Psychosomatic and depressive symptoms from age eight to age eighteen

Adolescent Psychiatry, 1999 by Schmidt, M H, Lay, B, Esser, G, Ihle, W

Even today, when the psychoanalytic position that depression in childhood (i.e., before puberty) could hardly exist (e.g., Malmquist, 1971) has been given up, there are two approaches for defining depressive disorders during that age period: On the basis of an empirical study, Carlson and Cantwell (1980) criticized the concept of masked depression, which nevertheless has been held in serious textbooks (Graham, 1986). This concept proposed that classical depressive symptoms in children are masked by age-related behavior problems (e.g., hyperactivity, aggression and somatic complaints, phobias, underachievement, and delinquency). Ling, Oftedal, and Weinberg (1970) argued this position in dealing with the coincidence of headache and depression in children. It has never been clear how such masking symptoms could be differentiated from nonmasking disorders of the same kind in nondepressive children. Later, this position was dropped in favor of the idea of age-related "associated features" versus "essential symptoms" of childhood depression (Cantwell, 1983) under which somatic symptoms were subsumed as well.

More recent concepts have abandoned the idea of different symptoms in childhood and adult depression. But, in symptom lists like the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSMIll-R]; American Psychiatric Association, 1987), somatic problems such as eating disorders, sleeping disorder, fatigue, and weight loss are included. The Tenth Revision of the International Classification of Diseases (ICD-10; World Health Organization, 1991) describes a special concomitant somatic syndrome. Because one of the best longitudinal studies dealing with depressive symptoms (Hoffmann, 1991) did not take somatic complaints into account, we followed this question using data from a German cohort study that independently checked somatic and depressive complaints at ages 8, 13, and 18. In this study, exploratory evaluation was done taking into consideration three possible relations: (a) there is no association between both kinds of symptoms at any age, (b) there is a continuous association between somatic and depressive symptoms, and (c) there are different associations at different age levels.

Subjects and Method

Out of a total population of 1,444 German 8-year-olds born between March and September 1970 and living in Mannheim on March 1, 1978, 361 (25%) were randomly drawn and asked to participate in the investigation. Out of these, 129 (36%) refused to take part in the study, and 16 were excluded due to low intelligence (IQ below 70), chronic diseases or severe handicaps, or because they had moved away from the area during the course of the study. The remaining 216 children formed the random sample.

Each of the 1,444 families of the initial population was asked to fill out a 40-item behavior questionnaire (an adapted version of the Conners scale) and to grant permission to their child's teacher to fill out the same screening instrument. After the random sample had been drawn and separated, screening data for 733 children were available. In order to increase the number of subjects with behavior problems, the most conspicuous 25% of the children with the highest scores in the teacher and parent questionnaire were selected. Together with the 216 subjects of the random sample, they formed the total field sample of 399 8year-olds. Out of these, 356 (89%) could be reexamined at age 13, 340 (85%) also at age 18 (see Figure 1). Prevalence rates quoted in this chapter are related to subjects of the random sample. All other calculations were made on the basis of the total number of assessed children and adolescents.

Symptoms and child psychiatric disorders were determined by expert rating after a 2-hour parent interview. In the second and third stages of the study, case definition was further supplemented by an additional adolescent interview carried out with the 13- and 18-year-olds. All assessment decisions were made by child psychiatrists and experienced clinical psychologists. Case definitions and diagnoses were based on the evaluation of 28 to 39 symptoms assessed as being absent (0), moderate (1), or severe (2), depending on the information provided by the respective interview items. More methodological details have been described elsewhere (Esser, Schmidt, and Woerner, 1990; Esser et al., 1992). Overall prevalence rates were estimated to be 16.2% at age 8, 17.8% at age 13, and 16.0% at age 18. In the original study (Esser et al., 1990; Esser et al., 1992), diagnoses were classified in four different categories following ICD-9: neurotic and emotional disorders (ICD 300 & 313), conduct disorders associated or not associated with emotional problems (ICD 312), hyperkinetic syndromes (ICD 314), and other specific symptoms and syndromes (ICD 307). In the present study, we summed up symptoms typical of these four diagnoses to sum scores.

Somatic complaints and psychosomatic symptoms were treated equally and thus were categorized in one group, but somatic complaints based on somatic disorder were excluded, of course. Due to the agedependent developmental status, we checked for only 7 psychosomatic symptoms at age 8, 10 symptoms at age 13, and 11 symptoms at age 18 (see Table 1). The definitions of depressed mood and the various psychosomatic symptoms originate from the Mannheimer Elterninterview (Esser et al., 1989).