 |
|
Consequences and Correlates of Adolescent Depression
Sherry Glied, PhD;
Daniel S. Pine, MD
Arch Pediatr Adolesc Med. 2002;156:1009-1014.
ABSTRACT
| |
Objective To examine the correlates and consequences of high levels of depressive
symptoms among adolescents.
Design Secondary analysis of the 1997 Commonwealth Fund Survey of the Health
of Adolescent Girls, a survey of a nationally representative sample of 4648
adolescent boys and girls between the ages of 10 and 18 years, inclusive,
conducted in school settings. The self-administered questionnaire contains
a screening instrument for depression based on the Children's Depression Inventory.
Outcome Days of school missed, performance at grade level, alcohol use, drug
use, smoking, and bingeing.
Results After controlling for sociodemographics, life events, sexual abuse,
physical abuse, and exposure to violence, relative to other children, children
and adolescents with high degrees of depressive symptoms missed about 1 day
more of school in the month preceding the survey (P<.05) and had higher odds of smoking (odds ratio, 1.84; P<.001), bingeing (odds ratio, 2.02; P<.001),
and suicidal ideation (odds ratio, 16.59; P<.001).
Conclusion High levels of depressive symptoms are correlated with serious and significant
consequences, even after controlling for life circumstances.
INTRODUCTION
THE DIRECT COSTS of medical care utilization and the morbidity and mortality
costs of mental health problems for children younger than 15 years has been
estimated at $2 billion in 1985, but estimates for youth younger than 19 years
that include all related costs, including costs of juvenile justice and educational
programs, have ranged as high as $20 billion.1-2
Depression in adolescence might also generate important nonmedical costs
in several ways. First, depression may lead girls and boys to miss school
or to fall behind in school. Education is a critical determinant of adult
earnings, so if school attendance and performance are substantially affected
by depression, adolescents may lose earnings in the future. Depression may
inhibit school performance of children and adolescents, just as such symptoms
reduce work performance among adults.3-5
Second, depression may affect other aspects of well-being. Such effects could
occur through a connection between depression and dangerous behaviors, such
as alcohol and drug use, bingeing, and smoking. Children with emotional and
behavioral disorders in general are significantly more likely to experience
substance use and are at higher risk of involvement with the juvenile justice
system.6-7 There is also a suggestion
that adolescent depression affects susceptibility to infectious disease.8 Risky behaviors are quite prevalent among youth. Data
from the 1999 Youth Risk Behavior Surveillance Survey indicate that more than
one third of youth in grades 9 through 12 currently smoke cigarettes, one
half currently use alcohol, and more than one fourth currently use marijuana.9 Further, depression may raise the risk of suicide
in children and adolescents, as it does in adults.10-11
According to data from the Youth Risk Behavior Surveillance Survey, nearly
20% of youth seriously considered attempting suicide during the preceding
year.9
It is difficult to assess the consequences of depressive symptoms because
depression in adolescents is often associated with many other factors that
also raise the risk of undesirable behaviors and outcomes. Mental health problems
in adolescents tend to be concentrated in the most disadvantaged groups—children
from minority groups, from single-parent families, and from low-income families.
Furthermore, family studies suggest that the prevalence of depression is higher
among adolescents from families that include a parent with depression, and
these children may be at risk for other poor outcomes as well.12
Adolescent depression may also be associated with environmental adversity.
The relationship between depression and extreme stress has been demonstrated
in children subjected to natural disasters, children who are homeless, and
children subjected to physical or sexual abuse.13-15
While these studies consistently note associations between depression and
extreme adversity, the findings are limited by the nature of the generally
nonrepresentative samples in most studies.
The relationship between adolescent depression and other, less extreme
life events has been examined primarily in clinic-based samples. While these
studies consistently note an association between life events and adolescent
depression, the findings are limited by the referred nature of these samples.16-19 This
relationship has been examined in 3 epidemiologic samples, with each study
noting a consistent relationship between the 2 constructs.20-22
In this article, we examine the prevalence and correlates of depressive
symptoms among children and adolescents. We then turn to the consequences
of depression in adolescence: the degree to which depressive symptoms are
correlated with school performance and with dangerous behaviors, particularly
alcohol and drug use and eating problems. We examine the extent to which these
negative outcomes associated with depression persist after controlling for
sociodemographic and other risk factors that are associated with both higher
rates of depression and higher risk of problem indicators. Previous research
has shown associations between depression and some of these risk behaviors.
This analysis broadens the range of behaviors considered to include school
performance as well as a range of unhealthy behaviors. It describes these
associations in a large community sample. Assessing the relationship between
depression and adverse outcomes is complicated by the fact that depression
is also correlated with other factors that raise the risk of adverse outcomes,
such as life events and abuse. Moreover, some correlates of adolescent depression,
such as abuse or adverse life circumstances, may carry independent risks for
adverse consequences, such as excessive alcohol use.
Under these circumstances, relatively large studies in representative
samples of adolescents, such as the Commonwealth Fund Survey of the Health
of Adolescent Girls (CFSAG), provide particular advantages. Specifically,
relative to smaller or less representative studies, studies based in large
representative samples facilitate more precise, generalizable estimation of
independent association that both adolescent depression and correlates of
depression, such as adverse life events or sexual abuse, exhibit with various
types of adverse outcomes.
METHODS
DATA AND MEASURES
We used data from the CFSAG, a nationally representative sample of adolescents.23 The CFSAG was a classroom-based study. Classrooms
were selected for the survey in a 2-stage, stratified, and clustered sampling
process (stratification variables involve school type, grade coverage, urbanicity,
and region). Replacements for schools choosing not to participate were selected
by nearest ZIP code within the same cell. This survey design shows variations
similar to a random sample about 88% as large. In-class questionnaires were
administered to 6748 students (3586 girls and 3162 boys) in grades 5 through
12. Approximately half (3216) were in grades 5 through 8 and half (3532) were
in grades 9 through 12. All of the students in the classes selected completed
the survey. A total of 297 schools, including public, private, and parochial
schools, participated in the nationally representative survey. An oversample
of 32 urban schools was included to facilitate a more complete analysis of
responses by ethnicity and income. Fieldwork was conducted by Louis Harris
and Associates Inc, Rochester, NY, from December 1996 to June 1997 and sponsored
by the Commonwealth Fund, New York, NY.23 Data
from students were collected in compliance with each participating school's
own informed consent procedure. The protocol for this analysis of the data
obtained from the Commonwealth Fund survey received expedited review approval
from the Columbia-Presbyterian Medical Center Institutional Review Board,
New York. For the present study, the sample was restricted to those 4648 respondents
who were between the ages of 10 and 18 years and had completed survey questions
on depressive symptoms, family structure, income, and ethnicity. Respondents
with incomplete data were significantly more likely to be behind a grade and
to express suicidal ideation (P<.001), were somewhat
less likely to drink (P<.02), and (among the small
minority of subject with incomplete data who responded to questions on depressive
symptoms) had slightly, but not significantly, more depressive symptoms than
did those with complete data. Thus, while these results may understate the
negative correlates of depressive symptoms, it is unlikely that other missing
subjects can account for the positive associations we found in the remaining
sample. Other studies have used these data for a variety of purposes, including
to describe prevalence and risk factors for mental illness, to study adolescent
access to medical care, and to explore adolescents' preferences about physician
characteristics.24-27
The survey asked adolescents extensive questions about their health
status, risk behaviors, and school performance. Respondent demographic and
socioeconomic information was also reported. This included age, sex, race,
region, urban or suburban residence, and family financial status. Family finances
were assessed on the basis of whether the family had money problems frequently,
occasionally, rarely, or never. One question was also asked concerning parental
history of depression. The survey asked adolescents whether they engaged in
risk behaviors (overeating, smoking, and drinking alcohol), how many days
of school they missed because of illness in the preceding month, and their
grade level. We used the information on age and grade to assess whether the
child was below the age-appropriate grade level. The survey also asked adolescents
whether they engaged in risk behaviors when experiencing stress. The format
of the questions was multiple choice, with responses grouped into categories.
Additional details on the student questionnaire can be found in Simantov et
al.28
Depressive symptoms were assessed with the Children's Depression Inventory
(CDI). This self-report questionnaire was originally developed by Kovacs in
198529 as a screening measure for the diagnosis
of major depression in children. The questionnaire consists of a series of
forced-choice items, for which an adolescent marks one of the statements most
consistent with his or her current mental state. This allows a rating of depressive
symptoms to be made on a 3-point scale, from absent to definitely present.
These questions rate current depressive symptoms that had been present during
the preceding 2 weeks. The CDI exists as both a 26-item and a 10-item questionnaire,
with the 10-item version being used to screen for major depression. The measure
exhibits satisfactory internal reliability and test-retest reliability, as
well as satisfactory predictive validity for the clinical diagnosis of major
depression in children.30
The CFSAG used a 9-item version of the CDI. This version included all
of the items in the 10-item CDI except for item 3 ("I do most things OK").
The highest possible score on our 9-item CDI is 18. We used a score of 9 or
higher on the CDI to estimate the prevalence of major depression symptoms
in this sample. Previous clinical validations of the short-form administration
of the CDI have established that a cutoff score of 9 optimizes the sensitivity
and the specificity of the screening instrument.30
Since our data used the 9-item version of the CDI, a cutoff score of 9 should
produce lower-bound estimates of the prevalence of depressive symptoms. We
repeated these analyses with raw CDI scores used in place of the cutoff indicator.
These results were uniformly stronger than those reported in this article.
ANALYSIS
We conducted the analysis with Software for Statistical Analysis of
Survey Data.31 Our analysis incorporated CFSAG
sample weights. We used  2 and t tests
for bivariate relationships between depression, incomes, factors, and problem
indicators. We used multivariate logistic and linear regressions to estimate
multivariate relationships. The prevalence of major depression in children
and adolescents has been examined in many relatively large epidemiologic surveys
that have relied on standardized interviews.32-36
As reviewed by Harrington,37 the prevalence
in the community is approximately 5%, although there is variability across
studies, depending on the stringency of the applied impairment threshold and
the measure used to make the diagnosis. In the CFSAG, the overall prevalence
of depression in the (weighted) sample was 7.1%.
RESULTS
SOCIODEMOGRAPHIC CORRELATES
In the CFSAG, the prevalence of depression in boys was 5%, whereas that
in girls was 9%. Figure 1 shows
the prevalence of depression by age for boys and girls. As expected, rates
were quite low among 10-year-old girls and boys. Rates for girls rapidly rose
above those for boys and were much higher by age 14 years. Table 1 provides prevalence rates for boys and girls by race, family
structure, family history of depression, and family income.
|
|
|
|
Rates of depression among boys and girls.
|
|
|
|
|
|
|
Table 1. Prevalence of Depression by Socioeconomic Characteristics
|
|
|
In these data, rates of depression do not vary substantively or significantly
among race and ethnic groups. Previous studies have shown higher rates of
mental health problems among children from divorced or single-parent families.38-40 In these data there
was an increased prevalence of depression in boys with divorced parents. Among
those who responded to the question (three fourths of the full sample), nearly
one third reported that a family member had had depression. Adolescents from
such families were much more likely to meet criteria for depression than were
those who did not report a family history of depression. Finally, rates of
depression were much higher—4 times as high—among girls and boys
in very-low-income families than among girls and boys in high-income families.
This finding suggests that environmental factors may contribute to depression
risk.
ENVIRONMENTAL RISK FACTORS
Table 2 provides prevalence
rates for depression in girls and boys, by history of physical or sexual abuse,
and by the number of life events experienced in the preceding year. For convenience,
we report results for quartiles of life events. (In the multiple regression
analyses that follow, we used direct counts of events.)
|
|
|
|
Table 2. Prevalence of Depression by Risk Factors
|
|
|
Nearly 10% of girls and 3% of boys in the sample reported a history
of sexual abuse. A history of physical abuse was reported by 13% of girls
and 9% of boys in the sample. For both girls and boys, a history of sexual
or physical abuse was strongly related to depressive symptoms. Indeed, almost
one fourth of girls with a history of either type of abuse met criteria for
depression. The survey asked whether violence at home had ever been so serious
that an adolescent contemplated leaving home. About one fourth of girls and
boys reported this high level of violence. Again, a history of violence was
strongly and significantly related to depression in both girls and boys. The
relationship between life events and depression was positive in both girls
and boys. Consistent with previous studies,16-22
girls and boys who had experienced severe life stresses in the year before
the interview were much more likely to meet criteria for depression than were
those whose lives had been less stressful.
PROBLEM INDICATORS
We next examined the correlations between depressive symptoms and problem
indicators. We examined 2 measures of school performance: days of school missed
because of illness and whether a child was in the expected grade level (age
minus 6). We examined the 4 measures of problem behaviors included in the
CFSAG survey: alcohol use, drug use, smoking, and bingeing. Finally, we examined
whether a girl or boy reported suicidal ideation. Table 3 reports rates of these problem indicators and behaviors
among depressed and nondepressed adolescent girls and boys.
|
|
|
|
Table 3. Problem Outcomes and Depression
|
|
|
Depression was correlated with a significant increase in the number
of school days missed. Depressed adolescent girls were also almost twice as
likely to be behind a grade in school as those who were not depressed. Both
girls and boys who were depressed reported much higher rates of use of alcohol,
drugs, smoking, and bingeing. Indeed, more than 65% of depressed girls and
boys engaged in at least 1 of these risk behaviors. Finally, suicidal ideation
was substantially more frequent among depressed adolescents than among those
who were not depressed.
As we noted already, depression is correlated with environmental risk
factors that occur disproportionately in families that are also socioeconomically
disadvantaged.41 Risk behaviors that are associated
with depression may, instead, be a consequence of socioeconomic disadvantage
or of environmental risk factors.
We next examined these outcomes in multivariate analyses that also control
for sociodemographic characteristics and risk factors. The odds ratios and
regression coefficients for depression, after adjusting for sociodemographic
characteristics and risk factors, are reported in Table 4. We found that, for most problem indicators, high levels
of depressive symptoms were positive predictors of problems, even after controlling
for a wide range of socioeconomic variables and environmental risk factors.
As expected, many of these risk factors were also independent predictors of
problem indicators.
|
|
|
|
Table 4. Problem Indicators and Depression (Multivariate Analysis)*
|
|
|
In the multivariate analysis, depressive symptoms were most strongly
associated with smoking, bingeing, and suicidal ideation (P<.05). Adolescents with high levels of depressive symptoms missed,
on average, nearly 1 day more of school in the preceding month than similar
counterparts.
COMMENT
While depression may raise the risk of any or all of these negative
outcomes, the outcomes themselves may place adolescents at risk of depression.
For example, girls and boys who are doing poorly at school may become depressed
in consequence. Alternatively, these negative outcomes, and depression, may
be a consequence of other underlying problems. For example, those who use
alcohol or drugs or engage in self-destructive behavior may also be depressed.
Finally, suicidal thoughts are a marker of depression (so that the relationship
between depression and suicidal thoughts cannot be separated).
While we cannot determine causality in these data, we can use information
in the CFSAG about whether adolescents drink alcohol, use drugs, smoke, or
eat when they are stressed. Depressed girls were more likely than nondepressed
girls to report that they ate when stressed. Both depressed girls and depressed
boys were more likely than their nondepressed counterparts to report that
they stopped eating when stressed, that they drank alcohol when stressed,
that they smoked when stressed, and that they used drugs when stressed. These
results suggest that depression does, indeed, raise the risk of engaging in
high-risk behaviors.
The present study draws on observational cross-sectional data. Thus,
the correlations observed herein are not necessarily causal. Adolescents may
become depressed because they are performing poorly in school or are using
drugs. We cannot exclude the possible effects of reverse causality on our
results. The CFSAG relies on adolescent self-report of mental health symptoms,
risk behavior, and family characteristics. The validity of these self-reports
has not been established.
CONCLUSIONS
The CFSAG data suggest that there are important consequences of depression
in adolescents. The data strongly suggest that adolescents who have been subject
to traumatic life events and to abuse (sexual or physical) are at significantly
higher risk of depression. These results hold for both girls and boys. Depressed
adolescents are at much higher risk of poor performance at school, of using
drugs and alcohol, and of bingeing. Together, these findings suggest that
depression is an especially serious problem among children who live in risky
environments and that depression is, in turn, associated with other serious
risks.
The results of this study show that school attendance, smoking, bingeing,
and suicidal ideation are significantly correlated with depression. Information
about these indicators and behaviors as well as the presence of traumatic
life events could be powerful tools for physicians in the difficult task of
identifying adolescent depression and initiating treatment. Overall, studies
show that about 1 in 20 adolescents currently suffers from depression, suggesting
that routine screening for depression has considerable merit. In this study,
among adolescents who missed more than 10 days of school in the preceding
month, smoked, engaged in bingeing, or had suicidal thoughts, rates of elevated
depressive symptoms were more than twice as high. Thorough screening for depression
in this group is critical.
| What This Study Adds
Previous research has documented the high prevalence of depression among
adolescents. Several researchers have also argued that depression in adolescence
is correlated with serious sequelae. Assessing the relationship between depression
and adverse outcomes is complicated by the fact that depression is also correlated
with other factors that raise the risk of adverse outcomes, such as life events
and abuse.
This study used data collected on a large random sample of adolescents
to assess the relationship between depressive symptoms and adverse outcomes.
The data also contained measures of family background, abuse, and life events,
so we were able to control for these factors. We found evidence that, after
controlling for these factors, depressive symptoms are correlated with missing
school, smoking, bingeing, and suicidal ideation.
|
|
AUTHOR INFORMATION
Accepted for publication May 29, 2002.
This project was supported by the Commonwealth Fund, New York, NY.
We thank Kathrine Jack for research assistance.
Reprints are not available from the authors.
From the Department of Health Policy and Management, Mailman School
of Public Health, Columbia University, New York, NY (Dr Glied); and Section
on Development and Affective Neuroscience, Mood and Anxiety Disorders Program,
National Institute of Mental Health–Intramural Research Program, Bethesda,
Md (Dr Pine).
REFERENCES
| |
1. Rice DP, Kelman S, Miller LS, Dunmeyer S. The Economic Costs of Alcohol and Drug Abuse and
Mental Illness: 1985: Report Submitted to the Office of Financing and Coverage
Policy of the Alcohol, Drug Abuse, and Mental Health Administration, US Department
of Health and Human Services. San Francisco: Institute for Health and Aging, University of California;
1990.
2. Jaskulski T. Child Mental Health. Washington, DC: Intergovernmental Health Policy Project, George Washington
University; 1993.
3. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The economic burden of depression in 1990. J Clin Psychiatry. 1993;54:405-418.
ISI
| PUBMED
4. Ryan ND, Puig-Antich J, Ambrosini P, et al. The clinical picture of major depression in children and adolescents. Arch Gen Psychiatry. 1987;44:854-861.
ABSTRACT
5. Puig-Antich J, Kaufman J, Ryan ND, et al. The psychosocial functioning and family environment of depressed adolescents. J Am Acad Child Adolesc Psychiatry. 1993;32:244-253.
ISI
| PUBMED
6. Koyanagi C, Gaines C. All Systems Failure. Washington, DC: National Mental Health Association and the Federation
of Families for Children's Mental Health; 1993.
7. Lewis DO, Shanok SS. Medical histories of delinquent and nondelinquent children: an epidemiological
study. Am J Psychiatry. 1977;134:1020-1025.
FREE FULL TEXT
8. Cohen P, Pine DS, Must A, Kasen S, Brook J. Prospective associations between somatic illness and mental illness
from childhood to adulthood. Am J Epidemiol. 1998;147:232-239.
FREE FULL TEXT
9. Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior surveillance—United States, 1999. MMWR Morb Mortal Wkly Rep. 2000;49(SS-5):1-32.
10. Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 1996;53:339-348.
ABSTRACT
11. Gould MS, King R, Greenwald S, et al. Psychopathology associated with suicidal ideation and attempts among
children and adolescents. J Am Acad Child Adolesc Psychiatry. 1998;37:915-923.
FULL TEXT
|
ISI
| PUBMED
12. Rende R, Weissman M, Rutter M, Wickramaratne P, Harrington R, Pickles A. Psychiatric disorders in the relatives of depressed probands, II: familial
loading for comorbid non-depressive disorders based upon proband age of onset. J Affect Disord. 1997;42:23-28.
FULL TEXT
|
ISI
| PUBMED
13. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse and psychiatric disorder in young adulthood,
II: psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc Psychiatry. 1996;35:1365-1374.
FULL TEXT
|
ISI
| PUBMED
14. Goenjian AK, Pynoos RS, Steinberg AM, et al. Psychiatric comorbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry. 1995;34:1174-1184.
FULL TEXT
|
ISI
| PUBMED
15. Zima BT, Wells KB, Benjamin B, Duan N. Mental health problems among homeless mothers: relationship to service
use and child mental health problems. Arch Gen Psychiatry. 1996;53:332-338.
ABSTRACT
16. Goodyer IM. Recent undesirable life events: their influence on subsequent psychopathology. Eur Child Adolesc Psychiatry. 1996;5(suppl 1):33-37.
17. Goodyer IM, Herbert J, Tamplin A, Secher SM, Pearson J. Short-term outcome of major depression, II: life events, family dysfunction,
and friendship difficulties as predictors of persistent disorder. J Am Acad Child Adolesc Psychiatry. 1997;36:474-480.
FULL TEXT
|
ISI
| PUBMED
18. Tamplin A, Goodyer IM, Herbert J. Family functioning and parent general health in families of adolescents
with major depressive disorder. J Affect Disord. 1998;48:1-13.
FULL TEXT
|
ISI
| PUBMED
19. Williamson DE, Birmaher B, Anderson BP, al-Shabbout M, Ryan ND. Stressful life events in depressed adolescents: the role of dependent
events during the depressive episode. J Am Acad Child Adolesc Psychiatry. 1995;34:591-598.
FULL TEXT
|
ISI
| PUBMED
20. DuBois DL, Felner RD, Meares H, Krier M. Prospective investigation of the effects of socioeconomic disadvantage,
life stress, and social support on early adolescent adjustment. J Abnorm Psychol. 1994;103:511-522.
FULL TEXT
|
ISI
| PUBMED
21. Ge X, Lorenz FO, Conger RD, Elder GH Jr, Simons RL. Trajectories of stressful life events and depressive symptoms during
adolescence. Dev Psychopathol. 1994;30:467-483.
FULL TEXT
22. Monck E, Graham P, Richman N, Dobbs R. Adolescent girls, II: background factors in anxiety and depressive
states. Br J Psychiatry. 1994;165:770-780.
FREE FULL TEXT
23. Schoen C, Davis K, Collins KLG, Des Roches C, Abrams M. The Commonwealth Fund Survey of the Health of Adolescent
Girls. New York, NY: Commonwealth Fund; 1997.
24. Schraedley PK, Gotlib IH, Hayward C. Gender differences in correlates of depressive symptoms in adolescents. J Adolesc Health. 1999;25:98-108.
FULL TEXT
|
ISI
| PUBMED
25. Hayward C, Gotlib IH, Schraedley PK, Litt IF. Ethnic differences in the association between pubertal status and symptoms
of depression in adolescent girls. J Adolesc Health. 1999;25:143-149.
FULL TEXT
|
ISI
| PUBMED
26. Klein JD, Wilson KM, McNulty M, Kapphahn C, Collins KS. Access to medical care for adolescents: results from the 1997 Commonwealth
Fund Survey of the Health of Adolescent Girls. J Adolesc Health. 1999;25:120-130.
FULL TEXT
|
ISI
| PUBMED
27. Kapphahn CJ, Wilson KM, Klein JD. Adolescent girls' and boys' preferences for provider gender and confidentiality
in their health care. J Adolesc Health. 1999;25:131-142.
FULL TEXT
|
ISI
| PUBMED
28. Simantov E, Schoen C, Klein J. Health-compromising behaviors: why do adolescents smoke or drink? identifying
underlying risk and protective factors. Arch Pediatr Adolesc Med. 2000;154:1025-1033.
FREE FULL TEXT
29. Kovacs M. The Children's Depression Inventory (CDI). Psychopharmacol Bull. 1985;21:995-998.
ISI
| PUBMED
30. Carlson GA, Cantwell DP. Unmasking masked depression in children and adolescents. Am J Psychiatry. 1980;138:445-449.
FREE FULL TEXT
31. Stata Corp. Stata Statistical Software: Release 7.0. College Station, Tex: Stata Corp; 2001.
32. Anderson JC, Williams SM, McGee RO, Silva PA. DSM-III disorders in preadolescent children:
prevalence in a large sample from the general population. Arch Gen Psychiatry. 1987;44:69-76.
ABSTRACT
33. Bird HR, Canino G, Rubia-Stipec M, et al. Estimates of the prevalence of childhood maladjustment in a community
survey in Puerto Rico: the use of combined measures. Arch Gen Psychiatry. 1988;45:1120-1126.
ABSTRACT
34. Cohen P, Cohen J, Brook J. An epidemiological study of disorders in late childhood and adolescence,
II: persistence of disorders. J Child Psychol Psychiatry. 1993;34:869-877.
ISI
| PUBMED
35. McGee R, Feehan M, Williams S, Anderson J. DSM-III disorders from age 11 to age 15 years. J Am Acad Child Adolesc Psychiatry. 1992;31:50-59.
ISI
| PUBMED
36. Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3):
description, acceptability, prevalence rates, and performance in the MECA
study. J Am Acad Child Adolesc Psychiatry. 1996;35:865-877.
FULL TEXT
|
ISI
| PUBMED
37. Harrington R. Affective disorders. In: Rutter M, Taylor E, Hersov L, eds. Child and
Adolescent Psychiatry: Modern Approaches. London, England: Blackwell
Scientific Publications; 1995:330-350.
38. Bolgar R, Zweig-Frank H, Paris J. Childhood antecedents of interpersonal problems in young adult children
of divorce. J Am Acad Child Adolesc Psychiatry. 1995;34:143-150.
FULL TEXT
|
ISI
| PUBMED
39. Wallerstein JS. The long-term effects of divorce on children: a review. J Am Acad Child Adolesc Psychiatry. 1991;30:349-360.
ISI
| PUBMED
40. Fergusson DM, Horwood LJ, Lynskey MT. Parental separation, adolescent psychopathology, and problem behaviors. J Am Acad Child Adolesc Psychiatry. 1994;33:1122-1131.
ISI
| PUBMED
41. Johnson JG, Cohen P, Dohrenwend BP, Link BG, Brook JS. A longitudinal investigation of social causation and social selection
processes involved in the association between socioeconomic status and psychiatric
disorders. J Abnorm Psychol. 1999;108:490-499.
FULL TEXT
|
ISI
| PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
