Based on former empirical studies and theoretical models the present study investigated, whether stress symptoms, stress coping and somatic complaints are different between depressed girls and healthy controls. 148 girls with a mean age of 15 years were studied twice with 6 months between the two assessments. 74 fulfilled DSM IV criteria for major depression at first assessment. Stress symptoms, stress coping and somatic complaints were measured with validated German questionnaires. Depressed girls showed more stress symptoms and a higher stress vulnerability. On the other hand, in stress coping depressed girls preferred destructive strategies and had a lack of useful behaviors such as problem solving or search for social support. Stress load was significantly influenced by the severity of somatic complaints and also by inadequate stress coping such as resignation, but not by hyperactivity of HPA axis.
Keywords: Stress; Depression; Stress coping; Somatic complaints; Girls; Cognitive model
Depression in children and adolescents is frequent.
In a representative sample from Germany lifetime prevalence for depression in youth of 21% was found .
In Middle East countries 57% of youth have been observed to be depressed .
A unique and consistent model for etiology and maintenance of depression in adolescents is not available at present. Therefore, we review empirically supported factors, that have been proposed by  as a basis for explaining depression in adolescents.
The risk to develop a psychiatric disorder in general is heightened for children from families with a low socioeconomic status. This has been already shown in a large epidemiological study by .
Children from families with a low income had a threefold greater probability to develop a depressive disorder. This has been confirmed in a study by .
The families are characterized by the lack of positive supporting interactions with parents. These may be extremely focusing on conflicts and therefore provoke anger and aggression in children. Such conditions are especially present, when a high degree of parental psychopathology could be identified .
A controlled study of  showed that psychosocial stressors reinforce the depression and are also more frequent as a consequence of depression.
This has been supported in a study of  by a longitudinal analysis.
Destructive stress coping in adolescents diagnosed as depressed has been found in .
The severity of depressive symptoms is significantly correlated with cortisol levels during a laboratory stressor .
A long duration of depression leads to stress related hyperactivity of HPA axis .
A dysregulated feedback of cortisol secretion after stress is reported by . Cortisol does not recover.
A lack of social support results in a hyperactivity of HPA axis. Not seeking social support then is responsible for the maintenance of depression as well as for hyperactivity of the HPA axis .
In a twin study with 1300 families explained variance in depression by somatic complaints was 44%. 
Complaints which were in particular related to sleep have been observed in 38% in a sample of .
The empirical literature shows, that depression in adolescents is characterized by a high stress load but on the other hand by inadequate stress coping. In addition somatic complaints are frequent. In a longitudinal design the present study investigated differences in stress load, stress coping, and somatic complaints between depressed girls and controls. Differences in activity of HPA axis are also taken into account.
All Patients were recruited from the Department of child and adolescent psychiatry in a general hospital in Trier and fulfilled DSM IV criteria for major depression which was proved by a structured clinical interview.
A control group was recruited by advertisements in the local newspaper.
The study was approved by the ethical committee of the University of Trier (17.2.2010).
All participants were paid for participation.
Patients and controls were assessed twice with a time interval of 6 months between the two measurement points (Table 1).
Major Depression (n=74)
15.7 ± 2.1
15.1 ± 2.4
High school (%)
Parents academic education %
Table 1: Description of the sample.
There were no significant differences between patients and controls with respect to these characteristics.
The severity of depression was assessed by the Depression Inventory for children and adolescents (DIKJ) .
Reactions to stressful situations were obtained by the coping questionnaire for children and adolescents (SVF-KJ) . The questionnaire measures reactions to stress, when a stress situation is imaged. It comprises strategies which reduce stress as well as strategies that enhance stress. 9 subscales are provided.
Stress load was assessed by the questionnaire for stress and stress coping for children and adolescents (SSKJ) .
The subscales comprise: 1) Vulnerability to stress; 2) Physical symptoms of stress such as headache, stomach ache or exhaustion; 3) Psychological symptoms of stress such as depressed mood and anxiety.
All participants collected saliva samples after awakening to determine cortisol.
Somatic complaints were measured by the Giessen Complaint Questionnaire for children (GBB) . It comprises the subscales exhaustion, stomach ache, pain in legs, circulatory problems, and complaints of a cold.
The depressed girls had a mean value of 19.3 ± 7.5, the controls of 9.7 ± 6.4 on the Depression Scale (DIKJ).
As expected the mean for the depressed girls was significantly higher and indicates clinically significant depression according to norm-tables for this questionnaire.
Somatic complaints were obtained with the Giessen Complaint Questionnaire for children (GBB). It comprises the subscales exhaustion, stomach ache, pain in legs, Circulatory problems, and complaints of a cold. Internal consistency of the subscales is 80  (Table 2).
Scale of SSKJ
15.5 ± 3.0
17.7 ± 2.8
Physical stress symptoms
10.1 ± 2.7
11.8 ± 3.0
Psychol. stress symptoms
21.9 ± 5.5
27.6 ± 5.1
Table 2: Mean values for stress load in patients and controls (M ± SD).
The statistical analysis for comparison between depressed patients and controls with MANOVA for all three scales simultaneously was significant with F (3,144) = 16.2, p<0.001.
They felt more stress load physically as well as psychologically and were more vulnerable to the perception of stress situations (Table 3).
Scales of SVFKJ
17.2 ± 5.4
14.9 ± 5.4
11.2 ± 5.5
9.6 ± 5.0
Control of stress
23.2 ± 4.3
19.9 ± 5.9
Positive self instruction
22.5 ± 5.0
18.0 ± 6.7
20.4 ± 4.9
18.1 ± 5.9
13.8 ± 6.3
19.0 ± 7.1
17.9 ± 6.1
21.5 ± 7.0
8.5 ± 5.8
13.7 ± 7.5
11.7 ± 6.4
15.6 ± 6.9
Table 3: Mean values for stress coping strategies in patients and controls (M ± SD).
The comparison of the means with a MANOVA for all 9 scales simultaneously yields F (9,138) = 4.4, p<0.001.
The coping strategies of the girls with depression were significantly more inadequate than those of the controls.
They avoid stress situations passively. If a stress situation was present, they ruminate extensively over the situation. Resignation and aggression are also possible, whereas a lack of constructive reactions such as the search for social support can be observed (Table 4).
Time of cortisol sample
7,2 ± 3,8
6,7 ± 3,5
+ 30 minutes
10,4 ± 3,9
10,8 ± 4,4
+ 45 minutes
9,9 ± 3,9
11,3 ± 4,2
+ 60 minutes
8,9 ± 4,0
10,7 ± 4,3
Table 4: Depicts mean cortisol after awakening for the comparison groups (Mean ± SD) in nmol/ml.
Mean cortisol over time was analyzed by MANOVA for repeated measurement. A significant interaction effect between cortisol over time and comparison group was found F (3,132) = 3.01, p <0.04. Excluding awakening all means were higher for girls with major depression (Table 5).
8.7 ± 4.9
14.2 ± 5.4
7.1 ± 3.4
9.4 ± 4.0
Pain in legs
5.4 ± 3.9
8.7 ± 5.3
4.1 ± 3.5
8.0 ± 4.5
Complaints of a cold
10.4 ± 4.3
11.7 ± 4.5
Table 5: Somatic complaints for girls with depression and controls (M ± SD).
The comparison of the mean values with MANOVA for all scales simultaneously yielded F (5,139) = 10.1, p<0.001, depressed girls suffered significantly more by somatic complaints, in particular by exhaustion, pain in legs and circulatory problems.
Linear multiple regression analysis was used to identify effects of stress coping, cortisol after awakening, and somatic complaints on stress load after 6 months.
Regression analysis 1:
Dependent variable was psychological stress load according to SSKJ.
As predictors served the coping strategy rumination, and mean cortisol 60 minutes after awakening.
The regression equation was significant with F (2,138) = 6,4 p<.002 and an explained variance of 7%. A significant predictor was rumination.
Regression analysis 2:
Dependent variable was psychological stress load according to SSKJ.
As predictors served the coping strategy passive avoidance and mean cortisol 60 minutes after awakening.
The regression equation was significant with F (2,138) = 6,6 and an explained variance of 8%. A significant predictor was passive avoidance.
Regression analysis 3:
Dependent variable was psychological stress load
Predictors were somatic complaints according to GBB, the coping strategy resignation and mean cortisol 60 minutes after awakening.
The regression equation was significant with F (7,135) = 8, 8 p<0.001 and an explained variance of 29%. Significant predictors were resignation, exhaustion and stomachache.
Female adolescents with depression reported a markedly higher stress load than their nondepressed counterparts. This was true for general vulnerability against stress, for psychological stress load and also for physiological signs of stress.
This is a confirmation of data which are known from former investigations.
In a study with standardized diaries in 15-year-old depressed children a heightened vulnerability to stressors such as family conflicts or school problems was a highly significant predictor for maintenance of depressive symptoms  and may also be interpreted as a risk factor for developing depression. A correlation between stress load and depression has been seen in a case-control study.
Inadequate stress coping is also figured in . A high degree of depression led to behavior such as denying stress, rumination, self blame, and resignation, but not to constructive tries to deal with stress such as problem-solving 2 empirical findings is in line with our data on stress load in depressed adolescents.
An experimental investigation was performed by . Depressed children and controls were exposed to different psychosocial stressors and cortisol changes were measured over time. The depressed children had significantly greater alterations of cortisol which persisted over time, indicating a continuing stress load on a biological level. Unfortunately, stress coping was not obtained, because the children were too young to provide an adequate self-report by questionnaire.
Another investigation in depressed adolescents found that a high response of cortisol after awakening indicated high stress load and predicted depression. The influence of stress coping remained unclear. 
The results of the regression analyses seem to be a meaningful extension of previous data insofar as a significant influence of somatic complaints and stress coping on stress load can be concluded. A high stress load and inadequate stress coping has been proposed to maintain depression in the long-term in adults by  already. Our results for adolescents can be integrated in this model which should take into account in particular the role of somatic complaints.
A treatment recommendation may be to diagnose somatic complaints carefully and probably take into account medication or family assessment.
The present study cannot be interpreted without limitations. The sample size was relatively small and only girls have been investigated. A generalization to boys at the moment is not possible. Also the age range was restricted to younger adolescents. Further it has to be considered that all information was based on self ratings and future investigation should take into account external evaluation.
- Ravens-Sieberer U, et al. Psychische Gesundheit von Kindern und Jugendlichen in Deutschland. Ergebnisse aus der BELLA-Studie im Kinder und Jugendgesundheits survey (KiGGS). 2007; 50: 871-878.
- Omari O, et al. Prevalence and Predictors of Depression, Anxiety, and Stress among Youth at the Time of COVID-19: An Online Cross-Sectional Multicountry Study. Depression Research and Treatment. 2020; Article ID 8887727.
- Rao U, Chen L. Characteristics, correlates, and outcomes of childhood and adolescent depressive disorders. Dialogues in Clinical Neuroscience. 2009; 11: 45-62.
- Costello E, et al. The Great Smoky Mountains Study of Youth. Goals, design, methods, and the prevalence of DSM-III-R disorders. Archives of General Psychiatry. 1996; 53: 1129-1136.
- Goodman E, et al. A multilevel analysis of the relation of socioeconomic status of adolescent depressive symptoms: does school context matter? Journal of Pediatrics. 2003; 143: 451-456.
- Séguin M, et al. Adolescent depression, family psychopathology and parent/child relations: a case control study. Canadian Child and Adolescent Psychiatry Review. 2003: 2-9.
- Krackow E, Rudolph K. Life stress and the accuracy of cognitive appraisals in depressed youth. Journal of Clinical Child and Adolescent Psychology. 2008; 37: 376-385.
- Compas B, et al. Latent variable analysis of coping, anxiety/depression, and somatic symptoms in adolescents with chronic pain; Journal of Consulting and Clinical Psychology. 2006; 74: 1132-1142.
- Asarnow J, et al. Coping strategies, self perceptions, hopelessness, and perceived family environments in depressed and suicidal children. Journal of Consulting and Clinical Psychology. 1987; 55: 361-366.
- Morris M, et al. Depressive symptom composites associated with cortisol stress reactivity in adolescents. Journal of Affective Disorders. 2017; 210: 181-188.
- Booij S, et al. Chronicity of depressive problems and the cortisol response to psychosocial stress in adolescents: the TRAILS study. Psychoneuroendocrinology. 2013; 38: 659-666.
- Lopez-Duran N, et al. HPA-axis stress reactivity in youth depression: evidence of impaired regulatory processes in depressed boys. Stress. 2015; 18: 545-553.
- Stroud C, et al. The cortisol awakening response (CAR) interacts with acute interpersonal stress to prospectively predict depressive symptoms among early adolescent girls. Psychoneuroendocrinology. 2019; 107: 9-18.
- Ask H, et al. Common Etiological Sources of Anxiety, Depression, and Somatic Complaints in Adolescents a Multiple Rater twin Study. Journal of Abnormal Child Psychology. 2015.
- Lopes M, et al. Sleep Complaints as Risk Factor for Suicidal Behavior in Severely Depressed Children and Adolescents. CNS Neuroscience & Therapeutics. 2016.
- Stiensmeier-Pelster J, et al. Depression inventory for children and adolescents (DIKJ). 2009.
- Hampel P, et al. Questionnaire for stress coping in children and adolescents (SVF-KJ). 2001.
- Lohaus A, et al. Questionnaire to measure stress load in children and adolescents (SSKJ). 2006.
- Barkmann C, Brähler E. Giessen Complaint Questionnaire for children (GBB). 2009.
- Beck A, et al. Cognitive Therapy of Depression. 2002.
- Luby J, et al. Alterations in stress cortisol reactivity in depressed preschoolers relative to psychiatric and no disorder comparison groups. Archives of General Psychiatry. 2003; 60: 1248-1255.
- Herres J, et al. Emotional Reactivity to Negative Adult and Peer Events and the Maintenance of Adolescent Depressive Symptoms: a Daily Diary Design. Journal of Abnormal Child Psychology. 2016; 44: 471-481.
- Horrwitz A, et al. Specific coping behaviors in relation to adolescent depression and suicidal ideation. Journal of Adolescence. 2011; 34: 1077- 1085.
- Starr L, et al. Childhood adversity moderates the influence of proximal episodic stress on the cortisol awakening response and depressive symptoms in adolescents. Development and Psychopathology. 2017; 29: 1877-1893.