The unmet needs in diagnosis and treatment of mood disorders in children and adolescentsDiagnosing pediatric 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.
Section snippets
Depression is comorbid with other specific disorders
It makes little sense to assess the child for depression without assessing for other psychiatric disorders, including, at the very least, anxiety disorders, ADHD, and CD. Psychiatric diagnoses are not orthogonal, entirely separate constructs but rather a useful way of representing a more complex underlying process. Child psychiatric disorders show high rates of comorbidity, as do adult psychiatric disorders. This comorbidity occurs at a much higher rate than can be accounted for by the base
Content validity versus criterion validity
One could optimize criterion validity (i.e., discrimination between those with the disorder and those without) by dropping all questions that do not significantly contribute to this discrimination. Such an approach is not, in general, useful in research studies in which one needs content validity, that is, assessment of the full range of symptoms associated with the disorder. Such broader assessment is also critical if measures of severity are to be extracted from the diagnostic instrument and
The parent and the child as informants
When asked about the same domains, children and their parents give significantly different information Angold et al 1987, Nguyen et al 1994. In general, parents give more reliable or complete descriptions of behaviors, and children give a better description of their internal affect states; however, this rule is only approximate. In research interviews, sometimes one finds the child giving a complete description of behaviors and affect states, but the parent is oblivious or, alternatively, one
Questions that are inherently difficult for children
Some kinds of questions are inherently difficult for children, including questions about internal affect state, questions that contain time concepts, and questions in which the child or adolescent has to exercise judgment (Perez et al 1998). The structure of the interview can partially offset these problems. For example, in the K-SADS interview, the parent is questioned first, and the time course is elucidated during the parent interview. Then the interviewer can use that information to better
Is there a “best” instrument?
There are a number of well-known validated instruments used to diagnose pediatric depression and other child psychiatric disorders including the Child and Adolescent Psychiatric Assessment (CAPA; Angold and Costello 2000), K-SADS-PL (Present and Lifetime Version; Kaufman et al 1997) and other versions of the K-SADS (Ambrosini 2000), Diagnostic Interview Schedule for Children (DISC; Fisher et al 1993, Schwab-Stone et al 1996, Shaffer et al 1996, Shaffer et al 2000, Shaffer et al 1993),
Discussion
For research studies with high per-subject costs (e.g., treatment studies or studies of psychobiology), interviews with the highest inter-rater agreement and greatest elucidation of individual symptoms are generally used even though such instruments require experienced interviewers and extensive training. For such studies, the cost of assessment of the individual child is trivial compared with other costs. Individual studies may target more questions to a particular area because the time one
Acknowledgements
Aspects of this work were presented at the conference, “The Unmet Needs in Diagnosis and Treatment of Mood Disorders in Children and Adolescents,” October 17–18, 2000, in Washington, DC. The conference was sponsored by the National Depressive and Manic-Depressive Association through unrestricted educational grants provided by Abbott Laboratories, AstraZeneca, Bristol-Meyers Squibb Company, Forest Laboratories Inc., Glaxo Wellcome Inc., The Henry Foundation, Janssen Pharmaceutica, Eli Lilly and
References (34)
Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS)
J Am Acad Child Adolesc Psychiatry
(2000)- et al.
The Child and Adolescent Psychiatric Assessment (CAPA)
J Am Acad Child Adolesc Psychiatry
(2000) - et al.
Childhood and adolescent depressionA review of the past 10 years. Part II
J Am Acad Child Adolesc Psychiatry
(1996) - et al.
Childhood and adolescent depressionA review of the past 10 years. Part I
J Am Acad Child Adolesc Psychiatry
(1996) - et al.
Sensitivity of the Diagnostic Interview Schedule for Children, 2nd edition (DISC-2.1) for specific diagnoses of children and adolescents
J Am Acad Child Adolesc Psychiatry
(1993) - et al.
Epidemiology of childhood depressive disordersA critical review
J Am Acad Child Adolesc Psychiatry
(1990) - et al.
Prepubertal and young adolescent bipolarity versus ADHDAssessment and validity using the WASH-U-KSADS, CBCL and TRF
J Affect Disord
(1998) - et al.
Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL)Initial reliability and validity data
J Am Acad Child Adolesc Psychiatry
(1997) Presentation and course of major depressive disorder during childhood and later years of the life span
J Am Acad Child Adolesc Psychiatry
(1996)- et al.
Parent-child agreement in prepubertal depressionFindings with a modified assessment method
J Am Acad Child Adolesc Psychiatry
(1994)
Major depression and conduct disorder in prepuberty
J Am Acad Child Adolesc Psychiatry
Diagnostic Interview for Children and Adolescents (DICA)
J Am Acad Child Adolesc Psychiatry
More on the DICA
J Am Acad Child Adolesc Psychiatry
Computerized interviews as a method of assessing psychopathology in children
Compr Psychiatry
Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2 3)
J Am Acad Child Adolesc Psychiatry
The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3)Description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study
J Am Acad Child Adolesc Psychiatry
NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV)Description, differences from previous versions, and reliability of some common diagnoses
J Am Acad Child Adolesc Psychiatry
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