Elizabeth J. Costello

Puberty and depression: the roles of age, pubertal status and pubertal timing

BACKGROUND Previous work has indicated that the 2:1 female:male sex ratio in unipolar depressive disorders does not emerge until some time between ages 10 and 15. METHODS Data from four annual waves of data collection from the Great Smoky Mountains Study (GSMS) involving children aged nine to 16 were employed. RESULTS Pubertal status better predicted the emergence of the expected sex ratio than did age. Only after the transition to mid-puberty (Tanner Stage III and above) were girls more likely than boys to be depressed. The timing of this transition had no effect on depression rates. Before Tanner Stage III, boys had higher rates of depression than girls, and the prevalence of depression appeared to fall in boys at an earlier pubertal stage than that at which it began to rise in girls. In addition, recent transition to Tanner Stage III or higher had a transient effect in reducing the prevalence of depression in boys. CONCLUSIONS The period of emergence of increased risk for depression in adolescent girls appears to be a relatively sharply demarcated developmental transition occurring in mid-puberty. Previously reported effects of the timing of puberty (which have tended to be transient) appeared less important in increase of risk for depression than pubertal status.

Scales to assess child and adolescent depression: checklists, screens, and nets.

Abstract Child self-report and parent-report measures of depressive symptoms are useful both for preliminary screening and to monitor change in symptomatology. These two aims, however, demand different psychometric properties. Currently available self- and/or parent-reports of depressive symptoms are reviewed in terms of their content validity and criterion validity. There is wide variability in the symptoms covered by the Childrens Depression Inventory (CDI), Center for Epidemiological Studies Depression Scale for Children (CES-DC), Depression Self-Rating Scale (DSRS), Childrens Depression Scale (CDS), and Mood and Feelings Questionnaire (MFQ). A review of criterion validity showed that information needed is often unavailable. Suggestions are made for ways to provide information that will enable clinicians and researchers to select measures for their purposes.

Pubertal changes in hormone levels and depression in girls

BACKGROUND Throughout their reproductive years, women suffer from a higher prevalence of depression than men. Before puberty, however, this is not the case. In an earlier study, we found that reaching Tanner Stage III of puberty was associated with increased levels of depression in girls. This paper examines whether the morphological changes associated with puberty (as measured by Tanner stage) or the hormonal changes underlying them are more strongly associated with increased rates of depression in adolescent girls. METHODS Data from three annual waves of interviews with 9 to 15-year-olds from the Great Smoky Mountains study were analysed. RESULTS Models including the effects of testosterone and oestradiol eliminated the apparent effect of Tanner stage. The effect of testosterone was non-linear. FSH and LH had no effects on the probability of being depressed. CONCLUSIONS These findings argue against theories that explain the emergence of the female excess of depression in adulthood in terms of changes in body morphology and their resultant psychosocial effects on social interactions and self-perception. They suggest that causal explanations of the increase in depression in females need to focus on factors associated with changes in androgen and oestrogen levels rather than the morphological changes of puberty.

Validity of the NIMH Diagnostic Interview Schedule for Children: A comparison between psychiatric and pediatric referrals

The NIMH Diagnostic Interview Schedule for Children (DISC) was used to evaluate 40 psychiatric referrals aged 7–11 and 40 pediatric referrals matched for age, sex, race, and socioeconomic status. Each parent and child was interviewed separately using parallel versions of the interview, DISC-P and DISC-C, and parents completed the Child Behavior Checklist (CBCL). The psychiatric referrals had more psychiatric diagnoses and higher symptom scores than the pediatric referrals. Parent reports discriminated better between the criterion groups than child reports. In both groups, mild oppositional behavior and fears were commonly reported by parents, whereas mild separation anxiety, fears, and dysthymia were commonly reported by children. Attention deficit disorder, conduct disorder, and affective disorders were much more common among psychiatrically referred children. There was an association (x2=37.1, p < 001) between abnormally high CBCL scores and diagnoses derived from the interview with the parent, but the association between the CBCL and the child interview was not significant. Over all, the results support the validity of the DISC-P, and to a lesser extent that of the DISC-C, in discriminating psychiatric from pediatric referrals, at the level of both symptoms and severe diagnoses, but not at the mild/moderate level of diagnosis.

Stimulant Treatment for Children: A Community Perspective

OBJECTIVE To examine the use of prescribed stimulants in relation to research diagnoses of attention-deficit hyperactivity disorder (ADHD) in a community sample of children. METHOD Data from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky Mountains Study were analyzed. RESULTS Over a 4-year period, almost three quarters of children with an unequivocal diagnosis of ADHD received stimulant medications. However, girls and older children with ADHD were less likely to receive such treatment. Most children with impairing ADHD symptoms not meeting full criteria for DSM-III-R ADHD did not receive stimulant treatment. Stimulant treatment in this group was significantly related to the level of symptoms reported by parents and teachers and was much more common in individuals who met criteria for oppositional defiant disorder. The majority of individuals who received stimulants were never reported by their parents to have any impairing ADHD symptoms. They did have higher levels of nonimpairing parent-reported ADHD symptoms, higher levels of teacher-reported ADHD symptoms, and interviewer-observed ADHD behaviors, but these typically fell far below the threshold for a DSM-III-R diagnosis of ADHD. CONCLUSIONS In this area of the Great Smoky Mountains, stimulant treatment was being used in ways substantially inconsistent with current diagnostic guidelines.

Psychiatric disorders among American Indian and white youth in Appalachia: the Great Smoky Mountains Study

OBJECTIVES This study examined prevalence of psychiatric disorders, social and family risk factors for disorders, and met and unmet needs for mental health care among Appalachian youth. METHODS All 9-, 11-, and 13-year-old American Indian children in an 11-county area of the southern Appalachians were recruited, together with a representative sample of the surrounding population of White children. RESULTS Three-month prevalences of psychiatric disorders were similar (American Indian, 16.7%; White, 19.2%). Substance use was more common in American Indian children (9.0% vs 3.8% in White children), as was comorbidity of substance use and psychiatric disorder (2.5% vs 0.9%). American Indian poverty, family adversity (e.g., parental unemployment, welfare dependency), and family deviance (parental violence, substance abuse, and crime) rates were higher, but the rate of family mental illness, excluding substance abuse, was lower. Child psychiatric disorder and mental health service use were associated with family mental illness in both ethnic groups but were associated with poverty and family deviance only in White children. Despite lower financial barriers, American Indian children used fewer mental health services. CONCLUSIONS This study suggests that poverty and crime play different roles in different communities in the etiology of child psychiatric disorder.

A test–retest reliability study of child-reported psychiatric symptoms and diagnoses using the Child and Adolescent Psychiatric Assessment (CAPA-C)

Seventy-seven 10-18-year-old psychiatric in-patients and out-patients took part in a test-retest study of the Child and Adolescent Psychiatric Assessment (CAPA). They were interviewed on two occasions several days apart. Overall reliability of diagnosis ranged from kappa = 0.55 (conduct disorder) to 1.0 (substance abuse or dependence). In general, reliability for scale scores of psychopathology was somewhat lower in out-patients than in-patients, though the opposite was the case for anxiety disorders and psychosocial incapacity and the reliability of the diagnosis of conduct disorder--the only individual diagnosis sufficiently common to permit this comparison. Unreliability of reports of behavioural problems was found to be related to admitting to being a liar in the first interview. The implications of these results for the use of the CAPA are discussed.

Child Psychiatric Disorders and Their Correlates: A Primary Care Pediatric Sample

Psychiatric interviews with 300 parents and children drawn from a first-stage screening sample of 789 children aged 7 to 11 attending primary care pediatric clinics, were carried out using the Diagnostic Interview Schedule for Children. The weighted prevalence of one or more DSM-III disorders was 11.8% based on parent interviews, 13.8% based on child interviews, and 22.0% based on either. Correlates of specific disorders varied depending on the informant, but parent-reported stress in the childs life was associated with disorders reported by both parent and child. The study confirms a high rate of unrecognized and untreated child psychopathology in the community.

Use, persistence, and intensity: patterns of care for children's mental health across one year.

This paper explores the use, persistence, andintensity of services for childrens mental healthproblems across a variety of service sectors during aone year period. Data come from the Great SmokyMountains Study. Analyses focus on childrens psychiatricsymptomatology and impairment, service use, and factorsthat may influence the relationship between psychiatricproblems and service use across a one year period. Findings show that approximately 20% ofchildren used some mental health services from somesector during the year. Childs symptomatology andcharacteristics of parents were associated with use and persistence of services. Parentsperceptions of impact on the family were associated withservice use, persistence, and intensity.

The Pediatrician as Gatekeeper to Mental Health Care for Children: Do Parents' Concerns Open the Gate?

Data from a study of children seen for pediatric care in a Health Maintenance Organization are used to examine factors which influence the likelihood that a pediatrician will identify a psychiatric problem and refer an identified child to a mental health specialist for further evaluation and treatment. Parental level of distress, family psychiatric history, and discussion of parental concerns with the pediatrician were found to be important. Characteristics of the service delivery system which may impede appropriate identification and referral are discussed. Implications for participation of child and adolescent psychiatrists in the training of pediatricians are presented.