Adolescents’ Perceived Weight Associated With Depression in Young Adulthood: A Longitudinal Study
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Longitudinal Studies Unit, School of Population Health, University of Queensland, Herston Rd, Herston, QLD 4006, Australia. E-mail: firstname.lastname@example.org
Objective: The objective of this study is to examine whether adolescents’ measured BMI and self- or mother's perception of weight status at age 14 are associated with depression at age 21.
Research Methods and Procedures: The study participants were a subsample of 2017 participants of the Mater–University of Queensland Study of Pregnancy and Its Outcomes, a population-based birth cohort study, which commenced in 1981 in Brisbane, Australia, for whom measured BMI at ages 14 and 21 and information on self-reported mental health problems were available at the age 21 follow-up. A total of 1802 individuals had measured BMI and reported weight perception in a supplementary questionnaire at 14 years, and their self-reported mental health problems were reported at 21 years. Mental health was measured using Center for Epidemiology Studies Depression Scale and Young Adults Self-Reported depression/anxiety at 21 years of age.
Results: We found that both young adult males and females who perceived themselves as overweight at age 14 had more mental health problems compared with those who perceived themselves as the right weight. When we combined adolescents’ weight perception with their measured BMI categories, weight perception but not measured overweight was associated with mental health problems for males and females at age 21. This association remained after adjusting for potential confounders, including adolescents’ behavioral problems, family meals, diet, physical activity, and television watching.
Conclusions: This study suggests that the perception of being overweight during adolescence is a significant risk factor for depression in young adult men and women. The perception of being overweight during adolescence should be considered a possible target for a prevention intervention.
The population prevalence of childhood overweight and obesity has significantly increased in most industrialized countries over the last 2 to 3 decades (1). These trends are likely to have major public health consequences, including increases in type 2 diabetes, cardiovascular diseases, some forms of cancer and behavioral problems, and some of these are now occurring in obese children (1)(2). As well as the recognized physical consequences, attention is increasingly being focused on determining if mental disorders, such as depression, may also result from obesity. Although the literature predominantly agrees that obese people who seek weight-loss treatment have higher rates of depression (3)(4), it is still unclear whether weight perception or overweight/obesity in the general population is a risk factor for depression.
Although the majority of studies examining obesity and depression have been cross-sectional, there has been some evidence for an association in some of the few prospective studies (5)(6)(7)(8)(9)(10)(11)(12). Of these, 2 were representative of the general adolescent population, although BMI was only self-reported (8)(9). One looked for an association between BMI at age 14 and depression at age 31 and found no association using the recommended cut-off point for the Hopkins Symptom Checklist-25 (8)(13). The other study had a follow-up period of only 1 year (9). Although it initially found an association between overweight status and depression in both young male and females and older female adolescents, this became null after controlling for dieting and self-perceived health (9). A study examining rural youth found an association between psychiatric disorders and chronic obesity only (i.e., obesity in childhood and adolescence) (11).
Behavioral problems are considered indicative of mental health disorders. In our recent study, we found that, among adolescent females only, there was a positive linear association between body size and behavioral problems, but prospective analyses found no association for either sex (14). A study on adults, which found an association between obesity and depression, suggested other mediating factors might be involved, such as weight perception (15).
Hence, an alternative hypothesis suggests that it is not the excess weight that causes mental problems per se but rather the person's or significant other's perception of the person's weight (16)(17). Prospective studies indicated obese students have a worse body image and lower self-esteem than their non-obese counterparts (18)(19), and cross-sectional analyses specifically examining depression or anxiety and weight perception in adolescents have found an association (16)(20)(21)(22). There have also been correlations found between the perception of excess weight and juvenile delinquency in both sexes (22) and hostility in boys (23). Also, people (age range, 17 to 49 years) who were told they were overweight had an immediate increase in depression and decrease in self-esteem (24).
The aims of this birth-cohort study are to determine whether adolescents’ BMI, categorized as normal or overweight, and the change in BMI categories from adolescence to young adulthood, is associated with depression in young adulthood, and to examine if either self- or mother's perception of her child's overweight status at age 14 is associated with depression at age 21 years.
Research Methods and Procedures
The Mater-University Study of Pregnancy and Its Outcomes (MUSP)1 is a prospective study of 7223 women and their offspring, who received antenatal care at a major public hospital in Brisbane between 1981 and 1983 and delivered a live singleton child who was not adopted before leaving the hospital (25). Participants gave signed informed consent for their participation and that of their children. Full details of the study participants and measurements have been previously reported (25)(26). Of 7223 respondents, 53% at 14 years and 36% at 21 years had measured height and weight. In this study, the analyses are restricted to 2017 adolescents and young adults for whom we had prospective information on measured height and weight at 14 and 21 years and mental health measured using Center for Epidemiology Studies Depression Scale (CES-D) and depression/anxiety symptomatology (27) at 21 years. There were 1802 individuals who had measured BMI and reported weight perception in a supplementary questionnaire at age 14 years (the first 1000 participants of 7223 respondents did not get these supplementary questions at the age 14 follow-up) and their self-reported mental health problems were reported at 21 years. The main reason for fewer participants undergoing physical assessment was the insufficient funding. However, in general, participants who were lost to follow-up (did not attend the 14- and 21-year follow-ups but attended at delivery) were more likely to be males and of Asian and Aboriginal/Torres Strait Islander background (all p values <0.001). Their mothers were more likely to be teenagers when they gave birth, to be less educated, to be single or cohabitating, to have three or more children, to use tobacco and alcohol during pregnancy, and to be anxious and depressed at their first antenatal visit (all p values <0.001). Written informed consent from the mothers was obtained at all data collection phases and from the young adults at the age 21 follow-up of the study. Ethics committees at the Mater Hospital and the University of Queensland approved each phase of the study.
The main outcome in all analyses is the young adults’ mental health measured using the CES-D (28) and depression/anxiety symptoms (27) at 21 years. The CES-D is a widely used 20-item self-report scale that measures the current (symptoms rated for the past week) level of depressive symptomatology in the general population, with an emphasis on depressed mood during the past week. Each item (e.g., “I felt depressed”) has 4 response options [rarely or none of the time (<1 day) = 0; some or a little of the time (1 to 2 days) = 1; occasionally or a moderate amount of the time (3 to 4 days) = 2 and most or all of the time (5 to 7 days) = 3] and possible range of scores of 0 to 60, with higher scores indicating the presence of more symptomatology (reliability Cronbach's α = 0.88). The CES-D incorporates the main symptoms of depression, has been validated in community and primary care populations (29), and has good test-retest reliability (30).
In the community or psychiatric settings, depression and anxiety disorders show a high prevalence of comorbidity of these 2 disorders (31)(32). In this study, the young adults’ symptoms of anxiety and depression during the last 6 months were measured at the 21-year follow-up using the Young Adult Self-Report (YASR) version of the Child Behavior Checklist (CBCL) (27). This YASR version has 17 items each with 3 response options (not true = 0; somewhat or sometimes true = 1; and very or often true = 2) and possible range of scores of 0 to 51, with higher scores indicating the presence of more symptomatology (reliability Cronbach's α = 0.91). The YASR is a questionnaire for subjects 18 to 30 years of age, and contains 110 problem items that can be scored on 8 syndromes, including an Anxious/Depressed subscale. The YASR provides the capacity to compare the behaviors of the child, adolescent, and young adult using a consistent standardized measure (33). Syndromes of YASR have been found to have good validity; the items in each subscale have good reliability and are associated with DSM-III-R diagnoses obtained from structured interviews (27).
Measurements of Exposure
We considered 2 exposures: 1) adolescents’ BMI (weight in kg/height in meters squared) using the measured height and weight; and 2) adolescent perception of their weight and maternal perception of their offspring's weight at 14 years based on the supplementary questionnaires. The first 1000 or so participants did not get these supplementary questions at the 14-year follow-up. In all assessments of height and weight, the average of 2 measures of the participant's weight, lightly clothed with a scale accurate to 0.2 kg, was used. A portable stadiometer was used to measure the height. Overweight was defined according to standard definitions derived from international surveys by Cole et al. (34).
At the 14-year follow-up, adolescents were asked in a supplementary questionnaire to respond to the statement “Do you think of yourself …” by selecting 1 of 5 possible options: “very underweight,” “slightly underweight,” “about the right weight,” “slightly overweight,” or “very overweight.” In the analysis of perception of child weight status, the 5 categories were collapsed into 3 categories because of small numbers in the 2 extreme categories. The children who answered very or slightly underweight were classified as believing that they were underweight, and those who responded very or slightly overweight were classified as believing they were overweight. Children answering at about the right weight were classified as believing they were neither underweight nor overweight. Similarly, at the 14-year follow-up, mothers were asked to complete the statement, “Do you think your child is…” by giving 1 of 5 possible responses: “very underweight,” “slightly underweight,” “about the right weight,” “slightly overweight,” or “very overweight.” In the analysis of maternal perception of child weight status, the 5 categories were also collapsed into 3 categories because of small numbers in the 2 extreme categories.
Finally, we combined perceived weight with measured BMI categories into 6 mutually exclusive groups: perceived about the right weight and measured BMI was normal, perceived about the right weight and measured overweight, perceived underweight and measured BMI was normal, perceived underweight and measured overweight, perceived overweight and measured BMI was normal, and perceived overweight and measured overweight, to identify whether perceived overweight or underweight predicts young adults’ mental health problems irrespective of measured overweight. Because of small numbers for the category perceived overweight and measured BMI was underweight (n = 15), this group was not included in the main analysis.
Measurements of Confounders
The following factors were considered to be potential confounding factors on the basis of published studies or a priori knowledge (35) of their association with BMI or weight perception at 14 years (exposure) and offspring's mental health at 21 years (outcome): socioeconomic status, family conflict, adolescent externalizing and internalizing behavioral problems, diet, physical activity, and sedentary behavior (36)(37)(38)(39). These were measured by maternal age and maternal education at first clinical visit (did not complete secondary school, completed secondary school, completed further/higher education) and the Parent-Adolescent Communication (40) at the 14-year follow-up. Child characteristics considered were child behavioral problems (both externalizing and internalizing) and maternal reported child diets, physical activity, and television watching at 14 years. Child externalizing and internalizing behavioral problems were assessed from maternal reports of child behavior using Achenbach's CBCL (41) at age 14 (we refer to those with scores above the 90th centile as having behavioral problems). The CBCL is a widely used, standardized, empirically based parental report instrument designed to assess behavioral problems (both externalizing and internalizing) and competencies of children 4 to 16 years of age (42). This instrument has been shown to have construct validity and is standardized for age and sex. The internalizing scale also includes a depression/anxiety subscale. Childhood diet and physical activity data were obtained from maternal report at the 14-year follow-up. Mothers were asked to report the frequency of their child's consumption of fast food, salad, soft drinks, and red meat (all with response options of rarely or never, at least 2 or 3 times a week, or most days), the family attitude to having meals together (not really important, quite important, or very important), the amount of time her child spent watching television (<1 hour per day, 1 to <3 hours per day, 3 to <5 hours per day, or ≥5 hours per day), and the number of days per week the child engaged in physical activity (0 to 3 days per week or 4 to 7 days per week).
We first tabulated the distribution of height, weight, BMI, and mental health score separately for males and females (Table 1). Sex differences of this distribution were compared by one-way ANOVA, by computing an F test when the comparison was between 2 continuous assessments, and by computing a χ2 test when the comparison was based on BMI categories (Table 1). Statistical evidence for a difference in effect between males and females was assessed by computing a likelihood ratio test of the interaction with sex. As we found statistical evidence that the effect differed between the sexes, results are presented for males and females separately.
Table 1. . Distribution of height, weight, BMI, change in BMI categories between ages 14 and 21, and mean score of depression at age 21
|Mean (SD) height at age 14||996||1.66 (0.09)||1021||1.62 (0.06)||<0.001|
|Mean (SD) weight at age 14||996||56.03 (12.43)||1021||55.12 (11.18)||0.08|
|Mean (SD) BMI at age 14||996||20.30 (3.48)||1021||20.87 (3.83)||<0.004|
|Mean (SD) height at age 21||996||1.79 (0.07)||1021||1.65 (0.06)||<0.001|
|Mean (SD) weight at age 21||996||77.81 (15.38)||1021||65.91 (14.94)||<0.001|
|Mean (SD) BMI at age 21||996||24.36 (4.44)||1021||24.13 (5.23)||0.286|
|Change in BMI (%) between ages 14 and 21|| || || || || |
| Normal-weight at ages 14 and 21||584||58.63||615||60.24||0.140|
| Normal-weight at age 14 but overweight at age 21||170||17.07||137||13.42|| |
| Overweight at age 14 but normal-weight at age 21||56||5.62||63||6.17|| |
| Overweight at ages 14 and 21||186||18.67||206||20.18|| |
|Adolescent perceptions (%) of their weight|| || || || || |
| Underweight||142||16.57||124||13.12|| |
| About the right weight||507||59.16||427||45.19|| |
|Maternal perceptions (%) of her child's weight|| || || || || |
| Underweight||131||15.67||107||11.68|| |
| About the right weight||558||66.75||628||68.56|| |
|Mean CES-D score (SD)||966||9.97 (7.54)||1021||11.78 (8.53)||<0.001|
|Mean depression/anxiety (SD)||966||6.81 (6.00)||1021||9.29 (6.63)||<0.001|
Multiple linear regression models were used to determine the mean difference in young adults’ mental health score by BMI at 14 years, taking into account potential confounding factors. Similarly, the change in BMI between ages 14 and 21 and mental health score at 21 years was assessed using multiple regression models adjusting for potential confounding factors. Unadjusted and adjusted mean difference in young adults’ mental health scores by adolescents’ weight perceptions were assessed using multiple regression models (Table 2). Similarly, we used multiple regression models to estimate unadjusted and adjusted mean difference in young adults’ mental health scores by using combined indicators of perceived and observed weight status at 14 years adjusting for the potential confounding factors (Table 3).
Table 2. . Mean difference in young adults’ depression scores by adolescents’ weight perception adjusting for potential confounding factors
|CES-D|| || || || || || |
| About the right weight||480||0||0||410||0||0|
| Underweight||134||−0.36 (−1.76, 1.04)||−0.34 (−1.74, 1.06)||122||2.45 (0.52, 4.37)||2.37 (0.43, 4.30)|
| Overweight||198||0.48 (−0.73, 1.69)||0.46 (−0.75, 1.67)||373||2.47 (1.13, 3.81)||2.23 (0.88, 3.57)|
|Depression/anxiety|| || || || || || |
| About the right weight||480||0||0||410||0||0|
| Underweight||134||0.22 (−0.91, 1.36)||0.19 (−0.97, 1.34)||122||1.23 (−0.13, 2.59)||1.24 (−0.12, 2.61)|
| Overweight||198||1.08 (0.09, 2.06)||1.07 (0.07, 2.06)||373||1.60 (0.65, 2.54)||1.41 (0.46, 2.36)|
Table 3. . The unadjusted and adjusted mean differences in depression scores at age 21 with the combined indicator of adolescents’ perceived and measured weight status
|CES-D|| || || || || || |
| Perceived about the right weight and measured normal-weight||428||0||0||377||0||0|
| Perceived about the right weight but measured overweight||52||−0.67 (−2.79, 1.43)||−0.75 (−2.83, 1.34)||33||−3.27 (−6.66, 0.11)||−3.90 (−7.31, −0.49)|
| Perceived underweight but measured normal-weight||125||−0.42 (−1.88, 1.04)||−0.38 (−1.83, 1.08)||116||2.31 (0.33, 4.29)||2.21 (0.22, 4.20)|
| Perceived overweight but measured normal-weight||62||2.20 (0.25, 4.15)||2.13 (0.19, 4.07)||183||2.46 (0.78, 4.14)||2.27 (0.59, 3.96)|
| Perceived overweight and measured overweight||136||−0.41 (−1.82, 1.00)||−0.41 (−1.82, 0.99)||190||1.96 (0.30, 3.62)||1.52 (−0.16, 3.20)|
|Depression/anxiety|| || || || || || |
| Perceived about the right weight and measured normal-weight||428||0||0||377||0||0|
| Perceived about the right weight but measured overweight||52||−0.98 (−2.68, 0.73)||−1.07 (−2.79, 0.65)||33||−1.96 (−4.35, 0.43)||−2.21 (−4.62, 0.20)|
| Perceived underweight but measured normal-weight||125||0.40 (−0.78, 1.58)||0.37 (−0.83, 1.57)||116||1.13 (0.27, 2.53)||1.13 (−0.28, 2.53)|
| Perceived overweight but measured normal-weight||62||2.44 (0.86, 4.02)||2.33 (0.74, 3.93)||183||1.33 (0.14, 2.52)||1.23 (0.04, 2.42)|
| Perceived overweight and measured overweight||136||0.30 (−0.84, 1.44)||0.29 (−0.87, 1.44)||190||1.54 (0.37, 2.71)||1.21 (0.03, 2.40)|
In a sensitivity analysis, instead of using externalizing and internalizing behavioral scales as confounding factors, we included depression/anxiety scale measured by the CBCL to examine whether depression/anxiety levels influenced weight perception and weight status at age 14, which has an impact on young adults’ mental health.
To determine whether loss of follow-up affected the validity of our findings, we undertook a weighted analysis using inverse probability (of having missing outcome data) weights (43). All analyses were undertaken using Stata version 9.2 (StataCorp LP., College Station, TX).
The distribution of height, weight, BMI at ages 14 and 21, as well as adolescents’ weight perceptions and mental health problems at 21 years is presented in Table 1 separately for males and females. At age 14, females had a higher BMI than males. By age 21, males, on average, gained over 10 kg weight more than females. However, their mean BMI at age 21 was nearly the same. By age 21, 35.62% of males and 33.31% of females were overweight. More males than females became overweight during the transition from age 14 to 21. While 59.16% of males perceived that they were about the right weight, only 45.19% of females perceived that they were the right weight. More females than males perceived themselves as overweight (41.69% vs. 24.27%). Two thirds of mothers considered their adolescent children to be about the right weight. Mothers underestimated overweight status both for males and females. By age 21, females had greater mental health problems than males.
In regression models for both males and females, adjusting for potential confounding factors, the mean BMI at age 14 was not associated with the mean difference in CES-D or YASR score at age 21 (data not presented). For both males and females, the mean difference in depression score at age 21 and change in overweight status between ages 14 and 21 were not associated with mental health scores measured using CES-D or YASR (data not presented).
The unadjusted and adjusted mean differences in depression scores at age 21 for the adolescents’ perceived weight status are presented in Table 2. These results are for the 812 males and 905 females with complete data on all variables included in the fully adjusted models. Adolescent males who perceived themselves as overweight had a greater mean YASR score by age 21 compared with males who perceived themselves to be about the right weight (Table 2). Adolescent females who perceived themselves as overweight had greater mean CES-D as well as YASR scores compared with females who perceived themselves as about the right weight. These associations are independent of potential confounding factors including adolescents’ externalizing and internalizing behavioral problems.
The unadjusted and adjusted mean difference in depression scores at age 21 for the combined indicator of adolescents’ perceived and measured weight status is presented in Table 3. These results are for the 803 males and 899 females with complete data on all variables included in the fully adjusted models. In the fully adjusted model, both young males and females who perceived themselves as overweight but had a normal BMI at 14 years had more mental health problems measured using CES-D or YASR at 21 years than those who perceived themselves as about right and measured normal-weight. In addition, adolescent women who perceived themselves as underweight but their measured BMI was normal had more mental health problems by age 21 compared with their counterparts.
When we repeated the analysis in Tables 2 and 3 substituting in maternal perceptions of their adolescent offspring's weight, we found none of the associations was statistically significant (results are not presented). In the sensitivity analysis, adjusting for depression/anxiety levels measured by CBCL at age 14 did not alter any results from what is presented here. When we repeated the analyses using weights for factors that predicted non-response, the results did not differ substantially from those presented here.
In this prospective follow-up of mother and child study, we found that both young adult males and females who perceived themselves as overweight at age 14 had more mental health problems compared with those who perceived themselves as about the right weight. When we combined adolescents’ weight perception with their measured BMI categories, we found weight perception but not measured overweight was associated with mental health problems for males and females at 21 years of age. Overall, this association appeared stronger for females compared with males (p < 0.05 for a sex difference). This association remained independent after adjusting for potential confounding factors including adolescents’ depression/anxiety and other behavioral problems, Parent-Adolescent Communication, family meals, diets, physical activity, and television watching.
Ours is the first longitudinal study, to our knowledge, to support evidence from cross-sectional studies that have found correlations between perceived overweight and depression in both sexes (16)(18)(20)(21)(22). Similar to our results, a study that found an association between BMI and problem behavior (which incorporated depression) in adolescents found the greater predictor of problem behavior to be weight perception (20). Our results also agree with females being more dissatisfied with their body weight than males (20)(44).
There are several possible explanations for this relationship between weight perception and depression. First, feeling overweight could be a negative cognition typical of a depressive style of thinking, which at age 14 may only be mild, but over time may develop into more recognizable depressive symptoms. We conducted a sensitivity analysis, which indicated that depression/anxiety in adolescence was not the key factor for the association between weight perception at age 14 with depression in young adulthood. Second, at age 14, the perception of being overweight may occur without any significant lowering of mood. However, if this was to continue over many years, it could be a significant risk factor for depression. Third, there may be some mediating factor that results in a perception of being overweight and the eventual outcome of depression. Current hypotheses concerning factors associated with adolescent misperception of overweight status include weight teasing by their peers or family (45), peer isolation (46), increasing conflict in adolescent-parental relationships (37), and media perceptions, and these could conceivably result in future depression. It is well established that the most extreme weight misperception is seen in individuals with anorexia nervosa, which is more prevalent in women (47). The apparent feminine biological vulnerability to depression may also influence these results (48). Gender-related differentials in any of the factors mentioned above could explain why weight misperception is greater in females than males. Genetic influences, such as serotonin transporter polymorphism, may also influence weight perception and depression, although evidence is mixed (49)(50). Finally, theoretically, the two variables could be unrelated, but parallel each other in their development over time.
Our results should be seen in the context of some limitations. The loss to follow-up in our cohort was considerable. Our results would be biased if the associations we have assessed were non-existent or in the opposite direction in non-participants, which is unlikely. To further assess whether those lost to follow-up produced bias in our results, we attached inverse probability weighting to subjects included in the analyses to restore the representation of those lost to follow-up. We followed the method suggested by Hogan et al. and used robust standard errors estimates in these models (43). We found no difference between the weighted and unweighted results, which suggests that attrition is unlikely to have substantively biased our findings. We have compared our estimates of overweight or obese at ages 14 and 20 to 24 to similar age categories in the Australian National Nutritional Survey 1995 and the results are comparable. At age 14, the prevalence of overweight or obesity was 25% in MUSP and 23% in Australian National Nutritional Survey. At age 21, the prevalence of overweight was 34% in MUSP. At age 20 to 24, the prevalence of overweight in Australian National Nutritional Survey was the same (34%). Any small differences are likely to be explained by regional variations, and this comparison does not suggest a major problem with selection due to loss to follow-up. Young adults’ mental health was measured using self-reported CES-D and YASR at 21 years, which are proxy measures of clinical disorder. Both the CES-D and YASR are known to be valid and reliable (27).
The fact that one third of adolescent boys and nearly half of adolescent girls perceived themselves as overweight but had a measured BMI that was classified as normal using clinical cut-off values suggests that individual perception of average weight conflicts with the clinical definition of normal weight and overweight. Given that the perception of being overweight is a cognitive schema, it is likely that this could be changed through appropriate cognitive-behavioral interventions. Potential practitioner interventions include universal education strategies that inform adolescents that weight misperceptions are common. Provision of easily understood weight guidelines also could be a corrective intervention. General medical and school nurse practitioners could be better informed of the weight misperception–depression link. Selective strategies include inclusion of weight perception in adolescent physical and emotional health screening. Targeted interventions with depressed youth should consider weight misperception as a possible risk factor. Lastly, the impact of adolescent exposure to slimming messages has led to media literacy programs (51) and warrants further research.
This study suggests that the perception of being overweight during middle adolescence is a significant risk factor for depression in young adult men and women. There is some evidence that depression is a risk factor for a range of cardiovascular diseases, including type 2 diabetes (52)(53). Nonetheless, overweight and obesity in adolescence remains a serious risk factor for cardiovascular disease, which needs continued attention. Further research is needed to confirm these findings and to identify likely pathways.
The authors thank all participants in the study, the MUSP data collection team, and Greg Shuttlewood, University of Queensland, who helped to manage the data for the MUSP. The study was supported by the University of Queensland Early Career Grant (to S.C.). The core study was funded by the National Health and Medical Research Council of Australia, but the views expressed in the paper are those of the authors and not necessarily those of any funding body.
Nonstandard abbreviations: MUSP, Mater-University Study of Pregnancy and Its Outcomes; CES-D, Center for Epidemiology Studies Depression Scale; YASR, Young Adult Self-Report; CBCL, Child Behavior Checklist.