Is the Children's Depression Inventory Short version a valid screening tool in pediatric care? A comparison to its full-length version
Introduction
Depression is a common mental disorder even in childhood: A meta-analysis of epidemiological studies reported a point-prevalence of 2.8% for prepubertal children under the age of 13 [1]. Prevalence rates are even higher for children suffering from medical illnesses. Substantially elevated rates of major and minor depression ranging between 11% and 29% were found for various somatic conditions, such as migraine and epilepsy [2], congenital heart disease [3], inflammatory bowel disease and cystic fibrosis [4], cancer [5], burn injuries [6] and orthopedic procedures [7].
Since early-onset depression negatively affects the course of somatic diseases [8] and tends to persist into adolescence [9], early recognition is essential. However, pediatricians often feel uncomfortable diagnosing psychiatric disorders in their patients [10], [11], and indeed, only one in five mentally ill children or adolescents is being identified [12]. Specifically for depression, an even lower detection rate of 12.5% was found [13]. Self-report questionnaires to screen for depression can be one helpful tool for pediatricians to improve low recognition rates [14], [15].
The most established self-report measure of depressive symptoms for child samples is the 27-item Children's Depression Inventory (CDI, [16], [17]). The CDI has been translated into several languages. In the present study, a slightly modified German version was used [18].
Research on the criterion validity of the CDI recommends various cutoffs to distinguish between depressed and non-depressed patients in samples differing in psychosocial impairment.
A high cutoff score of 19 was recommended to differentiate between severely affected psychiatric inpatients and a non-symptomatic school sample [19].
For screening in moderately affected clinically referred samples, cutoffs between 12 and 17 have been found. Timbremont et al. [20] reported a cutoff of 16 in patients aged 8 to 18 who were referred from in- and outpatient facilities to centers of childhood psychopathology. A lower cutoff of 12 was found by Lobovits and Handal [21] in a sample of 8- to 12-year old children referred to outpatient psychology service centers. Using this cutoff, 88% of the 50 children were correctly classified as depressed or non-depressed with regard to the DSM-III criteria for major affective disorder.
So far, only one research group explored cutoff scores in mildly affected medically ill children who had a pediatricians' referral to evaluate their emotional state [22]. In this sample of 81 8 to 19 year olds mainly suffering from chronic medical conditions, a cutoff of 11 was found [22]. For validation of the CDI a best estimate procedure was applied based on a structured diagnostic interview and medical records. The number of correctly identified cases (sensitivity) was 80%, whereas 70% were correctly classified as non-depressed (specificity).
For screening purposes in time-limited pediatric settings, Kovacs [17] recommends the 10-item CDI Short version (CDI:S). So far, criterion validity of the CDI:S in terms of diagnostic accuracy for screening for depression has not been examined, even though there are a number of studies applying the CDI:S. Yet, they focused on different aspects of validity, such as concurrent validity [e.g., [23], [24], [25]].
Apart from the CDI:S, there are two other established screening instruments for prepubertal children, the Short Mood and Feelings Questionnaire (MFQ-SF, [26]) and the Child Behavior Checklist (CBCL, [27]). In a study that particularly addressed medically ill children using the MFQ-SF as opposed to the structured Diagnostic Interview Schedule for Children (DISC, [28]) an overall accuracy of 84%, a sensitivity of 80% and a specificity of 81% were reported [29]. The sample consisted of children aged 11 to 17 with and without asthma who were enrolled in a health maintenance organization. For the CBCL, a diagnostic accuracy of 77% was found in clinically referred 6 to 18 year olds [30].
This is the first study to assess the validity of the Children's Depression Inventory Short version (CDI:S) as opposed to the CDI for screening among prepubertal medically ill patients. It was hypothesized that the CDI:S would be equally valid as the CDI.
Section snippets
Procedure
Recruitment took place in three pediatric hospitals and three pediatric surgery hospitals and was arranged sequentially in time units of three months, each between September 2009 and November 2010. Monday through Friday, all newly admitted in- and outpatients between 9 and 12 years and their parents were invited to participate in the study. Children had to meet the following inclusion criteria as documented by the medical staff to assure they could complete the screening instrument autonomously:
Sample description
Participating patients (n = 406) and excluded patients (n = 227) did not differ significantly with respect to age (t(631) = − 1.80, p = .073) or sex (χ2(1, 633) = 3.71; p = .054). The mean age of participants was 10.5 years (SD = 1.10) including 43.8% females and 56.2% males. Thirty participants (18 boys, 12 girls) fulfilled the diagnostic criteria of a depressive disorder according to the DSM-IV-TR as represented in the Kinder-DIPS interview. Point prevalence was 7.4%, 3.2% accounting for minor depression and
Discussion
The aim of the present study was to investigate and to compare the criterion validity of the Children's Depression Inventory (CDI) and its short version (CDI:S) in a sample of medically ill children.
The CDI showed good diagnostic accuracy as well as balanced values for sensitivity and specificity (both above 80%) at an optimal cutoff ≥ 12 for the German 26-item version. An identical cutoff of 12 for the original 27-item version was reported by Lobovits and Handal [21] for clinically referred
Conflict of interest
All authors have completed the Unified Competing Interest form and declare that the Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy received funding by the Bavarian State Ministry of the Environment and Public Health in the scope of the initiative Gesund.Leben.Bayern. Apart from that, the authors have no competing interests to report.
Acknowledgments
This study was funded by the Bavarian State Ministry of the Environment and Public Health in the scope of the initiative Gesund.Leben.Bayern. We thank the Departments of Pediatrics and Pediatric Surgery of the Hospital “Dritter Orden”, the Departments of Pediatric and Pediatric Surgery of the University Hospital “Schwabing”, the Department of Pediatric Surgery of the University Hospital “Dr. Haunersches Kinderspital” and the Department of Pediatrics of the Hospital “Harlaching” for their
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