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Evidence-based assessment/Depression in youth (assessment portfolio)

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EBA Implementation
Assessment phases
Steps 1-2: Preparation phase

Preparation phase

Steps 3-5: Prediction phase

Prediction phase

Steps 6-9: Prescription phase

Prescription phase

Steps 10-12: Process/progress/outcome phase

Process phase

What is a "portfolio"?

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For background information on what assessment portfolios are, click the link in the heading above.

Want even more information about this topic? There's an extended version of this page here.

Preparation phase

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Diagnostic criteria for depression in youth

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ICD-11 Diagnostic Criteria

  • Depressive Disorders
    • Depressive disorders are characterized by depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioural, or neurovegetative symptoms that significantly affect the individual’s ability to function. A depressive disorder should not be diagnosed in individuals who have ever experienced a manic, mixed or hypomanic episode, which would indicate the presence of a bipolar disorder.
  • Single Episode Depressive Disorder
    • Single episode depressive disorder is characterized by the presence or history of one depressive episode when there is no history of prior depressive episodes. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.
      • Note: The ICD-11 lists 10 additional subcategories of single episode depressive disorder. They can be found here.
  • Recurrent Depressive Disorder
    • Recurrent depressive disorder is characterized by a history or at least two depressive episodes separated by at least several months without significant mood disturbance. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least two weeks accompanied by other symptoms such as difficulty concentrating, feelings of worthlessness or excessive or inappropriate guilt, hopelessness, recurrent thoughts of death or suicide, changes in appetite or sleep, psychomotor agitation or retardation, and reduced energy or fatigue. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a Bipolar disorder.
      • Note: The ICD-11 lists 10 additional subcategories of recurrent depressive disorder. They can be found here.
  • Dysthymic Disorder
    • Dysthymic disorder is characterized by a persistent depressive mood (i.e., lasting 2 years or more), for most of the day, for more days than not. In children and adolescents depressed mood can manifest as pervasive irritability.The depressed mood is accompanied by additional symptoms such as markedly diminished interest or pleasure in activities, reduced concentration and attention or indecisiveness, low self-worth or excessive or inappropriate guilt, hopelessness about the future, disturbed sleep or increased sleep, diminished or increased appetite, or low energy or fatigue. During the first 2 years of the disorder, there has never been a 2-week period during which the number and duration of symptoms were sufficient to meet the diagnostic requirements for a Depressive Episode. There is no history of Manic, Mixed, or Hypomanic Episodes.
  • Mixed Depressive and Anxiety Disorder
    • Mixed depressive and anxiety disorder is characterized by symptoms of both anxiety and depression more days than not for a period of two weeks or more. Neither set of symptoms, considered separately, is sufficiently severe, numerous, or persistent to justify a diagnosis of a depressive episode, dysthymia or an anxiety and fear-related disorder. Depressed mood or diminished interest in activities must be present accompanied by additional depressive symptoms as well as multiple symptoms of anxiety. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. There have never been any prior manic, hypomanic, or mixed episodes, which would indicate the presence of a bipolar disorder.

Changes in DSM-5

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  • The diagnostic criteria for depressive disorders changed slightly from DSM-IV to DSM-5-TR. Summaries are available here and here.


Base rates of adolescent depression in different clinical settings

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This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rates of adolescent depression that they are likely to see in their clinical practices.

  • To find prevalence rates across multiple disorders, click here.
Demography Setting Base Rate Diagnostic Method
French general practitioner network[1] Children and adolescents attending primary care (2002) 5.0% CES-D, CBCL, Kiddie Schedule for Affective Disorders and Schizophrenia - Present and Lifetime Version (KSADS-PL) y
All of U.S.A.[2] National Comorbidity Survey-Adolescent (ages 13-18) (2010) 6.9%-15.4% National Comorbidity Survey-Adolescent (NCS-A) Interview Schedule p, y
North Carolina[3][4] Great Smoky Mountains Study: Community Sample (ages 9-13) (1997) .03-1.45% CAPA = Child and Adolescent Psychiatric Assessment
All of U.S.A. Acute psychiatric hospitalizations in 2009-2010 children (under the age of 15) (Blader & Carlson, 2010) 13% Centers for Disease Control survey of discharge diagnoses
Northwestern U.S.A. high school[5] High school students (1993) 9.6% KSADS
All of U.S.A.[2] Gender differences, males and females, respectively (2010) 7.5%-15% NCS-A Interview Schedule p, y
Varied[6] Meta-analysis, adolescents 13 to 18 years (2006) 5.7% DISC, CIDI, SDI, K-SADS, CAS, CAPA, IOW, DAWBA
All of U.S.A.[7] National Comorbidity Survey-Adolescent Supplement (NCS-A) (2015) 11.0% CIDI
American middle school[8] Ethnically diverse sample of middle school (Grades 6-8) students (1997) 1.9% (Chinese descent) to 6.6% (Mexican descent) DISC
American public school[9] High school freshman in public school (2009) 18.4% GHQ-12 and BDI
Cross-sectional sample of socioeconomic groups[10] Adolescents 12-17 (2016) increased from 8.7% in 2005 to 11.3% in 2014 NCS-Replication
Epidemiological (CDC)[11] 2.1%

p:Parent interviewed as component of diagnostic assessment; y:youth interviewed as part of diagnostic assessment.

Prediction phase

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Psychometric properties of screening instruments for adolescent depression

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The following section contains a list of screening and diagnostic instruments for adolescent depression. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly-reaching screening instruments, click here.
Screening instruments for adolescent depression
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Mood and Feelings Questionnaire (MFQ)[12] Self-report 6-17 5-10 minutes
Revised Children’s Anxiety and Depression Scale (RCADS) [13] Questionnaire (Child) 6-18 12 minutes

PDFs for RCADS

Subscales

Translations

User Guide

Patient Health Questionnaire 9 (PHQ-9) Self-report 18+ 3-5 minutes Free for download and use if specific criteria met. Can be downloaded here

Assessment Center Online Adult Version

Assessment Center Online Parent Version

Assessment Center Online Child version

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Likelihood ratios and AUCs of screening measures for adolescent depression

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Screening Measure (Primary Reference) AUC LR+ (score) LR- (score) Clinical Generalizability Download
WHO-5 Well-being Index (WHO-5) 3[14][15] .885 (N=294) 4.40 (raw score 11+) .15 (raw score ≤) General sample of adolescents from Norway and Denmark Link to free download:

WHO-5

Hopkins Symptom Checklist-10 (HSCL-10) (short version of SCL-90)[16] [17] .8862 (N=294) Boys: 7.2, Girls: 3.2 (raw score 16/10) Boys: .14, Girls: .17 (raw score ≤) General sample of adolescents from Norway and Denmark Link to site to contact:

HSCL-10

6-item Kutcher Adolescent Depression Scale (KADS)[18] .89 (N=309) 3.17 (raw score 6) .11 (raw score ≤) Link to free download:

KADS

Interpreting depression screening measure scores

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For information on interpreting screening measure scores, click here.

Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad-reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Diagnostic instruments specific for adolescent depression

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Diagnostic instruments for adolescent depression
Measure Format (Reporter) Age Range Administration Time Where to Access
Child and Adolescent Psychiatric Assessment (CAPA)[19] Structured with the option for additional semi-structured inquires 9-18 1 to 2 hours Information available through the Developmental Epidemiology Center at Duke University here
Diagnostic Individual Schedule for Children IV (DISC-IV)[20] Structured Parent Age: 6-17

Youth Age: 9-17

1.5 to 2 hours Interviewer manual download found here
Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KIDS) Structured Parent Age: 6-17

Youth Age: 13-17

15-50 minutes Free for download and use if specific criteria met. Can be downloaded here
Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Semi-structured interview 6-18 45-75 minutes Link to download here

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Severity scales for adolescent depression

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Diagnostic instruments for adolescent depression
Measure Informant Format (Reporter) Age Range Administration/

Completion Time

Free and Accessible Measures
Children's Depression Rating Scale - Revised (CDRS-R)[21] Parent Structured Interview 6-12 15-20 minutes
Reynolds Adolescent Depression Scale 2 (RADS-2) Youth Questionnaire 13-17 5-10 minutes
Revised Children's Anxiety and Depression Scale (RCADS) Youth Questionnaire 6-18 12 minutes

Note: Reliability and validity are included in the extended version. This table includes measures with Good or Excellent ratings.

Process phase

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The following section contains a brief overview of treatment options for depression and a list of process and outcome measures for adolescent depression. The section includes benchmarks based on published norms and on mood samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information on differences between process and outcome measures, see the page on the process phase of assessment.

Process measures

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A. Mood and Energy Thermometer  This is an improved and practical way of monitoring complex mood cycles and daily schedules. Given that some clinicians and patients may get confused about different 1 to 10 scales (e.g., a 10 could mean extreme depression or extreme mania or no depression), the Mood & Energy Thermometer improves the language in communicating (and monitoring) mood. Moreover, many children report their energy levels more accurately than their moods and therefore, energy levels are incorporated into the mood rating. The Mood & Energy Thermometer that was developed at Western Psychiatric Institute and Clinic (WPIC; and used in about 400 kids) rates mania and increased energy on a 1 to 10 scale, rates depression and tiredness on a -1 to -10 scale, and attempts to form a common language between patients, families, and clinicians. This scale also takes into account the amount of time spent depressed or manic; for example, -4 would mean “mild depression” and “mild tiredness” present ≥50% of the time, and -3 would mean “mild depression” and “mild tiredness” present < 50% of the time. The inclusion of measuring energy levels is consistent with the DSM-5, as energy level is now included in the DSM-5 as a main mood symptom criterion. Bipolar track patients (whether they experienced mania, depression, or mixed features) rated their (Q: is the parent rating his/her own moods/energy, or his/her child's?) mood and energy levels every day on this scale, and a master’s-level clinician met with them on a daily basis to help them better identify and record their mood symptoms, which has significant clinical value not only for treatment but also to prevent future episodes.[22]

B. Life Charts

Outcome and severity measures

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  • This table includes clinically significant benchmarks for Depression in Youth specific outcome measures
  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptations of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for adolescent depression
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
Benchmarks Based on Published Norms
A B C 95% 90% SEdifference
Beck Depression Inventory-II 4 22 15 9 8 4.8
CBCL T-scores
(2001 Norms) 		Total 49 70 58 5 4 2.4

Note: Benchmarks based on mood samples are included in the extended version.

4.1.b – Beck Depression Inventory- II, ages 13 and up[23]

4.1.c – KSADS Depression Rating Scale (Axelson, 2006)

4.1.d – Children’s Depression Rating Scale-Revised (CDRS-R; Elva et al., 1996)

4.1.e – Children’s Depression Inventory, ages 7-17 (CDI; Kovacs, 1992)

Treatment

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For treatment of depression in youth, there are two main types of treatment: psychosocial interventions and medication. There has been significant controversy over the use of psychotropic medications with children and many studies have looked at the efficacy of medication, psychosocial interventions, or a combination of both.

One of the most effective treatments for depression in youth is psychosocial interventions, which has been shown to lead to substantial reduction in symptoms for children and adolescents. A recent meta-analysis found that psychosocial interventions had an effect size of 1.14 and the reduction in depressive symptoms was maintained over time. On the other hand, the meta-analysis reported that pharmacological treatments did not lead to significant symptom reduction and had an effect size of 0.19.[24] Additionally, medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) have presented concerns about increasing suicidality and harmful behavior.[25] One of the most commonly used psychosocial interventions is cognitive behavioral therapy, which consists of individual or group sessions in which the provider helps the client address cognitive distortions and maladaptive thinking patterns that contribute to the maintenance of depressive thoughts.[26]

  • Please refer to the page on adolescent depression for more information on available treatment for adolescent depression or go to Effective Child Therapy for a curated resource on effective treatments for adolescent depression.

Wiki Resources & Item Content Overlap

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Visual depiction of symptom overlap between 7 commonly used pediatric depression measures.
Portfolio Theme Wikipedia Article Wikiversity Article
Major Depressive Disorder Yes No
Pediatric Depression Yes No
Graphical depiction of symptom overlap between 7 commonly used measures of pediatric depression symptoms.
This table describes all measures used in Price's analysis of item content overlap among commonly used measures of pediatric depression.
Scale Wikipedia Article Wikiversity Article Source Papers
QIDSSR No No Rush et al., 2003
BYI No, but BAI and BDI pages exist. No, but a BAI page exists. Bose-Deakins & Floyd, 2004
CBCL Yes No Garrison & Earls, 1985

Achenbach & Rescorla, 2001

RCADS No No Chorpita et al., 2000
SMFQ Yes Yes Angold & Costello, 2001
PHQA9 Yes Yes Johnson et al., 2002

Pediatric Depression Scales - Full Item Content Overlap Table

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External Resources

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  1. ICD-10 diagnostic criteria
  2. Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
  3. NIMH (information about adolescent depression)
  4. John's Hopkins Resource Guide (a guide about adolescent depression, treatment, and more)
  5. OMIM (Online Mendelian Inheritance in Man)
    1. 608516
    2. 608520
    3. 608691
  6. eMedicine entry for adult depression
  7. Effective Child Therapy
    1. Effective Child Therapy is a website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.


References

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Click here for references
  1. ↑ Mathet, F.; Martin-Guehl, C.; Maurice-Tison, S.; Bouvard, M.-P. (2003-09). "[Prevalence of depressive disorders in children and adolescents attending primary care. A survey with the Aquitaine Sentinelle Network"]. L'Encephale 29 (5): 391–400. ISSN 0013-7006. PMID 14615688. https://pubmed.ncbi.nlm.nih.gov/14615688. 
  2. ↑ 2.0 2.1 Merikangas, Kathleen Ries; He, Jian-Ping; Burstein, Marcy; Swanson, Sonja A.; Avenevoli, Shelli; Cui, Lihong; Benjet, Corina; Georgiades, Katholiki et al. (2010-10). "Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A)". Journal of the American Academy of Child and Adolescent Psychiatry 49 (10): 980–989. doi:10.1016/j.jaac.2010.05.017. ISSN 1527-5418. PMID 20855043. PMC 2946114. https://pubmed.ncbi.nlm.nih.gov/20855043. 
  3. ↑ Costello, E. J.; Farmer, E. M.; Angold, A.; Burns, B. J.; Erkanli, A. (1997-05). "Psychiatric disorders among American Indian and white youth in Appalachia: the Great Smoky Mountains Study". American Journal of Public Health 87 (5): 827–832. doi:10.2105/ajph.87.5.827. ISSN 0090-0036. PMID 9184514. PMC 1381058. https://pubmed.ncbi.nlm.nih.gov/9184514. 
  4. ↑ Angold, A.; Costello, E. J. (2000-01). "The Child and Adolescent Psychiatric Assessment (CAPA)". Journal of the American Academy of Child and Adolescent Psychiatry 39 (1): 39–48. doi:10.1097/00004583-200001000-00015. ISSN 0890-8567. PMID 10638066. https://pubmed.ncbi.nlm.nih.gov/10638066. 
  5. ↑ Lewinsohn, PM; Hops, H; Roberts, RE; Seeley, JR; Andrews, JA (February 1993). "Adolescent psychopathology: I. Prevalence and incidence of depression and other DSM-III-R disorders in high school students.". Journal of abnormal psychology 102 (1): 133-44. PMID 8436689. 
  6. ↑ Costello, EJ; Erkanli, A; Angold, A (December 2006). "Is there an epidemic of child or adolescent depression?". Journal of child psychology and psychiatry, and allied disciplines 47 (12): 1263-71. PMID 17176381. 
  7. ↑ Avenevoli, S; Swendsen, J; He, JP; Burstein, M; Merikangas, KR (January 2015). "Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment.". Journal of the American Academy of Child and Adolescent Psychiatry 54 (1): 37-44.e2. PMID 25524788. 
  8. ↑ Roberts, RE; Roberts, CR; Chen, YR (February 1997). "Ethnocultural differences in prevalence of adolescent depression.". American journal of community psychology 25 (1): 95-110. PMID 9231998. 
  9. ↑ Goyal, Sunil; Srivastava, Kalpana; Bansal, Vivek (2009-01-01). "Study of prevalence of depression in adolescent students of a public school". Industrial Psychiatry Journal 18 (1). doi:10.4103/0972-6748.57859. http://www.industrialpsychiatry.org/text.asp?2009/18/1/43/57859. 
  10. ↑ Mojtabai, Ramin; Olfson, Mark; Han, Beth (2016-12-01). "National Trends in the Prevalence and Treatment of Depression in Adolescents and Young Adults". Pediatrics 138 (6): e20161878. doi:10.1542/peds.2016-1878. ISSN 0031-4005. PMID 27940701. http://pediatrics.aappublications.org/content/138/6/e20161878. 
  11. ↑ Perou, Ruth; Bitsko, Rebecca H.; Blumberg, Stephen J.; Pastor, Patricia; Ghandour, Reem M.; Gfroerer, Joseph C.; Hedden, Sarra L.; Crosby, Alex E. et al. (2013-05-17). "Mental health surveillance among children--United States, 2005-2011". MMWR supplements 62 (2): 1–35. ISSN 2380-8942. PMID 23677130. https://www.ncbi.nlm.nih.gov/pubmed/23677130. 
  12. ↑ "CEBC » Assessment Tool › Mood And Feelings Questionnaire Mfq". www.cebc4cw.org. Retrieved 2018-03-01.
  13. ↑ Ebesutani, Chad; Reise, Steven P.; Chorpita, Bruce F.; Ale, Chelsea; Regan, Jennifer; Young, John; Higa-McMillan, Charmaine; Weisz, John R. (2012). "The Revised Child Anxiety and Depression Scale-Short Version: Scale reduction via exploratory bifactor modeling of the broad anxiety factor.". Psychological Assessment 24 (4): 833–845. doi:10.1037/a0027283. ISSN 1939-134X. http://doi.apa.org/getdoi.cfm?doi=10.1037/a0027283. 
  14. ↑ Bech, P; Olsen, LR; Kjoller, M; Rasmussen, NK (2003). "Measuring well-being rather than the absence of distress symptoms: a comparison of the SF-36 Mental Health subscale and the WHO-Five Well-Being Scale.". International journal of methods in psychiatric research 12 (2): 85-91. PMID 12830302. 
  15. ↑ Christensen, KS; Haugen, W; Sirpal, MK; Haavet, OR (June 2015). "Diagnosis of depressed young people--criterion validity of WHO-5 and HSCL-6 in Denmark and Norway.". Family practice 32 (3): 359-63. PMID 25800246. 
  16. ↑ Haavet, OR; Christensen, KS; Sirpal, MK; Haugen, W (13 July 2007). "Diagnosis of depression among adolescents--a clinical validation study of key questions and questionnaire.". BMC family practice 8: 41. PMID 17626643. 
  17. ↑ Haavet, OR; Sirpal, MK; Haugen, W; Christensen, KS (April 2011). "Diagnosis of depressed young people in primary health care--a validation of HSCL-10.". Family practice 28 (2): 233-7. PMID 20937663. 
  18. ↑ LeBlanc, JC; Almudevar, A; Brooks, SJ; Kutcher, S (2002). "Screening for adolescent depression: comparison of the Kutcher Adolescent Depression Scale with the Beck depression inventory.". Journal of child and adolescent psychopharmacology 12 (2): 113-26. PMID 12188980. 
  19. ↑ Angold, Adrian; Costello, E. Jane (2000-1). "The Child and Adolescent Psychiatric Assessment (CAPA)". Journal of the American Academy of Child & Adolescent Psychiatry 39 (1): 39–48. doi:10.1097/00004583-200001000-00015. https://linkinghub.elsevier.com/retrieve/pii/S0890856709660998. 
  20. ↑ Shaffer, David; Fisher, Prudence; Lucas, Christopher P.; Dulcan, Mina K.; Schwab-Stone, Mary E. (2000-1). "NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, Differences From Previous Versions, and Reliability of Some Common Diagnoses". Journal of the American Academy of Child & Adolescent Psychiatry 39 (1): 28–38. doi:10.1097/00004583-200001000-00014. https://linkinghub.elsevier.com/retrieve/pii/S0890856709660986. 
  21. ↑ Mayes, Taryn L.; Bernstein, Ira H.; Haley, Charlotte L.; Kennard, Betsy D.; Emslie, Graham J. (2010-12). "Psychometric Properties of the Children's Depression Rating Scale–Revised in Adolescents". Journal of Child and Adolescent Psychopharmacology 20 (6): 513–516. doi:10.1089/cap.2010.0063. ISSN 1044-5463. PMID 21186970. PMC PMC3003451. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3003451/. 
  22. ↑ 22.0 22.1 22.2 22.3 "Instruments | CABS | University of Pittsburgh". pediatricbipolar.pitt.edu. Retrieved 2018-05-31.
  23. ↑ Beck AT, Steer RA, Brown G. 1996. Beck Depression Inventory. San Antonio, TX: Harcourt Brace Educ. Meas. 2nd ed.
  24. ↑ Michael, Kurt D; Crowley, Susan L. "How effective are treatments for child and adolescent depression?". Clinical Psychology Review 22 (2): 247–269. doi:10.1016/s0272-7358(01)00089-7. https://doi.org/10.1016/S0272-7358(01)00089-7. 
  25. ↑ Jane Garland, E.; Kutcher, Stan; Virani, Adil; Elbe, Dean (2016). "Update on the Use of SSRIs and SNRIs with Children and Adolescents in Clinical Practice". Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal De l'Academie Canadienne De Psychiatrie De L'enfant Et De L'adolescent 25 (1): 4–10. ISSN 1719-8429. PMID 27047551. PMC PMC4791100. https://www.ncbi.nlm.nih.gov/pubmed/27047551. 
  26. ↑ Driessen, Ellen; Hollon, Steven D.. "Cognitive Behavioral Therapy for Mood Disorders: Efficacy, Moderators and Mediators". Psychiatric Clinics of North America 33 (3): 537–555. doi:10.1016/j.psc.2010.04.005. http://linkinghub.elsevier.com/retrieve/pii/S0193953X1000047X. 
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