977), The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1:385-401. Rosenfeld, S. (1980), Sex differences in depression; do women always have higher rates? J, Health Soc. Behav., 21:33-42. Schoenbach, V. J., Garrison, C. Z. & Kaplan, B. H. (1984), Epidemiology of adolescent depression. Public Health Rev., 12:159189. - - Kaplan, B. H., Wagner, E. H., Grimson, R. C. & Miller, F. T. (1983), Prevalence of self-reported depressive symptoms in young adolescents. Am. J. Public Health, 73: 1281-1287. - - Kaplan, B. H., Grimson, R. C. & Wagner, E. H. (1982), Use of a symptom scale to study the prevalence of a depressive syndrome in young adolescents. Am. J. Epidemiol., 116-791-800. Somervell, P. D., Leaf, P. J., Weissman, M. M., Blazer, D. G. & Bruce, M. L. (1989), The prevalence of major depression in black and white adults in five United States communities. Am. J. Epidemiol., 130:725-735. Swearingen, E. M. & Cohen, L. H. (1985), Measurement of adolescents' life events: the junior high life experience survey. Amer. J. Community Psychol., 13:69-85. Tausig, M. (1982), Measuring life events. J. Health Soc. Behav., 23:52-64. Vinokur, A. & Selzer, M. L. (1975), Desirable vs. undesirable life events: their relationship to stress and mental distress. J. Pers. Soc. Psychol., 32:329-337. Warheit, G. J., Holzer, C. E. & Schwab, J. J. (1973), An analysis of social class and racial differences in depressive symptomatology. J. Health Soc. Behav., 14:291-299. Weissman, M. M., Sholomakas, D., Pottenger, M., Prusoff, B. A. & Locke, B. Z. (1977), Assessing depressive symptoms in five psychiatric populations: a validation study. Am. J. Epidemiol. 106:203-214.
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