Impact of emotional and behavioral symptoms on quality of life in children and

adolescents
Author(s): Dejan Stevanovic
Source: Quality of Life Research, Vol. 22, No. 2 (March, 2013), pp. 333-337
Published by: Springer
Stable URL: http://www.jstor.org/stable/24722707
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Qual
Qua! Life
Life Res
Res(2013)
(2013)22:333-337
22:333-337
DOI
DOI 10.1007/s
10.1007/s11136-012-0158-y
11136-012-0158-y

BRIEF COMMUNICATION

Impact of emotional and behavioral symptoms on qua

in children and adolescents

Dejan Stevanovic

Accepted: 7 March 2012/Published online: 23 March 2012

Springer Science+Business Media B.V. 2012

Abstract
Abstract Abbreviations
Abbreviations

Purpose
Purpose To
To evaluate
evaluatehow
howlevels
levelsofofanxiety,
anxiety,
depressive
depressive
QOLQOL Qualityof
Quality of life
life
and behavioral
and behavioral symptoms
symptomsinfluence
influenceself-perceived
self-perceived PedsQL
quality
quality The The
PedsQL Pediatric Quality
Pediatric Qualityof
of Life Inventory
Life Inventory
of
of life
life(QOL)
(QOL)
in general
in general
population
population
of children
of children
and and Version
Version4.0
4.0
adolescents.
adolescents. SCARED Screen for Child SCARED Anxiety
Screen forRelated
Child Anxiety
Emotional
Related Emotional
Method
Method A A total
totalofof237
237children
childrenand
andadolescents
adolescentsagedaged Disorders Questionnaire
Disorders Questionnaire
8-18years
8-18 years participated
participated in study.
in the the study. The Screen
The Screen SMFQ
for Childfor Short
Child Mood
SMFQ and Short
Feeling
Mood
Questionnaire
and Feeling Questionnaire
Anxiety
Anxiety Related
RelatedEmotional
EmotionalDisorders
DisordersQuestionnaire
Questionnaire SDQ SDQStrengths
Strengths and
and Difficulties
Difficulties Questionnaire
Questionnaire
(SCARED),
(SCARED), Short
Short Mood
Mood and
andFeeling
FeelingQuestionnaire
Questionnaire(SMFQ)
(SMFQ)
and Strengths
Strengths and
and Difficulties
DifficultiesQuestionnaire
Questionnaire(SDQ)
(SDQ)were
were
used to
to assess
assess levels
levels of
of anxiety,
anxiety,depressive
depressiveand
andbehavioral
behavioral
Introduction
symptoms, respectively.
symptoms, respectively.The
ThePediatric
Pediatric Quality
Quality of of
LifeLife Introduction
Inventory (PedsQL)
Inventory (PedsQL)was
wasused
usedfor
forQOL
QOL assessments.
assessments. In In
a a
regression
regression model,
model, the
the PedsQL
PedsQLscore
scorewas
wasthe dependentAlthough
thedependent Althoughfrequently
frequentlyreported
reported that
that mental
mental health
health substan
substan
variable,
variable, while
while anxiety,
anxiety,depressive
depressiveand
andbehavioral
behavioralsymptoms tially
symptoms tiallyinfluences
influenceseveryday
everyday living, data about
living, data aboutnegative
negativeeffects
effects
werethethe
were QOLQOL predictors. of mental health problems
predictors. on the
of mental health quality
problems on of
thelife (QOL)
quality in (QOL) in
of life
Results In
Results In children,
children,thetheSCARED
SCAREDand and SMFQ
SMFQ generalpopulation
scores general
scores population of
of children
children and adolescents
adolescents are
are lacking.
lacking,
togetherwith
together withage
age and
and gender
gender explained
explained 30 %30of%theofvari The European KIDSCREEN and the German
the vari- The European KIDSCREEN and the German BELLA BELLA studystudy
ance in
in the
the PedsQL
PedsQL scores
scores (F(F==12.31,
12.31,pp< <0.001),
0.001),while found that mental health problems displayed
while found that mental health problems displayed strongstrong aggra
aggra
adolescents, the
in adolescents, thesame
samesetsetofofvariables
variables was
was vating
responsible
responsible effects
vating on QOL
effects [1, 2].
on QOL OnlyOnly
[1,2], one one
prospective study
prospective study
for
for 36
36 %% of
ofthe
thevariance
variance (F (F
= 15.77,
= 15.77,
p <p0.001). TheThe found
< 0.001). found that
that QOL
QOL worsened
worsenedasasa awhole
wholeininchildren
childrenandand ado
ado
SCAREDwas
SCARED wasa more
a more significant
significant predictor
predictor than
than the lescents
the SMFQ.
SMFQ. followed
lescents over over
followed 3 years, but the
3 years, but decline in QOL
the decline was was
in QOL
The
The SDQ
SDQ scores
scoresdid
didnot
notemerge
emergeas as
thethe
PedsQL
PedsQL predictors.noted
predictors. notedin
inthose
those whose
whose mental
mental health deteriorated [3],
health deteriorated [3],
ConclusionLevels
Conclusion Levelsofof anxiety
anxiety andand depressive
depressive symptoms,InI"these
symptoms, thesestudies,
studies,the
theimpact
impactofofmental
mentalhealth
healthiningeneral
general
but not
but notbehavioral
behavioral ones,
ones, significantly
significantly affectaffect on QOLonwas
self-reported
self-reported QOLevaluated, and we
was evaluated, andlack
we data regarding
lack data howhow
regarding
QOLin
QOL ingeneral
general population
population of children
of children particular symptoms affect QOL in non-referred children
and adolescents. particular symptoms affect QOL in non-referred children
and adolescents.
and adolescents.
and adolescents.Evaluating
Evaluatingeffects
effects
ofof particular
particular symptoms
symptoms
Keywords
Keywords Children
Children Adolescents
Adolescents Anxiety
Anxiety is important
is important because
because different
different mental
mental health
health problemsmay
problems may
Depression
Depression Behavioral
Behavioral problems
problems Quality of
Quality
life of lifeaffect
affectQOL
QOLtoto
varying degrees
varying and
degrees may
and display
may various
display various
effects
effects when
whenconsidered
consideredcombined.
combined.This
This
study
study
waswas
concon
ducted
ducted with
withan
anaim
aim(1)
(1)totodetermine
determineindependent
independent
effects
effects
of of
levels
levels of
of anxiety,
anxiety,depressive
depressiveand
and
behavioral
behavioral
symptoms
symptoms
on on
D. Stevanovic (E3)
D. Stevanovic (E3)
Department
self-perceivedGeneral
QOL, the
and (2) to examine
self-perceived QOL, andtheir impact
(2) to examine onimpact on
their
Department of Psychiatry,of Psychiatry,
General Hospital Sombor, Hospital Sombor, . . . r , .
Apatinski
Apatinski put
put 38, 25000 Sombor, Serbia 38, 25000 Sombor. QOL taking into account
Serbiathe age QOL
and gender of children in
lakin
e-mail:
e-mail: and adolescents.
dejanstevanovic@eunet.rs and adolescents.
dejanstevanovic@eunet.rs

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 334 Qual Life Res (2013) 22:333-337

Methods emotional, conduct, hyperactivity/inattention, peer rela

tionship and pro-social behavior. Each item is scored on a
Participants 3-point scale, and the sum of all answered items in a scale
is its total score. Higher scores indicate larger difficulties.
Based on the probability of type I error of 0.05, power The SDQ conduct, hyperactivity/inattention and peer
(1beta) of 0.9 and medium effect size of 0.15 calculated problems scale assesses behavioral symptoms, and thus,
in G*Power version 3.1.2. [4], 116 subjects were needed only these were analyzed.
for a linear multiple regression analysis when testing seven
predictors. Data analysis
In total, 118 children (53 (44.9 %) boys and 65 (55.1 %)
girls) aged 8-12 years (M = 10.94, SD = 0.62 years) and Mean and standard deviations for the PedsQL, SCARED,
119 adolescents (54 (45.4 %) men and 65 (54.6 %) SMFQ and SDQ scores were calculated for children and
women) aged 13-18 years (M = 14.53, SD = 1.6 years) adolescents, t test was used to analyze statistical differ
participated in the study. School psychologist from two ences between the groups. The SCARED, SMFQ and SDQ
elementary and one secondary school randomly selected were transformed into 7"-scores, where T-score 60 was used
as a cut-off value indicative of significant symptoms
the participants until the required number was reached. The
participation was on a voluntary basis, and all children and
reaching clinical levels and needing further assessment [8],
adolescents gave their written consents together with one Zero-order correlations were computed to determine the
parent. relationships between levels of anxiety, depressive and
The Ethics Committee of the Clinic for Neurology and behavioral symptoms and QOL. Because of the known
Psychiatry for Children and Youth in Belgrade approved comorbidity between psychological symptoms, partial
the study. correlations were computed between QOL and depressive
symptoms (controlling for anxiety and behavioral symp
Questionnaires toms), between QOL and anxiety symptoms (controlling
for depressive and behavioral symptoms), and between
The Pediatric Quality of Life Inventory Version 4.0 QOL and behavioral symptoms (controlling for anxiety and
(PedsQL) was used for QOL assessments [5,6]. This 23-item depressive symptoms) to determine unique effects.
questionnaire assesses physical, emotional, social and school Afterward, data were analyzed using regression analy
functioning. Items are 5-point-scaled and transformed into a sis. The dependent variable was the PedsQL score. Pre
0-100 scale, with the total score presenting the sum of all dictor variables included gender and age entered on the first
items over the number of items answered. Higher scores block, the SCARED and SMFQ score entered on the sec
indicate better QOL. For the purpose of the present study, ond block, as emotional symptoms, and the SDQ conduct,
only the total PedsQL score was used. hyperactivity/inattention, and peer problems score entered
Levels of anxiety symptoms were identified using the on the third block, as behavioral symptoms. Gender and
Screen for Child Anxiety Related Emotional Disorders age were considered controlling variables and were entered
QuestionnaireSCARED [7, 8J. The SCARED possesses using force entry method on the first block, while anxiety,
41 items related to the symptoms of the entire spectrum of depressive and behavioral symptoms were entered using
childhood anxiety disorders (panic/somatic, generalized stepwise method in order to determine the contribution of
anxiety disorder, separation anxiety, social phobia and each to the variance of the PedsQL score.
school avoidance). Each item is scored on a 3-point scale,
and the sum of all answered items is the SCARED score.

The higher the SCARED score, the higher the levelsResults

of
anxiety symptoms are.
Between children and adolescents, a statistically significant
Levels of depressive symptoms were identified using the
Short Mood and Feeling QuestionnaireSMFQ [8]. The
difference was found considering the PedsQL, SCARED,
SMFQ and SDQ conduct and hyperactivity/inattention
SMFQ possesses 13 items related to symptoms of depression
problems score (Table 1). Based on 7-score 60, between 11
in children and adolescents. Each item is scored on a 3-point
(9.3 %) and 31 (26.1 %) participants had significant emo
scale, and the sum of all answered items gives the SMFQ
score. The higher the SMFQ score, the higher the levelstional
of or behavioral symptoms reaching clinical levels
depressive symptoms are. (Table 2).
Levels of behavioral problems were assessed by theThere were statistically significant, inverse zero-order
correlations between the PedsQL and SCARED, SMFQ
Strengths and Difficulties Questionnaire (SDQ) [9]. The
SDQ possesses 25 items in five scales that evaluate
and SDQ scores for the children's ratings (Table 3). Except

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 Qual Life Res (2013) 22:333-337 335

Table
Table 1 Mean (M) and 3 Correlations between the
standard PedsQL, SCARED, SMFQ and
deviations (SD
SDQ scoresscores
SCARED, SMFQ and SDQ

Score Children Adolescents t test (p value) PedsQL

PedsQL score score
Bivariate Partial
Bivariate Partial
Adolescents Children
Children Adolescents
Children Children Adolescents
Adolescents
PedsQL 83.10 (11.12) 78.58
78.58 (10.79)
(10.79) 3.17
3.17 (<0.001
(<0.001))
SCARED 16.07 (10.88) 19.13(11.19) -2.14(0.03) SCARED
SCARED score -0.49**
score -0.49** -0.54**
-0.54** -0.39**
-0.39** -0.38**
-0.38**
SMFQ 3.88 (4.26) 5.81 (4.61) -3.33 0.001) SMFQ
SMFQ score -0.43**
score -0.43** 0.46** -0.18
-0.46** -0.18 -0.24*
-0.24*
SDQ conduct 1.74 (1.23) 2.50 (1.34) -4.53 0.001) SDQconduct
SDQ conduct -0.23*
-0.23* -0.14
-0.05 -0.14
-0.05 -0.03
-0.03
problems problems
problems score
score
SDQ 2.10 (2.01) 3.08 (2.06)
(2.06) -3.71
-3.71 (<0.001)
0.001) -0.15 -0.01
-0.01
SDQ -0.31**
SDQ -0.25**
-0.31** -0.25** -0.15
hyperactivity/
hyperactivity/
hyperactivity/
hyperactivity/
inattention
inattention
inattention
inattention
problems problems
problems score score
SDQ peers 2.02 (1.79) 2.39 (1.85) -1.59 (0.11) -0.01 -0.05
SDQ
SDQ peerspeers -0.23*
-0.23* -0.21*
-0.21* -0.01 -0.05
problems
problems score

: p < 0.05, ** p < 0.01

Table 2 The PedsQL, SCARED, SMFQ and SDQ T score distri children's ratings. Besides for the SCARED score (-0.38,
bution p < 0.01), a statistically significant, inverse partial corre
T-
T- score
score Children Adolescents lation was also found for the SMFQ score (0.24,
p < 0.05) considering the adolescents' ratings.
SCARED <60 101 (85.6 %) 96 (80.7 %)
From the regression method of the children's ratings
>60 17 (14.4 %) 23 (19.3 %)
(Table 4), the model emerged with age, gender and the
SMFQ <60 101 (85.6 %) 94 (79.0 %) SCARED and SMFQ scores explaining 30 % of the vari
>60 17 (14.4 %) 25 (21.0 %) ance in the PedsQL score (F = 12.31, p < 0.001). For the
SDQ conduct problems<60 107 (90.7 %) 93 (78.2 %) adolescents' ratings, the same set of variables in the model
>60 11 (9.3 %) 26 (21.8 %) was responsible for 36 % of the variance (F = 15.77,
SDQ hyperactivity/ <60 101 (85.6 %) 88 (73.9 %) p < 0.001). In both models, the SCARED score (24 and
inattention problems >60 17 (14.4 %) 31 (26.1 %) 30 % respectively for children and adolescents) predicted
SDQ peers problems <60 106 (89.8 %) 104 (87.4 %) more additional variance than the SMFQ score (5 and 4 %
>60 12 (10.2 %) 15 (12.6 %) respectively for children and adolescents) (Table 4).

for the SDQ conduct problems score, the zero-order cor

relations were also statistically significant for the adoles
Discussion

cents' ratings. A statistically significant, inverse partial

correlation with the PedsQL score was observed only Before
for discussing the main findings, it is worth mentioning
the SCARED score (0.39, p < 0.01) considering the
the prevalence rates of emotional and behavioral symptoms

Table 4 Multiple regression analysis

Model* Unstandardized coefficients Standardized t (p value) F (p value) Model summary

coefficients

B SE Beta
SE Beta R R1- change

Children
Children

-0.62 1.78
Gender -0.62 1.78 -0.03
-0.03 -0.35
-0.35 (0.73)
(0.73) 12.31
12.31 (cO.OOl)
(<0.001) 0.30
0.30 0.01
Age (years) -0.42 1.44 -0.02 -0.29 (0.77)
SCARED
SCARED score
score -0.38
-0.38 0.09
0.09 -0.38
-0.38 -4.22
-4.22 (<0.001
(<0.001)
) 0.24
SMFQ score -0.69 0.23 -0.27 -2.99 (< 0.001) 0.05
Adolescents

Gender -2.88 1.67 -0.13 -1.73 (0.09) 15.77 (<0.001) 0.36 0.02
Age (years) -0.21 0.52 -0.03 -0.39 (0.69)
SCARED score
SCARED score -0.42
-0.42 0.09
0.09 -0.45
-0.45 -4.89
-4.89 (<0.001
(<0.001)
) 0.30
SMFQ score -0.51 0.21 -0.22 -2.43 (0.02) 0.04

Dependent variable: PedsQL score

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 336 Qua! Life Res (2013) 22:333-337

of the study participants. Nearly

impact on QOL when controlled for comorbidity. Third,
adolescents had the correlations between the PedsQL and
significant SCARED/SMFQ
anxiety
sive symptoms. were
A moderate, but they were low between the PedsQL
significant and
numb
activity/inattention SDQ, indicating that thereproblems
could be more items in the QOL (2
(15.6 %) and peer measure that evaluate similar hypotheses/paradigms
problems were rep
Depending on resented by the
the ageSCARED and SMFQ items. Thus, there
studied, d
assessment methods could be some overlappingused in
in the concepts measured. epid
prevalence rates for anxiety disorders are 6-20 %, The findings should also be considered in terms of some
depression 2-20 %, conduct problems 1-16 % and hyper limitations. The cross-sectional design of the study is a
activity/inattention problems 5-20 % [10-13], Considering major limitation because it was not possible to determine
that using screening questionnaires (like in this study) whether mental health had a direct effect on QOL, whether
usually yields higher rates, the prevalence rates of emo QOL influenced mental health or whether the relationship
tional and behavioral symptoms are in the reported ranges. was bidirectional. Additionally, using only self-reported
In both children and adolescents, it was found that levels questionnaires could further limit the generalization of the
of QOL significantly decreased as levels of anxiety, results. Finally, while the study considered randomization,
depressive and behavioral symptoms (except peer problems more severe cases with behavioral problems might not be
for adolescents) increased and vice versa. Furthermore, included.
considering the comorbidity between the symptoms among As a conclusion, this study demonstrated that levels of
children, only levels of anxiety symptoms had strong anxiety and, to a lesser degree, depressive symptoms, but
negative correlations with QOL, when controlled for not behavioral symptoms, significantly affect self-per
depressive and behavioral symptoms. Besides symptoms of ceived QOL in general population of children and adoles
anxiety, symptoms of depression also had strong negative cents. These findings are unexpected; thus, more research
correlations with QOL among adolescents. Further analy is needed in order to consider more parsimonious models
ses showed that when all symptoms modeled together and (structure equation modeling) of emotional and behavior
controlled for age and gender, strong variations in QOL symptoms and QOL perceptions using other measures and
could be predicted by levels of depressive and anxiety consider other risk and protective factors.
symptoms. Levels of anxiety symptoms accounted for
Conflict of interest None.
significantly more additional variations in QOL than
depressive symptoms. Behavioral symptoms, conduct,
hyperactivity/inattention and peer problems were not sig
nificant predictors of QOL.
Past studies demonstrated that mental health problems References

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