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Children’s Depression Inventory in Estonia

Article  in  European Child & Adolescent Psychiatry · April 2007

DOI: 10.1007/s00787-007-0650-z

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 Eur Child Adolesc Psychiatry (2008)
17:162–170 DOI 10.1007/s00787-007-0650-z ORIGINAL CONTRIBUTION

Algi Samm Children’s Depression Inventory in Estonia

Airi Värnik
Liina-Mai Tooding Single items and factor structure by age and gender
Merike Sisask
Kairi Kõlves
Anne-Liis von Knorring

j Abstract The aim of study was study. Factor analysis obtained

Accepted: 8 August 2007
Published online: 14 September 2007
A. Samm (&) Æ A. Värnik Æ M. Sisask
K. Kõlves
Estonian-Swedish Mental Health and
Suicidology Institute,
Estonian Centre of Behaviour &
Health Science
Õie 39
Tallinn 11615, Estonia
E-Mail: algi.samm@mail.ee
L.-M. Tooding Æ A. Samm Æ A. Värnik
Faculty of Social Sciences
Tartu University
Tartu, Estonia
A. Värnik Æ M. Sisask
Faculty of Social Sciences
Tallinn University
Tallinn, Estonia
A.-L. von Knorring
Dept. of Neuroscience, Child and
Adolescent Psychiatry
University Hospital
Uppsala, Sweden
to estimate the score of symptoms
of depression with the Children’s
Depression Inventory (CDI)
among Estonian schoolchildren
aged 7–13-year-old, according to
age and gender differences, and to
identify the components in factor
analysis characterising self-re-
ported childhood symptoms of
depression. The applicability of
the CDI in 7-year-old children was
also estimated. The number of
subjects in the study was 725 (342
girls and 383 boys), and the mean
age was 10.2 (SD 1.7). The mean
total score of the CDI for the
whole sample was 9.96 (SD = 6.3,
range 0–39, median 9.0). The
mean scores of symptoms of
depression among children did
not differ by gender or age. There
were no significant differences in
the CDI mean scores between 7-
year-old compared to older
schoolchildren in the present
five factors: anhedonia, ineffec-
tiveness, negative self-esteem,
negative mood and interpersonal
problems. Significant gender and
age differences were found: girls
reported more symptoms of
anhedonia and negative self-es-
teem, and boys reported more
symptoms of ineffectiveness.
Younger children reported more
symptoms of anhedonia and inef-
fectiveness, and older children
negative self-esteem. The study
serves as baseline data before
intervention of the EC project
‘‘European Alliance Against
Depression’’.
j Key words Children’s Depres-
sion Inventory (CDI) –
symptoms – childhood depres-
sion – multifactorial structure

need to have direct assessment concerning children’s

Introduction
Depression in children and adolescents is a major
public health problem. Self-rated symptoms of
depression inventories have a significant role in
clinical and population-based research with the pur-
pose of studying the distribution of specific symp-
toms, in order to define clinical or alarm thresholds or
in screening for symptoms of depression [27]. The
ECAP 650
mental health [15, 17].
The CDI, devised by Maria Kovacs [15, 17] is one
of the most widely used instruments in epidemio-
logical studies to assess children and adolescents’ self-
report levels of depression. Several items concern the
consequences of depression in contexts that are spe-
cifically relevant to children e.g. school. The CDI has
typically been used to explore the prevalence of

Children’s Depression Inventory (CDI), a self-rated symptoms of childhood depression in the epidemio-
symptoms scale, was developed in response to the logical studies, both in clinical and community sam-
 A. Samm et al. 163
CDI in Estonian schoolchildren

ples [1, 2, 15, 17, 18, 20, 26, 27, 29, 31]. To our
knowledge, there are no studies concerning the
screening of childhood depression in populations of
post-soviet countries.
Studies have shown that children are able to
experience depressive affects and cognitions from an
early age. From 8-year-old and onwards, children are
considered to be able to report their own depressive
emotions and cognitions separate from their envi-
ronmental context [3, 14, 16, 17, 27, 29, 31]. About 7-
year-old have been included only in some studies [12,
23, 25] and the applicability of the CDI to 7-year-old
and younger has been matter of debates.
Studies using the CDI as a diagnostic tool have
confirmed the reliability and validity of the instrument
[13, 15, 20, 30–32]. Although research has shown that
this inventory is moderately correlated with other
measures of depressive disorder, the instrument is
insufficient for diagnosis in a clinical population [5, 7,
15, 20, 32]. A primary diagnostic measure should be a
structured interview to determine diagnostic status [7].
Kovacs emphasises the CDI as an assessment tool in
treatment-outcome studies [15].
The aim of this study was (a) to estimate the score
of symptoms of depression with the CDI in a popu-
lation of schoolchildren by gender and age, (b) to
identify the components characterising self-reported
childhood symptoms of depression and (c) to evaluate
if the CDI is also applicable to 7-year-old children.
Methods
j Subjects
The study was conducted among elementary school
children in a district of Estonia (Haapsalu/Läänemaa)
in 1996 and 2004 as a regular screening. A stratified
sampling method was used [4]. The study approached
grades 1–6 in all 10 schools of the county. Three
classes from each grade were randomly selected for
the study. All children in the selected 18 classes were
supposed to participate.
The children were 7–13-year-old and were divided
during the analysis into two age groups: a younger
group (7–10-year-old) from grades 1 to 4, and an
older group (11–13-year-old), who attended grades 5
and 6. The reasons for grouping were, first, that the
age of 7–10-year-old is considered to be pre-puberty
and 11–13-year-old to be peri-puberty. Second, pri-
mary school in the Estonian educational system is
divided into two stages, grades 1–4 where the class
teacher teaches all subjects, and grades 5–6 where
subject teachers teach specific subjects.
The final number of subjects was 725 (383 boys
and 342 girls). The mean age of the entire sample was
10.2 (SD 1.7): 10.3 (SD 1.7) for boys and 10.2 (SD 1.7)
for girls, which were statistically non-significant.
Distribution of children by gender and age for both
study years is shown in Table 1. The distribution of
children by grades was similar to the age cohorts.
j Instrument
The present study used Maria Kovacs’ 27-item self-
report questionnaire, which contains items regarding
cognitive, emotional and behavioural aspects of
depression in children. The CDI quantifies a range of
symptoms of depression including disturbed mood,
hedonic capacity, vegetative functions, self-evaluation
and interpersonal behaviour [15, 17].
In the present study a 26-item questionnaire was
used to represent the original 27-item CDI. The
question concerning suicidal tendencies was excluded

Table 1 Gender distribution by age

groups, 1996 and 2004 1996 2004 Total

Gender n % Mean age (SD) n % Mean age (SD) n % Mean age (SD)

Boys
7–10 years 77 8.9 (1.0) 108 8.7 (1.1) 185 8.8 (1.1)
11–13 years 122 11.7 (0.7) 68 11.8 (0.7) 190 11.7 (0.7)
Total 199 52.0 10.6 (1.6) 176 53.8 9.9 (1.8) 375 52.8 10.3 (1.7)
Missinga 7 1 8
Girls
7–10 years 71 8.9 (1.2) 92 8.6 (1.2) 163 8.7 (1.2)
11–13 years 112 11.5 (0.6) 59 11.8 (0.8) 171 11.6 (0.7)
Total 183 48.0 10.5 (1.6) 151 46.2 9.9 (1.8) 334 47.2 10.2 (1.7)
Missinga 7 1 8
Both genders
7–10 years 148 8.9 (1.1) 200 8.7 (1.1) 348 8.8 (1.1)
11–13 years 234 11.6 (0.6) 127 11.8 (0.7) 361 11.7 (0.7)
Total 382 100 10.6 (1.6) 327 100 9.9 (1.8) 709 100 10.2 (1.7)
Missinga 14 2 16
a
Age was missing
164 European Child & Adolescent Psychiatry (2008) Vol. 17, No. 3
Ó Steinkopff Verlag 2007
in line with Moilanen’s recommendations (1990) to
avoid the possibility that consciousness about a pre-
viously unconscious suicidal idea could emerge in the
child’s mind [22]. The CDI was translated from Eng-
lish to Estonian and back with high coincidence.
j Procedure
The children filled in the questionnaire during a
regular school lesson and were asked to endorse one
of the three statements, that best described the way he
or she had felt and thought during the preceding
2 weeks, on each item of the questionnaire. The re-
search assistant slowly read out the separate items to
the whole class in the presence of the teacher, while
each subject read along silently on his/her own copy
and marked the answers. The purpose of this proce-
dure was to assist those children with reading or
attention problems [15]. The pupils had the possi-
bility to ask questions if they didn’t understand an
item, which were then clarified by the teacher or re-
search assistant. In this way the anonymity was
guaranteed.
Statistical analysis was performed with SPSS 13.0
for Windows. Differences between the mean values of
continuous data for different groups were analysed
with an independent sample t-test and an analysis of
variance (ANOVA) and controlled with non-para-
metric tests (Mann–Whitney U-test and Kruskal–
Wallis). To extract factors of the CDI principal com-
ponents procedure by a Varimax rotation was used.
The items which had loadings of more than 0.30 on
any of the factors were accepted. Reported factors
were analysed by gender and age and gender/age
interaction using ANOVA. Cronbach alpha was used
to calculate the internal consistency of the whole
questionnaire as well as single factors.
Since of the high number of tests carried out, the
significance level of 0.01 was used to compare single
items. In other comparisons the significance level of
0.05 was applied.
Missing values by single items had a mean value of
seven and the median was six (range 3–17). Two
individuals had three, 11 had two and 42 had one
missing item. If more than three of the items were
missing, the form was excluded from the analysis
(n = 9).
Results
j The reliability and scores of the CDI
The reliability was estimated by internal consistency
and analysed by means of the coefficient of Cronbach
alpha, which was 0.82 for the entire sample. Item to-
tal-score correlation coefficients (Pearson), r = 0.28–
0.53, were all significant at the P < 0.0001 level for the
whole sample.
The mean total score for the whole sample was 9.96
(SD = 6.3, range 0–39, median 9.0). There were no
statistically significant differences in the CDI mean
scores of the study years (1996 and 2004), and there
were no gender or age effects. Thus, both study years
were handled as one entire sample.
Although no differences between genders were
found in the total CDI scores, there were significant
differences in the scores of the single items (Table 2).
Boys scored higher in items such as ‘‘I have to push
myself all the time to do my schoolwork’’, and ‘‘I can
never be as good as kinds’’. Girls scored higher in
items such as ‘‘I feel like crying every day’’, and ‘‘I
cannot make up my mind about things’’, and ‘‘Most
days I do not feel like eating’’.
Significant differences were found in the CDI mean
scores of the single items between the two age groups
7–10 years and 11–13 years (Table 3). The younger
age group scored higher in the items: ‘‘Nothing is fun
at all’’, ‘‘I am sure that terrible things will happen to
me’’, ‘‘I do not want to be with people at all’’, ‘‘I have
trouble sleeping almost every night’’, ‘‘I am tired all
the time’’, and ‘‘I worry about aches and pain all the
time’’ (Table 3). The older age group scored higher in
the items ‘‘I do everything wrong’’, and ‘‘I hate my-
self’’.
j Factor analysis
In order to discover the CDI items’ distribution,
sample factor extraction was conducted with the
eigenvalue of 1, and seven factors were reported
describing 47.9% of the total variance. A 5-factor
model was chosen because it was clearly interpretable
as five distinct dimensions of depression and was best
suited to describe our data. This explained 39.9% of
the variance (Table 4).
Factor one, anhedonia, (Cronbach a = 0.65) ex-
plained 9.6% of the variance, and psychosomatic
complaints and absence of pleasure was brought out.
Analysis indicated significant effects regarding gender
(F = 9.0, df = 1, P = 0.003) and age (F = 47.8, df = 1,
P < 0.001). However, no differences between gender
and age interaction effects (F = 2.2, df = 1, P = 0.139)
were reported. Anhedonia was reported more in girls
than boys, and was expressed more in the younger age
group than the older.
Factor two, ineffectiveness, (Cronbach a = 0.66)
explained 8.9% of the variance and included a pessi-
mistic view of one’s coping ability at school. Analysis
indicated significant effects regarding gender
(F = 18.4, df = 1, P < 0.001) and age (F = 28.4,
 A. Samm et al. 165
CDI in Estonian schoolchildren

Table 2 Single items’ scores of the

CDI by gender No. Items of CDI Boys Girls t P

Mean SD Mean SD

1. I am sad all the time 0.07 0.29 0.11 0.33 )1.38 0.168
2. Nothing will ever work out for me 0.77 0.73 0.70 0.71 1.30 0.193
3. I do everything wrong 0.74 0.47 0.70 0.48 1.28 0.200
4. Nothing is fun at all 0.36 0.49 0.30 0.47 1.84 0.070
5. I am bad all the time 0.13 0.39 0.07 0.28 2.23 0.026
6. I am sure that terrible things will happen to me 0.41 0.65 0.39 0.60 0.36 0.717
all the time
7. I hate myself 0.20 0.47 0.22 0.48 )0.66 0.510
8. All bad things are my fault 0.22 0.47 0.21 0.47 0.25 0.805
9. I feel like crying every day 0.08 0.30 0.21 0.47 )4.51 0.000
10. Things bother me all the time 0.49 0.73 0.52 0.73 )0.70 0.484
11. I do not want to be with people at all 0.19 0.54 0.27 0.65 )1.78 0.075
12. I can not make up my mind about things 0.49 0.62 0.63 0.62 )3.15 0.002
13. I look ugly 0.56 0.52 0.56 0.55 )0.08 0.936
14. I have to push myself all the time to do my schoolwork 0.76 0.78 0.55 0.71 3.81 0.000
15. I have trouble sleeping almost every night 0.23 0.51 0.28 0.57 )1.33 0.186
16. I am tired all the time 0.31 0.61 0.36 0.64 )1.15 0.252
17. Most days I do not feel like eating 0.30 0.56 0.42 0.61 )2.84 0.005
18. I worry about my aches and pains all the time 0.43 0.66 0.56 0.72 )2.46 0.014
19. I feel alone all the time 0.35 0.59 0.43 0.57 )1.97 0.500
20. I never have fun at school 0.48 0.61 0.41 0.56 1.56 0.119
21. I do not have any friends 0.30 0.49 0.37 0.51 )1.82 0.069
22. I do very badly in subjects I used to be good at 0.67 0.72 0.59 0.72 1.59 0.113
23. I can never be as good as kinds 0.62 0.71 0.44 0.66 3.38 0.001
24. Nobody really loves me 0.29 0.50 0.35 0.56 )1.43 0.152
25. I never do what I am told 0.26 0.48 0.26 0.47 )0.02 0.988
26. I get into fights all the time 0.20 0.45 0.18 0.39 0.75 0.456

Table 3 Single items’ scores of the

CDI by age groups (7–10 and 11–13) No. Items of CDI 7–10 year 11–13 year t P

Mean SD Mean SD

1. I am sad all the time 0.10 0.34 0.08 0.28 1.09 0.277
2. Nothing will ever work out for me 0.72 0.74 0.73 0.70 )0.22 0.823
3. I do everything wrong 0.65 0.50 0.79 0.44 )4.23 0.000
4. Nothing is fun at all 0.39 0.51 0.27 0.44 3.24 0.001
5. I am bad all the time 0.10 0.36 0.10 0.32 0.00 1.000
6. I am sure that terrible things will happen 0.52 0.70 0.28 0.53 5.20 0.000
to me all the time
7. I hate myself 0.15 0.41 0.28 0.53 )3.71 0.000
8. All bad things are my fault 0.18 0.46 0.24 0.47 )1.47 0.143
9. I feel like crying every day 0.16 0.42 0.11 0.36 1.67 0.095
10. Things bother me all the time 0.49 0.72 0.53 0.75 )0.75 0.455
11. I do not want to be with people at all 0.29 0.66 0.17 0.51 2.80 0.005
12. I cannot make up my mind about things 0.56 0.68 0.55 0.56 0.16 0.877
13. I look ugly 0.52 0.53 0.61 0.53 )2.32 0.020
14. I have to push myself all the time to do my schoolwork 0.61 0.80 0.71 0.72 )1.68 0.094
15. I have trouble sleeping almost every night 0.31 0.58 0.20 0.49 2.77 0.006
16. I am tired all the time 0.44 0.71 0.24 0.51 4.24 0.000
17. Most days I do not feel like eating 0.39 0.64 0.32 0.53 1.62 0.105
18. I worry about aches and pain all the time 0.60 0.74 0.39 0.62 4.11 0.000
19. I feel alone all the time 0.43 0.63 0.35 0.53 1.93 0.055
20. I never have fun at school 0.40 0.60 0.50 0.56 )2.27 0.023
21. I do not have any friends 0.37 0.51 0.30 0.49 2.06 0.040
22. I do very badly in subjects I used to be good at 0.59 0.75 0.66 0.69 )1.41 0.160
23. I can never be as good as kinds 0.50 0.69 0.56 0.69 )1.21 0.229
24. Nobody really loves me 0.32 0.55 0.32 0.51 )0.04 0.971
25. I never do what I am told 0.24 0.48 0.28 0.47 )0.97 0.334
26. I get into fights all the time 0.22 0.45 0.16 0.39 2.16 0.031
166 European Child & Adolescent Psychiatry (2008) Vol. 17, No. 3
Ó Steinkopff Verlag 2007

Table 4 Principal component

analysis with Varimax rotation of CDI CDI item no. Loadings
items
Factor 1 2 3 4 5

I. Anhedonia
18. I worry about aches and pain all the time 0.614 0.067 )0.061 0.021 )0.096
16. I am tired all the time 0.564 0.028 )0.021 0.183 0.211
15. I have trouble sleeping almost every night 0.505 0.078 0.210 )0.058 0.156
19. I feel alone all the time 0.472 )0.030 0.190 0.195 0.292
6. I am sure that terrible things will happen to me all the time 0.421 0.012 )0.046 0.235 0.105
10. Things bother me all the time 0.416 0.222 0.049 0.383 )0.306
17. Most days I do not feel like eating 0.409 0.178 0.156 )0.165 0.144
4. Nothing is fun at all 0.350 0.225 0.298 0.052 0.165
12. I cannot make up my mind about things 0.324 0.289 0.159 0.012 0.077
II. Ineffectiveness
14. I have to push myself all the time to do my schoolwork 0.139 0.7490 )0.068 0.077 0.004
22. I do very badly in subjects I used to be good at 0.138 0.5770 0.264 )0.125 0.099
23. I can never be as good as kinds 0.009 0.5470 0.201 0.245 0.141
2. Nothing will ever work out for me 0.278 0.5290 0.342 )0.009 )0.108
3. I do everything wrong )0.140 0.3800 0.291 0.211 0.169
III. Negative self-esteem
13. I look ugly )0.057 0.244 0.664 )0.047 0.077
24. Nobody really loves me 0.168 0.141 0.606 0.223 0.035
21. I do not have any friends 0.235 )0.026 0.462 )0.139 0.423
7. I hate myself 0.068 0.239 0.460 0.269 0.078
IV. Negative mood
9. I feel like crying every day 0.324 )0.160 0.359 0.346 )0.144
5. I am bad all the time 0.050 0.101 )0.042 0.624 0.077
1. I am sad all the time 0.228 )0.114 0.329 0.539 0.163
8. All bad things are my fault 0.027 0.234 0.219 0.473 0.211
V. Interpersonal problems
26. I get into fights all the time 0.299 0.110 0.023 0.154 0.655
25. I never do what I am told )0.052 0.396 )0.125 0.258 0.476
20. I never have fun at school 0.042 0.263 0.272 0.036 0.428
11. I do not want to be with people at all 0.291 )0.044 0.115 0.106 0.413

CDI, Children’s Depression Inventory numeration of the items reflects the list of M. Kovacs’ questionnaire, which was used
in the study
Extraction method, Principal component analysis; Rotation method, Varimax with Kaiser normalization, a rotation
converged in 24 iterations
To extract factors of the CDI principal components procedure by a Varimax rotation was used. The items which has
loadings of more than 0.30 or any of the factors were accepted as it described in the paragraph of procedure (page 3 in
this article) and marked in bold in table 4

df = 1, P < 0.001), but no differences between gender
and age interaction effects (F = 0.02, df = 1,
P = 0.878) were reported. The boys had higher scores
than the girls. The older children had remarkably
higher scores of ineffectiveness than the younger
children.
Factor three, negative self-esteem, (Cronbach
a = 0.58) showed 8.3% of the variance, and reflected
low self-esteem and feelings of being unloved. There
were significant gender (F = 7.2, df = 1, P = 0.008)
and age effects (F = 5.2, df = 1, P = 0.023), but no
gender and age interaction effects (F = 0.4, df = 1,
P = 0.504). The girls reported more symptoms than
the boys. The older age group had lower self-esteem
than the younger age group.
Factor four, negative mood, (Cronbach a = 0.46)
explained 6.6% of the variance, and described feelings
of sadness and guilt. There were no gender (F = 0.09,
df = 1, P = 0.763), nor age effects (F = 0.24, df = 1,
P = 0.625), and no gender or age interaction
(F = 0.12, df = 1, P = 0.734) effects.
Factor five, interpersonal problems, (Cronbach
a = 0.48) explained 6.5% of the variance. This factor
brought out lack of communication skills and loneli-
ness. There were no gender (F = 1.0, df = 1,
P = 0.318), age (F = 2.6, df = 1, P = 0.107) or gender
and age interaction (F = 1.2, df = 1, P = 0.281) effects.
j Applicability in 7-year-old
About 63, seven-year-old schoolchildren participated
in the study: 28 boys and 35 girls. The mean total
score in this age group was 9.3 (SD = 5.1, range 0–
23), and the median was 9.0. No significant differ-
ences were found between the mean total score of
7- and 8-year-old [10.5 (SD = 6.0) (t = )1.22,

% Negative self-esteem (Factor 3) also showed a sig-
30
7 8-10
25
20
15
10
5 effects. A 7-year-old scored higher on negative mood
0
0-3 4-7 8-11 12-15 16-19 20-23 24-27
Total CDI score
Fig. 1 Distribution of CDI scores by age; 7-, 8–10 and 11–13-year-old
P = 0.225)], or 8–10-year-old [10.4 (SD = 6.4),
(t = )1.29, P = 0.198)], or 8–13-year-old [10.1
(SD = 6.4) (t = )0.84, P = 0.404)].
The distribution of CDI scores between 7, 8–10 and
11–13-year-old, was similar (H = 2.40, P = 0.301),
and is shown in Fig. 1.
When the mean scores of the single items between
7- and 8-year-old were compared, only one significant
difference was found: the item ‘‘I hate myself’’ was
scored higher by 8-year-old (t = )2.763, P = 0.007).
Between seven and 8–10-year-old there were six
items, which differed significantly: 7-year-old scored
higher in ‘‘I am sad all the time’’ (t = 2.78, P = 0.006)
and lower in ‘‘I do everything wrong’’ (t = )3.32,
P = 0.001), ‘‘I look ugly’’ (t = )3.32, P = 0.001),
‘‘Nothing will ever work out for me’’ (t = )3.33,
P = 0.001), ‘‘I hate myself’’ (t = )2.49, P = 0.013),
and ‘‘I can never be as good as kinds’’ (t = )2.67,
P = 0.008).
The factor analysis showed a significant age dif-
ference between 7- and 8-year-old in the items rep-
resented by ineffectiveness (Factor 2). There were
significant effects for age (F = 8.3, df = 1, P < 0.005),
but no differences to gender or to gender and age
interaction effects were reported; 7-year-old had
lower scores of ineffectiveness than 8-year-old.
Between 7- and 8–10-year-old there were significant
differences in four of the five factors. A significant effect
for age (F = 6.2, df = 1, P < 0.014) in the anhedonia
factor (Factor 1) was found. A 7-year-old compared to
8–10-year-old had higher symptom loadings. However,
no differences depending on gender or gender and age
interaction effects were reported.
Significant effects for age (F = 14.1, df = 1,
P < 0.001) and gender (F = 5.1, df = 1, P < 0.025),
but no differences to gender and age interaction ef-
fects were found for the ineffectiveness factor (Factor
2). The 8–10-year-old had remarkably higher scores
of ineffectiveness than the 7-year-old, and the boys
reported higher scores than the girls.
A. Samm et al. 167
CDI in Estonian schoolchildren
11-13 nificant age effect (F = 6.1, df = 1, P = 0.014), but no
differences to gender or to gender and age interaction
effects (Factor 3); 8–10-year-old had lower self-esteem
than 7-year-old.
Negative mood (Factor 4) showed a significant age
effect (F = 4.1, df = 1, P = 0.043) but no differences
depending on gender or to gender and age interaction
than 8–10-year-old.
28-31 32-35 36-39 There were no differences concerning age effects in
interpersonal problem factor (Factor 5).
Discussion
The aim of this study was to estimate the scores of
symptoms of depression with the use of the CDI in a
sample of Estonian schoolchildren, to identify the
components characterising self-reported childhood
symptoms of depression, and to evaluate if the CDI is
also applicable in 7-year-old children.
j CDI scores by gender and age
The mean score in our sample was similar to previ-
ously reported findings in a non-clinical sample of
Italian [27], Canadian [15] and American student
samples [15, 26, 31]. In our study the mean scores for
both genders were higher than those reported in a
comparative Swedish study [20].
There are inconsistencies in previous findings of
the gender and age effect. In some studies, including
the present study, no significant differences in the
total CDI scores were found between boys and girls [2,
15]. Other studies have indicated that prepubertal
girls’ scores were slightly lower than boys’, but girls
scored higher from age 13 [24, 35]. Young adolescents
scored lower than pre-adolescence children [20, 27].
This study found that both boys and girls scored
highest in the item titled ‘‘Nothing will ever work out
for me’’, but statistically significant gender differences
were found in other items. Boys scored higher than
girls in the items: ‘‘I have to push myself all the time
to do my schoolwork’’, and ‘‘I can never be as good as
kinds’’, and girls scored higher in the items ‘‘I feel like
crying every day’’, and ‘‘I cannot make my mind
about things’’, and ‘‘Most days I do not feel like eat-
ing’’. These findings suggest the centrality of gender
specific symptoms of depression.
The statement with the highest score in younger
children, ‘‘Nothing will ever work out for me’’, and
that for older children, ‘‘I do everything wrong’’, re-
flect the children’s vulnerability towards external de-
mands. Younger children also complained more often
about tiredness.
168 European Child & Adolescent Psychiatry (2008) Vol. 17, No. 3
Ó Steinkopff Verlag 2007
j Factorial structure of the CDI
Depression measured by the CDI is accepted as a
multidimensional construct in which individual dif-
ferences by age and gender usually appear [2, 27]. The
number and essence of the extracted factors from the
CDI have varied in different studies. The 5-factor
model of the present study was clearly interpretable as
five distinct dimensions of depression, a model, which
has also been supported by other studies [2, 5, 6, 33].
In the present study significant gender and age
differences were found in three of five factors. Girls
reported more symptoms of anhedonia and negative
self-esteem, and boys reported more symptoms of
ineffectiveness. Similar results were reported by Aluja
and Blanch [2]. Boys showed anhedonia more often
than girls in Finland, and also tended to score higher
on low self-confidence [22].
The factor analysis of the present study found
symptoms of anhedonia to be expressed more in
younger children than older children. Young children
scored remarkably higher scores of ineffectiveness
and lower self-esteem. These findings are in line with
the study of Chan where the level of symptom of
depression tended to be highest among older students
[5]. In a community-based sample of children, the
highest scored factor was anhedonia. Individual self-
efficacy might have a different relationship to
depression among children dependent on differences
in socio-cultural environments [33]. In Estonian
society, boys have greater demands from their social
context, which expresses gender differences such as
complaints about more ineffectiveness than girls.
In 1997, Chan presented a causal model of per-
ceived academic and social competence; perceived
incompetence may lead to depression, and depression
may lead to perceived incompetence, an idea, which is
similar to the ineffectiveness factor in our study. Chan
suggests that a third unknown factor may cause both
perceived incompetence and depression [5].
Our result supports the interpretation revealing
that girls tend to ‘‘internalise’’ depression at an earlier
age than boys, and that they tend to manifest inter-
nally focused characteristics, e.g. sadness, negative
body-image, somatic preoccupation, more often [14,
20, 31]. Boys tend to manifest more behavioural
components of depressive moods, and that estimation
of incompetence is an important predictor of
depression among boys [29].
j Applicability of the CDI in the 7-year-old
Little is known about depression in early childhood;
more research is available about adolescent depres-
sion. Previous studies have shown that children are
able to experience depressive affects and cognitions,
and that children aged eight and older are considered
able to report their own depressive moods and cog-
nitions as something separate from their environ-
mental contexts [14, 16, 17, 27, 29].
As one purpose of the present study was to eval-
uate the applicability of the CDI in 7-year-old chil-
dren, we compared the scores of 7-year-old with the
scores of older ages. There were no significant dif-
ferences between 7- and 8-year-old’s mean total
scores. Comparing 8–10-year-old children with 7-
year-old by single items, the differences between the
two groups might be explained by their development
of abstract thinking and vocabulary. The younger
children rate themselves in more concrete terms,
which is expected due to the immaturity of their
cognitive development. The older children are able to
judge their own normative actions with respect to
their own normative standards and they use more
generalised trait-like descriptions when describing
themselves and seem to be increasingly vulnerable to
the feelings of helplessness and hopelessness [34].
Overall physical, psychological and intellectual
development in children has accelerated in many
countries, and now also symptoms of depression
might be possible to express in a more valid way by
the younger children. For example, mean norms of
IQ-tests of children have been inflated over time
suggested to be caused by environmental factors such
as better nutrition, mental stimulation and schooling
[21, 28].
According to our study, it could be concluded that
the CDI is applicable to 7-year-old concerning scores.
However, there are some differences. We must keep in
mind that the 7-year-old children in our study are
sampled from a normal population. Whereas in
clinical samples the children probably have more
cognitive and developmental problems. Therefore,
our statement is not valid for clinical populations.
j Ethical and methodological considerations
Estonia had the highest suicide rate in Europe during
the mid 1990’s, when this study was planned [36]. To
avoid possible harm to vulnerable children, we didn’t
include the question about suicidal ideation, which
might have been be too stressful to answer, particu-
larly for children of the younger age group [22].
Children from 5 years of age have a concept of death,
but suicide attempts and especially completed sui-
cides are rare before puberty [8, 19]. However, suicide
attempts have been reported in children younger than
five and a few cases of completed suicide in this age-
range have been registered in the Nordic countries
[9].
 A. Samm et al. 169
CDI in Estonian schoolchildren

An informed consent was obtained from the school
administrations. The CDI questionnaire was well ac-
cepted by Estonian schoolchildren, parents and
teachers, and no refusals to complete the question-
naire were met. Children filled in the questionnaire in
the presence of their schoolteacher and a research
assistant. Parents were informed about the study’s
design. They also had questionnaires to fill in and
none of them forbade their child from participating.
Accordingly, this study had the indirect approval
from all of the parents of the children who partici-
pated in it. As the study was anonymous, the children
could not be later identified.
The data was gathered twice (1996 and 2004) with
an interval of 8 years, in the same district and with
the same method. One of the authors (AV) partici-
pated in obtaining material for both study years and
led the study.
The fact that all of the children responded may be
explained by the fact that Estonians lived under a
totalitarian system for more than 50 years, which
made people, in general, compliant. Moreover, Esto-
nian schoolchildren still have a high respect for
teachers’ authority.
The 7% of the children not attending school on the
day, when the self-reported inventory was conducted,
probably had a worse health status and higher CDI
ratings than the children who participated in the study.
This suggests that the high CDI score in this population
could be even higher than our findings suggest.
j Challenges for prevention
Earlier studies have reported that the majority of
depressed children were left without psychiatric
assessment and help. One possible solution could be
to provide self-reported screening, including items
about symptoms of depression as a part of any
regular check-up (or screening instrument) for
schoolchildren, which could be used as a basis for
opening discussion with the children’s caregivers
[11, 29].
The present study serves as a baseline for evalua-
tion by the EC project ‘‘European Alliance Against
Depression’’: a multilevel system of intervention,
which involves a comprehensive network of different
countries, and is currently expanding into the area of
childhood mental health involving symptoms of
depression [10].
j Acknowledgements The current study was funded by the Esto-
nian Health Insurance Fund (Grant no. 144/88) and an Estonian
Scientific Foundation project number 7132, ‘Suicide trend in Es-
tonia during independence: What are the associations with socio-
political, economic and public health indicators?’. Ingrid Danilov,
Liivia Anion and Tiina Kütt from Läänemaa county are thanked for
their assistance in data collection.

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