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 StudiesDepression Scale (CES-D) was administered to 550 students 3 times, at the beginning of the seventh, eighth, andninth grades. Blacks and females had higher scores than did whites and males. Scores of blacks and males declinedmore over the 3 year period than did those of females and whites. The stability of individual students' depressionscores 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 lifeevents 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 thefrequency, correlates, and predictors of depressive symp­tomatology in adolescence. To date, frequency estimateshave varied considerably, raising questions regarding thestability of reported symptomatology (Schoenbach et al.,1984; Garrison et al., 1988). Although a number of differentcorrelates and predictors have been suggested, a recurringtheme has been that life events and family environment mayplay important roles in the genesis of depressive symptom­atology (Garrison et al., 1985). Accordingly, the purposeof 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, andthe onset or existence of depressive symptomatology in thisage group.

Method

The data for this investigation were collected during thescreening phase of a larger longitudinal study of depressivesymptomatology, major depressive disorder, and suicidalideation in young adolescents. When completed, the largerstudy (which includes both school-administered depressionscreens and clinician-administered diagnostic interviews) willprovide estimates of the frequency of major depressive dis­order and validation of the Center for Epidemiologic StudiesDepression Scale (CES-D) in young adolescents. The cur­rent analysis, however, focuses on the frequency, stability,and predictors of depressive symptomatology, as determinedfrom the school screening data.

Data collection occurred annually in the fall of 3 con­secutive years (1985-1987) from subjects attending fourpublic middle schools within a selected suburban school

Accepted February 2, 1990.From the Department ofEpidemiology and Biostatistics, University

of South Carolina.This research was supported through a grant from the National

Institute of Mental Health (MH40363) which the authors gratefullyacknowledge.

Reprint requests to Dr. Garrison, Department ofEpidemiology andBiostatistics, University of South Carolina, Columbia, S.C. 29208.

0890-8567/9012904-0581$02.0010© 1990by theAmerican Academyof Child and Adolescent Psychiatry.

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district in the Southeast. All students enrolled in the seventhgrade in 1985 were eligible for inclusion in the study. Thedata were collected in the classroom where students com­pleted a self-administered questionnaire that included a de­mographic section, the 20-item CES-D (Radloff, 1977), amodified version of the Coddington Life Events Scale forAdolescents (Coddington, 1972), and the 30-item FamilyAdaptability and Cohesion Evaluation Scales (Olson et al.,1982).

The CES-D is a 20-item self-report symptom rating scaledeveloped to measure depressive symptomatology in com­munity adult populations (Radloff, 1977). The items in­cluded in the scale represent the major symptoms of thesyndrome of depression as identified by clinical judgment,frequency of use in other questionnaires for depression, andfactor analytic studies. When completing the CES-D, thesubject is asked to report on his/her feelings during thepreceding 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") designedto measure the duration or frequency of symptoms. Eachitem has a possible value of zero to three; thus, the totalscore has a range of 0 to 60. This single score is used toindex the degree of depressive symptomatology present. Inadult populations, scores of 16 or more generally have beenused 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 ofthe Holmes and Rahe (1967) approach to measuring lifestress. When completing the instrument, the adolescent isasked to report the number of times within the past 12months that he or she has experienced certain life events.The scale contains a total of 50 events, judged as requiringa significant amount of social readjustment of adolescents.It was developed by having several groups of judges (243teachers, pediatricians, and mental health workers) evaluatea list of events in terms of the degree of adjustment required

GARRISON ET AL.

by each event. The items are oriented toward the types ofstressful life events relevant to the adolescent age group.

The Coddington Scale has been modified for use in thisstudy. Items involving drug use and pregnancy were deleted(at the request of the school). Additional items includingitems involving college plans, employment, marriage, anddriving were also omitted, because of the peripheral natureof these concerns to most early adolescents. Two itemsdealing with physical appearance were added. It was thoughtthat for the purpose of the present study this area was notadequately addressed in the original scale .

The modified life events scale contained a total of 41events (19 desirable and 22 undesirable) . (The designationof events as either desirable or undesirable was done withthe realization that just about any event may be viewed aspositive or negative depending on the circumstances sur­rounding the event and the way the event is perceived bythe child.) Events could be reported as occurring more thanonce during the preceding year.

Life event scores were calculated for undesirable anddesirable events as an unweighted sum of the number ofitems of the respective type. Items with missing responseswere assigned a value of zero. Maximal possible scoreswere 90 (for undesirable events) and 56 (for desirable events).Unweighted rather than weighted sums were used, as theappropriateness of the weights assigned has not been welldocumented. In any case , available evidence suggests thatweighted and unweighted scores are highly correlated withone 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 andemotional climate within his or her family. This parameterfocused on the amount of cohesion and adaptability present(Olson et aI., 1982). Both cohesion and adaptability wereseen as existing on continuums. In particular, cohesion en­compassed the emotional bonding which family membershad toward one another as well as the individual autonomythat the teen experienced in the family system. The extremehigh 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 highautonomy. Adaptability was defined as the ability of thefamily system to change its power structure, role relation­ships, and rules in response to situational and developmentalstress. The low extreme of adaptability signaled rigidity orno change. Alternately, the high extreme denoted chaos oroverwhelming change (Olson et aI., 1982).

This particular conceptualization of family environmentwas 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 mostfunctional and indicates an optimal balance on both dimen­sions.

Family environment was measured using the Family

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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 cohesionitems and 14 adaptability items. Items reflect statementsabout 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) indicatesthat the family member perceives extreme closeness andlimited autonomy in the family . A low score (less than 48)indicates a perception of low emotional bonding and highindividual autonomy. A midrange score (48 to 64) indicatesa balance between bonding and autonomy.

The possible range for the total adaptability score is 14to 70. A high total score (greater than 52) characterizes thefamily as chaotically organized with capriciously shiftingrules, roles , and power structure . A low score (less than38) characterizes the family as rigidly organized. A mod­erate score (38 to 52) characterizes the family as having abalance between stability and change .

Results

The sample included the 550 individuals who participatedin all 3 years of the study. Eighty-seven percent were whiteand 54% were female . At the study's onset, subjects rangedin age from 11 to 15 years, with the majority (95%) betweenthe ages of 12 and 13. Approximately 56% of the subjectslived in a family unit where both natural parents were pres­ent, while 23% lived in a single parent family. A largenumber of subjects did not know the educational status oftheir mother (25%) or father (35%). Thirteen percent ofmothers 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 the782 seventh graders who responded to the initial question­naire in 1985. Since 95% to 98% of the students enrolledin the middle schools completed the questionnaire in anygiven year, the observed attrition (30%) primarily representsstudents who moved out of the school district and were nolonger available for inclusion in the study. Comparison ofthose individuals who participated all 3 years with individ­uals participating less than 3 years indicates that the latterindividuals were somewhat more likely to be male and wereolder (12.52 versus 12.21 years, p = 0.0001), had higherCES-D (17.55 versus 15.60, p = 0.01), undesirable lifeevent (10.52 versus 8.42, p = 0.0001) scores, and hadlower adaptability (43.80 versus 45.37, p = 0.05) andcohesion (54.58 versus 57.47, P = 0.002) scores .

Inspection of the overall distribution of CES-D scoresprovides some interesting information (Table 1). First, acomparison of mean depression scores for the various racegender groups indicates that blacks generally had higherscores than whites and that females consistently had higherscores than males. Second, a significant time effect is pres­ent in that the scores of blacks and males tended to declinemore over the 3 year period than did those of females andwhites. This trend is most apparent among the black males.

J.Am.Acad. Child Adolesc .Psychiatry, 29:4, July 1990

T ABLE 1. Mean CES-Da Scores and Standard Deviations byRace-Gender Graul' and Year (N = 550)

DEPRESSIVE SYMPTOMS IN ADOLESCENTS

T ABLE 2. Pearson Correlation of CES-Da Scores over Time(N = 550)

Race-Gender

White malesN =225

White femalesN= 254

Black malesN= 31

Black femalesN =40

Total550

1985

13.98(8.52)15.80(9.58)18.57(9 .78)21.12(9.13)15.60(9.32)

1986

11.76(7.60)16.69

(10.90)14. 13(5.88)20.0 7

(10.49)14.78(9.37)

1987

11.66(8.59)16.44

(10.79)11.29(5.24)19.60

(11.01)14.43

(10.07)

Year

Race-Gender 85-86 86-87 85-87

White males 0.53 0.39 0.42White females 0.5 1 0.47 0.31Black males 0.29 0.3 0 0.33Black females 0.65 0.57 0.34Total 0.53 0.49 0.36

a CES-D = Center for Epidemiologic Studies Depression Scale.

a CES-D = Center for Epidemiologic Studies Depression Scale.

Results from a repeated measures analysis of variance showthat these race , gender, time, time x race , and time Xgender differences are all significant (p < 0.03).

The stability of individual students' depression scores wasless consistent than the overall distributions, with 1 and 2year 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) correlationsand in the residual correlations (0.51 for 1985-86 and 0.35for 1985-87) that adjust for race and gender. Considerationof these same correlations in the specific race-gender groupsshows that the expected pattern of decreasing correlationswith 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 symptomatology. Two types of dichotomous depres­sion measures were calculated . In the first, subjects withscores greater than or equal to 30 (a score that approximatedthe top decile in all 3 years) were deemed high scorers . Inthe second, a classification based on the Research Diag­nostic Criteria for major depressive disorder was con­structed. All students meeting the criteria were deemed highscorers. Between 8% and 10% of the students obtained highscores depending on the year and the scoring scheme em­ployed. Although over 90% of the students with low scoresin 1985 or 1986 had low scores the following year, onlyabout 30% of those with high scores in one year had highscores 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 therelationship of the various sociodemographic, life event,and family environment variables to the continuous CES-Dscore. Separate analyses were performed for each year andfor the cross-sectional and longitudinal data . Race, gender,and any other variable meeting a 0.05 significance levelwere retained in the models. The variables considered forentry 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 bestpredictor (in terms of the amount of variance explained) ofthe depressive symptom score (Table 3). Undesirable life

J .Am .Acad. Child Adolesc .Psychiatry ,29:4, July 1990

events were significant, but far less important. Adaptabilityfailed to enter the model in 1986 and 1987, a finding pos­sibly explained by the high correlation between adaptabilityand cohesion. The above factors , together with race andgender, explained 32% to 35% of the variance in CES-Dscores.

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 totalvariance. Undesirable events retained small but significanteffects. Adaptability was significant only in the 1985 model.Cohesion was not significant in either model. Together , thelongitudinal factors with race and gender explained between21% and 28% of the total variation in subsequent years'CES-D scores (Table 4).

Discussion

The most prominent characteristics of study subjects lostto follow-up when compared to those participating in all 3years 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 lossesmay decrease the ability to generalize the study results andcould potentially bias them.

The finding that females attain higher depressive symp­tom scores than males and blacks higher scores than whitesis consistent with previous results with adolescents (Kandeland Davies , 1982; Schoenbach et al. , 1983; Garrison et al.,1985, 1988). The reason for the time dependent decreasein scores for males but not females is not clear. However ,the resulting pattern coincides with findings in adults wherefemales report higher levels of depressive symptomatologyand higher rates of major depressive disorder (Warheit etaI., 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 similarrates of major depressive disorder have been observed inboys and girls . It may be that the emotional or biologicalchanges that accompany early adolescence are responsiblefor the attainment of more adult-like patterns.

Findings suggest that adolescent depressive symptomscores vary considerably over time. Although 90% of thelow scorers remained low scorers, only 30% of high scorers

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GARRISON ET AL.

TABLE 3. Multiple Regression Models of Continuous Depression Scores with Life Event andFamily Environment Variables, Cross-Sectional Data

Coefficients

1985 1986 1987

Hierarchical Hierarchical HierarchicalVariables Coefficient R2 Coefficient R2 Coefficient R2

Intercept 25.62 22.84 17.54Race 2.56 0.03 1.12 0.01 -0.09 0.003Sex 2.14 0.01 3.95 0.06 4.80 0.07Cohesion -0.19 0.20 -0.32 0.24 -0.23 0.19Undesirable 0.39 0.06 0.28 0.03 0.56 0.08Desirable -0.14 0.01Adaptability -0.19 0.02Model R2 0.32 0.34 0.35

remained high over a year's interval. The suggestion is thata single screening score that reflects the amount of symp­tomatology present during the preceding week may not beindicative of the amount of symptomatology present overlong periods of time. This is not surprising as both depres­sive symptoms and the disorder are generally viewed asevidencing transient or fluctuant natures.

The relationship of CES-D measured symptomatologyduring the previous week to major depression in youngadolescents is an important question that cannot be ad­dressed with the data reported here. (Completion of thediagnostic interview phase of the larger study and analysisof that data will allow the authors to address the relation­ship.) In a community study of adults using the CES-D witha cutpoint of sixteen, Myers and Weissman (1979) reporteda sensitivity of 63% and a specificity of 94%. In clinicalstudies with adults, the reported sensitivities and specific­ities have ranged from 74% to 97% and from 56% to 86%respectively. Preliminary data from the adolescent groupindicates similar results but with a higher cutpoint.

The best predictor of the cross-sectional depressive symp­tom scores was cohesion which explained between 19% and24% of the CES-D variance in any given year. The observedassociation was one with higher levels of depressive symp­tomatology being reported at lower levels of cohesion. Itappears that although the perception of a disengaged family(i.e., low emotional bonding and high individual autonomy)is associated with higher depressive symptomatology, theperception of the opposite extreme (enmeshment, signifyingan overidentification with the family) is not. This findingcoincides with the earlier work of Garrison et al. (198$)and does not support the hypothesized model in which eitherextremes of family functioning are equally associated withdepressive symptomatology.

In longitudinal models, the previous year's CES-D scorewas the best predictor of the subsequent CES-D score, ex­plaining between 12% and 20% of the variance. Cohesionwas not significant. It may be that by including previousyears' CES-D scores in the longitudinal models, the authorshave controlled for baseline symptomatology and thus largelynegated the effects of perceived family cohesion.

Undesirable life events retained significant but smaller

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TABLE 4. Multiple Regression Models Predicting 1987 ScoresUsing 1985 or 1986 Life Event and Family Environment Variables

1985 1986

Hierarchical HierarchicalVariables Coefficient R2 Coefficient R2

Intercept 6.72 1.71Race -0.06 0.01 -0.01 0.005Sex 4.76 0.06 3.01 0.07CES-D 0.28 0.12 0.44 0.20Undesirable 0.17 0.01 0.22 0.01Adaptability -0.12 0.01Model R2 0.21 0.28

effects (explaining between 1% and 8% of the variance) inboth longitudinal and cross-sectional models. It seems thatin early adolescence family environment may be a moreimportant predictor of depressive symptomatology than lifeevents. A product (interaction) term involving the life eventand family variables did not enter any of the models, evenwhen the significance level for entry was set at 0.50. Thesuggestion is that family environment does not interact withnegative life events to modify the adverse impact of theseevents on depressive symptomatology.

Although the authors were able to explain between 21%and 36% of the variance in depressive symptom scores, themajority of the variation was unexplained by the basic de­mographic, family, and life event data collected. Futureinvestigations in the area will be strengthened by refinementof the tools used to collect these data. Consideration shouldalso be given to additional potential risk factors, such asfamily history of depression or other affective disorders,socialization and peer relations, substance use and abuse,and problem solving and coping abilities. Although previousstudies may have investigated the effect of one or two ofthese variables, no study to date has collected data on thiswide an array of potential predictors and then simultaneouslylooked at their contribution to the development of depressivesymptoms or major depressive disorder. A longitudinalcommunity-based study designed to elicit detailed infor­mation regarding all of these parameters from both adoles-

J. Am.Acad. Child Adolesc. Psychiatry, 29:4, July 1990

cents and their parent(s) could provide the optimal mech­anism for improving an understanding of the phenomena.

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