Centre for Epidemiological Studies Depression Scale for Children (CES-DC)

Abstract

The Centre for Epidemiological Studies Depression Scale for Children (CES-DC) is a widely utilized 20-item self-report inventory developed in 1980 by Weissman, Orvaschel, and Padian in the USA. Derived from the adult CES-D scale (Radloff, 1977), the CES-DC was modified specifically for youth populations. It serves primarily as a screening tool for depressive symptoms and for monitoring symptom improvement in children and adolescents aged 6 to 17 years. The scale employs a 4-point Likert scale, generating total scores ranging from 0 to 60. A crucial clinical cut-off score of 15 or higher suggests the presence of significant depressive symptomatology, necessitating further clinical assessment, though the instrument itself is not intended for diagnostic purposes.

Keywords

CES-DC, Depression, Child Assessment, Adolescent Mental Health, Screening, Psychometrics, Depressive symptoms, Self-report inventory

Authors

Myrna M. Weissman, Harriett Orvaschel, Nancy Padian

Purpose

The primary purpose of the CES-DC is the efficient screening and assessment of the frequency and severity of depressive manifestations in children and adolescents. It is designed to identify youths who may be experiencing clinically significant levels of depressive symptoms, thereby facilitating early identification and intervention, which is imperative given that these manifestations frequently go undiagnosed (Essau et al., 2013).

While the CES-DC is valuable for identifying individuals who require further assessment, it should not be used as a standalone diagnostic instrument. Researchers and clinicians utilize the scale in various settings, including community surveys and clinical environments, across diverse cultural contexts such as the USA, Iran, Germany, Spain, Sweden, and China, demonstrating its broad applicability in epidemiological studies.

Construct

The CES-DC measures the level of depressive symptoms experienced by the respondent over the past week. The scale’s theoretical structure, replicated from the adult CES-D, encompasses four core factors: depressed affect, positive affect, somatic activity, and interpersonal functioning (Radloff, 1977; Fendrich et al., 1990).

The 20 items are rated on a 4-point frequency scale, where 0 represents “not at all” and 3 represents “a lot.” To mitigate response bias, four items (questions 4, 8, 12, and 16) are positively worded and subsequently reverse-scored. Higher cumulative scores reflect greater levels of depressive symptomatology. However, studies suggest the instrument may be more sensitive to general emotional distress rather than strictly aligning with clinical depressive disorders defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) (Faulstich, 1986).

Validity

The validity of the CES-DC has been extensively assessed across diverse populations. Convergent validity has been established through significant positive correlations with other widely accepted instruments used to assess depressive constructs in youth, such as the Children Depression Inventory (CDI) and the Beck Depression Inventory (BDI) (Doerfler et al., 1988; Faulstich et al., 1986).

Furthermore, the scale demonstrates correlations with broader behavioral and emotional problems; for instance, it correlated significantly with the Child Behaviour Checklist (CBCL), suggesting that increased depressive symptoms correspond to greater overall behavioral difficulties (Achenbach, 1979). Studies also indicated a significant positive correlation between the CES-DC and the State Anxiety Scale for Children (SACS), highlighting the overlap between heightened anxiety and depressive symptoms in children (Li et al., 2010). Regarding discriminant validity, the CES-DC has shown efficacy in distinguishing between children and adolescents with and without formal psychiatric diagnoses (Fendrich et al., 1990; Weissman et al., 1980).

Reliability

The psychometric properties of the CES-DC are generally considered robust, particularly concerning reliability (Essau et al., 2013). Internal consistency, measured by Cronbach’s alpha, ranges from good to excellent, documented between .71 and .91 across various studies and cultures (Barkmann et al., 2008; Li et al., 2010).

Test-retest reliability has been strong in adolescent samples (ages 12–18), with coefficients typically ranging from .70 to .85 (Barkmann et al., 2008; Li et al., 2010). However, the scale’s reliability is compromised when used with younger children. Faulstich et al. (1986) reported very poor test-retest reliability for children, hypothesizing that the tool’s wording or format may exceed the comprehension level of younger respondents. This variability suggests the CES-DC may be measuring state characteristics rather than stable trait characteristics, particularly in younger populations, thus warranting caution when interpreting results from clinical samples of children.

Factor Analysis

The factor structure of the CES-DC is based on the four factors originally identified in the adult CES-D by Radloff (1977). Confirmatory factor analyses across international studies involving child and adolescent samples have consistently replicated this structure (Bettge et al., 2008; Essau et al., 2013; Fendrich et al., 1990; Li et al., 2010).

The four factors measured are:

• Depressed Affect
• Positive Affect (Reverse-scored items contribute heavily here)
• Somatic Activity/Complaints
• Interpersonal Functioning Difficulties

Despite the consistent factor structure, it is critical to remember that the scale is a screening tool. Because it does not strictly align with the specific diagnostic criteria outlined in the DSM, the aggregated scores should be viewed as representative of depressive symptomatology requiring further clinical investigation rather than a definitive diagnosis (Faulstich et al., 1986).

Instrument

Test Type: Self-report screening inventory

Format: 20 items rated on a 4-point Likert scale (frequency over the past week)

Language Available: English, German, Chinese, Spanish, Swedish (and others due to broad international use)

Population Group: Children and Adolescents

Age Group: 6 to 17 years

Population Details: Implemented across various cultural and community settings globally, including the USA, Iran, Germany, Spain, Sweden, and China.

Test Methodology: Respondents indicate how frequently they experienced specific feelings or behaviors in the preceding week. Total scores range from 0 to 60. A score of 15 or above suggests significant depressive symptomatology.

Keywords

CES-DC, Psychometric properties, Screening tool, Adolescence, Self-report, Depressed affect, Somatic complaints, Factor structure, Cut-off score

Authors

Author ORCID Identifier: N/A (Information not provided in source content)

Affiliation Email addresses: N/A (Information not provided in source content)

Correspondence Address: N/A (Information not provided in source content)

Permissions & Fee and Test Year

One of the significant advantages of the CES-DC is its accessibility. The instrument is publicly accessible with no cost affiliated with its use (Essau et al., 2013). The scale was formulated and introduced in 1980.

Reference’s

Achenbach, T. (1979). The child behavior profile: an empirically based system for assessing children’s behavioral problems and competencies. International Journal of Mental Health, 7, 24-42.

Barkmann, C., Erhart, M., & Schulte-Markwort, M. (2008). The German version of the Centre for Epidemiological Studies Depression Scale for Children: psychometric evaluation in a population-based survey of 7 to 17 years old children and adolescents – results of the BELLA study. European Child and Adolescent Psychiatry, 17, 116-124.

Bettge, S., Wille, N., Barkmann, C., Schulte-Markwort, M., Ravens-Sieberer, U., & BELLA Study Group (2008). Depressive symptoms of children and adolescents in a German representative sample: Results of the BELLA study. European Child & Adolescent Psychiatry, 17, 71-81.

Doerfler, L.A., Felner, R.D., Rowlinson, R.T, Raley, P.A., & Evans, E. (1988). Depression in children and adolescents: a comparative analysis of the utility and construct validity of two assessment measures. Journal of Consulting and Clinical Psychology, 56, 769-772.

Essau, C.A., Olaya, B., Gholamreza, P., Gilvarry, C., & Bray, D. (2013). Depressive symptoms among young children and adolescents in Iran: A confirmatory factor analytic study of the centre for epidemiological studies depression scale for children. Child Psychiatry and Human Development, 44, 123-136. doi:10.1007/s10578-012-0314-1

Faulstich, M.E., Carey, M.P., Ruggiero, L., Enyart, P., & Gresham, F. (1986). Assessment of depression in childhood and adolescence: An evaluation of the center for epidemiological studies depression scale for children (CES-DC). American Journal of Psychiatry, 143(8), 1024-1027.

Fendrich, M., Weissman, M.M., & Warner, V. (1990). Screening for depressive disorder in children and adolescents: Validating the Centre for Epidemiological Studies Depression Scale for Children. American Journal of Epidemiology, 131, 538-551.

Li, H.C.W., Chung, O.K.J., & Ho, K.Y. (2010). Centre for epidemiologic studies depression scale for children: Psychometric testing of the Chinese version. Journal of Advanced Nursing, 66, 2582-2591.

Li. H.C.W., & Lopez, V. (2007). Development and validation of a short form of the Chinese version of the State Anxiety Scale for Children. International Journal of Nursing Studies, 44, 566-573.

Olson, G., & von Knorring, A.L. (1997). Depression among Swedish adolescents measured by the self -rating scale Centre for Epidemiological Studies Depression Sale for Children (CES-DC). European Child and Adolescent Psychiatry, 6, 81-87.

Radloff, L.S. (1977). A CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

Weissman, M.M., Orvaschel, H., & Padian, N. (1980). Children’s symptom and social functioning self-report scales: Comparison of mothers’ and children’s reports. Journal of Nervous Mental Disorders, 168(12), 736-740.

Items of the Centre for Epidemiological Studies Depression Scale for Children (CES-DC)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

The CES-DC is a 20-item scale derived from the adult CES-D. An example of an item modification made for youth comprehension is:

• Original CES-D item: “I felt like everything I did was an effort”
• Modified CES-DC item: “ I felt like I was too tired to do things”

Four items (questions 4, 8, 12 and 16) are positively worded and reverse-scored to control for response bias. These items are scored as follows:

• Score of 3 indicates “not at all”
• Score of 2 indicates “a little”
• Score of 1 indicates “some”
• Score of 0 indicates “a lot”