The Johns Hopkins Depression Scale: Normative Data and Validation in Child Psychiatry Patients PARAMJIT T. JOSHI , M .D ., JOSEPH A . CAPOZZOLI, R.N. ,
AND
JOS EPH T. COYLE, M .D.
Abstract. With a newly devised 38-item symptom checklist based upon DSM-1I1 criteria for major affective disorder . norm ative data were obtained on 1.004 school children. aged 5 to 13 years . The items on the checklist were sco red on a seve rity scale of 0 to 4 with a maximum score of 152. The average raw scores in this populat ion was 31.2 . SO ± 2.4 . Of 57 inpatients. 27 met DSM ·1lJ criteria for a major affective disorder and obtain ed mean raw scores of 66 .8. SO ± 13.4. The 30 nondeprcsscd inpatients had score s of 36.4. SO ± 5.3. The dif ferenc es in the raw scores between the depre ssed inpatients and normal control s, and depressed and nondepres sed inpatients were found to be statistically significant (p < 0 .0 I). The new checkl ist can serve as a potent ial screening instrument , is not time co nsuming, and has been stand ardized on a large normal control population for age and sex. J . Am . Acad . Child Adolesc. Psychiatry. 1990, 29, 2:283- 288 . Key Words: Depre ssion Rating Scale , major affective disorder, normative mood data. time. Thus, it is noteworthy that self-rating instruments , such as the Beck Depre ssion Scale (Albert and Beck , 1975), have resulted in the finding of a prevalence of serious depres sion in adoles cents of up to 33%, whereas more objective measurements suggest a much lower prevalence of major affecti ve disorder of approximately I % to 2% (Kashani and Simonds, 1979). Thus, a rating instru ment that reliably assists in identifying serious depre ssion in children and adole scent s, and in measuring symptom change during treatment . would repre sent a significant benefit to the field . In the present study , the authors have attempted to develop a rating instrument , based upon the diagno stic criteria of DSM-Ill that could be applied to children and adole scents when admini stered by parents or by others with detailed knowledge of their behavior (APA, 1980). Based upon clinical experience, the diagnostic criteria of DSM-Il! for major depression were transformed into endorsable statements relevant to child and adolescent psychopathology . Symptoms of depression addressed in the rating scale include cognit ive, affective, and vegetative symptoms as they are manifested in this age group. The present study examines the ability of this rating scale to differentiate children hospitalized on a psychiatric inpatient unit who bear a consentual diagnosi s of major depressive disorder from those children with other psychiatric diagnoses. Furthermore, normative data in a study of over 1,000 school age children aged 5 to 13 year s have been developed .
Over the last decade, it has become increasingly apparent that major depressive disorder is a significant contributor to serious psychiatric disturb ance in childhood and adolescence (Rutter et al., 1970; Carlson and Strober, 1978). In fact , some data suggest that the prevalence of this disorder may be increasing (Shaffer and Fisher, 1981). In adults, selfreport of symptoms is the most frequent basis for diagnosis of affective disorder s. In this regard , rating instruments such as the Hamilton Depression Scale (Hamilton, 1960) and the structured interviews such as the Schedule for Affective Disorders and Schizophreni a (SADS) (Spitzer and Endicott , 1978) serve as broadl y validated methods for rating symptoms of depres sion and their response to treatment. In child psychiatry, a number of instruments, includin g the Beck Depres sion Scale (Beck et al . , 1961) and the Childhood Depression Inventory (Kovacs , 1981) have been developed for asses sing symptoms of depression in children . Both of these instruments rely upon self-rat ing by the patients. However, the reliabilit y of self-report of symptoms in children and adole scents is likely to be affected by a number of confounding factors. There is a lack of concordance between self-ratin g and the evaluation by parent s of depressive symptoms as suggested by Kazdin et al ., (1983). This is partially due to the fact that there are two different sources of inform ation and, more importantly, because the parents are not generally aware of their children 's depressive symptomatology . Furthermore, children ' s selfrating may be much more sensitive to immedi ate life circumstances than adults, and therefore, more variable over
Method and Procedures Instrument Design The John s Hopkin s Depre ssion Checklist for Ch ildren is a 38-item instrument which was developed from the criteria of DSM-!Il for the diagnosis of major depres sive disorder (see Append ix). The diagnostic criteria were tran sformed into descriptions of depre ssive symptoms , using langu age and terminol ogy that could be easily understood by both parents and clinici ans . The questions fall into five major symptom categories: mood, energy, behavior, somatic complaints, and vegetative symptoms. These were then , in tum, operationally defined by clinical symptoms that are observed
Accepted August 7, 1989. From the Division of Child Psychiatry, Departm ents of Psychiatry and Pediatrics, The Johns Hopkins University School of Medicine. Baltimore. Maryland . Presented in part at the 34th Annual Meeting of The Am erican Academy of Child and Adolescent Psychiatry . Washington. DC. October 1987. Reprint requests to Dr . Joshi. Director . Inpatient Services. The Johns Hopkins University. School of Medicine. CMSC 3-341. 600 N . Wolfe St .. Baltimore. MD 2 1205 . 0890 -8567/9012902-0283$02 .00/0© 1990 by the American Academy of Child and Adolescent Psychiatry .
283
JOSHI ET AL.
in children suffering from major depressive disorder based upon the clinical experience of the authors and their colleagues. A preliminary list of 42 items were then evaluated by four child psychiatrists, two psychiatric nurses, and a child psychologist with regard to their clarity and developmental relevance to these five categories and further refined to 38 items. The time period covered by the checklist is 2 weeks which is the DSM-III criteria for duration of the illness. The items on the checklist are scored on a severity scale of to 4. There are 10 items on the checklist which reflect depressive symptoms worded in the converse and hence are scored 4 to in order to determine consistency and validity of the assessments of individual raters. Thus, the maximum score on the checklist is 152 (38 x 4). Since the checklist is designed to be an objective measure, the child is not interviewed. It takes about 10 minutes to fill out the checklist and the prerequisite is that the rater be familiar with the child on a daily basis.
°
°
Normative Data The subjects for the normative data resided within the greater Baltimore area. The Board of Education in Baltimore County identified three schools in different geographical locations and population clusters, whereas the Board of Education in Baltimore City chose to randomly select children in schools across the city. In both cases, the children were attending regular classrooms and were not receiving resource help or needing special education. While information about race and socio-economic status could not be obtained in the survey, students in Baltimore County schools were predominantly white and came from families in the middle to upper middle income levels, whereas the student population in Baltimore City was over 60% black and came from families in middle to lower middle class and impoverished backgrounds. For the normative data, the aim was to select children who were not handicapped in any identified way in the school setting. In Baltimore County, the authors met personally with the principals of the three schools selected and the presidents of their respective parent-teachers associations. The checklists were passed out by the teachers to the students in their homerooms, who in tum brought them home for their parents to complete. Included with the checklist was a letter explaining the purposes and the objectives of the survey. The identity of the children remained anonymous and the schools forwarded the completed questionnaires to the authors. In Baltimore City, the Board of Education provided the authors with self-adhesive labels of children's home addresses, which were randomly picked by a computer. The cover letter and the checklist were mailed with a self-addressed, stamped envelope for their return. Patient Assessments Patients admitted to the Johns Hopkins Child Psychiatry Inpatient Unit over a 1 year period were assessed with the instrument by their primary nurse between 10 and 14 days after admission. The Child Psychiatry Inpatient Unit consists of 13 beds and is a short-term unit (average length of stay is 34 days) for the diagnosis and treatment of children 284
TABLE
1. Raw Scores Obtained on Depressed Inpatients
Age Years
Males
Females
5 0 0 2 6 0 7 3 3 I 0 8 9 0 2 10 3 2 11 5 0 I 12 2 4 13 0 Total 13 15 Total mean raw score: 66.8 SO ± 13.4
Mean Raw Scores 70.5 65.1 72.0 72.5 60.0 64.4 59.3 81.0
with severe psychiatric disorders. The upper age limit for admission is 14 years, and the average age on the unit is 9.3 years. Children are admitted regardless of sex, race, or socioeconomic status; 34% of the patients admitted over the last year came from economically disadvantaged circumstances with insurance coverage by Medical Assistance. Discharge diagnosis was based on DSM-III criteria and was arrived at by a consensus of two child psychiatrists and a child psychologist. The primary nurse-evaluator, who administered the instrument, was blind to diagnosis at the time. Results
Psychiatric Patients During the period of study, 22 children hospitalized on the psychiatric inpatient unit fulfilled the DSM -III diagnostic criteria for major affective disorder at discharge. In addition, there were five other children who fulfilled DSM-III criteria for major affective disorder, except that the duration of illness was less than 2 weeks prior to admission. These were included in the study because they fulfilled the criteria for duration of the illness by the end of the first week of hospitalization. Fourteen were males and 13 were females. Table 1 presents the data for these 27 depressed children with respect to age, sex, and scores on the depression checklist. The lowest score obtained among the 27 patients was 52 in two patients, and the highest was 123 in one patient. The mean score for this group was 66.8 ± 13.4 (± SD). In addition, 30 nondepressed inpatients, hospitalized at the same time, were studied. The mean score for this population of psychiatrically disturbed children was 36.4 ± 5.3 (± SD), which was significantly different from that of the depressed population (p < 0.01). Notably, the mean score on the checklist for the nondepressed psychiatric inpatients did not differ significantly from the mean score for the normal population. (Table 2) Normative Data From the control population, a total of 1,010 completed questionnaires were received from parents of children aged 5 to 13. The compliance rate for the County schools was 82%, whereas that from the City schools was lower with 48.4%. The higher compliance with the County schools may J. Am.Acad. Child Ado/esc. Psychiatry, 29:2, March 1990
VA LIDA T ION OF A CHILD DEPR ESSI ON SCA LE T AB L E
2. Comparison of Mea n Raw Scores ill the Three Groups Studied'
X A. B. C.
Depressed inpatients (N = 27) Non-depressed inpatients (N = 30) Normal controls (N = 1,004)
66.8 ± 36.4 ± 31.2 ±
T A BL E
3. Raw Scores Obtained all No rmal Controls Raw Scores
SD
Age (Years)
Males
Females
13.4 5.3 2.4
5 6 7 8 9 10 II 12 13 Mean scores Total mean raw score: 3 1.2 (SD
29.39 29.70 31.00 3 1.70 30.49 32.00 32.60
28.10 34. 10 26.10 31.50 32.30 28.30 28.60 32. 10 36.60 30.89
" A & B , p < O. OI. A & C, p < 0.01. B & C, NS.
reflect the direct contact with principals and member s of the parent teacher associations, or possibly, differences in educational and socio-economic status. The justification for combining the two group s of controls was to minimize the differences in the averages, since the inpatient populati on studied reflect both groups . The study population consisted of 51.8 % males and 48 .2% females. Table 3 present s the mean scores for sex and age from 5 to 13 years. The mean score for the entire populat ion was 31.2 ± 2.4 (± SD). The results were relatively uniform across the popul ation with the mean scores for males being slightly greater than that for female s and a tendency for scores to increa se slightly with age in females . Figure 1 presents the graphical distribution of the scores for the entire population. The score distribution closely approximates that of a theoretical curve for a gaussion distribution based upon the mean and standard deviation of the raw scores. Of import ance , there does not appear to be much of a " floor effect " as symmetry of distribution is relatively well perserved on the lower end of the scale. With the assumption of the normal distribution of scores, 30 children would be expected to have a score greater than 60 on this 2 SD basis (i.e., > 2 standard deviat ions above the mean). In fact, six children achieved scores in excess of 60 . Notably, their questionnaires were accompanied by letters written by their parents indicating that their child was either
D .W 34.00 31.6 1 ± 2.4 )
already under psychiatric care or had previously been treated for depression.
Discussion Rating scales have proved to be quite helpful in evaluating symptomatology in childhood psychiatri c and behavioral disorders as exemp lified by the broad use for assessing attention deficit disorder by the Conners Beha vioral Checklist, an instrument with considerable degre e of validit y and reliability (Conners, 1969). With regard to affective disorders, several instrument s have gained currenc y in measuring depressive symptoms in children and adolescents . Two commonl y used instruments are the Beck 's Depre ssion Scale (Beck et al. , 1961) and the Children' s Depression Inventory (Kovacs, 1981). Both instruments are based upon self-assessment, which while sensitive to the mood state at the time of administration , appear to suffer from a lack of attention to physiologic symptoms that are an important feature of major depressive disorder. Furthermore , recent studies suggest a rather poor correlation between depre ssive
100
~ w ., CD ::» U)
80 60
u,
0
•
40 20 0 0
FIG .
20
40
60
80
I . Raw scores on Depression Scale Normative sample.
l .Am.Acad. Child Adolesc. Psych iatry, 29:2, March 1990
285
JOSHI ET AL.
symptoms endorsed by children and adolescents in selfrating scales as compared to those rated by significant others in their lives (Kazdin et al., 1983). In the authors' own experience with children on a psychiatric inpatient unit, little constancy over time in the scores on the Children's Depression Inventory were found both in patients with and without major depressive disorder (Joshi, unpublished data). Recent years have witnessed the growing appreciation that affective disorders can occur in adolescents and prepubertal children (Chambers et aI., 1982; Puig-Antich, 1982). Evidence now indicates that the syndromic features of major depressive disorder in children do not differ from those in adults, although particular symptomatic manifestations must be understood in the developmental perspective (Carlson and Cantwell, 1982). Although detailed structured interviews are available to assist in the diagnosis of depression in children (e.g., Kiddie-SADS), there does not appear to be a simple instrument for assessing depression in children and adolescents that could be used by parents and others with intimate knowledge of the child for assistance in diagnosis and monitoring symptom change. Accordingly, the present instrument was developed on the basis of the DSMIII criteria for major depressive disorder on which symptoms were presented in the context of child or adolescent manifestations. Based upon clinical experience of the authors and evaluations by other experienced child psychiatrists, psychiatric nurses, and child psychologists, a symptom checklist with 38 items that encompassed the five major symptomatic areas of depression-mood, energy, behavior, somatic complaints, and vegetative symptoms-was developed. The symptom checklist, when applied to children hospitalized on a child psychiatry inpatient unit by their primary nurse, appeared to very effectively differentiate children independently diagnosed as suffering from major depressive disorder from those suffering from other serious psychiatric disturbances. These preliminary results suggest that the rating scale may have face validity for distinguishing major depressive disorder from other psychiatric disturbances of children and adolescents. To develop an estimate of the sensitivity of the instrument, the performance of "normal" children on the instrument as assessed by their parents was studied. Two school systems were involved in this aspect of the project, which presented a broad spectrum of socio-economic representation as well as racial background. All students were attending regular classrooms and were not receiving resource help or special education. The mean score in this population of over 1,000 children, ranging in age from 5 to 13, was 31 and the distribution of scores approached that of a normal bell-shaped curve. This mean score suggested that the average child experienced some minimal to mild symptoms
286
of depression as assessed in the parental rating. However, consistent with the gaussion nature of the distribution, some of the children exhibited few if any symptoms. Furthermore, the symmetrical gaussion distribution in the normals did not suggest a significant "floor effect" and the mean score was approximately 20% of the maximal score on the instrument. It was noteworthy that 1% of the children in the normal populations scored greater than four standard deviations above the mean, a range that overlapped with the scores of children in the inpatient study that were clinically diagnosed as suffering from major depressive disorder. In several cases, parents sent notes with the rating scales indicating that these children were currently being treated or had been treated for psychiatric problems. Recent prevalence studies have indicated that the point prevalence of major affective disorder in prepubertal children is approximately 1%, a value not inconsistent with the number of children in the present survey that exhibited scores that were highly deviant from the norm (Rutter et aI., 1976; Shaffer and Fisher, 1981). This finding suggests that the symptom checklist may also be useful as a screening instrument for identifying children in non-psychiatric settings that are at high risk for affective disorder. Of course, conclusive evidence for this would require a detailed evaluation of positive children as well as a sample from the population with scores in the normal range to determine the validity of the scores. Compared to the currently available instruments such as the K-SADS and the Children's Depression Rating Scale (CDRS) (Poznanski et al., 1979) this instrument is much less time consuming and does not need sophisticated skills. Taken together, the present, preliminary results suggest that the instrument may be a sensitive and specific way for identifying children suffering from major depressive disorder. This conclusion must, however, be tempered by the limitations of the design of the study. The inpatient assessments were carried out by psychiatric nurses who are particularly sensitive to, and skilled in, the evaluation of pathologic behaviors. In contrast, the normative data were obtained by parental evaluations in an anonymous fashion in which it is not possible to determine their comprehension of the questions or their appreciation of the symptoms that their children mayor may not exhibit. Nevertheless, the study in the schools did identify a small population of children that were sufficiently symptomatic to fall in the range of those diagnosed for major depressive disorder in the inpatient setting, and several of these were reported by their parents, in an unsolicited fashion, as suffering from significant psychiatric disturbances. Additional studies will be required to assess the validity, sensitivity, and specificity of the instrument. The authors are currently in the process of comparing the sensitivity and specificity of the instrument with the K-SADS and also studying test, retest reliability.
l.Am.Acad. Child Adolesc.Psychiatry, 29:2, March 1990
VALIDATION OF A CHILD DEPRESSION SCALE
Appendix THE JOHNS HOPKINS DEPRESSION CHECKLIST FOR CHILDREN HDCL-C
Age _ _ Grade _ _ Sex _ _ Not At All
Sometimes
Pretty Much
Very Much
All The Time
I . Complains of stomach aches
2. 3. 4. 5. 6. 7. 8. 9. 10. II .
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25 . 26. 27. 28. 29 . 30. 31. 32. 33 . 34 . 35. 36. 37. 38.
Pouts and sulks Appears happy Unable to make up his/her mind Cries often Moves slowly Complains of headache Demonstrates slow speech Spends more time with adults Talks a lot Spends time alone in room Carefree in spirit Self critical He finds it difficult to leave parents Enjoys new situations Forgetful Easily frustrated Tires easily Gets angry Hostile to others Sullen Bowel problems Cheerful in nature Nausea or vomiting Temper outbursts Neat appearance Suicidal thoughts Eats poorly Falls asleep well Refuses to go to scho ol Leaves school - "hooks" Moody or irritable Talks about fear of parent s dying Works on task enthusiastically Sleeps through the night Awakens in morning earlier than necessary Needs help from adult s Generally outgoing
Mar/83;JC: PJ Children's Inpatient Unit CMSC-4 West The Johns Hopkins Hospital Baltimore, Maryl and 21205 References American Psychiat ric Association (1980 ), Diagnostic and Statistical Manual of Mental Disorders-DSM Ill . Washington , DC: Author. Albert, N. & Beck, A. T . (1975 ), Incidence of depression in early adolescence: a preliminary study. J ournal of Youth and Adol escence. 4:301-307.
J.Am.Acad. Child Adolesc . Psychiatry, 29:2, March 1990
Beck , A. T ., Ward , C. H. , Mendelson , M. et a!' (1961) , An inventory for measur ing depression. Arch . Gell. Psychiat ry , 4:561-571. Carlson , G. A. & Cantwell, D. P. (1982 ), Diagnosis of ch ildhood depression : a compar ison of the Weinberg and DSM-III criteria . J . Am. Acad . Child Psychiatry, 3:247-250. - - Strober, M. (1978), Manic-depressive illness in early adole scence. J. Am. Acad . Child Psychiatry, 17:138-153.
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JOSHI ET AL.
Chambers, W. J., Puig-Antich, J., Tabrizi, M. A. & Davies, M. (1982), Psychotic symptoms in prepubertal major depressive disorder. Arch. Gen. Psychiatry, 39:921-927. Conners, C. K. (1969), A teacher rating scale for use in drug studies with children. Am. J. Psychiatry, 126:884-888. Hamilton, M. (1960), A rating scale for depression. J. Neurol. Neu-
rosurg. Psychiatry, 23:56-61. Kashani, J. & Simonds, J. F. (1979), The incidence of depression in children. Am. J. Psychiatry, 136:1203-1205. Kazdin, A. E., French, N. H., Unis, A. S. et al. (1983), Assessment of childhood depression: correspondence of child and parent ratings. J. Am. Acad. Child Psychiatry, 22:157-164. Kovacs, M. (1981), Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica (Basel), 46:305-315.
288
Poznanski, E. 0., Cook, S. C. & Carrol, B. J. (1979), A depression rating scale for children. Pediatrics, 64:442-50. Puig-Antich, J. (1982), Major depression and conduct disorder in prepuberty. J. Am. Acad. Child Psychiatry, 21: 118-128. Rutter, M., Graham, P., Chadwick, O. F. D. & Yule, W. (1976), Adolescent turmoil: fact or fiction. J. Child Psychol. Psychiatry, 17:35-56. Shaffer, D. & Fisher, P. (1981), The epidemiology of suicide in children and young adolescents. J. Am. Acad. Child Psychiatry, 20:545-565. Spitzer, R. L. & Endicott, J. (1978), The Schedule for Affective Disorders & Schizophrenia. New York: New York State Psychiatric Institute.
J. Am. Acad. Child Adolesc. Psychiatry, 29:2, March 1990
AND
JOS EPH T. COYLE, M .D.
Abstract. With a newly devised 38-item symptom checklist based upon DSM-1I1 criteria for major affective disorder . norm ative data were obtained on 1.004 school children. aged 5 to 13 years . The items on the checklist were sco red on a seve rity scale of 0 to 4 with a maximum score of 152. The average raw scores in this populat ion was 31.2 . SO ± 2.4 . Of 57 inpatients. 27 met DSM ·1lJ criteria for a major affective disorder and obtain ed mean raw scores of 66 .8. SO ± 13.4. The 30 nondeprcsscd inpatients had score s of 36.4. SO ± 5.3. The dif ferenc es in the raw scores between the depre ssed inpatients and normal control s, and depressed and nondepres sed inpatients were found to be statistically significant (p < 0 .0 I). The new checkl ist can serve as a potent ial screening instrument , is not time co nsuming, and has been stand ardized on a large normal control population for age and sex. J . Am . Acad . Child Adolesc. Psychiatry. 1990, 29, 2:283- 288 . Key Words: Depre ssion Rating Scale , major affective disorder, normative mood data. time. Thus, it is noteworthy that self-rating instruments , such as the Beck Depre ssion Scale (Albert and Beck , 1975), have resulted in the finding of a prevalence of serious depres sion in adoles cents of up to 33%, whereas more objective measurements suggest a much lower prevalence of major affecti ve disorder of approximately I % to 2% (Kashani and Simonds, 1979). Thus, a rating instru ment that reliably assists in identifying serious depre ssion in children and adole scent s, and in measuring symptom change during treatment . would repre sent a significant benefit to the field . In the present study , the authors have attempted to develop a rating instrument , based upon the diagno stic criteria of DSM-Ill that could be applied to children and adole scents when admini stered by parents or by others with detailed knowledge of their behavior (APA, 1980). Based upon clinical experience, the diagnostic criteria of DSM-Il! for major depression were transformed into endorsable statements relevant to child and adolescent psychopathology . Symptoms of depression addressed in the rating scale include cognit ive, affective, and vegetative symptoms as they are manifested in this age group. The present study examines the ability of this rating scale to differentiate children hospitalized on a psychiatric inpatient unit who bear a consentual diagnosi s of major depressive disorder from those children with other psychiatric diagnoses. Furthermore, normative data in a study of over 1,000 school age children aged 5 to 13 year s have been developed .
Over the last decade, it has become increasingly apparent that major depressive disorder is a significant contributor to serious psychiatric disturb ance in childhood and adolescence (Rutter et al., 1970; Carlson and Strober, 1978). In fact , some data suggest that the prevalence of this disorder may be increasing (Shaffer and Fisher, 1981). In adults, selfreport of symptoms is the most frequent basis for diagnosis of affective disorder s. In this regard , rating instruments such as the Hamilton Depression Scale (Hamilton, 1960) and the structured interviews such as the Schedule for Affective Disorders and Schizophreni a (SADS) (Spitzer and Endicott , 1978) serve as broadl y validated methods for rating symptoms of depres sion and their response to treatment. In child psychiatry, a number of instruments, includin g the Beck Depres sion Scale (Beck et al . , 1961) and the Childhood Depression Inventory (Kovacs , 1981) have been developed for asses sing symptoms of depression in children . Both of these instruments rely upon self-rat ing by the patients. However, the reliabilit y of self-report of symptoms in children and adole scents is likely to be affected by a number of confounding factors. There is a lack of concordance between self-ratin g and the evaluation by parent s of depressive symptoms as suggested by Kazdin et al ., (1983). This is partially due to the fact that there are two different sources of inform ation and, more importantly, because the parents are not generally aware of their children 's depressive symptomatology . Furthermore, children ' s selfrating may be much more sensitive to immedi ate life circumstances than adults, and therefore, more variable over
Method and Procedures Instrument Design The John s Hopkin s Depre ssion Checklist for Ch ildren is a 38-item instrument which was developed from the criteria of DSM-!Il for the diagnosis of major depres sive disorder (see Append ix). The diagnostic criteria were tran sformed into descriptions of depre ssive symptoms , using langu age and terminol ogy that could be easily understood by both parents and clinici ans . The questions fall into five major symptom categories: mood, energy, behavior, somatic complaints, and vegetative symptoms. These were then , in tum, operationally defined by clinical symptoms that are observed
Accepted August 7, 1989. From the Division of Child Psychiatry, Departm ents of Psychiatry and Pediatrics, The Johns Hopkins University School of Medicine. Baltimore. Maryland . Presented in part at the 34th Annual Meeting of The Am erican Academy of Child and Adolescent Psychiatry . Washington. DC. October 1987. Reprint requests to Dr . Joshi. Director . Inpatient Services. The Johns Hopkins University. School of Medicine. CMSC 3-341. 600 N . Wolfe St .. Baltimore. MD 2 1205 . 0890 -8567/9012902-0283$02 .00/0© 1990 by the American Academy of Child and Adolescent Psychiatry .
283
JOSHI ET AL.
in children suffering from major depressive disorder based upon the clinical experience of the authors and their colleagues. A preliminary list of 42 items were then evaluated by four child psychiatrists, two psychiatric nurses, and a child psychologist with regard to their clarity and developmental relevance to these five categories and further refined to 38 items. The time period covered by the checklist is 2 weeks which is the DSM-III criteria for duration of the illness. The items on the checklist are scored on a severity scale of to 4. There are 10 items on the checklist which reflect depressive symptoms worded in the converse and hence are scored 4 to in order to determine consistency and validity of the assessments of individual raters. Thus, the maximum score on the checklist is 152 (38 x 4). Since the checklist is designed to be an objective measure, the child is not interviewed. It takes about 10 minutes to fill out the checklist and the prerequisite is that the rater be familiar with the child on a daily basis.
°
°
Normative Data The subjects for the normative data resided within the greater Baltimore area. The Board of Education in Baltimore County identified three schools in different geographical locations and population clusters, whereas the Board of Education in Baltimore City chose to randomly select children in schools across the city. In both cases, the children were attending regular classrooms and were not receiving resource help or needing special education. While information about race and socio-economic status could not be obtained in the survey, students in Baltimore County schools were predominantly white and came from families in the middle to upper middle income levels, whereas the student population in Baltimore City was over 60% black and came from families in middle to lower middle class and impoverished backgrounds. For the normative data, the aim was to select children who were not handicapped in any identified way in the school setting. In Baltimore County, the authors met personally with the principals of the three schools selected and the presidents of their respective parent-teachers associations. The checklists were passed out by the teachers to the students in their homerooms, who in tum brought them home for their parents to complete. Included with the checklist was a letter explaining the purposes and the objectives of the survey. The identity of the children remained anonymous and the schools forwarded the completed questionnaires to the authors. In Baltimore City, the Board of Education provided the authors with self-adhesive labels of children's home addresses, which were randomly picked by a computer. The cover letter and the checklist were mailed with a self-addressed, stamped envelope for their return. Patient Assessments Patients admitted to the Johns Hopkins Child Psychiatry Inpatient Unit over a 1 year period were assessed with the instrument by their primary nurse between 10 and 14 days after admission. The Child Psychiatry Inpatient Unit consists of 13 beds and is a short-term unit (average length of stay is 34 days) for the diagnosis and treatment of children 284
TABLE
1. Raw Scores Obtained on Depressed Inpatients
Age Years
Males
Females
5 0 0 2 6 0 7 3 3 I 0 8 9 0 2 10 3 2 11 5 0 I 12 2 4 13 0 Total 13 15 Total mean raw score: 66.8 SO ± 13.4
Mean Raw Scores 70.5 65.1 72.0 72.5 60.0 64.4 59.3 81.0
with severe psychiatric disorders. The upper age limit for admission is 14 years, and the average age on the unit is 9.3 years. Children are admitted regardless of sex, race, or socioeconomic status; 34% of the patients admitted over the last year came from economically disadvantaged circumstances with insurance coverage by Medical Assistance. Discharge diagnosis was based on DSM-III criteria and was arrived at by a consensus of two child psychiatrists and a child psychologist. The primary nurse-evaluator, who administered the instrument, was blind to diagnosis at the time. Results
Psychiatric Patients During the period of study, 22 children hospitalized on the psychiatric inpatient unit fulfilled the DSM -III diagnostic criteria for major affective disorder at discharge. In addition, there were five other children who fulfilled DSM-III criteria for major affective disorder, except that the duration of illness was less than 2 weeks prior to admission. These were included in the study because they fulfilled the criteria for duration of the illness by the end of the first week of hospitalization. Fourteen were males and 13 were females. Table 1 presents the data for these 27 depressed children with respect to age, sex, and scores on the depression checklist. The lowest score obtained among the 27 patients was 52 in two patients, and the highest was 123 in one patient. The mean score for this group was 66.8 ± 13.4 (± SD). In addition, 30 nondepressed inpatients, hospitalized at the same time, were studied. The mean score for this population of psychiatrically disturbed children was 36.4 ± 5.3 (± SD), which was significantly different from that of the depressed population (p < 0.01). Notably, the mean score on the checklist for the nondepressed psychiatric inpatients did not differ significantly from the mean score for the normal population. (Table 2) Normative Data From the control population, a total of 1,010 completed questionnaires were received from parents of children aged 5 to 13. The compliance rate for the County schools was 82%, whereas that from the City schools was lower with 48.4%. The higher compliance with the County schools may J. Am.Acad. Child Ado/esc. Psychiatry, 29:2, March 1990
VA LIDA T ION OF A CHILD DEPR ESSI ON SCA LE T AB L E
2. Comparison of Mea n Raw Scores ill the Three Groups Studied'
X A. B. C.
Depressed inpatients (N = 27) Non-depressed inpatients (N = 30) Normal controls (N = 1,004)
66.8 ± 36.4 ± 31.2 ±
T A BL E
3. Raw Scores Obtained all No rmal Controls Raw Scores
SD
Age (Years)
Males
Females
13.4 5.3 2.4
5 6 7 8 9 10 II 12 13 Mean scores Total mean raw score: 3 1.2 (SD
29.39 29.70 31.00 3 1.70 30.49 32.00 32.60
28.10 34. 10 26.10 31.50 32.30 28.30 28.60 32. 10 36.60 30.89
" A & B , p < O. OI. A & C, p < 0.01. B & C, NS.
reflect the direct contact with principals and member s of the parent teacher associations, or possibly, differences in educational and socio-economic status. The justification for combining the two group s of controls was to minimize the differences in the averages, since the inpatient populati on studied reflect both groups . The study population consisted of 51.8 % males and 48 .2% females. Table 3 present s the mean scores for sex and age from 5 to 13 years. The mean score for the entire populat ion was 31.2 ± 2.4 (± SD). The results were relatively uniform across the popul ation with the mean scores for males being slightly greater than that for female s and a tendency for scores to increa se slightly with age in females . Figure 1 presents the graphical distribution of the scores for the entire population. The score distribution closely approximates that of a theoretical curve for a gaussion distribution based upon the mean and standard deviation of the raw scores. Of import ance , there does not appear to be much of a " floor effect " as symmetry of distribution is relatively well perserved on the lower end of the scale. With the assumption of the normal distribution of scores, 30 children would be expected to have a score greater than 60 on this 2 SD basis (i.e., > 2 standard deviat ions above the mean). In fact, six children achieved scores in excess of 60 . Notably, their questionnaires were accompanied by letters written by their parents indicating that their child was either
D .W 34.00 31.6 1 ± 2.4 )
already under psychiatric care or had previously been treated for depression.
Discussion Rating scales have proved to be quite helpful in evaluating symptomatology in childhood psychiatri c and behavioral disorders as exemp lified by the broad use for assessing attention deficit disorder by the Conners Beha vioral Checklist, an instrument with considerable degre e of validit y and reliability (Conners, 1969). With regard to affective disorders, several instrument s have gained currenc y in measuring depressive symptoms in children and adolescents . Two commonl y used instruments are the Beck 's Depre ssion Scale (Beck et al. , 1961) and the Children' s Depression Inventory (Kovacs, 1981). Both instruments are based upon self-assessment, which while sensitive to the mood state at the time of administration , appear to suffer from a lack of attention to physiologic symptoms that are an important feature of major depressive disorder. Furthermore , recent studies suggest a rather poor correlation between depre ssive
100
~ w ., CD ::» U)
80 60
u,
0
•
40 20 0 0
FIG .
20
40
60
80
I . Raw scores on Depression Scale Normative sample.
l .Am.Acad. Child Adolesc. Psych iatry, 29:2, March 1990
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symptoms endorsed by children and adolescents in selfrating scales as compared to those rated by significant others in their lives (Kazdin et al., 1983). In the authors' own experience with children on a psychiatric inpatient unit, little constancy over time in the scores on the Children's Depression Inventory were found both in patients with and without major depressive disorder (Joshi, unpublished data). Recent years have witnessed the growing appreciation that affective disorders can occur in adolescents and prepubertal children (Chambers et aI., 1982; Puig-Antich, 1982). Evidence now indicates that the syndromic features of major depressive disorder in children do not differ from those in adults, although particular symptomatic manifestations must be understood in the developmental perspective (Carlson and Cantwell, 1982). Although detailed structured interviews are available to assist in the diagnosis of depression in children (e.g., Kiddie-SADS), there does not appear to be a simple instrument for assessing depression in children and adolescents that could be used by parents and others with intimate knowledge of the child for assistance in diagnosis and monitoring symptom change. Accordingly, the present instrument was developed on the basis of the DSMIII criteria for major depressive disorder on which symptoms were presented in the context of child or adolescent manifestations. Based upon clinical experience of the authors and evaluations by other experienced child psychiatrists, psychiatric nurses, and child psychologists, a symptom checklist with 38 items that encompassed the five major symptomatic areas of depression-mood, energy, behavior, somatic complaints, and vegetative symptoms-was developed. The symptom checklist, when applied to children hospitalized on a child psychiatry inpatient unit by their primary nurse, appeared to very effectively differentiate children independently diagnosed as suffering from major depressive disorder from those suffering from other serious psychiatric disturbances. These preliminary results suggest that the rating scale may have face validity for distinguishing major depressive disorder from other psychiatric disturbances of children and adolescents. To develop an estimate of the sensitivity of the instrument, the performance of "normal" children on the instrument as assessed by their parents was studied. Two school systems were involved in this aspect of the project, which presented a broad spectrum of socio-economic representation as well as racial background. All students were attending regular classrooms and were not receiving resource help or special education. The mean score in this population of over 1,000 children, ranging in age from 5 to 13, was 31 and the distribution of scores approached that of a normal bell-shaped curve. This mean score suggested that the average child experienced some minimal to mild symptoms
286
of depression as assessed in the parental rating. However, consistent with the gaussion nature of the distribution, some of the children exhibited few if any symptoms. Furthermore, the symmetrical gaussion distribution in the normals did not suggest a significant "floor effect" and the mean score was approximately 20% of the maximal score on the instrument. It was noteworthy that 1% of the children in the normal populations scored greater than four standard deviations above the mean, a range that overlapped with the scores of children in the inpatient study that were clinically diagnosed as suffering from major depressive disorder. In several cases, parents sent notes with the rating scales indicating that these children were currently being treated or had been treated for psychiatric problems. Recent prevalence studies have indicated that the point prevalence of major affective disorder in prepubertal children is approximately 1%, a value not inconsistent with the number of children in the present survey that exhibited scores that were highly deviant from the norm (Rutter et aI., 1976; Shaffer and Fisher, 1981). This finding suggests that the symptom checklist may also be useful as a screening instrument for identifying children in non-psychiatric settings that are at high risk for affective disorder. Of course, conclusive evidence for this would require a detailed evaluation of positive children as well as a sample from the population with scores in the normal range to determine the validity of the scores. Compared to the currently available instruments such as the K-SADS and the Children's Depression Rating Scale (CDRS) (Poznanski et al., 1979) this instrument is much less time consuming and does not need sophisticated skills. Taken together, the present, preliminary results suggest that the instrument may be a sensitive and specific way for identifying children suffering from major depressive disorder. This conclusion must, however, be tempered by the limitations of the design of the study. The inpatient assessments were carried out by psychiatric nurses who are particularly sensitive to, and skilled in, the evaluation of pathologic behaviors. In contrast, the normative data were obtained by parental evaluations in an anonymous fashion in which it is not possible to determine their comprehension of the questions or their appreciation of the symptoms that their children mayor may not exhibit. Nevertheless, the study in the schools did identify a small population of children that were sufficiently symptomatic to fall in the range of those diagnosed for major depressive disorder in the inpatient setting, and several of these were reported by their parents, in an unsolicited fashion, as suffering from significant psychiatric disturbances. Additional studies will be required to assess the validity, sensitivity, and specificity of the instrument. The authors are currently in the process of comparing the sensitivity and specificity of the instrument with the K-SADS and also studying test, retest reliability.
l.Am.Acad. Child Adolesc.Psychiatry, 29:2, March 1990
VALIDATION OF A CHILD DEPRESSION SCALE
Appendix THE JOHNS HOPKINS DEPRESSION CHECKLIST FOR CHILDREN HDCL-C
Age _ _ Grade _ _ Sex _ _ Not At All
Sometimes
Pretty Much
Very Much
All The Time
I . Complains of stomach aches
2. 3. 4. 5. 6. 7. 8. 9. 10. II .
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25 . 26. 27. 28. 29 . 30. 31. 32. 33 . 34 . 35. 36. 37. 38.
Pouts and sulks Appears happy Unable to make up his/her mind Cries often Moves slowly Complains of headache Demonstrates slow speech Spends more time with adults Talks a lot Spends time alone in room Carefree in spirit Self critical He finds it difficult to leave parents Enjoys new situations Forgetful Easily frustrated Tires easily Gets angry Hostile to others Sullen Bowel problems Cheerful in nature Nausea or vomiting Temper outbursts Neat appearance Suicidal thoughts Eats poorly Falls asleep well Refuses to go to scho ol Leaves school - "hooks" Moody or irritable Talks about fear of parent s dying Works on task enthusiastically Sleeps through the night Awakens in morning earlier than necessary Needs help from adult s Generally outgoing
Mar/83;JC: PJ Children's Inpatient Unit CMSC-4 West The Johns Hopkins Hospital Baltimore, Maryl and 21205 References American Psychiat ric Association (1980 ), Diagnostic and Statistical Manual of Mental Disorders-DSM Ill . Washington , DC: Author. Albert, N. & Beck, A. T . (1975 ), Incidence of depression in early adolescence: a preliminary study. J ournal of Youth and Adol escence. 4:301-307.
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Beck , A. T ., Ward , C. H. , Mendelson , M. et a!' (1961) , An inventory for measur ing depression. Arch . Gell. Psychiat ry , 4:561-571. Carlson , G. A. & Cantwell, D. P. (1982 ), Diagnosis of ch ildhood depression : a compar ison of the Weinberg and DSM-III criteria . J . Am. Acad . Child Psychiatry, 3:247-250. - - Strober, M. (1978), Manic-depressive illness in early adole scence. J. Am. Acad . Child Psychiatry, 17:138-153.
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Chambers, W. J., Puig-Antich, J., Tabrizi, M. A. & Davies, M. (1982), Psychotic symptoms in prepubertal major depressive disorder. Arch. Gen. Psychiatry, 39:921-927. Conners, C. K. (1969), A teacher rating scale for use in drug studies with children. Am. J. Psychiatry, 126:884-888. Hamilton, M. (1960), A rating scale for depression. J. Neurol. Neu-
rosurg. Psychiatry, 23:56-61. Kashani, J. & Simonds, J. F. (1979), The incidence of depression in children. Am. J. Psychiatry, 136:1203-1205. Kazdin, A. E., French, N. H., Unis, A. S. et al. (1983), Assessment of childhood depression: correspondence of child and parent ratings. J. Am. Acad. Child Psychiatry, 22:157-164. Kovacs, M. (1981), Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica (Basel), 46:305-315.
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Poznanski, E. 0., Cook, S. C. & Carrol, B. J. (1979), A depression rating scale for children. Pediatrics, 64:442-50. Puig-Antich, J. (1982), Major depression and conduct disorder in prepuberty. J. Am. Acad. Child Psychiatry, 21: 118-128. Rutter, M., Graham, P., Chadwick, O. F. D. & Yule, W. (1976), Adolescent turmoil: fact or fiction. J. Child Psychol. Psychiatry, 17:35-56. Shaffer, D. & Fisher, P. (1981), The epidemiology of suicide in children and young adolescents. J. Am. Acad. Child Psychiatry, 20:545-565. Spitzer, R. L. & Endicott, J. (1978), The Schedule for Affective Disorders & Schizophrenia. New York: New York State Psychiatric Institute.
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