Validation of Malay Version of Children Depression Inventory (CDI ...

VALIDATION OF THE MALAY VERSION OF CHILDRENDEPRESSION INVENTORY (CDI) AMONG CHILDRENAND ADOLESCENTS ATTENDING OUTPATIENTCLINICS IN KOTA BHARU, KELANTAN.MY Rosliwati* MMed; H Rohayah** MMed; BYM Jamil** MMed, M.Sc;S Zaharah*** MComMed.________________________________________________________________________ABSTRACTThe aim of this study is to validate the Malay version of CDI amongchildren and adolescents attending outpatient clinics at UniversitiSains Malaysia Hospital (USM), Kota Bharu, Kelantan. Sixty childrenand adolescents attending outpatient clinics were interviewed usingthe Diagnostic and Statistical Manual of Mental Disorders, FourthEdition (DSM-IV) and completed the Malay version of CDI.Reliability and validity of the Malay version of CDI were analyzed.Validation study showed that the Malay version of CDI had asatisfactory reliability (Cronbach’s alpha 0.83). At the cut-off score of18, the Malay version CDI had 90% sensitivity and 98% specificity indetecting depression. In conclusion, the Malay version of CDI has asatisfactory validity and reliability.Keywords:Children Depression Inventory, depressionINTRODUCTIONThe validation of instrument such asCDI across different cultural groups iscrucial to provide evidence of the scalesensibility to cultural diversity and tohelp identify symptomatic differencebetween groups (1). CDI differentiatesdepressive disorder from anxiety anddisruptive behaviour disorder (2). CDIalso differentiates children andadolescents with major depression ordysthymia from those with otherpsychiatric disorders or from the normalones (3).It is, in fact, a self-report,symptom-oriented scale which requiresat least a first grade reading level andwas designed for school-aged childrenand adolescents. It has 27 items, each ofwhich consists of three choices. Thechild is instructed to select one sentencefor each item that best describes him orher for the past two weeks. It measuresdepressive symptoms in children andadolescents, aged 7 to 17 years. The CDIprofile contains the following fivefactors plus a total score normedaccording to age and sex: (i) negative

mood, (ii) interpersonal problems, (iii)ineffectiveness, (iv) anhedonia and (v)negative symptoms.Previous study used CDI todetect and evaluate symptoms of majordepressive disorder or dysthymicdisorder in children or adolescents, andto distinguish between children withthose disorders and children with otherHowever, in another study, Charman(1994) found that there was a greatvariability in the cut-off score rangedfrom 12 to 25 (8).Lack of validation measures inthe Malay version for local populationespecially in children and adolescents isthe main concern for clinicians.The aim of this study is tovalidate the Malay version of ChildrenDepression Inventory (CDI) amongchildren and adolescents attendingoutpatient clinics at Universiti SainsMalaysia Hospital (HUSM), Kota Bharu,Kelantan.METHODSThis study was approved by theResearch & Ethical Committee, Schoolof Medical Sciences, Universiti SainsMalaysia. Written informed consent wasobtained from parents or guardians afterdetailed explanations given on the study.Sixty children and adolescentsaged 7-17 attending outpatient clinicswere randomized using systematicrandom sampling. The exclusion criteriainclude children with mental retardationand children with organic brainsyndrome.psychiatric conditions (4,5,6). CDI canbe administered repeatedly in order tomeasure changes in depression over timeand to evaluate the result of treatmentfor depressive disorders. It is regarded asadequate for assessing the severity ofdepressive symptoms. Shemesh et al.found that at cut-off score of 11, theinventory correctly identified 80% ofcases, with specificity of 70% (7).CDI was translated to the Malaylanguage and back translated intoEnglish by two school teachers who areproficient in both languages. Bothscales, the original and the backtranslatedversions were compared todetermine the accuracy of thetranslation. Assistance from the Centrefor Language and Translation, USM wassought to finalize the draft. CDI was firsttested on 20 children at the HUSMPaediatric outpatient clinics.All subjects were asked to fill inthe self-administered Malay version ofCDI before clinical interview. Theresearcher was blind to CDI scores attime of interview. All subjects were theninterviewed individually by a researcher(the first author) who was trained inpsychiatric interview and examination.A diagnosis was made based on thecriteria of Major depressive episode inDSM-IV and Mini InternationalNeuropsychiatric Interview (MINI) forMajor Depressive Episode (2004) (MINIkid). Internal consistency of CDI wasdetermined using corrected item-totalcorrelation and Cronbach’s alphacoefficient. Correlation between CDIscores and MINI kid was used toindicate concurrent validity.

MINI kidIt is designed as a brief structuredinterview for the Axis I psychiatricdisorder in Diagnostic and StatisticalManual of Mental Disorders, FourthEdition (DSM-IV) and InternationalClassification of Diseases Tenth Edition(ICD-10). Its validity and reliabilitystudies have been done comparing MINIto SCID-P for DSM-III-R and the CIDI(a structured interview developed byWHO for lay interviewers for ICD-10).It has a high validity and reliability,takes about 12 minutes to beadministered and has nine questionswhich answered yes or no. The totalanswer of YES for more than 5 wasconsidered as Major depressive episode.Statistical analysisData entry and analyses were carried outusing SPSS software version 12.0.RESULTSCharacteristic of the respondentsThe age of the subjects ranged from 7 to17 years, (mean: 12.2 years, SD 2.34).11 (18.3%) respondents were diagnosedto have depression (Table 1).Reliability Analysis of CDIInternal consistency of CDI wasdetermined using corrected item-totalcorrelation and Cronbach’s alphacoefficient. (Table 2)Table 1 Demographiccharacteristic of depressed vs. nondepressedrespondents (using clinicaldiagnosis)Demographic Depression statuscharacteristics Depressed Nondepressedn % n %All 11 18.3 49 81.7SexMale 7 11.7 25 41.7Female 4 6.7 24 40.0Agegroup7-12 6 10.0 28 46.7years13-17years5 8.3 21 35.0Validity Analysis of CDIa) CDI scores versus clinicaldiagnosesTotal score of CDI was compared withthe clinical diagnoses and the meanscore of CDI was highest in depressivegroup and lowest in non-depressivegroup. The mean scores were 25.1 and10.3 in depressive group and nondepressivegroup respectively. CDIscores do significantly differ acrossclinical diagnoses (χ 2 =21.45, p

Table 2: Internal consistency for CDIQuestionCorrecteditem-totalcorrelationAlpha ifitemdeleted1 0.44 0.832 0.19 0.833 0.35 0.834 0.07 0.845 0.65 0.816 0.17 0.837 0.68 0.828 0.41 0.839 0.49 0.8210 0.55 0.8211 0.48 0.8212 0.36 0.8313 0.26 0.8314 0.53 0.8215 0.47 0.8216 0.35 0.8317 0.46 0.8218 0.26 0.8319 0.02 0.8520 0.49 0.8221 0.50 0.8222 0.48 0.8223 0.38 0.8324 0.28 0.8325 0.29 0.8326 0.30 0.8327 0.14 0.83Cronbach’s alpha 0.83Figure 1: Receiver OperatingCharacteristic curve(ROC) for CDISensitivity1.00.80.60.40.20.0ROC Curve0.0 0.2 0.4 0.6 0.8 1.01 - SpecificityDiagonal segments are produced by ties.At the cut-off score of 18, CDI detectsdepression at the.sensitivity of 90%.specificity of 98%c) The optimum cut-off score for CDIThe optimum cut-off score fordepression was 18 according tocoordinates of the ROC curves..positive predictive value of 100%. negative predictive value of 96%

Table 3: Sensitivity and specificity atdifferent cut-off pointsPositive ifgreater orequal toSensitivity(%)Specificity(%)0 100.0 0.02.0 100.0 2.03.5 100.0 4.04.5 100.0 8.05.5 100.0 14.06.5 100.0 22.07.5 100.0 32.08.5 100.0 34.09.5 100.0 46.010.5 100.0 52.011.5 90.0 58.012.5 90.0 62.013.5 90.0 70.014.5 90.0 78.015.5 90.0 84.016.5 90.0 92.017.5 90.0 98.019.0 80.0 100.020.5 70.0 100.022.5 60.0 100.025.5 50.0 100.028.5 40.0 100.033.0 30.0 100.036.5 10.0 100.038.0 0.0 100.0DISCUSSIONThe Malay version of ChildrenDepression Inventory (CDI) is a selfadministeredinstrument validated for theMalaysian population.Several studies have assessed itsinternal consistency, structural factorreliability, test-retest (stability),administration methods and cut-offscores. For instance, Kovacs (1992) hadproposed the Cronbach’s alpha rangebetween 0.71-0.87 (3). He suggested anadequate cut-off score, based on rawtotal scores needs to be established tominimize false negatives (i.e. clinicallydiagnosed children and adolescents witha depressive disorder who are notclassified as such by means of the CDI)and false positives (i.e. children andadolescents who are falsely classified asdepressed by means of the CDI).Furthermore, Kovacs (1992)recommended a cut-off score of 13 as tominimize false negatives and for clinicalsample; a higher cut-off score of 19minimizes false positives and used innon-clinical sample.Most studies use multi-stagestrategy in non- clinical samples with acut-off score of 19, which seem to bespecific enough in identifying samplesof potentially depressed children andadolescents following the suggestions byKovacs (6).In this study, at the optimumscore of 18, the CDI had a sensitivity of90% and a specificity of 98%. Rivera etal (2005) used depression section of theSpanish version of Diagnostic InterviewSchedule for Children (adapted to aSpanish version) and Beck DepressionInventory as the gold standard. Hereported the cut-off score of 20 with asensitivity of 69%, specificity of 43%,positive predictive value of 64% andnegative predictive of 49%. It is clearthat sensitivity and specificity scoresdiffer from one population to anotherand one cannot assumes based on metricequivalents (9). On the other hand,Timbremont & Braet (2004) suggestedcut-off scores of 13 and 19. They hadshown a satisfactory receiver-operatingcharacteristic (ROC) for screeningpurposes using KID-SCID (Dutch

version) as a gold standard for clinicaldiagnosis (2).Finally, this study illustrates the fact thatthe Malay version of ChildrenDepression Inventory could be used as avalid and reliable screening tool fordepression in the Malaysian population.The cut-off score of 18 in this samplehas shown good sensitivity andspecificity.ACKNOWLEDGEMENTThis study was conducted under shorttermgrant from Universiti SainsMalaysia.REFERENCES1. Abdul-Khalec AM, Solimon HH. Across cultural evaluation ofdepression in children in Egypt,Kuwait and the United State.Psychological Reports, 1999:85:973-980.2. Timbremont B, Braet C. Assessingdepression in youth: Relationbetween the Children’s DepressionInventory and a structured interview.Journal of Clinical Child andAdolescentPsychology,2004:33:1:149-157.3. Kovacs M. Children DepressionInventory. New York: Multi-HealthSystems, 1992.4. Fristad MA, Weller EB, Weller RA etal. Self-report versus biologicalmarkers in assessment of childhooddepression. Journal of AffectiveDisorder, 1988:15:3:339-345.5. Hodges-Kay U, Ypisilanti US.Depression and anxiety in children:A comparison of self-reportquestionnaires to clinical interview.Psychological assessment, 1990:2:4:376-381.6. Bahls SC. Epidemiology ofdepressive symptoms in adolescentsof a public school in Curitiba, Brazil.Revision Brazil Psychiatry,2002:24:2:204-212.7. Shemesh E et al. Children’sDepression Inventory validated inmedically ill children. Journal of theAmerican Academy of Child&AdolescentPsychiatry,2005:44:12: 1249-12578. Charman T. The stability ofdepressed mood in youngadolescents: a school based survey.Journal of Affective Disorder,1994:30:109-16.9. Rivera CL, Bernal G, Rosello J. TheChildren Depression Inventory(CDI) and the Beck DepressionInventory (BDI): Their validity asscreening measures for majordepression in a group of PuertoRican adolescents. InternationalJournal of Clinical and HealthPsychology, 2005:5:485-498.* Dept of Psychiatry, HospitalSentosa, Kuching, Sarawak** Dept of Psychiatry,*** Women’s Health Development Unit,School of Medical Sciences, UniversitiSains Malaysia.

Correspondence:Dr Rohayah Hussein,Dept of Psychiatry,USM.E-mail: rohayah@kb.usm.my