Symptom Endorsement Differences on the Children s Depression Inventory With Children and Adolescents on an Inpatient Unit

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1 JOURNAL OF PERSONALITY ASSESSMENT, 76(3), Copyright 2001, Lawrence Erlbaum Associates, Inc. Symptom Endorsement Differences on the Children s Depression Inventory With Children and Adolescents on an Inpatient Unit Heidi Liss and Vicky Phares Department of Psychology University of South Florida Laura Liljequist Department of Psychology Murray State University Responses to the Children s Depression Inventory (CDI; Kovacs, 1992), administered during intake, were collected from 521 children and adolescents (aged 7 to 17) at an inpatient crisis stabilization unit. Participants were grouped into 1 of 3 diagnostic groups: solely depressive, solely aggressive, or both depressive and aggressive. Self-report of symptoms for each diagnostic group, age and gender differences, and racial and ethnic differences in symptoms were examined in this study. There was a significant difference between the endorsement pattern of solely depressive and solely aggressive participants, whereas those categorized as both depressive and aggressive displayed an endorsement pattern similar to those who were solely aggressive. There was a significant gender difference in overall symptom report, with girls showing higher overall symptom levels than boys. This gender difference was significant for both the younger and the older age groups. These results held true even when gender was covaried out of the diagnostic group analyses and when diagnostic group was covaried out of the gender analyses. Symptom endorsement did not differ based on race and ethnicity. The primary contribution of this study centers around the findings from the item analyses of the CDI. These results are discussed in relation to the discriminant validity of the CDI and the need for additional research into comorbidity. The Children s Depression Inventory (CDI; Kovacs, 1992) is one of the most widely used self-report measures of depression for children and adolescents. Regardless of the theoretical model by which researchers conceptualize depression,

2 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 397 the CDI is frequently used to assess children s and adolescents self-reported levels of depression (Eley & Stevenson, 1999; Fristad, Emery, & Beck, 1997; Hammen & Compas, 1994). A number of studies have investigated the CDI in relation to developmental differences and gender differences (e.g., Allgood-Merten, Lewinsohn, & Hops, 1990). A few studies have assessed the CDI based on children s or adolescents race and ethnicity (e.g., Barreto & McManus, 1997; Roberts & Sobhan, 1992). Recently, however, the CDI has received a great deal of scrutiny to ascertain whether it measures features other than depression. A number of factor-analytic studies have tested the structure of the CDI to ascertain whether comorbidity is a confound in the use of the CDI (e.g., Craighead, Curry, & Ilardi, 1995; Weiss & Weisz, 1988). This issue raises questions regarding the basic psychometric properties of the CDI, especially as related to discriminant validity (Ruggiero, Morris, Beidel, Scotti, & McLeer, 1999). Across gender, age, and race and ethnicity, there are high rates of comorbidity between major depressive disorder and other disorders (Angold, Costello, & Erkanli, 1999). Conduct disorders are among the most common comorbid diagnoses with depression. Conduct disorder occurs in 16% to 33% of children diagnosed with major depression(milling& Martin, 1992). Aggression and depression have been found to co-occur, even in nonclinical samples(o Connor, McGuire, Reiss, Hetherington,& Plomin, 1998; Weiss & Catron, 1994). Berkowitz (1990) proposed a cognitive neoassociationist perspective on depression that helps explain high levels of comorbidity. This model suggests that feelings of anger and aggression often appear when sadness or depression have been activated cognitively. This process occurs because both sadness and anger are part of a general negative affect. One way to examine the relation between depression and aggression is to examine those children who have a diagnosis of both depression and conduct disorder. Puig-Antich (1982) found that prepubertal boys with diagnoses of both depression and conduct disorder showed demographic characteristics and affective patterns similar to those seen in boys diagnosed only with depression. Dadds, Sanders, Morrison, and Rebgetz (1992) also found that interaction patterns in families with children diagnosed as both depressed and conduct disordered were similar to the family interaction patterns of children diagnosed as solely depressed and were different from the patterns in families with children diagnosed as solely conduct disordered. Overall, it appears that children and adolescents who are diagnosed with both a depressive disorder and a conduct disorder are more similar to children and adolescents who are diagnosed with a depressive disorder than youth who are diagnosed with a conduct disorder. To tease apart the issues related to comorbidity, factor-analytic studies have been conducted that examine the factor structures of the CDI in relation to diagnostic status. A number of studies have established that different factor structures exist when children and adolescents in nonclinical groups are compared with those in clinical groups (Carey, Faulstich, Gresham, Ruggiero, & Enyart, 1987; Hodges,

3 398 LISS, PHARES, LILJEQUIST Siegel, Mullins, & Griffin, 1983). Different factor structures have also been found when comparing age and gender (Craighead, Smucker, Craighead, & Ilardi, 1998; Weiss & Weisz, 1988; Weiss et al., 1991, 1992). Interestingly, overall CDI scores have not been able to distinguish between samples of children diagnosed with internalizing disorders, such as major depressive disorder, and children diagnosed with externalizing disorders, such as conduct disorder (Nelson, Politano, Finch, Wendel, & Mayhall, 1987; Norvell & Towle, 1986). The CDI was found to distinguish between inpatient children and school children; however, the CDI did not distinguish between inpatient children rated as depressed (by staff, peers, and their individual therapist) and those rated as nondepressed (Saylor, Finch, Spirito, & Bennett, 1984). There has been somewhat less attention to the specific CDI items that could possibly confound the differentiation between depressive disorders and aggressive disorders. Although the factoranalytic studies are informative with regard to specific items that load on different factors for boys and girls of different ages, there has not been as much attention paid to the CDI items that might actually be assessing externalizing behavior in contrast to depressive symptoms. Because the CDI is often used in assessment and clinical decision making, it is important that this measure be shown to have good discriminant validity, with elevated scores reflecting increased depressive symptomatology, rather than externalizing behavior. Although convergent validity is more readily established on most measures, discriminant validity is equally important. In fact, Compas (1997) suggested that the lack of clear evidence of discriminant validity is a shortcoming of the CDI. One study that did explore these issues was conducted by Craighead et al. (1995). CDI factor scores and total scores were compared for adolescents who were diagnosed with major depressive disorder, conduct disorder, or an anxiety disorder. When compared with adolescents without a diagnosis of major depression, adolescents diagnosed with major depression scored higher on all five factors of the CDI as well as the total CDI score. Adolescents diagnosed with conduct disorder scored significantly higher on the externalizing factor, which consists of Items 5 (misbehavior), 15 (low motivation), 23 (poor schoolwork), 26 (oppositional), and 27 (fighting). In addition, Weiss and Weisz (1988) found that externalizing scores on parent-reported problem ratings on the Child Behavior Checklist (Achenbach, 1991) correlated with total CDI scores for clinically referred adolescents even when Items 5, 26, and 27 were eliminated. Although there are indications of racial and ethnic differences of depression in nonclinical populations, there is less evidence of differences in clinical populations. In a national survey of adolescents, Roberts and Sobhan (1992) found that Mexican American participants reported higher levels of depressive symptoms than did White, African American, and Hispanic (non-mexican American) participants. In a nonclinical sample of young adolescents, Roberts and Chen (1995) found that Mexican American adolescents reported a higher level of depressive

4 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 399 symptoms than did White adolescents. Conversely, in a clinical sample of adolescents who were receiving either outpatient or inpatient services, Roberts, Chen, and Solovitz (1995) did not find differences in the diagnostic rates of major depression when White, African American, and Mexican American adolescents were compared. No racial and ethnic differences were found in overall CDI scores when comparing African American and White youngsters who were emotionally disturbed (Nelson et al., 1987). Taken together, these studies suggest that although the CDI still can function as a measure of overall depression, there may be specific items that are more related to aggressive and conduct-related problems. To further establish discriminant validity, this study explored item and total score differences based on diagnosis, gender, age, and race and ethnicity in a sample of children and adolescents at an inpatient facility. It was expected that children and adolescents with aggressive and conduct problems would score significantly higher on CDI Items 5 (misbehavior), 15 (low motivation), 23 (poor schoolwork), 26 (oppositional), and 27 (fighting) when compared with children and adolescents who were experiencing depressive problems. Adolescent girls were expected to report higher overall scores on the CDI than adolescent boys. Given that this was a clinical sample, no total score differences were expected based on race and ethnicity. Participants METHOD A total of 521 children and adolescents (296 girls and 225 boys), ranging in age from 7 to 17, were included in the study. Girls comprised slightly more than half of the sample (56.8% and 44.2% boys). The mean age of the participants was 13.9 years (SD = 2.2), with boys averaging 13.4 years (SD = 2.4) and girls averaging 14.2 years (SD = 1.9). The sample was 64.7% White, 21.2% African American, and 12.9% Hispanic American. The remaining 1.2% identified themselves as belonging to another racial or ethnic group. Based on the procedures described later, 47.4% of the participants (168 girls and 79 boys) were found to have a sole diagnosis of major depression, dysthymia, or adjustment disorder with depressed mood (no conduct problems); 18.2% of the sample (24 girls and 71 boys) had a sole diagnosis of oppositional defiant disorder, conduct disorder, intermittent explosive disorder, or adjustment disorder with disturbance or conduct (no depression); and 34.4% of the sample (104 girls and 75 boys) had comorbid diagnoses of some sort of depressive disorder and some type of aggressive disorder. Within these diagnostic groupings, the following specific diagnoses were represented: depressive group (88 major depression, 108 dysthymia, and 51 adjustment disorder with depressed mood), aggressive group (35 oppositional defiant disorder, 14 conduct disorder, 43 intermittent explosive disorder, and 3 adjustment

5 400 LISS, PHARES, LILJEQUIST disorder with disturbance of conduct), and combined depressive aggressive group (120 adjustment disorder with mixed disturbance of emotions and conduct; depressive diagnoses: 11 major depression, 38 dysthymia, 10 adjustment disorder with depressed mood; aggressive diagnoses: 31 oppositional defiant disorder, 11 conduct disorder, and 17 intermittent explosive disorder). Procedures Participants data were obtained archivally from a short-term, inpatient facility for children and adolescents. This public facility serves youth in crisis due to severe depression, suicidal or homicidal behavior, severe family conflicts, and presentation of psychotic symptoms. All children must meet involuntary commitment criteria (i.e., danger to self or others) to be admitted. The facility is part of the community mental health system, which serves families who are from primarily lower socioeconomic, urban areas. Most children and adolescents are hospitalized in this facility for 7 to 10 days. There are approximately 400 admissions to this unit annually, with many clients having multiple admissions. Only data from a client s first admission were included in this study. A total of 27% of the participants in this study went on to be admitted to the unit again within the time span of the study. Data were collected from a recent 3-year span of time. Data were only included in the study for children and adolescents who had completed the CDI at admission and who had received a firm diagnosis or diagnoses (not provisional). Children and adolescents were not included in the study if they had a diagnosis related to limited intellectual functioning (e.g., mental retardation), a diagnosis related to limited contact with reality (e.g., schizophrenia), or a diagnosis that could not clearly be categorized as either depressive or aggressive or comorbid (e.g., a sole diagnosis of alcohol dependency, attention deficit hyperactivity disorder, posttraumatic stress disorder, or bipolar affective disorder). At the time of intake to the crisis stabilization unit, children and adolescents who had adequate intellectual functioning and sufficient connection with reality completed the CDI. Children or adolescents who did not have adequate reading abilities were read the questions by the intake counselor. If available, children s and adolescents parent or guardian provided demographic data. These data were gathered for research purposes. Scores on the CDI were not used in determining or confirming diagnoses. Although a provisional psychiatric diagnosis was given by the attending psychiatrist at the time of intake, Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) diagnoses at time of discharge were used. These diagnoses are based on a thorough evaluation, including client interview, collateral information, and observations by the clinical treatment team and are therefore believed to be more meaningful than the diagnosis at intake. A total of five psychiatrists (with the consultation of the clinical treatment team) pro-

6 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 401 vided diagnoses for cases used in this study. One psychiatrist provided a majority of the diagnoses for the sample (more than 78%), and another provided nearly 21% of the diagnoses. The other three psychiatrists combined provided less than 1% of the diagnoses. The principal investigator and an advanced graduate student research assistant independently sorted cases into the three groups based on diagnosis: solely depressive, solely aggressive, or both depressive and aggressive. If there was a disagreement as to group membership, the case was dropped from the study. The initial sample consisted of 792 clients, but 98 were dropped due to missing or incomplete data, 14 were dropped due to a diagnosis of mental retardation, 6 were dropped due to inappropriate age level (younger than 7 years old), 145 were dropped due to a disqualifying diagnosis (e.g., alcohol dependency, bipolar affective disorder, attention deficit hyperactivity disorder, provisional diagnosis, etc.), and 8 cases were dropped because there was no agreement between the principal investigator and research assistant as to group membership. Data analyses were conducted on the remaining 521 children and adolescents. Measure The CDI is a 27-item measure that is appropriate for youth aged 7 to 17 years old. Items are scored from 0 to 2, with higher scores reflecting higher levels of that symptom. Internal consistency has been well established, but there is evidence to suggest that test retest reliability is more stable in clinical samples than in nonclinical samples (Saylor et al., 1984). Normative data (Nelson et al., 1987) have suggested that girls are more likely to endorse Items 2, 4, 6, 9, 13, 16, 20, 21, and 24 at the 1 or 2 level than other items on the CDI (for item descriptions, see Table 1). Boys are more likely to endorse Item 4 than any other item on the CDI. When considering developmental differences, the likelihood of endorsing an item at the highest level of 2 increased with age. Adolescents tended to endorse Items 2, 4, 9, 13, 20, and 21 more than any other items, whereas younger children were more likely to endorse Items 4 and 9 more than any other items. Consistent with previous research, normative data suggested that adolescent girls reported more symptoms than adolescent boys, but there were no gender differences when younger children were compared (Nelson et al., 1987). Descriptive Statistics RESULTS Participants in the sample had a mean total CDI raw score of 17.2 (SD = 10.8). This is reflective of a T score that ranges between 57 and 62, depending on age and gen-

7 402 LISS, PHARES, LILJEQUIST TABLE 1 Mean CDI Item Scores by Diagnostic Group Diagnostic Group CDI Item Depressive Aggressive Both F Value 1 (Sadness) 0.83 a 0.38 b 0.50 b 17.59* 2 (Concern for future) 0.95 a 0.65 b 0.69 b 9.66* 3 (Self-criticism) (Anhedonia) (Misbehavior) (Safety concerns) (Self-hatred) 0.68 a 0.31 b 0.44 b 11.73* 8 (Self-blame) (Suicidal) 1.09 a 0.40 c 0.83 b 34.03* 10 (Tearfulness) 0.77 a 0.36 b 0.69 a 8.74* 11 (Irritability) (Antisocial feelings) (Indecision) (Discontent with appearance) 0.72 a 0.41 b 0.40 b 14.01* 15 (Low motivation) (Insomnia) 0.77 a 0.46 b 0.53 b 7.46* 17 (Fatigue) (Poor appetite) 0.79 a 0.45 b 0.60 a/b 6.59* 19 (Somatic symptoms) (Loneliness) 0.89 a 0.57 b 0.67 b 7.97* 21 (Dislikes school) (Few friends) (Poor schoolwork) (Poor comparison to peers) (Unloved by others) (Oppositional) (Fighting) Note. CDI items are scored from 0 (no problem) to2(problematic). For items showing significant F values, the post hoc Scheffé test was performed. Different letters in superscript show significant difference between means based on the Scheffé test. CDI = Children s Depression Inventory. *Significant after Bonferroni correction, p <.003. der. As would be expected from an inpatient crisis stabilization unit, children and adolescents in this sample were experiencing higher than average levels of distress. Overall Group Differences on the CDI Before analyzing diagnostic group, gender, and age differences separately, an overall multivariate analysis of variance (MANOVA) of total CDI score was conducted

8 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 403 to explore main effects and interaction effects between these three grouping variables. Based on past research (Kovacs, 1992), age was dichotomized into younger (7 to 12 years old) and older (13 to 17 years old) groups. There were fewer participants in the younger group (78 boys and 45 girls) than in the older group (147 boys and 251 girls). Note that race and ethnicity were not included in this overall MANOVA because these analyses were considered more exploratory than the analyses related to diagnostic group, age, and gender. In addition, although the sample was relatively large and ethnically diverse, splitting this sample by four different grouping variables (diagnostic group, age, gender, and race and ethnicity) would have reduced the statistical power significantly. The overall MANOVA was significant, F(11, 509) = 2.98, p <.001. The main effects for diagnostic group (p <.007) and gender (p <.011) were significant, but the main effect for age (p >.05) was not significant. Specifically, the depressive group reported the highest level of symptoms (M = 19.17, SD = 11.73), followed by the group with both depressive and aggressive diagnoses (M = 15.65, SD = 9.45), with the aggressive group reporting the lowest amount of overall symptoms on the CDI (M = 14.55, SD = 9.67). For gender, girls reported significantly more symptoms (M = 18.80, SD = 10.89) than did boys (M = 14.91, SD = 10.28). The lack of a significant main effect for age is reflected in the comparable means for the younger (M = 16.76, SD = 9.60) and older (M = 17.23, SD = 11.14) groups. The two-way interaction effects (diagnostic category by gender, diagnostic categorybyage,andagebygender)werenotsignificant(ps>.05),norwasthethree-way interaction effect (p >.05). Because no interaction effects were significant, and because only the main effects for diagnostic group and gender were significant, the following analyses of diagnostic group and gender were conducted without covariates. Note, however, that when parallel analyses were conducted with covariates, comparable results were revealed. Specifically, when diagnostic group differences were evaluated with gender as a covariate, a similar pattern of results emerged. When gender differences were evaluated with diagnostic group as a covariate, similar results were revealed. Thus, the results presented here are comparable whether gender and diagnostic group are covaried out of the analyses. Although these results do not tease apart gender and diagnostic category completely, these analyses reflect gender and diagnoses as they co-occur in clinical populations naturally. Diagnostic Group Differences on the CDI Based on the significant main effect for diagnostic group that was presented earlier, subsequent analyses of variance (ANOVAs) were conducted for each CDI item separately. Means were compared using Scheffé s method (p <.05) to control for familywise error rates (Keppel, 1982). Bonferroni correction (p <.003) was also used to control for the large number of analyses. Results of these analyses are given in Table 1.

9 404 LISS, PHARES, LILJEQUIST Items 1 (sadness), 2 (concern for future), 7 (self-hatred), 9 (suicidal), 10 (tearfulness), 14 (discontent with appearance), 16 (insomnia), 18 (poor appetite), and 20 (loneliness) were endorsed at a significantly higher level for depressive participants than for aggressive participants. Participants with both depressive and aggressive symptoms did not differ from aggressive participants on Items 1 (sadness), 2 (concern for the future), 7 (self-hatred), 14 (discontent with appearance), 16 (insomnia), 18 (poor appetite), and 20 (loneliness), and did not differ from depressive participants on Item 10 (tearfulness). Overall, children and adolescents who were diagnosed with both depressivetype and aggressive-type disorders showed a response pattern that approximated that of children and adolescents with aggressive-type only disorders, although there were also some commonalities in response style with the depressed-typeonly children. Item 9 (suicidal) showed a significant difference in endorsement among all three groups, with aggressive participants showing the lowest endorsement and depressive participants showing the highest endorsement. This was the only item that showed a significant response difference across the three groups. The same pattern of results was found when gender was covaried in the analyses. Gender Differences on the CDI Because boys and girls differed significantly in their report of overall depressive symptoms, individual ANOVAs were conducted for each item. As can be seen in Table 2, girls endorsed Items 1 (sadness), 7 (self-hatred), 9 (suicidal feelings), 10 (tearfulness), 11 (irritability), 14 (discontent with physical appearance), 16 (insomnia), 17 (fatigue), 18 (poor appetite), and 20 (loneliness) at a significantly higher level than did boys. There were no items that boys endorsed significantly higher than girls after Bonferroni correction. The same pattern of results was found when diagnostic grouping was covaried in the analyses. Racial and Ethnic Differences on the CDI A one-way ANOVA was conducted to determine whether reported level of depressive symptoms differed by ethnic group. Three racial and ethnic groups (White, African American, and Hispanic American) were chosen for the analysis because they comprised almost 99% of the sample. The mean total CDI scores were as follows: 17.2 (SD = 10.8) for Whites, 17.7 (SD = 10.9) for African Americans, and 16.1 (SD = 11.0) for Hispanic Americans. No significant differences were found among the racial and ethnic groups in their endorsement of depressive symptoms, F(2, 518) = 0.83, p >.5. Because the overall ANOVA was not significant, no further item analyses were conducted to compare groups based on race and ethnicity. Notably, race and ethnicity were not correlated with total CDI or any other major variables in this study (ps >.05).

10 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 405 TABLE 2 Mean CDI Item Scores by Gender Gender CDI Item Male Female F Value 1 (Sadness) * 2 (Concern for the future) (Self-criticism) (Anhedonia) (Bad behavior) (Safety concerns) (Self-hatred) * 8 (Self-blame) (Suicidal feelings) * 10 (Tearfulness) * 11 (Irritability) * 12 (Antisocial feelings) (Indecision) (Pretty/handsome) * 15 (Motivation) (Insomnia) * 17 (Fatigue) * 18 (Appetite) * 19 (Somatic symptoms) (Loneliness) * 21 (Enjoy school) (Friends) (Poor schoolwork) (Comparison to peers) (Loved by others) (Oppositional) (Fighting) Note. CDI = Children s Depression Inventory. *Significant after Bonferroni correction, p <.003. DISCUSSION This study adds to the support for the discriminant validity of the CDI. In addition, this study adds information to the understanding of children s and adolescents endorsement style on the CDI with regard to age, gender, race and ethnicity, and diagnostic group (solely depressed, solely aggressive, and both depressed and aggressive). Contrary to what was expected, children and adolescents who were categorized as both depressive and aggressive showed an endorsement style that was more similar to aggressive participants than depressive participants. Given that there was a higher percentage of boys in the aggressive group, but a higher percent-

11 406 LISS, PHARES, LILJEQUIST age of girls in the combined depressive and aggressive group, this pattern of findings suggests that results are not just based on a confound between diagnostic group and gender. Of all of the items on the CDI, Item 9 (suicidal) was the only item that discriminated among all three groups, with the highest endorsement by depressive participants and the lowest endorsement by aggressive participants. The suicide item has been identified in other studies as particularly meaningful in using the CDI to distinguish between groups (Esposito & Clum, 1999). In previous studies and factor analyses (Craighead et al., 1995; Norvell & Towle, 1986; Weiss & Weisz, 1988), CDI Items 5 (misbehavior), 15 (low motivation), 23 (poor schoolwork), 26 (oppositional), and 27 (fighting) have been shown to represent a factor of misbehavior. In this study, none of these items was endorsed at a higher level for the aggressive group when compared with the depressive group. One explanation for this difference is that the children and adolescents in this study may differ from those in other studies. The children and adolescents in this clinical facility were admitted, in part, due to their danger to themselves or others. It may be that the depressed children in this study were different from depressed children in other studies, given that these clients have shown themselves to be potentially dangerous. A surprising finding was that the participants who had comorbid diagnoses (both depressive-type and aggressive-type) were more similar to the aggressive-type group than the depressive-type group in their responses to CDI items. This finding is counter to prior research (Dadds et al., 1992; Puig-Antich, 1982), which suggested that participants who were dually diagnosed with both depressive-type and aggressive-type disorders would respond similarly to those who were diagnosed with only a depressive-type disorder. It is important to note, however, that the previous research focused on personal and familial factors for the children and adolescents, rather than the CDI endorsement pattern as was explored in this study. Therefore although external, objective factors point to one clustering (comorbid and depressivetype participants), self-reports of participants own subjective experience reveals another clustering of diagnostic groups (comorbid and aggressive type). Adolescent girls were expected to report more symptoms than adolescent boys (Nelson et al., 1987; Weiss & Weisz, 1988), but this study found that girls reported higher CDI scores than boys across both age groups even when diagnostic group was covaried. Girls accounted for slightly more than half of the total sample, which is an unusual phenomenon for an inpatient sample. Nolen-Hoeksma and Girgus (1994) concluded that girls have more risk factors for the development of depression that tend to become relevant during adolescence. It is possible that the special circumstances (e.g., stressors) that led to an earlier admission for the children who were brought to the crisis unit at such a young age may also be related to risk factors that were relevant to an early onset of depression in these children (Compas, Grant, & Ey, 1994; Compas et al., 1997). Although these results regarding gender may have been influenced by the composition of the diagnostic group-

12 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 407 ings (i.e., more girls in the depressive group and more boys in the aggressive group), these findings remained consistent even after controlling for diagnostic groupings. Research on gender differences remains difficult, given that gender and symptoms are confounded in clinical settings as well as nonclinical settings (Hartung & Widiger, 1998; Wichstrom, 1999). Although some differences in depressive symptoms based on race and ethnicity have been found in previous studies of community samples (Roberts & Chen, 1995; Roberts & Sobhan, 1992), few differences have been found within clinical samples (Nelson et al., 1987; Roberts et al., 1995). In addition, the differences that have been found in nonclinical samples have been primarily due to higher rates of depressive symptoms in Mexican American children and adolescents. Unfortunately, more specific data on subgroups of Hispanic Americans are not available for our sample. One clear advantage to the racial and ethnic comparison in this study is that race and ethnicity and socioeconomic status (SES) were not confounded (for discussion of race and ethnicity and SES, see Samaan, 2000). Because this facility serves children and adolescents from primarily low-ses families, comparisons across racial and ethnic groups were not hampered by differences in SES levels among groups. Although preserving internal validity, the main disadvantage is that these results may not be generalizable to a higher income population. In addition, Barreto and McManus (1997) suggested that depression in children and adolescents from resource-poor communities should be viewed in the context of environmental factors rather than individual limitations of the child or adolescent. The results of this study suggest that the CDI has discriminant validity. Depressed participants had significantly higher total scores than the other groups. Although this finding is not new, the contribution of this study centers around the item analyses and the investigation of the discriminant validity of the items on the CDI. Specifically, the inpatient sample used for this study showed differences in individual self-reported symptoms between those who were diagnosed solely with depressive disorders and those diagnosed solely with aggressive-related disorders. Those youngsters who were diagnosed with both depressive and aggressive-related disorders reported symptoms that resembled those of the youngsters who experienced solely aggressive-related disorders. The differences between diagnostic groups in symptom reports on the CDI provide some support for the use of the CDI as a tool in determining diagnosis. The CDI taps into internalizing symptoms, but individual items on the CDI also tap into externalizing issues. Noting differences in item endorsement patterns could aid in differentiating among diagnoses. Clinicians should be aware that elevated CDI scores do not invariably reflect solely depressive symptomatology. Furthermore, one must be careful not to overlook the presence of depression in a child with aggressive behavior. As the pattern of results in this study demonstrates, the internal subjective experience of a child with both depressive and aggressive disorders may be more similar to that of the child

13 408 LISS, PHARES, LILJEQUIST with a sole diagnosis of an aggressive disorder. This finding suggests that in considering treatment approaches, one might be well advised to approach the child with a comorbid diagnosis in a manner similar to the way one approaches the treatment of youth with an aggressive disorder. The primary contribution of this study centers around the item analyses that show different patterns of responses for diagnostic groups and gender. Although these findings are important in understanding the discriminant validity of items on the CDI, it should be noted that nearly two thirds of the items did not show differential patterns based on diagnostic grouping or gender. Thus, although there were notable patterns of group differences on items, the majority of items on the CDI did not distinguish between diagnostic groups or gender. The items that did distinguish between groups, and especially the suicide item that distinguished between the depressive, aggressive, and combined groups, were meaningful in showing differential patterns of responses on the CDI. Limitations to the study should be mentioned. Because data were collected archivally, and because structured diagnostic interviews (e.g., the Diagnostic Interview Schedule for Children [DISC]; Schaffer, 1996) were not used at this facility, diagnoses were based on parent and child interviews by the psychiatrist, meetings with the clinical treatment team, and reviews of relevant material (e.g., previous psychological evaluations, reports from teachers, etc.). Unfortunately, this limitation is often the price paid for obtaining clinical data in the field, in a setting that is first and foremost a public treatment facility. Furthermore, there is evidence that structured diagnostic interviews do not always provide more accurate diagnoses. For example, the DISC quite often yields very different prevalence rates of diagnoses depending on whether parents, children, or both parents and children are interviewed (Costello, 1989). Interestingly, the Diagnostic Interview for Children and Adolescents (Reich, 1996) was actually validated by using the discharge diagnosis (Vitiello, Malone, Buschle, Delaney, & Behar, 1990), which was the method of diagnosis used in this study. The sample used in this study came solely from one inpatient facility, so further study should be conducted with a broader sample of inpatient youth, particularly those from nonurban areas or higher socioeconomic classes. The low number of younger participants (aged 7 to 12) in this study was problematic in the age analyses due to low statistical power in comparisons with this group as well as unequal cell sizes that existed when comparing between groups. The potential confound between gender and diagnostic groups was another limitation to this study. Although covarying out these influences yielded similar results, the issue remains an important one for further study. Diagnostic groupings and gender are confounded in naturally occurring clinical settings, so addressing this issue (without masking over the issue by artificially creating equal sample sizes of boys and girls with depressive or aggressive problems) is warranted (Hartung & Widiger, 1998).

14 SYMPTOM ENDORSEMENT DIFFERENCES ON THE CDI 409 Despite these limitations, results suggest that the CDI provides good discriminant validity based on item endorsement patterns within an inpatient population in the community mental health system. This study indicates that such patterns can aid in differentiating diagnoses in aggressive, depressive, and comorbidly aggressive depressive children. Further examination of response patterns on the CDI of other symptom groups, such as anxiety disorders, is warranted (Ruggiero et al., 1999). Although previous studies have found that CDI total scores may not discriminate among diagnostic groups, these data suggest that combining the total score with individual item endorsement patterns may result in increased confidence in the CDI as a diagnostic aid. ACKNOWLEDGMENTS This article is based on the masters thesis by Heidi Liss under the supervision of Vicky Phares. We would like to thank the staff and clients at the Children s Crisis and Stabilization Unit. In addition, thanks go to John Hernandez, Kevin Marrone, Octavio Salcedo, Doug Stimac, and Gianna Rendina for their help in completion of this project. REFERENCES Achenbach, T. M. (1991). Manual for the Child Behavior Checklist and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. Allgood-Merten, B., Lewinsohn, P. M., & Hops, H. (1990). Sex differences and adolescent depression. Journal of Abnormal Psychology, 99, Angold, A., Costello, E. J., & Erkanli, A. (1999). Comorbidity. Journal of Child Psychology and Psychiatry, 40, Barreto, S., & McManus, M. (1997). Casting the net for depression among ethnic minority children from the high-risk urban communities. Clinical Psychology Review, 17, Berkowitz, L. (1990). On the formation and regulation of anger and aggression, a cognitiveneoassociationistic analysis. American Psychologist, 45, Carey, M. P., Faulstich, M. E., Gresham, F. M., Ruggiero, L., & Enyart, P. (1987). Children s Depression Inventory: Construct and discriminant validity across clinical and nonreferred (control) populations. Journal of Consulting and Clinical Psychology, 55, Compas, B. E. (1997). Depression in children and adolescents. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp ). New York: Guilford. Compas, B. E., Grant, K. E., & Ey, S. (1994). Psychosocial stress and child and adolescent depression: Can we be more specific? In W. M. Reynolds & H. F. Johnston (Eds.), Handbook of depression in children and adolescents (pp ). New York: Plenum. Compas, B. E., Oppedisano, G., Connor, J. K., Gerhardt, C. A., Hinden, B. R., Achenbach, T. M., & Hammen, C. (1997). Gender differences in depressive symptoms in adolescence: Comparison of national samples of clinically referred and nonreferred youths. Journal of Consulting and Clinical Psychology, 65, Costello, E. J. (1989). Child psychiatric disorders and their correlates: A primary care pediatric sample. Journal of the Academy of Child and Adolescent Psychiatry, 28,

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