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6.

1 Research Project:
Analysis of Childrens Depression Inventory

Brian Mann
CNS 736
June 21, 2015

The most common mental disorder affecting children and adolescents is


depression, which has an overall prevalence of 2.5 % for children and 8.3 % for

Analysis of Childrens Depression Inventory - Mann


adolescents aged under 15 (Huang, 2014). Depression is expressed through a series
of symptoms that include loss of interest in activities normally performed, low selfesteem, social isolation, fatigue, crying, sleep and eating disorders, and selfdefeating impulses. In children and adolescents, irritability, difficulties to interact
effectively with classmates and family members, behavior problems, cognitive
alterations, and decreased academic performance are also observed (Figueras
Masip, 2010). This paper discusses the use of Childrens Depression Inventory in the
assessment of childhood and adolescent depression.
The clinical assessment of depression takes place in various phases:
diagnosis and prognosis, treatment, follow-up, and evaluation of treatment efficacy.
Self-reports are useful instruments both for diagnoses and to appraise treatment
efficacy. The Childrens Depression Inventory is one of the most frequently used selfreports for the assessment of depressive symptomatology in infancy and
adolescence. The CDI was created from the Beck Depression Inventory to be
administered to children and adolescents of school age (Figueras Masip, 2010).
The CDI was originally published in 1992, based on items from the Beck
Depression Inventory (BDI) and is designed to assess depressive symptoms in
children 7 to 17 years old. There are four versions of the CDI: (a) the original version
(CDI), which includes 27 items; (b) the CDI-Short Form (CDI: S) with 10 items; (c) the
CDI-Parent version (CDI:P) composed of 1 7 items; and (d) the CDI-Teacher version
(CDI:T) composed of 12 items. The latter two versions ask parents and teachers,
respectively, to rate a child's depressive symptoms as they have occurred in the
past 2 weeks using a 4-point Likert-type response scale. The self-report CDI and CDI:
S versions ask children to rate then own depressive symptoms as they have
occurred over the past 2 weeks using a 3-point Likert-type response scale (Freeman,

Analysis of Childrens Depression Inventory - Mann


2007). The cost of a single administration of the CDI is about $2.20, whereas the
examiner kit costs $135.00 (Muller, 2012).
The CDI is available for use in 23 languages. The CDI takes about 15 minutes
to complete, and the CDLS takes about 5 minutes to complete. Items are written at
a 7-year-old reading level. The CDLP and CDLT can be completed in about 5
minutes. Scoring takes about the same amount of time as administration and can
be completed by hand with the QuikScore form or by computer. Scores for the CDI
are reported on five subscales (i.e., Anhedonia, Ineffectiveness, Interpersonal
Problems, Negative Mood, and Negative Self-Esteem) and are summed to interpret a
Total Depression score. This interpretive strategy was supported by exploratory
factor analysis. Scores on the CDLP and CDLT are interpreted as a total score or by
using two subscales: Emotional Problems and Functional Problems (Muller, 2012).
The CDI is a Level B instrument designed for use as a screening measure and
should not be used to make diagnostic decisions. The leveling system (A, B, C)
specifies publisher requirements to purchase and use an instrument. Level A
instruments are open access with no educational or licensure requirements for the
examiner. Level B instruments require that examiners have a master's degree in
counseling, psychology, or a related field; a graduate course in assessment; and
appropriate supervised experience. Level C instruments require a doctoral degree or
state licensure allowing administration of the Level C test, along with appropriate
supervised experience (Muller, 2012).
The CDI is a norm-referenced instrument, but it was not standardized on a
nationally representative sample, nor was racial or socioeconomic demographic
data collected (Muller, 2012).

Analysis of Childrens Depression Inventory - Mann


In clinical samples, the internal consistency of the CDI ranges between .71
and .89 and between .57 and .84 and in community samples, the internal
consistency of the CDI ranges between .75 and .94 and between .73 and .89
(Figueras Masip, 2010).
There are conflicting results on whether the CDI can differentiate between
youth with and without a depressive disorder. Most studies have found the CDI can
successfully discriminate psychiatric patients from non-referred youth. Several
studies also have found significant differences in the CDI scores of depressed and
non-depressed psychiatric youth (Hodges, 1990), although other studies have not
found significant differences (Timbremont, 2004).
Through various studies, test-retest reliability is strong in the short term
however becomes less reliable over longer periods. Test-retest reliability coefficients
of .87 at one week, .84 at two weeks, and .54 at 6 month follow-up. The CDI
measures a state rather than a trait, the interval between test and retest should be
short, between two and four weeks (Figueras Masip, 2010).
Fristad recently reviewed published studies of childhood depression. Half of
them used the CDI. Of these studies, 68% did not use a clinical or structured
interview to determine diagnostic status. When the CDI was used alone to assess
depressive symptoms, 44% of studies referred to high CDI scorers as "depressed"
without providing a clear cautionary statement (i.e., either stating that the CDI
cannot be used to diagnose depression or clarifying limitations regarding
generalization of findings from a nonclinical to a clinical sample (Fristad, 1997).
Fristads comments raise several concerns. First, it may suggest that the CDI
instrument is being used clinically as a diagnostic shortcut rather than its intended

Analysis of Childrens Depression Inventory - Mann


use as a simple screening measure within the more formal process of diagnosis.
Secondly, in the absence of more formal diagnostic assessments each of these
studies are inherently flawed by the overreliance on this tool.
The CDI uses a cutoff score, which is a numerical value used to select
individuals considered to be meeting a certain condition, in this case is presence of
depressive symptoms. The recommended cutoff scores, established by the CDI
developer, Kovacs, have been put into question.
Normative data are reported in the test manual on a sample of 1,266
American public school children, age 716 years. These children were not assessed
for the presence or absence of depression according to diagnostic criteria and so
are assumed to have a mix of cases (those meeting diagnostic criteria for a formal
depressive disorder) and non-cases. Data from a separate clinical sample of 134
adolescents who did meet criteria for depressive disorders were collected over a 9year period. On the basis of these data, Kovacs has recommended various cutoff
scores on the CDI when screening for depression in children. Matthey found issues
with the statistical calculations used to determine the base rate of depression in the
sample; the use of the base rate as the criterion against which a cutoff score is
calculated; and third, the clinical usefulness of the suggested cutoff scores, based
on the more usual method of calculating cutoff scores (Matthey, 2002).
Base rates are the prevalence of a condition in the population and are
calculated by examining reasonably large representative samples of the population
of interest (Anastasi, 1988). Kovacs has reported that using her samples of 1,266
schoolchildren and 134 depressed children, the base rate of depression is 9.57%
(134 as a percentage of the total number of children; viz, 1,400). There is a basic

Analysis of Childrens Depression Inventory - Mann


flaw in this calculation, which renders the reported base rate invalid. The 134
depressed children were not part of the original sampling procedure; rather, they
were a collection of cases seen clinically over a period of some 9 years. Kovacs
could have chosen to continue collecting data on clinic-referred children for, say, a
further 5 years. In this case, she might have ended up with CDI information on 600
depressed children (an arbitrary figure for the purpose of illustration). With her
original calculations, this would then mean the base rate for depression would be
32.15% not 9.57%. As this illustrates, base rates can be calculated only by
observing the occurrence of depression in the one sample (Anastasi, 1988), in this
case, on the sample of 1,266 children. Unfortunately, Kovacs did not assess the
presence of diagnostic criteria in this sample, and so the base rate for depression is
unknown (Matthey, 2002).
Kovacs cutoff scores on the CDI have been calculated with this base-rate
information, with the goal being to approximate the actual base rates as closely as
possible. Thus, using the cutoff score of 20 produces a predicted positive rate of
9.86% (true positives of 1.36%, plus false positives of 8.50%), and hence the
suggestion that this score is best when screening in a general population in which
the previously calculated base rate is 9.57%. This method of calculating cutoff
scores is unusual (Matthey, 2002).
The method reported in the CDI manual for calculating the base rate of
depression in schoolchildren is flawed. Second, the use of base-rate information to
determine cutoff scores for screening for depression is weak. Third, using the data
reported in the manual indicates that the CDI has poor cutoff properties and should
not therefore be used for screening purposes, leaving Matthey with the opinion that

Analysis of Childrens Depression Inventory - Mann


the CDI is better suited to monitoring changes in a childs mood rather than
determining the need for intervention (Matthey, 2002).
Despite the concerns centered on the original normative data set, the CDI
continues to be studied with respect to establishing improved cut off points. For
example, in a recent study involving a sample of 1705 participants and a clinical
sample of 102 participants, Massip found a reliability coefficient range, for both
samples, from .82 (test) to .84 (retest) in the community sample, and .85 (test,
clinical sample); test-retest reliability is .81 in the community sample. Massip
determined the cut-off point that best differentiates between depressive and
community participants is 19, with a sensitivity of 94.7%, a specificity of 95.6%, a
positive predictive value (PPV) of .90, and a negative predictive value (NPV) of .98
(Figueras Masip, 2010).
In another recent study, Timbremont found that a cutoff score of 13 had a
NPV of 97.7%, suggesting this cutoff score would result in a small number of missed
cases. Therefore, this cutoff score can be used in a clinical sample to identify
children and adolescents who can receive further assessment. A higher cutoff score
of 19 minimizes the proportion of false positives but results in a higher proportion of
false negatives. He concluded that this cutoff score is adequate in general screening
because it is undesirable to incorrectly diagnose child problems (Timbremont,
2004).
Discriminant validity also concerns differentiation among different types of
disorders. Especially in the field of internalizing disorders, there is overlap between
symptoms of anxiety and depression. This is often reflected in high correlations
between scores on child anxiety and depression measures. Most studies indicate

Analysis of Childrens Depression Inventory - Mann


that child and adolescent self-report measures are not sensitive in differentiating
among types of internalizing disorders. This has led some authors to believe that
self-report measures, such as the CDI, assess negative affectivity in general, rather
than depression in particular. The results suggest that the CDI successfully
discriminates depressive disorders from anxiety and disruptive behavior disorders
(Timbremont, 2004).
It was mentioned earlier that racial or socioeconomic demographic data was
not collected as part of the initial norm-referencing data set. This raises obvious
concerns. Also, depending on the studies, some investigators have found that males
score higher than females while other authors have found that females score higher
than males (Figueras Masip, 2010). Emphasis is now being placed on factor analysis
as an improved way of identifying the correlated items into clusters associated with
depression. A study was conducted in 2006 which measured the variance across
gender, age and ethnic groups. Smucker and Craighead identified the following CDI
factors: (1) Dysphoric Mood which includes measures of sadness, self-hate, crying
spells, irritability and loneliness; (2) Acting Out which includes measures of
misbehavior, school-work difficulty, drop in school performance, disobedience, and
fighting; (3) Loss of Personal and Social Interest which includes measures of
anhedonia, social withdrawal, school dislike, lack of personal friendships; (4) SelfDeprecation which includes measures of pessimism, self-hate, negative body image,
low self-esteem, feeling unloved; and (5) Vegetative Symptoms which include
measures of indecisiveness, sleep disturbance, fatigability, and negative somatic
preoccupation (Hodges, 1990).
The CAS is a diagnostic interview for children and adolescents. It generates
clinical diagnosis as well as symptom counts for scales containing diagnostically

Analysis of Childrens Depression Inventory - Mann


related items. The relationship between the CDI factors and the CAS symptom
scales was examined. A regression was conducted for each of the five factors. For
each of the CDI factors, the regression was significant (Hodges, 1990).
In conclusion, the CDI is a well-researched instrument and the most popular
assessment tool used in the study of child and adolescent depression. Originally
designed to be a screening measure that indicates the presence and severity of
symptoms associated with depression, it has come to be used in research and
clinical practice more of a diagnostic tool. Its ease of use and efficient
administration may lead some clinicians to over rely on it as a stand-alone tool, but
is not sufficient for diagnosis. The CDI has strong psychometric properties of
discriminant validity, internal consistency, short-term test re-test reliability. One of
the problems relating to the CDI include concerns over the original normative data
set used to establish cut-off scores, however new data has been generated which
appears to be offsetting this deficiency. Also, the lack of gender, age and cultural
data is now being addressed through studies that are focused on factor analysis
which appears consistent with the CAS interview.

Sources:

Analysis of Childrens Depression Inventory - Mann


Carey, M. P., Gresham, F. M., Ruggiero, L., Faulstich, M. E., & Enyart, P. (1987).
Children's depression inventory: Construct and discriminant validity across clinical
and nonreferred (control) populations. Journal of Consulting and Clinical Psychology,
55(5), 755.
Carle, A. C., Millsap, R. E., & Cole, D. A. (2008). Measurement bias across gender on
the children's depression inventory. Educational and Psychological Measurement,
68(2), 281.
Cole, D. A., & Martin, N. C. (2005). The longitudinal structure of the children's
depression inventory: Testing a latent trait-state model. Psychological Assessment,
17(2), 144.
Craighead, W. E., Smucker, M. R., Craighead, L. W., & Ilardi, S. S. (1998). Factor
analysis of the children's depression inventory in a community sample.
Psychological Assessment, 10(2), 156-165.
Figueras Masip, A., Amador-Campos, J. A., Gmez-Benito, J., & del Barrio Gndara, V.
(2010). Psychometric properties of the children's depression inventory in community
and clinical sample. The Spanish Journal of Psychology, 13(2), 990.
Finch, A. J., Saylor, C. F., & Edwards, G. L. (1985). Children's depression inventory:
Sex and grade norms for normal children. Journal of Consulting and Clinical
Psychology, 53(3), 424-425.
Frnov, L., Lukavsk, J., & Preiss, M. (2008). Relationship of Childrens Depression
Inventory Factor Structure to School Achievement. Studia Psychologica, 50(4), 383.
Fristad, M. A., Emery, B. L., & Beck, S. J. (1997). Use and abuse of the children's
depression inventory. Journal of Consulting and Clinical Psychology, 65(4), 699-702.
Hodges, K., & Craighead, W. E. (1990). Relationship of children's depression
inventory factors to diagnosed depression. Psychological Assessment: A Journal of
Consulting and Clinical Psychology, 2(4), 489-492.
Huang, C., & Dong, N. (2014). Dimensionality of the children's depression inventory:
Meta-analysis of pattern matrices. Journal of Child and Family Studies, 23(7), 1182.
Matthey, S., & Petrovski, P. (2002). The children's depression inventory: Error in
cutoff scores for screening purposes. Psychological Assessment, 14(2), 146.
Mattison, R. E., Handford, H. A., Kales, H. C., Goodman, A. L., & McLaughlin, R. E.
(1990). Four-year predictive value of the children's depression inventory.
Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2(2),
169-174.

Analysis of Childrens Depression Inventory - Mann


Muller, B. E., & Erford, B. T. (2012). Choosing assessment instruments for depression
outcome research with school-age youth. Journal of Counseling and Development,
90(2), 208.
The children's depression inventory: A systematic evaluation of psychometric
properties. (1984). Journal of Consulting and Clinical Psychology, 52(6), 955-967.
Saylor, C. F., Finch, A. J., Spirito, A., & Bennett, B. (1984). The children's depression
inventory: A systematic evaluation of psychometric properties. Journal of Consulting
and Clinical Psychology, 52(6), 955-967.
Smucker, M. R., Craighead, W. E., Craighead, L. W., & Green, B. J. (1986). Normative
and reliability data for the children's depression inventory. Journal of Abnormal Child
Psychology, 14(1), 25-39.
Taylor, J. J., Grant, K. E., Amrhein, K., Carter, J. S., Farahmand, F., Harrison, A., . . .
Katz, B. N. (2014). The manifestation of depression in the context of urban poverty:
A factor analysis of the children's depression inventory in low-income urban youth.
Psychological Assessment, 26(4), 1317.
Twenge, J. M., & Nolen-Hoeksema, S. (2002). Age, gender, race, socioeconomic
status, and birth cohort differences on the children's depression inventory: A metaanalysis. Journal of Abnormal Psychology, 111(4), 578.
Timbremont, B., Braet, C., & Dreessen, L. (2004). Assessing depression in youth:
Relation between the children's depression inventory and a structured interview.
Journal of Clinical Child & Adolescent Psychology, 33(1), 149-157.