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BHIPP Bulletin

Depression Screening Tools For Your Pediatric Primary Care Toolbox
Volume 2, Issue 10
April 2017

Primary care providers (PCPs) are often the first health care professionals to identify depressive symptoms in children and adolescents. Screening scales can help determine which patients in clinical care are in need of further clinical assessment of depression. These depression screening scales can quickly establish a baseline level of depressive symptoms, which can then be monitored. The Bright Futures Guidelines led by the American Academy  of Pediatrics (AAP) has recommended adolescent depression screening begin at age 12 years. Although the value of the routine use of screening scales is not entirely clear, they are often clinically helpful to identify children with depressive symptoms.  

Depression screening scales are typically based on self-report responses so that a definitive diagnosis typically requires additional information (from clinical interview or collateral informants). The Guidelines for Adolescent Depression in Primary Care (GLAD-PC) summarize the evaluation of depression for PCPs and review the process of diagnosing depressive disorders in youth. The GLAD-PC toolkit provides tools based on these recommendations. GLAD-PC experts suggest PCPs should screen for depression in adolescents who present either: 1. Risk factors for depression or 2. A complaint of emotional problems.  Additional guidance for PCPs is available from the AAP publication “Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit” which lists pediatric mental health screening tools in a tabular form. Although several pediatric depression screening scales exist, here we review two commonly used scales that are freely available: the Patient Health Questionnaire 9-Item (PHQ-9) and the Center for Epidemiological Studies Depression Scale for Children (CES-DC).

Patient Health Questionnaire 9-Item (PHQ-9)
The depression module of the PHQ-9 depression screen was adapted for use with adolescents (PHQ-9: Modified for Teens) from the adult PHQ-9. The PHQ-9 is a validated and widely used scale that screens for depression in adult primary care. The PHQ-9 depression screen modified for teens uses 9-items to screen for depression in youth aged 12-18 years of age. It takes under 5 minutes to score. These nine items are self-rated based on how frequently the symptoms have occurred over the past two weeks. Nine symptom items are reviewed, which  encompass: mood, anhedonia, vegetative symptoms (sleep and appetite), self-attitude, concentration, psychomotor activity and suicidal thoughts. Each item is rated according to frequency from 0 (not at all) to 3 (nearly all the days). The modified PHQ-9 for teens includes questions on dysthymia, level of impairment and suicide attempts. To obtain a total score, add the numbers obtained in the nine questions above.

The modified PHQ-9 score has been used as an indicator of depressive symptom severity.  In a sample of adolescents, a cut-off score of 11 or more has been found to indicate the need for further evaluation for depression. The PHQ-9 in adolescents has been reported to have good sensitivity (89%) and specificity (79%) for depression, similar to adults. Taken together, the PHQ-9 is brief and simple to score with good test qualities, making it an excellent depression screening tool for adolescents in primary care practices. 
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
The CES-DC , which has been used in children as young as 6 years of age, was modified from the adult version [the Center for Epidemiological Studies Depression Scale (CES-D)]. The CES-DC is a twenty question self-report scale which screens for pediatric depressive symptoms within the past week. Each of the 20 items are rated on a scale from 0 to 3. It takes approximately 5 to 10 minutes to complete.  A cutoff of 15 has been reported to indicate significant depressive symptoms; higher scores suggest increasing depressive symptoms. The test is helpful to screen for depression mainly in teens. The CES-DC can aid as an adjunct in establishing a baseline of depressive symptoms in youth; however, it may not be as helpful in younger children.

Depression screening scales are important tools PCPs can use to quickly identify depressive symptoms in youth. Typically, finding elevated scores on depressive screening tools should indicate the need for further diagnostic assessment. Consultation, such as through collaborative care models and phone consultation (such as BHIPP) may help PCPs in this process. Identifying depressive symptoms with screening tools is a very critical first step in the early identification of depression, which may have important implications for these youth.
  • Zisook S, Rush AJ, Lesser I, et al. Preadult onset vs. adult onset of major depressive disorder: a replication study. Acta Psychiatr Scand 2007; 115:196-205.
  • Zuckerbrot, R, Cheung, A, Jensen PS et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC):1. Identification, Assessment and Initial Management. Pediatrics; Nov 2007: e 1299-e1312.
  • GLAD-PC toolkit;  (Verified April 3rd, 2017)
  • Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit; (verified April 3rd, 2017)
  • Mitchell AJ, Yadegarfar, M, Gill J et al. Case finding and screening utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies. Br J Psych Open. 2: 2016; 127-138.
  • Richardson LP, McCauley E., Grossman DC et al. Evolution of the Patient Health Questionnaire-9 Item for Detecting Major      Depression Among Adolescents. Pediatrics. Dec 2010; 1117-1123.
  • Allgaier AK, Pietsch, Ruhe B et al. Screening for Depression in Adolescents: Validity of the Patient Health Questionnaire in Pediatric Care. Depression and Anxiety. 2012; 906-913.
  • Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 16(9): Sep 2001; 606-13.
  • Weissman MM, Orvaschel H, Padian N. Children’s Symptoms and social functioning self-report scale: comparison of mothers’ and Children’s reports. J of Nervous and Mental Disease. 168: 736-740.
  • Fendrich M, Weissman M, Warner V. Screening for depressive disorder in children and adolescents: Validating the Center of epidemiologic studies depression scale for children. American Journal of Epidemiology. 131: 1989; 538-551.
  • Richardson LP, McCauley, E, Grossman D. et al. Evaluation of the Patient Health Questionnaire-9 Item for Detecting Major Depression Among Adolescents. Pediatrics 126: Dec 2010,; 1117-1123.
  • Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017   (verified April 3rd, 2017)
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The BHIPP telephone consultation line will be closed on the following days:
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BHIPP is a Community Champion of the Children's Mental Health Matters! Campaign

And you can be too! 

Help raise awareness about the importance of children's mental health in your community! Join the Children's Mental Health Matters! Campaign to promote Children's Mental Health Awareness Week in Maryland (May 1-7, 2017). 

For more information, visit the Campaign's website



Clinical Report from the American Academy of Pediatrics - 
Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment


From Pediatrics, March 2017

Abstract: Children who have suffered early abuse or neglect may later present with significant health and behavior problems that may persist long after the abusive or neglectful environment has been remediated. Neurobiological research suggests that early maltreatment may result in an altered psychological and physiologic response to stressful stimuli, a response that deleteriously affects the child’s subsequent development. Pediatricians can assist caregivers by helping them recognize the abused or neglected child’s emotional and behavioral responses associated with child maltreatment and guide them in the use of positive parenting strategies, referring the children and families to evidence-based therapeutic treatment and mobilizing available community resources.

Continue reading here
Maryland Chapter AAP offers Free
In-Office Training - Developmental Screening 

The one-hour training reviews Maryland's current approved and recommended developmental screening tools, as well as information on interpreting and documenting screening results and coding and billing for services. 

View flyer.

For more information:
Emily Evers, MPH, CHES


BHIPP Bulletin Newsletter Archive

March 2017: Child Abuse Reporting
February 2017: Trauma and Adverse Childhood Experiences (ACEs)
January 2017: FAQs about Stimulant Dosing
December 2016: Bullying
November 2016: Learning Disorders and Intellectual Disability
October 2016: Educational Services: Know Your Rights and Resources
September 2016: Goodbye Summer, Hello School (Refusal)
August 2016: College Students and ADHD
July 2016: It's Summertime! ADHD and "Drug Holidays"
June 2016: Understanding Vyvanse
May 2016: Children's Mental Health Awareness Week, May 1-7, 2016
April 2016: "Universal" approaches for child mental health problems
March 2016: Pharmacological interventions for sleep concerns
February 2016: Behavioral interventions for sleep concerns
January 2016: Assessment of sleep disorders
November 2015: 5S's: Key questions for consultation
October 2015: Case discussion regarding school refusal
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