summary

O R I G I N A L P A P E R

Self-Reported Depressive Symptoms Have Minimal Effect on Executive Functioning Performance in Children and Adolescents

Benjamin D. Hill • Danielle M. Ploetz •

Judith R. O’Jile • Mary Bodzy • Karen A. Holler •

Martin L. Rohling

Published online: 9 May 2012

� Springer Science+Business Media, LLC 2012

Abstract The relation between mood and executive

functioning in children and adolescents has not been previ-

ously reported. This study examined the association between

self-reported depressive symptoms in both clinical outpa-

tient and psychiatric inpatient samples to the following

measures of executive functioning: the Controlled Oral

Word Association Test, Animal Naming, Trail Making Test,

and Wisconsin Card Sorting Test. Records from children and

adolescents aged 7–17 years old with an IQ [ 70 were examined. Data were gathered at either an outpatient neu-

ropsychology clinic (n = 89) or an inpatient psychiatric

hospital setting (n = 81). Mood was measured with the

Children’s Depression Inventory. Generally, statistical

associations between self-reported depressive symptoms and

executive functioning were small and non-significant. The

variance predicted by mood on measures of executive

functioning was minimal (generally less than 2 %) for the

total sample, the outpatient group, inpatient group, and a

subgroup who endorsed elevated mood symptoms. These

results suggest that impaired performance on measures of

executive functioning in children and adolescents is mini-

mally related to self-reported depressive symptoms.

Keywords Executive functioning � Mood � Depression � Cognitive ability � Neuropsychological assessment

Introduction

There is a long standing debate that has generated a con-

siderable amount of research in adults concerning the

relationship between levels of emotional disturbance and

their effects on performance on standard neuropsycholog-

ical tests. It appears that when the literature is taken as a

whole, adults diagnosed with psychiatric disorders tend to

perform worse than individuals without diagnoses (Basso

and Bornstein 1999; Cassens et al. 1990; Kindermann and

Brown 1997; Sackeim et al. 1992; Sherman et al. 2000;

Sweet et al. 1992; Tancer et al. 1990; Veiel 1997).

Depression, the most common mood disorder, is generally

associated with dysfunctional memory performance in the

adult literature (Burt et al. 1995; Christensen et al. 1997).

However, adult studies have shown conflicting patterns of

results across other neuropsychological domains. Some

researchers have reported depression to also be associated

with executive dysfunction (McDermott and Ebmeier

2009; Reppermund et al. 2007; Merriam et al. 1999; Martin

et al. 1991). However, others studies have reported no

effect of depression on executive functioning (Castaneda

et al. 2008; Miller et al. 1991; Rohling et al. 2002, Markela-

Lerenc et al. 2006).

While many different adult populations have been

examined regarding mood and neurocognitive functioning,

there are a more limited number of published studies

B. D. Hill (&) � D. M. Ploetz � M. L. Rohling Department of Psychology, University of South Alabama,

Mobile, AL 36688, USA

e-mail: [email protected]

J. R. O’Jile

Department of Psychiatry and Human Behavior,

University of Mississippi Medical Center/VA Medical Center,

Jackson, MS 39206, USA

M. Bodzy

Boston Neuropsychological Services, Nedham, MA 02494, USA

K. A. Holler

Department of Psychiatry and Human Behavior,

Alpert Medical School of Brown University/Butler Hospital,

Providence, RI 02906, USA

123

J Child Fam Stud (2013) 22:398–404

DOI 10.1007/s10826-012-9592-2

examining this issue in children and adolescents. A study by

Emerson et al. (2005) examined a small sample of boys ages

9–11 years old who reported high levels of comorbid anxiety

and depressive symptoms as measured by the State-Trait

Anxiety Inventory for Children (Spielberger et al. 1973) and

the Children’s Depression Inventory (CDI; Kovacs and Beck

1977). Two measures were utilized in this study, the Trails

Making Test (TMT; Reitan 1955) and the Concept Forma-

tion subtest from the Woodcock-Johnson Test of Cognitive

Abilities-Revised (Woodcock and Johnson 1989). Both of

these measures can be considered indices of executive

functioning ability. Impaired performance on these measures

was noted for the group with high endorsement of mood

symptoms compared to the group with low endorsement of

mood symptoms, with deficits noted in sequencing, alter-

nation, and problem-solving tasks. Another study compared

30 depressed children and adolescents ages 9 to 17 years to

matched controls using the CNS-Vital Signs computerized

battery (Brooks et al. 2010). Those with depression per-

formed worse than the control group on memory and com-

plex attention domains, with deficits noted on delayed verbal

and visual memory, reaction time, and accuracy/inhibition

on complex attention tasks.

Also, currently depressed older adolescents have been

noted to be significantly slower than non-depressed ado-

lescents at switching attentional resources (Wilkinson and

Goodyer 2008), which is likely to affect executive func-

tioning. However, Kyte et al. (2005) reported that atten-

tional flexibility, inhibition, and decision-making abilities

were not impaired on a computerized assessment battery

for a similar age group of adolescents who had recently

recovered from a first episode of major depression. Like-

wise, Maalouf et al. (2011) reported impaired executive

functioning in currently depressed adolescents that was not

present in adolescents in remission from depression. Micco

et al. (2009) assessed executive functioning in children

ages 6 to 17 years old who were at high risk for developing

depression based on parental diagnosis. Currently depres-

sed offspring showed impaired executive functioning,

whereas those who were not yet symptomatic did not show

these impairments. This suggests that executive function-

ing deficits are likely related to current symptoms rather

than trait markers for depression.

As clinical lore postulates that neurocognitive deficits

are attributable to mood when self-reported depressive

symptom inventories are elevated, many clinicians are

reluctant to interpret neurocognitive deficits in the presence

of comorbid depressive or anxiety symptoms in both adult

and child/adolescent populations (Sweet et al. 1992; Baron

2004). Also, to our knowledge, very few studies have

directly evaluated the effect of depression in children and

adolescents on measures that predominantly assess execu-

tive functioning.

As such, the aim of the present study was to evaluate the

degree to which self-reported depressive symptoms would

predict performance on tasks of executive functioning in a

clinically relevant, heterogeneous child/adolescent sample

referred for neuropsychological evaluation. We believed

that findings regarding the effect of mood on executive

functioning in this group would largely replicate the adult

literature, as planning, motor sequencing, and impulse

control are reported to reach almost fully developed stages

by early adolescence (Chelune and Thompson 1987; Baker

et al. 2001; Huizinga et al. 2006).

Based on recent findings in adults (Smitherman et al.

2007; Hill et al. 2008; Castaneda et al. 2008), we hypothe-

sized that self-reported symptoms of depression would be

minimally associated with performance on common mea-

sures of executive functioning in the present child/adolescent

sample. We additionally hypothesized that the association

between self-reported mood and executive functioning per-

formance would be minimal regardless of symptom severity

or clinical setting (outpatient vs. inpatient).

Method

Participants

Two samples were utilized in this study, an outpatient and

inpatient sample. The outpatient sample consisted of

archival data extracted from 89 child/adolescent patients

referred for outpatient neuropsychological assessment to a

clinic located within an academic medical center. The

primary DSM-IV-TR diagnoses (American Psychiatric

Association 2000) of patients were determined by the

results of comprehensive neuropsychological testing and

clinical interview. Individuals having an IQ B 70 were

excluded from data analysis so as to prevent extremely low

intellectual functioning and potential developmental dis-

abilities from tainting the sample. This was a mixed clin-

ical sample, with the most common primary Axis I

diagnoses being attention-deficit/hyperactivity disorder

(n = 55) followed by mood disorders (n = 14) and anxiety

disorders (n = 13). Some participants had multiple diag-

noses. The mean age was 11.0 years (SD = 2.5;

range = 7–16), and 64.0 % of the participants were male.

Of the 89 participants, 53.5 % were Caucasian, 41.9 %

were African-American, 3.5 % were Native American, and

1.2 % were listed as Other. The mean Peabody Picture

Vocabulary Test, 3rd Edition (PPVT-III; Dunn and Dunn

1997) score was 94.0 (SD = 19.3).

The second sample consisted of 81 children and ado-

lescents who were recent inpatient admissions to a psy-

chiatric hospital. The primary DSM-IV-TR diagnoses

(American Psychiatric Association 2000) of patients were

J Child Fam Stud (2013) 22:398–404 399

123

determined by the results of comprehensive neuropsycho-

logical testing, clinical interview, and psychiatric consult.

Individuals having an IQ B 70 were again excluded from

data analysis. This was a mixed clinical sample, with the

most common primary Axis I diagnoses being mood dis-

orders (n = 58), anxiety disorders (n = 15), and attention-

deficit/hyperactivity disorder (n = 10). Some participants

had multiple diagnoses. The mean age was 12.5 years

(SD = 3.0; range = 7–17 years), and 67.9% of the par-

ticipants were male. Of the 81 participants, 84.4% were

Caucasian, 9.4% were Hispanic, 3.1% were African-

American, and 3.1% were Asian. The mean PPVT-III

standard score was 99.2 (SD = 14.5).

Materials and Procedures

For both populations, the parents or guardians of all par-

ticipants provided informed consent for the use of the

evaluation data and all data was analyzed under the pur-

view of an institutional review board. Patients were

administered the following commonly-used measures of

executive functioning as part of a larger neuropsychologi-

cal battery: the Trail Making Test (TMT; Reitan 1955), the

Wisconsin Card Sorting Test (WCST; Heaton et al. 1993),

and the Controlled Oral Word Association Test (COWAT;

Benton and Hamsher 1989). For the TMT, parts A and B

were both given and for the COWAT, FAS and animal

naming were utilized. Not all individuals received all tests.

The specific number of individuals in the outpatient setting

who completed each test were as follows: n = 47 WCST,

n = 75 TMT (parts A and B), and n = 84 COWAT (FAS

and animal naming). The specific number of individuals in

the inpatient setting who completed each test were as fol-

lows: n = 70 WCST, n = 80 TMT A, n = 76 TMT B, and

n = 75 COWAT (FAS and animal naming).

The Trail Making Test (TMT; Reitan 1955) assesses

visual scanning and mental sequencing abilities via

graphomotor output. It has been reported to be extremely

sensitive to neurological dysfunction in both adults and

adolescents, particularly part B (Reitan and Wolfson 2004).

While the TMT part A is a simple task of visual scanning

that is often considered an index of processing speed, Part

B requires more complex rapid alternation between cog-

nitive tasks. TMT Part B has traditionally been viewed as a

measure of executive functioning as it assesses more

response set maintenance ability, mental flexibility, and the

ability to divide attention (Strauss et al. 2006; Baron 2004).

For this study, the variable of interest was the amount of

time required to complete part B.

The Wisconsin Card Sorting Test (WCST) is the most

commonly used assessment of executive functioning after

the TMT (Rabin et al. 2005). It indexes both reasoning

skills and the ability to maintain cognitive flexibility in the

face of shifting task demands. The test is believed to

operate similarly in both adults and adolescents by

approximately age 9–10 years (Kizilbash and Donders

1999). Participants are given a deck of cards and instructed

to match the top card to one of four stimuli cards. Matching

may occur on one of 3 categories and sorting criteria

change throughout the test. This study employed the 128

card hand-administered version. The variable of interest

was the percentage of perseverative errors made. Other

possible variables such as number of categories completed

and failure to maintain set were not used because the data

were extremely skewed with most individuals having

normal performances.

The Controlled Oral Word Association Test (COWAT)

is typically considered a measure of verbal fluency that is

highly related to executive functions (Baron 2004). It is

also thought to be sensitive to neurodevelopment (Cohen

et al. 1999). It consists of three trials where the participant

is asked to name as many words as being with a single

letter of the alphabet in a set amount of time. The letters F,

A, and S were used in this study. The participant is

instructed to not use proper nouns or variations of words

previously given during the test. A semantic fluency ver-

sion of the COWAT was also used in this study were the

participant was asked to generate as many animals as

possible during a set time. Instructions were given not to

repeat animal names. For this study, the variables of

interest were the total number of words generated on the

three verbal fluency trials as well as the separate total

number of animals generated on the single semantic flu-

ency trials.

All patients were administered the Children’s Depres-

sion Inventory (CDI; Kovacs and Beck 1977) as part of the

evaluation procedure. The CDI is a 27-item self-report

measure of depressive symptoms in children and adoles-

cents. It measures negative mood, interpersonal problems,

anhedonia, negative self-esteem, and feelings of ineffec-

tiveness. A cutoff score of 19 for severe depressive

symptoms in children was proposed by Kovacs (1981).

However, a cutoff score of 12 has been used in previous

studies of this genre (Emerson et al. 2005).

All measures were administered in accordance with their

standardized protocols. T-scores were utilized for data

analyses because some of the older patients were adminis-

tered the adult version of a test per standard of care.

Descriptive statistics are presented for all of the measures

that were given in this study (see Table 1). Most measures

were normally distributed and had reasonable skewness and

kurtosis coefficients ([-1 and \1). COWAT animals and WCST perseverative errors had kurtosis coefficients [3.0. The data was assessed for outliers by converting all utilized

variables to z-scores and scores in excess of 3.29 in either

direction where considered outliers and replaced with the

400 J Child Fam Stud (2013) 22:398–404

123

next closest T-score within the z-score range of 3.29

(Tabachnick and Fidell 2001). Six such cases were found in

the outpatient sample, and none were found in the inpatient

data. After the replacement, the data was analyzed again and

no such outliers were found in the data.

Statistical Analyses

To initially assess the relation between measures of exec-

utive functioning and self-reported mood symptoms,

Pearson correlations were computed between the CDI and

our neuropsychological measures. Next, regression analy-

ses were utilized and the coefficient squared to determine

the amount of variance in each criterion measure that the

mood scales individually predicted. First, an analysis was

conducted on the combine inpatient and outpatient data to

evaluate the amount of variance accounted for by the CDI

raw score on performance on the measures of executive

function. The following criterion variables were examined:

TMT part A, TMT part B, WCST percentage perseverative

errors, and COWAT FAS and Animals total number of

words generated. All performances on the executive mea-

sures were converted to normed T-scores (Strauss et al.

2006) that were used in the regression analysis. The raw

CDI score was utilized as this is more consistent with the

view of depressive symptoms as a pathological and non-

normally distributed variable. Unique variance accounted

for was expressed as point estimates of effect sizes by

squaring the regression coefficient. Two more regression

analyses were completed to evaluate inpatient and outpa-

tient CDI scores predictions separately.

A power analysis was performed to determine the

number of participants needed to attain power = 0.80 at

a = 0.05 in our regression analyses. A moderate effect size equal to 0.35 was proposed based on both the literature and

what would be relevant clinically. G*Power 3.1.1 software

(Faul et al. 2007) was utilized and it was estimated that 46

participants would be needed to meet the proposed power

and alpha requirements for our analyses. All of the fol-

lowing analyses exceeded this requirement.

Results

Correlation and Aggregate Regression Analyses

Table 1 displays the mean T scores and standard deviations

for all variables as well as the correlations of the mood

measures to the executive functioning measures. Correla-

tions between CDI scores and the neuropsychological

measures ranged from 0.05 to -0.22 for outpatients and

-0.06 to -0.19 for inpatients. None of these correlation

coefficients were significantly different from 0.

Table 2 presents the point estimates of effect sizes (R2

values) for the series of regression analyses for the com-

bined, outpatient, and inpatient samples. For the combined

sample, the unique variance accounted for by self-reported

depressive symptoms was less than 2% on all executive

functioning measures. Unique variance predicted by the

CDI ranged from \0.001 to 0.017. For the outpatient sample, the unique variance accounted for by self-reported

depressive symptoms was less than 5% for all executive

functioning measures, with the CDI scores accounting for

almost no variance in all measures except for TMT part A.

Variance in executive functioning predicted by the CDI

scores for the outpatient sample ranged from \0.001 to 0.049. For the inpatient sample, the variance in executive

functioning accounted for by self-reported depressive

symptoms was less than 2% on all of executive functioning

measures, ranging from 0.004 to 0.018. We also calculated

Cohen’s d for all measures comparing the outpatient

sample to the inpatient sample. The between groups effect

size for CDI was d = 0.43 while the average between

Table 1 Mean scores and correlations of the CDI and executive functioning measures

Outpatient Inpatient

Mean (SD) CDI r Mean (SD) CDI r

CDI 12.7 (8.0) 16.1 (8.0)

TMT A 38.6 (25.2) -0.22 41.4 (19.1) -0.08

TMT B 37.1 (21.8) -0.05 41.3 (18.1) -0.06

WCST % errors 43.7 (14.4) -0.02 46.1 (16.7) -0.11

COWAT FAS 42.1 (14.5) 0.05 48.4 (13.2) -0.13

Animal naming 49.3 (12.4) -0.01 45.6 (9.6) -0.19

CDI is raw score; all other scores are T scores. CDI Children’s Depression Inventory, TMT A Trail Making Test Part A, TMT B Trail Making Test Part B, WCST % Errors Wisconsin Card Sorting Test Percentage of Perseverative Errors, COWAT Controlled Oral Word Association Test. None significant at p \ .05

Table 2 R2 point estimates of percent of variance accounted for executive functioning by CDI scores for combined, outpatient, and

inpatient samples

Measure R2

CDI combined CDI inpatient CDI outpatient

TMT A 0.017 0.049 0.007

TMT B 0.001 0.002 0.004

WCST % errors 0.005 \0.001 0.013 COWAT FAS \0.001 0.002 0.018 Animal naming 0.015 \0.001 0.037

CDI Children’s Depression Inventory, TMT A Trail Making Test Part A, TMT B Trail Making Test Part B, WCST % Errors Wisconsin Card Sorting Test Percentage of Perseverative Errors, COWAT Controlled Oral Word Association Test. None significant at p \ .05

J Child Fam Stud (2013) 22:398–404 401

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groups effect size for all of the executive functioning

measures was d = 0.12. This indicates that while inpatient

status had a moderate effect on self-reported depressive

symptoms, inpatient psychiatric status had only a small

effect on performance on measures of executive function-

ing overall.

Elevated Endorsement Subgroup Regression Analyses

Our initial analysis of data from the entire sample was done

to ascertain whether, as clinical lore postulates, negative

affect deleteriously influences executive functioning per-

formance in a general mixed clinical child/adolescent

sample. These results suggest that self-reported depressive

symptoms minimally affect measures of executive func-

tioning in children and adolescents seen clinically, regard-

less of setting. However, it is possible that children and

adolescents with high levels of depression might be affected

when the typical referral sample is not. To address this, we

conducted another set of regression analyses only examin-

ing individuals with CDI raw scores [12 (as per Emerson et al. 2005). This approach subsumed all individuals in the

outpatient sample with a depression diagnosis and 20 of the

35 inpatients who were diagnosed with depression resulting

in 33% of these individuals with CDI scores [12 having an Axis I diagnosis of a mood disorder. We then repeated all of

the original analyses in the elevated endorsement subgroup

(n = 79). Similar results were found to the original com-

plete clinical sample for the effect of self-reported depres-

sive symptoms on executive functioning (see Table 3). The

unique variance accounted for by self-reported depressive

symptoms was 3% or less on all measures. Unique variance

predicted by the CDI ranged from 0.002 to 0.031.

Discussion

The results of this study revealed several interesting find-

ings. First, in general, no clinically significant effect of

self-reported depressive symptoms negatively impacting

executive functioning performance was observed in the

complete child/adolescent sample used in this study. This

lack of effect was found in both clinical outpatient and

psychiatric inpatient samples, indicating that severity of

psychiatric symptoms was likely not a significant con-

found. In fact, psychiatric status (outpatient vs. inpatient)

had a small effect on measures of executive functioning

despite having a moderate effect on self-reported depres-

sive symptoms. Additionally, self-reported depressive

symptoms were not found to affect performance on any of

the neuropsychological measures used in this study to a

clinically meaningful extent in the sample of children and

adolescents with elevated endorsement of mood symptoms.

Therefore, contrary to clinical lore, the results of this study

do not support the common practice of differentially

interpreting impairments in executive functioning when

depressive symptoms are present.

These results are generally contrary to the few previous

studies examining this issue in children and adolescents

(Kusché et al. 1993; Emerson et al. 2005; Wilkinson and

Goodyer 2008) that have reported that mood symptoms

affect neurocognitive performance in children and adoles-

cent. However, the current results are consistent with the

majority of studies in the adult literature (Grossman et al.

(1994); Miller et al. 1991; Rohling et al. 2002; Markela-

Lerenc et al. 2006; and Castaneda et al. 2008) that have

found no significant relationship between neuropsycho-

logical performance and mood symptoms in large diverse

samples. Also, our discrepant findings from the previous

child and adolescent literature may be due to the fact that

none of the previous studies had examined this issue in a

sample similar to the one utilized in this study nor did they

broadly assess the domain of executive functioning in the

same manner as this study. It is also relevant that the

previous child and adolescent studies (Kusché et al. 1993;

Emerson et al. 2005; Wilkinson and Goodyer 2008)

focused on group differences. That is, their results sup-

ported a probable difference between groups with and

without mood symptoms without taking into account effect

size. The present study focuses entirely on the size of the

effect of self-reported mood symptoms on executive

functioning, which is likely more informative for those

making clinical decisions in child and adolescent

populations.

A limitation of the study is that, while a number of the

participants did have an Axis I mood diagnosis, this can not

be categorized as a sample with severe mood issues. This is

relevant as it has been hypothesized that it is the severity of

mood symptoms that affects neuropsychological function-

ing more than the presence of symptoms. However, we did

attempt to address this issue with the present sample by

analyzing the smaller subgroup of children and adolescents

Table 3 R 2

point estimates of variance accounted for by CDI for

children and adolescents with elevated mood scores (CDI [ 12)

Measure R2

TMT A 0.008

TMT B 0.002

WCST % errors 0.002

COWAT FAS 0.013

Animal naming 0.031

CDI Children’s Depression Inventory, TMT A Trail Making Test Part A, TMT B Trail Making Test Part B, WCST % Errors Wisconsin Card Sorting Test Percentage of Perseverative Errors, COWAT Controlled Oral Word Association Test. None significant at p \ .05

402 J Child Fam Stud (2013) 22:398–404

123

who had an elevated level of endorsement of mood

symptoms. Again, we found no evidence that depressive

symptoms negatively affect executive functioning in this

group endorsing more severe symptoms. As such, the

argument that the range of mood symptoms in our sample

was too restricted to find such an effect is not probable

from our standpoint. The results of this study demonstrate

that self-reported depressive symptoms likely do not have a

clinically significant effect on performance on commonly

used measures of executive functioning in child and ado-

lescent similar to the sample utilized in this study (i.e.,

generally average intellectual functioning and not severely

neurologically compromised). Further, our findings argue

against considering the effect of mood when interpreting

executive impairments in children and adolescents for the

majority of cases seen in clinical settings.

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