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Depression - Ongoing Assessment
Overview
The primary goal of ongoing clinical assessment of a child or adolescent with depression is to accurately diagnose the disorder so that treatment and support can be provided to restore normal function and a normal developmental trajectory. The goals of this section are to briefly review assessment with an emphasis on basic necessary information, differential diagnosis, and when to refer to a specialist.Screening
Screening tools for depression are validated in research settings but poorly studied in “real world” clinical use. Routine screening for asymptomatic patients is not currently recommended. Consider using the validated assessment instruments below when you suspect depression. They may also be used to follow and quantify changes in depression severity over time or in response to treatment. Specific instructions for use can be found on the websites where they are sold. [Sharp: 2002]Children's Depression Inventory (CDI) age 7 to 17; 1st grade reading level, Spanish version available; self-, parent-, or teacher-report; 27 items, 10 to 30 minutes to complete. Available at MHS Psychological Assessments and Services.
Center for Epidemiological Studies-Depression Scale for Children (CES-DC): ages 12 to 18; 6th grade reading level, Spanish version available; 20 items, 5 to 10 minutes to complete. Depression Scale for Children (Bright Futures) (
37 KB)
Center for Epidemiological Studies-Depression Scale (CES-D): ages 14 and older; 6th grade reading level, no Spanish version; 5 to 10 minutes to complete. Center for Epidemiologic Studies - Depression Scale (CES-D) (
171 KB)
Reynolds Child Depression Scale: ages 8 to 12; 2nd grade reading level, Spanish version available; self-report; 30 items, 10 to 15 minutes to complete. Available at Reynolds Child Depression Scale (PAR, Inc.) or search from the retailer's home page at PAR, Inc..
Reynolds Adolescent Depression Scale: ages 13 to 18; 3rd grade reading level, no Spanish version; self-report; 30 items, 5 to 10 minutes to complete. Available at Reynolds Adolescent Depression Scale (PAR, Inc.) or search from the retailer's home page at PAR, Inc..
Beck Depression Inventory (BDI): ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete. Available at Pearson Assessments.
Diagnostic Criteria
The diagnosis of specific depressive disorders is based on criteria set forth in the DSM-IV.[American: 2000] The full criteria can be found on the Initial Diagnosis page.History And Examination
Interim History
Asking about depressive symptoms is the first step in ongoing assessment. A stepwise approach may help save time:- Has the patient felt depressed, hopeless or sad often over the past month, or has she/he felt less interest in or enjoyment of usual activities often over the past month. Depression and diminished interest (aka anhedonia) are cardinal symptoms of depression – one or the other must be present for diagnosis.
- Positive replies should prompt further questioning. The combination of either depressed mood or diminished interest in usual
activities, along with 4 of the following symptoms fulfills criteria for major depression:
- changes in sleep
- feelings of guilt or worthlessness
- low energy
- poor concentration
- appetite or weight change
- psychomotor slowing or agitation
- suicidal thoughts or gestures
Use of a validated screening tool (see “Screening” above) is up to the clinician. A screening tool may be administered prior to a visit, eliminating or reducing the need for the questions outlined in 1 and 2. If depression concerns are uncovered in the course of a routine visit, scheduling another visit within a week to address depression may be reasonable and a screening tool could be administered in the interim. If a patient is expressing suicidal thoughts then measures must be taken immediately to ensure safety. See the Related Issue Suicidality.
Developmental and Educational Progress
The child's developmental level is very important to consider when looking for behaviors and changes in mood that might signal a depressive disorder.Children and adolescents with developmental delays can also develop depression. The term "dual diagnosis" refers to the combination of intellectual disability/mental retardation and a psychiatric disorder in the same patient.
See the Related Issue Depression Through Childhood Development for more detail.
Physical Exam
General
A normal physical exam can help to rule out medical illness as a cause for depressive symptoms. Examination is also helpful to address the multiple physical complaints (e.g. abdominal pain) which often accompany depression. If a patient presents with concerns of depression, has had a recent physical exam (within the past 6-12 months), and has no new physical complaints or illnesses on review of systems, the physical exam may be deferred at the clinician's discretion to allow more time for interviewing.Testing
Laboratory Testing
Tests to consider while following a child or adolescent with a depressive disorder include TSH to screen for hypothyroidism and urine drug screen to screen for substance use, which may be complicating or causing the depression. A urine pregnancy test should be considered in females to allow for consideration of pregnancy in treatment decisions.Subspecialist Collaborations and Other Resources
Patients currently expressing active suicidal ideation or who have recently made a suicide attempt should be referred for inpatient psychiatric hospitalization.
Child Psychiatry (see Services below for relevant providers)
May aid in diagnosing and/or providing continuing care. Due to chronic shortages in the US, these subspecialists often primarily see patients with the most severe mental illnesses or those with complicating biological, psychological, or social factors. Consider referral for depression for patients who:
- Have no improvement after 6 to 8 weeks of medications or therapy
- Require more than two psychotropic medications to control symptoms
- Require psychiatric hospitalization
- Have parents with significant emotional impairment or substance use issues
- Have complex psychosocial issues (e.g. history of abuse/neglect, legal problems, poor parental support/supervision, family conflict)
- Have family history suggesting adverse reactions to therapy (e.g. planned antidepressant therapy in a patient with family history of bipolar disorder)
- Are young (6 years or under)
- Have chronic medical illness
See also AACAP Guidelines: When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist.
Referral is necessary for patients with suspected bipolar disorder or depression with psychotic features.
Child Psychology (see Services below for relevant providers)
A clinical child psychologist will have a PhD or PsyD. Individuals with bachelors or masters degrees in psychology are generally not trained or qualified to diagnose or treat mental illness. All states have licensing requirements for psychologists. Psychologists may be trained in various fields – clinical psychologists or counseling psychologists are the most apt to evaluate or treat depression. Psychologists may perform diagnostic interviewing or specific testing, such as intelligence or personality testing. Psychologists may provide psychotherapy but are not generally trained nor permitted to prescribe medications (although two states, Louisiana and New Mexico, allow clinical psychologists with special training to prescribe some medications). Many psychologists will, however, consult with prescribers, such as physicians, to help coordinate diagnosis and treatment.
Social Work (see Services below for relevant providers)
There are varying levels of academic degrees and fields of expertise in Social Work. All states have specific licensing requirements for social workers. Independently practicing social workers or those working in a hospital or healthcare setting should have a minimum of a master’s degree. Mental Health and Substance Abuse Social Workers are the most apt to be involved in evaluating or treating depression. Social workers may interview for assessment but usually are not qualified to make a formal mental health diagnosis. Social workers may provide psychotherapy and may consult with other specialists to coordinate treatment.
Counseling (see Services below for relevant providers)
Aside from psychologists, and social workers, there are a number of disciplines that may provide psychotherapy. Most often, these counselors hold a masters degree in Clinical Mental Health Counseling, Marriage and Family Therapy, or Substance Abuse and Behavior Counseling. Counselors, like social workers, may do interviewing for assessment purposes but they usually are not qualified to make a formal mental health diagnosis. Most states have specific licensing requirements for governing counselors in practice.
Medical Conditions Causing Diagnosis
Cancer, hematologic disorders, endocrine disorders, immunologic disorders, and infectious diseases (especially HIV) are among the illnesses that can present with depressive symptoms. So-called vegetative symptoms, such as low energy, psychomotor retardation, sleep disturbance, and appetite disturbance, are more common in medical illnesses that mimic depression. Presence of prominent guilt, worthlessness, or suicidal thoughts or behavior should raise suspicion for comorbid depression as these symptoms are not commonly found solely due to medical illness in children. If depressive symptoms predate diagnosis of the medical illness or if depressive symptoms arise in a chronically ill child or adolescent when other symptoms or signs of the illness are stable or improving, suspicion should also be raised for a separate depressive disorder.For more detail, see the Differential Diagnosis section on the Initial Diagnosis page.
Resources
Information & Support
For Professionals
Depression Resource Center (AACAP)
Information for clinicians and families, including FAQs, information on brochures (“Facts for Families”), books, videos, practice
parameters, research, and getting help for depression; from the American Academy of Child & Adolescent Psychiatry.
For Parents and Patients
Support
NAMI Utah
Utah Chapter of the National Alliance on Mental Illness; provides advocacy, and information about mental illnesses.
National Alliance on Mental Illness
Provides information about mental illnesses, links to state chapters, information about conferences, and links to additional
resources.
Tools
Depression Scale for Children (Bright Futures)
( 37 KB)
free depression screening tool for ages 12-18 (Center for Epidemiologic Studies - Depression Scale for Children); 6th grade
reading level; 20 items; 5-10 minutes to complete.
Beck Depression Inventory-II (Pearson Assessments)
ages 14 and older; 6th grade reading level, Spanish version available; 21 items, 5 to 10 minutes to complete.
Center for Epidemiologic Studies - Depression Scale (CES-D)
( 171 KB)
free short depression scoring tool for ages 14 years and older, 6th grade reading level.
Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care)
Designed for primary care practices to help in the diagnosis and management of maternal depression; contains screening tools,
patient handouts, medication information, resources, and references and includes the 9-question Public Health Questionnaire
(PHQ-9). Available for download upon agreement to terms.
MHS Psychological Assessments and Services
Children's Depression Inventory (CDI) may be purchased and downloaded from this website.
PAR, Inc.
Reynolds Child Depression Scale may be purchased and downloaded from this website.
Patient Health Questionnaire 9
This is a validated, quick, and free screening tool for depression to be used by primary care providers.
Reynolds Adolescent Depression Scale (PAR, Inc.)
screening instrument for depressive symptomatology in adolescents; purchasable from this site.
Reynolds Child Depression Scale (PAR, Inc.)
Screen for depressive symptoms in grades 3-6, available for purchase.
Services
For other services related to this condition, browse our Services categories or search our database.
Page Bibliography
American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (Text Revision).
4th edition (June 2000) ed. Washington, DC: American Psychiatric Association;
2000.
0890420254
Sharp LK, Lipsky MS.
Screening for depression across the lifespan: a review of measures for use in primary care settings.
Am Fam Physician.
2002;66(6):1001-8.
PubMed abstract / Full Text