Journal of Child and Family Studies

, Volume 27, Issue 5, pp 1661–1670 | Cite as

Pediatric Depression Symptoms, Executive Functioning Weaknesses, and Associated Neuropsychological and Psychiatric Outcomes

  • Elyssa B. Weber
  • Jane Studeny
  • Brian C. Kavanaugh
  • Nathan E. Cook
  • Charles E. Gaudet
  • Kyle McCurdy
  • Karen A. Holler
Original Paper


Despite numerous studies in adults, only a handful of studies have examined executive functioning (EF) in childhood depression. Our study examined the relationship between significant depressive symptoms and an EF weakness in a child inpatient psychiatric setting. A medical chart review was conducted for 98 ethnically diverse 6- to 12-year-old boys and girls, who received a neuropsychological evaluation during their psychiatric inpatient hospitalization. Children were classified as having depressive symptoms if they had a T-Score 1.5 SD above the mean on at least 1 subdomain of the Childhood Depression Inventory and classified as having an EF weakness if they had a T-score 1.5 SD below the mean on at least 1 test of executive functioning. Results indicated that compared to children with either depressive symptoms only or only an EF weakness, children with both depressive symptoms and an EF weakness had poorer cognitive test performance on a measure of immediate memory (F(2,72) = 4.07, p = .000; Cohen’s d = −.83 and −.90, respectively) and longer hospitalizations stay (F(2,93) = 4.04, p = .021; Cohen’s d = .54 and .62, respectively). Additionally, children with both depressive symptoms and an EF weakness had higher rates of ADHD than children with depressive symptoms only (OR = 2.11) and higher rates of EF weaknesses than children with only an EF weakness (t(60) = 2.54, p = .014; Cohen’s d = .68). Results suggest that not all children with depressive symptoms have an EF weakness; however, children who present with this comorbidity are at risk for more cognitive difficulties and significant psychiatric outcomes including prolonged hospitalizations.


Children, Depression Executive dysfunction Inpatient Length of stay 


Author Contributions

E.B.W.: conceptualized and designed the study, executed statistical analyses, and drafted the initial manuscript. B.C.K.: conceptualized and designed the study, executed statistical analyses, drafted several parts of the manuscript, critically reviewed the manuscript, and approved the final version. J.S., N.E.C., and G.C.: consulted about the study, helped draft and revise the manuscript, critically reviewed the manuscript, and approved the final version. K.M.: critically reviewed the manuscript and approved the final version. K.A.H.: conceptualized and designed the study, critically reviewed the manuscript, and approved the final version.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required. Please see the methods section for further details of informed consent procedures.


  1. Alexopoulos, G. S., Kiosses, D. N., Klimstra, S., Kalayam, B., & Bruce, M. L. (2002). Clinical presentation of the “depression–executive dysfunction syndrome” of late life. The American Journal of Geriatric Psychiatry, 10, 98–106.PubMedGoogle Scholar
  2. Alvarez, J. A., & Emory, E. (2006). Executive function and the frontal lobes: A meta-analytic review. Neuropsychology Review, 16, 17–42.CrossRefPubMedGoogle Scholar
  3. Austin, M. P., Mitchell, P., & Goodwin, G. M. (2001). Cognitive deficits in depression. The British Journal of Psychiatry, 178, 200–206.CrossRefPubMedGoogle Scholar
  4. Beery, K. E. (2004). The Beery-Buktenica developmental test of visual-motor integration: Beery VMI, with supplemental developmental tests of visual perception and motor coordination, and stepping stones age norms from birth to age six: Administration, scoring and teaching manual. Minneapolis, MN: NCS Pearson.Google Scholar
  5. Bardach, N. S., Coker, T. R., Zima, B. T., Murphy, J. M., Knapp, P., Richardson, L. P.,… Mangione-Smith, R. (2014). Common and costly hospitalizations for pediatric mental health disorders. Pediatrics, 133, 602–609.Google Scholar
  6. Beauchamp, M. H., Brooks, B. L., Barrowman, N., Aglipay, M., Keightley, M., Anderson, P., & Zemek, R. (2015). Empirical derivation and validation of a clinical case definition for neuropsychological impairment in children and adolescents. Journal of the International Neuropsychological Society, 21(8), 596–609.CrossRefPubMedGoogle Scholar
  7. Briere, J. (1996). Trauma symptom checklist for children. Odessa, FL: Psychological Assessment Resources.Google Scholar
  8. Chaytor, N., Schmitter-Edgecombe, M., & Burr, R. (2006). Improving the ecological validity of executive functioning assessment. Archives of ClinicalNneuropsychology, 21(3), 217–227.CrossRefGoogle Scholar
  9. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates.Google Scholar
  10. Crowe, S. F. (1998). The differential contribution of mental tracking, cognitive flexibility, visual search, and motor speed to performance on parts A and B of the Trail Making Test. Journal of Clinical Psychology, 54, 585–591.CrossRefPubMedGoogle Scholar
  11. Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine, 11(1), 126.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Diamond, A. (2013). Executive functions. Annual Review of Psychology, 64, 135.CrossRefPubMedGoogle Scholar
  13. Emerson, C. S., Mollet, G. A., & Harrison, D. W. (2005). Anxious-depression in boys: An evaluation of executive functioning. Archives of Clinical Neuropsychology, 20, 539–546.CrossRefPubMedGoogle Scholar
  14. Fleming, J. E., & Offord, D. R. (1990). Epidemiology of childhood depressive disorders: A critical review. Journal of the American Academy of Child & Adolescent Psychiatry, 29, 571–580.CrossRefGoogle Scholar
  15. Franklin, T., Lee, A., Hall, N., Hetrick, S., Ong, J., Haslam, N., & Vance, A. (2010). The association of visuospatial working memory with dysthymic disorder in pre-pubertal children. Psychological Medicine, 40, 253–261.CrossRefPubMedGoogle Scholar
  16. Fröjd, S. A., Nissinen, E. S., Pelkonen, M. U., Marttunen, M. J., Koivisto, A. M., & Kaltiala-Heino, R. (2008). Depression and school performance in middle adolescent boys and girls. Journal of Adolescence, 31, 485–498.CrossRefPubMedGoogle Scholar
  17. Fuchs, L. S., Fuchs, D., & Compton, D. L. (2004). Monitoring early reading development in first grade: Word identification fluency versus nonsense word fluency. Exceptional Children, 71(1), 7–21.CrossRefGoogle Scholar
  18. Fuhs, M. W., Nesbitt, K. T., Farran, D. C., & Dong, N. (2014). Longitudinal associations between executive functioning and academic skills across content areas. Developmental Psychology, 50(6), 1698–1709.CrossRefPubMedGoogle Scholar
  19. Gilbert, S. J., & Burgess, P. W. (2008). Executive function. Current Biology, 18(3), R110–R114.CrossRefPubMedGoogle Scholar
  20. Henry, L. A., & Bettenay, C. (2010). The assessment of executive functioning in children. Child and Adolescent Mental Health, 15, 110–119.CrossRefGoogle Scholar
  21. Holler, K., Kavanaugh, B., & Cook, N. E. (2014). Executive functioning in adolescent depressive disorders. Journal of Child and Family Studies, 23, 1315–1324.CrossRefGoogle Scholar
  22. Holmes, C. J., Kim-Spoon, J., & Deater-Deckard, K. (2016). Linking executive function and peer problems from early childhood through middle adolescence. Journal of Abnormal Child Psychology, 44(1), 31–42.CrossRefPubMedPubMedCentralGoogle Scholar
  23. Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., & Wang, P. (2010). Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748–751.CrossRefPubMedGoogle Scholar
  24. Kavanaugh, B. C., Gaudet, C. E., Dupont-Frechette, J. A., Tellock, P. P., Maher, I. D., Haisley, L. D., & Holler, K. A. (2016). Failure to maintain set as a predictor of childhood depression within a children’s psychiatric inpatient sample. Psychiatry Research, 246, 644–649.CrossRefPubMedGoogle Scholar
  25. Kovacs, M. (1992). The Children’s Depression Inventory (CDI). Manual. Toronto: Multi-Health Systems.Google Scholar
  26. Kovacs, M., & Staff, M. H. S. (2011). Children’s Depression Inventory 2 (CDI2). Toronto: Multi-Health Systems.Google Scholar
  27. Lafayette Instrument Company (2002). Grooved pegboard test user instructions. Lafayette, IN: Lafayette Instrument Co.Google Scholar
  28. Lundy, S. M., Silva, G. E., Kaemingk, K. L., Goodwin, J. L., & Quan, S. F. (2010). Cognitive functioning and academic performance in elementary school children with anxious/depressed and withdrawn symptoms. The Open Pediatric Medicine Journal, 4, 1.CrossRefPubMedPubMedCentralGoogle Scholar
  29. March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 554–565.CrossRefGoogle Scholar
  30. March, J. S. (2012). Manual for the Multidimensional Anxiety Scale for Children-(MASC2). North Tonawanda, NY: MHS.Google Scholar
  31. Meyers, J. E., & Meyers, K. R. (1995). Rey complex figure test and recognition trial professional manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
  32. McDermott, L. M., & Ebmeier, K. P. (2009). A meta-analysis of depression severity and cognitive function. Journal of Affective Disorders, 119, 1–8.CrossRefPubMedGoogle Scholar
  33. Muris, P., Merckelbach, H., Ollendick, T., King, N., & Bogie, N. (2002). Three traditional and three new childhood anxiety questionnaires: Their reliability and validity in a normal adolescent sample. Behaviour Research and Therapy, 40, 753–772.CrossRefPubMedGoogle Scholar
  34. Pennington, B. F., & Ozonoff, S. (1996). Executive functions and developmental psychopathology. Journal of child psychology and psychiatry, 37(1), 51–87.Google Scholar
  35. Pentz, M. A., Shin, H., Riggs, N., Unger, J. B., Collison, K. L., & Chou, C. P. (2015). Parent, peer, and executive function relationships to early adolescent e-cigarette use: A substance use pathway? Addictive Behaviors, 42, 73–78.CrossRefPubMedGoogle Scholar
  36. Porter, R. J., Bowie, C. R., Jordan, J., & Malhi, G. S. (2013). Cognitive remediation as a treatment for major depression: A rationale, review of evidence and recommendations for future research. Australian and New Zealand Journal of Psychiatry, 47, 1165–1175.CrossRefPubMedGoogle Scholar
  37. Sheslow, D., & Adams, W. (2003). Wide range assessment of memory and learning (2nd ed.). Lutz, FL: Psychological Assessment Resources.Google Scholar
  38. Snyder, H. R. (2013). Major depressive disorder is associated with broad impairments on neuropsychological measures of executive function: a meta-analysis and review. Psychological Bulletin, 139, 81.CrossRefPubMedGoogle Scholar
  39. Stuss, D. T. (2011). Functions of the frontal lobes: Relation to executive functions. Journal of the International Neuropsychological Society, 17, 759–765.CrossRefPubMedGoogle Scholar
  40. Timbremont, B., Braet, C., & Dreessen, L. (2004). Assessing depression in youth: Relation between the Children’s Depression Inventory and a structured interview. Journal of Clinical Child and Adolescent Psychology, 33(1), 149–157.CrossRefPubMedGoogle Scholar
  41. Vilgis, V., Silk, T. J., & Vance, A. (2015). Executive function and attention in children and adolescents with depressive disorders: A systematic review. European Child & Adolescent Psychiatry, 24(4), 365–384.CrossRefGoogle Scholar
  42. Wagner, S., Müller, C., Helmreich, I., Huss, M., & Tadić, A. (2015). A meta-analysis of cognitive functions in children and adolescents with major depressive disorder. European Child & Adolescent Psychiatry, 24, 5–19.CrossRefGoogle Scholar
  43. Wechsler, D. (1999). Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: Psychological Corporation.Google Scholar
  44. Wechsler, D. (2003). Wechsler Intelligence Scale for Children-WISC-IV. San Antonio, TX: Psychological Corporation.Google Scholar
  45. Wechsler, D. (2011). WASI-II: Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: Psychological Corporation.Google Scholar
  46. Wechsler, D. (2014). Wechsler Adult Intelligence Scale–Fourth Edition (WAIS–IV). San Antonio, TX: Psychological Corporation.Google Scholar
  47. Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., & Pennington, B. F. (2005). Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review. Biological Psychiatry, 57(11), 1336–1346.CrossRefPubMedGoogle Scholar
  48. Zakzanis, K., Mraz, R., & Graham, S. (2005). An fMRI study of the trail making test. Neuropsychologia, 43, 1878–1886.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University of Massachusetts BostonBostonUSA
  2. 2.Antioch University New EnglandKeeneUSA
  3. 3.E. P. Bradley Hospital/Alpert Medical School of Brown UniversityRiversideUSA
  4. 4.Massachusetts General Hospital/Harvard Medical SchoolBostonUSA
  5. 5.University of Rhode IslandSouth KingstownUSA
  6. 6.Salve ReginaNewportUSA

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