Depression in Hospitalized Child Psvchiatrv Patients J
J
Approaches to Measuring Depression
Theodore A . Petti, M.D.
Abstract. Depression in childhood remains a controversial issue in psychiatry. This paper reviews the present heterogeneous approach to defining depression in children and attempts a critical discussion of scales that have been proposed to diagnose depression and measure changes in its course. Scales which have statistically significant agreement with each other, and/or with the clinician’s impression of depression are detailed; and those measuring related phenomena are piesented. Dii-ections for future research are also provided.
Depression as a childhood phenomenon has appeared with increasing frequency in the psychiatric and pediatric literature and is prototypical of the problems confronting child psychiatry today in its move from art to science. Hard facts are difficult to establish in a system so fluid as that of the developing child, 6 to 12 years old, where consensus regarding even descriptive diagnosis remains unsatisfactory and elusive. A wide spectrum of opinion and dogma exists concerning depression in childhood. Some workers (Mahler, 1961; Rie, 1966) deny its existence; sotne see its presence in seemingly the whole spectrum of childhood psychopathology (Murray, 1970); while others have attempted to limit it to more specific criDr. Petti s i Assistant Professor of Child Psychiatry at the Unliwrsity of Pittsburgh School of Medicine and Director of the Children’s P.yyrhiatrir Intensizle Care S m i c e at Wertern Psychiatric Institute and Clinic. This work was begun whik the author was a fellow in Child and Adolescent P.rychiatq, NYUBellmue Medical Center, New York, and presented at the Annual Meeting of the American Academy of Child Psychiat?, October 1976. I m h to thank Drs. M . Campbell, M . Hnssibi, C. Koh, T. Shapiro, and M . S?monds (New York), S . Kupietz (Brooklyn),C . K . Conners (Pittsburgh),Ms. M . Leiberton (Pittcburgh),and the residents and staff of the Children’s liiiit Bellezrur Psychiatric Hospital for their encouragement and a.csistance. Reprints may be requested at Children’s Psychiatric Intensive Care Services, Western Psychiatric Institute and Clinic,381 I O’Hara Street, Pittsburgh, PA 15261. 002-7 138/78/1701-0049$01.02 0 1978 American Academy of Child Psychiatry
49
50
Theodore A . Petti
teria (GAP, 1966) or link it to the framework of manic-depressive illness as a clinical entity (Campbell, 1939). Unlike the classification of adult depression, where historically predominant approaches have been established, used, challenged, rejected or accepted, and adopted for research and clinical practice, no such trends have emerged in child psychiatry. T h e literature is most notable for a heterogeneous mixture of descriptive etiological classifications in which depressed affect, mood, and disorder are used interchangeably. A major difficulty in classification has been the absence of diagnostic criteria or agreement as to what constitutes depression. Rutter (1972) makes the cogent point that misery and unhappiness occur in. childhood as does depression, but that unhappiness as a sytnptotn and depressive illness are not synonymous. Rutter considers the question of whether depression in childhood differs from that of the adult form to be the most important issue and suggests, as does Conners (1 976), that comparing children with depressive symptoms by cluster or component analysis might lead to a more systematic method of differentiating children with depressive symptoms from those with depressive disorders.
CRITERIA FOR DEPRESSION An objective of this paper is to present a critical review of the literature concerned with defining depression in children with reference to identifying and measuring changes in depressive symptornatology through the use of specific criteria or scales. T h e criteria for making the diagnosis of childhood depression vary greatly, and a sense of amorphous nonspecificity pervades the literature. Frommer ( 1968), for instance, views childhood depression as presenting usually as a nonspecific somatic malaise, much less often as “obviously psychological-undue anxiety and nervousness, phobias, . . . obsessional behavior and rituals or tics” (p. 117), and least often as depression, possibly including suicidal ideation. In contrast, Poznanski and Zrull ( 1 970) require the expression of an affective state of chronic unhappiness or sadness as essential to the diagnosis. Glaser (1967) describes “masked depressions” of children and accepts depression as existing when expressed feelings of hopelessness, helplessness, inadequacy, worthlessness, rejection by others, and isolation d o not correspond to the patient’s immediate environment or the examiner’s observation of the actual situation. “Depressive equivalents” are described by Toolan (1 962) as manifesta-
Depression in Hospitalized Children
51
tions of depression leading to an inference of its existence, but his criteria in particular suffer from lack of specificity and typify the majority of literature concerning dysphoric moods in childhood.
PROPOSED SCALES FOR DIAGNOSIS A N D MEASUREMENT Specajicf o r Depression Lucas et al. (1963) developed a 9-item depression rating scale which nurses completed daily for a heterogeneous population of children and adolescents. T h e listed items were loaded toward depressive equivalents and were not accompanied by descriptions to aid in generalization of its use. T h e diagnosis of the developmentally overlapping subtypes of depression proposed by McConville et al. ( 1973) and McConville and Boag ( 1976) is based on a 15item questionnaire. Relying heavily on the verbal productions of children in a residential facility, the examiner scores each item from 0 (absent) to 2 (mentioned often) during the first weeks of inpatient assessment. An arbitrary cutoff of 5 points has been chosen. T h e affective subtype is depicted by such items as sadness, crying, helplessness, hopelessness, and separation and nurturance concerns. It is most common in depressed children aged 6 to 8 years. T h e negative self-esteem items are more commonly found in children aged 8 to 12 years, and include demeaned self-estimate, low estimate of self-worth to others, and assumption of continuing failure or misfortune. T h e third or guilt depression subtype was found to be uncommon and generally follows a loss that began after the age of 10 years. T h e items include exclusive guilt, passive and active thoughts of self-destruction, and restitution with the lost one. In the setting from which it was developed, this seems to be a particularly good scale to screen for the presence or absence of depression. Interrater reliability was high in the ratings of depression. It finds its limits when it needs to be used to evaluate or measure change in outpatients or children hospitalized in acute care facilities. Cytryn and McKnew (1974) postulate a hierarchy of depressive development: at the basic level of fantasy, prior to verbalization or manifestation of depressed mood, depressive themes predominate-as in the so-called masked depressions. When the fantasy defense fails to operate and the factors causing the depression fail to be resolved, then depressive verbalizations occur. This, they contend, is present in most children manifesting an acute depressive reaction or in some recovering from a chronic depressive reaction.
52
Theodore A . Petti
When, over time, the second-level defenses fail, the depression is manifested by depressive mood and behavior. This is typical of the chronic depression or early stages of acute reaction. T h e authors also assert that in carefully studied cases of resolving depression the third level is first resolved, usually followed by the verbal level of manifest depression, and the fantasy level clears usually only after resolution of depressive conflict. T h e scale they have developed measures three categories of mood and affect: mood and behavior; talk; and fantasy. Each of these is divided along a continuum of depression to mania from high (scored as 9, 8, 7) to moderate, to low (scored as 3, 2, l ) , to absent. Each subsection contains a written description: e.g., “talk” scored as high in depression is described as “talk of suicide, being killed, abandoned, hopeless”; moderate for mood and behavior, as “dejected, occasionally teary-eyed, voice monotone with little inflection”; low in fantasy, as “disappointed, thwarted, mistreated, excluded, blamed, criticized” (Rapoport, 1976). A like continuutn is presented for the hypomanic end of the scale. Adequate interrater reliability utilizing the scale on a large sample of outpatient children has been demonstrated (Riddle and Rapoport, 1976). A major problem in accepting this manner of following the course of childhood depression or even of making the diagnosis lies in the subjective nature of defining or measuring the first or fantasy level of the depressive pyramid. Such themes as mistreatment, thwarting, blame o r criticism may constitute aspects of depression, but may also be related to anxiety or variants of acceptable fantasy for the child’s age group. In a theoretical framework in which the investigators postulate the predictability of the manifestations of depression throughout the various phases of the life cycle, the most telling objection is the observation of early latencyaged children who clearly manifest depressed mood, behavior, and verbalizations, without showing depressive affect on the fantasy level. Moreover, many older prepubertal children, manifestly depressed, are unable to produce fantasy material. T h e fact that fantasy material cannot be elicited from a child may be a prime indicator of the depth of the depression the child is experiencing. An earlier approach to diagnosing depression in children is that of Christe (1966). Depression was diagnosed on the basis of a clinical exam and the child’s response on the Koch test-a draw-a-tree test. Evaluation of the drawing consisted of a subjective analysis and included a formal statistical analysis of the size of various parts of the tree. Elaborate tables are provided by the author. T h e test itself has not found wide acceptance.
Depression in Hospitalized Children
53
Since the factors of adult and childhood depression are similar in many ways, one might expect a relative ease in adapting such adult scales of depression as the Hamilton Psychiatric Rating Scale or the Beck Depression Scale to children. Albert and Beck (1973) utilized the Beck Depression Inventory, Short Form, with a school population of 1 1- to 13-year-olds with some measured success in identifying depression. T h e sensitivity of this scale must be questioned, since in a coeducational, parochial elementary school in suburban Philadelphia, 60% of the girls and 5. 1% of the boys in the seventh grade were described as mildly or moderately depressed, and a higher level of depression was found among eighth-graders. Using an extension of this scale, the Children’s Depression Inventory (CDI), Kovacs et al. (1976) found that moderate to severe depression was relatively infrequent in a sample of 39 hospitalized psychiatric patients and 20 normal controls aged 8 to 13 years. T h e CDI is a 27-item scale, with each item consisting of statements graded from 0 (absent) to 3 (severe). T h e child’s feelings of the past week are the subject for report and are based on symptoms generally accepted as characteristic of adult depressions and include sadness, pessimism, failure, anhedonia, shame, withdrawal, insomnia. Utilizing data from a structured clinical interview, the Interview Schedule for Children (ISC), the same workers found a highly significant correlation between the clinician’s global depression rating and the scores from 20 selected items of the CDI. ISC contains 37 items of symptoms or symptom clusters including ( 1 ) those related to adult depressions: emotional, cognitive, motivational features; ( 2 ) those features cited as masking depression; and (3) i t e m such as drug abuse, current suicidal ideation, depressed demeanor, vegetative symptomatology, and aspects of mental status. Definitions are given for each item, specific questions are listed to elicit the information, and specific criteria for assessing severity are provided. Interrater reliability is reported as acceptable, but needing improvement. A depression factor was one of five factors derived from the data by component analysis. A clear difference between patient and control samples based on global depression ratings was evidenced, with 14% of the patients substantially depressed and 24% who showed mild depression compared to 3% of the nonclinic children who showed mild depression. Both the CDI and ISC have great potential for measuring and following the course of childhood depression. Another scale based on adult criteria for depression which certainly merits further use and validation is that devised by Ling et al. (1970) and refined by Weinberg et al. (1973) in which 10 cat-
54
Theodore A . Petti
egories of depressive symptomatology have been arbitrarily chosen. These include 40 items subsumed under 10 headings: dysphoric mood; self-deprecatory ideation; aggressive behavior; sleep disturbance; change in school performance; diminished socialization; change in attitude toward school; somatic complaints; loss of usual energy; and unusual changes in appetite and/or weight. To be considered depressed, a child had to have at least 1 item from each of the first 2 categories and 1 from any other 2 categories. T h e symptoms had to be of concern to the child or his parent(s), a change from the “usual self,” and present for at least one month. T h e scale, developed and used with outpatients referred to an educational-diagnostic center, could too easily rate a child as depressed who manifested symptoms only inarginally regarded as depressive, i.e., a child who at times is irritable, has beliefs of persecution, sudden anger, and incomplete homework. Even with this shortcoming, this approach has great potential in screening for depression in children. A modified version of this scale was developed at Bellevue Psychiatric Hospital, the Bellevue Index of Depression (BID). Each of the 40 items is rated for the absence or degree of severity on a scale from 0 (absent) to 3 (severe). To be considered depressed on the BID, a child must meet the criteria for the Weinberg et al. Index of Depressive Symptomatology (WIDS) and obtain a total score of 20. T h e WIDS and BID were used with children 6 to 12% years old, admitted to the Bellevue Psychiatric Hospital unit for acutely ill and emotionally disturbed children, who had communicative speech and a parent or guardian available to provide a reliable history. Both were scored using data obtained from the child, involved adults, and school-related reports. T h e presence or absence of depression as defined by the two scales was then compared to a psychiatric clinician’s impression of the presence or absence of depression. T h e clinician was not restricted by the 1-month limitation. Due to the difficulties involved in interviewing parents, two sets of procedures were instituted. In the first, I interviewed the parents and child, examined referral documents, completed the rating scales, and queried the child’s primary psychiatrist or the ward attendant concerning the presence or absence of depression in the child. This is referred to as the independent sample. When the parent o r child was not available, the child’s social worker or psychiatrist was interviewed to provide the needed data. T h e psychiatrists were not asked for criteria regarding their diagnosis of depression. From May 1974 through June 1975, 73 children were evaluated.
Depression in Hospitalized Children
55
T h e independently rated group consisted of 39, the other group of 34 children. There was little difference in results between the two samples. In table 1, the results obtained for the dependent, independent, and total samples for both scales are compared to the judgment of the clinician. There was statistically significant agreement between the clinician and the two scales for both the dependent and independent samples and for the total sample. Agreement of 89% between the WIDS and the BID scales for the total Table 1 Comparison of children rated positive or negative for depression by the WIDS (A) and the BID Scale (B) to that of the clinician in the “Dependent” sample (N = 34), the “Independent” sample ( N = 39), and total sample (N = 73), and the scales to each other (C) WIDS
(A)
Clinician Positive Negative
Dependent (N = 34) Positive Negative 18 5
4 7
p < .05 73% Agreement (B) Clinician Positive Negative
Positive Negative
Total (N = 73)
Positive
Negative
Positive
Negative
24 3
3 9
42 8
7 16
p
J
Approaches to Measuring Depression
Theodore A . Petti, M.D.
Abstract. Depression in childhood remains a controversial issue in psychiatry. This paper reviews the present heterogeneous approach to defining depression in children and attempts a critical discussion of scales that have been proposed to diagnose depression and measure changes in its course. Scales which have statistically significant agreement with each other, and/or with the clinician’s impression of depression are detailed; and those measuring related phenomena are piesented. Dii-ections for future research are also provided.
Depression as a childhood phenomenon has appeared with increasing frequency in the psychiatric and pediatric literature and is prototypical of the problems confronting child psychiatry today in its move from art to science. Hard facts are difficult to establish in a system so fluid as that of the developing child, 6 to 12 years old, where consensus regarding even descriptive diagnosis remains unsatisfactory and elusive. A wide spectrum of opinion and dogma exists concerning depression in childhood. Some workers (Mahler, 1961; Rie, 1966) deny its existence; sotne see its presence in seemingly the whole spectrum of childhood psychopathology (Murray, 1970); while others have attempted to limit it to more specific criDr. Petti s i Assistant Professor of Child Psychiatry at the Unliwrsity of Pittsburgh School of Medicine and Director of the Children’s P.yyrhiatrir Intensizle Care S m i c e at Wertern Psychiatric Institute and Clinic. This work was begun whik the author was a fellow in Child and Adolescent P.rychiatq, NYUBellmue Medical Center, New York, and presented at the Annual Meeting of the American Academy of Child Psychiat?, October 1976. I m h to thank Drs. M . Campbell, M . Hnssibi, C. Koh, T. Shapiro, and M . S?monds (New York), S . Kupietz (Brooklyn),C . K . Conners (Pittsburgh),Ms. M . Leiberton (Pittcburgh),and the residents and staff of the Children’s liiiit Bellezrur Psychiatric Hospital for their encouragement and a.csistance. Reprints may be requested at Children’s Psychiatric Intensive Care Services, Western Psychiatric Institute and Clinic,381 I O’Hara Street, Pittsburgh, PA 15261. 002-7 138/78/1701-0049$01.02 0 1978 American Academy of Child Psychiatry
49
50
Theodore A . Petti
teria (GAP, 1966) or link it to the framework of manic-depressive illness as a clinical entity (Campbell, 1939). Unlike the classification of adult depression, where historically predominant approaches have been established, used, challenged, rejected or accepted, and adopted for research and clinical practice, no such trends have emerged in child psychiatry. T h e literature is most notable for a heterogeneous mixture of descriptive etiological classifications in which depressed affect, mood, and disorder are used interchangeably. A major difficulty in classification has been the absence of diagnostic criteria or agreement as to what constitutes depression. Rutter (1972) makes the cogent point that misery and unhappiness occur in. childhood as does depression, but that unhappiness as a sytnptotn and depressive illness are not synonymous. Rutter considers the question of whether depression in childhood differs from that of the adult form to be the most important issue and suggests, as does Conners (1 976), that comparing children with depressive symptoms by cluster or component analysis might lead to a more systematic method of differentiating children with depressive symptoms from those with depressive disorders.
CRITERIA FOR DEPRESSION An objective of this paper is to present a critical review of the literature concerned with defining depression in children with reference to identifying and measuring changes in depressive symptornatology through the use of specific criteria or scales. T h e criteria for making the diagnosis of childhood depression vary greatly, and a sense of amorphous nonspecificity pervades the literature. Frommer ( 1968), for instance, views childhood depression as presenting usually as a nonspecific somatic malaise, much less often as “obviously psychological-undue anxiety and nervousness, phobias, . . . obsessional behavior and rituals or tics” (p. 117), and least often as depression, possibly including suicidal ideation. In contrast, Poznanski and Zrull ( 1 970) require the expression of an affective state of chronic unhappiness or sadness as essential to the diagnosis. Glaser (1967) describes “masked depressions” of children and accepts depression as existing when expressed feelings of hopelessness, helplessness, inadequacy, worthlessness, rejection by others, and isolation d o not correspond to the patient’s immediate environment or the examiner’s observation of the actual situation. “Depressive equivalents” are described by Toolan (1 962) as manifesta-
Depression in Hospitalized Children
51
tions of depression leading to an inference of its existence, but his criteria in particular suffer from lack of specificity and typify the majority of literature concerning dysphoric moods in childhood.
PROPOSED SCALES FOR DIAGNOSIS A N D MEASUREMENT Specajicf o r Depression Lucas et al. (1963) developed a 9-item depression rating scale which nurses completed daily for a heterogeneous population of children and adolescents. T h e listed items were loaded toward depressive equivalents and were not accompanied by descriptions to aid in generalization of its use. T h e diagnosis of the developmentally overlapping subtypes of depression proposed by McConville et al. ( 1973) and McConville and Boag ( 1976) is based on a 15item questionnaire. Relying heavily on the verbal productions of children in a residential facility, the examiner scores each item from 0 (absent) to 2 (mentioned often) during the first weeks of inpatient assessment. An arbitrary cutoff of 5 points has been chosen. T h e affective subtype is depicted by such items as sadness, crying, helplessness, hopelessness, and separation and nurturance concerns. It is most common in depressed children aged 6 to 8 years. T h e negative self-esteem items are more commonly found in children aged 8 to 12 years, and include demeaned self-estimate, low estimate of self-worth to others, and assumption of continuing failure or misfortune. T h e third or guilt depression subtype was found to be uncommon and generally follows a loss that began after the age of 10 years. T h e items include exclusive guilt, passive and active thoughts of self-destruction, and restitution with the lost one. In the setting from which it was developed, this seems to be a particularly good scale to screen for the presence or absence of depression. Interrater reliability was high in the ratings of depression. It finds its limits when it needs to be used to evaluate or measure change in outpatients or children hospitalized in acute care facilities. Cytryn and McKnew (1974) postulate a hierarchy of depressive development: at the basic level of fantasy, prior to verbalization or manifestation of depressed mood, depressive themes predominate-as in the so-called masked depressions. When the fantasy defense fails to operate and the factors causing the depression fail to be resolved, then depressive verbalizations occur. This, they contend, is present in most children manifesting an acute depressive reaction or in some recovering from a chronic depressive reaction.
52
Theodore A . Petti
When, over time, the second-level defenses fail, the depression is manifested by depressive mood and behavior. This is typical of the chronic depression or early stages of acute reaction. T h e authors also assert that in carefully studied cases of resolving depression the third level is first resolved, usually followed by the verbal level of manifest depression, and the fantasy level clears usually only after resolution of depressive conflict. T h e scale they have developed measures three categories of mood and affect: mood and behavior; talk; and fantasy. Each of these is divided along a continuum of depression to mania from high (scored as 9, 8, 7) to moderate, to low (scored as 3, 2, l ) , to absent. Each subsection contains a written description: e.g., “talk” scored as high in depression is described as “talk of suicide, being killed, abandoned, hopeless”; moderate for mood and behavior, as “dejected, occasionally teary-eyed, voice monotone with little inflection”; low in fantasy, as “disappointed, thwarted, mistreated, excluded, blamed, criticized” (Rapoport, 1976). A like continuutn is presented for the hypomanic end of the scale. Adequate interrater reliability utilizing the scale on a large sample of outpatient children has been demonstrated (Riddle and Rapoport, 1976). A major problem in accepting this manner of following the course of childhood depression or even of making the diagnosis lies in the subjective nature of defining or measuring the first or fantasy level of the depressive pyramid. Such themes as mistreatment, thwarting, blame o r criticism may constitute aspects of depression, but may also be related to anxiety or variants of acceptable fantasy for the child’s age group. In a theoretical framework in which the investigators postulate the predictability of the manifestations of depression throughout the various phases of the life cycle, the most telling objection is the observation of early latencyaged children who clearly manifest depressed mood, behavior, and verbalizations, without showing depressive affect on the fantasy level. Moreover, many older prepubertal children, manifestly depressed, are unable to produce fantasy material. T h e fact that fantasy material cannot be elicited from a child may be a prime indicator of the depth of the depression the child is experiencing. An earlier approach to diagnosing depression in children is that of Christe (1966). Depression was diagnosed on the basis of a clinical exam and the child’s response on the Koch test-a draw-a-tree test. Evaluation of the drawing consisted of a subjective analysis and included a formal statistical analysis of the size of various parts of the tree. Elaborate tables are provided by the author. T h e test itself has not found wide acceptance.
Depression in Hospitalized Children
53
Since the factors of adult and childhood depression are similar in many ways, one might expect a relative ease in adapting such adult scales of depression as the Hamilton Psychiatric Rating Scale or the Beck Depression Scale to children. Albert and Beck (1973) utilized the Beck Depression Inventory, Short Form, with a school population of 1 1- to 13-year-olds with some measured success in identifying depression. T h e sensitivity of this scale must be questioned, since in a coeducational, parochial elementary school in suburban Philadelphia, 60% of the girls and 5. 1% of the boys in the seventh grade were described as mildly or moderately depressed, and a higher level of depression was found among eighth-graders. Using an extension of this scale, the Children’s Depression Inventory (CDI), Kovacs et al. (1976) found that moderate to severe depression was relatively infrequent in a sample of 39 hospitalized psychiatric patients and 20 normal controls aged 8 to 13 years. T h e CDI is a 27-item scale, with each item consisting of statements graded from 0 (absent) to 3 (severe). T h e child’s feelings of the past week are the subject for report and are based on symptoms generally accepted as characteristic of adult depressions and include sadness, pessimism, failure, anhedonia, shame, withdrawal, insomnia. Utilizing data from a structured clinical interview, the Interview Schedule for Children (ISC), the same workers found a highly significant correlation between the clinician’s global depression rating and the scores from 20 selected items of the CDI. ISC contains 37 items of symptoms or symptom clusters including ( 1 ) those related to adult depressions: emotional, cognitive, motivational features; ( 2 ) those features cited as masking depression; and (3) i t e m such as drug abuse, current suicidal ideation, depressed demeanor, vegetative symptomatology, and aspects of mental status. Definitions are given for each item, specific questions are listed to elicit the information, and specific criteria for assessing severity are provided. Interrater reliability is reported as acceptable, but needing improvement. A depression factor was one of five factors derived from the data by component analysis. A clear difference between patient and control samples based on global depression ratings was evidenced, with 14% of the patients substantially depressed and 24% who showed mild depression compared to 3% of the nonclinic children who showed mild depression. Both the CDI and ISC have great potential for measuring and following the course of childhood depression. Another scale based on adult criteria for depression which certainly merits further use and validation is that devised by Ling et al. (1970) and refined by Weinberg et al. (1973) in which 10 cat-
54
Theodore A . Petti
egories of depressive symptomatology have been arbitrarily chosen. These include 40 items subsumed under 10 headings: dysphoric mood; self-deprecatory ideation; aggressive behavior; sleep disturbance; change in school performance; diminished socialization; change in attitude toward school; somatic complaints; loss of usual energy; and unusual changes in appetite and/or weight. To be considered depressed, a child had to have at least 1 item from each of the first 2 categories and 1 from any other 2 categories. T h e symptoms had to be of concern to the child or his parent(s), a change from the “usual self,” and present for at least one month. T h e scale, developed and used with outpatients referred to an educational-diagnostic center, could too easily rate a child as depressed who manifested symptoms only inarginally regarded as depressive, i.e., a child who at times is irritable, has beliefs of persecution, sudden anger, and incomplete homework. Even with this shortcoming, this approach has great potential in screening for depression in children. A modified version of this scale was developed at Bellevue Psychiatric Hospital, the Bellevue Index of Depression (BID). Each of the 40 items is rated for the absence or degree of severity on a scale from 0 (absent) to 3 (severe). To be considered depressed on the BID, a child must meet the criteria for the Weinberg et al. Index of Depressive Symptomatology (WIDS) and obtain a total score of 20. T h e WIDS and BID were used with children 6 to 12% years old, admitted to the Bellevue Psychiatric Hospital unit for acutely ill and emotionally disturbed children, who had communicative speech and a parent or guardian available to provide a reliable history. Both were scored using data obtained from the child, involved adults, and school-related reports. T h e presence or absence of depression as defined by the two scales was then compared to a psychiatric clinician’s impression of the presence or absence of depression. T h e clinician was not restricted by the 1-month limitation. Due to the difficulties involved in interviewing parents, two sets of procedures were instituted. In the first, I interviewed the parents and child, examined referral documents, completed the rating scales, and queried the child’s primary psychiatrist or the ward attendant concerning the presence or absence of depression in the child. This is referred to as the independent sample. When the parent o r child was not available, the child’s social worker or psychiatrist was interviewed to provide the needed data. T h e psychiatrists were not asked for criteria regarding their diagnosis of depression. From May 1974 through June 1975, 73 children were evaluated.
Depression in Hospitalized Children
55
T h e independently rated group consisted of 39, the other group of 34 children. There was little difference in results between the two samples. In table 1, the results obtained for the dependent, independent, and total samples for both scales are compared to the judgment of the clinician. There was statistically significant agreement between the clinician and the two scales for both the dependent and independent samples and for the total sample. Agreement of 89% between the WIDS and the BID scales for the total Table 1 Comparison of children rated positive or negative for depression by the WIDS (A) and the BID Scale (B) to that of the clinician in the “Dependent” sample (N = 34), the “Independent” sample ( N = 39), and total sample (N = 73), and the scales to each other (C) WIDS
(A)
Clinician Positive Negative
Dependent (N = 34) Positive Negative 18 5
4 7
p < .05 73% Agreement (B) Clinician Positive Negative
Positive Negative
Total (N = 73)
Positive
Negative
Positive
Negative
24 3
3 9
42 8
7 16
p
