Journal of Affectke Disorders, 26 ( 1992) 53-58 0 1992 Elsevier Science Publishers B.V. All rights reserved 01650327/92/$05.00
JAD 00925
learning disabilities Mary A. Fristad *
a-b,Shani Topolosky
bj Eiizabeth
B. Weller
aand
Ronald A. Weller a
Department of Pwchiatry and Neurosciences Progmm, and ’ Department of Psychology, The Ohb State Urkersity Columbus, Ohio, USA (Received 12 February 1492) (Revision received 23 April 1992) (Accepted 6 May 1992)
Occurrence of learning disabilities was determined in 30 inpatient children aged 6-12 with major depressive disorder (MDD). Learning disabilities (LD) occurred seven times more often compared to community base rates (33% v 4.7%). While rates of comorbid diagnoses, severity of depression, and children’s and parents’ reports (DICA-C, DICA-P) did not differ between groups, teachers’ reports (TRS, TRF) indicated increased classroom problems and poorer adaptive functioning in MDD/LD subjects (P < O.OOOI). Key words= Children; Depression; Learning disabilities; Intellectual dysfunction
Major depressive disorder (MDD) has been associated with impaired intellectual function in adults (Colby and Gotlib, 1988; Fogel and Sparadeo, 1985; McAIlister, 1981; Henry et al., 1973) and children (Brumback et al., I980a,b). However, studies of intellectual impairment in depressed children have been limited by small sampie sizes (Brumback et al., 198Oa) and possible referral bias (Brumback et al., 198Ob). As 1.52% of elementary school-aged children may be depressed (Kashani and Simonds, 1979), the rela-
Correspondence ro: Ivlaq~ A. Fristad, Department of Psy chiatry and Neurosciences Program, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210-1228, USA.
tionship of depression to academic performance is of interest. Learning disabilities (LD) are present in 4.7% of children and adolescents, according to the United States Department of Education (1987). Intellectual deficits, behavioral problems, and affective symptoms all have been associated with LD (Ritter, 1989; Rourke et al., 1989; Hoyle and Serafica, 1988; Bruck, 1986; Epstein et al., 1986; Margalit and Raviv, 1984; Paget and Reynolds, 1984; Bryan et al., 1981). An association between MDD and LD has been suggested (Kashani et al., 1982; Livingston, 1985). Livingston (1985) reviewed the literature on this topic and hypothesized three potential relationships between depression and learning disabilities: 1) depression causes or exacerbates learning problems; 2) learning disabitities cause or exacerbate depression; or 3) a specific brain
dysfunction can lead to both MDD and LD in some children. Livingston suggested that determining rates of LD in MDD children wouId be important in clarifying the nature of the rcfationship between these disorders. Kashani et al. (1982) studied the association of lMDD and LD in 100 children aged 9-12 hospitalized at a community mental health center. Thirteen children had MDD and 27 had kD using DSM-III criteria (American Psychiatric Association, 1980). Eight of the 13 (62%) MDD children also had LD, whereas only 19 of the 87 (22%) non-depressed children had ED (P < 0.003). The authors felt this threefold increase in LD observed among MDD children implied either a causal relationship between ED and MDD or ii predisposition for some children to manifest bozh conditions. Although !irnited, previous studies suggest an overlap between depression and learning disabilities. However, possible referral bias and small sample sizes limit interpretation of findings. Only one study has specifically examined rates of LD in MDD subjects, but its sample size was smaI1 (N = 13). Alth ough both MDD and LD have been associated with increased rates of behavioral and affective disturbance (Ollcndick and Yule, 1990; Rourke et al., 1989; Jensen et al., 1988), the degree of such impairment in depressed children with and without learning disabilities has not been established. The purpose of this study was to: 1) determine rates of LD in a larger inpatient sample of consecutively admitted and systematically assessed children with MDD; and 2) compare intellectual, behavioral, and affective function in children with both a major depressive disorder and learning disorder (MDD/LD) and children with a major depressive disorder but no learning disorder (MDD/OnIyJ. Method Subjects
Subjects were 30 chiIdrcn with MDD aged A-12 (M + SD = 10.4 f 1.6) consecutiveIy admitted to a child psychiatry inpatient unit. There were 24 30~s and 6 girls. Their socioeconomic
status (SES: Holrmgshead and RedIich, 1958) ranged from 2 to 5 (M + SD = 3.8 + 1.0). Most children (N = 23: 77%) had one or more comorbid Axis 1 diagnosis, most frcquentIy conduct disorder (CD: N = 91, oppositional defiant disorder (ODD: N = 6), and attention deficit hyperactivity disorder (ADHD: N = 3). Twelve other diagnoses occurred in only one or two children each. Children with mental retardation (IQ < 70) or neurologic disorders were excluded from the study. Learning disabilities traditionalIy have been defined in ,a variety of ways. For purposes of this study, the DSM-III-R criterion of academic ski11 being ‘marR:edly below the expected level’ was used to dci’inc LD. This definition was operatiunalized by requiring a 1.5 standard deviation discrepancy between measures of global intelligence (i.e., Full Scale IQ on the WISC-R) and achievement (i.e., Reading, Writing, or Arithmetic on the Woodcock-Johnson). Such a criterion has been used by previous researchers (Hoyle and Serafica, 1988; Ritter, 1989) and provides a replicable definition, which is important, as some studies have relied on less clear criteria (Bloom and Raskin, 1980; Epstein et aI., 1986; Mashani et al.. 1982).
rm?llectuul
jimctir-rrlictg
Three instruments were used to assess intellectual functioning. The Wechsler Intelligence Scale for Children-Revi:sed (WPSC-R: Wechsler, 1974) was used to measure overall intellectual ability. Eleven subtests iall ten standard scales plus Digit Span) were a.dministered. The Woodcock-Johnson Psychocducational Battery, Part II (WJ: Woodcock :.md Johnson, 1977) was used to measure educr:Gonal skills including reading, writing, arithmetic,’ and knowledge of science, social science and I’lumanities. The Beery-Buktenica Test of Visual-‘,ltiIotor Integration (VMI: Beery, 1989) was used : to assess visual-spatial-motor integration.
Behs*iord and affectire fimctioning Four /nstrumcnts were used to assess bchavioral and affective functioning. The Diagnostic
Interview for Children and AdoIcsccnts-Child and Parent Version (DICA-C and DICA-P; Reich and Wclner, 1989; Reich et al., 1982) was used to evaluate psychopathotugy according to DSM-IIIR criteria (American Psychiatric Association, 1987). The Children’s Depression Rating Scale Revised (CDRS-R: Poznanski et al., 19851 was used to assess the presence and severity of depressive symptoms. The Conncrs’ Teacher Rating Scale (TRS: Conncrs, 1969) provided teachers’ ratings of behavioral symptoms at school according to three factors: conduct, hyperactivity, and inattentive-passive. The commonly used IO-item Hyperactivity index was aLo determined. Thi Child Behavior Checklist-Teacher Report Form (TRF: Achonbach, 1978; Achenbach and Edelbruck, 19791 was used to provide teacher ratifigs of internalizing, externalizing, and overall behavioral symptoms as well as adaptive functioning of the children at school.
Each child was clinically depressed at the time of evaluation, regardless of when it occurred. The clinical rating scale fur depression (CDRS-R) was completed by the treatment team early in the child’s hospitalization. Teacher rating forms (TRS and TRFI were completed by the child’s teacher prior to the child’s hospitalization. Sample sizes for these measures were greatly reduced, as many children were hospitalized during summer months, when teacher reports were not available (MDD/LD group, N = 4; MDD/ Only group, N = 14). Age, S%, overall intelligence, and rafes of comorbid diagnoses did not differ between children who did and those who did not receive teacher ratings.
lntcllcctual tests (WISC-R, WJ. and VMlI and ihe structured interview (DICAI wert; administercd by a trained psychomctris;t who was expcricnced in their administration to children. There were five exceptions to this procedure. In these five cases, children had reccivcd intellectua1 testing within the six months prior to hospitalization. Unfortunately, not all WISC-R, W.i, and VMI scale scores were available for these five subjjtc’cts.
Unless otherwise noted, chi-square analyses were used tu compare categorical variables, with Yates’ correction added as needed fur small sample sizes. Student’s C-tests with Satterthwaite’s correctiun for unequal variance applied as needed (Sattcrthwaitc, 194(i) were used to compare continuous variables. Reslllks
There were 10 subjects with MDD/LD and 20 subjects with MDD/Qnly. Groups did not differ
TABLE 1 Occurrence of Icarning disrrhilitics (LD) in 30 children with major deprt~ivc general population base rates
disorder (MDD)
compared to previously
Type of LD
MDD subjects
I3ase rate ”
Relative risk h
Any LD Reading Writing Arithmelic Articulation
33% I 75 73”; c.
4.75 C 2-a; rl ~__#J L’ < ?-tic,; d
7.0 3.4 3.h 3.4
< X year-hold. lOC7r 2 6 years old, 55 ’
1.4
3-10% cl 3-10/CPT II
0.h 0.6
Language: rcceptivtt cxprebsivc
175 7%
3% 3%
reprlrted
” DSM-III-R (American Psychiatric Association. iYX7): ’ ratio of MDD rate to base rate; C U.S. Department of Education (19x7); “5% used in calculation of relalive risk; u 5~4 used in c;i]cu]ati(jn of relative risk, as depressed subjects’ mean age was l(j.4 Years old.
in terms of gender distribution (MDD/LD = 9 boys and I girl; MDD/Only = 15 boys and 5 girls), age IMDD/LD = 10.7 _t 1.4 years; MDD/ Only = 10.2 k 1.7 years), SES as determined by the Hollingshead and Redlich scale UUDD/LD = 3.6 _t 0.7; MDD/Only = 3.9 k 1.1) or handedness (MDD/LD = right 90%; left 20%; MDD/Only = right 85%; left 10%; mixed 5%). Prerdertce of Learning Disabdiiies it1 MDD Children Prevalences of ED diagnoses in this sample were compared to reported base rates in the general population (Table 1). Rates of LD were greatly increased in these MDD children compared to base rates. Each MDD/LD child had approximately two LD diagnoses (Mean + SD = 2.0 &. 1.2, range = l-4). Learning disabilities included: writing, 7; reading, 5; arithmetic, 5. Two children had articulation disorders and one child had both a receptive language disorder and an expressive language disorder, based on additional speech/language evaluations, in addition to their academic skills !earning disability.
Full Scale IQ (FSIQ), Verbal IQ (VIQ), Performance IQ (PIQ) were higher in the MDD/LD group than in the MDD/Only group (FSIQDD/L - 115.8 + 16.8; MDD/ Only = 99.4 + 13.8; f = 2.80; P < 0.01; VIQ-MDD/LD = 113.8 f 18.3; MDD/Only = 99.7 + 14.8; t = 2.23; P < 0.03; PIQ-MDD/LD = 112.9 f 15.8; MDD/ Only = 99.1 + 11.6; t = 2.42; P < 0.03). VMI scores were similar between groups.
Occurrence of clinicians’ comorbid Axis I diagnoses did not differ between th? two groups. Similarly, parents’ and children’s ratings of additional psychopathology and clinicians’ ratings of severity of depression (i.e., rates of DICA-P and DICA-C diagnoses and CDRS-R total scores) did not differ between the groups. However, teachers’ reports indicated signifi-
cant differences between groups. Given the small sample sizes for these analyses (MDD/LD, N = 4; MDD/Only, N = 141, a t test comparing differences in scores was used to compare the pattern of results between groups. On 818 comparisons of behavior problems and 6/6 comparisons of adaptive functioning, the MDD/LD group had more behavior problems and poorer adaptive functioning compared to the MDD/Only group. These findings reached statistical significance for the behavior problem scales (I = 7.98, df = 7, P < 0.0001) and the adaptive behavior scales (I = 12.24;
Discussion
The percent of with one or more disabilities children was increased available base rates from the general population (33% vs 4.7%0. These were based on clear and replicable criteria defining disabilities. criteria, such as have been used in other studies (Bloom and Raskin, 1980; Epstein et al., 1986; Kashani et al., 1982), even more might have been identified as disabled. example, in another study of 13 depressed children, Kashani et al. (1982) found 62% had concomitant severely depressed children comorbid disability. Teachers reported MDD/LD had more and poorer functioning hypothesized that of depression or other comorbid conditions such as attention hyperactivity might have contributed increased at school, the groups did not differ on rates of clinician comorbid diag-
57
noses, DICA-C or DICA-P reported diagnoses, or severity of depression, as indicated on the CDRS-R. This suggests that additional difficulties experienced by MDD/LD children in the classroom may be due to the stress and frustration caused by their learning disabilities. Although limited in scope, this study has several methodologic strengths. All children had MDD and received routine intellectual evaluations as part of their inpatlent treatment or had been tested recently. None had been referred specifically for assessment of neuropsychological problems. Hence, referral bias was reduced. This study also utilized the largest sample of MDD children to date whose intellectual functioning has been examined. Wnfortunately, teachers’ ratings were available for only a small number of the sample, as many subjects were hospitalized during summer months when their teachers were unavailable. Thus, replication of these findings in a larger sample would be desirable. The sampl-, consisted predominantly of boys, although this is typical of studies examining children hospitalized for depression (Asarnow and Ben-Meir, 1988; Kashani et al., 1982). Additionally, comparison with results from a normal control sample would provide current rather than historical indices of normality for the tests used in this study. Despite the Iimitations of this study, these findings have clinical and research implications. Mental health professionaIs should be aware that learning disabilities may be present in depressed children. Early identification and treatment of all diagnostic conditions is necessary to provide the most effective treatment. More research on the complex relationship between emotional and intellectual functioning in children clearly is needed. In particular, replication of these findings in an outpatient sample ana a longitudinal follow-up of children with MDD/LD compared to MDD/Only are needed to clearly define the relationship between depression and learning disabilities.
We wish to thank Gali Gill and Brian Jones for statistical consultation.
References Achenbach, T.M. (14781 The child behavior profife: 1. mys aged G-11. J. Consult. Clin. Psychology 4, 478-488. Achenbach, T-M. and Edelbrack, C.S. (1979) The child behavior Profile: 13. Boys aged 22-16 and girls aged 6-11 and 12-16. J. Consult. Clin. Psychology 4?, 223-233. American Psychiatric Association. (1980) Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, DC.
American Psychiatric Association. (198f) ibid. (3rd ed. revised) Washington, DC. Asarnow, J.R. and Ben-Meir, S. (1988) Children with schizophrenia spectrum and depressive disorders: a comparative study of premorbid adjustment, onset pattern and severity of impairment. J. Child. Psychol. Psychiat. 29, 477-488. Beer-y, K-E. (1989) The VMI Developmental Test of VisualMotor integration: Administration, Scoring, and Teaching Manual (3rd revision) Cleveland: Modern Curriculum Press. Bloom, A.S. and Raskin, L.M. (1980) WISC-R verbal-performance iQ discrepancies: A comparison of tearning disabled children to the normative sample. J. Chn. Psychology 36,322-323. Bruck, M. (1986) Social and emotional adjustments of learning disabled children: A review of the issues. In: S. Ceci (Ed.), Handbook of Cognitive, Social, Neuropsychological Aspects of Learning Disabilities (Vol. 1) (pp. 361-380) Lawrence Earlbaum Assoc. Hillsdale, NJ. Brumback. R.A.. Staton, R.D. and Wilson H. (1980a) Neuropsychological study of children during and after remission of endogenous depressive episodes. Percept. Motor Skills 50, 1163- 1167. Brumback, R.A., Jackoway, M.K. and Weinberg, W-A. (1980b) Relation of intelligence to childhood depression in children referred to an educational diagnostic center. Percept. Motor Skills 50, 11-17. Bryan, T.H., Sonnefeld, L.J. and Greenberg, F.Z. (1982) Children’s and parents’ views of integration tactics. Learn. Disabil. Quart. 4, 170-179. Colby, C.A. and Gotlib, I.H. (1988) Memory deficits in depression. Cognit. Therapy Res. 12,6l l-627. Conners, C.K. (1969) A teacher rating scale for use in drug studies with children. Am. J. Psychiatry 124, 884-888. Epstein, M.H., Cullinan, D. and Lloyd, J.W. (1986) Behaviorproblem patterns among the learning disabled: III-Replication across age and sex. Learn. Disabil. Quart. 9, 43-54. Fogel, B.S. and Sparadeo, F.R. (1985) Focal cognitive deficits accentuated by depression. J. Nerv. Ment. Dis. 173, 120124. Henry, G-M., Weingartner, H. and Murphy, D.L. (1973) Influences of affective states and psychoactive drugs on verbal learning and memory. Am. J. Psychiatry 130, 966-971. Hollingshead, A.V. and Redlich, F.C. (19%) Social Class and Mental Illness. John Wiley and Sons, NY, PP. 398-407Hoyle, S.G. and Serafica, F.C. (1988) Peer status of children with and without learning disabilities-a multimethod study. Learn. Disabil. Quart. 11, 322-330.
Jensen, J.B.. Burke. N. and Garfinkcl, B.D+ (1988) Depression and symptoms of attention deficit disorder with hyperactivity. J. Am. Acad. Child Adolesc. Psychiatry 27. 742-747. Kashuni, J.H. and Simon&. J+F. (1979) The incidence of depression in children. Am. J. Psychiatry I3h. 121)3-1205. Kashani. J.H.. Cantwell, D&P., Shekim, W.O. and Reid, J.C. (1982) Major depressive disorder in children admitted to an inpatient community mental health center. Am. J. Psychiatry 139, 671-672. Livingston. R. (1985) Depressive illness and learning difficulties: Research needs and practical implications. J. Learn. Disahil. 18, 518-520. Margalit, M. and Raviv. A. (1984) Learning disabilities’ expressions of anxiety in terms of minor somatic complaints. J. Learn. Disabil. 17. 226-228. McAllister, T.W. 11981) Cognitive functioning in the affective disorders. Comp. Psychiatry 22, 572-588. Ollendick. T.H. and Yule. W. (19901 Depression in British and American children and its relation to anxiety and fear. J. Consult. Clin. Psychology 58, 126-129. Paget. K.D. and Reynolds. C.R. (1984) Dimensions, levels, and reliabilities on the revised Children’s Manifest Anxiety Scale with learning disabled children, J. Learn. Disabil. 17. 137-141. Poznanski, E.O.. Freeman. L.N. and Mokros. H.B. (1985) Children’s Depression Rating Scale-Revised. Psychopharm. Bull. 24, 979-989.
Reich, W., Herjanic. B., Welncr, Z. and Gandhi, P.R. (19821 Development of a structured psychiatric interview for children: Agreement on diagnosis comparing child and parent interviews. J. Abnorm. Child Psychol. 10, 325-336. Reich, W. and Weiner, 2. (19881 The Diagnostic Interview for Children and Adolescents-Revised. Unpublished manuscript. Washington University, St. Louis. MO. Ritter, D.R. (1989) Social competence and problem behavior of ad&scent girls with learning disabilities. J. Learn. Disabil. 22, &(I-461. Rourke, B.P., Young, G.C. and Leenaars, AA. (1Y89) A childhood learning disability that predisposes those afflicted to adolescent and adult depression and suicide risk. J. Learn. Disabil. 22, 169-173. Satterthwaite, F.W. (1936) An approximate distribution of estimates of variance components. Biometrics Bull. 2, I f@-113. U.S. Department of Education. (19X7) Ninth Annual Report to Congress: The implementation of the Education of the Handicapped Act. ‘U.S. Department of Education, Washington. DC, pp. 3-S. Wechsler. D. (19741 Manual for the Wechsler Intelligence Scale for Children-Revised. Psychological Corporation, New York. Woodcock, R.W. and Johnson. M.B. (19771 Woodcock-Johnson Psycho-Educational Battery, Part II: Test of Achievement. Teaching Resources Corpcwation. Mingham. MA.
JAD 00925
learning disabilities Mary A. Fristad *
a-b,Shani Topolosky
bj Eiizabeth
B. Weller
aand
Ronald A. Weller a
Department of Pwchiatry and Neurosciences Progmm, and ’ Department of Psychology, The Ohb State Urkersity Columbus, Ohio, USA (Received 12 February 1492) (Revision received 23 April 1992) (Accepted 6 May 1992)
Occurrence of learning disabilities was determined in 30 inpatient children aged 6-12 with major depressive disorder (MDD). Learning disabilities (LD) occurred seven times more often compared to community base rates (33% v 4.7%). While rates of comorbid diagnoses, severity of depression, and children’s and parents’ reports (DICA-C, DICA-P) did not differ between groups, teachers’ reports (TRS, TRF) indicated increased classroom problems and poorer adaptive functioning in MDD/LD subjects (P < O.OOOI). Key words= Children; Depression; Learning disabilities; Intellectual dysfunction
Major depressive disorder (MDD) has been associated with impaired intellectual function in adults (Colby and Gotlib, 1988; Fogel and Sparadeo, 1985; McAIlister, 1981; Henry et al., 1973) and children (Brumback et al., I980a,b). However, studies of intellectual impairment in depressed children have been limited by small sampie sizes (Brumback et al., 198Oa) and possible referral bias (Brumback et al., 198Ob). As 1.52% of elementary school-aged children may be depressed (Kashani and Simonds, 1979), the rela-
Correspondence ro: Ivlaq~ A. Fristad, Department of Psy chiatry and Neurosciences Program, The Ohio State University, 473 West 12th Avenue, Columbus, OH 43210-1228, USA.
tionship of depression to academic performance is of interest. Learning disabilities (LD) are present in 4.7% of children and adolescents, according to the United States Department of Education (1987). Intellectual deficits, behavioral problems, and affective symptoms all have been associated with LD (Ritter, 1989; Rourke et al., 1989; Hoyle and Serafica, 1988; Bruck, 1986; Epstein et al., 1986; Margalit and Raviv, 1984; Paget and Reynolds, 1984; Bryan et al., 1981). An association between MDD and LD has been suggested (Kashani et al., 1982; Livingston, 1985). Livingston (1985) reviewed the literature on this topic and hypothesized three potential relationships between depression and learning disabilities: 1) depression causes or exacerbates learning problems; 2) learning disabitities cause or exacerbate depression; or 3) a specific brain
dysfunction can lead to both MDD and LD in some children. Livingston suggested that determining rates of LD in MDD children wouId be important in clarifying the nature of the rcfationship between these disorders. Kashani et al. (1982) studied the association of lMDD and LD in 100 children aged 9-12 hospitalized at a community mental health center. Thirteen children had MDD and 27 had kD using DSM-III criteria (American Psychiatric Association, 1980). Eight of the 13 (62%) MDD children also had LD, whereas only 19 of the 87 (22%) non-depressed children had ED (P < 0.003). The authors felt this threefold increase in LD observed among MDD children implied either a causal relationship between ED and MDD or ii predisposition for some children to manifest bozh conditions. Although !irnited, previous studies suggest an overlap between depression and learning disabilities. However, possible referral bias and small sample sizes limit interpretation of findings. Only one study has specifically examined rates of LD in MDD subjects, but its sample size was smaI1 (N = 13). Alth ough both MDD and LD have been associated with increased rates of behavioral and affective disturbance (Ollcndick and Yule, 1990; Rourke et al., 1989; Jensen et al., 1988), the degree of such impairment in depressed children with and without learning disabilities has not been established. The purpose of this study was to: 1) determine rates of LD in a larger inpatient sample of consecutively admitted and systematically assessed children with MDD; and 2) compare intellectual, behavioral, and affective function in children with both a major depressive disorder and learning disorder (MDD/LD) and children with a major depressive disorder but no learning disorder (MDD/OnIyJ. Method Subjects
Subjects were 30 chiIdrcn with MDD aged A-12 (M + SD = 10.4 f 1.6) consecutiveIy admitted to a child psychiatry inpatient unit. There were 24 30~s and 6 girls. Their socioeconomic
status (SES: Holrmgshead and RedIich, 1958) ranged from 2 to 5 (M + SD = 3.8 + 1.0). Most children (N = 23: 77%) had one or more comorbid Axis 1 diagnosis, most frcquentIy conduct disorder (CD: N = 91, oppositional defiant disorder (ODD: N = 6), and attention deficit hyperactivity disorder (ADHD: N = 3). Twelve other diagnoses occurred in only one or two children each. Children with mental retardation (IQ < 70) or neurologic disorders were excluded from the study. Learning disabilities traditionalIy have been defined in ,a variety of ways. For purposes of this study, the DSM-III-R criterion of academic ski11 being ‘marR:edly below the expected level’ was used to dci’inc LD. This definition was operatiunalized by requiring a 1.5 standard deviation discrepancy between measures of global intelligence (i.e., Full Scale IQ on the WISC-R) and achievement (i.e., Reading, Writing, or Arithmetic on the Woodcock-Johnson). Such a criterion has been used by previous researchers (Hoyle and Serafica, 1988; Ritter, 1989) and provides a replicable definition, which is important, as some studies have relied on less clear criteria (Bloom and Raskin, 1980; Epstein et aI., 1986; Mashani et al.. 1982).
rm?llectuul
jimctir-rrlictg
Three instruments were used to assess intellectual functioning. The Wechsler Intelligence Scale for Children-Revi:sed (WPSC-R: Wechsler, 1974) was used to measure overall intellectual ability. Eleven subtests iall ten standard scales plus Digit Span) were a.dministered. The Woodcock-Johnson Psychocducational Battery, Part II (WJ: Woodcock :.md Johnson, 1977) was used to measure educr:Gonal skills including reading, writing, arithmetic,’ and knowledge of science, social science and I’lumanities. The Beery-Buktenica Test of Visual-‘,ltiIotor Integration (VMI: Beery, 1989) was used : to assess visual-spatial-motor integration.
Behs*iord and affectire fimctioning Four /nstrumcnts were used to assess bchavioral and affective functioning. The Diagnostic
Interview for Children and AdoIcsccnts-Child and Parent Version (DICA-C and DICA-P; Reich and Wclner, 1989; Reich et al., 1982) was used to evaluate psychopathotugy according to DSM-IIIR criteria (American Psychiatric Association, 1987). The Children’s Depression Rating Scale Revised (CDRS-R: Poznanski et al., 19851 was used to assess the presence and severity of depressive symptoms. The Conncrs’ Teacher Rating Scale (TRS: Conncrs, 1969) provided teachers’ ratings of behavioral symptoms at school according to three factors: conduct, hyperactivity, and inattentive-passive. The commonly used IO-item Hyperactivity index was aLo determined. Thi Child Behavior Checklist-Teacher Report Form (TRF: Achonbach, 1978; Achenbach and Edelbruck, 19791 was used to provide teacher ratifigs of internalizing, externalizing, and overall behavioral symptoms as well as adaptive functioning of the children at school.
Each child was clinically depressed at the time of evaluation, regardless of when it occurred. The clinical rating scale fur depression (CDRS-R) was completed by the treatment team early in the child’s hospitalization. Teacher rating forms (TRS and TRFI were completed by the child’s teacher prior to the child’s hospitalization. Sample sizes for these measures were greatly reduced, as many children were hospitalized during summer months, when teacher reports were not available (MDD/LD group, N = 4; MDD/ Only group, N = 14). Age, S%, overall intelligence, and rafes of comorbid diagnoses did not differ between children who did and those who did not receive teacher ratings.
lntcllcctual tests (WISC-R, WJ. and VMlI and ihe structured interview (DICAI wert; administercd by a trained psychomctris;t who was expcricnced in their administration to children. There were five exceptions to this procedure. In these five cases, children had reccivcd intellectua1 testing within the six months prior to hospitalization. Unfortunately, not all WISC-R, W.i, and VMI scale scores were available for these five subjjtc’cts.
Unless otherwise noted, chi-square analyses were used tu compare categorical variables, with Yates’ correction added as needed fur small sample sizes. Student’s C-tests with Satterthwaite’s correctiun for unequal variance applied as needed (Sattcrthwaitc, 194(i) were used to compare continuous variables. Reslllks
There were 10 subjects with MDD/LD and 20 subjects with MDD/Qnly. Groups did not differ
TABLE 1 Occurrence of Icarning disrrhilitics (LD) in 30 children with major deprt~ivc general population base rates
disorder (MDD)
compared to previously
Type of LD
MDD subjects
I3ase rate ”
Relative risk h
Any LD Reading Writing Arithmelic Articulation
33% I 75 73”; c.
4.75 C 2-a; rl ~__#J L’ < ?-tic,; d
7.0 3.4 3.h 3.4
< X year-hold. lOC7r 2 6 years old, 55 ’
1.4
3-10% cl 3-10/CPT II
0.h 0.6
Language: rcceptivtt cxprebsivc
175 7%
3% 3%
reprlrted
” DSM-III-R (American Psychiatric Association. iYX7): ’ ratio of MDD rate to base rate; C U.S. Department of Education (19x7); “5% used in calculation of relalive risk; u 5~4 used in c;i]cu]ati(jn of relative risk, as depressed subjects’ mean age was l(j.4 Years old.
in terms of gender distribution (MDD/LD = 9 boys and I girl; MDD/Only = 15 boys and 5 girls), age IMDD/LD = 10.7 _t 1.4 years; MDD/ Only = 10.2 k 1.7 years), SES as determined by the Hollingshead and Redlich scale UUDD/LD = 3.6 _t 0.7; MDD/Only = 3.9 k 1.1) or handedness (MDD/LD = right 90%; left 20%; MDD/Only = right 85%; left 10%; mixed 5%). Prerdertce of Learning Disabdiiies it1 MDD Children Prevalences of ED diagnoses in this sample were compared to reported base rates in the general population (Table 1). Rates of LD were greatly increased in these MDD children compared to base rates. Each MDD/LD child had approximately two LD diagnoses (Mean + SD = 2.0 &. 1.2, range = l-4). Learning disabilities included: writing, 7; reading, 5; arithmetic, 5. Two children had articulation disorders and one child had both a receptive language disorder and an expressive language disorder, based on additional speech/language evaluations, in addition to their academic skills !earning disability.
Full Scale IQ (FSIQ), Verbal IQ (VIQ), Performance IQ (PIQ) were higher in the MDD/LD group than in the MDD/Only group (FSIQDD/L - 115.8 + 16.8; MDD/ Only = 99.4 + 13.8; f = 2.80; P < 0.01; VIQ-MDD/LD = 113.8 f 18.3; MDD/Only = 99.7 + 14.8; t = 2.23; P < 0.03; PIQ-MDD/LD = 112.9 f 15.8; MDD/ Only = 99.1 + 11.6; t = 2.42; P < 0.03). VMI scores were similar between groups.
Occurrence of clinicians’ comorbid Axis I diagnoses did not differ between th? two groups. Similarly, parents’ and children’s ratings of additional psychopathology and clinicians’ ratings of severity of depression (i.e., rates of DICA-P and DICA-C diagnoses and CDRS-R total scores) did not differ between the groups. However, teachers’ reports indicated signifi-
cant differences between groups. Given the small sample sizes for these analyses (MDD/LD, N = 4; MDD/Only, N = 141, a t test comparing differences in scores was used to compare the pattern of results between groups. On 818 comparisons of behavior problems and 6/6 comparisons of adaptive functioning, the MDD/LD group had more behavior problems and poorer adaptive functioning compared to the MDD/Only group. These findings reached statistical significance for the behavior problem scales (I = 7.98, df = 7, P < 0.0001) and the adaptive behavior scales (I = 12.24;
Discussion
The percent of with one or more disabilities children was increased available base rates from the general population (33% vs 4.7%0. These were based on clear and replicable criteria defining disabilities. criteria, such as have been used in other studies (Bloom and Raskin, 1980; Epstein et al., 1986; Kashani et al., 1982), even more might have been identified as disabled. example, in another study of 13 depressed children, Kashani et al. (1982) found 62% had concomitant severely depressed children comorbid disability. Teachers reported MDD/LD had more and poorer functioning hypothesized that of depression or other comorbid conditions such as attention hyperactivity might have contributed increased at school, the groups did not differ on rates of clinician comorbid diag-
57
noses, DICA-C or DICA-P reported diagnoses, or severity of depression, as indicated on the CDRS-R. This suggests that additional difficulties experienced by MDD/LD children in the classroom may be due to the stress and frustration caused by their learning disabilities. Although limited in scope, this study has several methodologic strengths. All children had MDD and received routine intellectual evaluations as part of their inpatlent treatment or had been tested recently. None had been referred specifically for assessment of neuropsychological problems. Hence, referral bias was reduced. This study also utilized the largest sample of MDD children to date whose intellectual functioning has been examined. Wnfortunately, teachers’ ratings were available for only a small number of the sample, as many subjects were hospitalized during summer months when their teachers were unavailable. Thus, replication of these findings in a larger sample would be desirable. The sampl-, consisted predominantly of boys, although this is typical of studies examining children hospitalized for depression (Asarnow and Ben-Meir, 1988; Kashani et al., 1982). Additionally, comparison with results from a normal control sample would provide current rather than historical indices of normality for the tests used in this study. Despite the Iimitations of this study, these findings have clinical and research implications. Mental health professionaIs should be aware that learning disabilities may be present in depressed children. Early identification and treatment of all diagnostic conditions is necessary to provide the most effective treatment. More research on the complex relationship between emotional and intellectual functioning in children clearly is needed. In particular, replication of these findings in an outpatient sample ana a longitudinal follow-up of children with MDD/LD compared to MDD/Only are needed to clearly define the relationship between depression and learning disabilities.
We wish to thank Gali Gill and Brian Jones for statistical consultation.
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