Abstract
Seven percent of children are reported to have a developmental language disorder (DLD; Norbury et al., 2017; Tomblin et al., 1997). An increased risk for depressive symptoms is consistently reported in children with DLD. Clinical levels of depression range from 20% to 39% in children and adolescents with DLD compared with 14% to 18% in peers without DLD (Beitchman et al., 1996; Botting, Toseeb, Pickles, Durkin, & Conti-Ramsden, 2016; Conti-Ramsden & Botting, 2008). However, the level of depressive symptoms often shows small or no correlations with the type and severity of communication problems in children with DLD (Beitchman et al., 1996; Botting et al., 2016; St. Clair, Pickles, Durkin, & Conti-Ramsden, 2011).
The Study
Purpose
The purpose of this study was to examine why children with DLD are more vulnerable to developing depressive symptoms than children without DLD, given that the severity of their communication problems only makes a small contribution to explaining these symptoms.
Various studies with children from a community population have demonstrated that emotion regulation (ER) is related to fewer depressive symptoms (Joormann & Stanton, 2016; Schafer et al., 2017). ER is the cognitive and behavioral processes a person uses to monitor emotions, to modify the strength of the own emotional experience and the strength and timing of the expression of emotions to reach personal and social goals (Gross, 1998). Children with DLD are reported to experience difficulties regulating negative emotions (Brinton, Fujiki, Hurst, Jones, & Spackman, 2015; Fujiki, Spackman, Brinton, & Hall, 2004). This study used a longitudinal design to examine the extent to which different ER strategies were risk or protective factors for the level of and changes in depressive symptoms in children with and without DLD.
Participants
The severity of depressive symptoms was examined in children with and without DLD between the ages of 8 and 16 years across 18 months. Children completed self-report questionnaires on three occasions with 9 months in between each measurement. A total of 114 children with a diagnosis of DLD and 214 without DLD participated in the study. Children received a diagnosis of DLD if they had receptive and/or expressive language abilities below 1.5 SD of the mean of the population. Children without DLD were included if they had no neurodevelopmental disorders, as indicated by their parents, and had language abilities in the average range, which was assessed with two subtests of the Clinical Evaluation of Language Fundamentals (CELF; semantic relations and text understanding; Kort, Schittekatte, & Compaan, 2008).
Assessment Materials
Depressive symptoms
Depressive symptoms were assessed with the Child Depression Inventory (CDI; Kovacs, 1992), which examines behavioral, cognitive, and emotional symptoms of depression in children from the age of 8 years. An adapted version of the CDI (Theunissen et al., 2011) was used to reduce the amount of language for children with DLD. Children read one statement and endorsed if a statement was not (1), a bit (2), or most of the time (3) true. Participants completed the CDI at Times 1, 2, and 3.
ER strategies
ER strategies were measured with the self-report Coping scale (Wright, Banerjee, Hoek, Rieffe, & Novin, 2010). This questionnaire measures whether children almost never (1), sometimes (2), or often (3) use specific behaviors when they have a problem. Approach strategies were measured with 12 items (e.g., “I try to think of different ways to solve the problem” and “I ask someone in my family for advice”). Avoidant strategies (12 items) measured whether children tended to trivialize problems or distract themselves from a problem (e.g., “I tell myself it doesn’t matter” or “I do something else to help me forget about it”). The Externalizing subscale measured the venting of emotions through verbal or physical aggressive behaviors (e.g., “I stamp my feet or slam or bang doors”). The Worry/Rumination Questionnaire (10 items; Miers et al., 2007) measured how much children had the tendency to dwell on a problem without trying to change anything (e.g., “When I have a problem, I cannot stop thinking about it”).
Communication problems
Communication of problems of children with DLD were measured with the Dutch version of the Children’s Communication Checklist–2 (CCC-2; Geurts et al., 2009; Norbury, Nash, Baird, & Bishop, 2004). The CCC-2 contains eight scales measuring problems with speech, syntax, semantics, coherence, and pragmatic problems: initiation of conversations, nonverbal communication, use of context, and stereotypical language.
Performance IQ (PIQ)
Children were tested with the Wechsler Intelligence Scale for Children (WISC; Kort et al., 2005), Snijders-Oomen Nonverbal Intelligence Test (Tellegen & Laros, 2011), or Wechsler’s Nonverbal Test (Wechsler & Naglieri, 2008), which all give an indication of PIQ.
Results
Children with DLD reported higher levels of depressive symptoms than children without DLD.
Significant interaction between age and diagnosis showed a small decrease in depressive symptoms across time for children with DLD but not for children without DLD.
There was high variability within individuals in depressive symptoms across time in both groups.
All ER strategies contributed to the prediction of depression in both groups.
Children in both groups reported less depressive symptoms when they reported higher mean levels of approach strategies, less worry, and less externalizing strategies.
Differences in the severity of pragmatic, speech, and syntax of children with DLD did not explain the severity of their depressive symptoms.
Semantic problems with children with DLD contributed to the prediction of more depressive symptoms and were related to more maladaptive ER strategies such as higher levels of worry.
More pragmatic problems contributed to the prediction of more externalizing strategies in children with DLD.
Discussion
Worry is a risk factor for depression and contributed similarly in both children with and without DLD. Children from both groups who reported externalizing strategies also reported more depressive symptoms. In addition to studying risk factors, the authors investigated the approach and avoidant ER strategies students used. Children with DLD reported more avoidant strategies that their non-DLD peers. In this study, the avoidant strategies appeared to help the children with DLD deal with negative feelings.
Children with DLD have fewer social opportunities early in life and as a consequence, they may develop less adaptive ways of coping which may affect their level of depression later in life. Children with DLD in this study used more maladaptive ER strategies that could contribute to the prediction of higher depressive symptoms.
Possible Explanations for Depressive Symptoms
Emotional awareness or the ability to identify one’s own emotions and their antecedents in the situation causing them has a strong protective function in the development of depressive symptoms. Children with DLD have shown impairments in the recognition of emotions, and in their understanding of emotional antecedents (e.g., Bakopoulou & Dockrell, 2016; Fujiki et al., 2004). It is possible that the associations the researchers found between the semantic language problems of children with DLD and their maladaptive ER strategies are mediated by this difficulty in understanding emotions.
The frequently reported social problems of children with DLD could affect their feelings of well-being, as a high incidence of being bullied has been shown to explain elevated levels of depressive symptoms in children with DLD.
Children with DLD might be particularly vulnerable to depressive symptoms during transitional periods when they must cope with new and demanding situations.
Implications
Because children with DLD are more at risk for early depressive symptoms than for those without DLD, it is crucial to have a better understanding of factors contributing to these mental health problems. Children with DLD were more likely to use maladaptive strategies, such as worrying and externalizing strategies, which in turn are important risk factors for depressive symptoms. For therapeutic planning purposes, it is important for professionals working with children with DLD to know that the same approach and avoidant strategies that help children without DLD seem also to be beneficial for children with DLD. Future studies need to identify factors related to the development of depression for children with DLD, to decrease their risk for depression.