Spanish Journal of Psychology (2014), 17, e13, 1–8.
© Universidad Complutense de Madrid and Colegio Oficial de Psicólogos de Madrid
Depressive Symptoms and Suicidal Ideation in
Adolescents Accompanying a Parent in Recyclable
Suicide and suicidal ideation among the young are a
major global public health concern (Mann et al., 2005).
Suicide is the third leading cause of death among 10
to 24 years-old adolescents (Hoyert, Kung, & Smith,
2005). In 2007, the suicide rate in the United States
approximated 12 per 100,000 (Center for Disease
Control and Prevention, 2012). In Europe, it is estimated
that between 4 and 40 in 100,000 people commit sui-
cide yearly (Charlton, Kelly, Dunnell, Evans, & Jenkins,
1993). In Latin American countries the rate is estimated
at 6.5 per 100,000 (Serfaty, 1998).
The most prevalent suicide risk factor is the presence
of mental disorders, in particular, mood and anxiety
disorders (Foley, Goldston, Costello, & Angold, 2006).
The onset of Major Depressive Disorder (MDD) is
often during early adolescence and is associated with
considerable functioning and psychosocial impairments
(Rao & Chen, 2009) in addition to high indices of
suicide (American Academy of Child and adolescent
Psychiatry, 2012). The estimated prevalence of MDD in
pre-adolescents (6 to 12 years) is 2% and increases to
8% in adolescents aged 13 to 17 years (Birmaher et al.,
1996). Despite the high incidence of suicide and preva-
lence of MDD among adolescents and pre-adolescents
(Zalsman et al., 2006), there remain few studies address-
ing risk factors that may act as psychosocial stressors
leading to suicide attempts and to the onset of MDD
among these groups. Furthermore, several studies
have demonstrated that in addition to mood disor-
ders there are numerous adversities early in life such
as interpersonal difficulties, socioeconomic difficulties,
and maltreatment during childhood that can act as risk
factors for suicide and suicidal behavior (Johnson,
Cohen, Gould, Kasen, Brown, & Brook, 2002). Family
income along with other family variables such as
parental separation or divorce have also been shown
to be significantly associated with depressive symp-
toms in children (Tracy, Zimmerman, Galea, McCauley,
& Stoep, 2008). Additionally, studies have shown
that children are particularly vulnerable to various
risk factors that have been associated with mental
health problems, such as low levels of education,
large families, absence of one parent, frequent nega-
tive life events, family history of mental illness,
Gabriela B. Etcheverry1, Érico F. Pereira2 and Mara L. Cordeiro3
1 Faculdades Pequeno Príncipe (Brazil)
2 Universidade do Estado de Santa Catarina (Brazil)
3 University of California Los Angeles (USA)
Abstract. The relationship between mental health and poverty has been well documented in adults. However, few
studies have addressed how low socioeconomic status and psychosocial vulnerabilities may influence depressive symp-
toms in adolescents. The current study was carried out in a non-randomly selected sample of 239 adolescents whose
parents work as ragpickers (waste collectors for recycling) in Brazil. In-person interviews were conducted, and the pres-
ence of depressive symptoms and suicidal ideation were assessed using the Children’s Depression Inventory (CDI). We
observed that 23% (CI±5.34) of the adolescents presented with depressive symptoms and 35% (CI±6.05) had suicidal
ideation. Fatigue or loss of energy (p = .012) and irritable mood (p = .013) were significantly higher among boys than girls
according to DSM-IV criteria. However, we found no gender differences in DSM-IV criteria for Major Depressive
Disorders (MDD) or Dysthymic Disorder (DD) in diminished interest or pleasure, weight loss or weight gain, decreased
appetite, sleep problems, feelings of worthlessness, diminished concentration or ability to think, recurrent thoughts
of death, suicidal ideation, or low self-esteem. There were no significant gender differences in total CDI score, however
a greater percentage of girls presented with depressed mood than boys (29.9% vs. 17.1%, p < .05).
Received 27 March 2012; Revised 21 February 2013; Accepted 2 April 2013
Keywords: adolescence, depression, suicidal ideation, poverty, Children’s Depression Inventory.
Correspondence concerning this article should be addressed
to Mara L. Cordeiro, Ph.D. Instituto de Pesquisa Pelé Pequeno
Principe. Av. Silva Jardim, 1632. 80250–120. Curitiba (Brazil). Phone:
+55–4133101036. FAX: +55–4133221446.
We thank the clinical psychologist Cassia R. Benko, the Social
Foundation Association (FAS) of the city of Curitiba for helping to
reach the families, and we thank the adolescents and their families for
participating in the study. This study was funded by the Brazilian
State of Parana Department of Science, Education and Technology
(SETI, Conv. 003/07).
2 G. B. Etcheverry et al.
and/or exposure to violence (Carlini-Cotrim, Gazal-
Carvalho, & Gouveia, 2000; Steinberg & Duggal, 2004).
In a longitudinal study, Johnson, et al. (1999) found
that a low family socioeconomic level is associated
with a high risk of anxiety, depression, disruptive
disorders, and personality disorders in children.
Additionally, children living in structurally deprived
neighborhoods with few resources tend to have more
mental health problems than those who live in more
structured neighborhoods (Xue, Leventhal, Brooks-
Gunn, & Earls, 2005). Furthermore, the socio-emotional
health of children is worse when the physical condi-
tion of their residence and immediate neighborhood
is poor (Gifford & Lacombe, 2006). Other factors,
including low maternal educational level, unem-
ployment, or the presence of depression in the family
may also affect the mental health of children, primarily
through internalizing psychopathologies such as depres-
sion, anxiety, withdrawal, and somatic complaints (Xue
et al. 2005). Poor socioeconomic conditions as well as
adverse circumstances during childhood are impor-
tant risk factors for suicide (Agerbo, Nordentoft, &
Mortensen, 2002; Beautrais, Joyce, & Mulder, 1998).
In developing countries such as Brazil and India,
there are many people living in poor socioeconomic
conditions (Chandra, Osorio-Rodarte, & Braga, 2009).
“Ragpickers” are workers who collect recyclable trash
to earn a small living. These individuals play an impor-
tant, although frequently unrecognized, role in the
garbage management system in metropolitan areas
(Figure 1). The practice of collecting recyclable trash to
earn a small wage is an established practice in Brazil
and India (da Silva, Fassa, Siqueira, & Kriebel, 2005;
Ray, Mukherjee, Roychowdhury, & Lahiri, 2004). It is
estimated that there are nearly 800,000 ragpickers in
Brazil (Carmo, 2009), and this social category is growing
due to the current economic crisis. The increasing number
of ragpickers reflects a change in habits over the last
few decades. While modern life offers the privileges of
comfort, convenience and practicality, it also encourages
industries to produce more, leading to an increase in the
volume of trash produced, particularly in urban areas.
Most ragpickers in Brazil have recently moved to
urban areas from small towns or other poor regions of
the country. Many are unable to find well paying jobs
and are temporarily unemployed. It is estimated that
for every 1000 Brazilian ragpicker, 4000 trees are saved
monthly. This savings represents the monthly collec-
tion of 200 tons of paper in a single urban area, such as
in the Brazilian southern city of Curitiba (Voitch, 2008),
a city with an estimated population of 2 million that
produces 2.4 thousand tons of trash a day. While the
ragpickers play a fundamental role in maintaining a
healthy environment, studies addressing the mental
health of these workers and their children who often
accompany their parents to work are sparse. To the
best of our knowledge, there has been only one prior
empirical study investigating psychiatric disorders in
the ragpicker population (da Silva, Fassa, & Kriebel,
2006) and this study did not address how their children
may be affected.
The aim of the present study was to assess the pres-
ence of depressive symptoms and suicidal ideation
in adolescents whose families work as ragpickers in an
urban area in the south of Brazil.
A total of 244 adolescents (56% female, 44% male)
whose parents work as ragpickers in a city in
Southern Brazil, were invited to participate in the
Figure 1. “Ragpickers”
Depression and Suicidal Ideation in Adolescentes 3
study. The participants were between 12 and 17 years
old with a mean age of 13.4 years (Table 1). The inclu-
sion criteria were: a) both the adolescents and at least
one parent were able to read or comprehend Brazilian-
Portuguese; b) at least one parent worked as a ragpicker
in the metropolitan area surrounding Curitiba, a south-
ern city in Brazil; c) the adolescent’s legal guardian
agreed to the adolescent’s participation by signing an
informed consent; and d) no more than two siblings
per family could participate in the study. This research
was approved by the Committee on Research Ethics
for Human Beings at our Institution.
Depressive symptoms and suicidal ideation were
assessed by the Children’s Depression Inventory (CDI),
developed in 1985 by Kovacs (Kovacs, 1985). The CDI
is a questionnaire adapted from the Beck Depression
Inventory and consists of 27 self-reported items specif-
ically designed for adolescents between 7 and 17 years
of age (Kovacs, 1985). The CDI was initially translated
and validated in Brazil by Gouveia and colleagues
(Gouveia, Barborsa, Almeida, & Gião, 1995). In this
Brazilian version of the CDI, the authors reduced the
original number of 27 questions to 20 and suggested a
cut-off point of 17 (Gouveia, et al., 1995). In addition,
there is a second version translated and often used in
Brazil, which kept the 27 questions as originally pro-
posed by Kovacs, and these authors suggested a cut-
off point of 13 for indication of depressive symptoms
(Baptista, 1997). The current study employed the full
version of the CDI including all 27 items (Baptista,
1997). An exploratory factorial analysis of the 27-item
CDI has shown strong validity for use in the Brazilian
population (Wathier, DellÁglio, & Bandeira, 2008). The
CDI evaluates the presence of negative mood, negative
self-esteem, hedonistic capacity, and other interpersonal
behaviors, including suicidal ideation (Kovacs, 2003).
While the CDI is a self-reported questionnaire, the
researcher is available during administration to answer
questions that arise. Each item of the CDI has three
choices (scored as 0, 1 or 2; 0 = asymptomatic,
1 = moderately symptomatic and 2 = clinically symp-
tomatic), with the participant choosing which one
best describes their state in the last two weeks. The
overall CDI score can range from 0 to 54. A longitudinal
study (Devine, Kempton, & Forehand, 1994) demon-
strated that on average, the results of the CDI are sta-
ble over time in individuals not receiving medication.
The internal consistency coefficient of the original
instrument was (α =.86) in the normative sample
(Kovacs, 1985) and in the translated version used in
this study had an alpha reliability of .85 (Wathier, et
al., 2008), and the internal consistency for our sample
was (α = .79). Epidemiological studies have established
cutoff points, typically between 15 and 17 points indi-
cating depression (Charman, 1994). The inventory
includes one question regarding thoughts of self-harm.
In the current study participants were classified as
harboring suicidal ideation if they chose either “I
think about killing myself but would not do it” or “I
want to kill myself”, scoring 1 or 2 respectively, on
item number 9, as suggested by Kovacs (2003).
The Statistical Package for the Social Sciences (SPSS
version 20.0) was used for analysis. Descriptive statis-
tical analyses included averages, standard deviations,
maximums and minimums. The Kruskal-Wallis test
was used to examine differences between males and
females on CDI items that correspond with DSM-IV
criterion symptoms for Major Depressive Disorders
(MDD) and Dysthymic Disorders (DD). A p-value < .05
was considered statistically significant.
Of the 244 adolescents invited to participate, 239 from
185 families met the criteria for inclusion and agreed
to participate. Of the participants, 16 (7%) worked
only as ragpickers of recyclable material (with their
own or a rented means of transportation, Figure 1),
34 (14%) worked only as recyclers within the recycling
shed, and 189 (79%) worked in both collecting and
Table 1 shows the demographic data of study partic-
ipants. The study included 134 girls (54%) and 105
boys (44%) with an average age of 13.4 years (standard
deviation = 1.5). In terms of education, 39 subjects had
never attended formal school (16.3%), 42 had com-
pleted 2–4 years of school (17.6%), 134 had completed
between 5–7 years of school (56.1%), and 24 were
between their eighth grade year and their first year of
high school. In the current study, 108 participants were
Table 1. Participant characteristics
Age, years (mean (SD))
Education (n, %)
Not in school
8th grade–1st year of high school
4 G. B. Etcheverry et al.
Table 2. Categorization of adolescent participants by depressive symptoms as determined by the Children’s Depression Inventory (CDI)
Mild (CDI > 13 to15)Mild to Moderate (CDI ≥ 16 > 19) Moderate to Severe (CDI ≥ 19)
Boys (n = 105)
Girls (n = 134)
Total Sample (n = 239)
CDI (n, %)
13.4 (1.3)13.6 (1.6) 13.6 (1.7)
13.4 (1.7)13.5 (1.7)13.6 (1.3)
Data shown are averages (standard deviation)
CDI scores of 13 and 19 have previously been rec-
ommended as cut-off points for MDD in clinical and
community samples, respectively (Roelofs et al., 2010;
Timbremont, Braet, & Dreessen, 2004), while other
studies have recommended a CDI score of between 15
and 17 as the cut-off score for MDD (Charman, 1994).
Recent studies assessing the presence of depressive
symptoms in Brazilian children with sickle cell anemia
adopted a cut-off point of 13 as suggestive of depres-
sion (Barreto & Cipolotti, 2011). The current study ana-
lyzed three groups: a) those scoring between 13 and 15
points as an indicator of mild depression; b) those with
scores equal or greater to 16 but less than 19 as mild to
moderate depression, and c) those scoring equal to or
above 19 points as moderate to severe depression. The
percentage of the study population belonging to each
of the three depressive groups categorized by CDI
points, age and gender is displayed in Table 2. The CDI
score results revealed that 23% of the sample presented
depressive symptoms (score of > 19 points) and 35%
(n = 84) of the study population presented with sui-
cidal ideation. Although not statistically significant
(p = .28), a greater percentage of girls (38%) had a high
index of suicidal ideation than boys (31%). Table 3
shows the correspondence of CDI items and DSM-IV
criterion symptoms for MDD and DD according to the
gender of participants. Regression analysis of DSM-IV
criteria found that significantly more girls (29.9%) than
boys (17.1%) presented with depressed mood (p = .013),
while boys scored significantly higher on DSM-IV cri-
teria for fatigue or loss of energy (p = .012) and psycho-
motor agitation (p = .013).
The incidence of depressive symptoms (23%) and the
incidence of suicidal ideation (35%) in adolescent rag-
pickers were high relative to the general population.
The relationship between mental health and poverty
has been extensively studied and well established in
developed countries (Costello, Compton, Keeler, &
Angold, 2003). However, in developing countries,
issues regarding mental health, particularly in children
and adolescents have not been given as much attention
(Belfer, 2008; Belfer & Saxena, 2006; Duarte et al., 2003).
Basic needs such as nutrition, sanitation, and other
health issues such as infectious diseases, have taken
priority over mental health. Furthermore, a stigma
associated with mental disorders remains, especially
in developing countries such as Brazil.
The findings of the current study suggest that ado-
lescent children of ragpickers are at risk for the devel-
opment of mental health issues, particularly MDD as
indicated by the high percentage of adolescents with
depressive symptoms (moderate to high on the CDI)
as well as suicidal ideation. Compared to the current
study findings that 35% of ragpicker children harbor
suicidal ideation, a cross-sectional population-based
study using a representative sample of adolescents
aged 11 to 15 years old living in a city in southern
Brazil (using the same question “9” of the CDI as used
in the present study) identified only 14.1% of youths
with suicidal ideation (Souza, et al., 2010). Another
Brazilian study using different screening tools in a
community sample (aged 14 to > 60 years old, n = 515
participants) detected suicidal ideation in 17.1% of
participants (Botega, et al., 2009). Furthermore, case-
control studies of community samples in Brazil found
that suicidal ideation was consistently associated with
depressive symptoms such as lack of energy and
depressed mood (da Silva, et al., 2006). Another study
conducted with Brazilian adolescents (7 to 13 years
old) using the 27-item CDI and a cut-off point of 17,
found that 13.9% presented depressive symptoms with
no difference among age and gender (Fonseca, Ferreira,
& Fonseca, 2005). Finally, a study conducted with
553 children and adolescents (aged 7 to 14.9 years) in
Hungary detected that 48% of their sample had sui-
cidal ideation and 30% had an actual suicide plan (Liu
et al., 2006).
The CDI includes 27 questions that reflect manifes-
tations of depressive symptoms that correspond with
DSM-IV criterion for MDD and DD (Kovacs, 2003).
Using these criterion symptoms, we observed that boys
Depression and Suicidal Ideation in Adolescentes 5
presented with more symptoms of psychomotor agita-
tion and fatigue than girls while there was no differ-
ence in prevalence or severity between genders in
other symptoms. These findings are consistent with a
previous study which evaluated 383 adolescents in an
outpatient clinic (Bennett, Ambrosini, Kudes, Metz, &
A study examining the link between depression,
stress, and risk behavior in North American adolescent
students found that 35% of students reported feeling
depressed/stressed for at least 10 days within the past
month (Brooks, Harris, Thrall, & Woods, 2002). A study
of juveniles in Brazil found that 22% presented with
indicators of depressive disorders using 18 on the CDI
as a cut-off score (Gouveia et al., 1995). In addition,
an epidemiological study using a CDI cut-off score of
19 found that 20.3% of students (aged 10 to 17 years)
presented with depressive symptoms in the state of
Paraná (Bahls, 2002). Compared to the aforementioned
studies, there was a higher incidence of depressive
symptoms in the participants in the current study.
Using a CDI score of 15 as a cut-off point, 19% of the
participants presented with mild to moderate symp-
toms of depression while 23% presented with mod-
erate to severe symptoms of depression (Table 2).
These numbers are similar to the above reviewed
studies. The high rate of depressive symptoms found
in the present study may be related to low socio-
economic factors. The majority of participating fam-
ilies live in areas without proper sanitation and many
families keep the recycled trash in their homes until
selling them. These factors have been described as
stressors which may cause emotional distress and lead
to non-psychotic psychiatric disorders (Costello et al.,
2003; Kuruvilla & Jacob, 2007; Pataki & Carlson, 1995).
Prior studies have suggested that low socioeconomic
status has a negative impact on mental health, and
may play a specific role in the expression of depressive
disorders (Regier et al., 1993; Reijneveld & Schene,
1998). Other studies have not found a relationship
between neighborhood socioeconomic characteristics
and depressive symptoms in young adults (Henderson
et al., 2005). However, a large community sample study
conducted in Brazil using regression models to control
for confounders and effect modifiers found that emo-
tional difficulties, lack of neighborhood support, infre-
quent church attendance, and depressive symptoms
were associated with suicidal ideation (da Silva et al.,
Prior studies have shown that suicide is correlated
with various factors such as sex, age, marital status,
socio-environmental circumstances, as well as certain
psychological traits (e.g. aggression and melancholia)
(Mello et al., 2007). It is likely that the living and eco-
nomical conditions of the adolescents in the current
study may account for the high incidence of suicidal
ideation. Factors associated with suicidal ideation
include female gender, alcohol consumption, and use
of illicit drugs (Carlini-Cotrim et al., 2000). However,
risk factors associated with successful suicide attempts
among adolescents differ between genders. Among
males previous suicide attempt, age 16 or older, associ-
ated mood disorder, and associated substance abuse
are leading risk factors, while among females, risk
factors include mood disorders and previous suicide
attempts (American Academy of Child and Adolescent
Table 3. Correspondence of CDI items and DSM-IV criterion symptoms for MDD and DD. Data shown are averages (standard deviation)
DSM-I V-Criterion Symptom
Sum of CDI items according to
DSM-IV criterion symptoms
p-value* Effect size d CI 95%Boys Girls
Markedly diminished interest
Weight loss or gain or
decreased or increased appetite
Feelings of hopelessness
Fatigue or loss of energy
nearly every day
Diminished ability to think or
2.48 (1.68) 2,28 (1.61)0.4240,1222.16–2.58
*by Kruskal-wallis, CI: Confidence interval.
6 G. B. Etcheverry et al.
Psychiatry, 2001). The majority of the participants in
the current study were in the initial stages of adoles-
cence, suggesting a possible rise in these indicators
over the course of adolescent development, since emo-
tional problems tend to increase with age (Liu et al.,
There are a number of limitations that should be
considered in the interpretation of the study results.
First, the sample used in the present study should not
be considered representative of all adolescent children
of ragpickers. Participants in the present study were
not randomly selected, and included only individuals
who worked at organized cooperatives and who were
given their personal home addresses by the local Social
Foundation Association, government run foundation.
In addition, the actual number of families working
as recyclers was obtained from the local government
environmental office. However, it is suspected that
some families may have unlawful records and may not
have been registered with this office. Second, we did
not investigate a group of higher socioeconomic status
participant to compare depressive symptoms and/or
suicidal ideation to the ragpicker group. Third, 108
participants were from the same family, and therefore
may not be considered independent samples as they
may share “family-based” stress, in addition to socio-
economic stress. Fourth, a structured psychiatric inter-
view based on DSM-IV criteria was not performed to
determine whether the depressive symptoms detected
by the CDI warranted a diagnosis of mood disorders.
However, prior studies have shown that the CDI has
valid psychometric properties (Figueras-Masip, Amador-
Campos, Gomez-Benito, & del Barrio Gandara, 2010)
and good sensitivity and specificity for predicting
depressive disorders in adolescents (El-Missiry, Soltan,
Hadi, & Sabry, 2011). In addition, the CDI total score
has been shown to not only predict depressive disor-
der but also differentiate between depression, anxiety,
and disruptive behavior disorder (Timbremont et al.,
In conclusion, the current results indicate that the
adolescent children of ragpickers are at a high risk for
developing psychiatric disorders, in particular major
depression. In addition, this population is at a high
risk for suicide. Furthermore, the results presented
suggest that these adolescents should be thoroughly
screened through a psychiatric evaluation and inter-
ventions should be in place to positively influence
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