“Clinical Assessment of Children and Adolescents with Depression,” Halifax, Nova Scotia, Canada; October 1, 2008 Pediatric Grand Rounds, IWK Health Centre *Although the core symptoms of depression are similar across the life span, developmental differences exist and should be taken into account in the assessment *With increasing age, there generally is an increase in melancholic symptoms, delusions, substance abuse, and suicidal ideation/attempts. *In contrast, younger children tend to have more somatic sxs, separation anxiety, behavior problems, temper tantrums, and hallucinations *Direct interviews with children and adolescents are critical because parents and teachers may not be aware of the youth’s depressive symptoms *Discrepant information between parents and their children should be solve in a cordial and non judgmental way *Assessment of suicidal and homicidal ideation and behaviors is mandatory *The interview process and screening questions utilized by research interviews such as the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (KSADS-PL) can be useful *Detection and diagnosis can be enhanced by available parent and child self-report measures

1. Clinical Assessment ofClinical Assessment of
Children and AdolescentsChildren and Adolescents
with Depressionwith Depression
Carlo G. Carandang, MDCarlo G. Carandang, MD
Diplomate, American Board ofDiplomate, American Board of
Psychiatry and NeurologyPsychiatry and Neurology
4South Inpatient Mental Health,4South Inpatient Mental Health,
IWK Health CentreIWK Health Centre

5. Key PointsKey Points
Although the core symptoms of depression are
similar across the life span, developmental
differences exist and should be taken into
account in the assessment
With increasing age, there generally is an
increase in melancholic symptoms, delusions,
substance abuse, and suicidal ideation/attempts.
In contrast, younger children tend to have more
somatic sxs, separation anxiety, behavior
problems, temper tantrums, and hallucinations

6. Key Points- cont.Key Points- cont.
Direct interviews with children and
adolescents are critical because parents
and teachers may not be aware of the
youth’s depressive symptoms
Discrepant information between parents
and their children should be solve in a
cordial and non judgmental way
Assessment of suicidal and homicidal
ideation and behaviors is mandatory

7. Key Points- cont.Key Points- cont.
The interview process and screening
questions utilized by research interviews
such as the Schedule for Affective
Disorders and Schizophrenia for School
Age Children, Present and Lifetime
Version (KSADS-PL) can be useful
Detection and diagnosis can be enhanced
by available parent and child self-report
measures

8. IntroductionIntroduction
We present a practical approach to
evaluate young persons for depression.
Much of what we do as clinicians is not
exclusively informed by evidence or hard
data.
In the end, unless a connection is made
with our young patients and their families
and unless we master the process of
assessing pediatric depression, no
amount of evidence will be applied to its
fullest.

9. Classification SystemsClassification Systems
Diagnostic and StatisticalDiagnostic and Statistical
Manual of Mental Disorders,Manual of Mental Disorders,
4th edition (DSM-IV)4th edition (DSM-IV)

This presentationThis presentation
The focus is on the DSM-IVThe focus is on the DSM-IV
depressive disorders, whichdepressive disorders, which
include major depressiveinclude major depressive
disorder and dysthymicdisorder and dysthymic
disorder.disorder.
WHO’s InternationalWHO’s International
Classification of Diseases,Classification of Diseases,
10th edition (ICD-10)10th edition (ICD-10)

10. Goals of AssessmentGoals of Assessment
Establish if the patient suffers from psychiatric
disorder(s)
Elicit the factors that may have caused or
contributed to disorder (genetic,
developmental, familiar, social)
Evaluate patients’ normal level of functioning
and the extent this has been impaired by the
illness

11. Goals of Assessment- cont.Goals of Assessment- cont.
Identify areas of strength as well as potential
supports within the family and the wider social
environment
Build trust and rapport

12. General Recommendations aboutGeneral Recommendations about
AssessmentAssessment
The initial evaluation involves obtaining data from
multiple sources, which include the youth, parents, and
teachers.

This comprises interviews with the youth alone (and, if indicated,
the parents alone) and interviews with both the youth and
parents.
Confidentiality should be discussed at the onset.

Confidentiality maintained unless the patient’s life or other
persons’ lives are at risk.

Role of clinicians as mandated reporters of abuse.

Sensitive issues: substance abuse, sexual activity, pregnancy:
do not break confidentiality unless special circumstances
Youth and parental consent to contact other informants
(e.g. teachers) should also be obtained.

13. CONDUCTING THECONDUCTING THE
ASSESSMENT INTERVIEWASSESSMENT INTERVIEW
Youth interview is critical because parents and
teachers tend to underreport depressive symptoms
Children are less likely to answer questions reliably
about mood, time concepts, comparing themselves to
their peers, and judgment
Interviewing the parent first allows the eliciting of
relevant information and the time course of
symptoms, which can be used later when
interviewing the child

14. CONDUCTING THECONDUCTING THE
ASSESSMENT INTERVIEW- cont.ASSESSMENT INTERVIEW- cont.
Mood constructs

have the child point to a face on a chart with a
variety of expressions/emotions.
Time constructs

“your parents said you have been sad since the
New Year” rather than “tell me about your moods
over the last 2 months.”
Comparing to peers and assessing judgment

ask parents and teachers

15. CONDUCTING THECONDUCTING THE
ASSESSMENT INTERVIEW- cont.ASSESSMENT INTERVIEW- cont.
Questions need to be simple, dealing with one
concrete issue at a time
Avoid leading questions (more likely to draw
“yes” answers and more false positives)
Avoid vague, open-ended questions (more
likely to draw “I don’t know” answers and
more false negatives)

16. RECONCILING CONFLICTING DATARECONCILING CONFLICTING DATA
AMONG PARENT, YOUTH, AND OTHERAMONG PARENT, YOUTH, AND OTHER
SOURCESSOURCES
Many instances arise when youth give
opposite information to their parents.
Further inconsistencies can come from other
sources, such as teachers, friends, and medical
records.
To reconcile these differences, clinicians can
use either the “Best-Estimate Diagnoses” or
the “OR” Rule.

17. RECONCILING CONFLICTING DATA:RECONCILING CONFLICTING DATA:
Best Estimate DiagnosesBest Estimate Diagnoses
Best Estimate DiagnosesBest Estimate Diagnoses

the process by which clinicians synthesize all
available data, resolve discrepancies between data
sources, and use their clinical judgment to arrive at
the final diagnosis.

18. Best-Estimate DiagnosesBest-Estimate Diagnoses
Data from direct interviews are given more weight
than to other reports.
When data are limited regarding family history,
positive reports receive greater weight than negative
reports.
Regardless of source, positive reports of symptoms in
excess of the minimum requirements to meet
diagnostic criteria receive more weight than positive
reports of symptoms that barely meet criteria.

19. Best-Estimate Diagnoses- cont.Best-Estimate Diagnoses- cont.
Symptoms supported by more convincing
examples should be given more weight than
those supported by vague or ambiguous
examples.
Data from informants with greater contact with
the patient are given more weight than from
those with less contact.

20. ““OR” RuleOR” Rule
“OR” Rule, where a symptom is counted
toward the criteria if either the parent or youth
endorses the symptom.
The “OR” Rule maximizes sensitivity at the
cost of specificity

May be useful in cases in which young persons
minimize symptoms.
This method may result in an increase in the
number of comorbid diagnoses.

22. SIGECAPSSIGECAPS
Mnemonics are helpful to remember theMnemonics are helpful to remember the
DSM-IV criteria for mood disordersDSM-IV criteria for mood disorders
5 out of 9 criteria, with one being5 out of 9 criteria, with one being
depressed or irritable mooddepressed or irritable mood
At least 2 weeks durationAt least 2 weeks duration

23. SIGECAPS- cont.SIGECAPS- cont.
Functional impairment (home, school,Functional impairment (home, school,
peer relations)peer relations)
KSADS: developmentally appropriateKSADS: developmentally appropriate
questions to elucidate each symptomquestions to elucidate each symptom

30. DEVELOPMENTAL DIFFERENCES IN THEDEVELOPMENTAL DIFFERENCES IN THE
CLINICAL PRESENTATION OFCLINICAL PRESENTATION OF
DEPRESSIONDEPRESSION
Children and adolescents with depression have
an overall clinical presentation that is similar
to adults.
Discrepancies can be attributed to age and
developmental level.

31. DEVELOPMENTAL DIFFERENCES IN THEDEVELOPMENTAL DIFFERENCES IN THE
CLINICAL PRESENTATION OFCLINICAL PRESENTATION OF
DEPRESSION- cont.DEPRESSION- cont.
Children

more somatic complaints, psychomotor agitation,
anxiety symptoms, behavior problems, ADHD-like
symptoms, hallucinations, and depressed affect
Adolescents

more melancholic symptoms (e.g., anhedonia,
guilt, early morning awakenings, weight loss),
delusions, suicidal behaviors, and substance abuse

32. Child Presentation ofChild Presentation of
DepressionDepression
Joel is a 9-year-old boy who lives with his
mother and younger sister. He presents to his
pediatrician with excessive stomach pains. On
further interview, Joel has been very moody,
irritable, and extremely defiant with his
mother. His stomach pains worsen at school,
resulting in frequent visits to the school nurse.

33. Child Presentation ofChild Presentation of
Depression- cont.Depression- cont.
Joel often worries that something dire will happen to
his mother, and he has missed many days of school
over the past several months, frequently calling his
mother to pick him up. His teacher is concerned
because Joel is usually a good student and is not
having the good grades he had achieved previously.
He hardly sleeps due to the stomach pain and is not
hungry. After his parents’ divorce last year, he rarely
sees his father and has recently started talking about
dying.

34. Adolescent Presentation ofAdolescent Presentation of
DepressionDepression
Chantal is a 16-year-old girl, entering grade
11. She lives at home with her mother, father,
and younger brother. She is anxious, self-
conscious, and gets average grades in school.
At the beginning of the school year her
performance deteriorated and she complained
of being unable to focus in class. She began
experimenting with cannabis, stating it helped
her to relax. Her parents noticed increasing
irritability at home and with friends.

35. Adolescent Presentation ofAdolescent Presentation of
Depression- cont.Depression- cont.
She refused to follow her parents’ rules, despite
having been compliant in the past, and she became
openly defiant and disrespectful. She was observed
making negative comments about herself. She also
reported chronic tiredness. A few months later, she
became tearful, spent most of her time in her room,
and did not want to go out with her friends. She was
eating more, mainly junk food, gaining 15 pounds in
4 months. She had trouble sleeping, felt exhausted,
and “dragging her feet” throughout the day.

36. Dysthymic DisorderDysthymic Disorder
3 of 7 criteria (with 1 being low or irritable mood)3 of 7 criteria (with 1 being low or irritable mood)
1 year of sustained mood symptoms1 year of sustained mood symptoms
Functional impairmentFunctional impairment

37. Dysthymic DisorderDysthymic Disorder
David is a 15-year-old boy in grade 9. He lives with
his parents and younger sister. David has been failing
school over the past year. He exhibits much anger at
school and at home most days of the week. He often
becomes angry at school because he does not want to
deal with people, and he has received multiple in-
school suspensions. He feels “crummy” about himself
and that he is not getting enough credit for the effort
he is putting to complete his schoolwork.

38. Dysthymic Disorder- cont.Dysthymic Disorder- cont.
He is not able to concentrate, and this frustrates him
even further as he claims he tries to complete the
work. He has difficulty falling asleep and is fatigued
throughout the day. He denies suicidal ideation,
feelings of guilt or hopelessness, reports good
appetite, and still enjoys hanging out with his friends
and playing his guitar. Besides school, his other
problem is his relationship with his father, who tells
David what to do, is very short and punitive,
especially about school problems.

39. Differential DiagnosisDifferential Diagnosis
 Several disorders can present with similar symptoms
 Differential diagnosis for depression:

Bipolar depression

Adjustment disorder with depressed mood

Bereavement

Posttraumatic stress disorder (PTSD)

Oppositional defiant disorder (ODD), ADHD

Pervasive developmental disorder

Mood disorder related to a general medical condition
(including substance-induced depression)

40. Mania: 3 symptoms for 1 weekMania: 3 symptoms for 1 week

41. Adjustment Disorder withAdjustment Disorder with
Depressed MoodDepressed Mood
In adjustment disorder, depressive symptoms
(sadness, tearfulness, hopelessness) appear
after the occurrence of an identifiable stressor
and do not meet criteria for a major depressive
episode, and does not last long enough to meet
time criteria for dysthymic disorder
The symptoms should occur within 3 months
of the onset of the stressor(s), and must not last
6 months after the offset of the stressor(s).

42. BereavementBereavement
Young persons can present with depressive
symptoms immediately after the death of a
loved one.
The symptoms may include sadness and
associated symptoms of poor appetite,
insomnia, and lack of concentration.
If the symptoms last 2 months, or are
particularly severe (e.g., psychotic, high
suicidality) or incapacitating, then major
depressive disorder should be considered.

43. POSTTRAUMATIC STRESS
DISORDER
PTSD shares symptoms with and can mimic
depression:

anhedonia (numbing of responsiveness)

social isolation (detachment from others)

hopelessness (sense of foreshortened future)

disrupted sleep patterns (increased arousal)
irritability (increased arousal)

difficulty concentrating (increased arousal)

44. POSTTRAUMATIC STRESS
DISORDER- cont.
Consider depression if the patient also has
suicidality
Consider PTSD if there has been abuse or if
the patient reexperiences the traumatic event
Comorbidity of PTSD and depression is
common

45. ODD and ADHDODD and ADHD
Depressed youth may be more prone to
oppositional and defiant behaviors as a
consequence of irritability
Temper tantrums may be a manifestation of
depressed mood
However, in depression, the behavioral
problems usually start after the onset of
depressive symptoms

46. Pervasive DevelopmentalPervasive Developmental
DisorderDisorder
Depressive-like symptoms can appear to
overlap with symptoms of autism:

lack of social reciprocity

failure to develop peer relationships

poor eye contact

47. MOOD DISORDER DUE TO
GENERAL MEDICAL CONDITION
Medication-induced depression

thorough evaluation of current and previous medications

special attention to the onset and offset of symptoms in
relation to medication changes

Corticosteroids, contraceptives, isotretinoin are associated
with depression, (last one with suicidal behaviors)
Substance-induced depression

thorough evaluation of substance use

urine toxicology screen
Infectious diseases

mononucleosis

48. MOOD DISORDER DUE TO
GENERAL MEDICAL CONDITION-
cont.
Neurologic disorders

migraine

traumatic brain injury (TBI)
Endocrine illnesses

thyroid disorders

diabetes
Other conditions

anemia

electrolyte abnormalities

malnutrition

50. Depression Rating Scales- cont.Depression Rating Scales- cont.

51. Depression Rating Scales- cont.Depression Rating Scales- cont.

53. Mood and FeelingsMood and Feelings
Questionnaire: MFQQuestionnaire: MFQ
Screening depression in the community:Screening depression in the community:

Short MFQ-C, 13 questions, selfShort MFQ-C, 13 questions, self
clinical cutoff 10clinical cutoff 10

Short MFQ-P, 13 questions, parent-reportShort MFQ-P, 13 questions, parent-report
clinical cutoff unknownclinical cutoff unknown
Rating severity of depression in clinic:Rating severity of depression in clinic:

MFQ-C, 33 questions, selfMFQ-C, 33 questions, self
clinical cutoff 29clinical cutoff 29

MFQ-P, 34 questions, parent-reportMFQ-P, 34 questions, parent-report
clinical cutoff 27clinical cutoff 27

57. Summary: Assessment ofSummary: Assessment of
Pediatric DepressionPediatric Depression
Utilize the interview process to establishUtilize the interview process to establish
rapport and elicit informationrapport and elicit information
Developmental differencesDevelopmental differences

Decreasing age, more somatic sxs, anxiety,Decreasing age, more somatic sxs, anxiety,
disruptive behaviorsdisruptive behaviors

Increasing age, more melancholic sxs,Increasing age, more melancholic sxs,
suicidal ideations/attempts, substance abusesuicidal ideations/attempts, substance abuse
SIGECAPS (MDE)SIGECAPS (MDE)

5 out 9 criteria including low mood/irritability5 out 9 criteria including low mood/irritability

58. Summary: Assessment ofSummary: Assessment of
Pediatric Depression- cont.Pediatric Depression- cont.
SIGECA (Dysthymic Disorder)SIGECA (Dysthymic Disorder)

3 out of 7 criteria including low mood/irritability3 out of 7 criteria including low mood/irritability
Differential DiagnosisDifferential Diagnosis
Utilize depression rating scalesUtilize depression rating scales

Mood and Feelings Questionnaire (MFQ)Mood and Feelings Questionnaire (MFQ)

59. Summary: Assessment ofSummary: Assessment of
Pediatric Depression- cont.Pediatric Depression- cont.
Assess overall functioningAssess overall functioning

Children’s Global Assessment Scale (CGAS)Children’s Global Assessment Scale (CGAS)
Monitor treatment longitudinally withMonitor treatment longitudinally with
scalesscales

MFQ, CGASMFQ, CGAS
Rating scales not a substitute for clinicalRating scales not a substitute for clinical
interviewinterview

60. Treating Child and AdolescentTreating Child and Adolescent
DepressionDepression
Authors: Rey J and Birmaher B (editors)Authors: Rey J and Birmaher B (editors)
Hardcover: 312 pagesHardcover: 312 pages
Price: $69.96 (US)Price: $69.96 (US)
Publisher: Lippincott Williams & Wilkins; 1Publisher: Lippincott Williams & Wilkins; 1
edition (January 1, 2009)edition (January 1, 2009)
Language: EnglishLanguage: English
ISBN-10: 0781795699ISBN-10: 0781795699
ISBN-13: 978-0781795692ISBN-13: 978-0781795692