# Evidence-based assessment/Depression in youth (assessment portfolio)/extended version

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## What is a "portfolio"?

* For background information on what assessment portfolios are, click the link in the heading above.
* Does all this feel like TMI? Click here to go to a condensed version.

## Preparation phase
### Diagnostic criteria for depression in youth

   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

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

### Base rates of adolescent depression in different clinical settings

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 | 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. | National Comorbidity Survey-Adolescent (ages 13-18) (2010) | 6.9%-15.4% | National Comorbidity Survey-Adolescent (NCS-A) Interview Schedule $^{p,y}$ |
| North Carolina | 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 | High school students (1993) | 9.6% | KSADS |
| All of U.S.A. | Gender differences, males and females, respectively (2010) | 7.5%-15% | NCS-A Interview Schedule $^{p,y}$ |
| Varied | Meta-analysis, adolescents 13 to 18 years (2006) | 5.7% | DISC, CIDI, SDI, K-SADS, CAS, CAPA, IOW, DAWBA |
| All of U.S.A. | National Comorbidity Survey-Adolescent Supplement (NCS-A) (2015) | 11.0% | CIDI |
| American middle school | Ethnically diverse sample of middle school (Grades 6-8) students (1997) | 1.9% (Chinese descent) to 6.6% (Mexican descent) | DISC |
| American public school | High school freshman in public school (2009) | 18.4% | GHQ-12 and BDI |
| Cross-sectional sample of socioeconomic groups | Adolescents 12-17 (2016) | increased from 8.7% in 2005 to 11.3% in 2014 | NCS-Replication |
| Epidemiological (CDC) | | 2.1% | |
$^p$:Parent interviewed as component of diagnostic assessment; $^y$:youth interviewed as part of diagnostic assessment.

## Prediction phase
### Psychometric properties of screening instruments for adolescent depression

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 | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Mood and Feelings Questionnaire (MFQ) | Self-report | 6-17 | 5-10 minutes | NA | A | G | A | X | Child Self Report - long version Child Self Report - short version Parent Report on Child - long version Parent Report on Child - short version Adult Self-Report - long version Adult Self-Report - short version Assessment Center Online- short version Assessment Center Online- long version |
| Reynolds Child Depression Scale (RCDS) *not free | Self-report | 7-13 years | 2-15 minutes | NA | A | A | G | | Link to purchase RCDS |
| Reynolds Adolescent Depression Scale (RADS) *not free | Self-report | 11-20 years | 5-10 minutes | NA | G | G | G | X | Link to purchase RADS |
| Children’s Depression Inventory (CDI and CDI2) *not free* | Self-report | 7-17 years old | 15-20 minutes or less | NA | A | G | A | X | Wikipedia page Link to purchase Website |
| Revised Children’s Anxiety and Depression Scale (RCADS) | Questionnaire (Child) | 6-18 | 12 minutes | G | G | G | A | | RCADS homepage Assessment Center Online Child Self Report Version Assessment Center Online Child Parent Report Version PDFs for RCADS RCADS Child Self-reported (8-18 years) RCADS Parent-reported Child Scoring Aid Parent Scoring Aid Subscales Depression Self-reported Depression Parent-reported Translations User Guide |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening measures for adolescent depression

| Screening Measure (Primary Reference) | AUC | LR+ (score) | LR- (score) | Citation | Clinical Generalizability | Download |
| Child Behavior Checklist (CBCL) Anxious/Depressed Scale T-score | .70 (N=470) | 3.78 (60+) | .39 (<60) | (Nolan et al., 1996) | High. Large diverse sample with mixed depression sample compared to samples without depression. | |
| CBCL Anxious/Depressed Scale T-score | .75 (N=1445) | 1.49 (raw score 9+) | .67 (raw score ≤) | (Eimecke et al., 2011) | | |
| CBCL Affective Problems Scale T-score | .78 (N=1445) | 1.49 (raw score 9+) | .67 (raw score ≤) | (Eimecke et al., 2011) | | |
| Youth Self Report (YSR) | .81 (N=207) | -- | -- | (Rey, et al., 1992) | | Link to purchase: YSR |
| Teacher’s Report Form (TRF) | | | | | | Link to purchase: TRF |
| WHO-Five Well-being Index (WHO-5) 3 | .885 (N=294) | 4.40 (raw score 11+) | .15 (raw score ≤) | (Christensen et al., 2015) | General sample of adolescents from Norway and Denmark | Link to free download: WHO-5 |
| Hopkins Symptom Checklist-6 (HSCL-6) (short version of Symptom Checklist-90 (SCL-90)) | .8547(N=294) | 3.8 (raw score 9+) | .19 (raw score ≤) | (Christensen et al., 2015) | General sample of adolescents from Norway and Denmark | |
| Hopkins Symptom Checklist-10 (HSCL-10) (short version of SCL-90) | .8862 (N=294) | Boys: 7.2, Girls:3.2 (raw score 16/10) | Boys:.14, Girls:.17 (raw score ≤) | (Haavet et al., 2011) | General sample of adolescents from Norway and Denmark | |
| Children’s Depression Inventory (CDI) | .877 (N=406) | 4.82 (raw score 12) | .2 (raw score ≤) | (Allgaier et al., 2012) | Medically ill children (pediatric hospital patients) | Link to purchase: CDI |
| Children’s Depression Inventory Short Version (CDI:S) | .882 (N=406) | 3.18 (raw score 3) | .09 (raw score ≤) | (Allgaier et al., 2012) | Medically ill children (pediatric hospital patients) | Link to purchase:CDI:S |
| 6-item Kutcher Adolescent Depression Scale (KADS) | .89 (N=309) | 3.17 (raw score 6) | .11 (raw score ≤) | (LeBlanc et al., 2002) | | Link to free download: KADS |
| Mood Disorder Questionnaire (MDQ) | 0.78 | 5.4 | 0.22 | | | Link to free download: MDQ |

### Interpreting depression screening measure scores

For information on interpreting screening measure scores, click here.

## Prescription phase
### Gold standard diagnostic interviews

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

### Diagnostic instruments specific for adolescent depression

Diagnostic instruments for adolescent depression :
| Measure | Informant | Parent Version (Age) | Youth Version (Age) | Format of Item Administration | Format of Response Style | Cost and Access | Administration Time (for full interview in minutes) | Rater Qualifications and Training |
| Child and Adolescent Psychiatric Assessment (CAPA) | Parent and Child | 9-18 | 9-18 | Structured with the option for additional semi-structured inquires | Close-Ended (Y/N) Mix of Close-Ended (Likert) and Open-Ended | Information available through the Developmental Epidemiology Center at Duke University | 60-120 | Bachelor’s degree plus required training by individuals trained on this interview (Angold & Costello, 2000) |
| Children’s Interview for Psychiatric Syndromes (ChIPS) | Parent or Child | 6-18 | 6-18 | Structured with the option for additional semi-structured inquires | Close-Ended (Y/N) | Approximately $90; Available through various retailers | 20-50 | Trained lay person supervised by a licensed clinician. Administration manual includes training materials. (Weller, Weller, Fristad, Rooney, & Schecter, 2000) |
| Diagnostic Individual Schedule for Children IV (DISC-IV) | Parent or Child | 6-17 | 9-17 | Structured | Close-Ended (Y/N) | Ranges from $150-$2000 per computer installation; Charge for paper version is minimal to cover copying and mailing expenses; email disc@worldnet.att.net | 90-120 | Lay person with supervision by a licensed clinician. Training is strongly recommended. Details on training available by contacting (“NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some... - PubMed - NCBI,” n.d.) |
| K-SADS-PL 2009 | Parent and Child | 6-18 | 6-18 | Semi-Structured | Close-Ended (Likert) and Open-Ended | Free for download and use if specific criteria met | 90 | Trained professional; Training is required |
| Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KIDS) | Parent or Child | 6-17 | 13-17 | Structured | Close-Ended (Y/N) | Free for download and use if specific criteria met | 15-50 minutes | Trained lay person supervised by a licensed clinician. Training by licensed clinician is recommended. http://harmresearch.org/index.php/mini-international-neuropsychiatric-interview-mini/ (Sheehan et al., 1998) |
| Patient Health Questionnaire 9 (PHQ-9) | Self | 18+ | | Self Report | Close-Ended (Likert) | Free for download and use if specific criteria met | 3-5 minutes | No training required. Available for free online here |

### Severity scales for adolescent depression

Diagnostic instruments for adolescent depression :
| Measure | Informant | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
| Children's Depression Rating Scale - Revised (CDRS-R) | Parent | Structured Interview | 6-12 | 15-20 minutes | G | A | G | G | X, GATW2 | Link to purchase CDRS-R PDF (excerpt) |
| Children's Depression Inventory 2 (CDI-2) | Youth and Parent | Questionnaire | 7-17 | 15-20 minutes | G | A | G | A | GATW2 | Link to purchase CDI |
| Reynolds Child Depression Scale 2 (RCDS-2) | Youth | Questionnaire | 7-13 | 5-10 minutes | G | G | G | A | | Link to purchase RCDS-2 |
| Reynolds Adolescent Depression Scale 2 (RADS-2) | Youth | Questionnaire | 13-17 | 5-10 minutes | G | G | G | A | GATW2 | Link to purchase RADS-2 |
| Revised Children's Anxiety and Depression Scale (RCADS) | Youth | Questionnaire | 6-18 | 12 minutes | A | A | G | A | X | Link to download RCADS |
| Schedule for Affective Disorders and Schizophrenia for School Aged Children (K-SADS) | Youth | semi-structured interview | 6-18 | ~15 minutes | G | | G | G | Yes | Link to free download |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process phase

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

   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.
   * Mood and Energy Thermometer
   * Mood and Energy Thermometer with Anger and Anxiety (with recording/monitoring card)
   * Mood and Energy Thermometer with Anger and Anxiety - Simplified Version
   B. Life Charts
   * To learn more about how life charts can be used with adolescent depression, see here
   * Life Charts for Depression and Bipolar

### Outcome and severity measures

* 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 | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms ||||||||
| | | A | B | C | 95% | 90% | SE$_{difference}$ |
| Beck Depression Inventory-II | | 4 | 22 | 15 | 9 | 8 | 4.8 |
| CBCL T-scores (2001 Norms) | Total | 49 | 70 | 58 | 5 | 4 | 2.4 |
| Benchmarks Based on Mood Samples ||||||||
| Gracious et al., 2002 ||||||||
| Young Mania Rating Scale - Parent (Full) | n/a | 5.2 | 22.1 | 14.4 | 4.3 | 3.6 | 2 |
| Young Mania Rating Scale - Parent (Brief) | n/a | 6.8 | 27.4 | 17.5 | 5 | 4.2 | 2.5 |
4.1.b – Beck Depression Inventory- II, ages 13 and up
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

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. Additionally, medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) have presented concerns about increasing suicidality and harmful behavior. 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.
* 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.

## External Resources

* ICD-10 diagnostic criteria
* Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
* NIMH (information about adolescent depression)
* John's Hopkins Resource Guide (a guide about adolescent depression, treatment, and more)
* OMIM (Online Mendelian Inheritance in Man)
** 608516
** 608520
** 608691
* eMedicine entry for adult depression
* Effective Child Therapy
** 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.