NIH Public Access: Adolescents With Depressive Symptoms and Their Challenges With Learning in School

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J Sch Nurs. Author manuscript; available in PMC 2013 June 19.
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J Sch Nurs. 2010 October ; 26(5): 377392. doi:10.1177/1059840510376515.
Adolescents with Depressive Symptoms and their Challenges

with Learning in School
Jennifer Humensky, PhD,
Center for Management of Complex Chronic Care, Edward Hines Jr VA Hospital, Hines, IL, USA
Sachiko A. Kuwabara, MA,
Department of Mental Hygiene, Bloomberg School of Public Health, Johns Hopkins University,
Baltimore, MD, USA
Joshua Fogel, PhD,
Department of Economics, Brooklyn College, Brooklyn, NY, USA
Corrie Wells [BA candidate],

California State University Monterey Bay, Seaside, CA, USA
Brady Goodwin [BA candidate], and
Oregon State University, Corvallis, OR, USA
Benjamin W. Van Voorhees, MD, MPH
Department of Medicine, Psychiatry, and Pediatrics, The University of Chicago, Chicago, IL, USA
Abstract
We examine school performance among 83 adolescents at-risk for major depression. Negative
mood interfered with subjective measures of school performance, including ability to do well in
school, homework completion, concentrate in class, interact with peers, and going to class. No
significant relationships were found for mood and objective measures of school performance
(school attendance, English and math grades). Students with a college-educated parent had
stronger performance in objective measures (school attendance and math grades), while males had
lower English grades. In qualitative interviews, adolescents reported that negative thinking led to
procrastination, which led to poor school performance, which led to more negative thinking.
Adolescents with depressive symptoms that do not meet the threshold for referral report struggles
in school. Understanding the specific challenges faced by adolescents with even low levels of
depressive symptoms can help school nurses, teachers, and parents identify appropriate
interventions to help adolescents succeed in school.
Keywords
Depression; Adolescent; Education; Mental Health
Introduction
Adolescence is a time when depressive symptoms increase substantially. In later
adolescence (ages 1518), lifetime prevalence for major depression is very similar to
SAGE Publications, Inc. All rights reserved.

The data collection and analyses were conducted while the corresponding author was a PhD Candidate at the Harris School of Public
Policy, University of Chicago, Chicago, IL. The views expressed in this article are those of the authors and do not necessarily reflect
the position or policy of the Department of Veterans Affairs.
Humensky et al.
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prevalence for adults (Hankin, 2006). Adolescence is also a crucial time in the development
of human capital. This is a time when key decisions are made, such as choosing to stay in
school, to take a college-preparatory curriculum and invest in higher education (Chen, Wu
and Tasoff, 2010). This can have long-term implications for employability and earnings.
Previous research examining the relationship between depression in adolescence and

subsequent educational attainment has had mixed findings. The National Comorbidity Study
(NCS), a representative sample of adults in the United States (US) found that those who
recalled early-onset mood disorder were less likely to graduate high school or college
(Kessler, Foster, Saunders & Stang, 1995). A second analysis of NCS found that males who
recalled onset of depression prior to age 16 had a reduced likelihood of graduating from high
school (Wilcox-Gok, Marcotte, Farahati & Borkoski, 2004). Other studies have found that
the relationship of depression on educational attainment is stronger for females. Fletcher
(2008), examining data from the National Longitudinal Study of Adolescent Health
(AddHealth) found that adolescent females with depression had reduced likelihood of high
school graduation and college enrollment. An analysis using genetic markers found that
female adolescents with depression had greater decreases in school performance than males
(Ding, Lehrer, Rosenquist & Audrain-McGovern, 2009). In addition, an analysis of data
from a randomized trial of patients with chronic depression found that females with early
onset major depressive disorder were less likely to complete college and had lower expected
earnings (Berndt, Koran, Finkelstein & Gelenberg, et al., 2000).
Other studies have not found a strong association between depressive symptoms in
adolescence and subsequent educational attainment. The Dunedin birth cohort study found
that anxiety and depression in adolescence had weak associations with subsequent
educational attainment (Miech, Caspi, Moffitt & Wright, et al., 1999). An analysis of the
NCS data found that depression did not have a significant association with educational
attainment (Jayakody, Danzinger & Kessler, 1998). The NCS Replication (NCS-R) in 2001
02 did not find that major depression or dysthymia were associated with decreased
probability of completing high school and college (Breslau, Lane, Sampson & Kessler,
2008). A study examining adults in the Baltimore Area Catchment Study, found that
depression did not have a strong association with educational attainment (Eaton, Muntaner,
Bovasso & Smith, 2001). A study of secondary school students in Finland found a negative
cycle, where depressive symptoms led to school burn-out, which in turn led to greater rates
of depressive symptoms (Salmela-Aro et al., 2009).
Beyond major depression, many adolescents have symptoms of depression, where although
not rising to the level of clinical depression, can still adversely affect functioning. About 20
50% of adolescents are reported to have subsyndromal levels of depression, defined as
depressive symptoms that are less severe than major depression (Hankin, 2006). These
adolescents are at high risk for developing major depression (Fergusson, Horwood, Ridder
& Beautrais, 2005; Cuijpers, de Graff, & van Forsselaer, 2004). There is some evidence that
adolescents with dysthymic disorder (mild, chronic depression) may have lower levels of
social support than adolescents with a history of major depression (Klein, Lewisohn &
Seeley, 1997). This may be due to the longer duration of dysthymia as compared to the
duration of major depressive episodes, one of the key defining criteria for major depression
(US DHHS, 1999). A longitudinal study of patients with early onset dysthymic disorder
found that longer duration of dysthymic disorder was associated with decreased functional
impairment 10 years later (Klein, Shankman & Rose 2006, 2008). However, as mentioned
above, the NCS-R did not find that dysthymia was associated with the probability of
completing high school or college (Breslau et al., 2008).
Humensky et al.
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The purpose of this paper is to examine the relationship between depressive symptoms and
school performance in a sample of adolescents at-risk for major depression. This study goes
beyond objective measures of school performance to also examine adolescents perceptions
of school performance. This study also incorporates qualitative analyses to help understand
the adolescents experiences.
Methods
Study Design
The data for this study were collected during the screening and baseline interviews in the
Competent Adulthood Transition with Cognitive-behavioral and Interpersonal Training
(CATCH-IT) trial. CATCH-IT is a randomized controlled trial of an Internet-based
depression prevention measure, targeting adolescents at risk of depression. The study design
has been described elsewhere (Van Voorhees, Vanderplough-Booth, Fogel & Gladstone, et
al., 2008; Van Voorhees, Fogel, Reinecke & Gladstone et al., 2009). Adolescents with subthreshold levels of depressive symptoms were identified by universal screening during
primary care appointments. Adolescents were defined as having sub-threshold levels of
depression if they indicated both depressed mood and either loss of pleasure or irritability
for a few days or more in the past two weeks. Adolescents had to meet these criteria both at
an initial screening and again at an intake interview 12 weeks later. Thirteen primary care
sites from five healthcare organizations, located in the Midwest and southern United States,
participated in the study. Eighty-three adolescents who were identified as having
subthreshold levels of depressive symptoms participated in this study. As this paper is not
testing the differences between the two randomized groups, the 83 participants are analyzed
as a whole.
Adolescent Recruitment
Recruitment took place from February 1, 2007 to November 30, 2007. Adolescents were
eligible for the study if they were between the ages of 1421 and met sub-threshold criteria
for depression (depressed mood and loss of pleasure or irritability for a few days or more in
the past two weeks) at initial screening and again 12 weeks later at a formal eligibility
assessment. After complete description of the study, written consent was obtained (parental
consent was obtained for those under age 18 and assent for those individuals). Individuals
were excluded if they met the criteria for major depression (three individuals with borderline
major depression were included at the request of their physicians), had bipolar disorder,
eating disorders, panic disorder, substance abuse, conduct disorder, generalized anxiety
disorder, schizophrenia, suicidal ideation or intent, or were undergoing active treatment for
major depression. Individuals were not excluded if they had symptoms of conduct disorder,
generalized anxiety disorder, or past substance abuse.
All protocols were approved by the University of Chicago Institutional Review Board and
local institutional review boards, and all procedures were Health Insurance Portability and
Accountability Act (HIPAA) compliant. The trial is registered at clinicaltrials.gov with
identifier number NCT00145912.
Sample Participation
A comparison of sample demographics to national adolescent demographics shows that the
sample is comparable to the national population. In the US national population, about 51
percent of adolescents ages 1521 are male and 37 percent are of minority descent (Census,
2008). In our sample, about 42 percent are male, and about 39 percent are of minority
descent. Since sample participants were recruited at primary care centers, it is possible that
Humensky et al.
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adolescents in our sample have greater access to health care or greater motivation to seek
care.
In addition to the quantitative analyses, qualitative interviews were conducted. Physician

interviews were recorded and transcribed. Two independent reviewers listened to and
evaluated the baseline interviews for themes based on a grounded theory approach (Glaser &
Strauss, 1967). The adolescents interview comments were analyzed using Atlas (Atlas.ti,
2008) and final themes and subtheme coding achieved > 90% concordance between the two
raters. We report the education themes from the initial interviews. These interviews were
conducted in the summer of 2008 at the University of Chicago Medical Center.
Dependent Variables
Objective Education MeasuresThis was measured first by whether the participant is
currently attending school (yes/no), and the most recent letter grade in English and Math
(4=A, 3=B, 2=C, 1=D or lower). These educational measures were adapted from the
AddHealth Wave I in-home questionnaire (AddHealth, 2008) to allow for comparison of
these results to other studies.
Subjective Education MeasuresThis was measured by whether participants believed

that feeling down or sad has affected their ability to do well in school, and whether feeling
down or sad has affected the ability to do well in school in the following ways:
concentrating on or completing homework, problems with teachers, concentrating in class,
coming to class on time/avoiding absences, and dealing with other students or fitting in.
These items were measured on a four point scale (1=not at all, 2=a little, 3=somewhat, 4=a
lot). As with the school performance items, these items were adapted from the AddHealth
Wave I in-home interview (AddHealth, 2008). Additionally, these items were selected based
on previous qualitative research of young adults with depression, which found that many
young adults with depression identified struggles with role transitions and relationships with
family and peers (Kuwabara, Van Voorhees, Gollan & Alexander, 2007). Thus, these
measures of perceived school performance were chosen to assess the relationships between
depression and functioning in school.
Independent Variables
Center for Epidemiologic Studies Depression (CES-D)The Center for

Epidemiologic Studies-Depression (CES-D) scale assesses depressive symptoms. The CESD asks a series of 20 questions about depressed mood. The CES-D has been validated in
adolescents (junior and senior high school students), in males and females, and in white and
non-white American English speaking populations (Radloff, 1977, 1991). Items were
imputed for those who responded to at least 10 of the 20 questions, to avoid losing cases
where respondents answered most of the CES-D items. The imputation method used for this
variable was Statas impute procedure (Stata, 2003). Stata uses numerous other variables in
the data set and analyzes the relationship of these variables to a particular variable using as
relevant linear regression for continuous variables and logistic regression for categorical
variables to impute the missing value. For the values for CES-D, the imputation was based
on the values of 12 study eligibility assessment items: the 9-item Patient Health
Questionnaire (PHQ-9) (Sptizer et al., 1999), and 3 other items of whether the respondent
reported difficulty in work or take care of things at home or get along, often felt hopeless
about the future in the past two weeks, and had serious thoughts of ending his/her life in the
past month.
Individual Demographic CharacteristicsControl variables included age, gender,
and race. Age was measured in a continuous manner while race, gender, and education were
Humensky et al.
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measured as binary variables (race: white=0/non-white=1), (gender: female=0/male=1),

(education: college educated=1 versus not college educated =0). For example, a binary (0/1)
variable with a value of 1 for education indicates that the highest-educated parent had a
college degree and was included as a measure of the familys socioeconomic status (SES)
(Wooldridge, 2000). Parental education was dichotomized into two categories (college
educated versus not) to limit the number of categorical variables in the models given the
small sample size of the data set. As inter-generational transfer of education is high
(Haveman and Wolfe, 1995), it is important to account for parental education when
assessing students educational attainment.
Protective Factors for Depressive SymptomsProtective factors included selfefficacy and support from family and friends. Descriptions of these variables have been
previously published elsewhere (Van Voorhees, Vanderplough-Booth, Fogel and Gladstone,
et al., 2008). Figure 1 lists the components of these variables and the Cronbachs alpha for
the self-efficacy scale. The support items were binary yes/no items and were just added
together for a total score.
General HealthGeneral health was included as a measure of physical health, which may
be correlated to depressive symptoms and also school performance (Ojeda, Frank, McGuire,
et al., 2009, Ettner, 2000). Respondents were asked to rate their general health (1=excellent,
2=very good, 3=good, 4=fair, 5=poor). The responses were collapsed into a binary measure
to preserve degrees of freedom in a small sample with fair/poor=1 and excellent/very good/
good=0.
AnxietyCo-occurring anxiety was defined as a binary variable with a positive value
indicating the respondent reported being very anxious, nervous or panicky in the last four
weeks, or had an episode or spell with sudden onset of anxiety, heart pounding, shortness of
breath or lightheadedness in the past four weeks.
Substance UseSubstance use was defined as a binary variable with a positive value
indicating that the respondent reported binge drinking (more than five alcoholic drinks in
one day) in the past four weeks or marijuana use in the past 6 months. Adolescents who
were identified as having current substance use disorders were excluded from the study, as
the design of Project CATCH-IT was to examine depressive symptoms in the absence of cooccurring substance use problems. However, adolescents with less severe substance use
were not excluded.
DelinquencyDelinquent behavior was defined as a binary variable with a positive value

indicating that the respondent reported ever engaging in two or more fights, bullying
someone two or more times, or stealing items worth $20 or more on two or more occasions.
Adolescents who were identified as having conduct disorder were excluded from the study,
as Project CATCH-IT sought to examine depressive symptoms in the absence of cooccurring conduct disorder. However, adolescents with less severe delinquent behaviors
were included in the study.
Analytic Methods
As appropriate, logistic regression or linear regression was used to examine the relationship
between depressive symptoms and the educational outcomes. Linear regression is used when
the outcome variable in the model is continuous, as it is in all outcomes studied in this study
with the exception of school attendance. Linear regression relates changes in the outcome, or
dependent variable, to changes in the predictors, or independent variables, as a linear
relationship (Wooldridge, 2000). Beta coefficients are included in the regression equation
Humensky et al.
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with each predictor multiplied by its specific beta coefficient. Logistic regression is used
when the outcome variable is dichotomous; in this study, in the outcome of school
attendance. Linear regression is not appropriate when examining dichotomous variables, as
it can predict outcomes as less than zero or greater than one (Wooldridge, 2000). Logistic
regression models utilize a density function that requires outcomes to fall between 0 and 1.
Coefficients from logistic regressions are reported here as odds ratios; e.g. if the model is
examining the association of parental education on probability of attending school and if the
odds ratio for parental education is 6.7, this indicates that the odds of attending school for
students with a college-educated parent is 6.7 times greater than the odds for students
without a college-educated parent, all else held constant (Szklo and Nieto, 2004).
Three multivariate models were analyzed for each of the nine educational outcome
variables. The first model examined the relationship between CES-D score and the
educational outcome, controlling for demographic variables (age, gender, race, and parental
education). The second model included all analyzed in Model 1 and also controlled for
protective factors for depression: self-efficacy, support of family and friends and general
health. The third model included all analyzed in Model 1 and also controlled for cooccurring mental health conditions (substance use, delinquency and anxiety). Due to
statistical over-adjustment concerns, the protective factors and general health variables were
not included in Model 3.Stata SE Version 10.0 (College Station, TX) was used to conduct
the statistical analyses. As this is a small sample, we did not wish to lose individuals to item
non-response. Therefore, missing items were imputed using Statas ICE program for
multiple imputation (UCLA, 2008). Multiple imputation uses Monte Carlo estimation to
create 5 simulated datasets based on observed values of all predictor variables in the models,
and combines the estimates from the five datasets to reduce the uncertainty (Stata, 2009). As
discussed below, results were qualitatively similar in the imputed and non-imputed samples.
Results
Descriptive Statistics
Descriptive statistics of the sample are reported in Table 1. The average age was almost 18
years, a lower percentage were male, and slightly more than one-third were non-white. More
than half reported a parent with a college degree. Approximately 88% reported current
school attendance. Participants had high levels of depressive symptoms, by virtue of the
recruitment focus. The average CES-D score was slightly above 22. As many populationbased studies designate anyone with a CES-D score above 16 as depressed (Radloff, 1977,
Chan, Orlando, Ghosh-Dastidar & Duan et al., 2004, Needham and Crosnoe, 2005, Pickard,
Dalal & Bushnell, 2006), the average CES-D score indicates a higher rate of depressive
symptoms in this sample than in the general population.
Depressed Mood and Objective School Performance
Table 2 shows analyses for measures of objective school performance, attending school,
English and math grades. With regard to attending school, being male was significantly
associated with lower odds for attendance and having a parent college graduate was
significantly associated with higher odds for attendance. This pattern occurred in all models,
with the exception of parent college graduate approaching significance in Model 2
(p=0.055). Depressive symptoms did not have any significant association with attending
school. With regard to English grade, few covariates were statistically significant. In model
3, having anxiety was significantly associated with higher English grades. In Models 2 and
3, gender approached statistical significance, with being male associated with lower grades
in English (p=0.060 and p=0.098 respectively). Depressive symptoms did not have any
significant association with English grade. With regard to math grade, those of non-white
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race had lower math grades, although this was only statistically significant in Model 2 and
approached significance in Models 1 and 3 (p=0.053 and p=0.072, respectively). In Model 2,
reporting fair/poor general health was significantly associated with lower math grades, while
having lower levels of friends support was associated with higher math grades (approaching
significance with p=0.082), and having a college-educated parent was associated with higher
math grades (approaching significance with p=0.051). In Model 3, anxiety was significantly
associated with higher math grades. Depressive symptoms did not have any significant
association with math grades.
Depressed Mood and Subjective School Performance
Table 3 shows the relationship between depressive symptoms and subjective measures of
school performance whether depressive symptoms affect the ability to do well in school,
concentrate on or complete homework and have problems with teachers. With regard to
ability to do well in school, no covariates were statistically significant in this model,
although the relationship between greater friends support and problems with ability to do
well in school approached significance (p=0.067). Higher levels of depressive symptoms
were significantly associated with higher levels of reporting that feeling down or sad affects
the ability to do well in school (p<0.001 in Models 1, 2, and 3). With regard to concentrating
on or completing homework, no covariates were statistically significant. Higher levels of
depressive symptoms were significantly associated with higher levels of problems
concentrating on or completing homework in Model 1 (p=0.001), although significance was
lost when controlling for protective factors, and this only approached significance when
controlling for other mental health problems (p=0.085). With regard to problems with
teachers, younger students were associated with higher levels of reporting problems with
teachers (p=0.027 and p=0.017 in Models 1 and 2, respectively), although this lost statistical
significance once other mental health problems were controlled for (p=0.097). Higher levels
of depressive symptoms were not significantly associated with problems with teachers.
Table 4 shows the relationship between depressive symptoms and subjective measures of
school performance whether feeling down or sad has led to problems with the ability to
concentrate in class, go to class and deal with other students. With regard to concentrating in
class, those of nonwhite race reported problems with ability to concentrate in class, although
this was not significant in Model 1 and only approached significance in in Models 2 and 3
(p=0.082 and p=0.087, respectively). Higher levels of depressive symptoms were
significantly associated with greater problems concentrating in class (p<0.001, p=0.001, and
p=0.028 in Models 1, 2 and 3, respectively). With regard to attending class, no covariates
were statistically significant. Higher levels of depressive symptoms were associated with
greater problems going to class, although this only approached significance when
controlling for protective factors (p=0.002, p=0.051, and p=0.031 in Models 1, 2, and 3,
respectively). With regard to dealing with other students, anxiety was associated with higher
levels of problems dealing with other students (Model 3, p=0.047). Higher levels of
depressive symptoms were significantly associated with greater problems dealing with other
students (p<0.001, p=0.001, and p=0.020 in Models 1, 2, and 3, respectively).
Several sensitivity analyses were conducted (data not shown). Results under imputation
were qualitatively similar to non-imputed results. However, the magnitude of the CES-D
coefficient was somewhat higher and statistical significance was somewhat greater in the
non-imputed results in models 2 and 3. Thus, the imputed results reported here represent a
more conservative estimate of the association between depressive symptoms and school
performance. Results were qualitatively similar when outcome variables were not imputed.
Results were also qualitatively similar when using an alternative measure of depressive
symptoms, the Patient Health Questionnaire-Adolescent (PHQ-A). Also, results were
generally qualitatively similar when males and females are analyzed separately. However,
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most coefficients lost statistical significance, particularly for males, most likely due to the
smaller sample size.
Qualitative Analysis
Three major themes emerged from the exploratory analysis of interview transcriptions:
difficulty completing assignments, concentrating in class, and cyclical patterns. Cyclical
patterns include situations in which negative thinking led to procrastination and poor
outcomes, which in turn led to greater procrastination and negative thinking. Excerpts from
interviews reflecting each theme are listed below.
Completing Assignments
Just about every time Ive ever had a paper assignment Ive gotten myself cranked
up and anxious as soon as I got the assignment, and then not started on it until the
night it was due because I didnt want to have to think about it.
I often get depressed and put off my work and it doesnt get done and I feel
unmotivated to do work.
I had already procrastinated in writing a paper, after the deadline passed and I was
still not finished. I began to get frustrated with myself and had a crying fit in which
I desperately wanted to hurt myself.
Concentrating in Class
I did awful on a history quiz and had bad thoughts about myself. Now every time
Im in history class I keep thinking of that quiz.
Not being able to pay attention in class is causing me to not perform in tests which
will make my applications look bad and not get a job offer.
I really want [to] do well in school, but sometimes I freeze up before the tests. I
cant concentrate, no matter how long Ive studied. This obviously puts my goal of
doing well in school on hold.
School Affected by Depressive Symptoms
Getting down on myself by thinking I didnt have the brains for my math class only
made it harder and took away the motivation to study.
I gave up on getting the best grades I could.
Lack of confidence in academic abilities and social skills leads to less ability to
concentrate and more distant social relationships.
Negative thinking reduces your confidence, therefore making it harder to do the
things you want and are even capable of doing.
Ill feel too anxious and unhappy to get my work done well or on time, which will
make me feel guilty, which will make me not want to think about working, which
will make the problem even worse, etc etc etc.
Ditching school makes me behind in all my classes, then I get very stressed about
when Im going to get all my work done, then I procrastinate and sometimes never
do my work.
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Discussion
This study found that for a sample of US adolescents at risk of developing depression,
increasing depressive symptoms are associated with many measures of impaired school
performance. Although there was no statistically significant relationship between depressive
symptoms and objective school performance (staying in school or English and math grades),
there was a statistically significant relationship between depressive symptoms and
perceptions of impairment in functioning. Participants with greater depressive symptoms
were more likely to report that feeling down or sad affected their ability to do well in school,
concentrate on or complete homework, to concentrate in class, attend class, and deal with
other students. There was only one perception of impairment that was not significant and
that was the relationships between depressive symptoms and problems with teachers. These
results were generally consistent after controlling for protective factors for depression and
other mental health disorders (with the exception of completing homework, which lost
statistical significance after protective factors were included in the model). In addition, the
qualitative analysis helps to understand the nature of depressive symptoms on school
performance. Respondents reported that depressive symptoms and negative thoughts led to
poor school performance, which in turn led to more negative thoughts, generating a cycle.
Thus, while it may be too soon to see strong outcomes in objective measures of school
performance (i.e. English or math grades), the long-term impact of these struggles may
negatively impact school performance whether in high school or even post high school and
also future labor market productivity.
As in previous work in the Dunedin study (Miech, Caspi, Moffitt & Wright et al., 1999), the
NCS-R (Breslau, Sampson & Kessler, 2008) and the Baltimore Area Catchment Study
(Eaton, Muntaner, Bovasso & Smith, 2001), we did not find strong negative associations
between depressive symptoms and traditional measures of school performance. Unlike
previous studies, however, we go beyond the objective measures of school performance to
examine the ways in which adolescents believe their schooling is adversely affected. Since
the adolescents in the sample had low levels of depressive symptoms, it is possible we are
seeing early struggles in school, which if not addressed, may contribute to long-term
struggles culminating in poor grades and lower rates of school completion.
With regard to other variables in the models, males had lower attendance in school and also
lower English grades. This is consistent with prior research examining gender differences in
school performance (Marsh and Yeung, 1998). Students of nonwhite race reported lower
math grades. This is consistent with previous literature on the differences in standardized
score testing between black and white students (Vanneman, Hamilton, Baldwin Anderson &
Rahrnan, 2009). Students who had a parent with a college degree reported higher rates of
attending school and math grades (approaching significance in Model 2 only). This is
consistent with prior research on the inter-generational transmission of education (Haveman
and Wolfe, 1995). Students with anxiety also reported higher English and math grades, and
were more likely to report that depressive symptoms affect their ability to deal with other
students at school. This is consistent with previous research which found that anxiety was
not significantly associated with decreased educational attainment (Miech et al., 1999).
In addition to the quantitative study, the qualitative analyses provide insight into why
students with depressive symptoms feel they struggle with school. The students reported that
problems build up over time where negative thinking leads to procrastination, which can
lead to further negative thinking, and falling further behind in school. The qualitative results
are consistent with Salmela-Aro and Holopainen (2009) who found evidence of a negative
cycle between depressive symptoms and school burn-out in adolescents in Finland.
Although it goes beyond the scope of this study to suggest specific interventions that might
Humensky et al.
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improve this cycle, it is possible that measures to reduce student anxiety (Alexander and
Onwuegbuzie 2007) and improve school connectedness (Catalano, Haggerty, Oesterle &
Fleming et al., 2004) may be particularly helpful to adolescents with depressive symptoms.
Some limitations to this study should be noted. Only 83 respondents completed the baseline
interview, and there is some item non-response on individual items. Multiple imputation was
conducted to avoid loss of cases, and results are qualitatively similar to the non-imputed
results. Additionally, this sample is not nationally-representative. It is a study of adolescents
with subthreshold levels of depressive symptoms. It took place in the Midwest and southern
United States at 13 participating primary care sites. In addition, it is possible that the poor
perceptions of school performance could simply be the result of the depressive symptoms of
the respondents where negative thinking could be causing the respondents to report that they
struggle in school when objective measures indicate that they are not. However, the
qualitative interviews provide insight as to how current struggles could have a negative
effect on school performance. Additionally, there is variation in responses to the ways in
which negative mood was associated with schooling (i.e. problems with concentrating in
class, attending class and dealing with other students were identified as problematic while
problems with teachers was not). This variation supports the point that respondents were not
simply stating that every aspect of school is problematic.
Implications for School Nursing Practice

School nurses are in a unique position to help students struggling with depressive symptoms,
as children and adolescents with depressive symptoms often present to the school nurse with
somatic complaints (Campo et al., 1999, Shannon et al., 2010). Common somatic symptoms
associated with anxiety and depression include stomachaches, recurrent abdominal pain
(RAP), headaches, and musculoskeletal pain (Figure 2). Additionally, students presenting
with multiple somatic complaints are also more likely to have mental health problems (Lieb
et al., 2000). School nurses have the opportunity to identify students who are presenting
regularly with somatic complaints, the so-called frequent flyers to the school health office
and can work with teachers and parents to refer students to appropriate mental health
services (Shannon et al., 2010). Furthermore, previous evidence has shown that, in the
absence of a registered school nurse, students with somatic complaints are more likely to
simply be sent home from school (Pennington & Delaney, 2008, Wyman, 2005) or returned
to class untreated (Shannon et al., 2010), which can result in missed opportunities for the
student to receive needed mental health care. School nurses can facilitate communication
between students, teachers, parents and other mental health professionals to help identify
and refer students at risk for depressive symptoms.
Conclusion
This study sheds shows that adolescents at risk for depression perceive these symptoms as
negatively affecting school performance. Notably, adolescents report that depressive
symptoms leads to difficulties in coming to and concentrating in class and dealing with other
students, and that struggles with school become a negative cycle. Interventions addressing
these problems while depressive symptoms are low may help interrupt the negative cycle
and improve educational trajectories. Understanding particular factors affecting school
performance can help school nurses, mental health personnel, parents, teachers and school
administrators to identify targeted interventions, such as interventions to promote study
skills to reduce procrastination and complete assignments. Teachers may be in a unique
position to help, as many students reported struggles in interactions with peers, but not with
teachers. Furthermore, understanding ways in which depressive symptoms may manifest in a
Humensky et al.
Page 11
school setting can help school nurses to identify those who are struggling and propose
solutions.
Acknowledgments
Benjamin W. Van Voorhees has served as a consultant to Prevail Health Solutions, Inc, Mevident Inc, San
Francisco and Social Kinetics, Palo Alto, CA, and the Hong Kong University to develop Internet-based
interventions. To facilitate dissemination, the University of Chicago recently agreed to grant a no-cost license to
Mevident Incorporated (3/5/2010) to develop a school-based version. Neither Dr. Van Voorhees nor the university
will receive any royalties or equity. Dr. Van Voorhees has agreed to assist the company in adapting the intervention
at the rate of $1,000/day for 5.5 days. The CATCH-IT Internet site and all materials remain open for public use and
made freely available to healthcare providers at http://catchit-public.bsd.uchicago.edu/. Funding support provided
by a NARSAD Young Investigator Award (Van Voorhees), Robert Wood Johnson Foundation Depression in
Primary Care Value Grant and a career development award (Van Voorhees) from the National Institutes of Mental
Health (NIMH K-08 MH072918-01A2).
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Humensky et al.
Page 14

Figure 1.
Protective Factors for Depression [R]=Item reversed
Humensky et al.
Page 15
Figure 2.
Somatic Symptoms Associated with Depression and Anxiety in Children and Adolescents


2.562
2.586
2.557
1.605
2.575
2.044
2.110
Feeling down or sad has affected ability to do well in school (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)
Feeling down or sad has affected ability to concentrate on or complete homework (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)
Feeling down or sad has led to problems with teachers (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)
Feeling down or sad has affected ability to concentrate in class (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)
Feeling down or sad has led to problems coming to class on time or avoiding absences (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)
Feeling down or sad has led to problems dealing with other students or fitting in (1=Not at all, 2=A little, 3=Somewhat, 4=A lot)

1.203
1.275
1.203
1.348
1.166
1.148
1.339
1.166
87.7%
Currently attending school

2.828
52.3%
Anxiety
Most recent grade in Math (4=A, 3=B, 2=C, 1=D or lower)
37.8%
Most recent grade in English (4=A, 3=B, 2=C, 1=D or lower)
21.0%
Delinquency
6.733
Substance use
15.128
Friend support scale
11.224
0.647
23.6%
12.731
General health fair/poor
1.030
Family support scale
56.9%
Highest educated parent is college graduate
Self-efficacy scale
38.1%
Non-white race
2.059
Percent
43.4%
17.446
Age
11.834
SD
Male (1=male, 0=female)
22.380
Mean
CES-D score (high value indicates more depressive symptoms)
Descriptive Statistics (n=83, missing data imputed by multiple imputation)
73
43
30
17
20
47
32
36
Frequency
Table 1
Humensky et al.
Page 16
0.085 (0.0080.854)*
0.261 (0.0183.892)
24.321 (0.927638.137)#
0.146 (0.0250.868)*
0.372 (0.0771.806)
6.722 (1.16538.800)*
--
--
--
--
--
--
--
--
Male
Non-white race
Parent college graduate
Self-efficacy
Family support
Friends support
Substance Use
Delinquency
Anxiety
Constant
= p <0.001
***
= p <0.01,
= p <0.05,
**
= p <0.10,
Note: Missing data imputed by multiple imputation.
0.815 (0.4551.462)
0.994 (0.6781.456)
--
--
--
--
2.945 (0.14460.264)
1.120 (0.7601.649)
1.131 (0.6551.952)
0.101 (0.0033.015)
--
2.146 (0.19323.819)
0.722 (0.1304.009)
0.587 (0.0764.540)
--
--
--
--
7.154 (1.16643.905)*
0.379 (0.0662.193)
0.148 (0.0230.952)*
1.039 (0.6791.590)
1.259 (1.151)
--
--
--
--
--
--
--
0.345 (0.324)
0.221 (0.246)
0.428 (0.261)
0.088 (0.065)
0.005 (0.011)
Age
0.995 (0.9001.101)
1.015 (0.9381.098)
CES-D Score
0.962 (0.8221.126)
Model 1
(SE)
Model 3
OR (95% CI)
Model 1
OR (95% CI)
Variable
Model 2
OR (95% CI)
English Grade
Attending School
1.630 (1.243)
--
--
--
0.215 (0.358)
0.040 (0.029)
0.012 (0.028)
0.008 (0.383)
0.425 (0.317)
0.413 (0.289)
0.495 (0.257)#
0.099 (0.064)
0.005 (0.015)
Model 2
(SE)
--
0.821 (0.356)*
3.011 (1.464)*
2.700 (1.242)*
0.646 (1.231)
--
--
0.641 (0.306)*
--
2.323 (1.349)#
0.710 (0.330)*
0.138 (0.356)
0.378 (0.478)
--
--
--
0.055 (0.030)#
--
0.511 (0.344)
0.523 (0.285)#
0.268 (0.360)
0.005 (0.079)
0.013 (0.015)
Model 3
(SE)
0.041 (0.027)
0.065 (0.313)
0.833 (0.389)#
--
--
--
--
--
--
0.546 (0.355)
0.968 (0.315)**
0.581 (0.293)#
0.054 (0.299)
0.421 (0.327)
--
--
--
--
0.319 (0.318)
0.176 (0.253)
0.150 (0.375)
0.016 (0.068)
0.010 (0.017)
Model 2
(SE)
0.186 (0.382)
0.022 (0.071)
0.125 (0.069)#
0.406 (0.241)#
0.004 (0.014)
Model 1
(SE)
0.009 (0.014)
Model 3
(SE
Math Grade
Relationships between Depressive Symptoms (CESD) and Objective School Performance: Attending School & High English and Math Grades (n=83)
Table 2
Humensky et al.
Page 17

0.053 (0.012)***
0.053 (0.010)***
0.046 (0.049)
0.198 (0.221)
0.066 (0.209)
0.036 (0.224)
-------0.520 (0.864)
CES-D Score
Age
Male
Non-white race
Self-efficacy
Family support
Friends support
Substance Use
Delinquency
Anxiety
Constant
= p <0.001
***
= p <0.01,
**
= p <0.05,
= p <0.10,
0.121 (1.005)
--
--
--
0.007 (0.984)
0.093 (0.257)
0.235 (0.237)
0.238 (0.286)
--
--
0.013 (0.257)
--
0.056 (0.027)#
--
0.064 (0.227)
0.069 (0.222)
0.162 (0.225)
0.070 (0.055)
0.053 (0.013)***
Model 3
(SE)
0.008 (0.030)
0.118 (0.228)
0.014 (0.286)
0.129 (0.278)
0.328 (0.218)
0.027 (0.052)
Model 2
(SE)
Model 1
(SE)
Variable
Ability to Do Well In School
1.218 (0.982)
--
--
--
--
--
--
--
0.173 (0.233)
0.037 (0.250)
0.068 (0.228)
0.023 (0.054)
0.037 (0.010)**
Model 1
(SE)
0.418 (0.322)
1.204 (1.092)
2.674 (1.203)*
0.000 (0.297)
0.118 (0.290)
--
--
--
--
0.136 (0.237)
0.039 (0.256)
0.074 (0.237)
0.026 (0.058)
0.025 (0.014)#
Model 3
(SE)
--
--
--
0.324 (0.292)
0.016 (0.029)
0.019 (0.028)
0.521 (0.301)
0.100 (0.319)
0.039 (0.296)
0.123 (0.228)
0.004 (0.052)
0.020 (0.014)
Model 2
(SE)
Concentrate/Complete Homework
3.662 (1.000)***
--
--
--
--
--
--
--
0.174 (0.300)
0.017 (0.239)
2.974 (1.185)*
--
--
--
0.189 (0.280)
0.040 (0.026)
0.036 (0.023)
0.381 (0.353)
0.005 (0.362)
0.267 (0.274)
0.339 (0.241)
0.141 (0.057)*
0.132 (0.058)*
0.209 (0.238)
0.012 (0.013)
Model 2
(SE)
0.002 (0.011)
Model 1
(SE)
3.257 (1.187)**
0.056 (0.373)
0.158 (0.288)
0.221 (0.352)
--
--
--
--
0.205 (0.275)
0.021 (0.246)
0.198 (0.256)
0.113 (0.066)#
0.003 (0.012)
Model 3
(SE)
Problems with Teachers
Relationships Between Depressive Symptoms and Subjective School Performance: Ability to Do Well in School, Ability to Concentrate on Homework
and Problems with Teachers
Table 3
Humensky et al.
Page 18

0.041 (0.012)**
-3.050 (1.150)*
0.042 (0.009)***
0.065 (0.050)
0.092 (0.210)
0.414 (0.244)
0.072 (0.215)
-------2.527 (0.918)**
CES-D Score
Age
Male
Non-white race
Self-efficacy
Family support
Friends support
Substance Use
Delinquency
Anxiety
Constant
= p <0.001
***
= p <0.01,
**
= p <0.05,
= p <0.10,
--
--
0.447 (0.288)
0.019 (0.026)
0.014 (0.033)
0.145 (0.272)
2.383 (0.993)*
0.461 (0.303)
0.106 (0.251)
0.140 (0.283)
--
--
--
--
0.036 (0.218)
0.449 (0.251)#
0.034 (0.289)
0.134 (0.217)
0.470 (0.262)#
0.053 (0.053)
0.031 (0.013)*
Model 3
(SE)
0.212 (0.217)
0.087 (0.052)
Model 2
(SE)
Model 1
(SE)
Variable
Concentrate in Class
0.517 (1.152)
--
--
--
--
--
--
--
0.243 (0.277)
0.203 (0.280)
0.030 (0.263)
0.102 (0.063)
0.037 (0.011)**
Model 1
(SE)
0.031 (1.346)
--
--
--
0.096 (0.322)
0.026 (0.029)
0.039 (0.034)
0.035 (0.373)
0.474 (0.391)
0.432 (0.319)
0.114 (0.282)
0.086 (0.064)
0.030 (0.015)#
Model 2
(SE)
0.161 (1.300)
0.050 (0.382)
0.276 (0.335)
0.054 (0.390)
--
--
--
--
0.263 (0.283)
0.232 (0.303)
0.089 (0.272)
0.087 (0.069)
0.037 (0.016)*
Model 3
(SE)
Coming to Class/Avoiding Absences
1.805 (0.987)#
--
--
--
--
--
--
--
0.109 (0.245)
0.118 (0.248)
0.307 (0.262)
0.062 (0.055)
0.051 (0.011)***
Model 1
(SE)
1.430 (1.153)
--
--
--
0.430 (0.295)
0.024 (0.026)
0.019 (0.024)
0.085 (0.275)
0.153 (0.280)
0.037 (0.272)
0.184 (0.279)
0.042 (0.057)
0.052 (0.014)**
Model 2
(SE)
1.495 (1.072)
0.573 (0.282)*
0.047 (0.272)
0.224 (0.343)
--
--
--
--
0.068 (0.251)
0.157 (0.251)
0.339 (0.261)
0.041 (0.058)
0.038 (0.015)*
Model 3
(SE)
Deal with Other Students
Relationships Between Depressive Symptoms (CES-D) and Subjective School Performance: Problems with Ability to Concentrate in Class, Go to Class,
Relationships with Other Students
Table 4
Humensky et al.
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Previous research examining the relationship between depression in adolescence and

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J Sch Nurs. Author manuscript; available in PMC 2013 June 19.

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In addition to the quantitative analyses, qualitative interviews were conducted. Physician

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Subjective Education MeasuresThis was measured by whether participants believed

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Center for Epidemiologic Studies Depression (CES-D)The Center for

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measured as binary variables (race: white=0/non-white=1), (gender: female=0/male=1),

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DelinquencyDelinquent behavior was defined as a binary variable with a positive value

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J Sch Nurs. Author manuscript; available in PMC 2013 June 19.

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J Sch Nurs. Author manuscript; available in PMC 2013 June 19.

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Implications for School Nursing Practice

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Salmela-Aro K, Savolainen S, Holopainen L. Depressive Symptoms and School Burnout During

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Protective Factors for Depression [R]=Item reversed

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