Formulated by Weissman, Orvaschel and Padian (1980) in the United States of America (USA), the Centre for Epidemiological Studies Depression Scale for Children (CES-DC) is one of the most widely used self-report inventories for the screening of depressive symptoms and the assessment of symptom improvement in children and adolescents aged 6- 17 years (Essau et al., 2013). The 20- item questionnaire was derived from the Centre for Epidemiological Studies Depression Scale for Adults (CES- D; Radloff, 1977), with the items later modified to encourage use with youths (Essau, 2013; Faulstich, Carey, Ruggiero, Enyart, & Gresham, 1986; Weissman et al., 1980). For instance, CES-D item “I felt like everything I did was an effort” was modified in the CES-DC to “ I felt like I was too tired to do things” (Essau, 2013). Possible scores range from 0- 60 and are calculated by summing scores from each question (Radloff, 1977; Weissman et al., 1980).
All items on the CES-DC are rated on a 4-point Likert scale in terms of its frequency of occurrence throughout the past week. A score of 0 indicates “not at all”; a score of 1 indicates “a little”; a score of 2 indicates “some”; and a score of 3 indicates “a lot” (Radloff, 1977; Weissman et al., 1980). To control for response bias, four items (questions 4, 8, 12 and 16) are worded positively and thus are scored in the reversed order when calculating total CES -DC scores; a score of 3 indicates “ not at all”; a score of 2 indicates “a little ”; a score of 1 indicates “some”; and a score of 0 indicates “a lot” (Radloff, 1977; Essau, 2013). Additionally, higher CES-DC scores correspond to greater levels of depressive symptoms (Radloff, 1977; Essau, 2013). Weissman et al. (1980) specify that a cut-off score of 15 is indicative of depressive symptomatology in children and adolescents. Taken together, youths who report scores of 15 or more may be experiencing significant levels of depressive symptoms and thus should be followed by further assessment (Weissman et al., 1980). Subsequently, based on the practitioner’s clinical judgement, further assessment is necessary for youths who exhibit symptoms of depression but do not screen positive (Weissman et al., 1980).
Researchers have implemented the CES-DC in both clinical and community settings, in addition to a number of differing cultures, including the USA (Faulstich et al., 1986; Fendrich, Weissman, & Warner, 1990; Weissman et al., 1980), Iran (Essau et al., 2013), Germany (Barkmann, Erhart, & Schulte-Markwort, 2008; Bettge et al., 2008), Spain (Aguilar & Berganza, 1990), Sweden (Olsson & von Knorring, 1997) and China (Li, Chung & Ho, 2010). As research has identified discrepancies in the severity of depressive symptoms amongst children and adolescents residing in different countries, it is plausible that culture may play an important role (Essau et al., 2013). For instance, Iranian females have proclivities to be viewed as being increasingly submissive provided their living conditions, approach in which they are socialised and the nation’s male-dominated societal constructs, hence potentially contributing to their higher reports of depressive symptoms (Essau et al., 2013). Following this perspective, studies that have implemented the CES -DC have indexed that girls tend to report significantly higher levels of depressive symptoms and impairments in daily functioning than boys, particularly somatic complaints (Bettge, et al., 2008; Essau et al., 2013; Fendrich, Weissman, & Warner, 1990; Olson & von Knorring, 1997). These gender discrepancies may be attributed to the psychological and social difficulties being more demanding for females, such as issues with body image and self-esteem (Essau et al., 2013). Moreover, Bettge and researchers (2008) identified significantly greater levels of depressive symptoms in
adolescents (12-17 years) than children (6-11 years). It is postulated that adolescents are potentially more sensitive to the description and perception of their depressive symptoms, even though such manifestations may not be intense enough to be classified as clinically significant (Bettge et al., 2008).
One of the major advantages of the CES-DC is that it is publically accessible with no cost affiliated with it (Essau et al., 2013). Subsequently, the psychometric properties of the CES-DC are renowned for their good reliability (Essau et al., 2013). The internal consistency of the CES-DC has been documented to range from good to excellent, with Cronbach’s alphas spanning from .71 to .91 (Barkmann et al., 2008; Essau et al., 2013; Li et al., 2010). Similarly, the CES-DC has evidenced strong test-retest reliability in adolescent samples (12 -18 years; Barkmann et al., 2008; Li et al., 2010), with coefficients ranging from .70 to .85. Conversely, given that it has been proposed that the CES-DC appears to measure state more than trait characteristics (Faulstich et al., 1986), test-retest reliability as the propensity to be negatively impacted. Germane to this, Faulstich et al. (1986) discovered that test- retest reliability for the CES-DC was very poor for children. This may be attributed to the wording or format of the tool, as it may surpass the comprehension level of young children (Faulstich et al., 1986). Collectively, when drawing conclusions from CES-DC data collected from clinical samples, results should be interpreted with caution.
A number of studies have also assessed the validity of the CES-DC. Researchers have examined the convergent validity of the CES- DC through the calculation of inter-correlational analyses with other inventories used for assessment of depressive symptoms in youths, such as the Children Depression Inventory (CDI; Doerfler, Felner, Rowlinson, Raley, & Evans, 1988) and the Beck Depression Inventory (BDI; Faulstich et al., 1986). Results have indexed significant correspondence between related concepts, suggesting that the CES-DC measures the same depressive constructs the CDI and BDI assess (Doerfler et al., 1988; Faulstich et al., 1986). Additionally, Achenbach (1979) reported that the CES-DC correlated significantly with Child Behaviour Checklist (CBCL), indicating that greater levels of depressive symptoms are related to greater levels of behavioural and emotional problems. Furthermore, Li et al. (2010) found a significant positive correlation between the Chinese version of the CES-DC and the State Anxiety Scale for Children (SACS; Li & Lopez, 2007), proposing that children experiencing heightened anxiety symptoms also report greater depressive symptoms. Germane to discriminant validity, studies have shown that the CES-DC is able to distinguish between children and adolescents presenting with or without psychiatric diagnoses (Fendrich et al., 1990; Weissman et al., 1980).
Radloff (1977) identified four factors when designing the CES-D, encompassing depressed affect, positive affect, somatic activity and interpersonal functioning. Confirmatory factor analyses demonstrate that these factors have also been replicated in various studies implementing the CES- DC amongst children and adolescent samples in different countries (Bettge et al., 2008; Essau et al., 2013; Fendrich et al., 1990; Li et al., 2010; Olson & von Knorring, 1997). However, as the CES-DC does not align with the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria, the CES-DC cannot be used as a diagnostic tool or for differential diagnoses encompassing depressive disorders (Faulstich et al., 1986). Similarly, the instrument is considered to be more sensitive to a subject’s emotional distress rather then their depressive symptoms (Faulstich, 1986). Collectively, further investigation is warranted if aggregated CES-DC scores are determined to be representative of depressive symptomatology (Faulstich et al., 1986; Fendrich, 1990).
Depressive problems continue to be a common occurrence amongst children and adolescents (Bettge et al., 2008). Given that these manifestations tend to go frequently undiagnosed, sufferers are delayed from accessing appropriate treatment (Essau et al., 2013). As such, early identification of clinically depressed children and adolescents is imperative so that suitable treatment can be administered, with much of this dependent on psychometrically rigorous screening instruments (Essau et al., 2013). Accumulating evidence suggests that that CES-DC is considered to be a reliable and valid tool for assessing and monitoring depressive symptoms in youths. However, its results should avoid being interpreted as a clinical diagnosis but instead signify the need for further evaluation. Provided its simplicity of scoring and administration, its implementation within psychiatric domains should be examined in further studies.
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