Diagnosing pediatric depression

Abstract

This review examines current instrumentation for making clinical and research diagnoses of depressive disorders in children and adolescents. Reliable assessment of depression in children requires gathering information from both the parent and child, as well as from all other available information. The methodology for obtaining information from the child must be adapted to reword and better obtain information in those domains that are inherently difficult for children, including questions about internal affect state and questions requiring judgment. Because child depression is highly comorbid with other psychiatric disorders, including anxiety, attention-deficit/hyperactivity disorder (ADHD), and conduct disorder (CD), it is imperative that these and other psychiatric disorders be simultaneously assessed. A number of structured and semistructured instruments address this task well. More work is needed to decrease the time burden and cost of reliable assessment of child depression.

Introduction

Major depressive disorder (MDD) has a point prevalence of about 2% in school-age children and 4% in adolescents (see review in Fleming and Offord 1990). There is a one-to-one gender ratio before puberty and a female excess after puberty; this increase in depression appears specifically related to puberty rather than age per se (Angold et al 1998). Pediatric MDD is associated with significant impairment in functioning Puig-Antich et al 1993, Puig-Antich et al 1985a, Puig-Antich et al 1985b. A majority of those with pediatric depression have a recurrent illness Kovacs et al 1984a, Kovacs et al 1984b. Episodes of depression last months or, in a significant minority, more than a year (Ryan et al 1987). Pediatric depression is treatable with both psychotherapeutic approaches and pharmacotherapeutic approaches (reviewed in Birmaher et al 1996a, Birmaher et al 1996b).

Perhaps surprisingly, despite expected effects of cognitive and emotional maturation on the clinical syndrome, it appears that the clinical picture of child and adolescent depression is remarkably similar to that of adult depression Kovacs 1996, Ryan et al 1987. Although the same criteria are used to diagnose pediatric depression as are used to diagnose adult depression, the finding of clinical similarity is not purely tautologic. The criteria symptoms could certainly vary (some might be much more or less frequent in the child), although the individual would continue to fit diagnostic criteria. Similarly, depressive symptoms not included in the diagnostic criteria also display an adultlike pattern. A few symptoms are somewhat less frequent in children than in adolescents or adults, including endogenecity-melancholic subtypes, suicide attempts, and lethality of suicide attempts; however, children show equal frequency of suicidal ideation and equal intent (Ryan et al 1987). Younger children have somewhat higher frequency of comorbid separation anxiety, phobias, somatic complaints, and comorbid behavioral problems (Ryan et al 1987).

This article reviews issues relevant to the clinical diagnosis of depression in children and adolescents. Systematic work on diagnosing pediatric depression has focused on the methodology of making diagnoses as part of research studies of epidemiology, studies of clinical treatment, or studies of longitudinal course.

This work has direct application to making systematic diagnoses in this population for clinical purposes; however, there are separate issues in making diagnoses in purely clinical settings which are, unfortunately, largely unaddressed to date. These include speed and ease of administration, optimizing the boundary between declaring an episode or not, and making extremely easy-to-follow rules for administering scoring of the instrument (e.g., simple decision trees with skip-outs). Little has been done in child and adolescent depression to address these additional important and researchable topics. Therefore, the remainder of this article considers the research work that has been done in making a research diagnosis of MDD, with the understanding that this work is all directly applicable to the task of making a diagnosis in the clinical setting as well.

Diagnosis of internalizing disorder in preschool children present particular problems, and the optimal methodology remains unclear. The diagnosis of pediatric depression depends on the parent or child being able to report the internal affect state of the child (depressed mood). This has proved to be a substantial obstacle in diagnosing preschool children because of the limited ability of very young children to identify dysphoric moods and to appropriately label such moods. Some success has been found with asking younger children to point to cartoon figures showing different facial emotions and to identify which of several different cartoon figures “they are most like.” One can, of course, use interview methods, largely with the parent, paralleling parental interview input in the diagnosis of school-age children, but that omits data from the child (which has proven crucial in school-age children). One can expect further advances in this area, but as yet the necessary validation of the success of these approaches is slight. Diagnosis of depression in preschool children is not further considered below.