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Toward Guidelines for Evidence-Based Assessment of

Depression in Children and Adolescents
Daniel N. Klein , Lea R. Dougherty & Thomas M. Olino
Published online: 07 Jun 2010.

To cite this article: Daniel N. Klein , Lea R. Dougherty & Thomas M. Olino (2005) Toward Guidelines for Evidence-Based
Assessment of Depression in Children and Adolescents, Journal of Clinical Child & Adolescent Psychology, 34:3, 412-432, DOI:
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 Journal of Clinical Child and Adolescent Psychology Copyright © 2005 by
2005, Vol. 34, No. 3, 412–432 Lawrence Erlbaum Associates, Inc.

Toward Guidelines for Evidence-Based Assessment

of Depression in Children and Adolescents
Daniel N. Klein, Lea R. Dougherty, and Thomas M. Olino
Department of Psychology, University at Stony Brook.

We aim to provide a starting point toward the development of an evidence-based as-

sessment of depression in children and adolescents. We begin by discussing issues rel-
evant to the diagnosis and classification of child and adolescent depression. Next, we
review the prevalence, selected clinical correlates, course, and treatment of juvenile
depression. Along with some general considerations in assessment, we discuss spe-
cific approaches to assessing depression in youth (i.e., interviews, rating scales) and
briefly summarize evidence on the reliability and validity of a few selected instru-
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ments. In addition, we touch on the assessment of several other constructs that are im-
portant in a comprehensive evaluation of depression (i.e., social functioning, life
stress, and family history of psychopathology). Last, we highlight areas in which fur-
ther research is necessary and conclude with some broad recommendations for clini-
cal practice given the current state of the knowledge.

In recent years, there has been a growing emphasis
on evidence-based medicine. In the field of mental
health, this has been reflected by the interest in empiri-
cally supported treatments and the development of evi-
dence-based practice guidelines (Chambless & Ollen-
dick, 2000; Drake, Rosenberg, Teague, Bartels, &
Torrey, 2003). Although the field of assessment has
lagged behind, interest in developing empirically sup-
ported approaches to clinical assessment has also be-
gun to emerge (Meyer et al., 2001).
A number of fundamental questions must be re-
solved to develop evidence-based approaches to clini-
cal assessment. First, what criteria should be consid-
ered in evaluating the evidence for various assessment
procedures and approaches? Reasonable criteria might
include several areas that have traditionally been
grouped under the rubric of reliability, such as in-
terrater reliability, scale homogeneity, and test–retest
stability, and several areas that have traditionally been
considered aspects of validity, such as content validity,
concurrent and discriminant validity, and construct va-
lidity. Other more specific considerations that are im-
portant in the assessment of psychopathology include
diagnostic accuracy (e.g., sensitivity and specificity,
which are aspects of convergent and discriminant va-
lidity, respectively), sensitivity to change, incremental
validity, and treatment and prognostic utility.
Second, what constitutes an acceptable level of reli-
ability or validity in each of these areas? Although
Rebecca S. Laptook provided helpful suggestions on an earlier
draft of this article.
Requests for reprints should be sent to Daniel N. Klein, De-
partment of Psychology, University at Stony Brook, Stony Brook,
NY 11794–2500. E-mail: dklein@notes.cc.sunysb.edu
rules of thumb exist for some of these criteria (e.g.,
kappa for levels of interrater reliability; Shrout, 2002),
there are few guidelines for interpreting the levels of
many forms of reliability and validity, and, in most in-
stances, the interpretation depends on the context. For
example, the meaning of an internal consistency coef-
ficient depends on the breadth of the construct being
assessed, and interpretations of interrater reliability
and test–retest reliability coefficients depend on the
study design (e.g., paired rater vs. independent inter-
view) and the test–retest interval, respectively. Finally,
some forms of validity (e.g., content and construct va-
lidity) are complex judgments that cannot be expressed
quantitatively using a standard metric.
Third, measures may have acceptable levels of
some forms of reliability and validity, unacceptable
levels of other forms, and no information bearing on
yet other forms. For example, many measures of de-
pressive symptomatology exhibit high concurrent va-
lidity but poor discriminant validity and lack data ad-
dressing treatment utility and incremental validity. How
should these disparate pieces of evidence be weighed
and combined into an overall evaluation of the
evidence?
Fourth, how many studies are necessary to conclude
that there is support for a given form of reliability and
validity? What if the results of different studies con-
flict? Should we insist that positive results be repli-
cated before accepting them, and, if so, do the studies
have to be conducted by independent groups?
Fifth, should an evidence-based approach to assess-
ment focus on the level of specific instruments or on
more general assessment approaches or strategies? It is
more difficult to evaluate the reliability and validity of
an approach, or group of measures, than a single instru-

412
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
ment. However, an approach- or strategy-based focus
may be more clinically useful and could lead to the de-
velopment of evidence-based assessment algorithms,
detailing sequences of assessments that might vary de-
pending on the results of the prior step.
Sixth, the empirical support for various assessment
instruments or approaches may vary depending on
their purpose. Although there are many reasons to con-
duct psychological assessments, some of the major
purposes are diagnosis, prognosis, treatment planning,
and treatment monitoring and evaluation. Some mea-
sures or approaches may have empirical support for
some purposes but not others (e.g., rating scales may
be useful for treatment monitoring and evaluation but
not for diagnosis). In addition, the utility of assessment
procedures may vary depending on the target pop-
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ulation (e.g., developmental level, ethnicity), context
(clinics vs. schools), and prevalence (or base rate) of
the disorder.
Finally, evidence-based assessment presupposes a
clear definition of the constructs to be assessed. For
many forms of psychopathology, the diagnostic con-
structs are controversial and are, at best, approxima-
tions of reality (Kendell & Jablensky, 2003). In addi-
tion, the targets of treatment planning are often unclear
and have limited empirical support, and key constructs
in assessing course and outcome (e.g., response, remis-
sion, recovery, relapse, recurrence) may be poorly de-
fined and based more on convention than data (E.
Frank et al., 1991).
These are general issues that cut across most spe-
cific disorders and clinical problems and must be ad-
dressed before evidence-based assessments for spe-
cific forms of child and adolescent psychopathology
can be developed. However, it is also important to con-
sider these problems at the level of the individual disor-
der, as they can have disorder-specific manifestations.
Moreover, there are additional, disorder-specific issues
that require consideration. In this article, we consider
some of the central issues that must be addressed in de-
veloping an evidence-based assessment of depression
in children and adolescents. We begin by discussing
the classification of child and adolescent depression;
review the prevalence, selected clinical correlates,
course, and treatment of juvenile depression; discuss
specific approaches to assessing depression in children
and adolescents; touch on the assessment of several
other constructs that are important in a comprehensive
evaluation of depression; highlight areas in which fur-
ther work is necessary; and conclude with some broad
recommendations given the current state of knowl-
edge. Although considerable work will be necessary
before an evidence-based approach to the assessment
of child and adolescent depression can be developed,
we believe that this is an important and worthwhile
task and hope that this article will help provide a start-
ing point for discussion.
Diagnosis and Classification of Child
and Adolescent Depression
The recognition of juvenile depression is relatively
recent, as prior to the 1970s most investigators and cli-
nicians believed that depression was extremely rare in
children. However, by the early 1980s it was apparent
that many children and adolescents met adult criteria
for major depressive disorder (MDD) and dysthymic
disorder (DD; Carlson & Cantwell, 1980).
There are a number of controversies and unresolved
issues in the diagnosis and classification of depression
in general and in children and adolescents in particular.
These issues include the continuity between child, ado-
lescent, and adult depression; whether depression is a
discrete entity or a region on a continuum of behavior;
whether it should be classified using a categorical or
dimensional system; what the boundaries are between
depression and normal variations in mood and other
forms of psychopathology; the identification of more
homogeneous subtypes; whether there are age-specific
expressions of depression; and the existence and mani-
festations of depression in very young children.
Continuity
There is considerable evidence for continuity be-
tween adolescent and adult depression; however, the
evidence for continuity between prepubertal and adult
depression is less consistent. The three major lines of
evidence that have attempted to address the issue of
continuity include studies of the clinical presentation,
longitudinal course, and familial aggregation of de-
pression. Depressed children, adolescents, and adults
tend to exhibit similar symptoms, although, as dis-
cussed later, there may be some developmental varia-
tions (Carlson & Kashani, 1988). Follow-up studies in-
dicate that depressed adolescents are at high risk for
developing episodes of MDD as adults (Lewinsohn,
Rohde, Klein, & Seeley, 1999; Weissman, Wolk, Gold-
stein, et al., 1999). However, follow-up studies of pre-
pubertal children have yielded mixed results, with
some studies indicating that depressed children are at
increased risk for depression in adulthood and other
studies failing to find evidence of increased risk, ex-
cept perhaps in particular subgroups (Harrington,
Fudge, Rutter, Pickles, & Hill, 1990; Weissman, Wolk,
Wickramaratne, et al., 1999). Finally, family studies
have found significantly higher rates of MDD in the
first-degree relatives of depressed adolescents than ad-
olescents with other forms of psychopathology and
adolescents with no history of psychiatric disorder
(Klein, Lewinsohn, Seeley, & Rohde, 2001). Family
studies have also found higher rates of MDD in the rel-
atives of depressed children than in the relatives of
healthy children; however, comparisons of rates of de-
pression in relatives of depressed children and children
413
 KLEIN, DOUGHERTY, OLINO
with other psychiatric disorders have yielded inconsis-
tent results (Kovacs, Devlin, Pollock, Richards, &
Mukerji, 1997; Puig-Antich et al., 1989).
The possibility of discontinuity between prepuber-
tal and postpubertal depression is further reinforced by
sex differences in prevalence (discussed more later).
Rates of depression are similar among boys and girls in
childhood, but the rate of depression is approximately
two times higher in female adolescents and adults. If
there is truly a discontinuity between child and adoles-
cent and adult depression, it would have important im-
plications for assessment, as what we presently regard
as a unitary construct would actually consist of two dif-
ferent disorders that are distinguished by the develop-
mental period in which they are observed.
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Discrete Versus Continuous
The question of whether mood disorders are dis-
crete entities or regions on a continuum has been de-
bated for much of the past century (Parker, 2000). This
topic is not merely of academic interest, as the answer
may provide clues regarding the nature of etiological
factors, help refine the definition of disorders and sub-
types, and indicate which assessment approaches and
statistical models provide optimal power (Beauchaine,
2003; Ruscio & Ruscio, 2002).
Currently, the suite of taxometric procedures devel-
oped by Meehl (1995) is regarded as the best means of
testing whether disorders are discrete or continuous.
However, we are aware of only two studies that have
applied these techniques to child and adolescent de-
pression. Using a large community sample, Hankin,
Fraley, Lahey, and Waldman (2005) did not find evi-
dence that MDD is a discrete entity in either children or
adolescents. However, in a clinical sample, Ambrosini.
Bennett, Cleland, and Haslam (2002) reported that the
melancholic subtype appeared to be discrete.
Categorical Versus Dimensional
Classification
Although classification systems for psychopatholo-
gy have typically used a categorical format, many in-
vestigators believe that dimensional systems are more
appropriate (e.g., Widiger & Clark, 2000). This debate
is frequently confused with the issue of discreteness, as
proponents of categorical models tend to assume that
psychiatric disorders are discrete entities, whereas ad-
vocates of dimensional models generally believe that
they are regions on a continuum. However, it is possi-
ble to advocate a categorical approach to classification
on the pragmatic grounds that it is an efficient means of
summarizing and communicating information about
clinical syndromes and guiding decision making for
treatment and policy without necessarily believing that
the disorders will ultimately prove to be etiologically
414
discrete (Kessler, 2002; Klein & Riso, 1993). Indeed,
this is the position taken by the Diagnostic and Sta-
tistical Manual of Mental Disorders (4th ed.
[DSM–IV]; American Psychiatric Association, 1994),
which employs a categorical format but states that it
does not assume that each mental disorder is a discrete
entity.
Most studies using dimensional approaches to de-
pression have simply summed the number of depres-
sive symptoms. However, it is unlikely that dimen-
sional classification systems that rely entirely on
symptoms will be sufficient, as the literature on adults
indicates that depressive symptoms wax and wane over
time and are not stable across episodes, plus there is
poor concordance between patients’ reports of symp-
toms and behavioral ratings by trained observers
(Klein, Shankman, & McFarland, in press). Hence, di-
mensional models must also consider key course vari-
ables such as the frequency and duration of episodes
(recurrence and chronicity; Shankman & Klein, 2002).
Boundaries
Given a categorical classification system, a critical
issue concerns the location of the boundaries between
depression and normal variations in mood and other
forms of psychopathology, such as the anxiety disor-
ders. The distinction between mood disorders and nor-
mal variations in mood, nonpathological dysphoria,
and responses to stress is complex, as it is influenced
by a variety of cultural, social, and economic factors
and has changed over time. Some investigators believe
that the current boundaries are too broad and include a
number of individuals with demoralization and tran-
sient responses to stress. The current boundaries may
be particularly problematic in adolescence, a period
that is characterized by major developmental transi-
tions and high levels of emotional intensity (Arnett,
1999). Consistent with this possibility, Wickramaratne
and Weissman (1998) reported that the rates of depres-
sion in offspring of depressed and nondepressed par-
ents differed in childhood and young adulthood but
that there were no differences in adolescence where
there was a marked increase in rates regardless of pa-
rental diagnosis. On the other hand, some investigators
believe that the current boundaries are too strict, point-
ing to evidence that subthreshold depressive symptoms
are common in juveniles and adults and are frequent-
ly associated with significant functional impairment
(e.g., Lewinsohn, Solomon, Seeley, & Zeiss, 2000).
There has also been a long-standing debate regard-
ing the boundary between depression and anxiety; for
example, are depressive and anxiety disorders distinct
conditions, are they variants of a single disorder, or is
there a third category of anxious depression that is dis-
tinct from both pure depression and pure anxiety? As
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
discussed later, numerous studies using both clinical
and community samples have documented high rates
of comorbidity between mood disorders and anxiety
disorders (Angold, Costello, & Erkanli, 1999). The re-
lation between depression and anxiety appears to be
complex. For example, Eaves and Silburg (2003) re-
cently reported evidence for three distinct pathways in
which childhood anxiety influences the development
of depression in adolescence: one in which genetic dif-
ferences in anxiety create later genetic differences in
depression; a second in which genes that affect early
anxiety increase sensitivity to adverse life events, in-
creasing risk for depression; and a third in which genes
that increase risk to early anxiety increase exposure to
depressogenic environmental influences. Moreover,
the relations between anxiety and depression differ de-
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pending on the specific anxiety disorder under consid-
eration (Silberg, Rutter, & Eaves, 2001).
Clark and Watson’s (1991) tripartite model is an im-
portant approach to describing the distinctive and over-
lapping aspects of depression and anxiety. The model
parses the domain of anxiety and depression into three
dimensions: general distress, anhedonia, and physio-
logical hyperarousal. Depression and anxiety are both
characterized by a high level of distress. However, de-
pression is uniquely characterized by a high level of
anhedonia, whereas anxiety is uniquely characterized
by a high level of physiological hyperarousal. These
predictions have been tested in a number of studies
of children and adolescents and have generally been
supported (e.g., Chorpita & Daleiden, 2002; Lonigan,
Phillips, & Hooe, 2003). An important implication of
the model for clinical assessment is that the distinction
between depression and anxiety can be sharpened by
emphasizing the two specific dimensions, anhedonia
and physiological hyperarousal, and de-emphasizing
symptoms reflecting general distress (e.g., negative af-
fect, insomnia, difficulty concentrating).
Subtypes
Most investigators believe that depression is etio-
logically heterogeneous. A major focus of the litera-
ture on the classification of depression in adults has
involved attempting to delineate more homogeneous
subtypes (Klein et al., in press). In addition to the uni-
polar–bipolar distinction (see Youngstrom, Findling,
Youngstrom, & Calbrese, 2005), subtypes have been
proposed on the basis of symptomatology (e.g., psy-
chotic, melancholic, atypical), course (e.g., age of on-
set, recurrent, chronic, and seasonal pattern), and the
combination of both (e.g., MDD vs. DD vs. double de-
pression). Unfortunately, the issue of heterogeneity has
largely been ignored in child and adolescent depres-
sion, hence it is unclear whether most of the subtypes
of adult depression can be meaningfully applied to
children. An important exception, however, is age of
onset. Consistent with the previous discussion about
the possible discontinuity between child and adoles-
cent depression, there is some evidence that pre- and
postpubertal onset depressions may differ with respect
to long-term course and familial aggregation (Weiss-
man, Wolk, Wickramaratne, et al., 1999).
Age-Specific Manifestations
Setting aside the issue of continuity at a fundamen-
tal, etiological level, the question of whether the clini-
cal presentations of MDD and DD differ as a function
of developmental level is complex and, as yet, unre-
solved. However, it is crucial in determining whether
the diagnostic criteria for MDD and DD and the con-
tent of interviews and rating scales for depression
should be modified for different age groups. As noted
previously, the available literature suggests that the
symptom picture is fairly similar in school-age chil-
dren, adolescents, and adults, although there is some
evidence that hopelessness and some vegetative and
motivational symptoms may be somewhat more fre-
quent in adolescents than children (Carlson & Kashani,
1988; Weiss & Garber, 2003). Nonetheless, the mani-
festations of particular symptoms do vary as a function
of the child’s level of cognitive and social develop-
ment. For example, younger children may appear sad
but have difficulty reporting their mood, and prepu-
bertal children may lose interest in their friends and ac-
tivities but are unlikely to experience decreased libido.
There have also been several studies exploring whether
there are developmental differences in the structure of
the depressive syndrome, although the findings have
been inconsistent (Weiss & Garber, 2003).
Depression in Very Young Children
There has been little systematic research on depres-
sion in preschool-age children and infants. Thus, it is
unclear whether a syndrome comparable to that iden-
tified in school-age children, adolescents, and adults
exists in younger children and, if it does, what the de-
fining and associated features are. However, in an im-
portant series of articles, Luby, Heffelfinger, Mrakot-
sky, et al. (2002) recently reported that MDD can be
identified in preschool-age children using modified
DSM–IV criteria with a shorter duration requirement
and provided preliminary evidence of construct validity.
Prevalence
Knowledge of base rates is an important consider-
ation in assessment, as they can have a significant im-
pact on the utility of assessment instruments and the
validity of clinical decisions. For example, it is difficult
for assessment instruments to improve on chance pre-
415
 KLEIN, DOUGHERTY, OLINO
diction in situations with very high or very low base
rates; and for instruments with a given sensitivity and
specificity, the positive predictive power of tests is
maximized in high base rate situations, whereas nega-
tive predictive power is maximized in low base rate sit-
uations (Meehl & Rosen, 1955).
Depressive disorders are relatively uncommon in
children but are more frequent in adolescents. In com-
munity samples, the 6-month prevalence of depressive
disorders is 1% to 3% in school-age children and 5% to
6% in adolescents; the lifetime prevalence in adoles-
cents is 15% to 20% (Garber & Horowitz, 2002; Lew-
insohn & Essau, 2002). Not surprisingly, the preva-
lence of depression is much higher in clinical settings,
with estimated rates of 8% to 15% in children and more
than 50% in adolescents (Schwartz, Gladstone, & Kas-
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low, 1998). There is no consistent gender difference in
the prevalence of depressive disorders in children;
however, the rates diverge in early adolescence, and by
age 15 the prevalence is approximately two times
higher in girls than boys (Hankin et al., 1998).
Associated Features
Two associated features that are important to con-
sider in assessing depression are functional impair-
ment and comorbidity, as both may influence course
and treatment response, as well as constituting impor-
tant treatment targets in their own right.
Functional Impairment
Depressive disorders are associated with signifi-
cantly poorer psychosocial functioning in children and
adolescents. Depressed children and adolescents often
exhibit significant impairment in family, school, and
peer functioning, and some degree of impairment may
persist after recovery from the depressive episode
(Garber & Horowitz, 2002; Lewinsohn & Essau,
2002). Depressed adolescents are also at risk for school
dropout and unplanned pregnancy (Waslick, Kandel, &
Kakouros, 2002). Depression is the leading risk factor
for youth suicide and may be a risk factor for the devel-
opment of other disorders such as substance abuse
(Birmaher, Arbelaez, & Brent, 2002). The causal rela-
tion between depression and functional impairment is
complex: Depression causes significant impairment,
but poor functioning may also be a risk factor for de-
pression. Thus, the association is probably reciprocal
and transactional.
Comorbidity
The majority of children and adolescents with
MDD or DD also meet criteria for other psychiatric
disorders. In a meta-analysis of studies using commu-
416
nity samples, Angold et al. (1999) reported that the me-
dian odds ratios for the associations of depression with
anxiety, conduct disorder, and attention deficit disorder
were 8.2, 6.6, and 5.5, respectively. Depression is also
often comorbid with eating, reading, and developmen-
tal disorders and general medical conditions. As noted
previously, there are a number of possible reasons for
these high comorbidity rates, including inadequacies
in the diagnostic system (e.g., splitting what is really a
single category, such as internalizing disorders, into
multiple subtypes, such as depression and generalized
anxiety disorder), one disorder causing the other (e.g.,
some forms of anxiety leading to depression; e.g.,
Cole, Peeke, Martin, Truglio, & Seroczynski, 1998),
the comorbid condition representing a distinct disorder
(e.g., depression and disruptive behavior disorders;
e.g., Harrington, Rutter, & Fombonne, 1996), or both
disorders having a common cause (Klein & Riso,
1993). Identifying the causes of comorbidity could
have important implications for revising the classifica-
tion system. However, even without understanding the
nature of the causal processes, comorbidity is clini-
cally important because it can obscure the existence of
a depressive disorder and is associated with greater im-
pairment and a poorer course and treatment response.
In addition, comorbid conditions may require attention
in their own right.
Course
Almost all children and adolescents with an episode
of MDD recover, although many continue to experi-
ence subsyndromal (or residual) symptomatology. The
length of episodes varies. The mean duration of epi-
sodes of MDD is approximately 7 to 8 months in clini-
cal samples, and episodes of DD last an average of 48
months (Birmaher et al., 2002; Kovacs, 1996). Rates of
relapse and recurrence of MDD are high, with the ma-
jority of depressed juveniles experiencing another epi-
sode within several years (Birmaher et al., 2002; Ko-
vacs, 1996). Long-term follow-up studies indicate that
adolescents with MDD are at high risk for experienc-
ing depressive episodes in adulthood; however, the
evidence for children with MDD is less consistent
(Birmaher et al., 2002).
The mechanisms and processes that serve to main-
tain depressive episodes and cause recurrences are
poorly understood, in part because most studies have
not distinguished between onset, maintenance, and re-
currence. However, longitudinal studies of the course
of depression in children and adolescents have identi-
fied a number of factors that appear to predict the dura-
tion of MDD episodes and the probability of re-
currence. These data provide important prognostic
information, although further work is needed to deter-
mine the relative importance of these predictors. Some
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
of the prognostic variables may themselves be reason-
able targets for intervention, although without a better
understanding of their causal role, it is uncertain
whether modifying them will hasten recovery or pre-
vent recurrence. Variables that are associated with a
longer time to recovery include an early age of onset,
greater severity of depression, suicidality, double de-
pression, the presence of comorbid anxiety or disrup-
tive behavior disorders, depressotypic cognitions, and
an adverse family environment (Birmaher et al., 2002).
Most of these factors also predict recurrence. Variables
that have been associated with an increased risk of re-
currence include greater severity, psychotic symptoms,
suicidality, a prior history of recurrent MDD, double
depression, the presence of subthreshold symptoms af-
ter recovery, a depressotypic cognitive style, recent
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stressful life events, an adverse family environment,
and a family history of MDD (particularly if it is recur-
rent; Birmaher et al., 2002).
It is difficult to determine the relative importance of
these prognostic factors, as there are few instances in
which most of these variables have been included in
the same study. However, in a study of a community
sample of depressed adolescents, Lewinsohn, Rohde,
Seeley, Klein, and Gotlib (2000) recently examined
most of these variables as predictors of recurrence in
young adulthood. They found that a prior history of re-
current MDD, a family history of recurrent MDD, per-
sonality disorder traits, and, for girls only, greater con-
flict with parents were significant and independent
predictors of subsequent recurrence.
Children and adolescents with MDD and DD are
also at risk for developing manic and hypomanic epi-
sodes. The probability of “switching” to bipolar disor-
der is higher in patients with psychotic symptoms,
psychomotor retardation, a family history of bipolar
disorder, a high familial loading for mood disorders, or
a combination of these (Birmaher et al., 2002; Geller,
Fox, & Clark, 1994).
Treatment
There is relatively strong support for the efficacy of
cognitive–behavioral therapy (CBT) and interpersonal
therapy for depressed adolescents (Asarnow, Jaycox,
& Tompson, 2001; Kaslow, McClure, & Connell,
2002). However, the few studies examining the effects
of family therapy, either alone or in conjunction with
treatment for the adolescent, have generally failed to
support its efficacy (Asarnow et al., 2001). Fewer data
are available on the efficacy of psychosocial interven-
tions in school-age children. Almost all of the clinical
trials in this age group have used variants of CBT, gen-
erally administered in a group format to children with
elevated levels of depressive symptoms but not neces-
sarily diagnoses. Although the findings have varied,
the majority of studies have reported evidence support-
ing the efficacy of CBT (Kaslow et al., 2002).
Little is known about the mechanisms underlying
the effects of CBT and interpersonal therapy on de-
pression in children and adolescents (or adults for that
matter; Kazdin, 2003). In addition, despite the efficacy
of psychosocial interventions for depressed children
and adolescents in clinical trials, there is evidence that
this may not translate into effectiveness in community
settings (Weisz, Donenberg, Han, & Weiss, 1995).
Finally, there are no data on the efficacy of treatments
for very young children with depression.
Controlled clinical trials of antidepressant medica-
tions in children and adolescents are also limited. The
available evidence indicates that the cyclic antidepres-
sants are not efficacious (Emslie & Mayes, 2001). The
data on newer medications, such as the selective sero-
tonin uptake inhibitors and atypical antidepressants,
is mixed. Four published double-blind placebo-con-
trolled trials have reported benefits in adolescents or
mixed samples of children and adolescents, but other
published and unpublished studies have failed to find
differences (Jureidini et al., 2004; Whittington et al.,
2004). In addition, questions have recently been raised
about whether several of the newer antidepressants are
associated with increased suicidal ideation and behav-
ior in children and adolescents (Jureidini et al., 2004;
Whittington et al., 2004).
Similar to adult depression, it appears that there are
high rates of relapse and recurrence when psychosocial
and pharmacological treatments are terminated. Un-
fortunately, there are few studies of continuation or
maintenance treatments for depressed children and ad-
olescents (Asarnow et al., 2001; Emslie & Mayes,
2001). Extrapolating from the adult literature, it may
be prudent to consider continuation and maintenance
treatment for patients with partial recovery or charac-
teristics associated with an increased risk of recurrence
(e.g., history of recurrent episodes, double depression,
family history of MDD, ongoing family conflict, or
other stressors).
Data on predictors of treatment response in de-
pressed children and adolescents is limited. However,
it appears that many of the same variables that predict a
more protracted recovery in naturalistic studies also
predict a poorer response to treatment (Emslie, Mayes,
Laptook, & Batt, 2003; Kaslow et al., 2002). Unfortu-
nately, there are even fewer data on predictors of differ-
ential treatment response, that is, which patients re-
spond better to some treatments than others. An
exception is one study that reported that comorbid anx-
iety disorder predicted a better response to CBT than to
systemic-behavioral family therapy or supportive ther-
apy (Brent et al., 1998). An intuitively appealing strat-
egy is to use patients’ deficits to guide treatment se-
lection (e.g., CBT for children and adolescents with
prominent depressive cognitions, interpersonal ther-
417
 KLEIN, DOUGHERTY, OLINO
apy for those with interpersonal problems, family ther-
apy for those with family dysfunction; Kaslow et al.,
2002). However, the limited evidence available for
both depressed youths and adults indicates that deficits
in particular areas do not predict a better response to
treatments designed to target those deficits (e.g., de-
pressive cognitions do not predict response to cogni-
tive–behavioral therapy; Asarnow et al., 2001; Sotsky
et al., 1991). To our knowledge, the alternative strategy
of matching treatment to strengths has not been investi-
gated for youth depression, although there have been
hints that it may be an effective approach for adults
(Sotsky et al., 1991).
General Considerations in Assessment
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Clinical assessment can be thought of as a sequence
including at least three phases: diagnosis and progno-
sis, treatment planning, and treatment monitoring and
evaluation. The major goal of the initial phase is to de-
velop a preliminary diagnosis and case conceptualiza-
tion. For depression, this includes determining whether
criteria are met for MDD or DD and ruling out ex-
clusionary diagnoses such as bipolar disorder and de-
pression due to a general medical condition or sub-
stance. As part of the assessment of depression, the
clinician must assess key symptoms (e.g., suicidal
ideation, psychotic symptoms) that might influence
treatment decisions. In addition, it is important to care-
fully assess the previous course of the depression (e.g.,
prior episodes, chronicity) due to its prognostic value
and possible implications for long-term treatment. It is
also important to assess comorbid psychiatric, devel-
opmental, and general medical disorders and areas of
significant functional impairment (e.g., family, school,
peers) both to determine whether depression is the
principle diagnosis that should be the primary target of
intervention and because of their prognostic implica-
tions. Finally, it is important to assess the child’s fam-
ily environment, school functioning, and peer relation-
ships; significant stressors and traumas; and family
history of psychopathology, as these factors have con-
siderable prognostic value.
Most of these variables are also critical for treat-
ment planning. Data on the severity and prior course of
depression, key symptoms such as suicidal ideation or
behavior and psychotic symptoms, comorbidity, and
functional impairment are important for determining
the appropriate treatment setting (e.g., inpatient vs.
outpatient), the intensity and duration of treatment, and
perhaps the treatment modality, although as noted pre-
viously, few data are available to guide these decisions.
Information on comorbidity is also necessary to deter-
mine whether other disorders should be monitored or
targeted for treatment. Data on comorbid mental, de-
velopmental, and general medical disorders, the family
418
environment, and family history of psychopathology
are important because they may suggest, contraindi-
cate, or complicate some treatment options (e.g., par-
ent counseling, family therapy) or suggest the need for
additional referrals for the patient or a family member.
Finally, it is critical to take a detailed history of previ-
ous treatment and assess the goals, attitudes, and moti-
vation of the child and parents with respect to the rele-
vant treatment options. This information is critical
both for treatment selection and for engaging the child
and family in treatment. As children and parents often
disagree on the selection of treatment targets (Hawley
& Weisz, 2003), it may take considerable negotiation
to develop a treatment plan that is acceptable to all
parties.
The third phase of assessment involves treatment
monitoring and evaluation. This entails systematically
assessing the degree of change in target symptoms and
impairments to determine whether treatment should be
continued, intensified, augmented, changed, or termi-
nated. As few guidelines are available to help clini-
cians determine when treatment should be modified,
this is an important area for future research.
Information Source
It is important to obtain data from multiple infor-
mants, including the child, parents, and teachers. Child
report is critical, as parents and teachers tend to report
lower levels of depressive and other internalizing
symptoms in children than youths report themselves
(Jensen et al., 1999). However, it is useful to supple-
ment youths’ reports with information from collaterals
to assess externalizing disorders. Parent reports are
particularly important for preadolescent children. Due
to developmental limitations in cognitive processes
and language abilities, children are less reliable report-
ers of psychopathology than adolescents (Edelbrock,
Costello, Dulcan, Kalas, & Conover, 1985). In addi-
tion, younger children have difficulty reporting on in-
formation requiring temporal parameters; therefore,
parents must be relied on for information on course
such as age of onset, previous episodes, and duration of
current episode (Kovacs, 1986). Finally, parents are
more involved in the day-to-day lives of children than
adolescents and therefore are more knowledgeable
about their behavior and activities.
Although obtaining data from multiple informants
is optimal, agreement between informants is only fair
to moderate (Achenbach, McConaughy, & Howell,
1987). In addition, depressed parents appear to have
a lower threshold for detecting depression in their
children, hence their reports tend to yield higher rates
of both true and false positives (i.e., increased sen-
sitivity but decreased specificity; Najman et al., 2000;
Richters, 1992; Youngstrom, Izard, & Ackerman,
1999).
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
Despite the substantial disagreement between in-
formants, there is evidence for the validity of both par-
ent and child reports (Jensen et al., 1999). In addition,
several studies have demonstrated that child, parent,
teacher, and clinician ratings all account for significant
unique variance in predicting subsequent outcomes
(Ferdinand et al., 2003; Verhulst, Dekker, & van der
Ende, 1997).
The low agreement between data sources presents a
significant challenge for clinicians who must decide
how to interpret and integrate conflicting information.
A variety of approaches to integrating data from multi-
ple informants has been discussed in the literature, in-
cluding assuming that the feature or diagnosis is pres-
ent if any informant reports it (the “or” rule), requiring
several informants to confirm the feature or diagnosis
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(the “and” rule), or developing various statistical pro-
cedures for optimizing prediction (e.g., Baillargeon et
al., 2001; Kraemer et al., 2003; Rubio-Stipec, Fitz-
maurice, Murphy, & Walker, 2003). The approach that
most closely mirrors clinical practice is the “best esti-
mate” procedure, in which the clinician uses his or her
best judgment to integrate and resolve conflicting re-
ports. This raises the possibility of bringing through
the back door the unreliability and idiosyncrasy that
structured interviews and standardized ratings scales
were developed to prevent (discussed later). However,
there is evidence from the adult literature that when
applied, following some general guidelines (e.g., self-
report takes precedence for internalizing disorders; in-
formant report is given priority for externalizing dis-
orders), the reliability of best-estimate diagnoses can
be very high (Klein, Ouimette, Kelly, Ferro, & Riso,
1994).
Attenuation Effect
Studies of interviews and ratings scales for both ju-
venile and adult psychopathology have often found
that rates of diagnoses and ratings of symptom severity
tend to decrease with repeated administrations, a phe-
nomenon referred to as the “attenuation effect” (Egger
& Angold, 2004). This has important implications for
treatment monitoring and evaluation, as it is difficult to
distinguish the attenuation effect from a positive re-
sponse to treatment for the individual patient. Al-
though there is no solution to this problem at present, it
behooves the clinician to be aware of this phenomenon
and to consider alternative explanations for what ap-
pears to be improvement on rating scales.
Approaches to Assessing Depression
in Children and Adolescents
The two major approaches to diagnosing and as-
sessing depression in children and adolescents involve
interviews and rating scales. Unfortunately, there are
no laboratory measures of psychosocial or biological
variables that are useful for clinical assessment at this
time (Garber & Kaminski, 2000; Waslick et al., 2002).
Several observational measures and coding systems
have been employed for assessing depression in chil-
dren; however, there is insufficient evidence to recom-
mend their use (Garber & Kaminski, 2000; Kendall,
Cantwell, & Kazdin, 1989).
Interviews can include unstructured clinical inter-
views and semistructured or fully structured inter-
views. Unstructured clinical interviews vary from cli-
nician to clinician with respect to format, duration,
focus, and coverage and therefore in the amount and
type of information elicited. The literature indicates
that clinicians using unstructured interviews often fail
to inquire about key aspects of psychopathology, par-
ticularly if it is inconsistent with their initial diagnostic
impressions (Angold & Fisher, 1999), and end up mak-
ing fewer diagnoses than clinicians using structured
interviews (Zimmerman, 2003). Thus, structured inter-
views are more comprehensive. In addition, they prob-
ably have greater interrater reliability, although we are
unaware of studies directly testing this. Although there
are few data on the incremental validity of structured
diagnostic assessments, Kashner et al. (2003) found
that when the results of semistructured diagnostic in-
terviews were provided to clinicians, it resulted in
changes in clinicians’ diagnoses and treatment, sug-
gesting that the additional information was perceived
as clinically useful and valid. Although most of this
work has focused on adults, there is evidence that some
of these findings may also apply to children and ado-
lescents (Hughes et al., 2000; Lewczyk, Garland, Hurl-
burt, Gearity, & Hough, 2003).
Semistructured interviews are often referred to as
“interviewer based” because the interviewer is respon-
sible for rating the criteria as accurately as possible, us-
ing all information at his or her disposal, and improvis-
ing additional questions or confronting the respondent
with inconsistencies when necessary. In contrast, fully
structured interviews are referred to as “respondent
based” because the interviewer’s role is limited to read-
ing the questions as written and recording the respon-
dent’s answers. Both approaches require judgments
about the presence and significance of symptoms and
other clinical features. In semistructured interviews,
these judgments are made by the interviewers, whereas
in fully structured interviews they are made by the re-
spondents. As a result, semistructured interviews were
designed for use by mental health professionals or
well-trained and supervised technicians and seek to
capitalize on their clinical training and experience,
whereas fully structured interviews were developed for
lay interviewers in large-scale epidemiological studies
in which the cost of interviewers with clinical training
is prohibitive.
419
 KLEIN, DOUGHERTY, OLINO
There have been few direct comparisons of the va-
lidity of semi- versus fully structured interviews. In the
absence of evidence to the contrary, we assume that the
interviewer-based approach yields higher quality data
than the respondent-based approach because the inter-
viewer presumably has a better sense of the constructs
being assessed than the respondent. However, there are
some data suggesting that fully structured interviews
administered by bachelor’s degree level technicians
may be useful in supplementing clinical evaluations in
clinical settings (Hughes et al., 2000).
Rating scales include clinician-administered, self-
report, and parent and teacher measures. Clinician-ad-
ministered rating scales are semistructured interviews
that focus on a circumscribed area of symptomatology
(e.g., depression). Unlike diagnostic interviews, they
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do not collect sufficient information to make a diagno-
sis (e.g., duration and exclusion criteria are generally
not assessed). Self-report and parent and teacher rating
scales are typically questionnaires that are self-admin-
istered by the designated informant (although they can
be read to younger children). Similar to clinician-
administered rating scales, self-, parent, and teacher
rating scales typically focus on current symptoms and
behavior and therefore do not provide sufficient infor-
mation to make diagnoses.
Due to their economy, self-, parent, and teacher rat-
ing scales can be used as screening instruments, with
elevated scores leading to a more intensive evaluation.
Self-rating scales are generally superior to parent and
teacher rating scales in screening for internalizing dis-
orders due to their greater sensitivity. However, even
the best self-rating scales have only moderate sensitiv-
ity and specificity, producing a substantial number of
false positives and false negatives (Kendall et al.,
1989). The most useful indexes for evaluating the clini-
cal utility of a screening instrument are positive predic-
tive power, the probability that individuals scoring
above the cutoff point on the instrument actually have
the disorder, and negative predictive power, the proba-
bility that individuals scoring below the cutoff point do
not have the disorder. Positive predictive power and
negative predictive power are strongly influenced by
the prevalence, or base rate, of the condition in the pop-
ulation being screened. Positive predictive power tends
to be low and negative predictive power tends to be
high in low base rate situations, whereas the inverse is
characteristic of high base rate situations. As the preva-
lence of child and adolescent depression tends to be
fairly low in most screening contexts, the use of
screeners often produces unacceptably low positive
predictive power, with the false positives greatly out-
numbering the true positives (Matthey & Petrovski,
2002; Roberts, Lewinsohn, & Seeley, 1991). Thus, the
potential economy and efficiency of screening must be
weighed against the costs of unnecessary extended
evaluations for false positive cases and the risks associ-
420
ated with missing false negative cases (Costello &
Angold, 1988).
In the next two sections, we briefly describe several
of the better researched and more widely used semi-
structured diagnostic interviews and rating scales. Due
to space limitations, we have been highly selective, and
there are a number of equally good but less widely used
measures that we have not included. For more informa-
tion, readers are referred to more comprehensive re-
views (Angold & Fisher, 1999; Brooks & Kutcher,
2001; Myers & Winters, 2002; Silverman & Rabian,
1999). In addition, we focus on general measures of
depression. There are also a number of measures of
specific components of the depressive syndrome, such
as self-esteem, hopelessness, depressive cognitions,
and suicidality (see Winters, Myers, & Proud, 2002,
for a review) that may be useful for particular cases, but
they are not reviewed here.
Semistructured Diagnostic Interviews
In this section, we briefly review the three most
widely used semistructured diagnostic interviews for
child and adolescent psychopathology: the Schedule
for Affective Disorders and Schizophrenia in School-
Age Children (K–SADS; Puig-Antich & Chambers,
1978), the Diagnostic Interview for Children and Ado-
lescents (Herjanic & Reich, 1982), and the Child and
Adolescent Psychiatric Assessment (CAPA; Angold,
Prendergast, et al., 1995). We do not discuss fully
structured respondent-based interviews, such as the
Diagnostic Interview Schedule for Children (Shaffer,
Fisher, & Lucas, 1999), as we believe that they are less
useful in clinical settings for the reasons described pre-
viously. Each interview assesses the criteria for most of
the major child and adolescent psychiatric disorders
and provides parallel versions for children and parents.
Although some of the instruments are used to interview
6- and 7-year-old children, it is questionable whether
children younger than 8 or 9 years old can provide
valid information in a diagnostic interview (Angold &
Fisher, 1999).
Evaluating the validity of semistructured diagnostic
interviews is complex, as they are usually used as the
“gold standard” against which other measures are
compared. Construct validity is probably the best stan-
dard (Angold & Costello, 2000), but given the current
state of the literature, it is impossible to distinguish the
construct validity of semistructured interviews from
the diagnoses that they are designed to assess. To try to
disentangle the construct validity of interviews from
diagnostic constructs, it is necessary to conduct head-
to-head comparisons of several interviews using the
same sample and the same criteria for construct valida-
tion (e.g., family history, course). As such studies have
not been conducted, we limit our discussion to the
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
interrater reliability and convergent validity of the in-
terviews. Although the distinction between MDD and
DD has important prognostic implications (Kovacs,
1996), the majority of studies combine them in a
higher order depressive disorder category or focus
solely on MDD. Hence, for the purposes of this article,
we focus on depressive disorders as broadly conceived.
The K–SADS (Puig-Antich & Chambers, 1978) is
the most widely used semistructured interview for chil-
dren and adolescents (6 to 18 years). It is also the least
structured of the semistructured interviews and there-
fore requires the greatest amount of clinical training
and experience. The K–SADS was modeled after the
adult Schedule for Affective Disorders and Schizo-
phrenia (SADS). There are a number of versions of the
K–SADS that assess DSM–IV criteria. These versions
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vary in format, whether they assess lifetime as well as
current psychopathology, and whether they also pro-
vide dimensional measures of symptom severity (for
detailed comparisons see Ambrosini [2000] and An-
gold & Fisher [1999]). Ratings are based on all sources
of information and clinical judgment. Administration
time of the parent and child interviews range from 35
min to 2.5 hr each, depending on the severity of the
child’s psychopathology. Interrater reliability has been
reported to be fair to excellent for depressive disorders
in several studies and has been particularly impressive
with the more recent versions of the K–SADS (Am-
brosini, 2000; Kaufman et al., 1997). Evidence for con-
vergent validity derives from numerous studies report-
ing correlations between the K–SADS and a variety of
clinician, self-, and parent rating measures of depres-
sion and internalizing behavior problems (Ambrosini,
2000; Kaufman et al., 1997).
The Diagnostic Interview for Children and Adoles-
cents (Herjanic & Reich, 1982) was originally de-
signed as a fully structured interview. However, more
recent versions are semistructured. The most recent
version of the Diagnostic Interview for Children and
Adolescents (Reich, 2000) assesses both Diagnostic
and Statistical Manual of Mental Disorders (3rd ed.,
rev. [DSM–III–R]; American Psychiatric Association,
1987) and DSM–IV criteria and includes separate inter-
views for children (6 to 12 years), adolescents (13 to 17
years), and parents. The interview adopts a lifetime
time frame and takes approximately 1 to 2 hr to com-
plete. Data on interrater reliability has varied across
studies, ranging from poor to good (Boyle et al., 1993;
Brooks & Kutcher, 2001; Reich, 2000). The Diagnos-
tic Interview for Children and Adolescents diagnoses
are moderately correlated with clinicians’ diagnoses
and clinician and self-rated measures of depressive
symptoms (Brooks & Kutcher, 2001; Ezpeleta et al.,
1997; Reich, 2000), providing some evidence of con-
vergent validity.
The CAPA (Angold, Prendergast, et al., 1995) as-
sesses the criteria for most major diagnoses in children
ages 9 to 17 years. The time frame for symptom assess-
ment is the preceding 3 months, and administration
time takes from 1 to 2 hr (Angold & Costello, 2000).
Although there are few data on the CAPA by investiga-
tors who were not involved in its development, the in-
terview has several very attractive features. First, it is
unique in that it includes an extensive glossary defining
specific symptoms and distress and frequency ratings.
As a result, the CAPA can be used by interviewers with
minimal clinical experience, as long as they adhere
closely to the definitions and conventions in the glos-
sary. Second, it includes a section for assessing impair-
ment in a number of areas, including family, peers,
school, and leisure activities, and also includes sec-
tions assessing the family environment and life events
and traumas. In the one published study of the test–re-
test reliability of the CAPA, Angold and Costello
(1995) reported that the kappas for MDD and DD were
.90 and .85, respectively, and that the intraclass corre-
lation for the MDD symptom scale was .88. Data on
the association between CAPA diagnoses of depres-
sion and other measures of depression have not been
published. However, Angold and Costello (2000) re-
ported that depression as diagnosed by the CAPA is as-
sociated with significant levels of functional impair-
ment and higher concordance among monozygotic
than dizygotic twins, supporting the construct validity
of the interview.
Rating Scales
In this section, we briefly review some of the more
widely used clinician, self-report, and multi-informant
rating scales for depression. Due to space limitations,
we do not discuss rating scales designed for adults that
are often used with older adolescents (e.g., the Hamil-
ton Rating Scale for Depression [Hamilton, 1967]; the
Beck Depression Inventory [Beck, Ward, Mendelsohn,
Mock, & Erbaugh, 1961]; and the Center for Epidemi-
ological Studies–Depression Scale [Radloff, 1977]).
However, these three measures have similar psy-
chometric properties in adolescent and adult samples
(Roberts et al., 1991) and have comparable reliability
and validity compared to measures that were specifi-
cally designed for juveniles. Hence, these measures ap-
pear to be acceptable alternatives for older adolescents.
In discussing reliability and validity, we focus on in-
ternal consistency and interrater reliability for clini-
cian-rated scales, internal consistency and test–retest
reliability for self- and multi-informant rating scales,
and convergent and discriminant validity and sensitiv-
ity to change for all rating scales.
The most widely used clinician scale for rating de-
pression is the Children’s Depression Rating Scale
(CDRS; Poznanski, Cook, & Carroll, 1979). Based on
the Hamilton Rating Scale for Depression, the CDRS
421
 KLEIN, DOUGHERTY, OLINO
was developed to assess current severity of depression
in children ages 6 to 12 years and is often used for ado-
lescents as well. The revised version (Poznanski &
Mokros, 1999) contains 17 items assessing cognitive,
somatic, affective, and psychomotor symptoms and
draws both on the respondent’s report and the inter-
viewer’s behavioral observations. It takes 15 to 20 min
to administer. It is designed to be administered sepa-
rately to the child and an informant, with the clinician
subsequently integrating the data using clinical judg-
ment. Cutoff scores are provided to aid in interpreting
levels of depression severity. The CDRS has only mod-
erate internal consistency but good interrater reliability
(Brooks & Kutcher, 2001; Myers & Winters, 2002). Its
convergent validity has been supported by moderate to
high correlations with the Hamilton Rating Scale for
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Depression and several self-rated depression scales
(Brooks & Kutcher, 2001; Myers & Winters, 2002;
Shain, Naylor, & Alessi, 1990). However, discriminant
validity is more problematic, as the CDRS has diffi-
culty distinguishing between depression and anxiety
and overestimates depression severity in children with
general medical conditions due to its emphasis on so-
matic symptoms (Brooks & Kutcher, 2001; Myers &
Winters, 2002). Finally, the CDRS has detected treat-
ment effects in both psychopharmacology and psycho-
therapy trials (Brooks & Kutcher, 2001; Myers & Win-
ters, 2002).
There are a number of widely used self-rating scales
for child and adolescent depression. We briefly review
four: the Children’s Depression Inventory (CDI; Ko-
vacs, 1992), Mood and Feelings Questionnaire (MFQ;
Angold, Costello, Messer & Pickles, 1995), Reynolds
Child Depression Scale (RCDS; Reyolds, 1989), and
Reynolds Adolescent Depression Scale (RADS;
Reynolds, 1987).
The CDI (Kovacs, 1992) is the most widely used de-
pression rating scale for children and adolescents. De-
veloped as a modified version of the Beck Depression
Inventory, it assesses severity of depression during the
previous 2 weeks in children ages 7 to 17 years. It in-
cludes 27 items covering a broad range of depressive
symptoms and associated features, with a particular
emphasis on cognitive symptoms, and takes 10 to 20
min to complete. A number of studies have reported
that the CDI has good internal consistency, and many
(but not all) studies have also reported good short-term
test–retest stability (Brooks & Kutcher, 2001; Kovacs,
1992; Silverman & Rabian, 1999). Studies of the factor
structure of the CDI have produced inconsistent find-
ings, with some indication that the factor structure var-
ies by age (Cole, Hoffman, Tram, & Maxwell, 2000;
Weiss & Garber, 2003). The CDI is moderately to
highly correlated with the CDRS, a number of other
self-rated depression scales, and other measures of re-
lated constructs (e.g., self-esteem, depressotypic cog-
nitions), supporting its convergent validity (Brooks &
422
Kutcher, 2001; Myers & Winters, 2002; Shain et al.,
1990; Silverman & Rabian, 1999). However, the dis-
criminant validity of the CDI is questionable, as it is al-
most as highly correlated with measures of anxiety as it
is with other measures of depression, and studies ex-
amining its ability to distinguish depressed from non-
depressed patients have yielded conflicting findings
(Myers & Winters, 2002; Silverman & Rabian, 1999).
Finally, the CDI has been shown to be sensitive to
change in several treatment studies (Brooks & Kutcher,
2001; Myers & Winters, 2002; Silverman & Rabian,
1999). One study reported that it was more sensitive in
detecting the effects of group CBT in school-age chil-
dren than the CDRS and the RCDS (Stark, Reynolds,
& Kaslow, 1987); however, another study found that it
was less sensitive to the effects of medication than the
CDRS (Emslie et al., 1997).
The MFQ (Angold, Costello, et al., 1995) was de-
veloped to assess depression over the past 2 weeks in
youth ages 8 to 18 years. It consists of 32 items cover-
ing the DSM–III–R criteria for depression and addi-
tional symptoms, such as loneliness and feeling un-
loved or ugly. Angold, Costello, et al. also developed a
shorter, 13-item version by selecting items that yielded
optimal discriminating power and internal consistency.
The MFQ takes approximately 10 min to complete. It
has good internal consistency and test–retest reliability
(Angold, Costello, et al., 1995; Wood, Kroll, Moore, &
Harrington, 1995). In addition, the MFQ has demon-
strated good convergent validity with respect to the
CDI, the Diagnostic Interview Schedule for Children,
the CAPA, and the K–SADS (Angold, Costello, et al.,
1995; Thapar & McGuffin, 1998; Wood et al., 1995).
The MFQ was also relatively successful in discriminat-
ing youths with diagnoses of depression from those
with nonmood disorders (Kent, Vostanis, & Feehan,
1997; Thapar & McGuffin, 1998). Finally, it has dem-
onstrated sensitivity to change in some, but not all,
clinical trials (Brooks & Kutcher, 2001).
The RCDS (Reynolds, 1989) and RADS (Reynolds,
1987) are 30-item scales designed to assess depressive
symptomatology (as represented in the Diagnostic and
Statistical Manual of Mental Disorders [3rd ed.];
American Psychiatric Association, 1980) during the
previous 2 weeks in youth ages 8 to 12 and 13 to 18
years of age, respectively. Each scale takes approxi-
mately 10 min to complete, although children may re-
quire some additional time. The Reynolds scales have
been used primarily with school, rather than clinical,
samples. Both scales have good internal consistency
and test–retest reliability (Brooks & Kutcher, 2001;
Myers & Winters, 2002; Reynolds, 1987, 1989). In ad-
dition, both are correlated with interview diagnoses
and other depression rating scales such as the SADS,
CDRS, Hamilton Rating Scale for Depression, CDI,
Beck Depression Inventory, and Center for Epidemio-
logical Studies–Depression Scale (Brooks & Kutcher,
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
2001; Myers & Winters, 2002; Shain et al., 1990).
Discriminant validity has not been well-studied, al-
though like most depression rating scales, the RADS is
moderately correlated with measures of anxiety (My-
ers & Winters, 2002). Both the RCDS and RADS are
able to detect treatment effects in controlled clinical
trials, although they may be somewhat less sensitive
than some other rating scales (Stark et al., 1987).
As noted earlier, it is important to obtain informa-
tion about child and adolescent depression from infor-
mants other than the youths themselves. Several of the
self-rating scales, such as the CDI, have been reworded
for use by parents and, in some cases, by teachers and
peers. Few psychometric data have been reported on
these adaptations. However, Cole et al. (2000) recently
compared child and parent report versions of the CDI.
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They reported that the two versions had similar internal
consistencies and test–retest reliabilities and that the
factor structure of the CDI was relatively similar, al-
though not identical, across informants.
In addition to these modified measures, there are a
number of multi-informant rating scales that are de-
signed to assess a broad range of child and adolescent
psychopathology using instruments that are compara-
ble across informants (Hart & Lahey, 1999). The most
widely used is the parent-report Child Behavior
Checklist (CBCL; Achenbach & Rescorla, 2001), and
its accompanying teacher report (Teacher Report Form
[TRF]) and child-report (Youth Self-Report [YSR])
versions. The CBCL and TRF are appropriate for
youth ages 5 to 18, whereas the YSR is designed for
youth ages 11 to 18. The CBCL and YSR assess the
child’s behavior over the past 6 months, whereas the
TRF uses a 2-month time frame. All three measures
take approximately 10 to 15 min to complete.
The CBCL includes 118 items assessing two broad-
band and eight narrowband scales identified using
factor analysis, as well as a social competence scale.
Extensive norms for the CBCL, TRF, and YSR are
available for both clinical and community samples, and
favorable psychometric properties of the instruments
have been documented in hundreds of studies. Unfor-
tunately, the CBCL’s utility in assessing depression, at
least as conceptualized in the DSM–IV, is limited. The
scale that is most relevant to depression is the nar-
rowband Anxious/Depressed scale, which combines
symptoms of anxiety and depression. In addition, some
other depressive symptoms are included on other
narrowband scales. Indeed, a latent class analysis of
the Anxiety/Depression scale was unable to distin-
guish distinct classes for depression and anxiety
(Wadsworth, Hudziak, Heath, & Achenbach, 2001).
Several investigators have attempted to develop alter-
native approaches to scoring the CBCL to assess de-
pression. For example, Lengua, Sadowski, Friedrich,
and Fisher (2001) developed a 12-item depression
scale from the CBCL that performed better than the
original Anxious/Depressed subscale in identifying
cases with a depressive disorder diagnosis. The CBCL
recently added a series of diagnostic scales that are
more closely geared to DSM–IV diagnoses; however,
studies of their association with semistructured, inter-
view-derived diagnoses have not yet been reported.
Assessment of Younger Children
As noted previously, the diagnosis and assessment
of depression in infants and preschool-age children is
still largely uncharted territory (Garber & Horowitz,
2002). Moreover, the administration of semistructured
interviews and self-rating scales to children under the
age of 8 or 9 years is questionable (Angold & Fisher,
1999), although there is some evidence for the validity
of the CDI in children as young as 5 to 6 years old
(Ialongo, Edelsohn, & Kellam, 2001).
The most widely used rating scales for psycho-
pathology in preschoolers are the downward exten-
sions of several of Achenbach’s instruments: the CBCL
1–5, a parent rating scale, and the TRF 1–5, a teacher
rating scale (Achenbach & Rescorla, 2004). To our
knowledge, the only rating scale specifically designed
to assess depression in preschoolers is the Preschool
Feelings Checklist, a brief parent-rated screening mea-
sure developed by Luby, Heffelfinger, Koenig-
McNaught, Brown, and Spitznagel (2004). Prelimi-
nary data on the sensitivity and specificity of the Pre-
school Feelings Checklist using a structured diagnostic
interview with a parent as the criterion was promising.
However, cross-validation of these findings is needed.
Egger and Angold (2004) recently developed a
downward extension of the CAPA for 2- to 5-year-old
children titled the Preschool Age Psychiatric Assess-
ment. The interrater reliability for this measure is com-
parable to other semistructured interviews with older
children and adults. A downward extension of the Di-
agnostic Interview Schedule for Children for pre-
schoolers is also in development (Shaffer et al., 1999).
Finally, a group of investigators sponsored by the
McArthur Foundation recently developed a battery
of assessment instruments for children in the early
school-age period (ages 4 to 7 years). It includes a par-
ent and teacher rating scale, the McArthur Health and
Behavior Questionnaire (Essex et al., 2002), and a
semistructured interview, the Berkeley Puppet Inter-
view (Ablow et al., 1999) that makes use of puppets to
provide a more developmentally sensitive assessment.
Both measures include scales tapping various domains
of symptomatology (including a subscale for depres-
sive symptoms), physical health, and peer and school
functioning. In the initial reports from this group, the
depression scale from the McArthur Health and Be-
havior Questionnaire parent and teacher forms had ad-
equate internal consistency and good test–retest reli-
423
 KLEIN, DOUGHERTY, OLINO
ability and discriminated clinic from community
participants (Ablow et al., 1999). Although a categori-
cal measure of depression from the McArthur Health
and Behavior Questionnaire parent form was not corre-
lated with diagnoses of MDD derived from the parent
version of the Diagnostic Interview Schedule for Chil-
dren, it was associated with a number of teacher-rated
indexes of impairment (Luby, Heffelfinger, Measelle,
et al., 2002). The Berkeley Puppet Interview depres-
sion scale had adequate internal consistency in a clinic
sample but poor internal consistency in a community
sample, had moderate test–retest reliability in both
samples, and discriminated the clinic from community
participants (Ablow et al., 1999).
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Assessment of Psychosocial
Functioning, Life Stress, and Family
History of Psychopathology
In this section we briefly discuss measures of psy-
chosocial functioning, life stress, and family history of
psychopathology due to the importance of these vari-
ables for prognosis, treatment planning, and treatment
monitoring and evaluation.
Psychosocial Functioning
Depression in children and adolescents is associ-
ated with significant impairment in family and peer re-
lationships and academic performance. The families of
depressed youths are often characterized by a lack of
cohesion and high levels of disengagement and criti-
cism (Sheeber, Hops, & Davis, 2001). The parents
of depressed children and adolescents exhibit less
warmth and support and greater control and rejection
than parents of controls (Garber & Horowitz, 2002;
Stein et al., 2000). Depressed youths have significant
peer difficulties and social skills deficits (Rudolph,
Hammen, & Burge, 1994) and often exhibit academic
underachievement, school attendance problems, and
school failure (Hammen, Rudolph, Weisz, Rao, &
Burge, 1999).
There are a variety of approaches and instruments
for assessing impairments and competencies in psy-
chosocial functioning (for reviews see Bird, 1999;
Canino, Costello, & Angold, 1999; John, 2001). Some
of the interviews and rating scales discussed previ-
ously include measures of functional impairments and
competencies. For example, the CAPA includes a com-
prehensive assessment of the major areas of child
psychosocial functioning (Angold & Costello, 2000);
the CBCL (Achenbach & Rescorla, 2001) has a
16-item social competence scale; and the Berkeley
Puppet Interview includes scales tapping academic and
social competence and peer acceptance (Ablow et al.,
1999). In this section, we briefly discuss several addi-
424
tional measures of psychosocial functioning in chil-
dren and adolescents. Although we do not comment on
their psychometric properties due to space limitations,
these measures generally have acceptable interrater re-
liability and convergent validity.
One group of measures consists of global or uni-
dimensional scales, such as the Child Global Assess-
ment Scale (C–GAS; Shaffer et al., 1983) and the Co-
lumbia Impairment Scale (Bird et al., 1993). The
C–GAS, adapted from the Global Assessment Scale
for adults (which is also the basis for DSM–IV Axis V),
is a single 100-point scale designed for clinicians to
rate the severity of symptomatology and functional im-
pairment. The rating is based on information collected
through other means (i.e., a diagnostic interview), as
the C–GAS does not provide questions. The Columbia
Impairment Scale is a respondent-based interview that
consists of 13 items tapping a variety of domains of so-
cial functioning and symptomatology that are com-
bined to form a single score. The C–GAS and Colum-
bia Impairment Scale are both very economical.
However, they each yield only one score, hence they do
not provide information on the nature of impairment in
specific areas of functioning. In addition, both mea-
sures combine symptoms and psychosocial function-
ing so that a child’s score could reflect problems in ei-
ther or both domains.
Several more extensive instruments are also avail-
able. The Child and Adolescent Functional Assess-
ment Scale (Hodges, 1999) is a widely used clini-
cian-rated instrument that takes approximately 30 min
to administer (see Bates, 2001, for a review). It as-
sesses five domains: Role Performance (including
School/Work, Home, and Community), Behavior To-
ward Others, Moods/Self-Harm, Substance Use, and
Thinking. The Functional Impairment Scale for Chil-
dren and Adolescents (S. J. Frank, Paul, Marks, & Van
Egeren, 2000) was developed to cover the same do-
mains as the Child and Adolescent Functional Assess-
ment Scale using a parent-report format and is briefer,
requiring 15 to 20 min to complete. Both the Child and
Adolescent Functional Assessment Scale and the
Functional Impairment Scale for Children and Adoles-
cents assess symptomatology as well as psychosocial
functioning. As these domains are assessed in separate
sections, it is possible to obtain information on func-
tioning alone. However, there is considerable overlap
between the symptom-focused sections and the inter-
views and rating scales discussed previously, and the
symptom sections are not comprehensive enough to
substitute for a diagnostic interview or depression rat-
ing scale.
There are several semistructured interviews for psy-
chosocial functioning that are designed to accompany
semistructured diagnostic interviews without overlap-
ping with more symptom-focused assessments. The
Social Adjustment Inventory for Children and Adoles-
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
cents (SAICA; John, Gammon, Prusoff, & Warner,
1987) assesses school functioning, peer relations,
home life, and spare time activities in youth ages 6 to
18 years. It takes about 30 min to complete and is ad-
ministered separately to the parent and child. One
study has reported that the SAICA performed better
than a global functioning scale in predicting the course
of depression in adolescents (Sanford et al., 1995). The
Psychosocial Schedule for School Age Children–Re-
vised (Lukens et al., 1983; Puig-Antich, Lukens, &
Brent, 1986) was designed to assess school function-
ing; relationships with parents, siblings, and peers; and
the parents’ marital relationship in children ages 6 to
16 years. Like the SAICA, it is administered separately
to the parent and child. Finally, an 11-item interview
based on the adult Longitudinal Interval Follow-up
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Evaluation-Range of Impaired Functioning Tool (Leon
et al., 1999) is currently being developed for children
and adolescents (Fisher, Leon, & Coles, 2002). Like
the SAICA and Psychosocial Schedule for School Age
Children–Revised, it assesses school, family, peer, and
recreational functioning but is briefer and can be easily
incorporated into a more comprehensive evaluation.
We are aware of only one self-report measure of
social adjustment for children. Weissman, Orvaschel,
and Padian (1980) modified the Social Adjustment
Scale–Self-Report, which was originally developed for
adults, for use with children and adolescents. This mea-
sure for children includes 23 items assessing social ad-
justment during the past 2 weeks in the areas of school
behavior, friends and spare time, family behavior, and,
for adolescents only, dating. Rohde, Clarke, Mace,
Jorgensen, and Seeley (2004) recently reported that the
Social Adjustment Scale–Self-Report was sensitive to
treatment effects in a sample of adolescents with
comorbid MDD and conduct disorder, whereas the
C–GAS was not. Although Weissman et al. included
children as young as 6 years in their original validation
sample, they did not examine age differences in the
psychometric properties of the instrument. Hence, it is
unclear whether the Social Adjustment Scale–Self-Re-
port is reliable and valid in preadolescents.
In addition to the instruments noted here, there are
numerous more focused measures designed to assess
specific areas of functioning. For example, there are a
number of widely used inventories assessing key di-
mensions of family functioning (e.g., Epstein, Bald-
win, & Bishop, 1983; Moos & Moos, 1981) and
parenting behavior (e.g., Schaefer, 1965), laboratory
tasks that have been used to examine the interaction
patterns of families of depressed children (see Garber
& Kaminski, 2000), and interview and laboratory mea-
sures of expressed emotion (e.g., Asarnow, Goldstein,
Tompson, & Guthrie, 1993). Finally, there are a variety
of peer nomination measures that can be used to assess
children’s social status in school (e.g., Coie, Dodge, &
Coppotelli, 1982). Unfortunately, peer nomination
measures are often difficult to use, as they require ac-
cess to all the students in the target child’s class.
Therefore it is often necessary to rely on teacher rat-
ings of peer functioning, which are moderately to
highly correlated with peer nomination data (Hues-
mann, Eron, Guerra, & Crawshaw, 1994).
Stressful Life Events
Prospective studies in children have shown that
stress, and particularly events related to loss, disap-
pointments, conflict, or rejection, predict the onset and
persistence of depressive symptoms (Garber & Horo-
witz, 2002; Goodyer, 2001). Life stress can be assessed
through self-administered questionnaires (e.g., John-
son & McCutcheon, 1980) or interviewer-based inter-
views (e.g., Goodyer, Kolvin, & Gatzanis, 1987; Ham-
men & Brennan, 2001; Sandberg et al., 1993;
Williamson et al., 2003). Questionnaires are more eco-
nomical, but semistructured interviews have a number
of critical advantages, including the ability to assess
the temporal relation between the stressor and the on-
set of the depressive episode; to distinguish potentially
important features of events such as long-term threat
and whether the event is independent of, versus de-
pendent on, the child’s behavior; and to minimize idio-
syncratic interpretations of items (Duggal et al., 2000;
Williamson et al., 2003).
Family History of Psychopathology
A number of studies have reported elevated rates of
depression, and often other forms of psychopathology,
in the relatives of depressed children and adolescents
(e.g., Klein et al., 2001). Family history data can be
elicited using diagnostic interviews conducted directly
with family members (the family interview method) or
by interviewing key informants about the other rela-
tives (the family history method). A number of semi-
structured interviews for eliciting family history in-
formation from informants are available, including
the Family History Research Diagnostic Criteria (An-
dreasen, Endicott, Spitzer, & Winokur, 1977), the
Family Informant Schedule and Criteria (Mannuzza &
Fyer, 1990), and a brief family history screening inter-
view developed by Weissman et al. (2000). Family his-
tory data collected from informants tends to have high
specificity but only moderate sensitivity. Hence, it is
advisable to obtain information from at least two infor-
mants to increase the probability of detecting psycho-
pathology in relatives.
Issues for Future Research
Developing guidelines for evidence-based assess-
ments of child and adolescent depression is a challeng-
425
 KLEIN, DOUGHERTY, OLINO
ing task, and a number of issues must be resolved to ac-
complish this aim. In this section, we briefly highlight
10 issues that we believe are particularly important.
1. There are a number of critical questions concern-
ing the target construct of depression that have signifi-
cant implications for the design and content of assess-
ment instruments. These include the issues of continuity
and developmental variations in the expression of de-
pression, whether depression is a discrete entity or a
continuous phenomenon, the boundaries between
depression and normal variations in mood and other
forms of psychopathology, and the identification of
more homogeneous subgroups. Thus, if the rates or
structure of depressive symptoms vary as a function of
developmental period, this should be reflected in the
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content and scoring of assessment instruments (e.g., it
may be necessary to develop multiple forms of the same
instrument for different developmental periods). Simi-
larly, whether depression is a categorical or dimensional
construct must be taken into account in the design and
scoring of the instrument to optimize reliability and va-
lidity (Ruscio & Ruscio, 2002). Shifts in the boundaries
of depression would have to be reflected in the content of
assessment instruments and would have significant im-
plications for convergent and discriminant validity.
Finally, if more homogeneous subtypes are identified,
the information necessary to identify them should be in-
cluded in standard assessment instruments.
2. There is a need for longitudinal studies of the
course of mood disorders in children and adolescents
that focus specifically on the predictors and processes
associated with recovery and recurrence. In addition,
there is a need for more research on predictors of dif-
ferential treatment response (i.e., variables that predict
response to one treatment but not another). In both
cases, valuable information regarding potential targets
for assessment and treatment could be provided.
3. Related to the problem of boundaries is the poor
discriminant validity of most depression rating scales,
particularly vis-à-vis anxiety disorders. This may be
due to the high representation of items tapping general
distress or negative affectivity that are common to both
depression and anxiety. Discriminant validity may be
improved by increasing the emphasis on aspects of de-
pression with greater diagnostic specificity, such as
anhedonia and low positive affectivity (Clark & Wat-
son, 1991; Chorpita & Daleiden, 2002).
4. Few studies have directly compared the reliabil-
ity or validity of different diagnostic interviews or rat-
ing scales in the same sample. As a result, we are
forced to base comparisons on different studies, each
using a single instrument. Hence, it is unclear whether
any advantages for particular instruments are due to the
properties of the instrument or to differences in the
methods used in the studies (Angold & Fisher, 1999).
426
5. Few data on the incremental validity (see Huns-
ley & Meyer, 2003) of these measures vis-à-vis un-
structured assessments or “assessment as usual” are
available. Although there is good reason to believe that
the semistructured interviews and standardized rating
scales reviewed here should provide more reliable and
comprehensive assessments, the evidence for this as-
sumption is limited and requires further testing.
6. Several treatments of child and adolescent de-
pression have at least preliminary evidence of efficacy
in clinical trials (although this does not assure effec-
tiveness in nonresearch contexts; Weisz et al., 1995).
Hence, the most critical criterion, at least from a clini-
cal perspective, is treatment utility (Hayes, Nelson, &
Jarrett, 1987): Does using these assessment instru-
ments lead to better treatment outcomes than not using
them? Hayes et al. and Nelson-Gray (2003) have de-
scribed a number of research designs that can be used
to test treatment utility that are easily implemented.
Conducting these studies should be a high priority.
7. Many of the measures discussed in this article
are time consuming and, therefore, costly to use. Even
if these measures are shown to have incremental valid-
ity and treatment utility, it will be necessary to demon-
strate that they are “cost effective” in the sense that the
incremental gain associated with their use equals or ex-
ceeds their marginal cost.
8. The selection of specific measures is only part of
an evidence-based approach to assessment. Perhaps
even more important is how the data produced by the
instruments is integrated and used for clinical deci-
sions. The problem of integrating data from multiple
informants for diagnosis and treatment evaluation was
discussed previously. This is clearly an area that re-
quires further work. In addition, the reliability and va-
lidity of case formulations and treatment planning is a
critical area in which little work has been done for
child and adolescent depression. However, if recent
research with adults is any indication (Bieling &
Kuyken, 2003), this is likely to be highly challenging.
9. Although it is important for clinicians to system-
atically monitor patient progress, there are few guide-
lines on the correspondence between specific scores
on particular rating scales and clinically meaningful
change points in course trajectories (e.g., response, re-
mission, recovery, relapse, recurrence) that guide deci-
sions regarding whether treatment should be intensi-
fied, changed, or discontinued. Fortunately, there are
some models in the adult literature that may be useful
in beginning to consider this issue (e.g., Jacobson,
Roberts, Berns, & McGlinchey, 1999; Lueger et al.,
2001; Riso et al., 1997).
10. Work on assessing depression in children under
the age of 8 years is just getting underway, and only
limited data on measures for this age group are avail-
able. The development and validation of assessment
 ASSESSMENT OF CHILD AND ADOLESCENT DEPRESSION
instruments for depression and its precursors in young
children is an important area for future research.
Recommendations for Clinical Practice
Although it will be some time before an evidence-
based approach to the assessment of child and adoles-
cent depression is available, we believe that it is possi-
ble to offer some tentative recommendations.
One of the major purposes of assessment is for diag-
nosis, prognosis, and treatment planning. An evalua-
tion of child and adolescent depression that is designed
to address these issues should include (a) determining
whether criteria are met for MDD or DD; (b) ruling out
exclusionary diagnoses such as bipolar disorder and
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depression due to a general medical condition or sub-
stance; (c) assessing key symptoms such as suicidal
ideation and psychotic symptoms that might influence
treatment decisions; (d) carefully assessing the previ-
ous course of the depression (e.g., prior episodes,
chronicity); (e) evaluating comorbid psychiatric, de-
velopmental, and general medical disorders; (f) assess-
ing family, school, and peer functioning; (g) exploring
significant stressors and traumas; and (h) assessing
family history of psychopathology.
To assess these areas, we recommend using inter-
viewer-based (or semistructured) interviews covering
psychopathology, psychosocial functioning, and fam-
ily history. This recommendation is not offered lightly,
as semistructured interviews require much more time
than clinicians typically devote to assessment. How-
ever, in light of evidence that key areas of psycho-
pathology are frequently overlooked when less sys-
tematic approaches are used, we believe that this is the
“best practice” approach to assessment. Given the time
requirements and cost of semistructured diagnostic in-
terviews, an important priority for future research is
the development of more efficient and streamlined pro-
cedures, such as creating screening modules or making
limited use of self- or parent-report screening measures,
to reduce the time needed to complete the interviews.
Although each of the semistructured diagnostic
interviews discussed in this article are reasonable
choices, our inclination is to use the K–SADS or the
CAPA. The K–SADS is the most widely used inter-
viewer-based diagnostic interview, has accumulated
strong support for its psychometric properties, and is
available in several versions that vary in terms of the
time period assessed and the precision of information
about specific symptoms. Although it is newer and less
extensively studied, the CAPA is also a good choice,
particularly because it also assesses social functioning
and stress.
If the K–SADS or a semistructured diagnostic inter-
view other than the CAPA is used, it should be supple-
mented with a measure of psychosocial functioning.
We recommend using a measure that assesses specific
areas of functioning (as opposed to a global assess-
ment) and does not overlap with the diagnostic inter-
view. The SAICA is the best-studied measure that
meets these requirements, although the Longitudinal
Interval Follow-up Evaluation-Range of Impaired
Functioning Tool is also attractive due to its brevity and
may prove to be a good alternative if future studies sup-
port its psychometric properties. Finally, the assess-
ment should include a semistructured family history
interview, such as the Family History Research Diag-
nostic Criteria.
We strongly recommend obtaining data on psycho-
pathology, social functioning, and family history from
multiple informants whenever possible. Data on psy-
chopathology and social functioning should be ob-
tained from both the child and the primary caretaker,
particularly for school-age children. It may be less use-
ful to conduct direct interviews with younger children,
and informant data may not be necessary for older ado-
lescents, particularly if the focus is on internalizing
disorders such as depression. It is often difficult to ob-
tain family history data from multiple sources, but
whenever possible, assessments should be conducted
with both the primary caretaker and another adult (or
older adolescent) who knows the family well.
When information from multiple sources is avail-
able, it raises the problem of how to integrate the diverse
data. We suggest using the best-estimate approach (e.g.,
Klein et al., 1994), although other approaches such as
the “or” rule (which maximizes sensitivity at the cost of
reduced specificity) are also reasonable.
After treatment has been initiated, it is important to
monitor and evaluate its effects on a regular basis using
clinician, self-rating, and parent-rating scales. Although
a reduction in scores should be viewed cautiously in
light of the possibility of attenuation effects, this pro-
vides a standard means of assessing progress and may
ultimately lead to the development of evidence-based
algorithms indicating when change in treatment is
needed to optimize patient outcomes. We recommend
using a clinician rating scale, such as the revised ver-
sion of the CDRS. It may also be useful to supplement
the revised CDRS with a self-rating scale. A number of
self-rating scales for depression in children and adoles-
cents are available, and the literature does not provide a
basis for choosing among them. Finally, it is important
to supplement clinician and self-rating scales with in-
formation from the primary caretaker, particularly for
preadolescents. Unfortunately, few clinician or rating
scales for child depression have been developed and
validated specifically for use with parents, although
measures designed for children are commonly adapted
for this purpose. At present, it appears best to use the
parent version of the CDI or a broadband parent-rating
scale such as the CBCL to obtain information from the
primary caretaker.
427
 KLEIN, DOUGHERTY, OLINO
Finally, self- and parent-rating scales may be used
in screening for child and adolescent depression in a
variety of settings. Screening measures can be useful
in increasing vigilance for patients with high scores.
However, their limited sensitivity and specificity indi-
cate that they should be used with caution, particularly
in contexts with very low (or very high) base rates. At
present, the literature does not provide a basis for
choosing among the various self- and parent-rating
scales for screening purposes.
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Received December 8, 2003
Accepted July 22, 2004