TEST EVALUATION PRESENTATION:CDI 2 & RCADS FOR CHILDHOOD DEPRESSION

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Childhood Depression- Prevalence• Almost 20% of children and youth in Canada

or roughly 1.5 million individuals suffer from a diagnosable psychiatric disorder. Two thirds of these suffered from more than one disorder and less than 20% receive therapeutic intervention (Canadian Mental Health Association).

• Depression affects 3.5% of children at any given time, impeding healthy psychosocial development. Diminished self-worth, academic struggles, and difficulties in social relations with family and peers exert a heavy toll on youth who are often unable to communicate the nature of their experience. Clinical depression during adolescence represents the strongest risk factor for teenager suicide and is linked to significant psychosocial impairment in adulthood (Roza, Hofstra, van der Ende, & Verhulst, 2003; Larun, Nordheim, & Ekeland, 2006 as cited in British Columbia Medical Association)

• Percentage of adults with mental illness who developed their symptoms in childhood or youth: 70% (Mental Health Commission of Canada).

DSM – V Criteria for Depressive Disorders in

Children

• There have been changes to the list of DSM depressive disorders • “Bipolar and related disorders [have been] separated from the

depressive disorders in DSM-V and placed between the chapters on schizophrenia spectrum and other psychotic disorders and depressive disorders in recognition of their place as a bridge between the two diagnostic classes in terms of symptomology, family history, and genetics” (APA, 2013, p.123).

• A new diagnosis has been added to the depressive disorder for children and adolescents called “disruptive mood dysregulation disorder”. This diagnosis is for persistent irritability and frequent extreme uncontrolled behaviour in children up to 12 or 18 years old.

• Quickly review the criteria for the three major diagnosis : Major Depressive Disorder, Disruptive Mood Dysregulation Disorder, and Persistent Depressive Disorder (Dysthymia)

• Then we will look at the two tests: CDI 2 & RCAD

DSM-V Criteria for Childhood Major Depressive DisorderMajor Depressive Disorder

A. Five or more of the following symptoms have been present during the same 2 – week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2)loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. Note: In children and adolescents, can be irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day. Note: in children, consider failure to make expected weight gain.

4. Insomnia or hypersomnia nearly every day.5. Psychomotor agitation or retardation nearly every day.6. Fatigue or loss of energy nearly every day.7. Feelings of worthlessness or excessive or inappropriate guilt nearly

every day.8. Diminished ability to think or concentrate, or indecisiveness, nearly

every day.9. Recurrent thought of death, recurrent suicidal ideation without

specific plan, or a suicide attempt or a specific plan for committing suicide. Cont…

Cont…B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

E. There has never been a manic episode or a hypomanic episode.

Coding includes severity and course specifiers.

DSM-V Criteria Childhood Persistent Depressive Disorder (Dysthymia)

A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for atleast 2 years.

Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

B. Presence, while depressed, of two (or more) of the following:1. Poor appetite or overeating2. Insomnia or hypersomnia3. Low energy or fatigue4. Low self esteem.5. Poor concentration or difficulty making decisions6. Feeling of hopelessness

C. During the 2 year period (1 year for children or adolescents) of the disturbance, the individual has never been without symptoms in Criteria A and B for more than 2 months at a time.

D. Criteria for a major depressive disorder may be continuously present for 2 years

Cont…E. There has never been a manic episode, and criteria have never been met for cyclothymic disorder.

F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

G. The symptoms are not attributable to the effects of a substance or another medical condition.

H. The symptoms cause clinically significant distress and impairment in social, occupational, or other important areas of functioning.

Severity scales and specifiers are part of the coding system- see p.169 of the DSM-V.

Major Depressive DisorderSymptoms of major depressive disorder include feelings of sadness and emptiness, difficulties getting out of bed, loss of appetite, excessive feelings of guilt, difficulties concentrating, and suicidal thoughts or plans. Major depression is diagnosed when symptoms are present for at least two weeks, have a sudden onset and are significant enough to impact daily functioning.DysthymiaSymptoms of dysthymia include feelings of hopelessness; sleeping and eating too much or too little; fatigue; poor concentration; and low self-esteem. These symptoms cause distress but are not as severe as the symptoms of major depression. Dysthymia is a long-term condition and is diagnosed when these symptoms are present nearly every day during a period of two years.SimilaritiesThe symptoms of major depressive disorder and dysthymia are very similar. Both disorders are characterized by sad mood, loss of pleasure and changes in appetite, sleep and energy. Both disorders can be treated successfully with medication and/or counseling.DifferencesDifferences between major depressive disorder and dysthymia are characterized by levels of severity, duration and persistence. For example, the change in mood in major depression occurs nearly every day during a period of two weeks, whereas in dysthymia, the mood disturbance occurs more days than not during a two-year period. Dysthymia may be reported less than major depression, as its symptoms are less severe and easier to live with.

Changes to DSM Criteria- A new disorder- Disruptive Mood Dysregulation DisorderA. Severe recurrent temper outbursts manifested verbally

and/or behaviourally that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.C. The temper outbursts occur, on average, three or more times per week.D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others.E. Criteria A-D have been present for 12 or more months.F. Criteria A-D are present in atleast two of threesettings (i.e. at home, at school, with peers) and aresevere in at least one of these.G. The diagnosis should not be made for the first time before the age of 6 or after the age of 18. Note: difference between forward and criteria.H. By history or observation, the age at onset of Criteria A-E is before 10 years.

Cont…I. There has never been a distinct period lasting more than 1 day

during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g. autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder).Note: This diagnosis cannot be coexists with many other diagnosis- please see DSM p. 156)

K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition

Note: This disorder was added in the disorder category because it “reflects the finding that children with this symptom pattern typically develop unipolar depressive disorders or anxiety disorders, rather than bipolar disorders, as they mature into adolescence and adulthood” (APA, 2013, p.155).

Other depressive disorders that could be identified in children are as follows:

- Premenstrual Dysphoric Disorder- Substance/Medication-Induced

Depressive Disorder- Depressive Disorder Due to Another

Medical Condition- Other Specified Depressive Disorder- Unspecified Depressive Disorder

You’re Halfway!

The Comorbidity of Depression and Anxiety in Childhood• As mentioned by both Scott and Terisha, depression

is often comorbid with anxiety. This is particular true in children.

• Rates of the comorbidity are estimated anywhere from 15 to 70 %.

• Some researchers are suggesting that childhood anxiety could be symptomology that later develops into depression in adolescence.

• There is also a great deal of theoretical debate as to whether anxiety and depression in children is a different construct.

• Nevertheless it is important to identify anxious feelings that might accompany depression in children.

Childhood Depression Inventory 2nd Edition (CDI 2) – Test Description- Background & Administration

• The CDI 2 is a second edition to the original CDI developed by Maria Kovacs in 1977

• The CDI 2 was also developed by Dr. Kovaks with Multi Health Systems• The CDI 2 assesses cognitive, behavioural, and affective signs of

depression in 7 to 17-year-old children and adolescents• The CDI-2 measures symptoms based on the DSM-IV• The assessment contains two self-rated scales (a full length and a

short version), as well as a parent and teacher report- providing multiple assessment viewpoints

• The CDI 2 has both a paper and computer based version; it can be hand scored, software scored, or scored online

• The CDI 2 is written at a second grade reading level and requires an A qualification level.

• The assessment takes 15 to 20 minutes. • The full kit is approximately $289.00 and comes with 25 sets of forms.

Each set of forms costs approximately $2 to replace. • The assessment is used to provide clinicians auxiliary information for

clinical diagnosis and therapy along with other sources, as well as a group based assessment for screening

(Yunhee, 2012)

CDI 2 Standardization

• The CDI 2 has improved the norm sample from the original CDI assessment

• CDI 2 standard sample included 1100 youngsters aged 7 to 17 years inhabiting 28 states throughout all four major geographical regions of the United States

• ethnic groups included Asian, African, Hispanic, White, and Multiracial/Other.

• The sample also included age and sex based norm groups• Because the instrument is so new there is appears to be no

renormed test results for the international community.• Considering the popularity and “gold standard” status of the

original CDI – this will likely occur over time(Yunhee,

2012)

CDI 2 Scales

• The CDI 2 has two subscales: Emotional problems and Functional problems

• these scales are subdivided into Negative Mood/Physical Symptoms and Negative Self-esteem/Ineffectiveness /Interpersonal Problems, respectively

• Child respondents answer three point Likart scales, while adults complete four point Likart scales.

• The sum or the test scores are standardized into T-scores (mean of 50 and deviation of 10) and categorized into five classification systems: Very elevated (T-score 70+, Percentile Rank 84-92), Elevated (T-score 65-69, Percentile Rank 93-97), High Average (T-score 60-64, Percentile Rank 98+), Elevated (T-score 70+, Percentile Rank 84-92), Average (T-score 40-59, Percentile Rank 16-83)

(Yunhee, 2012)

CDI 2 Validity• The validity of the CDI 2 subscale constructs were tested using the

confirmatory factor analysis model (CFA). • This model is used to test whether the test measures the researchers

intended construct. The model fit was very good with scores ranging from .58 to .7

• Further, MANCOVA and ANCOVA testing were completed to collect discriminate validity about how well the CDI 2 can distinguish between youth with major depressive symptoms and youth without them.

• ANCOVA tests for the difference in means between two or more groups, while MANOVA tests for the difference in two or more vectors of means The tests demonstrated that they could generally [show] appropriate accuracy in differentiating the MDD group from other groups

• Also, convergent validity was collected by comparing the CDI 2 with the Beck Depression Inventory-Youth version (BDI-Y; Beck, Beck, Jolly, & Steer, 2001) and the Conners Comprehensive Behaviour Rating Scales (Connors CBRS; Connors, 2008); the results showed that each assessment measured the same construct

(Yunhee, 2012)(French, Macedo, Poulson, Waterson, & Yu,

2013).

CDI 2 Reliability• The CDI 2 was tested for internal consistency using Crombach’s alpha

values, a method of estimating reliability when the items on a test are not scored dichotomously, an example would be a rating scale, like the scale used in the CDI 2.

• The test had an internal consistency score of .67 to .91 for total and all subscales for all age and sex groups. Based on recommendations provided by Drummond et.al. the test internal consistency meets from “marginally unreliable” to “acceptable” standards based on reliability coefficients of .7 or higher (Drummond & Jones, 2010)

• The test was also evaluated for time sampling errors on the standard error of measurement, using Test-retest reliability on self-reports. The results showed excellent short-term stability with nearly no change during the time interval. Long-term stability of confidence intervals would be unnecessary as there would be expected change in the depression over time.

(Yunhee, 2012)

Revised Childhood Depression and Anxiety Schedule (RCADS) Test Description- Background & Administration

• the RCADS is a revised form of the Spence Children’s Anxiety Scale (SCAS; Spielberger, 1973)

• The Child FIRST Program at UCLA is dedicated to improving the effectiveness of mental health services delivered to all children, through innovation in mental health treatment design, clinical decision-making and information-delivery models, and mental health system architecture and processes. A primary strategy of the program is to study efficient ways to identify, implement, adapt, and coordinate mental health treatments supported by the highest quality scientific research.

• it has been designed to assess symptoms from a range of anxiety disorders and major depression

• it is a 47-item self-report questionnaire• administered to children ages 6 to 18 years• it has an accompanying parent version, improving results by collecting

information from multiple viewpoints• the assessment can be used to compare pre and post scores to reveal

treatment-related changes in symptoms of anxiety and depression• the assessment can be hand scores or scored by computer software.• It takes 15 to 25 minutes to complete and is FREEE• the RCADS is available in several languages, but use of norms and

interpretations of T-scores should be done cautiously with non-English versions, as research is still underway on these instruments

(Muris, Meesters, & Schouten, 2002)(Weiss & Chorpita, 2011)

RCADS- Standardization• The RCADS was standardized with 513 children and adolescents

referred to the University of Hawai Center for Cognitive Behaviour Therapy

• major ethnic groups included: Caucasian (16%), Hawaiian (10.3%), Japanese American (9.6%), Fillipino (5.3%) and Multiethnic (43.3%) Thirty-two percent of the sample were girls and 67% were boys, from families of various marital status

• The RCADS-Parent version (RCADS-P) was standardized at the Center for Cognitive Behavioural Therapy in Honolulu, Hawaii and Judge Baker’s Children’s Hospital in Boston, Massachusetts with a sample of 557 referred children and adolescents).

• Of the 557, 490 participants met eligibility criteria and were fluent in English

• RCADS has also been standardized in Australia and Holland. (Ebesutani, Bernstein, Nakamura, Chorpita, & Weisz, 2010)

(Chorpita, Moffitt, & Gray, 2005)

RCADS –Scales

• RCADS scales include separation anxiety disorder (SAD), social phobia (SP), generalized anxiety disorder (GAD), panic disorder (PD), obsessive compulsive disorder (OCD), and major depressive disorder (MDD).

• These constructs are 4 choice scales that include: “never”, “sometimes”, “often”, and “always”.

RCADS- Validity• The RCADS was evaluated for the ability to measure intended constructs-

factor analysis, using the Goodness of Fit Index (GFI), the Comparative Fit Index (CFI), the Root Mean Square Error of Approximation (RMSEA), and Root Means Square Residual (RMR).

• The RCADS T scores have been validated by age and grade, providing superior accuracy of results based on age group norms.

• MANOVA and ANOVA were performed with the six RCADS scales. • T-scores are available for each age group and scale in the most recent

version of the RCADS user manual The RCADS has been compared to other similar tests (RCMAS, CDI) for convergent and discriminant validity. Self-report measures for MDD scale correlated positively with the CDI; while anxiety scales positively and significantly correlated with the RCMAS a receiver operator analysis (ROC) analysis was also completed on the RCADS to demonstrate the validity of the cut-off scores of the various RCADS scales. This analysis identifies the “sensitivity or probability that a child diagnosed with a disorder would be identified by the instrument, and the specificity, to the probability that an individual without a diagnosis would be identified by the instrument. ROC curves ranged from a sensitivity of .59 to .77 on the differing scales.

• The RCADS showed favorable convergent, discriminant, and factorial data(Chorpita, Moffitt, &

Gray, 2005)(Weiss & Chorpita,

2011)

RCADS- Reliability• RCADS scales were found to have an “acceptable” internal

consistency in this sample (Hawaii study) SAD=.78; SOC=.87, OCD=.82; PD=.88; GAD=.84, MDD=.87

• The RCADS-P also shows high internal consistency; scales had the following scores: MDD=.83, SAD=.83, GAD=.88, PD=.81, OCD=.84.

• Based on Drummond & Jones’ recommendation of numbers above .7 to determine the test to be acceptable, the RCADS and the RCADS-P has scored “acceptable” in regards to internal consistency .

(Ebesutani, Bernstein, Nakamura, Chorpita, & Weisz, , 2010)

(Chorpita, Moffitt, & Gray, 2005)

Conclusions:• The RCADS improves upon the limitations of the CDI and the RCMAS

ability to distinguish between depression and anxiety. • The RCADS is well suited to clinical settings that have mixed client

concerns and are interested in valid measures of DSM criteria the CDI 2 is limited in its capacity to measure or identify other DSM disorders, other than depression.

• There is also evidence that the CDI does not discriminate well between depression and other clinical diagnosis, such as anxiety and it is unknown if this is true of the newer version of the CDI.

• this severely limits the clinician’s ability to form diagnostic impressions and to narrow down diagnosis to match specific treatments. This limited scope of the test also allows for margin of error in the diagnostic process, because symptoms of anxiety could often be misdiagnosed as depression and/or features of anxiety disorders are unidentified.

• The CDI 2 is better suited to measurement of depression symptoms over time, once the client has already been diagnosed with MDD.

• the CDI 2 and the RCADS reviews illustrated that the tests had reliable results and that they were both valid for the constructs that they were intended to assess.

• In my opinion the validity of the RCADS is exceptional in that it can identify several constructs and comorbid disorders to major depression disorder in children. In a clinical setting the RCADS assessment is a better tool for diagnosis, while the CDI 2 is better utilized to manage and understand the severity of childhood depression over time

(Comer & Kendall, 2005; Saylor, Finch, Spirito, & Bennett, 1984 as cited in Thompson, 2012) (Muris, Meesters, & Schouten, 2002) (Chorpita, Moffit, & Gray, 2005)

References American Psychiatric Association, (2013). Diagnostic and Statistical Manual of Mental Disorders- 5th Ed. Arlington, VA: Library of Congress Cataloging-in-Publication Data.

British Columbia Medical Association, (2010). Guidelines & Protocols Advisory Committee: Anxiety and Depression in Children and Youth- Diagnosis and Treatment. Retrieved on July 23rd, 2013 on http://www.bcguidelines.ca/pdf/depressyouth.pdf. Cannon, M. & Weems, C. (2006). Do anxiety and depression cluster into distinct groups: a test of tripartite model

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scale in a clinical sample. Behaviour Research and Therapy, 43, 309-322.

Cote, S. (2009). Depression and anxiety symptoms: onset, developmental course and risk factors during early childhood. Journal of Child Psychology and Psychiatry. Retrieved on July 23rd, 2013 from : http://www.ncbi.nlm.nih.gov/pubmed/19519755. Drummond, R. & Jones, K. (2010). Assessment Procedures for Counselors and Helping Professionals- 7th Ed.,

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Mental Health Commission of Canada. Anti-stigma initiative page. Retrieved on July 23, 2013 on http://www.mentalhealthcommission.ca/English/Pages/AntiStigmaCampaign.aspx

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the Canadian Academy of Child & Adolescent Psychiatry, 21(1), 5-8. Weiss, D. & Chorpita, B. (2011). Revised Children’s Anxiety and Depression Scale: User’s Guide, Retrieved on

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